Speaker 1: We want to start with a disclaimer that throughout this
Speaker 1: series we feature explanations and stories that include some heavy material,
Speaker 1: including early pregnancy, loss, stillbirth, and other traumatic experiences of pregnancy, childbirth,
Speaker 1: and the postpartum period.
Speaker 2: Hi.
Speaker 3: My name's Catherine, and I'm really excited to share my
Speaker 3: birth story with you guys. I had a totally healthy,
Speaker 3: totally normal pregnancy. Nothing was wrong. There was no inclination
Speaker 3: that anything was going to be, you know, different about
Speaker 3: my baby when she was born. I come from a
Speaker 3: line of moderately tall people, with an outlier my brother
Speaker 3: being six foot seven. He is the tallest person in
Speaker 3: my entire family, and we don't really know where it
Speaker 3: came from. So, you know, I was very curious to
Speaker 3: know how big my baby was going to be, and
Speaker 3: I had asked around my thirty six week appointment if
Speaker 3: they had any idea how big she was going to be.
Speaker 3: I'd been measuring normal my entire pregnancy, and they said,
Speaker 3: you know, it's kind of hard to tell unless there's
Speaker 3: something very abnormal, like she's very small or vain large.
Speaker 3: It's kind of a surprise how big they're going to
Speaker 3: be within that, you know, like six to eight pound
Speaker 3: range that babies usually are, and I was very large
Speaker 3: when I went into labor. I went into labor at
Speaker 3: forty weeks in five days, so I just thought I
Speaker 3: was really, really pregnant. I didn't think anything of it,
Speaker 3: but when they started doing cervical checks while I was
Speaker 3: in labor, the doctor told me that he was feeling
Speaker 3: what he thought was going to be a nine pound baby,
Speaker 3: and I said, excuse me, because I had no idea
Speaker 3: I was going to have that big of a baby,
Speaker 3: like I had even asked. And I did fail my
Speaker 3: first gluecose check when we were doing them during pregnancy,
Speaker 3: but I passed the second three hour test, so they
Speaker 3: weren't really concerned. I was never diagnosed with gestational diabetes,
Speaker 3: so you can imagine my surprise. You know, I'm dilating
Speaker 3: and I'm getting an epidural and everything was going really normal.
Speaker 3: I pushed for almost four hours and I started just
Speaker 3: getting really fatigued. My epidural was kind of wearing off
Speaker 3: and it wasn't really working that well, so the doctor
Speaker 3: suggested setting up for a vacuusist delivery, which is where
Speaker 3: they literally use a suction cup to suctionto the baby's
Speaker 3: head to help you pull them out, and there's some
Speaker 3: complications that can come with that, so you know, they
Speaker 3: brought in some extra hands and it was a little
Speaker 3: nerve racking, and I was actually able to push her
Speaker 3: out on my very last push before they were going
Speaker 3: to start the vacuumsist. Everybody was all in their sterile
Speaker 3: field and everything, and I was able to push her out,
Speaker 3: and I ended up having a ten pound point zero
Speaker 3: one ounce baby girl who was a ninety six percentile
Speaker 3: for weight and ninety first percentile for height. And to
Speaker 3: this day, she's three and a half and she's still
Speaker 3: at the very top of her growth curve. She's probably
Speaker 3: almost forty five pounds and she's over three feet tall.
Speaker 3: She's a very tall girl. So we're gonna be really
Speaker 3: excited to see how tall she ends up the older
Speaker 3: she gets. But that's my birth story about how I
Speaker 3: almost had a vacuum cist and a surprise ten pound baby.
Speaker 4: Hi.
Speaker 5: I'm Nicole C. And this is my birth story. I
Speaker 5: had a pretty uneventful pregnancy. My water broke two days
Speaker 5: before my due date. I did everything I could to
Speaker 5: avoid birth drama. I chose the hospital for me, I
Speaker 5: researched my rights, I took the hospital's classes, I hired
Speaker 5: a doula, and I made a birth plan that I
Speaker 5: gave out to absolutely everyone. But none of that was enough.
Speaker 5: In the end, my baby was angled wrong. Even as
Speaker 5: I dilated and progressed, she would not ascend into the
Speaker 5: birth canal. Ultimately she began to struggle. As I later
Speaker 5: learned she had maconium aspiration syndrome or MIS. After twenty
Speaker 5: seven hours of labor, I had no choice put to
Speaker 5: undergo a sea section. Exhausted, scared and devastated, I was
Speaker 5: ripped away from my husband and doulah and wheeled into
Speaker 5: the operating room. During the sea section, I had my
Speaker 5: support people back, but still felt in the dark. I
Speaker 5: had no idea what was happening down there at any
Speaker 5: given stage, and was wholly unprepared for my current reality.
Speaker 5: After a few minutes, my baby, my Katie, emerged, purple
Speaker 5: and with an iron grip on the umbilic cord. There
Speaker 5: was no crying. They rushed her over to a separate
Speaker 5: area in the corner of the room. I had a
Speaker 5: video monitor where I could watch them work on her
Speaker 5: as my team continued to work on me. After a
Speaker 5: few minutes, she was rushed off to the nick You.
Speaker 5: My husband went with her. It was basically my worst
Speaker 5: nightmare of birth. Thankfully, after some initial help breathing in
Speaker 5: five days in the nick You, Katie came home, healthy, strong,
Speaker 5: and loud. She's nine months old now and absolutely thriving.
