Nov 2, 2017

Interview Transcript

Dr. Jones: Natural child birth, what is that? No woman wants an unnatural birth. But let's talk about normal labor or physiologic labor and how we can support it. This is Dr. Kirtly Jones from obstetrics-gynecology at University of Utah Health and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Today in The Scope studio, we're talking about normal or physiologic birth with Celeste Thomas, a certified nurse midwife and clinical director of birth care health care with the University of Utah College of Nursing. Welcome Celeste. So we all want a normal birth, but humans have these big babies and as a former of OB, all births looked a little risky to me, so let's talk about normal vaginal birth, or you use the word physiologic birth.

Celeste: Yeah, I prefer physiologic, because all birth is normal, right?

Dr. Jones: Yeah. Sort of.

Celeste: I mean, kind of. I mean, for us humans you're right, we do have big brains and so we have to come out sooner than a lot of mammals have to. So let's talk about physiologic birth though, right? Because when we talk about physiologic birth, we're talking about the things that drive birth, which are the hormones.

Dr. Jones: Oh, I'm all about hormones. Go for it.

Celeste: Right? So we're always about hormones at many different parts of our lives. So a lot of this stuff about keeping the room calm or comfortable sounds really nice, right? But it also serves a physiologic end, which is that when hormones are doing what they need to do, then birth runs more smoothly. We know this, because we know that there are things like: prostaglandins, oxytocin, beta endorphins, catecholamines, norepinephrine, epinephrine. All of these things actually build up and change as birth gets nearer, as spontaneous labor gets nearer, and they really serve good purposes. So we know for instance that epinephrine and norepinephrine and cortisol have effects on the fetal brain, pre-labor effects, so things that happen in the brain that are prepping that baby's brain for birth itself.

Dr. Jones: You mean like for getting squeezed?

Celeste: Yeah, for dealing with less oxygen.

Dr. Jones: Wow. I'd always wondered that we aren't weren't born with traumatic brain injury.

Celeste: Yeah. So they have preparations that happen in the fetal brain for dealing with less oxygen, because birth does lead to decreased oxygen for most babies just in the normal process and babies' brains ideally need to withstand that. And we know that there are synthetic versions of things that we use. For instance oxytocin, we will sometimes use a synthetic version called Pitocin, that's in the hospital, but we know also that the synthetic version of oxytocin doesn't necessarily act in the exact same way as naturally occurring oxytocin.

For instance, the synthetic version of oxytocin which causes contractions doesn't easily cross the blood-brain barrier. So this barrier to get into the brain in the same way that naturally occurring oxytocin that comes from the mother does. So there are things about that that are not exactly the same. So I think that the question is, what in the process . . . So sometimes there are ways to kind of safeguard the physiologic process even when things don't go exactly in the way that we were hoping, right, or even when things kind of go differently.

So some of the ways though that we can safeguard that process and allow these hormones to do what they need to do is we can allow labor to begin on its own when we are able to. We can allow labor to begin that way. And that means that we get this pre-labor up regulation in the uterus and allows that uterus to contract more efficiently with the oxytocin. We can get that pre-labor up regulation in the baby's brain as well to withstand decreased oxygen during labor. It also means we want to avoid excessive stress in labor. So a certain amount of stress in labor is normal and can actually beneficial but if that stress reaches a level that is excessive we've seen in a lot of studies that labor can actually shut down.

Dr. Jones: Well, so there's some good reason for that. I mean when you think about how long labors can be in humans. And maybe the tigers are coming or maybe you need to run away. And the fact that you could actually in early labor run away if you were afraid or if you weren't safe or if your baby wasn't safe, you could run away. Maybe it's a hurricane coming. Well, that's a long time to put it off. But we've known in women if they have a big scary thing, their labor can stop and then you end up having to start it up with external hormones and things like that.

