WEBVTT - Ep 170 Pregnancy: Act 3 0:00:00.240 --> 0:00:02.640 We want to start with a disclaimer that throughout this 0:00:02.800 --> 0:00:07.240 series we feature explanations and stories that include some heavy material, 0:00:07.440 --> 0:00:13.720 including early pregnancy, loss, stillbirth, and other traumatic experiences of pregnancy, childbirth, 0:00:13.960 --> 0:00:15.160 and the postpartum period. 0:00:17.200 --> 0:00:17.439 Hi. 0:00:17.560 --> 0:00:19.599 My name's Catherine, and I'm really excited to share my 0:00:19.640 --> 0:00:24.079 birth story with you guys. I had a totally healthy, 0:00:24.120 --> 0:00:28.560 totally normal pregnancy. Nothing was wrong. There was no inclination 0:00:28.680 --> 0:00:31.280 that anything was going to be, you know, different about 0:00:31.280 --> 0:00:34.599 my baby when she was born. I come from a 0:00:34.600 --> 0:00:38.560 line of moderately tall people, with an outlier my brother 0:00:38.640 --> 0:00:40.960 being six foot seven. He is the tallest person in 0:00:40.960 --> 0:00:42.640 my entire family, and we don't really know where it 0:00:42.640 --> 0:00:45.559 came from. So, you know, I was very curious to 0:00:45.560 --> 0:00:47.280 know how big my baby was going to be, and 0:00:47.400 --> 0:00:50.080 I had asked around my thirty six week appointment if 0:00:50.080 --> 0:00:51.800 they had any idea how big she was going to be. 0:00:52.280 --> 0:00:55.200 I'd been measuring normal my entire pregnancy, and they said, 0:00:55.240 --> 0:00:57.640 you know, it's kind of hard to tell unless there's 0:00:57.680 --> 0:01:00.600 something very abnormal, like she's very small or vain large. 0:01:01.240 --> 0:01:02.760 It's kind of a surprise how big they're going to 0:01:02.840 --> 0:01:05.720 be within that, you know, like six to eight pound 0:01:05.840 --> 0:01:09.240 range that babies usually are, and I was very large 0:01:09.280 --> 0:01:11.440 when I went into labor. I went into labor at 0:01:11.480 --> 0:01:14.240 forty weeks in five days, so I just thought I 0:01:14.280 --> 0:01:16.560 was really, really pregnant. I didn't think anything of it, 0:01:16.640 --> 0:01:19.760 but when they started doing cervical checks while I was 0:01:19.760 --> 0:01:22.800 in labor, the doctor told me that he was feeling 0:01:22.800 --> 0:01:24.600 what he thought was going to be a nine pound baby, 0:01:24.600 --> 0:01:26.880 and I said, excuse me, because I had no idea 0:01:26.880 --> 0:01:28.199 I was going to have that big of a baby, 0:01:28.240 --> 0:01:31.160 like I had even asked. And I did fail my 0:01:31.160 --> 0:01:33.640 first gluecose check when we were doing them during pregnancy, 0:01:33.640 --> 0:01:36.520 but I passed the second three hour test, so they 0:01:36.520 --> 0:01:39.839 weren't really concerned. I was never diagnosed with gestational diabetes, 0:01:40.280 --> 0:01:43.880 so you can imagine my surprise. You know, I'm dilating 0:01:43.959 --> 0:01:47.440 and I'm getting an epidural and everything was going really normal. 0:01:48.000 --> 0:01:50.480 I pushed for almost four hours and I started just 0:01:50.480 --> 0:01:53.760 getting really fatigued. My epidural was kind of wearing off 0:01:53.760 --> 0:01:55.639 and it wasn't really working that well, so the doctor 0:01:55.640 --> 0:01:58.440 suggested setting up for a vacuusist delivery, which is where 0:01:58.440 --> 0:02:01.080 they literally use a suction cup to suctionto the baby's 0:02:01.080 --> 0:02:03.400 head to help you pull them out, and there's some 0:02:03.440 --> 0:02:05.160 complications that can come with that, so you know, they 0:02:05.160 --> 0:02:07.200 brought in some extra hands and it was a little 0:02:07.280 --> 0:02:10.440 nerve racking, and I was actually able to push her 0:02:10.480 --> 0:02:13.400 out on my very last push before they were going 0:02:13.480 --> 0:02:15.560 to start the vacuumsist. Everybody was all in their sterile 0:02:15.600 --> 0:02:17.399 field and everything, and I was able to push her out, 0:02:17.919 --> 0:02:20.240 and I ended up having a ten pound point zero 0:02:20.280 --> 0:02:23.840 one ounce baby girl who was a ninety six percentile 0:02:23.840 --> 0:02:27.240 for weight and ninety first percentile for height. And to 0:02:27.240 --> 0:02:28.880 this day, she's three and a half and she's still 0:02:28.919 --> 0:02:31.200 at the very top of her growth curve. She's probably 0:02:31.240 --> 0:02:34.720 almost forty five pounds and she's over three feet tall. 0:02:34.760 --> 0:02:38.120 She's a very tall girl. So we're gonna be really 0:02:38.160 --> 0:02:39.960 excited to see how tall she ends up the older 0:02:40.000 --> 0:02:42.360 she gets. But that's my birth story about how I 0:02:42.360 --> 0:02:46.840 almost had a vacuum cist and a surprise ten pound baby. 0:02:46.919 --> 0:02:47.079 Hi. 0:02:47.440 --> 0:02:50.640 I'm Nicole C. And this is my birth story. I 0:02:50.680 --> 0:02:54.520 had a pretty uneventful pregnancy. My water broke two days 0:02:54.560 --> 0:02:57.840 before my due date. I did everything I could to 0:02:57.880 --> 0:03:01.280 avoid birth drama. I chose the hospital for me, I 0:03:01.360 --> 0:03:05.120 researched my rights, I took the hospital's classes, I hired 0:03:05.160 --> 0:03:07.280 a doula, and I made a birth plan that I 0:03:07.280 --> 0:03:11.120 gave out to absolutely everyone. But none of that was enough. 0:03:11.160 --> 0:03:15.040 In the end, my baby was angled wrong. Even as 0:03:15.040 --> 0:03:17.800 I dilated and progressed, she would not ascend into the 0:03:17.800 --> 0:03:21.800 birth canal. Ultimately she began to struggle. As I later 0:03:21.919 --> 0:03:27.640 learned she had maconium aspiration syndrome or MIS. After twenty 0:03:27.639 --> 0:03:29.919 seven hours of labor, I had no choice put to 0:03:30.000 --> 0:03:34.519 undergo a sea section. Exhausted, scared and devastated, I was 0:03:34.639 --> 0:03:37.920 ripped away from my husband and doulah and wheeled into 0:03:37.920 --> 0:03:41.400 the operating room. During the sea section, I had my 0:03:41.480 --> 0:03:44.280 support people back, but still felt in the dark. I 0:03:44.320 --> 0:03:46.880 had no idea what was happening down there at any 0:03:46.880 --> 0:03:50.680 given stage, and was wholly unprepared for my current reality. 0:03:51.800 --> 0:03:55.720 After a few minutes, my baby, my Katie, emerged, purple 0:03:55.840 --> 0:03:58.640 and with an iron grip on the umbilic cord. There 0:03:58.760 --> 0:04:02.160 was no crying. They rushed her over to a separate 0:04:02.200 --> 0:04:05.000 area in the corner of the room. I had a 0:04:05.040 --> 0:04:07.119 video monitor where I could watch them work on her 0:04:07.680 --> 0:04:11.400 as my team continued to work on me. After a 0:04:11.480 --> 0:04:13.480 few minutes, she was rushed off to the nick You. 0:04:14.480 --> 0:04:18.120 My husband went with her. It was basically my worst 0:04:18.200 --> 0:04:22.560 nightmare of birth. Thankfully, after some initial help breathing in 0:04:22.680 --> 0:04:26.240 five days in the nick You, Katie came home, healthy, strong, 0:04:26.360 --> 0:04:30.160 and loud. She's nine months old now and absolutely thriving. 0:04:31.000 --> 0:04:33.440 Even once I knew she was okay, though, I continued 0:04:33.440 --> 0:04:36.440 to a grieve for the birth experience I imagined, for 0:04:36.480 --> 0:04:40.160 the initial bonding time i'd missed for my babies first cry, 0:04:40.320 --> 0:04:43.040 for the opportunity to share that experience with my husband. 0:04:44.200 --> 0:04:46.719 I felt like I failed, like I should have done more. 0:04:47.600 --> 0:04:50.800 I think the rhetoric around c sections definitely contributed to 0:04:50.839 --> 0:04:54.080 my birth trauma and feelings of failure. All I heard 0:04:54.080 --> 0:04:56.040 ahead of time about them was how they're done way 0:04:56.080 --> 0:04:58.839 too much these days, and how you should challenge doctors 0:04:58.839 --> 0:05:03.679 who recommend them or even consider switching obs. In many cases, 0:05:03.760 --> 0:05:08.240 sea section discussion was sidestepped at every turn. It was like, 0:05:08.839 --> 0:05:11.960 don't worry about that or think about it too much. 0:05:12.680 --> 0:05:15.640 It's super unlikely you'll need one, and it's best not 0:05:15.680 --> 0:05:18.960 to scare yourself thinking about it, as if I was 0:05:19.000 --> 0:05:21.800 some delicate flower wholly id equipped to hear anything that 0:05:21.920 --> 0:05:26.320 wasn't sunshine and rainbows instead of an adult human who 0:05:26.520 --> 0:05:29.760 best case scenario was about to go through vaginal labor 0:05:29.800 --> 0:05:33.760 and delivery. I wish I had fought through the patronizing rhetoric, 0:05:34.320 --> 0:05:37.880 did more sea section research, and prepared myself for any possibility. 0:05:38.760 --> 0:05:41.640 Knowledge is empowering. Just as fed is best in the 0:05:41.640 --> 0:05:45.200 breastfeeding versus formula discussion, safe and healthy is best in 0:05:45.200 --> 0:05:50.040 the vaginal delivery versus sea section discussion. Every case, every 0:05:50.080 --> 0:05:53.440 birthing parent, and every baby is different. Every route to 0:05:53.480 --> 0:05:56.640 birth is valid. We all did the hardest thing. Don't 0:05:56.680 --> 0:06:00.320 let anybody, even your own brain tell you field. 0:06:46.600 --> 0:06:49.120 Thank you all so much for sharing your stories with us. 0:06:49.240 --> 0:06:52.200 It really truly means the world. And thank you to 0:06:52.440 --> 0:06:55.039 everyone who submitted a first hand account. We really did 0:06:55.040 --> 0:06:58.360 read each and every one of them, and we feel 0:06:58.760 --> 0:07:02.120 honored like it feels truly unbelievable and in the best 0:07:02.160 --> 0:07:05.320 way possible that so many people reached out to us, 0:07:05.680 --> 0:07:08.440 and we tried to include as many stories as we could, 0:07:08.520 --> 0:07:12.160 and so throughout this episode and the next episode, the 0:07:12.240 --> 0:07:15.200 last episode in our series, you will hear more first 0:07:15.200 --> 0:07:15.840 hand accounts. 0:07:15.920 --> 0:07:19.120 Yeah, thank you, seriously, so much to every single one 0:07:19.120 --> 0:07:21.640 of you for writing in. So many of you sent 0:07:21.720 --> 0:07:23.960 in your stories that you recorded that we weren't able 0:07:23.960 --> 0:07:27.760 to include, and we we are eternally grateful. They really 0:07:27.760 --> 0:07:29.160 do mean the world to us and we listened to 0:07:29.200 --> 0:07:30.720 and read every single one. 0:07:30.560 --> 0:07:38.000 So thank you eternally grateful. Is yeah. Yeah, Hi, I'm. 0:07:37.920 --> 0:07:39.680 Erin Welsh and I'm erin alman. 0:07:39.520 --> 0:07:41.960 Update and this is this podcast will kill. 0:07:41.840 --> 0:07:46.120 You, coming to you from the exactly right studios to 0:07:46.280 --> 0:07:51.080 record the third episode about pregnancy I know in our 0:07:51.120 --> 0:07:52.160 four episode series. 0:07:52.920 --> 0:07:56.120 It's been really fun so far. I've loved it. And 0:07:56.320 --> 0:07:58.360 the fact that we're doing this on video is really 0:07:58.520 --> 0:08:02.360 cool too because we get some props, yes, which is 0:08:02.480 --> 0:08:05.680 really really fun. So if you are like wanting to 0:08:05.720 --> 0:08:09.520 see what's going on when we're talking, which if you don't, 0:08:09.560 --> 0:08:12.680 that's okay too, but if you do, head to YouTube. 0:08:12.400 --> 0:08:15.040 Head to YouTube. I have some really good props for 0:08:15.080 --> 0:08:17.720 this episode, guys. I made them myself. 0:08:19.000 --> 0:08:21.560 The last episode two tennis ball. 0:08:21.760 --> 0:08:23.440 Yeah, that was the first episode. 0:08:24.160 --> 0:08:24.400 I know. 0:08:24.600 --> 0:08:25.280 It was a lot. 0:08:25.480 --> 0:08:30.520 Yeah my mind, it was great. Oh the placenta ye, yeah, 0:08:30.560 --> 0:08:31.120 that was good. 0:08:31.280 --> 0:08:34.199 Okay, So it's going to be a fun day today. 0:08:35.559 --> 0:08:37.719 And before we get into the episode, we want to 0:08:37.760 --> 0:08:40.920 share a few words about what these four episodes will cover. 0:08:41.000 --> 0:08:44.040 More broadly, and if you've already tuned into our first 0:08:44.160 --> 0:08:46.200 or second episode in this series, this is all going 0:08:46.240 --> 0:08:48.360 to sound familiar to you. But in case this is 0:08:48.360 --> 0:08:51.600 your first time tuning in, Welcome and we've got a 0:08:51.640 --> 0:08:54.679 few things that we want to share. So we're going 0:08:54.760 --> 0:08:57.000 to talk about what we will cover in each of 0:08:57.040 --> 0:09:00.280 these episodes, the language that we'll be using, and our 0:09:00.360 --> 0:09:03.920 overall goals with creating this series. So we decided early 0:09:03.960 --> 0:09:07.280 on to dedicate four episodes to cover pregnancy, one for 0:09:07.320 --> 0:09:11.760 each trimester, which is like very few episodes for such 0:09:11.800 --> 0:09:16.000 a tremendously huge topic. And yeah, we realized very early 0:09:16.040 --> 0:09:17.200 on that we're not going to be able to cover 0:09:17.240 --> 0:09:20.280 everything that we would possibly want to with pregnancy, and 0:09:20.320 --> 0:09:23.600 so throughout researching for these episodes, we started to jot 0:09:23.679 --> 0:09:25.360 down like, oh, we want to cover this in a 0:09:25.360 --> 0:09:28.000 future episode and cover that, And so if there are 0:09:28.040 --> 0:09:32.360 topics that you want more information on, please reach out. 0:09:32.520 --> 0:09:35.280 We'll add them to our list, our ever growing list, 0:09:35.480 --> 0:09:38.360 and we will be covering more pregnancy related topics in 0:09:38.400 --> 0:09:38.840 the future. 0:09:38.960 --> 0:09:42.800 Yeah, for sure. Yeah, this series has not, and it 0:09:42.920 --> 0:09:46.320 will not, by the end, answer every single question that 0:09:46.360 --> 0:09:49.440 you could have about pregnancy, or cover every experience that 0:09:49.480 --> 0:09:53.319 a person might have during their pregnancy, in large part 0:09:53.320 --> 0:09:56.560 because pregnancy is such an individual experience, as you heard 0:09:56.559 --> 0:09:59.120 from all of our first hand accounts. But what we 0:09:59.160 --> 0:10:01.480 aim to do with this whole series is take you 0:10:01.559 --> 0:10:04.800 through some of the broad changes that people might experience 0:10:04.880 --> 0:10:08.560 during pregnancy, childbirth, which is what we're talking about today, 0:10:08.880 --> 0:10:11.920 and the postpartum period, which will be next week's episode, 0:10:12.240 --> 0:10:15.520 and then also explore some of the historical and evolutionary 0:10:15.600 --> 0:10:19.760 aspects of pregnancy and childbirth. So each episode thus far 0:10:19.920 --> 0:10:24.560 has roughly corresponded to each trimester, very roughly, very roughly. 0:10:26.360 --> 0:10:29.679 In our first episode we covered how you even know 0:10:29.720 --> 0:10:33.240 whether or not you're pregnant, what that means, and what's 0:10:33.280 --> 0:10:35.640 happening in very early embryonic development. 0:10:36.080 --> 0:10:39.800 And our most recent episode, last episode, our second episode, 0:10:40.240 --> 0:10:44.280 we talked about the amazing organ that is the placenta. 0:10:44.559 --> 0:10:45.920 We love it. Do you love it? 0:10:45.960 --> 0:10:46.120 Now? 0:10:46.160 --> 0:10:48.240 Have you listened to that episode? You? 0:10:48.360 --> 0:10:49.560 Once you do, you will love it. 0:10:49.600 --> 0:10:51.959 You will love it. I feel confident in that. Absolutely 0:10:52.840 --> 0:10:53.679 pretty phenomenal. 0:10:54.720 --> 0:10:56.920 And then we also talked about some of these broad 0:10:57.000 --> 0:11:00.800 system body changes that happen during pregnancy and by system, 0:11:01.280 --> 0:11:04.920 and including focusing on some complications that can arise. 0:11:05.120 --> 0:11:07.679 Which I guess might make you not like the placenta 0:11:07.840 --> 0:11:08.960 a little bit too. 0:11:09.240 --> 0:11:11.920 It's a complicated you know, we have complicated feelings about 0:11:11.920 --> 0:11:15.760 the placenta, but we also appreciate its amazingness. 0:11:15.760 --> 0:11:16.600 It's amazingness. 0:11:16.640 --> 0:11:16.920 Yeah. 0:11:16.920 --> 0:11:21.560 Definitely, today's episode, which we're very excited about, will focus 0:11:21.600 --> 0:11:25.240 on childbirth itself, so labor and different modes of delivery 0:11:25.400 --> 0:11:28.760 and the history of the cesarean section air in. 0:11:28.960 --> 0:11:35.120 Gosh, there is so much to cover, literally, so exciting. Yeah, yeah, Okay. 0:11:35.120 --> 0:11:38.000 Our fourth episode, which is next week and it's our 0:11:38.000 --> 0:11:41.800 season finale, This will be about the concept of the 0:11:41.840 --> 0:11:46.760 fourth trimester, which is a really fascinating topic, and so 0:11:46.800 --> 0:11:48.840 we're going to be exploring some of the changes that 0:11:48.840 --> 0:11:53.240 can happen after pregnancy and talking's big picture history of 0:11:53.320 --> 0:11:57.480 how we moved childbirth from the home to hospital and 0:11:57.520 --> 0:11:59.439 some of the consequences of that. 0:12:00.679 --> 0:12:03.479 We intend for all of these episodes to be inclusive 0:12:03.600 --> 0:12:07.000 of all families, and we recognize that not everyone who 0:12:07.080 --> 0:12:10.840 experiences pregnancy identifies as a woman, so we try as 0:12:10.920 --> 0:12:12.760 much as we can in all of these episodes to 0:12:12.840 --> 0:12:16.240 use gender neutral language such as pregnant person, while at 0:12:16.280 --> 0:12:18.440 the same time we recognize that much of what we 0:12:18.480 --> 0:12:22.000 discuss when it comes to medical bias during pregnancy and childbirth, 0:12:22.160 --> 0:12:25.280 historically and in present day, is a result of gender 0:12:25.320 --> 0:12:28.920 discrimination and racism. So in those context we may also 0:12:29.000 --> 0:12:31.880 use the term woman or women, and throughout these episodes 0:12:31.880 --> 0:12:34.560 will be using terms like mother or maternal and paternal 0:12:34.640 --> 0:12:36.360 as these are what are used in the scientific and 0:12:36.400 --> 0:12:37.240 medical literature. 0:12:37.880 --> 0:12:40.559 We also want to acknowledge that there is no such 0:12:40.640 --> 0:12:44.480 thing as a normal pregnancy, not just one. There's not 0:12:44.679 --> 0:12:46.960 just one, there's not just one textbook example of right, 0:12:47.080 --> 0:12:49.839 this is how a pregnancy should go. But we also 0:12:49.960 --> 0:12:54.400 want to provide a baseline for the expected changes that happen, 0:12:54.480 --> 0:12:58.480 the expected physiologic and anatomic changes, so that we can 0:12:58.600 --> 0:13:01.720 understand when things is kind of maybe go outside of 0:13:01.760 --> 0:13:04.079 those boundaries and then what happens. And this kind of 0:13:04.120 --> 0:13:07.360 helps us to understand what complication actually means. 0:13:07.200 --> 0:13:13.480 Right exactly. Okay, there's a lot o disclaimers and information and. 0:13:13.760 --> 0:13:17.600 Thanks for thanks for sticking with us. 0:13:17.720 --> 0:13:19.360 I'm really excited about today. 0:13:19.400 --> 0:13:22.760 But first but first I almost forgot er. I was like, 0:13:22.880 --> 0:13:23.760 let's get started. 0:13:24.760 --> 0:13:26.280 It's quarantining that it is. 0:13:26.880 --> 0:13:28.120 Well, what are we drinking this week? 0:13:28.120 --> 0:13:30.559 We're drinking the same thing. We are great expected. We're 0:13:30.600 --> 0:13:34.000 not actually drinking it right now, but we have drunk it. 0:13:34.000 --> 0:13:35.000 It is so good. 0:13:35.120 --> 0:13:37.400 It is better than we expected. 0:13:38.360 --> 0:13:41.600 We can't reveal our secrets, our lack of confidence and 0:13:41.640 --> 0:13:42.880 our recipe making. 0:13:44.200 --> 0:13:47.640 It is very good. And we made a plusy burta 0:13:48.080 --> 0:13:53.959 with BlackBerry ginger Ale Minn. There's a video on YouTube. 0:13:54.120 --> 0:13:56.400 Was making it, which was very fun to make. 0:13:57.000 --> 0:13:58.040 It was really fun. 0:13:58.200 --> 0:14:01.360 It was really fun, and George to hard Stark provided 0:14:01.400 --> 0:14:05.040 a wonderful quarantine eye for us to go with this episode. 0:14:05.080 --> 0:14:08.600 So that is available on YouTube teeny it has. 0:14:08.520 --> 0:14:09.040 A name now. 0:14:09.120 --> 0:14:11.320 It's very cute. Oh my god, it's so much fun. 0:14:11.679 --> 0:14:12.320 It's really fun. 0:14:12.440 --> 0:14:14.640 Yeah, So you can find recipes. You can find those 0:14:14.720 --> 0:14:17.959 videos on YouTube, and we'll also have recipes on our 0:14:18.080 --> 0:14:20.640 social media, so make sure you're following us there as 0:14:20.640 --> 0:14:22.920 well as our website. This podcast will kill you dot 0:14:22.920 --> 0:14:23.640 com the. 0:14:23.480 --> 0:14:25.200 Third time and we sent it to me. 0:14:25.280 --> 0:14:26.800 I can say it's on our website. 