Speaker 5: Even once I knew she was okay, though, I continued
Speaker 5: to a grieve for the birth experience I imagined, for
Speaker 5: the initial bonding time i'd missed for my babies first cry,
Speaker 5: for the opportunity to share that experience with my husband.
Speaker 5: I felt like I failed, like I should have done more.
Speaker 5: I think the rhetoric around c sections definitely contributed to
Speaker 5: my birth trauma and feelings of failure. All I heard
Speaker 5: ahead of time about them was how they're done way
Speaker 5: too much these days, and how you should challenge doctors
Speaker 5: who recommend them or even consider switching obs. In many cases,
Speaker 5: sea section discussion was sidestepped at every turn. It was like,
Speaker 5: don't worry about that or think about it too much.
Speaker 5: It's super unlikely you'll need one, and it's best not
Speaker 5: to scare yourself thinking about it, as if I was
Speaker 5: some delicate flower wholly id equipped to hear anything that
Speaker 5: wasn't sunshine and rainbows instead of an adult human who
Speaker 5: best case scenario was about to go through vaginal labor
Speaker 5: and delivery. I wish I had fought through the patronizing rhetoric,
Speaker 5: did more sea section research, and prepared myself for any possibility.
Speaker 5: Knowledge is empowering. Just as fed is best in the
Speaker 5: breastfeeding versus formula discussion, safe and healthy is best in
Speaker 5: the vaginal delivery versus sea section discussion. Every case, every
Speaker 5: birthing parent, and every baby is different. Every route to
Speaker 5: birth is valid. We all did the hardest thing. Don't
Speaker 5: let anybody, even your own brain tell you field.
Speaker 1: Thank you all so much for sharing your stories with us.
Speaker 1: It really truly means the world. And thank you to
Speaker 1: everyone who submitted a first hand account. We really did
Speaker 1: read each and every one of them, and we feel
Speaker 1: honored like it feels truly unbelievable and in the best
Speaker 1: way possible that so many people reached out to us,
Speaker 1: and we tried to include as many stories as we could,
Speaker 1: and so throughout this episode and the next episode, the
Speaker 1: last episode in our series, you will hear more first
Speaker 1: hand accounts.
Speaker 2: Yeah, thank you, seriously, so much to every single one
Speaker 2: of you for writing in. So many of you sent
Speaker 2: in your stories that you recorded that we weren't able
Speaker 2: to include, and we we are eternally grateful. They really
Speaker 2: do mean the world to us and we listened to
Speaker 2: and read every single one.
Speaker 1: So thank you eternally grateful. Is yeah. Yeah, Hi, I'm.
Speaker 2: Erin Welsh and I'm erin alman.
Speaker 1: Update and this is this podcast will kill.
Speaker 2: You, coming to you from the exactly right studios to
Speaker 2: record the third episode about pregnancy I know in our
Speaker 2: four episode series.
Speaker 1: It's been really fun so far. I've loved it. And
Speaker 1: the fact that we're doing this on video is really
Speaker 1: cool too because we get some props, yes, which is
Speaker 1: really really fun. So if you are like wanting to
Speaker 1: see what's going on when we're talking, which if you don't,
Speaker 1: that's okay too, but if you do, head to YouTube.
Speaker 2: Head to YouTube. I have some really good props for
Speaker 2: this episode, guys. I made them myself.
Speaker 1: The last episode two tennis ball.
Speaker 2: Yeah, that was the first episode.
Speaker 4: I know.
Speaker 2: It was a lot.
Speaker 1: Yeah my mind, it was great. Oh the placenta ye, yeah,
Speaker 1: that was good.
Speaker 2: Okay, So it's going to be a fun day today.
Speaker 1: And before we get into the episode, we want to
Speaker 1: share a few words about what these four episodes will cover.
Speaker 1: More broadly, and if you've already tuned into our first
Speaker 1: or second episode in this series, this is all going
Speaker 1: to sound familiar to you. But in case this is
Speaker 1: your first time tuning in, Welcome and we've got a
Speaker 1: few things that we want to share. So we're going
Speaker 1: to talk about what we will cover in each of
Speaker 1: these episodes, the language that we'll be using, and our
Speaker 1: overall goals with creating this series. So we decided early
Speaker 1: on to dedicate four episodes to cover pregnancy, one for
Speaker 1: each trimester, which is like very few episodes for such
Speaker 1: a tremendously huge topic. And yeah, we realized very early
Speaker 1: on that we're not going to be able to cover
Speaker 1: everything that we would possibly want to with pregnancy, and
Speaker 1: so throughout researching for these episodes, we started to jot
Speaker 1: down like, oh, we want to cover this in a
Speaker 1: future episode and cover that, And so if there are
Speaker 1: topics that you want more information on, please reach out.
Speaker 1: We'll add them to our list, our ever growing list,
Speaker 1: and we will be covering more pregnancy related topics in
Speaker 1: the future.
Speaker 2: Yeah, for sure. Yeah, this series has not, and it
Speaker 2: will not, by the end, answer every single question that
Speaker 2: you could have about pregnancy, or cover every experience that
Speaker 2: a person might have during their pregnancy, in large part
Speaker 2: because pregnancy is such an individual experience, as you heard
Speaker 2: from all of our first hand accounts. But what we
Speaker 2: aim to do with this whole series is take you
Speaker 2: through some of the broad changes that people might experience
Speaker 2: during pregnancy, childbirth, which is what we're talking about today,
Speaker 2: and the postpartum period, which will be next week's episode,
Speaker 2: and then also explore some of the historical and evolutionary
Speaker 2: aspects of pregnancy and childbirth. So each episode thus far
Speaker 2: has roughly corresponded to each trimester, very roughly, very roughly.