Celeste: Absolutely. And sometimes even just going to the hospital, the smells of the hospital, the people talking to you, the bright lights, that can sometimes slow labor down. And we'll see that sometimes when a woman will get to the hospital and her contractions were two minutes apart at home, but now they're 10 minutes apart and kind of sluggish and not really picking up. So keeping the lights low, making sure she has the people around her that feel safe and comfortable to her. Keeping the questions to minimum, just whatever you need to know but not being excessive with that. Making sure that she has access to a doula which is a trained birth support person. Allowing her to move and eat as she needs to. These things are going to decrease those stress hormones and hopefully keep them in that optimal range.

Dr. Jones: Well, so let's back up just a sec, because certainly I could be in clinic and one in five women in the last couple of weeks of pregnancy will say, "Can't you just induce my labor? I just don't want to be pregnant anymore." That's a common . . . now on the one hand some of them say, "No, no, no, I don't want an induction," meaning start the synthetic hormones. But many women assume that doctors want to induce their labor. And maybe they live far away and they're afraid they won't get there on time, or maybe their husband's leaving to be deployed. I mean, there are thousands of reasons, and we've tried to do fewer and fewer inductions. And I think we're really dropping the number of inductions that we're doing. But women ask for it.

Celeste: Yeah, absolutely. I mean it's hard to say . . .

Dr. Jones: I want to tape your comments and say, "Oh no, your baby's brain isn't ready."

Celeste: Yeah. I mean, there are sometimes really good reasons to induce. We have to weigh the risks and benefits. But when we don't have a really good reason to do it, we need to talk with women about what the risks are. So maybe a baby's brain who isn't as primed to go without oxygen, maybe the baby's brain is not going to do us well in labor as the baby whose brain is primed. So it's something to talk about and really discuss with women, and let them know about the research that we have and the outcomes. They're better for spontaneous labor.

Dr. Jones: Well also women are given this due date which, not necessarily your patients, but mine used to think it was their God-given right to deliver by their due date, and so I'd say, "Here's an approximation. Here's your due date, but it could be a couple weeks on either side. So don't start counting down until it's a week or two after this date that we've given you."

Celeste: I almost feel that we kind of give women a disservice, by not giving them a range and just saying, "You could have your baby between this and this."

Dr. Jones: Right.

Celeste: And that would be totally normal, right? Dr. Jones: Right. Well, what are other good ways to support physiologic birth?

Celeste: The other things that are really important have to do a lot with the postpartum period. So when babies come out, making sure that as little as possible there is as little disruption to the process of baby being on the mother's skin as possible. And this is really interesting too because there are things about that postpartum period that we kind of tend to rush in the hospital. And I'm saying this because I've seen it and I've done it too. Where it's like, that baby is on her chest and it's kind of bobbing around and you're just like, "Baby go to the breast. It's over there." But it takes baby a while to get there.

Dr. Jones: But baby's got a headache.

Celeste: And sometimes baby has a headache. But that, it's interesting in the studies looking at babies who bob and are kind of looking around and don't necessarily get the breast in their mouth yet.

The mother's oxytocin goes much high than babies who are just latched on right away. So there seems to be some reason why these things are happening, so as much as possible to kind of watch for those danger signs of course and make sure mom's not bleeding too much or doing those things. But really allowing mom and baby in that little ecosystem, right? That's really important to a baby survival, allowing that to happen.

And the really interesting thing about these things is that, let's say you end up with a C-section. Well guess what? There's physiologic things we can support even in a C-section. We can allow skin to skin. We've been doing that in the operating room, right? So you can do skin to skin. There's a lot of studies now going on with the vaginal microbes.

Dr. Jones: Oh, we did a study. Listeners, you can actually tune in on that.

Celeste: Yeah. So again, there's a lot of stuff we don't know, but there's a lot of things that we can see physiologically that happen in nature that we can try to really safeguard.