0:14:26.960 --> 0:14:30.360 Okay, ready, on our website, this podcast will kill You 0:14:30.400 --> 0:14:32.920 dot com. You can find incredible things such as merch 0:14:33.000 --> 0:14:35.680 You can find links to our bookshop dot org affiliate account, 0:14:35.680 --> 0:14:38.560 and our Goodreads list, which Aaron Walsh curates. You can 0:14:38.560 --> 0:14:41.000 find transcripts from each and every one of our episodes. 0:14:41.040 --> 0:14:46.040 You can find our Bloodmobiles who does the music, every recovery, 0:14:46.160 --> 0:14:49.960 Thank you Panicked. You can find a contact us form 0:14:50.080 --> 0:14:53.600 and a first hand account form. 0:14:53.640 --> 0:14:54.920 There's probably more. 0:14:55.000 --> 0:14:56.600 All of the sources from each and every one of 0:14:56.600 --> 0:14:57.160 our episodes. 0:14:57.240 --> 0:14:59.200 Yeah, there, and there might be more. Tell us what 0:14:59.240 --> 0:15:01.280 we missed. Go check out our website. 0:15:01.360 --> 0:15:04.680 Go check out our website. Like what you meant me? 0:15:04.840 --> 0:15:06.960 And I was like, I don't know what I meant, Darren. 0:15:08.800 --> 0:15:11.000 This podcast will kill You dot dot com. 0:15:11.400 --> 0:15:13.880 Also a thing I always forget to do is thank 0:15:13.960 --> 0:15:17.440 you to everyone who has rated and reviewed us on 0:15:17.520 --> 0:15:20.120 Apple Podcasts or Spotify or wherever you like to listen. 0:15:20.200 --> 0:15:22.000 If you haven't and you want to take a minute 0:15:22.040 --> 0:15:24.160 to do that, we'd really appreciate it because it helps 0:15:24.240 --> 0:15:28.080 us out. Thanks for listening. Thanks, Let's stop talking so 0:15:28.120 --> 0:15:29.280 that we can start talking. 0:15:30.200 --> 0:15:33.400 I love that plan. Let's take a quick break and 0:15:33.440 --> 0:15:34.720 then we'll really get started. 0:15:34.800 --> 0:15:53.360 Okay, Hi, I'm Laura, and this is my pregnancy story. 0:15:53.600 --> 0:15:56.520 To begin, we've got to rewind briefly to April twenty eighteen. 0:15:57.000 --> 0:16:00.560 I was twenty seven and diagnosed with her too positive cancer. 0:16:01.280 --> 0:16:03.000 I didn't really have the time or funds to do 0:16:03.080 --> 0:16:05.800 any fertility preservation, so I opted to take a monthly 0:16:05.840 --> 0:16:08.240 shot to try to perserve my fertility, which put me 0:16:08.320 --> 0:16:11.360 into essentially early menopause. I did chem out through the 0:16:11.360 --> 0:16:13.880 summer and fall, and then opted for a double mastectomy 0:16:13.960 --> 0:16:16.400 that October. I got the news from my doctor that 0:16:16.440 --> 0:16:19.480 Halloween that I was cancer free. Part of me sometimes 0:16:19.560 --> 0:16:22.080 wishes I'd kept my breast tissue, but ultimately I wanted 0:16:22.080 --> 0:16:24.160 to be here for any future children and not worry 0:16:24.200 --> 0:16:27.960 about a recurrence, especially given my family history. Fast forward 0:16:28.000 --> 0:16:30.360 to October of twenty twenty one, we're in the thick 0:16:30.400 --> 0:16:33.000 of COVID. I found out I was pregnant. I didn't 0:16:33.040 --> 0:16:36.040 have the typical pre pregnancy symptoms like sore breasts that 0:16:36.120 --> 0:16:38.400 prompt some people to take a test. I had some 0:16:38.480 --> 0:16:40.840 mild nausea and was so tired, and my period was 0:16:40.880 --> 0:16:42.840 a little late, so I took a test and it 0:16:42.880 --> 0:16:46.240 was super positive. Other than the morning sickness that went 0:16:46.280 --> 0:16:48.960 away sometime during my second trimester. Luckily, I had a 0:16:49.000 --> 0:16:51.600 really smooth pregnancy, and I felt my most beautiful during 0:16:51.640 --> 0:16:54.240 that time. Funny enough, I didn't get any of the 0:16:54.280 --> 0:16:57.200 stereotypical cravings of pickles and peanut butter or other weird 0:16:57.200 --> 0:17:00.360 food concoctions, but I really wanted a turkey sat and 0:17:00.360 --> 0:17:03.360 fruits and veggies. Honestly, I've never eaten so healthy in 0:17:03.360 --> 0:17:06.480 my life. Along the way, I encountered some judgment from 0:17:06.480 --> 0:17:09.439 people when I requested no breastfeeding supplies at my baby shower. 0:17:09.680 --> 0:17:12.040 For those that didn't know I didn't have real boobs anymore, 0:17:12.160 --> 0:17:14.000 it didn't make sense to them why I wouldn't at 0:17:14.080 --> 0:17:16.879 least try to breastfeed my baby. So that's sort of 0:17:16.920 --> 0:17:19.080 one thing I wish I could bond with other moms over, 0:17:19.320 --> 0:17:22.600 but ultimately I'm happy with my decision. So now it's 0:17:22.680 --> 0:17:25.760 July fifth, twenty twenty two. I'm thirty nine weeks pregnant. 0:17:25.800 --> 0:17:28.200 It's eleven PM, and i'd finally laid down for bed 0:17:28.240 --> 0:17:31.040 after nesting and cleaning my whole house that day. Even 0:17:31.119 --> 0:17:33.720 being sick with COVID, I just tested positive the day 0:17:33.760 --> 0:17:36.240 before I got up because I felt the arch to pee, 0:17:36.280 --> 0:17:38.720 and in true dramatic fashion, just like the movies, my 0:17:38.800 --> 0:17:42.080 water broke in a huge gush. Of course, my hospital 0:17:42.080 --> 0:17:45.200 bag wasn't packed, so I frantically finished packing and headed 0:17:45.240 --> 0:17:48.000 for the hospital. I was checked in pretty immediately and 0:17:48.040 --> 0:17:50.760 in a labor room by midnight. Because both my partner 0:17:50.800 --> 0:17:52.879 and I were positive for COVID, we were quarantined to 0:17:52.920 --> 0:17:55.680 our room and we were in masks the whole time. 0:17:55.880 --> 0:17:57.680 Side note, it's not easier for fun to breed through 0:17:57.680 --> 0:17:59.800 contractions with a mask on. I did my whole labor 0:18:00.200 --> 0:18:03.040 way for nearly thirty hours. Then it was time to push, 0:18:03.240 --> 0:18:05.800 and it's not fast like the movies. I pushed for 0:18:05.840 --> 0:18:08.520 almost four hours, which felt like an eternity. Masks on, 0:18:08.720 --> 0:18:11.680 hard to breathe. My daughter was born in two thirty 0:18:11.680 --> 0:18:13.920 eight in the morning on July seventh. She's my lucky 0:18:14.000 --> 0:18:16.840 seven to seven post cancer miracle baby. Today, my daughter's 0:18:16.840 --> 0:18:19.080 two and a half and one wild redhead little girl. 0:18:19.160 --> 0:18:23.560 I'm six years cancer free and we're living our best life. 0:18:24.119 --> 0:18:26.159 My name is Jaden and I found out I was 0:18:26.200 --> 0:18:29.800 pregnant in January of twenty twenty four. Overall, it was 0:18:29.840 --> 0:18:33.520 a very normal pregnancy. However, at week twenty I started 0:18:33.520 --> 0:18:35.359 to measure on the high end of normal for my 0:18:35.400 --> 0:18:39.800 amniotic fluid. My baby was measuring large, so we decided 0:18:39.840 --> 0:18:42.840 to set an induction date for thirty nine weeks. However, 0:18:42.960 --> 0:18:45.320 a week after that, there was a large increase in 0:18:45.400 --> 0:18:48.840 amniotic fluid, so we elected to schedule an induction for 0:18:48.880 --> 0:18:52.840 thirty eight weeks for polyhydromnios. The biggest worry was that 0:18:52.880 --> 0:18:55.199 I would go into labor naturally and there was a 0:18:55.240 --> 0:18:59.400 possibility of umbilical cord prolapse, which would then be an emergency. 0:19:00.160 --> 0:19:02.879 After my induction was started, I made no progress for 0:19:02.920 --> 0:19:07.720 about fourteen hours because there was so much fluid, my 0:19:07.760 --> 0:19:10.399 baby was not able to exert enough pressure on my 0:19:10.440 --> 0:19:14.360 cervix to help advance labor. My waters were then manually 0:19:14.400 --> 0:19:17.560 broken and my labor started to progress. I labored that 0:19:17.600 --> 0:19:20.399 way for eighteen hours and was finally ready to push. 0:19:21.040 --> 0:19:23.440 I pushed for one and a half hours and made 0:19:23.480 --> 0:19:26.560 some great progress. The next one and a half hours, 0:19:26.840 --> 0:19:29.199 I made no progress and my baby was still at 0:19:29.240 --> 0:19:32.760 the same position. Because of this failure to descend, and 0:19:32.840 --> 0:19:35.679 she was not yet in distress, we decided to go 0:19:35.760 --> 0:19:40.080 in for a sea section. The sea section was uncomplicated, 0:19:40.119 --> 0:19:42.520 and my baby girl was born at thirty eight weeks 0:19:42.560 --> 0:19:47.040 and two days at seven pounds fifteen ounces. She is 0:19:47.119 --> 0:19:51.720 now a very healthy four and a half month old. 0:20:16.320 --> 0:20:21.280 Childbirth and humans is difficult. It is long, It is painful, 0:20:21.760 --> 0:20:25.400 It carries with its significant risks to mother and baby. 0:20:25.440 --> 0:20:28.919 After birth comes with its own set of challenges. Caring 0:20:28.960 --> 0:20:32.360 for a newborn that is largely helpless can be overwhelming. 0:20:32.520 --> 0:20:37.080 Largely is an understatement, and they are entirely, entirely helpless. 0:20:37.960 --> 0:20:42.119 And these human experiences are exceptional compared to most, but 0:20:42.280 --> 0:20:44.879 not all, other mammalian or primate species. 0:20:45.680 --> 0:20:46.680 Why Why? 0:20:46.720 --> 0:20:49.879 What did we do to deserve this? Why is it 0:20:50.000 --> 0:20:53.000 like this? Looking at the fossil record may give us 0:20:53.040 --> 0:20:55.200 part of the answer. So the story goes that our 0:20:55.280 --> 0:20:59.200 hominine ancestors evolved by pedalism, being able to move around 0:20:59.200 --> 0:21:03.320 on two feet rather than four Why? Just keep going why? 0:21:03.359 --> 0:21:03.560 Why? 0:21:04.320 --> 0:21:07.199 But why? Because maybe it allowed us to live in 0:21:07.240 --> 0:21:10.879 more varied habitats or acquire more varied food sources, or 0:21:10.920 --> 0:21:13.800 it'll it freed up our hands for tool use. There's 0:21:13.840 --> 0:21:17.399 many different ideas out there, but regardless of the reason, 0:21:17.560 --> 0:21:20.240 the shift to walking on two legs could only happen 0:21:20.440 --> 0:21:23.040 because of changes in the shape of our pelvis. 0:21:23.040 --> 0:21:25.639 Our pelvis are pelvis. 0:21:25.520 --> 0:21:28.879 And at some point after these anatomical changes, head size 0:21:28.960 --> 0:21:31.800 in our ancestors also grew as we got. 0:21:31.640 --> 0:21:36.280 Smarter after these pelvis changes, after the pelvis changes, and 0:21:36.320 --> 0:21:39.399 so that led to neonates with heads and bodies that 0:21:39.440 --> 0:21:42.240 were basically at the limit of the birth canal. 0:21:43.280 --> 0:21:45.520 But there was a cap on this growth in head 0:21:45.520 --> 0:21:49.159 and body size. Prenatally, our pelvises could only change up 0:21:49.200 --> 0:21:53.159 to a certain point. Past that point, additional alterations could 0:21:53.720 --> 0:21:56.800 maybe compromise our bipedalism. 0:21:56.400 --> 0:21:58.800 Affect our fitness somehow affect our fitness. 0:21:58.880 --> 0:22:01.399 Yeah, I mean it's like could if we needed to 0:22:01.440 --> 0:22:03.720 the pelvis to expand then we would lose the ability 0:22:03.760 --> 0:22:05.879 to like the balance and the movement and the running. 0:22:05.920 --> 0:22:06.080 You know. 0:22:06.119 --> 0:22:10.119 It's like, yeah, trade offs, you always come back, and 0:22:10.119 --> 0:22:13.640 they always come back to it. And so instead evolution 0:22:13.840 --> 0:22:17.040 had to think outside of the box, shifting some parts 0:22:17.119 --> 0:22:20.040 of fetal growth to take place outside of the womb 0:22:20.160 --> 0:22:23.280 rather than in it, such as brain growth and neurodevelopment. 0:22:23.440 --> 0:22:27.520 I love thinking of evolution in this very inaccurate way 0:22:27.520 --> 0:22:29.560 of giving it like agency. Yeah. 0:22:29.600 --> 0:22:32.560 Oh yeah, no, I know. I think evolutionary religis are like, 0:22:32.880 --> 0:22:37.720 what are you doing? Evolution does not have agency, It's yeah, yeah, 0:22:37.800 --> 0:22:39.679 but I mean that's that is how I'm going to 0:22:39.680 --> 0:22:41.680 present I love so yeah, that's you know. 0:22:41.840 --> 0:22:44.040 It's a good way to just think, like in your 0:22:44.080 --> 0:22:46.880 mind frame it it's just yeah, it's. 0:22:46.800 --> 0:22:49.159 The end result is the same, this is what happens. 0:22:51.440 --> 0:22:55.000 And but this long period of neurodevelopment after birth might 0:22:55.040 --> 0:22:58.000 be what allows us to learn more and have flexibility 0:22:58.160 --> 0:23:01.480 in our learning. At birth, the brain size of a 0:23:01.520 --> 0:23:04.600 neonate is about twenty five percent of what it'll be 0:23:04.640 --> 0:23:08.359 as an adult. Wow, which is the smallest neonate adult 0:23:08.359 --> 0:23:09.920 proportion of all primates. 0:23:09.960 --> 0:23:14.760 Like it is, oh, of all primate of all primates. Okay, interesting? Interesting, Yeah, 0:23:14.760 --> 0:23:17.760 so other primates, their brains come out already bigger. 0:23:17.560 --> 0:23:20.600 Already bigger compared to their adult brain size. Okay, interesting, 0:23:21.359 --> 0:23:25.160 And compared to other primates, our newborns seem especially helpless. 0:23:25.200 --> 0:23:28.120 You know, we can't cling, we can't hold our heads up, 0:23:28.359 --> 0:23:31.880 we can't coordinate our limbs, we can't even crawl for months, 0:23:31.920 --> 0:23:33.160 I know months. 0:23:33.160 --> 0:23:35.159 And you think of like the baby monkeys who can 0:23:35.240 --> 0:23:38.040 just go right and hold on so well, yeah, and 0:23:38.080 --> 0:23:41.200 ours can just do this palmer grass reflex and you're like. 0:23:41.280 --> 0:23:45.720 Thank you, good job, you're working hard. You know, we 0:23:45.880 --> 0:23:50.040 do work hard. True. Some researchers suggest that to match 0:23:50.080 --> 0:23:53.399 the developmental stage of other apes right after birth, humans 0:23:53.440 --> 0:23:57.639 would have gestations seven to twelve months, longer than our 0:23:57.720 --> 0:23:59.040 nine month gestation. 0:23:59.240 --> 0:24:00.000 No, thank you. 0:24:00.080 --> 0:24:03.320 There is some current debate on this point, like, yeah, 0:24:03.320 --> 0:24:07.520 there's nuance, there's papers, you can dig into it. Evolution 0:24:07.640 --> 0:24:10.320 seems to have handed us this trade off where we 0:24:10.359 --> 0:24:12.960 get to have these big brains, but we're also faced 0:24:13.000 --> 0:24:15.800 with the challenges of childbirth, where the neonate is at 0:24:15.800 --> 0:24:19.159 the capacity of our birth canal and requires round the 0:24:19.200 --> 0:24:23.399 clock care for months after birth. This is a precarious 0:24:23.400 --> 0:24:27.080 balance to strike with extremely high costs if things go awry. 0:24:27.880 --> 0:24:30.680 How have we dealt with this over human history? 0:24:30.760 --> 0:24:31.080 Tell me? 0:24:31.480 --> 0:24:32.720 One way is through cooperation. 0:24:33.119 --> 0:24:36.800 Oh, I know, humans and our cooperation and we are 0:24:36.920 --> 0:24:37.639 capable of it. 0:24:38.800 --> 0:24:42.560 Sorry, we were capable of it. No, just kidding. I 0:24:42.640 --> 0:24:46.400 hope our hominin ancestors, like many of our present day 0:24:46.440 --> 0:24:51.960 primate relatives, exhibited cooperative breeding and culture. Did our helpless 0:24:51.960 --> 0:24:55.280 babies lead us to evolve this cooperation or did we 0:24:55.280 --> 0:24:58.080 already have this type of culture and that allowed for 0:24:58.119 --> 0:25:01.600 the evolution of more helpless babies. We don't know. We 0:25:01.720 --> 0:25:04.560 probably weren't to ever know that answer, But what is 0:25:04.640 --> 0:25:08.119 certain is that many societies today have lost that cooperative 0:25:08.200 --> 0:25:12.159 child rearing. Some researchers have suggested that we feel this 0:25:12.440 --> 0:25:16.400 helplessness in human infants so strongly because of the way 0:25:16.440 --> 0:25:19.960 that many of us experience child rearing in our modern society, 0:25:20.240 --> 0:25:23.280 often isolated with a burden of care falling to one 0:25:23.359 --> 0:25:27.359 or two people. This is far removed from how our 0:25:27.400 --> 0:25:31.000 ancestors would have experienced child rearing in a cooperative social group. 0:25:31.720 --> 0:25:35.200 Childbirth was the same way attended by other members of 0:25:35.240 --> 0:25:37.879 your group. Like who knows how long women have been 0:25:37.920 --> 0:25:41.160 assisting other women in childbirth. But one paper I read 0:25:41.200 --> 0:25:44.840 suggested that when our species developed language that helped to 0:25:44.880 --> 0:25:48.920 pave the way for assisted childbirth, we could communicate our pain, 0:25:49.480 --> 0:25:53.040 our needs, and then pass down the knowledge that we acquired. 0:25:53.119 --> 0:25:57.119 Oh interesting, Yeah, Today that kind of community involvement for 0:25:57.240 --> 0:25:59.879 child rearing seems more of a rarity. And when it 0:26:00.000 --> 0:26:03.440 it's just you or you and one other person continuously 0:26:03.520 --> 0:26:05.960 on call, to take care of a newborn. That may 0:26:06.000 --> 0:26:10.639 emphasize the never ending needs of that newborn. Hmm, okay. 0:26:10.640 --> 0:26:13.640 The second thing is how we've dealt with the dangers 0:26:13.680 --> 0:26:18.200 of childbirth historically. There's no disputing that labor and delivery 0:26:18.240 --> 0:26:21.919 can be extremely dangerous for both mother and baby, even 0:26:21.960 --> 0:26:26.119 with all of our modern medical advancements and technologies. Is 0:26:26.119 --> 0:26:29.359 that how it's always been? That's a really difficult question 0:26:29.400 --> 0:26:29.800 to answer. 0:26:29.800 --> 0:26:33.159 It turns out I have thought about this so so 0:26:33.160 --> 0:26:36.280 so much for so many years. Now. I know that 0:26:36.720 --> 0:26:38.320 I wish that we could know. 0:26:39.720 --> 0:26:43.240 We can know something, Okay, tell me. Yeah. So, the 0:26:43.400 --> 0:26:46.640 historical data on this subject are limited, to say the least, 0:26:46.680 --> 0:26:50.199 and they're complicated by several factors, including the effect that 0:26:50.320 --> 0:26:54.080 medicine has had on maternal and neonatal mortality, which is 0:26:54.560 --> 0:26:58.520 has not been always in a positive direction. For instance, 0:26:58.520 --> 0:27:01.600 in the nineteenth century, as more male physicians attended childbirth 0:27:01.640 --> 0:27:05.320 after receiving little if any education and obstetrics, as people 0:27:05.359 --> 0:27:08.840 moved to crowded cities, as more women gave birth in hospitals, 0:27:08.880 --> 0:27:13.240 infectious disease became a leading driver of maternal and perinatal mortality. 0:27:13.320 --> 0:27:16.159 Right, and we talk a lot about that in our episode. 0:27:15.640 --> 0:27:18.960 On Selvis and people fever. 0:27:19.200 --> 0:27:22.040 Yeah yeah, just like which episode was that, because I 0:27:22.080 --> 0:27:23.600 know we covered it in detail. 0:27:23.760 --> 0:27:26.760 A long time, but yeah, yeah, But the specter of 0:27:26.880 --> 0:27:31.680 infectious disease during childbirth maybe a more recent development, relatively speaking. 0:27:32.359 --> 0:27:34.200 Some researchers have suggested. 0:27:33.760 --> 0:27:36.960 That early in our evolutionary history, birth might not have 0:27:37.040 --> 0:27:41.320 been as dangerous, but following the agricultural revolution around twenty 0:27:41.359 --> 0:27:44.520 thousand years ago, there was more over nutrition, and then 0:27:44.600 --> 0:27:47.199 that could lead to babies with heads and bodies straining 0:27:47.200 --> 0:27:49.360 the limits of the birth canal interesting. 0:27:49.520 --> 0:27:50.879 So it used to just be that if we were 0:27:50.920 --> 0:27:54.400 limited by nutrition, then your huh, I mean maybe maybe maybe, 0:27:54.480 --> 0:27:54.920 who knows? 0:27:55.000 --> 0:27:58.240 Ok yeah, okay. The industrial revolution in the eighteenth and 0:27:58.359 --> 0:28:03.040 nineteenth centuries may have contributed to difficult childbirth in other ways, 0:28:03.280 --> 0:28:06.959 For instance, rickets caused by vitamin D deficiency cr vitamin 0:28:07.040 --> 0:28:11.119 D episode, but the rickets can often lead to skeletal 0:28:11.240 --> 0:28:14.080 changes that decreased pelvis size and made it even more 0:28:14.160 --> 0:28:17.439 challenging for a baby to go through birth canal. The 0:28:17.560 --> 0:28:22.439 WHO today roughly estimates that five percent of births with 0:28:22.600 --> 0:28:26.359 labor starting spontaneously develop complications. 0:28:25.880 --> 0:28:27.560 Okay, five percent percent. 0:28:28.040 --> 0:28:31.960 Birth records from a late eighteenth century midwife, Martha Ballard, 0:28:32.240 --> 0:28:34.480 the book The Diary of a Midwife It's based on 0:28:34.520 --> 0:28:39.240 her story is incredible, suggested that five point six percent 0:28:39.280 --> 0:28:41.480 of births that she attended were difficult. 0:28:41.680 --> 0:28:43.560 Interesting, that five. 0:28:43.520 --> 0:28:47.680 Percent number for difficult labor or delivery pops up elsewhere 0:28:47.680 --> 0:28:51.960 throughout the eighteenth and nineteenth centuries until medical intervention increased, 0:28:52.040 --> 0:28:56.080 at which point then difficult increase as well. And it's 0:28:56.120 --> 0:29:00.440 not clear what that five percent complications rate means maternal 0:29:00.520 --> 0:29:02.800 or neonatal mortality historically. 