Speaker 2: In our first episode we covered how you even know
Speaker 2: whether or not you're pregnant, what that means, and what's
Speaker 2: happening in very early embryonic development.
Speaker 1: And our most recent episode, last episode, our second episode,
Speaker 1: we talked about the amazing organ that is the placenta.
Speaker 2: We love it. Do you love it?
Speaker 3: Now?
Speaker 2: Have you listened to that episode? You?
Speaker 1: Once you do, you will love it.
Speaker 2: You will love it. I feel confident in that. Absolutely
Speaker 2: pretty phenomenal.
Speaker 1: And then we also talked about some of these broad
Speaker 1: system body changes that happen during pregnancy and by system,
Speaker 1: and including focusing on some complications that can arise.
Speaker 2: Which I guess might make you not like the placenta
Speaker 2: a little bit too.
Speaker 1: It's a complicated you know, we have complicated feelings about
Speaker 1: the placenta, but we also appreciate its amazingness.
Speaker 2: It's amazingness.
Speaker 1: Yeah.
Speaker 2: Definitely, today's episode, which we're very excited about, will focus
Speaker 2: on childbirth itself, so labor and different modes of delivery
Speaker 2: and the history of the cesarean section air in.
Speaker 1: Gosh, there is so much to cover, literally, so exciting. Yeah, yeah, Okay.
Speaker 1: Our fourth episode, which is next week and it's our
Speaker 1: season finale, This will be about the concept of the
Speaker 1: fourth trimester, which is a really fascinating topic, and so
Speaker 1: we're going to be exploring some of the changes that
Speaker 1: can happen after pregnancy and talking's big picture history of
Speaker 1: how we moved childbirth from the home to hospital and
Speaker 1: some of the consequences of that.
Speaker 2: We intend for all of these episodes to be inclusive
Speaker 2: of all families, and we recognize that not everyone who
Speaker 2: experiences pregnancy identifies as a woman, so we try as
Speaker 2: much as we can in all of these episodes to
Speaker 2: use gender neutral language such as pregnant person, while at
Speaker 2: the same time we recognize that much of what we
Speaker 2: discuss when it comes to medical bias during pregnancy and childbirth,
Speaker 2: historically and in present day, is a result of gender
Speaker 2: discrimination and racism. So in those context we may also
Speaker 2: use the term woman or women, and throughout these episodes
Speaker 2: will be using terms like mother or maternal and paternal
Speaker 2: as these are what are used in the scientific and
Speaker 2: medical literature.
Speaker 1: We also want to acknowledge that there is no such
Speaker 1: thing as a normal pregnancy, not just one. There's not
Speaker 1: just one, there's not just one textbook example of right,
Speaker 1: this is how a pregnancy should go. But we also
Speaker 1: want to provide a baseline for the expected changes that happen,
Speaker 1: the expected physiologic and anatomic changes, so that we can
Speaker 1: understand when things is kind of maybe go outside of
Speaker 1: those boundaries and then what happens. And this kind of
Speaker 1: helps us to understand what complication actually means.
Speaker 2: Right exactly. Okay, there's a lot o disclaimers and information and.
Speaker 1: Thanks for thanks for sticking with us.
Speaker 2: I'm really excited about today.
Speaker 1: But first but first I almost forgot er. I was like,
Speaker 1: let's get started.
Speaker 2: It's quarantining that it is.
Speaker 1: Well, what are we drinking this week?
Speaker 2: We're drinking the same thing. We are great expected. We're
Speaker 2: not actually drinking it right now, but we have drunk it.
Speaker 1: It is so good.
Speaker 2: It is better than we expected.
Speaker 1: We can't reveal our secrets, our lack of confidence and
Speaker 1: our recipe making.
Speaker 2: It is very good. And we made a plusy burta
Speaker 2: with BlackBerry ginger Ale Minn. There's a video on YouTube.
Speaker 2: Was making it, which was very fun to make.
Speaker 1: It was really fun.
Speaker 2: It was really fun, and George to hard Stark provided
Speaker 2: a wonderful quarantine eye for us to go with this episode.
Speaker 1: So that is available on YouTube teeny it has.
Speaker 2: A name now.
Speaker 1: It's very cute. Oh my god, it's so much fun.
Speaker 2: It's really fun.
Speaker 1: Yeah, So you can find recipes. You can find those
Speaker 1: videos on YouTube, and we'll also have recipes on our
Speaker 1: social media, so make sure you're following us there as
Speaker 1: well as our website. This podcast will kill you dot
Speaker 1: com the.
Speaker 2: Third time and we sent it to me.
Speaker 1: I can say it's on our website.
Speaker 2: Okay, ready, on our website, this podcast will kill You
Speaker 2: dot com. You can find incredible things such as merch
Speaker 2: You can find links to our bookshop dot org affiliate account,
Speaker 2: and our Goodreads list, which Aaron Walsh curates. You can
Speaker 2: find transcripts from each and every one of our episodes.
Speaker 2: You can find our Bloodmobiles who does the music, every recovery,
Speaker 2: Thank you Panicked. You can find a contact us form
Speaker 2: and a first hand account form.