Dr. Jones: Yeah. Well I always liked doing deliveries in the almost dark and especially after the baby was born, to turn off the lights so the mom and the baby aren't squinting. The poor baby, the lights are too bright. All I need is a spot at the other end so I can make sure the bleeding isn't happening and get the placenta delivered and let the mom and the baby be in the dark and quiet. And it gives me a chance for my blood pressure to come down as well, as the deliverer, so until the baby is out my blood pressure is up. So I like the dark.

Celeste: Yeah. Absolutely, and I tend to do a kind of mindfulness exercise when I'm even in that second stage when she is pushing, so I really feel my feet on the ground, I want to stay really present, I don't want to get too anxious, want to kind of create that space for her. But also be vigilant, of course.

Dr. Jones: The other thing is that I've often seen and I can't say I've participated because I'm not a yelling person. But when women are pushing and people want them to push firmly, although I don't think there's any evidence that they have to push hard. The body will make them push hard. But they start yelling at someone to push. And you see this on TV. "Push, push." And I'd rather be sweet talked. So talk about your own practice in this regard.

Celeste: Well, think about it. I mean, in the physiology about birth, they actually call it the fetal ejection reflex. So in some ways it's like a reflex, in that when the baby's head reaches a certain point, you will push, and if you can feel it, you will push. So especially with a woman who doesn't have an epidural, you don't need to . . .

Dr. Jones: It's uncontrollable.

Celeste: Yeah, it's uncontrollable. If you have a woman with an epidural, they do some times need a little more guidance, but again, they'll get the hang of it. And really having to direct them in pushing, there's no evidence that that is beneficial.

Dr. Jones: I just don't think it's beneficial at 60 decibels or 80 decibels. I think you could probably coach someone. But when you watch it on TV, they're kind of yelling at the mom to push, and can't you sweet talk that baby out?

Celeste: Yeah, and it's a less like a sport and more like a bowel movement than anything else, right? I mean it's like there is a certain amount of . . .

Dr. Jones: We'll hold that thought. Let's just hold that thought. Well as we put things together, I want to briefly talk about home births and the safety of home births and some studies from Europe and compare the European experience with the American experience.

Celeste: Yeah. Absolutely. So there's been a number of studies on out of hospital birth, especially home birth in the Netherlands, in the United Kingdom for low risk women. And this is an option that's completely integrated into their health system, meaning these are midwives who work with the National Health Service. They have a set criteria of risk that they look at to see if someone is eligible for an out of hospital birth and they have set criteria for transferring when they need to.

Dr. Jones: And the transfer time is short. They're not a hundred miles from the hospital.

Celeste: Yeah. They actually have to be within about 15 minutes I think it is. So in that scenario, home birth can be a really safe option for low risk women. If you look here in the United States, we have a different health system. It's not comprehensive. It can be rather fractured. And so this ability to kind of transfer seamlessly into the hospital when you're having a home birth is not as smooth. And so there are some challenges that way. When you look at outcomes you can see that Cesarean rate for low risk women is lower when they are out of the hospital. And that's true regardless of if it's a birth center or if it's a home birth. The Cesarean rate is lower for low risk women than low risk women who are having their babies in the hospital.

Dr. Jones: Right, and that the women who aren't transferred. And clearly when get transferred the story is over in terms of . . .

Celeste: But you still need to follow those women, those transferred women, and that's something we're actually doing here in the state of Utah, is that we are now capturing the women who transferred in to see what are their outcomes like? And to be expected, the outcomes are not as good, right? If you transfer.

Dr. Jones: Right. But once you've gone from low risk to high risk at home, then that ends up being a bigger problem than going from low risk to high risk in the hospital.

Celeste: Absolutely.

Dr. Jones: But birth is a physiologic phenomenon and there are many, many of us on the planet, so we must be doing it pretty well. Even though the stories from 150 years ago are heartbreaking with the number of moms and babies that we lost, I think that we really do very well in various settings with people who are informed and supported. The biggest issue is supported. And we all want the safest and most comfortable birthing experiences for mom and we offer options that let women make some choices in their birthing experience. And thanks for joining us on The Scope.

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