0:29:02.400 --> 0:29:05.400 How does it and what is different? What is defined right. 0:29:05.440 --> 0:29:10.280 Exactly requiring intervention? Then? What is requiring intervention? How do 0:29:10.320 --> 0:29:11.200 we make those decisions? 0:29:11.280 --> 0:29:11.480 Yeah? 0:29:11.960 --> 0:29:16.880 Yeah, but those historic numbers and often the ones today, 0:29:16.960 --> 0:29:21.440 these estimates don't necessarily capture post natal issues such as 0:29:21.480 --> 0:29:26.320 like prolapsed uterus or fistulas something like that, which can 0:29:26.360 --> 0:29:29.680 be you know, long term permanent changes that are you know, 0:29:29.800 --> 0:29:34.640 affect your morbidity over time. But what strikes me is 0:29:34.960 --> 0:29:38.520 how different that five percent number is compared to the 0:29:38.560 --> 0:29:41.080 c section rate, which here in the US is around 0:29:41.160 --> 0:29:45.720 thirty three percent high, not the highest. Brazil holds that title, 0:29:45.720 --> 0:29:49.160 with fifty four percent of births done by cesarean Private 0:29:49.160 --> 0:29:51.400 hospitals have an eighty four percent C section rate in 0:29:51.400 --> 0:29:52.960 Brazil eighty four percent. 0:29:53.440 --> 0:29:54.720 Eighty four percent. 0:29:55.000 --> 0:30:03.360 Yeah, wow, yeah, okay, keep going, Okay. Complications encompasses a 0:30:03.440 --> 0:30:06.440 wide range of things, but C sections are one of 0:30:06.480 --> 0:30:10.600 the most common medical interventions for complications that arise during 0:30:10.640 --> 0:30:14.280 labor and delivery. How did this procedure go from being 0:30:14.320 --> 0:30:17.080 a rarity to one of the most performed surgeries in 0:30:17.120 --> 0:30:20.040 the US and around the world. What period and all 0:30:20.160 --> 0:30:24.360 surgery right, including like tonsilectomies, appendectomy replacements? 0:30:24.400 --> 0:30:24.560 Right? 0:30:27.680 --> 0:30:31.320 How has our attitude towards c sections changed during that 0:30:31.400 --> 0:30:34.840 time from when it was like a rare thing to commonplace? 0:30:35.680 --> 0:30:38.040 Are we doing more C sections than we should be doing? 0:30:38.520 --> 0:30:40.280 How do we know the answer to that? 0:30:40.400 --> 0:30:40.680 Yeah? 0:30:40.720 --> 0:30:42.320 And so today I want to take us through the 0:30:42.360 --> 0:30:44.520 history of C sections to try to answer some of 0:30:44.560 --> 0:30:47.160 these questions. And I know that C sections are not 0:30:47.200 --> 0:30:49.880 a universal experience, and by talking about C sections, I 0:30:49.920 --> 0:30:53.280 am skipping over other important aspects of labor and delivery. 0:30:53.320 --> 0:30:56.160 But I think, yeah, you'll get there perfect. And I 0:30:56.160 --> 0:30:59.640 think they're an extremely important topic given how common they are. 0:31:00.040 --> 0:31:04.520 How much rhetoric there is surrounding sea sections and how 0:31:04.720 --> 0:31:07.680 and I think that going through their history can give 0:31:07.720 --> 0:31:11.400 us some insight into how medicine has treated pregnant women 0:31:11.520 --> 0:31:15.480 and viewed risk over time, what risk means, what it 0:31:15.520 --> 0:31:18.480 looks like. This is a nuanced topic with so much 0:31:18.480 --> 0:31:20.320 amazing scholarship out there, and so I just want to 0:31:20.320 --> 0:31:23.120 shout out a couple of sources at the beginning so 0:31:23.160 --> 0:31:25.200 that you know that there's so much more opportunity to 0:31:25.320 --> 0:31:28.480 learn more. So one book is called Cesarean Section and 0:31:28.560 --> 0:31:33.040 American History of Risk, Technology and Consequence. That's by Jacqueline Wolf. 0:31:33.320 --> 0:31:36.560 And another is called Invisible Labor, The Untold Story of 0:31:36.560 --> 0:31:40.120 the Cesarean Section by Rachel Summerstein. All right, I'll be 0:31:40.120 --> 0:31:44.520 ready to talk about I want to start off by 0:31:44.600 --> 0:31:48.880 describing what happens during a sea section step by step. 0:31:49.000 --> 0:31:49.560 Wonderful. 0:31:49.800 --> 0:31:53.120 So I'm quoting directly from Rachel Summerstein's Invisible Labor here 0:31:53.120 --> 0:31:55.000 because I thought it was just a phenomenal description and 0:31:55.040 --> 0:31:55.960 I was like, perfect. 0:31:55.800 --> 0:31:58.200 Every meds street listening that's about to start their obed 0:31:58.320 --> 0:31:59.480 an rotation is thrilled. 0:32:00.520 --> 0:32:06.000 Okay, you here we go quote an anesthesiologist or nurse 0:32:06.000 --> 0:32:10.360 anesthetist uses spinal anesthesia or an epidural to anesthetize a 0:32:10.440 --> 0:32:13.760 mother regionally. Then the surgeon uses a scalpel to cut 0:32:13.760 --> 0:32:17.520 open the abdomen above the mon's pubis, slicing through layers 0:32:17.520 --> 0:32:19.800 of skin and fat and the fascia that covers the 0:32:19.840 --> 0:32:23.760 abdominal muscles. The physician parts but does not cut the 0:32:23.840 --> 0:32:27.600 rectus abdominous muscles six pack with her hands. Then she 0:32:27.680 --> 0:32:30.720 cuts through the peritoneum, the layer of tissue that contains 0:32:30.840 --> 0:32:33.800 organs in the abdomen, as if in a tightly sealed bag. 0:32:34.320 --> 0:32:37.160 She moves the bladder aside to reach the uterus, making 0:32:37.240 --> 0:32:40.040 yet another incision to open it. She presses on the 0:32:40.120 --> 0:32:42.320 uterus to push out the baby, which is the source 0:32:42.400 --> 0:32:44.640 of the pressure sea section moms are told they might 0:32:44.680 --> 0:32:48.280 experience during the operation. Once the baby is born, the 0:32:48.320 --> 0:32:52.000 surgeon removes the uterus from the patient's body, sometimes lifting 0:32:52.000 --> 0:32:54.840 it out completely like a bowling ball, to so it closed. 0:32:55.320 --> 0:32:58.200 Then she sutures the other layers of the patient's abdominal 0:32:58.240 --> 0:33:02.120 wall and finally closes the topmost layer. End quote. 0:33:02.400 --> 0:33:04.400 Yep, yeah, wholly accurate. 0:33:04.160 --> 0:33:07.200 But like it's amazing how you just think like, I 0:33:07.200 --> 0:33:09.400 feel like most people don't know the step by step, 0:33:10.400 --> 0:33:12.480 which is what's being cut in what order, how do 0:33:12.520 --> 0:33:14.480 you get the placenta out, like all these different things. 0:33:14.680 --> 0:33:18.520 Yeah, yeah, So it's also an incredible thing to get 0:33:18.560 --> 0:33:21.640 to watch, yeah, experience and be a part of. Like 0:33:21.680 --> 0:33:25.120 it is really really fascinating and interesting and incredible. 0:33:25.680 --> 0:33:27.880 It's amazing. And so this is the way that most 0:33:27.920 --> 0:33:31.400 sea sections are done today, but this is not how 0:33:31.440 --> 0:33:34.800 they've always been done. The earliest record of sea sections 0:33:34.800 --> 0:33:37.040 that we have dates back over two thousand years. 0:33:37.800 --> 0:33:40.680 Wow. Yeah, I feel like those were not good ones. 0:33:41.280 --> 0:33:44.000 Well, the intention of sea section has changed a lot 0:33:44.000 --> 0:33:47.040 over time, so it's clear that from these early and 0:33:47.080 --> 0:33:50.600 then subsequent ancient descriptions that this procedure was done very 0:33:50.680 --> 0:33:53.520 rarely and only when the mother had died or was 0:33:53.560 --> 0:33:56.320 thought beyond saving. So it was mostly like a last 0:33:56.320 --> 0:33:59.080 ditch effort to save the baby or baptize the baby 0:33:59.120 --> 0:34:02.400 before it died, or as a crucial step to prepare 0:34:02.440 --> 0:34:05.080 the bodies for burial, so mother and baby were often 0:34:05.120 --> 0:34:07.760 buried separately, so that was sort of part of the steps. 0:34:08.800 --> 0:34:11.920 Those babies that did survive were often viewed as gods, 0:34:12.160 --> 0:34:16.279 as heroes, or as extremely blessed, which is behind the 0:34:16.320 --> 0:34:19.960 common misconception of where the cesarean got its name, because 0:34:19.960 --> 0:34:23.920 it's not Julious, not Julius Caesar. Yeah yeah, so a 0:34:24.440 --> 0:34:26.759 lot of stories go oh, the cesarian got its name 0:34:26.800 --> 0:34:29.600 from Julius Caesar, the Roman emperor who was born vs. Section. 0:34:29.760 --> 0:34:33.440 Not true as far as we understand. Most scholars think 0:34:33.480 --> 0:34:35.680 that the name actually comes from a royal law from 0:34:35.680 --> 0:34:37.880 ancient Rome that decreed that the body of a pregnant 0:34:37.880 --> 0:34:40.399 woman could not be buried until the fetus had been 0:34:40.400 --> 0:34:41.680 removed and buried separately. 0:34:41.840 --> 0:34:42.720 Oh okay. 0:34:43.640 --> 0:34:47.719 Up until the nineteenth century, really, cesareans remained exceedingly rare, 0:34:48.000 --> 0:34:51.120 only performed in extreme instances, and the mother's life took 0:34:51.160 --> 0:34:55.279 precedence over the babies. Shockingly, there are cases where both 0:34:55.320 --> 0:34:59.200 mother and baby survived, the first being either in Prague 0:34:59.200 --> 0:35:02.960 in the thirteen hundred or Switzerland in the fifteen hundreds. Wow, 0:35:03.040 --> 0:35:07.400 I know, I know, But overall that outcome was like 0:35:07.640 --> 0:35:11.000 very very rare. Mostly a cesarean was viewed as a 0:35:11.000 --> 0:35:15.280 success if the mother survived, regardless of the baby's status. 0:35:15.800 --> 0:35:19.080 This would remain the case well into the twentieth century. 0:35:19.360 --> 0:35:22.560 An important exception to. This is in the case of 0:35:22.680 --> 0:35:26.560 enslaved black women, often the physician would consult the enslaver 0:35:26.760 --> 0:35:29.279 to see whether they wanted to preserve the life of 0:35:29.360 --> 0:35:34.839 the mother or the baby's. Okay, anyone surviving a sea 0:35:34.840 --> 0:35:37.279 section was still so notable that it often made the 0:35:37.320 --> 0:35:40.399 history books, such as the case of Alice O'Neil, an 0:35:40.440 --> 0:35:44.600 Irish woman who had labored for twelve days until her 0:35:44.600 --> 0:35:48.839 midwife married Donnelly by her side. This was seventeen thirty eight, 0:35:49.160 --> 0:35:52.439 and then Mary, her midwife, was like, the only way 0:35:52.480 --> 0:35:55.120 to save Alice, Alice's baby had died during this long 0:35:55.200 --> 0:35:57.759 labor already was to do a sea section, and so 0:35:57.880 --> 0:36:01.720 Mary performed the sea section and Alice made a full recovery. 0:36:01.840 --> 0:36:04.360 In England, the first c section where a mother survived 0:36:04.360 --> 0:36:07.560 took place in seventeen ninety three, and in the US 0:36:07.640 --> 0:36:10.440 the year after, although this is somewhat disputed. In the 0:36:10.520 --> 0:36:13.520 US case, there was a woman named Elizabeth Bennett, which 0:36:13.560 --> 0:36:17.080 is also you're thinking Pride and Prejudice. Okay, yes, there was. 0:36:17.160 --> 0:36:20.560 This is before Pride and Prejudice came out, which is interesting. 0:36:20.719 --> 0:36:22.960 I mean, I don't think it's probably that uncommon of 0:36:22.960 --> 0:36:26.520 a name, but Elizabeth was going through a difficult labor 0:36:26.560 --> 0:36:29.200 at her log cabin home, and her husband, who was 0:36:29.239 --> 0:36:32.520 a doctor, had called another doctor over to help. But 0:36:32.640 --> 0:36:35.080 this other doctor threw his hands up after an attempted 0:36:35.120 --> 0:36:39.680 forceps delivery didn't work, and so Elizabeth's husband took matters 0:36:39.719 --> 0:36:42.240 into his own hands, made an incision, pulled out baby 0:36:42.239 --> 0:36:45.360 in placenta, allegedly took out the ovaries while he was 0:36:45.400 --> 0:36:47.319 there to be like, I'm not making sure this doesn't 0:36:47.320 --> 0:36:50.239 happen again, and stitched her back up. Wow, mom and 0:36:50.280 --> 0:36:54.680 baby made a fast recovery. Wow, allegedly allegedly. Yeah, it's 0:36:54.719 --> 0:36:57.080 a little embellished like the telling of it, so who 0:36:57.120 --> 0:36:58.960 knows if it's true. And I want us to take 0:36:59.000 --> 0:37:01.319 all of these milestone to the grain of salt, not 0:37:01.520 --> 0:37:04.920 because maybe they happened, maybe they didn't happen, but also 0:37:05.040 --> 0:37:08.920 because they probably weren't the first. Like most histories of medicine, 0:37:08.960 --> 0:37:12.399 the starring characters in the story of cesareans are white 0:37:12.440 --> 0:37:15.080 male physicians in Europe or in the US. But that's 0:37:15.120 --> 0:37:18.279 not the whole picture. It's likely that there were other 0:37:18.320 --> 0:37:22.319 midwives like Mary Donnelly out there over the centuries performing cesareans. 0:37:22.320 --> 0:37:24.840 They just didn't send their reports to a medical journal 0:37:24.920 --> 0:37:27.920 because they couldn't write, or they didn't view it as remarkable, 0:37:28.040 --> 0:37:31.960 or they knew that it wouldn't be accepted. Similarly, who 0:37:32.000 --> 0:37:35.759 knows how many cesareans had been performed around the world historically. 0:37:36.120 --> 0:37:39.600 In the eighteen eighties, a British physician named Robert Felcon 0:37:40.040 --> 0:37:43.520 wrote about his experience in Uganda where he observed cesarean 0:37:43.560 --> 0:37:47.120 sections being performed in the eighteen eighties. The surgery seemed 0:37:47.320 --> 0:37:51.000 not uncommon, was intended to save both mother and child, 0:37:51.480 --> 0:37:55.480 was often successful, and used antisepsis in pain treatment using 0:37:55.600 --> 0:37:56.359 banana line. 0:37:56.719 --> 0:37:58.000 Oh interesting. 0:37:58.280 --> 0:38:01.920 Yeah, So the story of cesareans is in part just 0:38:01.960 --> 0:38:04.759 a reflection of whose work was deemed worthy of being 0:38:04.800 --> 0:38:09.120 included in medical journals and texts historically. As incomplete as 0:38:09.120 --> 0:38:12.080 that story is, it's what we've got. And so now 0:38:12.200 --> 0:38:16.040 let's turn to the beginning of the modern era of cesareans. 0:38:16.320 --> 0:38:21.200 Let's okay, death from infection, a lack of anesthesia, and 0:38:21.239 --> 0:38:24.680 no consensus on surgical procedure. When to do a cesarean, 0:38:24.719 --> 0:38:26.680 where to cut, should we take the placenta out? And 0:38:26.719 --> 0:38:32.439 so on? These things I know I'm starting off, but realistic. Yeah, yep, 0:38:33.200 --> 0:38:36.799 These things kept cesarean numbers low for most of the 0:38:36.840 --> 0:38:42.080 twentieth century. Between eighteen thirty eight and eighteen seventy eight, 0:38:42.480 --> 0:38:46.040 eighty nine c sections were performed in the US, sixty 0:38:46.080 --> 0:38:49.480 two percent of mothers died, sixty percent of babies died. 0:38:50.320 --> 0:38:54.400 One obstetrician from this era said, there is nothing in 0:38:54.440 --> 0:38:57.520 surgery about which the surgeon is so timid as a 0:38:57.520 --> 0:39:02.000 cesarean operation, and nothing in obstetric of which this obstetrician 0:39:02.160 --> 0:39:03.800 stands so much in dread. 0:39:04.800 --> 0:39:05.480 Yeah, okay. 0:39:06.680 --> 0:39:09.400 For the sentiment to change going into the twentieth century, 0:39:09.560 --> 0:39:15.800 four developments needed to take place. Anesthesia, antisepsis, blood transfusions, 0:39:15.840 --> 0:39:20.160 and surgical technique okay. Practicing primarily on women of color, 0:39:20.280 --> 0:39:23.880 poor women, disabled women, other women viewed as second class citizens, 0:39:24.320 --> 0:39:29.120 surgeons honed their approach to cesareans. Eduardo Poro introduced the 0:39:29.120 --> 0:39:32.600 Poro technique in eighteen seventy eight, which involved amputating the 0:39:32.680 --> 0:39:35.880 uterus at the cervix and suturing the cervix into the 0:39:35.880 --> 0:39:40.160 abdominal wall. Oh yeah, this actually did reduce infection and hemorrhage, 0:39:40.200 --> 0:39:43.839 brought the survival rate up to forty four percent. Max 0:39:43.880 --> 0:39:47.080 Sanger used silver wire in uterine sutures beginning in the 0:39:47.160 --> 0:39:51.160 late eighteen eighties, further improving survival rate. I think previously 0:39:51.160 --> 0:39:53.480 they were like, should we even suture the uterus back together? 0:39:54.040 --> 0:39:59.080 Because what infection was so bad? Yeah. By the nineteen tens, 0:39:59.440 --> 0:40:02.640 the overall maternal mortality rate for cesareans dropped to eight 0:40:02.680 --> 0:40:06.240 point one percent wow, which is lower than the fifty 0:40:06.320 --> 0:40:08.960 six percent it was in the late eighteen hundreds, but 0:40:09.120 --> 0:40:12.680 still very high for a surgery, so its use was debated, 0:40:13.160 --> 0:40:16.120 with the decision to cut often influenced by the social 0:40:16.200 --> 0:40:19.319 standing of the mother, which opened the door to eugenics, right, 0:40:19.360 --> 0:40:22.040 So the risk of a negative outcome was perceived to 0:40:22.080 --> 0:40:24.759 be lower in cases where you didn't care whether or 0:40:24.760 --> 0:40:25.920 not mother and baby lived. 0:40:26.080 --> 0:40:28.000 Oh my god, Okay, yeah. 0:40:28.480 --> 0:40:31.040 Inductions were often used as a way to prevent what 0:40:31.200 --> 0:40:34.719 was seen as an extremely risky procedure. But over the 0:40:34.719 --> 0:40:37.000 first they were like, well, we'll just in case we 0:40:37.000 --> 0:40:38.799 don't want to we want to avoid a cesareans, we'll 0:40:38.840 --> 0:40:42.840 just induce you. So that became very, very popular, But 0:40:42.960 --> 0:40:45.239 over the first seven decades of the twentieth century, that 0:40:45.320 --> 0:40:48.480 perception of risk would change. What started out as a 0:40:48.520 --> 0:40:51.720 surgery to be avoided at all costs, turned into something 0:40:51.719 --> 0:40:55.600 that you only did in extreme circumstances, then something to 0:40:55.600 --> 0:40:59.720 do in certain situations, and then only at the discretion 0:41:00.080 --> 0:41:04.640 the physician, to finally something that was routine. The reasons 0:41:04.640 --> 0:41:08.360 for this shift included those I mentioned earlier, transfusions, antsepsis 0:41:08.360 --> 0:41:13.040 anesthesia technique plus antibiotics introduced in the nineteen forties, and 0:41:13.120 --> 0:41:17.520 a gradual decline in maternal mortality from other causes. So 0:41:17.719 --> 0:41:22.000 as obstetricians got better at recognizing and treating or preventing 0:41:22.080 --> 0:41:25.960 complications for mom during pregnancy and childbirth, the focus then 0:41:26.160 --> 0:41:30.240 shifted to seeing a similar decrease in neonatal and perinatal mortality. 0:41:30.320 --> 0:41:34.719 Okay, because previously it had always been about maternal mortality 0:41:34.760 --> 0:41:38.560 and trying to reduce that, and the baby was always secondary. Yes, 0:41:38.600 --> 0:41:41.800 And then as we got better at reducing maternal mortality, 0:41:41.880 --> 0:41:44.920 now we said, okay, can we save these babies? Yes, exactly, 0:41:45.000 --> 0:41:46.040 got it, yep, yep. 0:41:46.440 --> 0:41:49.279 And so then we started to develop things like diagnostic 0:41:49.320 --> 0:41:53.360 tools Apgar score, the Freedman curve to measure how labor 0:41:53.440 --> 0:41:57.960 is progressing, X rays, ultrasound, and the electronic fetal monitor, 0:41:58.880 --> 0:42:01.200 which was introduced in the nineteen fifties, or a lot 0:42:01.200 --> 0:42:03.759 of these were were established by the nineteen fifties and 0:42:03.800 --> 0:42:06.760 nineteen sixties. Obviously, X rays were a long time previous 0:42:06.960 --> 0:42:11.520 to that, but these different diagnostic tools captured what seemed 0:42:11.600 --> 0:42:15.560 like more and more risk during childbirth, and thus more 0:42:15.640 --> 0:42:18.920 and more reason to do a sea section or placental 0:42:19.000 --> 0:42:23.040 issues pelvis size, estimated baby size, uterine rupture, pre eclampsy, 0:42:23.040 --> 0:42:25.800 et cetera. We got better at detecting those and measuring 0:42:25.800 --> 0:42:28.040 those and being like, well, we should can. 0:42:27.920 --> 0:42:30.319 We prevent the risk? So how can we not do 0:42:30.360 --> 0:42:31.160 something about it? 0:42:31.280 --> 0:42:33.000 Yes, exactly, that's what exactly? 0:42:33.120 --> 0:42:33.600 Yeah, okay. 0:42:34.520 --> 0:42:38.560 But in another way, what these instruments were doing, in part, 0:42:38.760 --> 0:42:43.880 was confirming what early male physicians involved in childbirth believed 0:42:44.000 --> 0:42:48.400 that pregnancy and childbirth were pathological processes in themselves. 0:42:49.800 --> 0:42:52.279 Oh I know, okay, yeah. 0:42:52.480 --> 0:42:55.799 By the nineteen seventies, the tides had fully turned and 0:42:55.840 --> 0:42:58.400 C sections were about to skyrocket, at least here in 0:42:58.440 --> 0:43:01.120 the US. To give give you some idea of this 0:43:01.280 --> 0:43:03.880 massive change, let me throw some numbers at you please. 0:43:04.640 --> 0:43:08.560 Until nineteen seventy, the US C section rate was five 0:43:08.600 --> 0:43:09.640 point five percent. 0:43:09.800 --> 0:43:10.680 Wow. Okay. 0:43:11.200 --> 0:43:14.279 Between nineteen sixty five and nineteen eighty seven, the rate 0:43:14.320 --> 0:43:17.400 of C sections grew four hundred and fifty five percent. 