Speaker 1: There's probably more.
Speaker 2: All of the sources from each and every one of
Speaker 2: our episodes.
Speaker 1: Yeah, there, and there might be more. Tell us what
Speaker 1: we missed. Go check out our website.
Speaker 2: Go check out our website. Like what you meant me?
Speaker 2: And I was like, I don't know what I meant, Darren.
Speaker 1: This podcast will kill You dot dot com.
Speaker 2: Also a thing I always forget to do is thank
Speaker 2: you to everyone who has rated and reviewed us on
Speaker 2: Apple Podcasts or Spotify or wherever you like to listen.
Speaker 2: If you haven't and you want to take a minute
Speaker 2: to do that, we'd really appreciate it because it helps
Speaker 2: us out. Thanks for listening. Thanks, Let's stop talking so
Speaker 2: that we can start talking.
Speaker 1: I love that plan. Let's take a quick break and
Speaker 1: then we'll really get started.
Speaker 6: Okay, Hi, I'm Laura, and this is my pregnancy story.
Speaker 7: To begin, we've got to rewind briefly to April twenty eighteen.
Speaker 7: I was twenty seven and diagnosed with her too positive cancer.
Speaker 7: I didn't really have the time or funds to do
Speaker 7: any fertility preservation, so I opted to take a monthly
Speaker 7: shot to try to perserve my fertility, which put me
Speaker 7: into essentially early menopause. I did chem out through the
Speaker 7: summer and fall, and then opted for a double mastectomy
Speaker 7: that October. I got the news from my doctor that
Speaker 7: Halloween that I was cancer free. Part of me sometimes
Speaker 7: wishes I'd kept my breast tissue, but ultimately I wanted
Speaker 7: to be here for any future children and not worry
Speaker 7: about a recurrence, especially given my family history. Fast forward
Speaker 7: to October of twenty twenty one, we're in the thick
Speaker 7: of COVID. I found out I was pregnant. I didn't
Speaker 7: have the typical pre pregnancy symptoms like sore breasts that
Speaker 7: prompt some people to take a test. I had some
Speaker 7: mild nausea and was so tired, and my period was
Speaker 7: a little late, so I took a test and it
Speaker 7: was super positive. Other than the morning sickness that went
Speaker 7: away sometime during my second trimester. Luckily, I had a
Speaker 7: really smooth pregnancy, and I felt my most beautiful during
Speaker 7: that time. Funny enough, I didn't get any of the
Speaker 7: stereotypical cravings of pickles and peanut butter or other weird
Speaker 7: food concoctions, but I really wanted a turkey sat and
Speaker 7: fruits and veggies. Honestly, I've never eaten so healthy in
Speaker 7: my life. Along the way, I encountered some judgment from
Speaker 7: people when I requested no breastfeeding supplies at my baby shower.
Speaker 7: For those that didn't know I didn't have real boobs anymore,
Speaker 7: it didn't make sense to them why I wouldn't at
Speaker 7: least try to breastfeed my baby. So that's sort of
Speaker 7: one thing I wish I could bond with other moms over,
Speaker 7: but ultimately I'm happy with my decision. So now it's
Speaker 7: July fifth, twenty twenty two. I'm thirty nine weeks pregnant.
Speaker 7: It's eleven PM, and i'd finally laid down for bed
Speaker 7: after nesting and cleaning my whole house that day. Even
Speaker 7: being sick with COVID, I just tested positive the day
Speaker 7: before I got up because I felt the arch to pee,
Speaker 7: and in true dramatic fashion, just like the movies, my
Speaker 7: water broke in a huge gush. Of course, my hospital
Speaker 7: bag wasn't packed, so I frantically finished packing and headed
Speaker 7: for the hospital. I was checked in pretty immediately and
Speaker 7: in a labor room by midnight. Because both my partner
Speaker 7: and I were positive for COVID, we were quarantined to
Speaker 7: our room and we were in masks the whole time.
Speaker 7: Side note, it's not easier for fun to breed through
Speaker 7: contractions with a mask on. I did my whole labor
Speaker 7: way for nearly thirty hours. Then it was time to push,
Speaker 7: and it's not fast like the movies. I pushed for
Speaker 7: almost four hours, which felt like an eternity. Masks on,
Speaker 7: hard to breathe. My daughter was born in two thirty
Speaker 7: eight in the morning on July seventh. She's my lucky
Speaker 7: seven to seven post cancer miracle baby. Today, my daughter's
Speaker 7: two and a half and one wild redhead little girl.
Speaker 7: I'm six years cancer free and we're living our best life.
Speaker 8: My name is Jaden and I found out I was
Speaker 8: pregnant in January of twenty twenty four. Overall, it was
Speaker 8: a very normal pregnancy. However, at week twenty I started
Speaker 8: to measure on the high end of normal for my
Speaker 8: amniotic fluid. My baby was measuring large, so we decided
Speaker 8: to set an induction date for thirty nine weeks. However,
Speaker 8: a week after that, there was a large increase in
Speaker 8: amniotic fluid, so we elected to schedule an induction for
Speaker 8: thirty eight weeks for polyhydromnios. The biggest worry was that
Speaker 8: I would go into labor naturally and there was a
Speaker 8: possibility of umbilical cord prolapse, which would then be an emergency.
Speaker 8: After my induction was started, I made no progress for
Speaker 8: about fourteen hours because there was so much fluid, my
Speaker 8: baby was not able to exert enough pressure on my
Speaker 8: cervix to help advance labor. My waters were then manually
Speaker 8: broken and my labor started to progress. I labored that
Speaker 8: way for eighteen hours and was finally ready to push.
Speaker 8: I pushed for one and a half hours and made
Speaker 8: some great progress. The next one and a half hours,
Speaker 8: I made no progress and my baby was still at
Speaker 8: the same position. Because of this failure to descend, and
Speaker 8: she was not yet in distress, we decided to go
Speaker 8: in for a sea section. The sea section was uncomplicated,
Speaker 8: and my baby girl was born at thirty eight weeks
Speaker 8: and two days at seven pounds fifteen ounces. She is
Speaker 8: now a very healthy four and a half month old.
Speaker 1: Childbirth and humans is difficult. It is long, It is painful,
Speaker 1: It carries with its significant risks to mother and baby.
Speaker 1: After birth comes with its own set of challenges. Caring
Speaker 1: for a newborn that is largely helpless can be overwhelming.
Speaker 2: Largely is an understatement, and they are entirely, entirely helpless.
Speaker 1: And these human experiences are exceptional compared to most, but
Speaker 1: not all, other mammalian or primate species.
Speaker 2: Why Why?
Speaker 1: What did we do to deserve this? Why is it
Speaker 1: like this? Looking at the fossil record may give us
Speaker 1: part of the answer. So the story goes that our
Speaker 1: hominine ancestors evolved by pedalism, being able to move around
Speaker 1: on two feet rather than four Why? Just keep going why?
Speaker 5: Why?
Speaker 1: But why? Because maybe it allowed us to live in
Speaker 1: more varied habitats or acquire more varied food sources, or
Speaker 1: it'll it freed up our hands for tool use. There's
Speaker 1: many different ideas out there, but regardless of the reason,
Speaker 1: the shift to walking on two legs could only happen
Speaker 1: because of changes in the shape of our pelvis.
Speaker 2: Our pelvis are pelvis.
Speaker 1: And at some point after these anatomical changes, head size
Speaker 1: in our ancestors also grew as we got.
Speaker 2: Smarter after these pelvis changes, after the pelvis changes, and
Speaker 2: so that led to neonates with heads and bodies that
Speaker 2: were basically at the limit of the birth canal.
Speaker 1: But there was a cap on this growth in head
Speaker 1: and body size. Prenatally, our pelvises could only change up
Speaker 1: to a certain point. Past that point, additional alterations could
Speaker 1: maybe compromise our bipedalism.
Speaker 2: Affect our fitness somehow affect our fitness.
Speaker 1: Yeah, I mean it's like could if we needed to
Speaker 1: the pelvis to expand then we would lose the ability
Speaker 1: to like the balance and the movement and the running.
Speaker 4: You know.
Speaker 1: It's like, yeah, trade offs, you always come back, and
Speaker 1: they always come back to it. And so instead evolution
Speaker 1: had to think outside of the box, shifting some parts
Speaker 1: of fetal growth to take place outside of the womb
Speaker 1: rather than in it, such as brain growth and neurodevelopment.
Speaker 2: I love thinking of evolution in this very inaccurate way
Speaker 2: of giving it like agency. Yeah.
Speaker 1: Oh yeah, no, I know. I think evolutionary religis are like,
Speaker 1: what are you doing? Evolution does not have agency, It's yeah, yeah,
Speaker 1: but I mean that's that is how I'm going to
Speaker 1: present I love so yeah, that's you know.
Speaker 2: It's a good way to just think, like in your
Speaker 2: mind frame it it's just yeah, it's.
Speaker 1: The end result is the same, this is what happens.
Speaker 1: And but this long period of neurodevelopment after birth might
Speaker 1: be what allows us to learn more and have flexibility
Speaker 1: in our learning. At birth, the brain size of a
Speaker 1: neonate is about twenty five percent of what it'll be
Speaker 1: as an adult. Wow, which is the smallest neonate adult
Speaker 1: proportion of all primates.
Speaker 2: Like it is, oh, of all primate of all primates. Okay, interesting? Interesting, Yeah,
Speaker 2: so other primates, their brains come out already bigger.
Speaker 1: Already bigger compared to their adult brain size. Okay, interesting,
Speaker 1: And compared to other primates, our newborns seem especially helpless.
Speaker 1: You know, we can't cling, we can't hold our heads up,
Speaker 1: we can't coordinate our limbs, we can't even crawl for months,
Speaker 1: I know months.
Speaker 2: And you think of like the baby monkeys who can
Speaker 2: just go right and hold on so well, yeah, and
Speaker 2: ours can just do this palmer grass reflex and you're like.
Speaker 1: Thank you, good job, you're working hard. You know, we
Speaker 1: do work hard. True. Some researchers suggest that to match
Speaker 1: the developmental stage of other apes right after birth, humans
Speaker 1: would have gestations seven to twelve months, longer than our
Speaker 1: nine month gestation.
Speaker 2: No, thank you.
Speaker 1: There is some current debate on this point, like, yeah,
Speaker 1: there's nuance, there's papers, you can dig into it. Evolution
Speaker 1: seems to have handed us this trade off where we
Speaker 1: get to have these big brains, but we're also faced
Speaker 1: with the challenges of childbirth, where the neonate is at
Speaker 1: the capacity of our birth canal and requires round the
Speaker 1: clock care for months after birth. This is a precarious
Speaker 1: balance to strike with extremely high costs if things go awry.