0:43:19.200 --> 0:43:22.960 In I'm sorry, that is such a short I think 0:43:22.960 --> 0:43:26.359 what I didn't realize about looking at these numbers is 0:43:26.560 --> 0:43:30.800 how short that timeframe was. When it just boomed. 0:43:31.000 --> 0:43:34.240 Yeah, electronic fetal monitoring was a big okay. 0:43:34.320 --> 0:43:36.960 Yeah. Oh that's really interesting, especially in the context of 0:43:37.000 --> 0:43:39.719 like today. Yep, okay, interesting. 0:43:40.560 --> 0:43:42.840 Yeah, and it became like it just there are so 0:43:42.920 --> 0:43:47.040 many different dynamics to this as well. Yeah. So in 0:43:47.160 --> 0:43:49.200 nineteen sixty five the rate was like four and a 0:43:49.200 --> 0:43:52.080 half percent. In nineteen eighty seven it was twenty five percent, 0:43:52.200 --> 0:43:54.120 which is also lower than it is today. 0:43:54.239 --> 0:43:54.520 Yeah. 0:43:55.440 --> 0:43:59.000 Articles or stories that referenced C sections of the nineteen 0:43:59.080 --> 0:44:02.680 sixties still in who did a definition of the procedure? 0:44:02.920 --> 0:44:03.440 Wow? 0:44:03.560 --> 0:44:06.920 Yeah okay, And those published after nineteen seventy didn't have to. 0:44:07.640 --> 0:44:12.160 And the shift wasn't entirely welcomed by all obstetricians, many 0:44:12.200 --> 0:44:15.319 of whom saw cesareans as requiring much less skill than 0:44:15.360 --> 0:44:19.120 assisting in vaginal birth interesting and were against expanding criteria 0:44:19.160 --> 0:44:22.160 for the procedure because they were afraid of their own marginalization. 0:44:22.520 --> 0:44:24.759 In part, interesting, the. 0:44:24.680 --> 0:44:29.000 Skills that had taken them years to learn and perfect 0:44:29.200 --> 0:44:31.560 would be pointless with a surgical technique that took a 0:44:31.600 --> 0:44:32.399 few weeks to learn. 0:44:33.000 --> 0:44:33.600 Interesting. 0:44:33.840 --> 0:44:37.799 Yeah, this is not unfounded, right. Few physicians today have 0:44:37.880 --> 0:44:41.280 ever attended a vaginal breach birth, and watching a monitor 0:44:41.680 --> 0:44:44.240 is no substitute for interacting with a patient and becoming 0:44:44.320 --> 0:44:47.840 familiar with the varied rhythms of labor and that patient 0:44:47.880 --> 0:44:52.040 themselves like the person who they are. The natural birth movement, 0:44:52.160 --> 0:44:54.840 beginning in the nineteen seventies was in part a reaction 0:44:55.000 --> 0:44:58.480 to the increasing medicalization of pregnancy and childbirth, which included 0:44:58.560 --> 0:45:01.680 su sections, and this, combined with the push for vaginal 0:45:01.680 --> 0:45:04.520 birth after c section v back in the nineteen eighties, 0:45:04.640 --> 0:45:06.960 led to a brief dip in C section rates in 0:45:07.000 --> 0:45:12.160 the US, but that decline was short lived as resistance 0:45:12.200 --> 0:45:15.879 to v backs grew among doctors, as insurance companies hiked 0:45:15.960 --> 0:45:19.200 up malpractice insurance rates for doctors who performed v backs, 0:45:19.320 --> 0:45:22.040 and as hospitals just began to forbade it as an option. 0:45:22.640 --> 0:45:27.880 Yeah, wow, hospital administration making decisions. Cool cool, cool, cool 0:45:27.680 --> 0:45:31.560 cool cool insurance love it? 0:45:33.600 --> 0:45:35.600 I mean I do think this is probably like a 0:45:35.680 --> 0:45:36.520 global issue. 0:45:36.560 --> 0:45:38.520 Obviously some degree based on this. 0:45:38.760 --> 0:45:42.640 These are US numbers for sure. Yeah. The one acessarean 0:45:42.719 --> 0:45:46.600 always a cesarean adage that was first popularized by Edwin 0:45:46.840 --> 0:45:52.720 Cragan in nineteen sixteen still holds sway nineteen sixteen. Yeah, 0:45:52.760 --> 0:45:56.799 the perception of risk had shifted. Before the nineteen seventies, 0:45:56.920 --> 0:46:00.520 c sections themselves were seen as the risk, and after 0:46:00.920 --> 0:46:05.360 not performing the procedure was the risk. Medical malpractice suits 0:46:05.400 --> 0:46:09.120 on failure to perform a sea section reinforce this, okay, 0:46:09.520 --> 0:46:12.400 But what seems to have gotten lost as cesareans became 0:46:12.680 --> 0:46:16.239 more normalized is that the procedure does carry with it 0:46:16.320 --> 0:46:19.920 substantial risk, which can be compounded in subsequent sea sections. 0:46:20.120 --> 0:46:22.080 I know you'll talk a little bit more about this, Aaron, 0:46:22.200 --> 0:46:26.960 but high rates of blood transfusions, emergency hysterectomies, postpartum depression, 0:46:27.040 --> 0:46:31.879 difficulty breastfeeding, newborn lung conditions, and in subsequent pregnancies, still birth, 0:46:32.000 --> 0:46:36.799 uterine ruptures, placental anomalies such as placenta acreda. We can 0:46:36.840 --> 0:46:39.640 see the impact of sea sections on placenta acreda by 0:46:39.640 --> 0:46:42.840 looking at rates over time from the nineteen thirties to 0:46:42.880 --> 0:46:46.439 the nineteen fifties, placenta acreda occurred in less than one 0:46:46.640 --> 0:46:48.080 in thirty thousand berths. 0:46:48.520 --> 0:46:49.560 Oh my gosh. 0:46:49.680 --> 0:46:52.000 By twenty sixteen, that number was down to one in 0:46:52.000 --> 0:46:55.000 two hundred and seventy two. Yeah, in large part due 0:46:55.000 --> 0:46:55.560 to sea sections. 0:46:55.680 --> 0:47:00.400 Right. Placenta acreda is when the placenta grows two deeply 0:47:00.760 --> 0:47:04.319 into the myometrium. In some cases it can actually go 0:47:04.440 --> 0:47:06.719 all the way through the myometrium and be adherent to 0:47:06.800 --> 0:47:09.960 like the outside wall or even into the abdominal cavity. 0:47:10.120 --> 0:47:12.960 It's a spectrum of disorders depending on how deep it is, 0:47:13.480 --> 0:47:17.399 and if it can be identified prior to delivery, then 0:47:17.719 --> 0:47:21.040 generally a sasarean section is necessary to be able to 0:47:21.160 --> 0:47:24.239 ensure that you can remove all of the placental tissue because, 0:47:24.239 --> 0:47:26.040 as we'll talk about, it's really important that the whole 0:47:26.040 --> 0:47:29.279 placenta comes out, but sometimes it's not identified and so 0:47:29.320 --> 0:47:31.759 then it can result in increased risk of hemorrhage and 0:47:31.800 --> 0:47:32.680 things like that. Yeah. 0:47:32.719 --> 0:47:35.560 And it's like, from my understanding is that risk of 0:47:35.560 --> 0:47:39.120 placenta accreta increases with every sea section because the potential 0:47:39.160 --> 0:47:41.640 for just the lack of like decidua that can form 0:47:41.760 --> 0:47:43.760 exactly where the previous scar is. 0:47:43.600 --> 0:47:45.200 Exactly because of the Cesaian scar. 0:47:45.360 --> 0:47:49.520 Yeah yeah, yeah, Okay, now that we've like talked about 0:47:49.520 --> 0:47:52.520 some of the negative things, I do want to just 0:47:52.680 --> 0:47:57.080 emphasize that sea sections are absolutely a life saving procedure. 0:47:57.160 --> 0:47:59.040 They really are, and they are incredibly safe. 0:47:59.160 --> 0:47:59.560 Yeah. 0:47:59.640 --> 0:48:01.640 I don't want to give the impression that they aren't. 0:48:02.280 --> 0:48:04.320 That's not the point I'm trying to make. The point 0:48:04.360 --> 0:48:08.000 is that while there are risks inherent in this procedure, 0:48:08.160 --> 0:48:10.440 risks that are worth it if it means a healthy 0:48:10.480 --> 0:48:15.640 mother and baby, these risks aren't always adequately communicated, whether 0:48:15.760 --> 0:48:19.799 in planned cesarean sections, unplanned ones, or in many what 0:48:19.920 --> 0:48:23.360 to expect while you're expecting books. The decision to conduct 0:48:23.360 --> 0:48:27.640 an unplanned cesarean isn't always explained to the person in labor, who, 0:48:27.680 --> 0:48:30.920 in their state of anxiety, pain, worry, doesn't feel like 0:48:30.920 --> 0:48:32.920 they can ask questions or be listened to. 0:48:33.200 --> 0:48:36.319 Or can't understand like everything that's happening all at once 0:48:36.360 --> 0:48:38.880 because it can change on a dime, exactly. 0:48:39.120 --> 0:48:39.400 Yeah. 0:48:39.520 --> 0:48:39.719 Yeah. 0:48:40.000 --> 0:48:43.319 Being in a room surrounded by people for whom this 0:48:43.440 --> 0:48:46.759 is an everyday occurrence seems like it should be reassuring, 0:48:47.080 --> 0:48:49.560 but what it can often be is silencing and isolating. 0:48:50.040 --> 0:48:52.400 Your fears are dismissed because oh, it's fine, we do 0:48:52.480 --> 0:48:54.920 this all the time, don't worry about it. Your questions 0:48:54.920 --> 0:48:57.399 aren't answered because the doctor is telling you there's no time, 0:48:57.480 --> 0:49:00.840 we have to do this now. And this crowded labor 0:49:00.920 --> 0:49:05.560 room filled with capable hands provides no comfort because most 0:49:05.560 --> 0:49:08.760 of them are strangers. They don't know you, you don't know them. 0:49:09.120 --> 0:49:11.640 This feeling of a loss of control might not be 0:49:11.719 --> 0:49:13.759 unique to sea sections, but it is something that gets 0:49:13.840 --> 0:49:17.200 minimized both during and after childbirth, both of which carries 0:49:17.239 --> 0:49:20.360 significant rates of emotional trauma. One study I saw reported 0:49:20.400 --> 0:49:23.560 forty five percent. The message is, well, you've got a 0:49:23.560 --> 0:49:25.400 healthy baby, what do you have to complain about? 0:49:25.400 --> 0:49:29.480 Get over it, you know, like, just enjoy your baby. Yeah, 0:49:29.480 --> 0:49:30.520 so they're screaming all the time. 0:49:31.719 --> 0:49:34.920 You enjoy. But this no big deal sentiment carries over 0:49:34.960 --> 0:49:37.800 into the physical trauma of sea sections, which are treated 0:49:37.880 --> 0:49:40.600 like the world's most minor surgery instead of the major 0:49:40.719 --> 0:49:42.680 abdominal surgery that they are. 0:49:42.880 --> 0:49:45.200 I do find that so interesting. 0:49:45.360 --> 0:49:48.480 Yeah, it's like, oh so serian, Oh my god, It's like, yeah, 0:49:48.480 --> 0:49:51.600 it must be nice for you. Yeah right, it's like what, like, 0:49:51.680 --> 0:49:54.120 how are you expected to carry your newborn to their 0:49:54.120 --> 0:49:56.640 first doctor's appointment when you aren't supposed to lift anything 0:49:56.680 --> 0:49:59.120 because your muscles have just undergone significant trauma. 0:49:59.239 --> 0:50:01.200 Yeah, and even if your newborn is only like six 0:50:01.320 --> 0:50:03.520 or seven pounds, your course's twelve. Then so now you're 0:50:03.560 --> 0:50:04.560 right your twenty pound max. 0:50:04.680 --> 0:50:04.799 Right? 0:50:05.440 --> 0:50:07.520 Great? And then how long? How long does that? 0:50:07.719 --> 0:50:07.920 You know? 0:50:09.719 --> 0:50:12.719 In the famous pregnancy book What to Expect While You're Expecting, 0:50:12.800 --> 0:50:15.399 You know this book. Everyone never read book? Okay, yeah, 0:50:15.400 --> 0:50:18.240 I haven't either, but I did come across this description 0:50:18.320 --> 0:50:22.400 of c sections in one edition. Instead of huffing, puffing 0:50:22.400 --> 0:50:24.680 and pushing your baby into the world, you'll get to 0:50:24.760 --> 0:50:27.480 lie back and let everyone else do the heavy lifting. 0:50:32.680 --> 0:50:34.799 I hope that was I don't even know what I 0:50:34.800 --> 0:50:35.440 hope about that. 0:50:35.440 --> 0:50:42.680 Discussion, because I, oh gosh. My charitable take is that 0:50:42.800 --> 0:50:45.560 maybe it was meant to be reassuring, reassuring and like, 0:50:45.600 --> 0:50:47.799 don't worry about it. This is something that you know, 0:50:47.880 --> 0:50:49.640 you don't have to stress about this major surgery. 0:50:49.719 --> 0:50:51.799 It's not helpful for either side because it makes it 0:50:51.800 --> 0:50:54.000 seem like a vaginal birth is like the worst possible 0:50:54.040 --> 0:50:56.040 thing in it so hard, and then it makes it 0:50:56.080 --> 0:50:58.600 seem like a cesarean section is so easy, and like 0:50:59.000 --> 0:51:02.239 neither one of those things are exactly true. Yeah, it's 0:51:02.360 --> 0:51:03.560 all still childbirth. 0:51:03.640 --> 0:51:09.239 It's all childbirth. Yeah yeah, yeah, ah it's and the 0:51:09.280 --> 0:51:11.480 thing is too. I also I also want to acknowledge 0:51:11.480 --> 0:51:14.719 it that might be someone's experience like that maybe maybe 0:51:14.760 --> 0:51:16.279 I don't. I don't want to say like everyone who 0:51:16.280 --> 0:51:18.879 has c sections had it's a horrible time, because maybe 0:51:18.880 --> 0:51:19.280 they didn't. 0:51:19.280 --> 0:51:21.439 Maybe it was like this is maybe it is totally fine, 0:51:21.480 --> 0:51:23.880 scheduled procedure and it goes exactly as planned and it 0:51:23.920 --> 0:51:27.080 was very relaxing and your recovery is easy and that's phenomenal. 0:51:26.640 --> 0:51:30.279 Right, or even if it was unplanned, and it's like yeah. 0:51:30.000 --> 0:51:32.439 And but the same can also be true for a vaginal. 0:51:32.120 --> 0:51:35.160 Delivery for sure. Yeah yeah, but I feel like, yeah, 0:51:35.200 --> 0:51:38.000 this this saying that way, describing it that way is 0:51:38.080 --> 0:51:39.720 so dismissive. 0:51:39.200 --> 0:51:42.120 Right, It's one way that it will go, yes, yeah, yeah. 0:51:42.239 --> 0:51:44.000 And it also sort of like is like, well, if 0:51:44.000 --> 0:51:47.160 you felt any any other way, then that's your that's 0:51:47.160 --> 0:51:52.120 on you, right, right. And this perception of c sections 0:51:52.200 --> 0:51:55.000 as being either like the easy way out or a 0:51:55.080 --> 0:51:58.960 vanity procedure, which is we'll get into that, yeah, or not. 0:51:59.200 --> 0:52:02.280 Real birth so incredibly harmful. And I feel like this 0:52:02.480 --> 0:52:06.600 idea of natural birth or the term natural birth implies 0:52:07.200 --> 0:52:11.799 unnatural birth, right, and that can be so othering, right 0:52:11.920 --> 0:52:15.000 that along with a million different books and articles and 0:52:15.080 --> 0:52:17.839 forums saying you should do this and you shouldn't do that. 0:52:18.040 --> 0:52:20.239 If you do this, you're a good mother. If you 0:52:20.320 --> 0:52:22.440 don't do this, then you're a bad mind. Like that 0:52:22.480 --> 0:52:23.120 sort of thing. 0:52:23.040 --> 0:52:25.720 Right, It compares and contrast in this way, right. 0:52:25.680 --> 0:52:27.880 The focus on skin to skin bonding in the minutes 0:52:27.920 --> 0:52:30.640 right after birth, what happens if you're under anesthesia or 0:52:30.640 --> 0:52:33.840 if baby is rushed away for extra care. That's okay, 0:52:34.080 --> 0:52:37.520 everything will be okay. But that message gets lost. Women 0:52:37.560 --> 0:52:41.000 who have c sections often have a more difficult time breastfeeding, 0:52:41.080 --> 0:52:43.759 which can then lead to shaming because that's not the 0:52:43.760 --> 0:52:46.200 way you're supposed to do it, when in reality, a 0:52:46.239 --> 0:52:50.399 fed baby is the best baby. The moral superiority tied 0:52:50.440 --> 0:52:53.360 to so much of pregnancy and childbirth can be crushing 0:52:53.440 --> 0:52:56.280 and isolating, especially when things are out of your control. 0:52:57.000 --> 0:52:59.680 Even the language that we use to describe reasons for 0:52:59.719 --> 0:53:01.200 seas sections shows this. 0:53:01.160 --> 0:53:02.560 Oh my gosh, I talk about this nail. 0:53:02.560 --> 0:53:09.160 You're to progress incompetent cervix, inefficient contractions, uterine dysfunction. Some 0:53:09.239 --> 0:53:12.799 women are told, you're not trying hard enough. I know, 0:53:13.040 --> 0:53:17.200 you're not strong enough. Yes, like you're you're not even 0:53:17.239 --> 0:53:19.200 you're not even pushing. What are you doing? Do you 0:53:19.239 --> 0:53:20.480 do you want to have a C section? 0:53:20.680 --> 0:53:20.880 You know? 0:53:21.200 --> 0:53:25.160 Sorry to I know, I know, yeah, but it's that 0:53:25.280 --> 0:53:28.800 all places the blame on them making the sea section 0:53:29.000 --> 0:53:32.080 solely their decision rather than what the doctor instructed. And 0:53:32.120 --> 0:53:35.560 it's so difficult to know, Like you, you have this plan, 0:53:36.040 --> 0:53:39.040 you you want to your birst to go a certain way, 0:53:39.160 --> 0:53:42.560 and then something goes not according to plan. What do 0:53:42.640 --> 0:53:44.560 you do? Do you feel like it's your fault? It's 0:53:44.600 --> 0:53:46.480 it's really complicated. 0:53:45.920 --> 0:53:48.480 And that I mean, that is the truth of our 0:53:48.640 --> 0:53:52.040 entire lives, right, Yeah, like you, we cannot plan everything. 0:53:52.080 --> 0:53:54.400 But I do think that, especially today, there is very 0:53:54.480 --> 0:53:57.920 much an emphasis on like having a plan and then 0:53:58.200 --> 0:54:00.680 things if things do not go accord to that plan, 0:54:00.920 --> 0:54:03.960 it makes it seem like you did something wrong, right 0:54:04.160 --> 0:54:06.239 when that's not reality. 0:54:06.400 --> 0:54:09.440 It's not reality. So it's really hard Yeah, it is 0:54:09.520 --> 0:54:11.520 really hard, and I think that what it does is 0:54:11.560 --> 0:54:16.000 sort of shift the attention away from where I think 0:54:16.040 --> 0:54:19.520 we need to be more like, have more discussions about 0:54:19.880 --> 0:54:23.319 you know, what are these drivers for this thirty three 0:54:23.400 --> 0:54:27.480 percent rate of C sections at the provider level, at 0:54:27.480 --> 0:54:32.000 the institutional level, at the systemic level. One overlooked aspect 0:54:32.080 --> 0:54:35.800 is the individual provider's reasons for deciding on a sea section. 0:54:36.360 --> 0:54:40.120 Trauma during childbirth is not exclusive to the mother, and 0:54:40.200 --> 0:54:43.560 as a provider, if you attend a traumatic vaginal birth, 0:54:43.640 --> 0:54:45.880 you might be more likely to suggest a sea section 0:54:46.080 --> 0:54:47.480 than your other colleagues. 0:54:47.560 --> 0:54:51.880 Every provider has seen traumatic everything. Yeah, and the things 0:54:51.920 --> 0:54:56.560 that obstetric providers see on a daily basis are trauma exactly. 0:54:56.719 --> 0:55:00.520 Yeah. Some hospitals I found this fascinating took to publishing 0:55:00.600 --> 0:55:03.640 or displaying each physician's cesarean rates and that led to 0:55:03.680 --> 0:55:04.320 them plummeting. 0:55:04.880 --> 0:55:11.520 Interesting wow, which suggests that maybe risk tolerance for vaginal 0:55:11.560 --> 0:55:14.759 birth is lower than physicians think it should be. 0:55:15.120 --> 0:55:17.279 And so I don't know what to make of that, 0:55:17.520 --> 0:55:20.680 but I do think that's that is Yeah, And then 0:55:20.680 --> 0:55:24.680 there's implicit bias. Black mothers are more likely to have 0:55:24.719 --> 0:55:27.920 SEE sections than white mothers, even if risk factors are similar. 0:55:28.520 --> 0:55:31.480 Does this suggest that non white mothers can't be trusted 0:55:31.480 --> 0:55:35.279 to give birth without medical intervention? Which is also then 0:55:35.320 --> 0:55:37.800 funny because it's like, but we're also you have pain, 0:55:38.520 --> 0:55:42.680 I don't believe you. Yeah. Other research shows that female 0:55:42.800 --> 0:55:46.879 obgui ns and maternal fetal medicine specialists are more likely 0:55:46.960 --> 0:55:50.120 to opt for an elective CESAIAN for themselves rather than 0:55:50.239 --> 0:55:53.440 low risk vaginal birth twenty one to thirty one percent 0:55:53.520 --> 0:55:58.480 preferred elective cesarean. So how does that personal preference bleed 0:55:58.520 --> 0:56:02.520 into their practice? Along with these individual drivers? What about 0:56:02.520 --> 0:56:05.680 the US medical system as a whole, driven by profits, 0:56:05.719 --> 0:56:09.200 fear of litigation? How do these things impact rates? And finally, 0:56:09.320 --> 0:56:11.919 how much of this rise in c sections is due 0:56:12.040 --> 0:56:15.960 to a corresponding rise in the actual risk factors for 0:56:16.000 --> 0:56:20.239 the procedure, like older age during pregnancy or higher rates 0:56:20.239 --> 0:56:24.640 of preeclampsia in recent decades. How appropriate is a comparison 0:56:24.680 --> 0:56:29.080 between historical and modern rates of difficult labor? Do these 0:56:29.239 --> 0:56:34.520 historical metrics capture neonatal or perinatal mortality injuries during childbirth? 0:56:34.600 --> 0:56:38.640 Disability caused by a difficult labor? I mean reiterate again, 0:56:38.719 --> 0:56:42.320 c sections are life saving in generally extremely safe procedure, 0:56:42.440 --> 0:56:46.279 but in order to reach the Who's recommended ideal C 0:56:46.480 --> 0:56:50.279 section rate of ten to fifteen percent, we really need 0:56:50.320 --> 0:56:53.239 to reassess the metrics that we use to make decisions 0:56:53.280 --> 0:56:58.480 about interventions. How are we measuring risk? How accurate are 0:56:58.520 --> 0:57:03.759 these measurements are the risk factors themselves? Increasing medical advancements 0:57:03.800 --> 0:57:06.720 have saved the lives of so many mothers and babies, 0:57:06.760 --> 0:57:10.759 but in our reliance on diagnostic tools and technologies, we've 0:57:10.880 --> 0:57:13.480 left something else behind, and that is the comfort that 0:57:13.560 --> 0:57:18.480 community can bring to pregnancy, childbirth, and child rearing, which 0:57:18.520 --> 0:57:21.200 is in part what I'll be talking about next a week. 0:57:21.320 --> 0:57:23.160 Excited next episode, But. 0:57:23.040 --> 0:57:24.760 For now, Aaron, I want to turn it over to 0:57:24.800 --> 0:57:28.520 you to tell me all everything about labor and delivery. 