Speaker 1: How have we dealt with this over human history?
Speaker 2: Tell me?
Speaker 1: One way is through cooperation.
Speaker 2: Oh, I know, humans and our cooperation and we are
Speaker 2: capable of it.
Speaker 1: Sorry, we were capable of it. No, just kidding. I
Speaker 1: hope our hominin ancestors, like many of our present day
Speaker 1: primate relatives, exhibited cooperative breeding and culture. Did our helpless
Speaker 1: babies lead us to evolve this cooperation or did we
Speaker 1: already have this type of culture and that allowed for
Speaker 1: the evolution of more helpless babies. We don't know. We
Speaker 1: probably weren't to ever know that answer, But what is
Speaker 1: certain is that many societies today have lost that cooperative
Speaker 1: child rearing. Some researchers have suggested that we feel this
Speaker 1: helplessness in human infants so strongly because of the way
Speaker 1: that many of us experience child rearing in our modern society,
Speaker 1: often isolated with a burden of care falling to one
Speaker 1: or two people. This is far removed from how our
Speaker 1: ancestors would have experienced child rearing in a cooperative social group.
Speaker 1: Childbirth was the same way attended by other members of
Speaker 1: your group. Like who knows how long women have been
Speaker 1: assisting other women in childbirth. But one paper I read
Speaker 1: suggested that when our species developed language that helped to
Speaker 1: pave the way for assisted childbirth, we could communicate our pain,
Speaker 1: our needs, and then pass down the knowledge that we acquired.
Speaker 1: Oh interesting, Yeah, Today that kind of community involvement for
Speaker 1: child rearing seems more of a rarity. And when it
Speaker 1: it's just you or you and one other person continuously
Speaker 1: on call, to take care of a newborn. That may
Speaker 1: emphasize the never ending needs of that newborn. Hmm, okay.
Speaker 1: The second thing is how we've dealt with the dangers
Speaker 1: of childbirth historically. There's no disputing that labor and delivery
Speaker 1: can be extremely dangerous for both mother and baby, even
Speaker 1: with all of our modern medical advancements and technologies. Is
Speaker 1: that how it's always been? That's a really difficult question
Speaker 1: to answer.
Speaker 2: It turns out I have thought about this so so
Speaker 2: so much for so many years. Now. I know that
Speaker 2: I wish that we could know.
Speaker 1: We can know something, Okay, tell me. Yeah. So, the
Speaker 1: historical data on this subject are limited, to say the least,
Speaker 1: and they're complicated by several factors, including the effect that
Speaker 1: medicine has had on maternal and neonatal mortality, which is
Speaker 1: has not been always in a positive direction. For instance,
Speaker 1: in the nineteenth century, as more male physicians attended childbirth
Speaker 1: after receiving little if any education and obstetrics, as people
Speaker 1: moved to crowded cities, as more women gave birth in hospitals,
Speaker 1: infectious disease became a leading driver of maternal and perinatal mortality.
Speaker 2: Right, and we talk a lot about that in our episode.
Speaker 1: On Selvis and people fever.
Speaker 2: Yeah yeah, just like which episode was that, because I
Speaker 2: know we covered it in detail.
Speaker 1: A long time, but yeah, yeah, But the specter of
Speaker 1: infectious disease during childbirth maybe a more recent development, relatively speaking.
Speaker 2: Some researchers have suggested.
Speaker 1: That early in our evolutionary history, birth might not have
Speaker 1: been as dangerous, but following the agricultural revolution around twenty
Speaker 1: thousand years ago, there was more over nutrition, and then
Speaker 1: that could lead to babies with heads and bodies straining
Speaker 1: the limits of the birth canal interesting.
Speaker 2: So it used to just be that if we were
Speaker 2: limited by nutrition, then your huh, I mean maybe maybe maybe,
Speaker 2: who knows?
Speaker 1: Ok yeah, okay. The industrial revolution in the eighteenth and
Speaker 1: nineteenth centuries may have contributed to difficult childbirth in other ways,
Speaker 1: For instance, rickets caused by vitamin D deficiency cr vitamin
Speaker 1: D episode, but the rickets can often lead to skeletal
Speaker 1: changes that decreased pelvis size and made it even more
Speaker 1: challenging for a baby to go through birth canal. The
Speaker 1: WHO today roughly estimates that five percent of births with
Speaker 1: labor starting spontaneously develop complications.
Speaker 2: Okay, five percent percent.
Speaker 1: Birth records from a late eighteenth century midwife, Martha Ballard,
Speaker 1: the book The Diary of a Midwife It's based on
Speaker 1: her story is incredible, suggested that five point six percent
Speaker 1: of births that she attended were difficult.
Speaker 2: Interesting, that five.
Speaker 1: Percent number for difficult labor or delivery pops up elsewhere
Speaker 1: throughout the eighteenth and nineteenth centuries until medical intervention increased,
Speaker 1: at which point then difficult increase as well. And it's
Speaker 1: not clear what that five percent complications rate means maternal
Speaker 1: or neonatal mortality historically.
Speaker 2: How does it and what is different? What is defined right.
Speaker 1: Exactly requiring intervention? Then? What is requiring intervention? How do
Speaker 1: we make those decisions?
Speaker 2: Yeah?
Speaker 1: Yeah, but those historic numbers and often the ones today,
Speaker 1: these estimates don't necessarily capture post natal issues such as
Speaker 1: like prolapsed uterus or fistulas something like that, which can
Speaker 1: be you know, long term permanent changes that are you know,
Speaker 1: affect your morbidity over time. But what strikes me is
Speaker 1: how different that five percent number is compared to the
Speaker 1: c section rate, which here in the US is around
Speaker 1: thirty three percent high, not the highest. Brazil holds that title,
Speaker 1: with fifty four percent of births done by cesarean Private
Speaker 1: hospitals have an eighty four percent C section rate in
Speaker 1: Brazil eighty four percent.
Speaker 2: Eighty four percent.
Speaker 1: Yeah, wow, yeah, okay, keep going, Okay. Complications encompasses a
Speaker 1: wide range of things, but C sections are one of
Speaker 1: the most common medical interventions for complications that arise during
Speaker 1: labor and delivery. How did this procedure go from being
Speaker 1: a rarity to one of the most performed surgeries in
Speaker 1: the US and around the world. What period and all
Speaker 1: surgery right, including like tonsilectomies, appendectomy replacements?
Speaker 2: Right?
Speaker 1: How has our attitude towards c sections changed during that
Speaker 1: time from when it was like a rare thing to commonplace?
Speaker 1: Are we doing more C sections than we should be doing?
Speaker 1: How do we know the answer to that?
Speaker 2: Yeah?
Speaker 1: And so today I want to take us through the
Speaker 1: history of C sections to try to answer some of
Speaker 1: these questions. And I know that C sections are not
Speaker 1: a universal experience, and by talking about C sections, I
Speaker 1: am skipping over other important aspects of labor and delivery.
Speaker 1: But I think, yeah, you'll get there perfect. And I
Speaker 1: think they're an extremely important topic given how common they are.
Speaker 1: How much rhetoric there is surrounding sea sections and how
Speaker 1: and I think that going through their history can give
Speaker 1: us some insight into how medicine has treated pregnant women
Speaker 1: and viewed risk over time, what risk means, what it
Speaker 1: looks like. This is a nuanced topic with so much
Speaker 1: amazing scholarship out there, and so I just want to
Speaker 1: shout out a couple of sources at the beginning so
Speaker 1: that you know that there's so much more opportunity to
Speaker 1: learn more. So one book is called Cesarean Section and
Speaker 1: American History of Risk, Technology and Consequence. That's by Jacqueline Wolf.
Speaker 1: And another is called Invisible Labor, The Untold Story of
Speaker 1: the Cesarean Section by Rachel Summerstein. All right, I'll be
Speaker 1: ready to talk about I want to start off by
Speaker 1: describing what happens during a sea section step by step.
Speaker 2: Wonderful.
Speaker 1: So I'm quoting directly from Rachel Summerstein's Invisible Labor here
Speaker 1: because I thought it was just a phenomenal description and
Speaker 1: I was like, perfect.
Speaker 2: Every meds street listening that's about to start their obed
Speaker 2: an rotation is thrilled.
Speaker 1: Okay, you here we go quote an anesthesiologist or nurse
Speaker 1: anesthetist uses spinal anesthesia or an epidural to anesthetize a
Speaker 1: mother regionally. Then the surgeon uses a scalpel to cut
Speaker 1: open the abdomen above the mon's pubis, slicing through layers
Speaker 1: of skin and fat and the fascia that covers the
Speaker 1: abdominal muscles. The physician parts but does not cut the
Speaker 1: rectus abdominous muscles six pack with her hands. Then she
Speaker 1: cuts through the peritoneum, the layer of tissue that contains
Speaker 1: organs in the abdomen, as if in a tightly sealed bag.
Speaker 1: She moves the bladder aside to reach the uterus, making
Speaker 1: yet another incision to open it. She presses on the
Speaker 1: uterus to push out the baby, which is the source
Speaker 1: of the pressure sea section moms are told they might
Speaker 1: experience during the operation. Once the baby is born, the
Speaker 1: surgeon removes the uterus from the patient's body, sometimes lifting
Speaker 1: it out completely like a bowling ball, to so it closed.
Speaker 1: Then she sutures the other layers of the patient's abdominal
Speaker 1: wall and finally closes the topmost layer. End quote.
Speaker 2: Yep, yeah, wholly accurate.
Speaker 1: But like it's amazing how you just think like, I
Speaker 1: feel like most people don't know the step by step,
Speaker 1: which is what's being cut in what order, how do
Speaker 1: you get the placenta out, like all these different things.
Speaker 2: Yeah, yeah, So it's also an incredible thing to get
Speaker 2: to watch, yeah, experience and be a part of. Like
Speaker 2: it is really really fascinating and interesting and incredible.
Speaker 1: It's amazing. And so this is the way that most
Speaker 1: sea sections are done today, but this is not how
Speaker 1: they've always been done. The earliest record of sea sections
Speaker 1: that we have dates back over two thousand years.
Speaker 2: Wow. Yeah, I feel like those were not good ones.
Speaker 1: Well, the intention of sea section has changed a lot
Speaker 1: over time, so it's clear that from these early and
Speaker 1: then subsequent ancient descriptions that this procedure was done very
Speaker 1: rarely and only when the mother had died or was
Speaker 1: thought beyond saving. So it was mostly like a last
Speaker 1: ditch effort to save the baby or baptize the baby
Speaker 1: before it died, or as a crucial step to prepare
Speaker 1: the bodies for burial, so mother and baby were often
Speaker 1: buried separately, so that was sort of part of the steps.