0:57:28.680 --> 0:57:32.880 I'm not going to tell you everything, but I'll cover 0:57:32.960 --> 0:57:35.440 a lot right after a short break. 0:57:35.720 --> 0:57:51.800 Yeah, it was in March of twenty twenty three that 0:57:51.840 --> 0:57:54.640 we lost our first baby to miscarriage. We've been trying 0:57:54.680 --> 0:57:57.600 to conceive for quite some time and were absolutely esthetic 0:57:57.680 --> 0:58:00.000 to become parents, but we ended up in the act 0:58:00.160 --> 0:58:04.120 in an emergency department following some bleeding. I remember getting 0:58:04.120 --> 0:58:06.920 the news and just completely breaking down. It was a 0:58:06.960 --> 0:58:09.000 really busy Friday night, and we were told that we 0:58:09.040 --> 0:58:11.360 should go home and come back the next day for 0:58:11.360 --> 0:58:12.880 a transvaginal ultrasound. 0:58:13.600 --> 0:58:14.320 When we were in that. 0:58:14.280 --> 0:58:18.120 Waiting room, we already knew that we had lost our baby, 0:58:18.520 --> 0:58:21.440 but we were surrounded by excited, happy parents who were 0:58:21.560 --> 0:58:24.280 waiting to get their own scans, and it just felt 0:58:24.280 --> 0:58:28.880 like such a lonely and isolating experience. Once they had 0:58:28.880 --> 0:58:31.240 done the scan to confirm that it wasn't an ectopic 0:58:31.280 --> 0:58:34.640 pregnancy that needed further intervention, we were told we should 0:58:34.680 --> 0:58:37.120 go home and wait for the fecal matter to pass 0:58:37.160 --> 0:58:40.320 on its own. It was a really bizarre situation where 0:58:40.920 --> 0:58:43.480 literally being told to flush your hopes and dreams down 0:58:43.480 --> 0:58:47.560 a toilet. It felt very cold and clinical. I never 0:58:47.600 --> 0:58:52.200 truly appreciated that so many pregnancies end in miscarriage. I 0:58:52.200 --> 0:58:54.680 think it's about one in four is the statistic, which 0:58:54.720 --> 0:58:58.000 is so many people who were affected by baby loss. 0:58:58.440 --> 0:59:00.640 To further this, I felt like I couldn't take any 0:59:00.640 --> 0:59:02.480 time off from work and that I was a failure 0:59:02.520 --> 0:59:04.960 in some ways, which I know, having spoken to other women, 0:59:05.520 --> 0:59:08.040 is something that I'm not alone with. It wasn't just 0:59:08.160 --> 0:59:11.040 the physical pain of having the miscarriage, but the emotional 0:59:11.080 --> 0:59:13.480 told that it took on me and my partner as well. 0:59:14.320 --> 0:59:17.200 Growing up, you're always told that if you have sex, 0:59:17.280 --> 0:59:20.720 you'll get pregnant, and obviously pregnancy equals a baby, but 0:59:20.760 --> 0:59:24.720 that is so not the case for so many people. Sadly, 0:59:24.760 --> 0:59:26.880 we were one of the unlucky few couples that go 0:59:26.960 --> 0:59:30.600 on to have reoccurrent miscourages, so that sort of feeling 0:59:30.600 --> 0:59:33.760 of isolation and loneliness has happened time and time again 0:59:33.840 --> 0:59:36.720 for us. Each time I felt like I should just 0:59:36.800 --> 0:59:39.120 get over it. There was lots of support when we 0:59:39.160 --> 0:59:42.240 had that first miscarriage, but after the second one, it 0:59:42.320 --> 0:59:45.200 sort of starts to dwindle, particularly with people in the workplace. 0:59:45.680 --> 0:59:48.600 In the UK, currently there's no paid time off, no 0:59:48.720 --> 0:59:50.720 legal right to have paid time off if you lose 0:59:50.760 --> 0:59:53.720 a baby under twenty four weeks of gestation. So I've 0:59:53.760 --> 0:59:57.520 actually been campaigning to introduce that. I'm really pleased to 0:59:57.560 --> 1:00:00.560 say that most recently we've managed to do that in 1:00:00.640 --> 1:00:03.160 my workplace and we're one of the first people within 1:00:03.520 --> 1:00:06.680 our industry to actually introduce paid time off for bereaved 1:00:06.720 --> 1:00:10.440 parents who lose a baby for miscarriage or for termination 1:00:10.560 --> 1:00:13.360 for medical reasons under twenty four weeks, and I hope 1:00:13.360 --> 1:00:16.720 that my story can empower other people to campaign for 1:00:16.760 --> 1:00:19.240 the same in their workplaces and to feel less alone. 1:00:20.960 --> 1:00:23.560 I am My name's Kate from Western Australia and I'm 1:00:23.560 --> 1:00:26.960 the mother of two pre term babies. After a fairly 1:00:27.000 --> 1:00:29.720 smooth pregnancy at the age of twenty eight, I gave 1:00:29.800 --> 1:00:32.920 birth to my son at just thirty weeks in five days. 1:00:33.520 --> 1:00:37.200 He was thirteen hundred and seventy five grams or about 1:00:37.240 --> 1:00:41.320 three pounds. Went to hospital after a really bad cramping, 1:00:41.440 --> 1:00:44.320 backache and bleeding and I was advised I was in 1:00:44.400 --> 1:00:48.080 pre term labor. It was given steroids for his lungs. 1:00:48.720 --> 1:00:51.440 Because he was so early, we had to be transferred 1:00:51.480 --> 1:00:54.120 to the public hospital, and by the time I had 1:00:54.160 --> 1:00:57.280 been embittered, they rushed me in for an emergency cesarean 1:00:58.120 --> 1:01:00.920 as they could feel his little feet poking out. I 1:01:00.960 --> 1:01:04.720 was completely terrified, with my teeth chattering uncontrollably from the 1:01:04.720 --> 1:01:09.120 epidural a. Some was lifted out onto a warming bed 1:01:09.160 --> 1:01:13.000 and given oxygen. To our relief. He cried, but I 1:01:13.040 --> 1:01:15.360 only got a glimpse of him as he was taken 1:01:15.400 --> 1:01:17.960 to the ICU to be intubated and placed in a 1:01:18.000 --> 1:01:22.240 HUMI crib. He then spent a day or so in 1:01:22.280 --> 1:01:26.520 the ICU on oxygen. He was then put on a 1:01:26.560 --> 1:01:29.439 sea pat machine and moved to the neonatal ward, where 1:01:29.440 --> 1:01:31.320 I was able to hold him for the first time. 1:01:31.520 --> 1:01:34.560 I remember the nurse tucking him under my singlet the 1:01:34.640 --> 1:01:38.360 skinned skin, which was such a surreal and amazing moment 1:01:38.480 --> 1:01:42.400 for me. To many ups and downs, Jimmy was discharged 1:01:42.400 --> 1:01:46.920 from hospital after nine long weeks, but he is now 1:01:46.960 --> 1:01:50.560 a pats turn fifteen years old. Two and a half 1:01:50.600 --> 1:01:53.600 years later, his sister was born when I was thirty 1:01:53.640 --> 1:01:55.960 two weeks and five days. I had the same cramping, 1:01:56.000 --> 1:01:59.320 the same back ache, but I got to hospital much earlier. 1:01:59.320 --> 1:02:02.040 This time. I was given steroids. They tried to slow 1:02:02.120 --> 1:02:05.440 everything down, which they did for a few hours, but 1:02:05.560 --> 1:02:08.840 she was also determined to make an early entrance. As 1:02:08.880 --> 1:02:12.000 she was head down and quite small in size, we 1:02:12.160 --> 1:02:16.000 decided I was safe to deliver vaginally. Evie was born 1:02:16.320 --> 1:02:19.520 at eighteen hundred and seventy five grams, which is about 1:02:19.560 --> 1:02:22.800 four pounds. She was breathing on her own and I 1:02:22.840 --> 1:02:25.720 was able to hold her almost straight after. The extra 1:02:25.800 --> 1:02:28.240 time and the pressure from the vaginal birth ensured that 1:02:28.360 --> 1:02:32.760 steroids worked on her lungs, which made such a huge difference. 1:02:33.400 --> 1:02:37.640 Evie came home with us just four weeks later. Having 1:02:37.640 --> 1:02:40.040 to leave your new baby to go home every day 1:02:40.160 --> 1:02:43.720 is so incredibly hard. So thank you so much, the 1:02:43.800 --> 1:02:47.760 nurses at king Edwary Memorial. You made it bearable and 1:02:47.800 --> 1:02:51.520 you were all so kind and so caring. Thank you. 1:03:16.560 --> 1:03:21.600 So by the end of the last episode, episode two, 1:03:22.200 --> 1:03:24.240 by the end of my section, I made it like 1:03:24.320 --> 1:03:26.800 most of the way through pregnancy, and I stopped just 1:03:26.880 --> 1:03:31.320 before the big event, delivery. And of course, Aaron, you 1:03:31.440 --> 1:03:35.800 beautifully walked us through some parts of delivery, especially see 1:03:35.800 --> 1:03:39.080 sections and how those go. But I'm going to focus 1:03:39.160 --> 1:03:42.400 a little bit on what most people because even at 1:03:42.440 --> 1:03:45.600 thirty three percent, most people, a lot of people, even 1:03:45.640 --> 1:03:48.320 in that thirty three percent of cesarean sections, go through 1:03:48.400 --> 1:03:51.920 some part of labor beforehand. So what the heck is that? 1:03:52.240 --> 1:03:53.800 What is that? What is labor? 1:03:54.040 --> 1:03:56.840 Can't wait to tell you? So I'm going to go 1:03:56.880 --> 1:04:00.560 through what we know about the biology of labor and 1:04:00.680 --> 1:04:04.520 then walk through delivery modes, methods, a little bit more 1:04:04.560 --> 1:04:07.880 on sea sections and vaginal deliveries. It's gonna be great. 1:04:08.680 --> 1:04:14.480 So what is labor? Yeah, okay, during our whole pregnancy, 1:04:14.600 --> 1:04:17.760 all of the hormones jutting around that we've talked about, progesterone, 1:04:17.800 --> 1:04:20.400 prosscline and blah blah blah, all these things, what they 1:04:20.440 --> 1:04:28.080 do is help to keep our uterus relatively quiescent, relatively relaxed. Okay, Often, 1:04:28.280 --> 1:04:33.080 especially late in pregnancy, we might see this irregular contractility. 1:04:33.600 --> 1:04:36.120 So anyone who has experienced what they call Braxton Hicks 1:04:36.160 --> 1:04:40.240 contractions knows what those are. It's basically just your uterus. 1:04:40.720 --> 1:04:43.120 Sometimes people describe it as getting ready for birth. I 1:04:43.160 --> 1:04:45.640 don't know that that's accurate, but it's just your uterus 1:04:45.680 --> 1:04:47.640 every once in a while is still going to have 1:04:47.720 --> 1:04:48.640 these contractions. 1:04:48.800 --> 1:04:50.960 What just what is a contraction? 1:04:51.520 --> 1:04:55.240 Yes, it is actually because your uterus has like the 1:04:55.280 --> 1:04:58.960 inner lining right the endometrium. But then it's a huge muscle. Yeah, 1:04:58.960 --> 1:05:02.880 and so it is the fibers contracting literally like like 1:05:02.960 --> 1:05:04.040 your biceps contracts. 1:05:04.080 --> 1:05:06.640 But I mean, like, what, what what is it? 1:05:06.920 --> 1:05:07.000 Like? 1:05:07.040 --> 1:05:09.840 How long does it contract? We're gonna get the no, no, 1:05:09.840 --> 1:05:11.680 we'll get there. But Braxton Hicks. 1:05:11.680 --> 1:05:14.800 Like Braxton Hicks contractions, are defined as Okay, so to 1:05:15.120 --> 1:05:16.840 kind of define that, we have to define what what 1:05:16.840 --> 1:05:19.040 do we mean by labor? Like how are you defining 1:05:19.080 --> 1:05:22.440 those contractions and what's the difference there? And that is 1:05:22.920 --> 1:05:26.520 what what they are doing. So the onset of labor 1:05:26.800 --> 1:05:29.240 is defined as when there is a switch in the 1:05:29.320 --> 1:05:35.640 contractions to where they are resulting in dilation and effacement 1:05:35.920 --> 1:05:39.800 of the cervix. Okay, So contractions that are happening where 1:05:39.840 --> 1:05:45.840 you're having perhaps pain sometimes they're painful, where your uterus 1:05:45.880 --> 1:05:50.000 is contracting, but there's no change in your cervix, those 1:05:50.040 --> 1:05:53.480 contractions are not considered labor contractions it So what we 1:05:53.520 --> 1:05:56.720 see with the onset of labor is that these contractions 1:05:57.000 --> 1:06:03.640 increase in frequency and intensity and they become regular, which 1:06:03.680 --> 1:06:06.760 means that they're occurring at regular intervals. What that interval 1:06:06.800 --> 1:06:09.280 is is going to vary. Right later on in labor, 1:06:09.280 --> 1:06:11.280 they're much closer together, maybe a minute or two, but 1:06:11.320 --> 1:06:14.160 at the start they could be like ten, fifteen, even 1:06:14.160 --> 1:06:18.600 twenty minutes apart. If they are causing cervical change, then 1:06:18.640 --> 1:06:20.560 they are considered labor contractions. 1:06:20.720 --> 1:06:24.640 Okay, did you say, like which hormones are causing this yet? 1:06:25.640 --> 1:06:27.880 Did I say what triggers labor. No, I did not 1:06:28.200 --> 1:06:33.120 error because we don't know what we don't. 1:06:32.960 --> 1:06:36.080 Know, I can't be right. Check your notes again. 1:06:37.200 --> 1:06:40.840 We don't know. I said what triggers labor to begin? 1:06:41.000 --> 1:06:47.560 What an excellent question. It is hypothesized. We think that labor, 1:06:47.600 --> 1:06:49.840 the onset of labor, is triggered by the fetus or 1:06:49.920 --> 1:06:54.760 the placenta, the feto placental unit. We think that because 1:06:54.800 --> 1:06:57.640 that is what happens in like sheep and cows and 1:06:57.800 --> 1:07:01.960 in those other animals. Know what enzymes are involved, we 1:07:02.080 --> 1:07:05.360 know like the specific hormonal triggers, but we do not 1:07:05.600 --> 1:07:07.640 know that in humans, and if we did, it would 1:07:07.680 --> 1:07:09.600 be so much easier to induce labor. 1:07:09.840 --> 1:07:13.400 Also, sheep and cows have less invasive placentas. 1:07:13.000 --> 1:07:15.320 I know, I know, so it's different. It's not the 1:07:15.360 --> 1:07:16.000 same in us. 1:07:15.840 --> 1:07:17.560 But I mean, we have we have animal models that 1:07:17.600 --> 1:07:18.800 we understand. 1:07:18.360 --> 1:07:21.920 That we under the process of labor the trigger the trigger, 1:07:22.200 --> 1:07:25.240 and so in us we don't have that trigger. We 1:07:25.360 --> 1:07:29.520 know that A really important thing is that oxytocin yep, 1:07:29.600 --> 1:07:33.080 which is a hormone that the like synthetic version of 1:07:33.120 --> 1:07:40.000 it is called pittocine, that triggers unine contractions but what 1:07:40.120 --> 1:07:44.480 triggers in someone who spontaneously goes into labor, what triggers that, 1:07:44.560 --> 1:07:47.280 because it's not just like just oxytocin is something else 1:07:47.320 --> 1:07:49.720 has to trigger the production of that. Yeah, we don't 1:07:49.760 --> 1:07:51.000 know what that is, okay. 1:07:51.080 --> 1:07:54.600 And then for the for the regularity of these contractions, 1:07:54.840 --> 1:07:57.280 like how is it just the speed at which it's 1:07:57.320 --> 1:07:59.960 being oxytocin is being released? What what is? 1:08:00.200 --> 1:08:00.520 Don't know? 1:08:01.680 --> 1:08:03.720 Okay, So like we don't know why. I mean, we 1:08:03.760 --> 1:08:06.280 know why they speed up, like the purpose of speeding it. 1:08:06.360 --> 1:08:08.720 Right, we know what they're doing, but we do not 1:08:08.920 --> 1:08:12.200 know very much about the physiology of what is triggering it. 1:08:12.560 --> 1:08:15.760 But we do know a lot about how labor progresses. 1:08:16.160 --> 1:08:17.879 So what I'm going to go through are the different 1:08:18.000 --> 1:08:22.200 stages of labor. There are three. The first stage has 1:08:22.240 --> 1:08:24.360 two different phases. So we'll talk about all of that. 1:08:25.840 --> 1:08:30.040 And to do that, I did bring some props. Yay, 1:08:30.120 --> 1:08:36.040 this is the Balloon's there something in? Don't worry, we'll 1:08:36.040 --> 1:08:38.360 get there. This is a balloon that is going to 1:08:38.360 --> 1:08:41.559 represent our uterus. So if you're just listening, imagine a balloon. 1:08:41.640 --> 1:08:44.439 It's inflated, okay, but it's not tied off at the bottom. 1:08:44.640 --> 1:08:48.360 All right, So this is a uterus and this part 1:08:48.400 --> 1:08:50.800 down here, like the part that you would blow into 1:08:50.880 --> 1:08:57.120 of a balloon, is the surfix during pregnancy. I spent 1:08:57.160 --> 1:09:00.640 so long I practiced at home and everything. It's helped me. 1:09:00.720 --> 1:09:04.080 It's great. So this part is the cervix, the part 1:09:04.080 --> 1:09:06.600 that you would blow into of the balloon during pregnancy 1:09:06.760 --> 1:09:10.640 and outside of pregnancy. It's long and it's firm. It 1:09:10.720 --> 1:09:12.640 kind of feels like the tip of your nose if 1:09:12.680 --> 1:09:16.680 you were to touch it. Okay, okay, and it is closed. 1:09:17.120 --> 1:09:20.519 So you see that there's no opening here. What is that? 1:09:20.800 --> 1:09:21.040 I mean? 1:09:21.120 --> 1:09:23.080 Like, but what is that the for you? 1:09:23.439 --> 1:09:27.320 It is a little puffball okay, craft puffball? 1:09:27.479 --> 1:09:29.120 And what is it representing. 1:09:29.240 --> 1:09:32.960 It is representing the mucus plug. So during pregnancy, your 1:09:32.960 --> 1:09:35.760 cervix is closed with a mucus plug. And so one 1:09:35.800 --> 1:09:38.240 of the first steps of labor is that this mucus 1:09:38.240 --> 1:09:44.960 plug is shed. So exciting, thank you. And then through 1:09:45.000 --> 1:09:48.320 the power of these contractions, these contractions that are regular 1:09:48.400 --> 1:09:52.040 that increase in frequency and it's not going to pop 1:09:52.080 --> 1:09:55.360 I've practiced. The cervix has to do two things. It 1:09:55.400 --> 1:09:59.040 has to dilate and it has to efface. Okay, So 1:09:59.760 --> 1:10:04.439 die means that it has to go from closed to open. 1:10:04.680 --> 1:10:08.720 It's not going to pop up aiming, and so it 1:10:08.800 --> 1:10:10.759 has to go from a state of being completely closed 1:10:10.800 --> 1:10:14.640 to about ten centimeters open in diameter. Okay's that is 1:10:14.680 --> 1:10:17.680 fully dilated. But it also, as you can see as 1:10:17.680 --> 1:10:21.479 I'm like, if I'm squeezing this, it's also getting thinner, right, 1:10:21.960 --> 1:10:25.479 it's not as deep. That's called effacement. So it has 1:10:25.520 --> 1:10:28.599 to go from like several centimeters kind of like thick 1:10:28.800 --> 1:10:32.520 and deep basically paper thin tissue. 1:10:32.200 --> 1:10:34.280 Got it. So it's just yeah, yeah, it's just. 1:10:34.280 --> 1:10:37.240 Smoothing out and kind of being coming more of a 1:10:37.280 --> 1:10:41.439 part of the actual uterus itself. Cool. Cool. So that 1:10:41.600 --> 1:10:44.920 happens all through the power of contractions. The first stage 1:10:44.920 --> 1:10:46.559 of labor. This is all part of the first stage 1:10:46.560 --> 1:10:50.040 of labor, dilation and effacement. It's divided into two parts, 1:10:50.479 --> 1:10:55.680 latent labor and active labor. And these definitions vary a 1:10:55.720 --> 1:10:58.120 little bit place to place, So just for transparency, I'm 1:10:58.200 --> 1:11:02.240 using US definitions from the American College of Obstetrics and Gynecology. 1:11:02.840 --> 1:11:05.479 They define latent labor as the phase from when the 1:11:05.520 --> 1:11:10.800 cervix is completely closed until six centimeters dilated, okay. And 1:11:10.840 --> 1:11:14.360 we have found through lots of studies on people's labor 1:11:14.400 --> 1:11:18.160 progression those labor curves, that six centimeters is kind of 1:11:18.200 --> 1:11:23.880 this magic number where after that point, the regularity with 1:11:24.080 --> 1:11:30.280 which you dilate can be predictable. Up until six centimeters, 1:11:30.680 --> 1:11:34.880 someone might have very very very slow change, So they 1:11:34.960 --> 1:11:38.280 might have a latent phase of labor that is many, many, 1:11:38.360 --> 1:11:43.479 many hours long, if those contractions are still happening at 1:11:43.520 --> 1:11:47.400 a regular interval. Even if again that interval is like 1:11:47.840 --> 1:11:51.320 ten fifteen to twenty minutes, if they're still having cervical change, 1:11:51.360 --> 1:11:55.719 albeit slow, that would still be considered labor just latent. 1:11:57.160 --> 1:12:00.759 There is estimates on how long does lay labor last, 1:12:00.840 --> 1:12:03.640 What is quote unquote normal, what is outside of the 1:12:03.760 --> 1:12:06.680 range of normal, And that is a little bit up 1:12:06.720 --> 1:12:10.479 in the air, okay, because latent labor can really vary. 1:12:10.479 --> 1:12:13.040 And most of the data that we have is the 1:12:13.080 --> 1:12:16.880 time between admission to the hospital and the onset of 1:12:16.920 --> 1:12:20.080 active labor. But that doesn't necessarily mean that your labor 1:12:20.120 --> 1:12:23.519 started when you entered the hospital. But that number is 1:12:23.560 --> 1:12:27.480 about sixteen hours. Wow, is the like ninety fifth percentile? 1:12:27.560 --> 1:12:29.640 Now that's not the average, that's like the long end. 1:12:29.920 --> 1:12:33.840 Oh okay, okay, but again that's that's gonna depend very 1:12:33.880 --> 1:12:36.479 much person to person. So latent labor is the time 1:12:36.520 --> 1:12:39.439 that like really really can vary. After you get to 1:12:40.720 --> 1:12:44.000 six centimeters, that is when you are now considered to 1:12:44.040 --> 1:12:46.599 be an active labor, and that is the time at 1:12:46.600 --> 1:12:50.160 which the cervical change should speed up to a predictable 1:12:50.200 --> 1:12:54.400 interval of about one centimeter every two hours, okay or 1:12:54.520 --> 1:12:58.800 less faster, it's totally fine. Sorry, that's a six okay, 1:12:59.000 --> 1:13:01.040 So to go for six to ten, you've got like 1:13:01.120 --> 1:13:03.640 eight hours, got it before a provider is going to 1:13:03.680 --> 1:13:08.320 be like this is taking too long, okay, okay, okay, ten, 1:13:08.400 --> 1:13:12.839 But ten is the fully fully dilated yeah, okay, okay. 1:13:13.320 --> 1:13:15.640 Questions about any of that, Yeah. 1:13:16.120 --> 1:13:18.559 Okay, So the active labor part is more. 1:13:18.360 --> 1:13:19.800 Predictable, more predictable. 1:13:20.040 --> 1:13:24.880 But then not everyone progresses through active labor, yeah the 1:13:24.920 --> 1:13:25.679 same way. 1:13:26.000 --> 1:13:29.280 Yeah, Well you mean through like that from six to 1:13:29.320 --> 1:13:32.200 ten centimeters, Yeah, in eight hours or whatever. Yeah, And 1:13:32.240 --> 1:13:34.800 so if they don't a few things might be the case. 1:13:35.000 --> 1:13:39.280 So one thing that should usually happen at some point 1:13:39.320 --> 1:13:42.439 prior to that, probably is that your water should break. 1:13:43.000 --> 1:13:44.800 If your water didn't break, on its own, then a 1:13:44.800 --> 1:13:46.760 provider might say, we should break it for you. This 1:13:46.840 --> 1:13:50.200 is a cruchet hook, which looks exactly like it does 1:13:50.200 --> 1:13:53.479 look exactly like an amni hook. This is the actual hook. 1:13:54.320 --> 1:13:56.719 You can see. It looks exactly identical it does. Yeah, 1:13:56.760 --> 1:13:59.920 it's just longer and not round and not round you. 1:14:00.000 --> 1:14:01.559 I wouldn't want to crouchet with that. 1:14:01.880 --> 1:14:04.559 No, yeah, yeah, yeah, But this is used to break 1:14:04.560 --> 1:14:07.919 somebody's water. Now. The reason that that's important is because 1:14:08.240 --> 1:14:13.120 the baby's head, which is hopefully down, exerts pressure on 1:14:13.280 --> 1:14:16.719 that cervix. If there is a bag of fluid there, 1:14:17.120 --> 1:14:20.519 then that might limit the amount of pressure that's being 1:14:20.520 --> 1:14:22.720 exerted and might make it so that your cervix is 1:14:22.760 --> 1:14:25.320 not dilating the way that it should. So that's the 1:14:25.400 --> 1:14:27.519 reason that a lot of times, if water hasn't broken 1:14:27.560 --> 1:14:30.040 on its own, that will be like an intervention that's 1:14:30.080 --> 1:14:32.200 recommended to help speed up the process of labor. 1:14:32.320 --> 1:14:34.840 What determines how much I was going to how much fluid? 1:14:34.840 --> 1:14:36.120 Oh yes, I was going to do it, but I 1:14:36.120 --> 1:14:37.519 think it actually might make a mess, So I'm going 1:14:37.560 --> 1:14:39.400 to stop that. I had a baby in there too. 1:14:39.720 --> 1:14:44.200 I'm envisioning the water going everywhere make a mess. Yeah. 1:14:44.479 --> 1:14:49.840 What determines how much liquid? How much amniotic fluid is 1:14:49.920 --> 1:14:50.679 in there? 1:14:51.880 --> 1:14:54.800 Big question? So AMIEC fluid is P? It's a fetus P. 1:14:55.120 --> 1:14:55.320 Yeah. 1:14:55.720 --> 1:14:57.800 So it depends on how much the fetus is peeing 1:14:57.840 --> 1:15:00.519 and whether or not their kidneys are working directly, and 1:15:00.560 --> 1:15:02.599 also how much they because then they drink that pea 1:15:03.520 --> 1:15:06.280 and so that it's like a whole thing. It's fetal development. 1:15:06.280 --> 1:15:07.320 I'm not going to get into it. 1:15:07.400 --> 1:15:09.200 Yeah, okay, So I. 1:15:09.200 --> 1:15:11.639 Don't have an answer for you. And what determines whether 1:15:11.720 --> 1:15:14.640 or not what determines whether or not it breaks spontaneously 1:15:15.040 --> 1:15:17.920 or has to be broken? Who knows what. 1:15:17.520 --> 1:15:19.640 What percentage breaks spontaneously? 1:15:19.680 --> 1:15:23.479 I don't ask question. Listen, In any case, at some 1:15:23.560 --> 1:15:26.360 point the water is likely going to break. Sometimes it doesn't. 1:15:26.360 --> 1:15:30.519 Babies can be born just fine. In call it's called amatic. 1:15:30.760 --> 1:15:34.200 There's a whole history we could talk about, beautiful. But 1:15:34.680 --> 1:15:37.200 in any case, when it does break, that allows for 1:15:37.240 --> 1:15:39.639 the fetal head to engage lower down in the pelvis, 1:15:39.720 --> 1:15:42.439 putting more pressure on the cervix and helping to ensure 1:15:42.439 --> 1:15:44.440 that you're getting adequate dilation and effacement. 1:15:46.040 --> 1:15:48.720 What I have a question, it might be it might 1:15:48.720 --> 1:15:53.639 be jumping ahead breach number one number two, which which 1:15:53.880 --> 1:15:56.760 how is what facing facing babyhead? 1:15:57.200 --> 1:15:58.760 I have a baby? Do you want me to show you? Yes, 1:15:58.800 --> 1:16:02.040 I love that I have a baby. Here. Most of 1:16:02.080 --> 1:16:05.479 the time a baby should be facing We like for 1:16:05.520 --> 1:16:08.479 them to be facing like this. If this is my body, 1:16:09.040 --> 1:16:12.200 so that they are facing down, their face is facing 1:16:12.240 --> 1:16:15.960 maternal backside, and their oxaput, which is the back part 1:16:15.960 --> 1:16:19.200 of their head, is anterior, meaning facing up towards my 1:16:19.280 --> 1:16:22.240 belly button. Okay, that is the easiest way for a 1:16:22.240 --> 1:16:25.000 baby to come out. They have to do some rotations 1:16:25.680 --> 1:16:28.560 within the pelvis in order to get there, which is 1:16:28.680 --> 1:16:31.800 very interesting. If a baby is facing the other way, 1:16:31.920 --> 1:16:36.120 so head up, which is how I was born, eyes 1:16:36.280 --> 1:16:38.880 up and open to the world, then it's a little 1:16:38.920 --> 1:16:41.960 bit harder because this forehead is wider, so it's just 1:16:42.040 --> 1:16:44.080 harder to push that through the canal first. 1:16:44.280 --> 1:16:46.280 It's so interesting because I feel like you and I 1:16:46.320 --> 1:16:49.559 have talked about this, where like primates, depending on the 1:16:49.560 --> 1:16:54.000 primate species, there's like different directions that tend for you know, 1:16:54.080 --> 1:16:57.600 neoonates to be born right and often like why we 1:16:57.680 --> 1:17:02.120 think that human childbirth is a cooperative process is social 1:17:02.160 --> 1:17:05.360 process is because of the direction interesting and so it's 1:17:05.439 --> 1:17:08.160 like it can be more difficult to you can't do 1:17:08.200 --> 1:17:08.679 that yourself. 1:17:08.720 --> 1:17:11.080 It's harder to do yourself. And also when your baby 1:17:11.120 --> 1:17:14.479 is born facing down, you can't see their face to 1:17:14.520 --> 1:17:16.800 be able to do things like clean their eyes, clean 1:17:16.840 --> 1:17:20.559 their mouth, things like that, which other primemates can. Now, 1:17:20.640 --> 1:17:23.800 if a baby is breach, that means that some part 1:17:23.960 --> 1:17:27.679 of their bottom or feet is what is facing down 1:17:27.920 --> 1:17:30.679 towards the cervix. There's a lot of different types of breach, 1:17:30.720 --> 1:17:32.040 and I'm not an expert on it, so I don't 1:17:32.080 --> 1:17:34.000 remember like the different names for all of it, whether 1:17:34.040 --> 1:17:36.200 it's like complete breach or foot laning or blah blah blah. 1:17:36.720 --> 1:17:39.400 But yeah, it's usually some combination of either their bottom 1:17:40.080 --> 1:17:42.599 or their feet or one foot or something like that. Okay, 1:17:43.160 --> 1:17:46.600 breach babies are we'll talk a little bit more about this. 1:17:46.720 --> 1:17:49.959 But like you said, it is a slightly more difficult 1:17:50.080 --> 1:17:54.040 vaginal delivery, and so very very often, especially in the US, 1:17:54.439 --> 1:17:56.400 it is recommended that people have a c section. If 1:17:56.400 --> 1:17:58.720 baby is breached and won't be turned around. 1:17:58.760 --> 1:18:01.160 It won't be turned around, try to Okay. 1:18:01.200 --> 1:18:03.800 Yeah, and there's things that there's procedures that people can 1:18:03.840 --> 1:18:06.040 do to try and get baby to turn. It's called 1:18:06.120 --> 1:18:09.799 external cephalic version, where they basically push on the uterus 1:18:09.840 --> 1:18:13.080 and try They usually give medicines to relax the tone 1:18:13.160 --> 1:18:15.559 of the uterus first, Yeah, to try and induce that 1:18:15.600 --> 1:18:20.040 baby to turn. What about shoulders, shoulder dystotia. Okay, let's 1:18:20.080 --> 1:18:22.240 get We're still on the first stage of labor, Aaron, 1:18:22.280 --> 1:18:26.320 we haven't gotten there yet, but actively were erin. So 1:18:26.520 --> 1:18:28.759 that was all the first stage of labor. We skipped 1:18:28.760 --> 1:18:30.960 ahead a little bit with that delivery question. But once 1:18:31.000 --> 1:18:34.400 we've reached ten centimeters, I'm gonna treat this with more reverence. 1:18:35.240 --> 1:18:37.559 That is when we've entered the second stage of labor, 1:18:37.560 --> 1:18:40.320 which is delivery. Okay, and I guess I kind of 1:18:40.320 --> 1:18:43.439 already went through some of this, but essentially delivery is 1:18:43.479 --> 1:18:45.200 going to go one of two ways. It's going to 1:18:45.360 --> 1:18:48.240 go vaginally or it's not, in which case it's going 1:18:48.360 --> 1:18:52.439 to go to a C section. Right, So, how long 1:18:52.800 --> 1:18:55.360 one ends up having to push in order to deliver 1:18:55.400 --> 1:18:59.400 a baby vaginally totally depends. It can be a few minutes, 1:18:59.520 --> 1:19:03.080 it can be several hours. It does tend to be 1:19:03.280 --> 1:19:06.160 a little bit longer. That someone is pushing if they've 1:19:06.160 --> 1:19:10.200 had an epidural, And that's in part because it just 1:19:10.280 --> 1:19:13.000 makes it harder to know exactly where you are pushing 1:19:13.120 --> 1:19:16.080 because you can't feel as much because an epidural numbs you. 1:19:16.320 --> 1:19:16.439 Right. 1:19:18.439 --> 1:19:22.439 But that's the second stage of labor's delivery. Did I 1:19:22.479 --> 1:19:24.320 answer all of your questions about the modes? 1:19:24.360 --> 1:19:26.920 And I think so? I think so great. 1:19:28.439 --> 1:19:30.479 But I do want to spend a little bit more 1:19:30.479 --> 1:19:34.519 time here, not just talking about vaginal deliveries, but also talking, 1:19:34.600 --> 1:19:38.760 like you said erin, about cesarean sections, because sometimes we 1:19:38.800 --> 1:19:42.639 don't make it to this second stage of labor. Sometimes 1:19:42.640 --> 1:19:44.480 we don't make it all the way to ten centimeters. 1:19:44.920 --> 1:19:47.320 Sometimes we might not even make it to six centimeters. 1:19:47.320 --> 1:19:49.080 There's a lot of different things that can happen during 1:19:49.120 --> 1:19:53.400 that first stage of labor. So I want to take 1:19:53.400 --> 1:19:56.799 a minute to talk about c sections, not the steps, 1:19:56.840 --> 1:20:00.400 because you already did that, but about how it is 1:20:00.479 --> 1:20:04.439 often decided whether or not to proceed with a cesarean section. 1:20:04.640 --> 1:20:07.040 Could I before we do that, because I do realize 1:20:07.080 --> 1:20:09.160 I had a question about labor. How is that? Like 1:20:09.200 --> 1:20:13.120 who is keeping track? And what? Yeah? How is that? 1:20:13.160 --> 1:20:13.360 Then? 1:20:13.479 --> 1:20:16.920 Sort of yeah, these I guess leading into this question 1:20:17.080 --> 1:20:17.920 of C section. 1:20:18.160 --> 1:20:20.559 Yeah, so, I mean it is all going to depend 1:20:20.600 --> 1:20:23.479 on where you are and what your situation is. Right, 1:20:23.840 --> 1:20:26.600 If you're delivering at home, then it's just like you 1:20:26.760 --> 1:20:30.439 keeping track of the timing of your contractions, of how 1:20:30.479 --> 1:20:34.320 long those contractions are lasting, how frequently they're coming, and 1:20:34.360 --> 1:20:36.760 like maybe hopefully you have someone who's there with you 1:20:36.800 --> 1:20:40.840 who's checking your cervical dilation and effacement at regular intervals. 1:20:41.760 --> 1:20:44.479 If you're in the hospital, most of the time, you 1:20:44.560 --> 1:20:48.160 will be attached to an electronic fetal monitor, which is 1:20:48.160 --> 1:20:50.760 what you talked about, that's going to be monitoring your 1:20:50.760 --> 1:20:53.479 contractions so you can see them on the monitor so 1:20:53.520 --> 1:20:57.240 we know are they getting closer together. The external ones 1:20:57.479 --> 1:21:01.479 cannot tell us how strong a contraction is because they're 1:21:01.560 --> 1:21:06.559 just measuring tension externally. The only way that we can 1:21:06.600 --> 1:21:10.240 actually measure the pressure that's being exerted on the fetus 1:21:10.320 --> 1:21:12.960 is through an internal monitor, which we do have. 1:21:13.400 --> 1:21:14.960 Are those continuous or intermittent? 1:21:14.960 --> 1:21:17.840 They are continuous. Your water has to be broken to 1:21:17.880 --> 1:21:20.800 be able to get into the uterine cavity. But that's 1:21:20.800 --> 1:21:24.120 something that sometimes people end up having because let's say, 1:21:24.160 --> 1:21:27.479 for example, you're getting to that active phase of labor 1:21:27.720 --> 1:21:30.120 where we are expecting a certain amount of cervical change 1:21:30.120 --> 1:21:33.200 and it's not happening. So that might mean that even 1:21:33.240 --> 1:21:37.040 though you're contracting at intervals that seem regular, it might 1:21:37.080 --> 1:21:39.360 be that they're not strong enough to be inducing the 1:21:39.400 --> 1:21:42.439 cervical change. That might mean that we have medications that 1:21:42.439 --> 1:21:45.479 can help, because that's potocin or oxytocin is the one 1:21:45.479 --> 1:21:48.600 that we use most commonly because that is what stimulates 1:21:48.640 --> 1:21:51.519 contraction of the uterus, and so that's going to increase 1:21:51.560 --> 1:21:55.839 the power of those contractions to induce that cervical change. 1:21:56.360 --> 1:21:59.320 Are you going to talk about intermittent versus continuous feel monitoring? 1:21:59.479 --> 1:22:02.000 I mean those are two options for monitoring. 1:22:02.120 --> 1:22:04.360 Yeah, But in terms of like the decision making and 1:22:04.400 --> 1:22:05.799 what that tells us, it's. 1:22:05.720 --> 1:22:09.160 So variable that there's not like an easy answer that 1:22:09.240 --> 1:22:11.879 I have for that. It's going to very hospital to hospital, 1:22:11.920 --> 1:22:13.960 it's going to very provider to provider, and it's going 1:22:14.000 --> 1:22:18.679 to also depend on your individual risk situation, where most 1:22:18.680 --> 1:22:21.360 people if they have any kind of any degree of 1:22:21.439 --> 1:22:24.439 potential complications or like known complications. Let's say that you 1:22:24.520 --> 1:22:28.120 have preocclampsia or you have gestational hypertension or something like that, 1:22:28.520 --> 1:22:30.559 more likely that someone's going to be recommended to have 1:22:30.600 --> 1:22:33.880 continuous fetal monitoring rather than if you were considered a 1:22:33.920 --> 1:22:37.680 low risk pregnancy. Okay, and again that low to high 1:22:37.760 --> 1:22:41.439 risk can change very quickly, especially during labor. Yeah, it 1:22:41.520 --> 1:22:44.840 also is of course going to depend on whether you 1:22:45.080 --> 1:22:48.439 came into labor spontaneously or whether you came in to 1:22:48.520 --> 1:22:51.840 be induced for some reason or another. And one of 1:22:51.840 --> 1:22:54.360 the ways that I have seen most people talk about it, 1:22:54.400 --> 1:22:55.920 and one of the ways that I think about it 1:22:55.920 --> 1:22:57.519 that I think makes the most sense, is that any 1:22:57.600 --> 1:23:00.639 time that a medical provider is going to be doing 1:23:00.640 --> 1:23:04.200 an intervention, then they most likely will want to have 1:23:04.280 --> 1:23:07.840 continuous monitoring, at least for a time, because I'm doing 1:23:07.880 --> 1:23:10.440 something that's going to potentially affect you and your baby, 1:23:10.560 --> 1:23:12.559 so I want to know what effect that's having. Yea, 1:23:12.640 --> 1:23:14.880 if that makes sense, Yeah, that does so, but it 1:23:14.960 --> 1:23:18.800 totally varies place to place, Okay, So don't ask me statistics. 1:23:19.760 --> 1:23:22.320 I will tell you some statistics about sea sections unless 1:23:22.320 --> 1:23:23.640 you have more questions about. 1:23:23.560 --> 1:23:26.080 I'm sure that I will, but we'll give me the stats. 1:23:26.080 --> 1:23:30.759 Okay. So, globally, rates of sea sections are about twenty 1:23:30.800 --> 1:23:33.840 one percent on average global, but that, like you mentioned, 1:23:33.880 --> 1:23:37.400 AARIN is not at all homogeneous in places like Sub 1:23:37.439 --> 1:23:41.240 Saharan Africa. Sea section rates are around five percent. In 1:23:41.320 --> 1:23:44.040 Latin America and the Caribbean up to forty two percent, 1:23:44.200 --> 1:23:47.280 and like you said, AARON even higher in some private hospitals. 1:23:48.000 --> 1:23:51.479 In various places in Europe, we have huge variation depending 1:23:51.479 --> 1:23:54.759 on what geographic region, from like twenty four to thirty percent. 1:23:55.320 --> 1:23:58.600 All across Asia, things can vary from like twelve to 1:23:58.680 --> 1:24:03.320 thirty three percent. It's like huge, huge amounts of Australia 1:24:03.360 --> 1:24:06.360 and New Zealand are averaging around thirty three percent, and 1:24:06.400 --> 1:24:08.719 then we in the US are in the thirty percent 1:24:08.840 --> 1:24:11.120 range right now. It's up and down the last few years. 1:24:12.080 --> 1:24:14.680 And like you said, the World Health Organization has a 1:24:14.720 --> 1:24:18.479 recommendation that no more than fifteen percent of deliveries are 1:24:18.520 --> 1:24:23.160 by cesarean section. I don't know exactly how they came 1:24:23.240 --> 1:24:26.599 up with that number, but it's my understanding that that 1:24:26.680 --> 1:24:30.040 number is based on data to try and match the 1:24:30.160 --> 1:24:35.960 risk benefit ratio. How can we maximize health of both 1:24:36.000 --> 1:24:40.479 the mother and the baby and not increase the risks 1:24:40.560 --> 1:24:43.840 that we know are associated with cesarean section because there are, 1:24:44.760 --> 1:24:48.080 and there are without a doubt, circumstances where c section 1:24:48.560 --> 1:24:51.439 has and will continue to save the life of either 1:24:51.520 --> 1:24:54.400 mother or baby or both or both. Yeah, and there 1:24:54.479 --> 1:24:58.760 is no doubt about that. But deciding exactly when that 1:24:58.840 --> 1:25:04.800 point is can some be really tricky. There are some 1:25:05.160 --> 1:25:10.760 cases that pretty universally we think and we know that 1:25:10.880 --> 1:25:13.880 a c section is the most likely to save the 1:25:13.920 --> 1:25:15.560 life of mother and baby and is probably going to 1:25:15.600 --> 1:25:18.840 be recommended across the board always with like no gray 1:25:18.920 --> 1:25:22.920 areas ready for some of those factors that might be 1:25:22.960 --> 1:25:26.920 something like a placenta previa or a known placenta, a creed, 1:25:26.960 --> 1:25:30.880 a spectrum disorder like we talked about. Those are situations 1:25:30.960 --> 1:25:33.680 that Cisaian delivery is going to save the life of 1:25:33.720 --> 1:25:35.800 the baby and might also save the life of the 1:25:35.800 --> 1:25:38.519 mom because especially with placenta previa, which is where the 1:25:38.560 --> 1:25:43.799 placenta is covering the cervix, you can have significant hemorrhage 1:25:43.800 --> 1:25:45.519 which can be very dangerous for the mom as well 1:25:45.560 --> 1:25:49.880 as the baby. Another one that might happen during the 1:25:49.920 --> 1:25:53.599 course of labor after that amniotic fluid sac is broken, 1:25:54.040 --> 1:25:58.560 is called cord prolapse, and that is an absolute emergency 1:25:58.800 --> 1:26:03.160 where the umbilical cord comes out through the cervix before 1:26:03.320 --> 1:26:07.280 any part of the baby, and that is going to 1:26:07.439 --> 1:26:10.360 trap blood flow and block blood flow to the chord, 1:26:10.800 --> 1:26:13.240 which is extremely dangerous for the baby. So that is 1:26:13.360 --> 1:26:18.879 pretty universally an emergency sea section scenario. We also generally 1:26:19.160 --> 1:26:22.599 across the board recommend cesarean sections if there is a 1:26:22.600 --> 1:26:27.280 first time genital herpes outbreak or an active genital herpes infection, 1:26:27.280 --> 1:26:29.519 which people don't talk about that often, yeah they really don't, 1:26:29.760 --> 1:26:32.080 but that puts baby, if they're born vaginally, at a 1:26:32.080 --> 1:26:35.160 pretty high risk for herpes encephalitis, and so it's usually 1:26:35.200 --> 1:26:37.439 recommended to do a sea section if that is known 1:26:37.479 --> 1:26:41.439 to be happening, if somebody has had a prior uterine 1:26:41.439 --> 1:26:44.960 surgery like a very large fibroid removal, or a previous 1:26:45.240 --> 1:26:49.479 midline sea section, because most of the time, if we 1:26:49.479 --> 1:26:52.160 look at our uterus again here, most of the time 1:26:52.240 --> 1:26:55.280 these days, sea sections are done transverse, so they're cut 1:26:55.320 --> 1:26:59.160 across what's called the lower uterine segment, and that usually 1:26:59.240 --> 1:27:03.360 heals very well and a second pregnancy after that is 1:27:03.360 --> 1:27:06.360 at lower risk of uterine rupture, higher risk than with 1:27:06.439 --> 1:27:11.120 no surgery, but a mid line so an incision that 1:27:11.160 --> 1:27:13.320 goes from the top to the bottom of the uterus 1:27:13.360 --> 1:27:15.400 is a very high risk for uterine rupture with a 1:27:16.040 --> 1:27:17.639 next pregnancy. 1:27:17.479 --> 1:27:19.360 And so is the difference. So I know that today 1:27:19.400 --> 1:27:24.080 we do more transverse incisions, but historically we used to 1:27:24.080 --> 1:27:25.920 do midline. Are there is there any reason to do 1:27:26.000 --> 1:27:28.280 midline that like people do midline today. 1:27:28.400 --> 1:27:30.840 Usually it's if the baby is very small, so like 1:27:30.960 --> 1:27:33.559 very premature, then it might be really difficult to get 1:27:33.560 --> 1:27:35.680 to that lower uterine segment because it's just not up 1:27:35.720 --> 1:27:38.559 like above the pubic bone, so it's harder to access, 1:27:39.200 --> 1:27:41.519 and there might be other, like anatomic reasons that it 1:27:41.560 --> 1:27:44.000 has to be done. I'm not a surgeon, so that's 1:27:44.040 --> 1:27:47.840 not on me. That's a good question though, And so 1:27:47.880 --> 1:27:50.800 in those cases, people are usually scheduled for like a 1:27:50.840 --> 1:27:54.200 planned C section to that is, to avoid labor, because 1:27:54.200 --> 1:27:58.080 the contractions of labor can be very risky. Yeah, And 1:27:58.200 --> 1:28:01.920 like we talked about already, in most cases babies who 1:28:01.920 --> 1:28:05.479 are breach booty down or feet down instead of head down, 1:28:05.920 --> 1:28:09.200 sea section is often recommended. And it's not because it's 1:28:09.240 --> 1:28:14.000 impossible to deliver a vaginal breach delivery, but it's for 1:28:14.040 --> 1:28:17.400 a few reasons there's some data from a few studies 1:28:17.400 --> 1:28:21.200 in the US at least that it is studies that 1:28:21.240 --> 1:28:25.880 were looking at a planned cesarean delivery for a breach 1:28:25.920 --> 1:28:30.439 baby versus a planned vaginal delivery, whether or not that 1:28:30.640 --> 1:28:33.160 ended in a vaginal or a sea section, right, because 1:28:33.160 --> 1:28:35.320 you might plan for vaginal end up having a sea section. 1:28:37.479 --> 1:28:41.040 That data suggested that it was marginally safer to do 1:28:41.080 --> 1:28:46.320 a planned cesarean section in the immediate term, okay, And 1:28:46.400 --> 1:28:48.760 so because of that, for a while it was like 1:28:48.840 --> 1:28:51.519 kind of across the board recommended that you do see 1:28:51.600 --> 1:28:55.479 sections for breach deliveries if they cannot be rotated by 1:28:55.520 --> 1:29:01.200 that external cephalic version. And that recommendation plus the fact 1:29:01.280 --> 1:29:05.000 that breach deliveries are rare. I don't have an exact 1:29:05.080 --> 1:29:07.880 number on that, but most of the time babies end 1:29:07.960 --> 1:29:11.880 up head down, and so a breach presentation is relatively rare. 1:29:12.280 --> 1:29:16.240 And with those two things combined, less and less obstetricians 1:29:16.240 --> 1:29:21.320 and midwives have experience in vaginal breach deliveries, which then 1:29:21.479 --> 1:29:25.080 makes them riskier because if you haven't practiced that hands on, 1:29:25.680 --> 1:29:27.559 then you don't have as much experience with it. It's 1:29:27.560 --> 1:29:30.519 more likely that something is going to go wrong. So 1:29:30.800 --> 1:29:33.360 that is a big reason why most of the time 1:29:33.360 --> 1:29:36.760 people are recommended to get a C section if they're 1:29:37.000 --> 1:29:40.240 known to have a breach baby. Yep, So that makes. 1:29:40.040 --> 1:29:41.600 It, it does make sense. Yeah, I mean, it's like, 1:29:41.640 --> 1:29:43.880 it's a big part of just this is a tool 1:29:43.960 --> 1:29:46.720 that we use exactly, and so it's yeah, and so 1:29:46.840 --> 1:29:50.640 because we have this option exactly, we don't have to 1:29:51.000 --> 1:29:54.000 necessarily explore the option that is very risky. 1:29:54.080 --> 1:29:57.160 It is. It is, it absolutely is. And there might 1:29:57.200 --> 1:29:58.920 be others that I have missed in terms of what 1:29:59.040 --> 1:30:03.880 the more like clear cut recommendations are. But a lot 1:30:04.240 --> 1:30:05.960 of the sea sections that are done, and in a 1:30:06.000 --> 1:30:07.840 lot of cases in studies that have looked at this, 1:30:07.920 --> 1:30:12.080 and it really varies location to location, but in a 1:30:12.120 --> 1:30:16.320 lot of cases, most sea sections are not necessarily done 1:30:16.360 --> 1:30:19.320 for those reasons. They are done for reasons that fall 1:30:19.439 --> 1:30:23.280 more in this gray area in terms of who makes 1:30:23.280 --> 1:30:26.920 that decision and what point is that decision made, And 1:30:26.960 --> 1:30:31.800 those are for indications like failure to progress, failure of 1:30:31.840 --> 1:30:36.720 an induction of labor, a rest of descent so that 1:30:36.800 --> 1:30:39.200 means baby doesn't come all the way down the birth 1:30:39.200 --> 1:30:43.080 camel and get stuck, or fetal intolerance of labor, which 1:30:43.080 --> 1:30:45.320 means we're monitoring and we see that baby's heart rate 1:30:45.400 --> 1:30:50.160 is tanking and not coming back up. And so those 1:30:50.160 --> 1:30:53.040 are a lot of the main reasons that we see 1:30:53.400 --> 1:30:55.160 in studies that have looked at, like what are the 1:30:55.160 --> 1:30:57.759 indicant what are the reasons for surgery in these cases? 1:30:59.760 --> 1:31:01.960 Those are more gray areas, and in some of those 1:31:02.000 --> 1:31:05.439 cases it might be that we are saving lives, but 1:31:05.760 --> 1:31:08.400 who and when and why, Like it's it's just a 1:31:08.439 --> 1:31:11.400 harder place to make that decision, and it's much more 1:31:11.439 --> 1:31:15.040 an individual decision in that gray area, right. 1:31:15.080 --> 1:31:18.400 Like individual meaning dependent upon the specific situation, the. 1:31:18.320 --> 1:31:22.200 Specific situation the person who is in labor, the person 1:31:22.240 --> 1:31:24.320 who is going to be doing that C section or 1:31:24.680 --> 1:31:27.599 vaginal delivery, and like what their comfort level is, right, 1:31:27.640 --> 1:31:29.559 And so that's also I think when you see the 1:31:29.600 --> 1:31:33.840 most potential for trauma associated with it in terms of 1:31:33.880 --> 1:31:37.320 how I'm going to experience that because it is usually 1:31:37.400 --> 1:31:39.000 not planned in those scenarios. 1:31:39.800 --> 1:31:43.559 It's tough because whose responsibility is that? And then I 1:31:43.560 --> 1:31:45.760 feel like there's a lot of blame associated with it 1:31:45.840 --> 1:31:48.320 and a lot of trauma associated with like the questions 1:31:48.360 --> 1:31:50.320 why didn't I do this? Why didn't I ask this, 1:31:50.400 --> 1:31:52.400 Why didn't my doctor do this? Why didn't my doctor 1:31:52.439 --> 1:31:56.479 tell me this? And it's so like, how do we 1:31:56.520 --> 1:32:00.639 fix that even beyond making sure that we're eating fetal 1:32:00.720 --> 1:32:04.560 monitoring correctly right, or we're using continuous versus intribitten or 1:32:04.600 --> 1:32:08.120 what like, all of these indications, beyond measuring those, how 1:32:08.120 --> 1:32:11.280 do we then make sure that everyone, as much as 1:32:11.320 --> 1:32:13.840 we can, is okay with this decision? 1:32:14.000 --> 1:32:16.200 Right? I mean that comes down to communication, Aaron, Let's 1:32:16.200 --> 1:32:16.679 be honest. 1:32:17.280 --> 1:32:18.360 Yeah, it's a big part of it. 1:32:18.360 --> 1:32:20.400 It's a big part of it. But then there's another 1:32:20.439 --> 1:32:23.120 piece that we haven't really got into, and that is 1:32:23.280 --> 1:32:27.280 elective cesareans. Yes, and that can be a first time 1:32:27.560 --> 1:32:31.840 delivery with an elective cesarean or what's called sometimes an 1:32:31.880 --> 1:32:35.240 elective repeat cesarean. So say, whatever the reason was, you 1:32:35.360 --> 1:32:37.840 ended up with a C section your first time, and 1:32:37.880 --> 1:32:40.840 then you decide to schedule a C section for your 1:32:40.880 --> 1:32:45.760 second or third or whatever delivery. Now, I think that 1:32:46.240 --> 1:32:49.680 in this scenario, sometimes, just like with so many of 1:32:49.720 --> 1:32:52.439 the indications that we have, like, there is a lot 1:32:52.520 --> 1:32:59.760 of judgment that is placed on that and sometimes it 1:33:00.320 --> 1:33:03.240 can get to the point where we have to kind 1:33:03.240 --> 1:33:05.080 of take a step back and say, like you said, 1:33:05.160 --> 1:33:10.040 who is making this decision? If we believe, which I do, 1:33:10.880 --> 1:33:13.680 that somebody should have the right to decide whether or 1:33:13.720 --> 1:33:17.439 not they want to become pregnant or carry a pregnancy 1:33:17.479 --> 1:33:20.560 to term or not, then shouldn't they also have the 1:33:20.640 --> 1:33:23.360 right to decide whether or not they want to attempt 1:33:23.360 --> 1:33:29.759 a vaginal delivery or not? Is that a crazy concept today? 1:33:29.800 --> 1:33:30.840 It is, Yes, it. 1:33:30.680 --> 1:33:33.120 Can be, but said, I think that that part is 1:33:33.200 --> 1:33:36.479 often missing, honestly, And we can focus a lot on 1:33:36.520 --> 1:33:39.280 the potential risks of C section, and they do exist. 1:33:39.640 --> 1:33:42.839 There are also risks associated with vaginal deliveries, of course, 1:33:43.040 --> 1:33:45.719 and so I think that if we are not under 1:33:45.840 --> 1:33:49.879 selling the potential risks and complications of this major abdominal surgery, 1:33:50.240 --> 1:33:54.080 then it should be a person's right to decide what 1:33:54.280 --> 1:33:57.160 they do, yeah, and not be judged for that, and 1:33:57.200 --> 1:33:58.040 not be judged for that. 1:33:58.120 --> 1:34:03.440 Okay, do you remember Gilmore girls Sherry who is Christopher's 1:34:03.760 --> 1:34:07.760 wife vaguely yeah, yeah, yeah, And she was like very 1:34:07.840 --> 1:34:09.960 much like make the show was making fun of her 1:34:10.040 --> 1:34:13.720 because she had a planned, planned C section and then 1:34:13.760 --> 1:34:15.760 she ended up not like she ended up going into 1:34:15.800 --> 1:34:18.519 labor early and had a vaginal birth. I think that's 1:34:18.560 --> 1:34:19.040 what I remember. 1:34:19.080 --> 1:34:19.920 I remember that, but. 1:34:19.960 --> 1:34:23.320 Just like that alone, that representation of like, here's this 1:34:23.520 --> 1:34:26.560 ridiculous type a personality. Blah blah blah, she wants a 1:34:26.600 --> 1:34:29.400 see section. That is, who is electing for a sea section? 1:34:29.560 --> 1:34:30.920 And then the judgment. 1:34:30.760 --> 1:34:33.559 Judgment inherent to that. It's like, we just can't win. 1:34:33.640 --> 1:34:37.680 When if you plan that was delivery and then you 1:34:37.720 --> 1:34:40.639 had a C section, you you know, are you're getting 1:34:40.720 --> 1:34:42.760 judged for that or you feel judged for that. If 1:34:42.760 --> 1:34:44.640 you plan for a C section, you're judgement. We just 1:34:44.680 --> 1:34:45.000 can't win. 1:34:45.200 --> 1:34:46.160 We can't wine. 1:34:46.360 --> 1:34:51.439 Goodness, I know, Aaron, I want to move on, Okay, 1:34:51.560 --> 1:34:54.240 can we sure? Okay? Do you have any other questions? 1:34:54.240 --> 1:34:54.679 Probably? 1:34:54.800 --> 1:34:57.080 I have other things about sea sections, like the risk 1:34:57.120 --> 1:35:00.639 of this and like the effects on the child. 1:35:01.360 --> 1:35:04.160 I have a question about c section how we classify 1:35:04.240 --> 1:35:06.519 see sections because a lot of people use the phrase 1:35:06.560 --> 1:35:10.200 emergency C section? What is that? Is that unplanned? And 1:35:10.240 --> 1:35:13.439 then there's stages of unplanned that's like urgent, extra urgent, 1:35:13.560 --> 1:35:14.639 super urgent. Yeah. 1:35:14.680 --> 1:35:17.200 I tried to get you data on this. I read 1:35:17.240 --> 1:35:20.680 a whole paper that was about the classifications of how 1:35:20.720 --> 1:35:23.879 we classify a sea section. Yeah, it is a disaster, 1:35:24.479 --> 1:35:26.960 of course, both in terms of like sometimes they're just 1:35:27.000 --> 1:35:30.400 classified by indication, Like we talked about the indication for 1:35:30.439 --> 1:35:32.960 the C section was failure to progress or whatever. It 1:35:33.080 --> 1:35:37.559 was fetal intolerance of labor. Sometimes they're classified by urgency. 1:35:37.840 --> 1:35:40.120 This was an emergent. This was an urgent, This was 1:35:40.120 --> 1:35:45.000 a planned Okay. Sometimes they're classified by like the status 1:35:45.000 --> 1:35:47.280 of the pregnant person, so this was this was a 1:35:47.320 --> 1:35:51.639 person with preoclampsia, this was whatever this had. This paper 1:35:51.720 --> 1:35:55.599 alone had like twenty seven different systems of classification, So like, 1:35:55.840 --> 1:35:57.479 I don't know, Okay, I'm. 1:35:58.000 --> 1:36:02.040 Planned and unplanned plan big picture of breakdown. 1:36:02.080 --> 1:36:03.800 But it is true that, like if you can think 1:36:03.840 --> 1:36:05.519 of some of the scenarios that I gave of, like 1:36:05.560 --> 1:36:07.839 this would one hundred percent of the time be recommended 1:36:07.880 --> 1:36:10.840 for C section, like a cord prolapse, that would be 1:36:11.040 --> 1:36:14.360 an emergency scenario because you have a cord that is 1:36:14.400 --> 1:36:18.559 being compressed. So yes, there are scenarios that are like, well, 1:36:18.640 --> 1:36:20.720 your baby is not looking great, so we might say 1:36:20.760 --> 1:36:23.680 let's do this urgently, but we're not like everyone's sprinting. 1:36:25.160 --> 1:36:27.280 And yeah, it's true that like there's a huge range. 1:36:27.360 --> 1:36:28.240 Yeah, there's a range. 1:36:28.400 --> 1:36:32.519 Yeah, there's also sometimes, and we kind of skipped over this, 1:36:33.320 --> 1:36:37.599 what are called operative vaginal deliveries, And that doesn't necessarily 1:36:37.640 --> 1:36:40.880 mean there's an operation, but it just might mean that 1:36:40.920 --> 1:36:44.160 somebody is having a vaginal delivery and the baby is 1:36:44.200 --> 1:36:46.720 having a hard time descending that birth canal. So there 1:36:46.760 --> 1:36:48.880 are things that can be done to help that process. 1:36:49.400 --> 1:36:50.960 Sometimes it's forceps. 1:36:51.280 --> 1:36:54.840 We still have still use percentage, and I'm sure there's 1:36:54.920 --> 1:36:56.439 various global blah blah blah. 1:36:56.479 --> 1:36:57.920 I don't have numbers on that because it also just 1:36:58.000 --> 1:37:01.519 varies hospital to hospital and training. How much training does 1:37:01.520 --> 1:37:03.720 it does an OBI get For the place forceps that 1:37:03.760 --> 1:37:06.839 I worked, there was someone who really was very adept 1:37:06.840 --> 1:37:09.080 at forceps and so would use them very frequently. So 1:37:09.120 --> 1:37:10.840 I know that the trainees there got a lot of 1:37:10.840 --> 1:37:13.519 training with forceps. At other places they might not. They 1:37:13.600 --> 1:37:16.760 might use what's called a vacuum. This is what it 1:37:16.840 --> 1:37:19.480 looks like if you're seeing this on video. It basically 1:37:19.680 --> 1:37:23.519 is a little disc, a plastic disc that sometimes has 1:37:23.560 --> 1:37:26.160 a bit of phone in the middle. This is placed 1:37:26.280 --> 1:37:30.880 on the baby's head here, yeah, and then you basically 1:37:31.120 --> 1:37:36.240 pump this up and it suctions itself to the baby's head, 1:37:36.760 --> 1:37:39.120 and then you're able to use that to pull the 1:37:39.160 --> 1:37:43.240 baby down to basically provide traction to help that baby descend. 1:37:43.640 --> 1:37:45.680 What about the soft spot so they can get a 1:37:45.680 --> 1:37:49.080 little bit of a hematoma there, Okay, yeah, but they 1:37:49.160 --> 1:37:49.880 usually do great. 1:37:50.360 --> 1:37:50.719 Wow. 1:37:51.400 --> 1:37:53.400 So yeah, So there's a lot of reasons why somebody 1:37:53.439 --> 1:37:55.680 might need a little bit of additional assistance, but not 1:37:55.960 --> 1:37:57.439 to the point of a C section. And it's all 1:37:57.439 --> 1:38:00.080 going to depend on the individual scenario and how how 1:38:00.240 --> 1:38:04.679 far you've progressed in labor up to that point. Okay, okay, 1:38:04.680 --> 1:38:06.639 but all of that was still just the second stage 1:38:06.680 --> 1:38:09.479 of labor. We have a whole nother stage to go. 1:38:11.280 --> 1:38:14.160 The third and final stage of labor is delivery of 1:38:14.200 --> 1:38:17.760 the placenta. Yeah, and that can take anywhere from like 1:38:17.920 --> 1:38:20.080 a couple of minutes to like a half an hour 1:38:20.240 --> 1:38:20.559 or so. 1:38:21.160 --> 1:38:21.680 Interesting. 1:38:21.840 --> 1:38:24.800 Most of the time the placenta detaches all on its own. 1:38:25.400 --> 1:38:28.599 Sometimes it doesn't, and it might get stuck, and then 1:38:28.640 --> 1:38:33.120 it might require manual removal, which can be quite uncomfortable. 1:38:34.040 --> 1:38:36.120 And then, like we talked kind of a lot about already, 1:38:36.439 --> 1:38:38.920 sometimes it might have gone too deep into the myometrium 1:38:38.960 --> 1:38:41.519 and actually have extended too far and might require surgery 1:38:41.560 --> 1:38:44.840 to remove, or in very extreme cases, it might require 1:38:44.880 --> 1:38:45.680 a hysterectomy. 1:38:45.960 --> 1:38:46.320 Okay. 1:38:46.880 --> 1:38:49.680 The reason that the removal of the placenta is so 1:38:49.840 --> 1:38:53.839 important is because without the placenta removed, you cannot stop 1:38:53.960 --> 1:38:56.760 the bleeding. So I want to talk about blood for 1:38:56.800 --> 1:39:02.839 a second. Yeah, I remember last episode. Our blood volume 1:39:02.920 --> 1:39:08.200 during pregnancy has increased by about fifty percent. At term, 1:39:08.520 --> 1:39:13.560 your uterus is receiving twelve to twenty percent, depending on 1:39:13.600 --> 1:39:16.519 which papers you read, of your total blood flow, your 1:39:16.600 --> 1:39:22.160 total cardiac output, which is like seven hundred milliliters every minute. 1:39:22.840 --> 1:39:29.040 That's wild. With every contraction, your uterus is shunting three 1:39:29.120 --> 1:39:32.599 hundred to five hundred milliliters of blood back into your 1:39:32.600 --> 1:39:35.200 circulation because it's just basically pushing out all of this 1:39:35.320 --> 1:39:38.439 blood like it's a sponge that you're ringing out. So 1:39:38.800 --> 1:39:43.439 immediately after delivery of the placenta, you have all of 1:39:43.479 --> 1:39:47.200 these spiral arteries in your uterus that have become enlarge 1:39:47.200 --> 1:39:51.599 in order to provide constant blood flow to the placenta. 1:39:51.640 --> 1:39:54.519 These have to find a way to stop because if 1:39:54.560 --> 1:39:57.439 they do not stop, then you are continuing to just bleed. 1:39:58.760 --> 1:40:02.759 So to do that, but your uterus has to clamp 1:40:02.840 --> 1:40:07.120 down very quickly, and it usually does, and it's phenomenal, 1:40:07.880 --> 1:40:11.200 Like after that placenta is out, your uterus goes from 1:40:11.200 --> 1:40:14.120 like the size of a watermelon, yeah, to like the 1:40:14.160 --> 1:40:17.760 size of a I don't know, miniature basketball, like yeah, 1:40:17.960 --> 1:40:23.840 very quickly. Yeah, but sometimes it doesn't. And postpartum hemorrhage, 1:40:24.240 --> 1:40:27.200 which is defined as the loss of more than one 1:40:27.520 --> 1:40:32.000 leader of blood okay, regardless of the method of delivery. 1:40:32.040 --> 1:40:33.920 It used to be defined differently for a C section 1:40:34.000 --> 1:40:36.519 versus a vaginal delivery. Okay, but it's not because now 1:40:36.520 --> 1:40:38.160 we know we can do se sections with very little 1:40:38.160 --> 1:40:44.559 blood loss. Yeah, postpartum hemorrhage one leader of blood. Even 1:40:44.720 --> 1:40:47.000 that much blood loss, a lot of times people are 1:40:47.040 --> 1:40:50.400 not symptomatic because of how much blood volume you have, 1:40:51.439 --> 1:40:55.880 which also means that people can lose a very significant 1:40:55.920 --> 1:41:00.519 amount of blood during the delivery process. Okay, Okay, let's 1:41:00.560 --> 1:41:00.960 go wrong. 1:41:01.040 --> 1:41:04.960 So because someone who is pregnant and at term has 1:41:05.080 --> 1:41:08.560 so much more blood than someone who is not pregnant. 1:41:08.160 --> 1:41:10.719 And so much blood is going to the uterus, yes. 1:41:10.960 --> 1:41:15.679 And so then that blood loss is not is not 1:41:15.760 --> 1:41:18.080 like as severe as it would be or like the 1:41:18.560 --> 1:41:20.439 consequence of it is not as severe as it would 1:41:20.479 --> 1:41:22.920 be if someone was the same amount of blood loss 1:41:22.960 --> 1:41:24.800 the same. Yeah, like because you have more blood to 1:41:24.880 --> 1:41:25.800 lose that you can live. 1:41:25.880 --> 1:41:28.840 You have more blood that you can lose, and you 1:41:28.880 --> 1:41:31.640 can lose way too much blood very quickly. Yes, So 1:41:31.680 --> 1:41:34.160 it's like both and yes, yes, yes, okay, And so 1:41:34.200 --> 1:41:36.120 that's why the limit is like one leader. One leader 1:41:36.160 --> 1:41:38.240 is a lot of leaders, a ton of blood, so 1:41:38.360 --> 1:41:40.960 much blood. But a lot of times people are maybe 1:41:41.000 --> 1:41:43.240 not symptomatic until they lose like one and a half 1:41:43.360 --> 1:41:45.240 liters or even two leaders of blood, which is like 1:41:45.320 --> 1:41:47.880 twenty five percent of your total bloodvaulume. It's a huge 1:41:48.160 --> 1:41:51.439 it's a huge amount of blood. So postpartum hemorrhage is 1:41:51.720 --> 1:41:55.280 estimated to effect anywhere from three to ten percent of deliveries, 1:41:55.320 --> 1:41:59.000 but it accounts for twenty percent of maternal deaths worldwide 1:41:59.720 --> 1:42:02.679 income countries. That number is less, in large part because 1:42:02.680 --> 1:42:05.959 we have really good options on how to stop postpartum hemorrhage. 1:42:07.000 --> 1:42:09.639 Though the rate of hemorrhage has been on the rise 1:42:11.000 --> 1:42:14.519 from in the US from nineteen ninety three to twenty fourteen, 1:42:14.880 --> 1:42:18.280 the rate of hemorrhage that required a blood transfusion, which 1:42:18.320 --> 1:42:21.760 is like not that means it's a pretty severe hemorrhage 1:42:22.200 --> 1:42:25.640 increased from eight per ten thousand deliveries to forty per 1:42:25.720 --> 1:42:30.080 ten thousand deliveries in the US. So why people are 1:42:30.120 --> 1:42:33.360 bleeding more in part probably because of other risk factors 1:42:33.400 --> 1:42:36.200 that are associated r like things like placenta accreda spectrum 1:42:36.240 --> 1:42:38.720 disorders which are on the rise, preaclampsia. A lot of 1:42:38.720 --> 1:42:42.840 these are risk factors for postpartum hemorrhage. There's four main 1:42:43.160 --> 1:42:46.520 things that we think of as like causal for postpartum hemorrhage. 1:42:46.960 --> 1:42:49.479 Most of the time it's because of uterine At me me, 1:42:49.600 --> 1:42:52.479 it's because of that uterus not clamping down to the 1:42:52.520 --> 1:42:54.960 size of a small basketball the way that it ought to, 1:42:55.640 --> 1:42:57.799 because then you just have so much blood being shunted 1:42:57.840 --> 1:43:00.439 to the uterus and it's just flowing down, blowing out 1:43:00.520 --> 1:43:03.360 because these arteries are not being clamped down. And the 1:43:03.479 --> 1:43:06.200 risks for having a uterus that has a hard time 1:43:06.200 --> 1:43:09.840 clamping down might be a retained placenta so a little 1:43:09.840 --> 1:43:13.040 piece of it that hasn't come off, or a prolonged 1:43:13.120 --> 1:43:17.760 labor Definitions vary on that. Gestational diabetes is a risk 1:43:17.880 --> 1:43:21.400 for this any kind of hypertensive disorders, and then there 1:43:21.680 --> 1:43:24.800 are probably other factors as well, But the other main 1:43:24.800 --> 1:43:28.360 factors that contribute to postpartum hemorrhage are things like trauma, 1:43:28.880 --> 1:43:32.040 so maybe lacerations, so that might not be even bleeding 1:43:32.080 --> 1:43:36.080 from the uterus, but just bleeding from elsewhere from lacerations, 1:43:37.040 --> 1:43:40.240 retain placenta or retain blood clots, even that can just 1:43:40.320 --> 1:43:42.880 prevent that uterus so it's like it's trying to clamp down, 1:43:42.880 --> 1:43:47.680 but there's something blocking it. And then also what they 1:43:47.760 --> 1:43:52.320 call thrombin or clotting factor deficiencies, which are not that uncommon, 1:43:52.520 --> 1:43:56.360 which is okay, like in general in general, because are 1:43:56.360 --> 1:44:00.160 like more like genetic susceptibilities, right, okay, Yeah, And there 1:44:00.160 --> 1:44:02.040 are a lot of different medications that we can now 1:44:02.200 --> 1:44:05.880 use to help stop the bleeding, to either induce contraction, 1:44:06.080 --> 1:44:09.800 and then also like devices like balloons and things like 1:44:09.840 --> 1:44:12.120 that that we can use to clamp down and block 1:44:12.160 --> 1:44:16.080 off those arteries, or in some cases people might need 1:44:16.120 --> 1:44:18.880 to have what's called a uterine artery embolization, so they 1:44:18.880 --> 1:44:21.320 put like a coil in to help block blood flow 1:44:21.360 --> 1:44:23.200 to the artery so you're not getting as much flow 1:44:23.240 --> 1:44:27.480 to that area. Okay, and that those kinds of developments 1:44:27.600 --> 1:44:32.360 are why we've seen a reduction in the mortality from hemorrhage. 1:44:32.840 --> 1:44:35.160 I see, even as we've seen an increase in the 1:44:35.280 --> 1:44:40.679 risk of hemorrhage. Okay, yeah, okay. But in the event 1:44:41.240 --> 1:44:45.639 that all of that happens well enough, and a baby 1:44:45.760 --> 1:44:51.080 is delivered one way or another, vaginally, spontaneously, vaginally, operatively 1:44:51.120 --> 1:44:55.080 so with assistance or a C section, after that third 1:44:55.120 --> 1:44:57.840 stage of labor, pregnancy is done. 1:45:00.040 --> 1:45:00.679 Or is it? 1:45:01.120 --> 1:45:03.639 Or is it? But that's where we'll pick up next week. 1:45:03.760 --> 1:45:04.000 Okay. 1:45:04.040 --> 1:45:06.120 I have a couple of questions that I jotted down. 1:45:06.680 --> 1:45:09.559 I saw you writing, Yeah, I didn't want to forget 1:45:09.640 --> 1:45:10.280 back labor. 1:45:10.520 --> 1:45:14.439 Ah, okay. So back labor just means that you're feeling 1:45:14.479 --> 1:45:18.320 the contractions primarily in your back rather than feeling them 1:45:18.320 --> 1:45:22.439 across your abdomen. Okay, why does it happen? I don't know. 1:45:22.560 --> 1:45:26.000 Is it just anatomic sometimes or et cetera. Sometimes people 1:45:26.040 --> 1:45:28.040 will say it's more based on position. 1:45:27.760 --> 1:45:28.840 Of the baby. 1:45:28.880 --> 1:45:31.559 So if the baby is op so on the put 1:45:31.600 --> 1:45:34.280 back and face up, then sometimes people are more likely 1:45:34.320 --> 1:45:36.800 to have back labor. Doesn't necessarily mean baby will come 1:45:36.840 --> 1:45:38.920 out that way because they rotate this way quite a 1:45:38.960 --> 1:45:43.000 lot during labor and delivery. Spiral spiral. Yeah, they don't 1:45:43.080 --> 1:45:45.240 like tend to flip upside down, though sometimes they do. 1:45:45.520 --> 1:45:49.360 Sorry baby, Okay, back labor, Yes, back labor. 1:45:49.640 --> 1:45:54.520 Tearing. Let's talk about tearing. Okay, let's talk about episiotomies. 1:45:54.720 --> 1:45:56.880 I have a little bit of extra notes here just 1:45:56.920 --> 1:45:57.720 for you. 1:45:57.720 --> 1:45:58.920 You know me, I do know it. 1:46:00.479 --> 1:46:05.080 An episiotomy means that somebody makes a cut, makes an 1:46:05.120 --> 1:46:08.840 incision in the perineum, in the skin of the perineum, 1:46:09.439 --> 1:46:12.439 so that's the space of skin between the opening of 1:46:12.479 --> 1:46:16.720 the vagina and the opening of your anus. They have 1:46:16.880 --> 1:46:19.479 very much fallen out of favor. Yeah, they have. They 1:46:19.600 --> 1:46:20.920 used to be quite common. 1:46:21.080 --> 1:46:22.760 You know that no one did a study on them 1:46:22.840 --> 1:46:26.519 until the nineteen seventies about are these something we should 1:46:26.560 --> 1:46:26.960 be doing? 1:46:27.080 --> 1:46:31.120 Not surprised at all. I have had the fortune of 1:46:31.160 --> 1:46:34.439 working with some pretty phenomenal obgi ns in my training, 1:46:34.720 --> 1:46:37.519 and one that I worked with explained it to me 1:46:37.680 --> 1:46:43.200 very well. I think as an episiotomy is helping to 1:46:43.280 --> 1:46:48.320 increase soft tissue, right because it's basically it's only skin, 1:46:48.520 --> 1:46:51.439 so you're cutting in skin most of the time. If 1:46:51.479 --> 1:46:54.880 a baby is having trouble descending to the birth canal, 1:46:55.200 --> 1:46:56.960 Shall I get out my pelvis model? 1:46:57.080 --> 1:46:57.360 Yes? 1:46:57.400 --> 1:47:01.160 Please, I have a very large pelvist here. Most of 1:47:01.200 --> 1:47:03.640 the time, if a baby is having trouble descending the 1:47:03.640 --> 1:47:07.400 birth canal, it's not soft tissue of your paraneum that's 1:47:07.439 --> 1:47:10.479 causing the trouble, or even the tissue of the vaginal 1:47:10.479 --> 1:47:15.679 canal itself. It's your bones, right, So episiotomies don't help 1:47:15.720 --> 1:47:16.400 with any of that. 1:47:16.920 --> 1:47:18.080 It's our bipedalism. 1:47:18.160 --> 1:47:21.559 It's our bipedalism, and so because of that, they have 1:47:21.640 --> 1:47:24.240 very much fallen out of favor. They make it easier 1:47:24.360 --> 1:47:28.040 for somebody to use their hands in the vaginal canal 1:47:28.200 --> 1:47:30.840 to help in the case of a difficult delivery, so 1:47:30.880 --> 1:47:33.760 it's not that they're never done. They also increase the 1:47:33.840 --> 1:47:36.320 risk of fourth degree tears, which is a tear that 1:47:36.360 --> 1:47:38.840 goes all the way into the anal sphincter itself and 1:47:38.920 --> 1:47:42.840 can have severe longtime consequences like an increased risk of 1:47:44.120 --> 1:47:47.800 fecal incontinence, fiscilla formation, other things like that. 1:47:47.880 --> 1:47:52.040 Yeah, I mentioned fishila. What is official. 1:47:51.760 --> 1:47:55.799 Officila is any connection between two places that doesn't belong. 1:47:55.920 --> 1:47:59.040 So most often in the case of like after a 1:47:59.120 --> 1:48:03.080 vaginal delivery, you might have a fistulla into the anal 1:48:03.120 --> 1:48:05.200 canal or something like that, like from the from the 1:48:05.280 --> 1:48:08.280 a from the rectum into the vagina or something like that. 1:48:08.720 --> 1:48:11.800 Very very uncommon these days. Used to be much much 1:48:11.840 --> 1:48:14.759 more common, very very. 1:48:14.720 --> 1:48:19.640 Common instruments pessories that people There are hundreds of variations 1:48:20.040 --> 1:48:22.439 of these that people would use to prevent, you know, 1:48:22.840 --> 1:48:25.760 to different and also uterine prolapse and so on and 1:48:25.760 --> 1:48:26.160 so forth. 1:48:26.360 --> 1:48:29.040 It's just like, so, yes, c sections have definitely reduced 1:48:29.040 --> 1:48:31.360 the risk of those kinds of things. Yeah, for sure, yes, 1:48:32.160 --> 1:48:36.519 but yes, but some degree of tearing is often it's 1:48:36.560 --> 1:48:40.320 really common, and the we call them different degrees based 1:48:40.360 --> 1:48:42.800 on how deep they go. Essentially, so whether it's just 1:48:42.880 --> 1:48:45.639 a skin tear, like just a small superficial tear that's 1:48:45.680 --> 1:48:49.000 called the first degree, A second degree tear goes through 1:48:49.200 --> 1:48:52.000 into the perineum, so into that space between the opening 1:48:52.080 --> 1:48:54.800 of the vagina and the anus. A third degree will 1:48:54.840 --> 1:48:57.000 go into the muscle, but not all the way to 1:48:57.040 --> 1:48:59.920 the anal sphincter, and then a fourth degree goes off 1:49:00.240 --> 1:49:03.120 and by the way, okay, so episiotomies have definitely fallen 1:49:03.120 --> 1:49:08.439 out of favor, they're still used in some places. Yeah. 1:49:08.760 --> 1:49:10.559 I didn't even mention the husband's ditch, but we're not 1:49:10.600 --> 1:49:12.799 going to go there, we won't. You you can google 1:49:12.880 --> 1:49:14.040 that and be horrified. 1:49:15.960 --> 1:49:18.599 Other questions aarin, I don't think so, Okay, I think 1:49:18.640 --> 1:49:20.720 I us a lot. I probably could have covered even more, 1:49:20.760 --> 1:49:24.280 but listen, there's so much to cover. I didn't even 1:49:24.280 --> 1:49:26.839 talk about epidurals, but that's for a future episode. 1:49:26.920 --> 1:49:29.760 Yeah, we really need to do episodes. I want to 1:49:29.840 --> 1:49:32.360 talk about Twilight Sleep in more detail. I want to 1:49:32.360 --> 1:49:34.000 talk about the development of epidurals. 1:49:34.080 --> 1:49:35.639 Yeah, yeah, there's the future episode. 1:49:35.720 --> 1:49:36.439 It is. 1:49:36.479 --> 1:49:38.280 We have a lot that you can learn more about 1:49:38.320 --> 1:49:40.040 just by reading the sources that we read. 1:49:40.200 --> 1:49:42.439 We read some great sources, so let me shout out 1:49:42.479 --> 1:49:44.840 a few. I already mentioned the two books that I read, 1:49:44.880 --> 1:49:49.559 Invisible Labor by Rachel Summerstein and cesarean section by Jacqueline Wolf. 1:49:49.920 --> 1:49:51.519 But I also want to shout out a couple other 1:49:51.560 --> 1:49:56.120 papers here. One is by Dunsworth and Eccleston called the 1:49:56.120 --> 1:50:00.439 Evolution of Difficult Childbirth and Helpless Hominin Infants from twenty fifteen, Okay, 1:50:00.680 --> 1:50:04.080 and then a paper by Rosenberg and Trevathan titled Birth 1:50:04.120 --> 1:50:07.280 Obstetrics and a Human Evolution from two thousand and two. 1:50:07.920 --> 1:50:09.080 Interesting stuff, Okay. 1:50:09.720 --> 1:50:12.160 I had a number of papers for this, a few 1:50:12.280 --> 1:50:16.400 that I will shout out. One was just from the 1:50:16.439 --> 1:50:18.560 New England Journal Medicine from nineteen ninety nine called the 1:50:18.560 --> 1:50:21.040 Control of Labor pre basic but a good overview of 1:50:21.439 --> 1:50:23.639 labor and what we think we know about it. One 1:50:23.640 --> 1:50:27.240 that I loved was from the Journal of Perinatal Medicine 1:50:27.280 --> 1:50:31.320 called Cesarean Section one hundred years nineteen twenty to twenty twenty. Oh, good, 1:50:31.320 --> 1:50:32.120 bad and the ugly. 1:50:32.200 --> 1:50:32.760 I read that one. 1:50:32.800 --> 1:50:33.360 It was really good. 1:50:33.400 --> 1:50:34.519 Pezzone really loved it. 1:50:35.240 --> 1:50:38.519 A review of postpartum hemorrhage titled Postpartum Hemorrhage from the 1:50:38.520 --> 1:50:41.400 New England Journal of Medicine twenty twenty one. And then 1:50:41.640 --> 1:50:43.600 a paper that I didn't even get into this but 1:50:43.840 --> 1:50:48.240 is very interesting was from twenty eighteen in Plos Medicine 1:50:48.479 --> 1:50:52.040 plus Medicine called long Term Risks and Benefits associated with 1:50:52.040 --> 1:50:55.840 Cesarean Delivery for Mother Baby and Subsequent Pregnancies Systematic review 1:50:55.840 --> 1:50:58.000 and meta analysis. And I didn't get into it, but there 1:50:58.080 --> 1:51:00.599 is a lot most of the data on se sections 1:51:00.640 --> 1:51:03.519 really focuses on short term risks and benefits, and there's 1:51:03.560 --> 1:51:05.839 not as much known about long term risks and benefits, 1:51:06.200 --> 1:51:09.040 and so this paper was interesting for that perspective. 1:51:09.160 --> 1:51:12.320 Well, and that's something that I feel like I thought, 1:51:12.360 --> 1:51:15.360 I now I do have another question is like is 1:51:15.400 --> 1:51:17.720 this this aspect of short versus long term? Because I 1:51:17.720 --> 1:51:20.280 think one of the things that often gets mentioned is 1:51:20.320 --> 1:51:23.680 like vaginal microbiome and stuff like that, and it's like, 1:51:24.080 --> 1:51:27.599 what are the long term outcomes? We talk about, oh, 1:51:27.640 --> 1:51:30.040 well the risks and you're going on your notes. 1:51:30.479 --> 1:51:31.800 I keep going, I've got notes. 1:51:31.880 --> 1:51:36.240 Yes, we talk about okay, well are there long term 1:51:36.240 --> 1:51:39.799 associations with allergies, autommune disorders? Stuff like that that often 1:51:39.840 --> 1:51:43.000 gets linked but we don't is the how is the 1:51:43.040 --> 1:51:44.519 data create Aaron? 1:51:44.640 --> 1:51:49.880 Okay, So there is data to support the idea that 1:51:50.000 --> 1:51:53.760 C sections might be associated with a slightly increased risk 1:51:53.840 --> 1:51:59.480 of asthma and other atopic diseases for the baby during childhood. 1:52:00.439 --> 1:52:04.200 That data does, it's not super strong, like going all 1:52:04.200 --> 1:52:06.800 the way to adulthood, if that makes sense, where like 1:52:06.920 --> 1:52:10.479 adults are not necessarily at higher risk of asthma and 1:52:10.560 --> 1:52:13.720 allergies if they were born by C section. But it's 1:52:13.760 --> 1:52:16.080 also in part like we just don't have studies that 1:52:16.240 --> 1:52:21.880 show that this idea of like a microbiome association. People 1:52:21.920 --> 1:52:25.560 really like this idea. There is data that there is 1:52:25.600 --> 1:52:28.719 a shift in the microbiome of babies who are born 1:52:29.400 --> 1:52:32.200 via the abdominal root, so via a C section, compared 1:52:32.240 --> 1:52:35.160 to babies who are born via vaginal delivery, but we 1:52:35.240 --> 1:52:38.000 do not have data to show any long term effects 1:52:38.000 --> 1:52:41.240 of this. We don't know that that is why we 1:52:41.280 --> 1:52:44.960 see this slightly increased risk of atopic diseases. Like, there's 1:52:45.000 --> 1:52:47.960 no causal link that we have there, it's all correlation. 1:52:49.160 --> 1:52:52.120 And there is right now no data to suggest that 1:52:52.320 --> 1:52:55.599 vaginal seeding, so like taking swabs from the vagina and 1:52:55.640 --> 1:52:57.280 putting it on a baby who is born se section. 1:52:57.320 --> 1:53:00.240 That's not recommended, at least by ACOG. Right now, we 1:53:00.280 --> 1:53:02.120 do not have data that it is safe or effective. 1:53:02.439 --> 1:53:06.719 The microbiome is just one of those words that means 1:53:07.000 --> 1:53:08.000 many different things. 1:53:08.080 --> 1:53:09.880 Yeah, we just don't We just don't have data on it. 1:53:09.960 --> 1:53:12.080 We don't have data, and it's so complex to do 1:53:12.120 --> 1:53:12.439 the data. 1:53:12.479 --> 1:53:14.719 Yeah, right, and and again it's like you you also 1:53:14.760 --> 1:53:17.200 have to take into account the short term is and benefits, 1:53:17.240 --> 1:53:19.160 and you can't just only think about these long term 1:53:19.200 --> 1:53:21.840 things like it's it is all very nuanced and there's 1:53:21.880 --> 1:53:25.439 not like a right or a wrong or a whatever right. 1:53:25.479 --> 1:53:28.600 It is all it is all childbirth. 1:53:28.760 --> 1:53:30.479 It's all child birth. I mean, I think also the 1:53:30.479 --> 1:53:32.639 effect size is the other thing that we just don't 1:53:32.640 --> 1:53:33.599 have good handle on, right. 1:53:33.760 --> 1:53:35.960 Definitely, not definitely not definitely not so so. 1:53:36.320 --> 1:53:39.080 Yeah, I feel like I have more to say, but 1:53:39.200 --> 1:53:41.000 I guess there's one more episode to say. 1:53:41.760 --> 1:53:42.800 Let's say it next week. 1:53:42.880 --> 1:53:47.400 Yes, a big, huge thank you really like we don't 1:53:47.439 --> 1:53:49.320 we don't have the words to thank all of the 1:53:49.360 --> 1:53:51.559 providers of our first hand accounts. It really means the 1:53:51.560 --> 1:53:53.280 world to us, so holy share your stories. 1:53:53.360 --> 1:53:55.720 Thank you, thank you, thank you, thank you, thank you. 1:53:56.040 --> 1:53:59.120 Thank you also to everyone here at Exactly Right Studios. 1:53:59.280 --> 1:54:01.760 We've got Leon, We've got Jessica, We've got Brent, We've 1:54:01.760 --> 1:54:04.080 got Craig, We've got everyone. 1:54:03.640 --> 1:54:05.960 Who's many amazing people. 1:54:06.080 --> 1:54:07.200 Thank you guys so much. 1:54:07.400 --> 1:54:10.600 Thank you. Thank you also to Bloodmobile for providing the 1:54:10.680 --> 1:54:12.400 music for this episode and. 1:54:12.560 --> 1:54:15.600 All of our episodes, and thank you to you listeners 1:54:15.880 --> 1:54:18.080 for listening. We've got a lot of fun doing these episodes. 1:54:18.080 --> 1:54:19.200 We've got one more still to come. 1:54:19.320 --> 1:54:22.800 Yeah what we hope you learned something or something I 1:54:22.880 --> 1:54:23.240 don't know. 1:54:23.400 --> 1:54:25.639 Yeah tell us, yeah, tell us we'd loved or hated 1:54:25.680 --> 1:54:29.240 it okay either way. And especial thank you as always 1:54:29.240 --> 1:54:30.639 to our trends. 1:54:31.240 --> 1:54:32.760 Really, your support means so much to us. 1:54:32.760 --> 1:54:35.120 We appreciate it. Thank you well. 1:54:35.200 --> 1:54:38.400 Until next time, wash your hands animals 1:55:02.480 --> 1:55:02.680 FU