Speaker 1: Those babies that did survive were often viewed as gods,
Speaker 1: as heroes, or as extremely blessed, which is behind the
Speaker 1: common misconception of where the cesarean got its name, because
Speaker 1: it's not Julious, not Julius Caesar. Yeah yeah, so a
Speaker 1: lot of stories go oh, the cesarian got its name
Speaker 1: from Julius Caesar, the Roman emperor who was born vs. Section.
Speaker 1: Not true as far as we understand. Most scholars think
Speaker 1: that the name actually comes from a royal law from
Speaker 1: ancient Rome that decreed that the body of a pregnant
Speaker 1: woman could not be buried until the fetus had been
Speaker 1: removed and buried separately.
Speaker 2: Oh okay.
Speaker 1: Up until the nineteenth century, really, cesareans remained exceedingly rare,
Speaker 1: only performed in extreme instances, and the mother's life took
Speaker 1: precedence over the babies. Shockingly, there are cases where both
Speaker 1: mother and baby survived, the first being either in Prague
Speaker 1: in the thirteen hundred or Switzerland in the fifteen hundreds. Wow,
Speaker 1: I know, I know, But overall that outcome was like
Speaker 1: very very rare. Mostly a cesarean was viewed as a
Speaker 1: success if the mother survived, regardless of the baby's status.
Speaker 1: This would remain the case well into the twentieth century.
Speaker 1: An important exception to. This is in the case of
Speaker 1: enslaved black women, often the physician would consult the enslaver
Speaker 1: to see whether they wanted to preserve the life of
Speaker 1: the mother or the baby's. Okay, anyone surviving a sea
Speaker 1: section was still so notable that it often made the
Speaker 1: history books, such as the case of Alice O'Neil, an
Speaker 1: Irish woman who had labored for twelve days until her
Speaker 1: midwife married Donnelly by her side. This was seventeen thirty eight,
Speaker 1: and then Mary, her midwife, was like, the only way
Speaker 1: to save Alice, Alice's baby had died during this long
Speaker 1: labor already was to do a sea section, and so
Speaker 1: Mary performed the sea section and Alice made a full recovery.
Speaker 1: In England, the first c section where a mother survived
Speaker 1: took place in seventeen ninety three, and in the US
Speaker 1: the year after, although this is somewhat disputed. In the
Speaker 1: US case, there was a woman named Elizabeth Bennett, which
Speaker 1: is also you're thinking Pride and Prejudice. Okay, yes, there was.
Speaker 1: This is before Pride and Prejudice came out, which is interesting.
Speaker 1: I mean, I don't think it's probably that uncommon of
Speaker 1: a name, but Elizabeth was going through a difficult labor
Speaker 1: at her log cabin home, and her husband, who was
Speaker 1: a doctor, had called another doctor over to help. But
Speaker 1: this other doctor threw his hands up after an attempted
Speaker 1: forceps delivery didn't work, and so Elizabeth's husband took matters
Speaker 1: into his own hands, made an incision, pulled out baby
Speaker 1: in placenta, allegedly took out the ovaries while he was
Speaker 1: there to be like, I'm not making sure this doesn't
Speaker 1: happen again, and stitched her back up. Wow, mom and
Speaker 1: baby made a fast recovery. Wow, allegedly allegedly. Yeah, it's
Speaker 1: a little embellished like the telling of it, so who
Speaker 1: knows if it's true. And I want us to take
Speaker 1: all of these milestone to the grain of salt, not
Speaker 1: because maybe they happened, maybe they didn't happen, but also
Speaker 1: because they probably weren't the first. Like most histories of medicine,
Speaker 1: the starring characters in the story of cesareans are white
Speaker 1: male physicians in Europe or in the US. But that's
Speaker 1: not the whole picture. It's likely that there were other
Speaker 1: midwives like Mary Donnelly out there over the centuries performing cesareans.
Speaker 1: They just didn't send their reports to a medical journal
Speaker 1: because they couldn't write, or they didn't view it as remarkable,
Speaker 1: or they knew that it wouldn't be accepted. Similarly, who
Speaker 1: knows how many cesareans had been performed around the world historically.
Speaker 1: In the eighteen eighties, a British physician named Robert Felcon
Speaker 1: wrote about his experience in Uganda where he observed cesarean
Speaker 1: sections being performed in the eighteen eighties. The surgery seemed
Speaker 1: not uncommon, was intended to save both mother and child,
Speaker 1: was often successful, and used antisepsis in pain treatment using
Speaker 1: banana line.
Speaker 2: Oh interesting.
Speaker 1: Yeah, So the story of cesareans is in part just
Speaker 1: a reflection of whose work was deemed worthy of being
Speaker 1: included in medical journals and texts historically. As incomplete as
Speaker 1: that story is, it's what we've got. And so now
Speaker 1: let's turn to the beginning of the modern era of cesareans.
Speaker 1: Let's okay, death from infection, a lack of anesthesia, and
Speaker 1: no consensus on surgical procedure. When to do a cesarean,
Speaker 1: where to cut, should we take the placenta out? And
Speaker 1: so on? These things I know I'm starting off, but realistic. Yeah, yep,
Speaker 1: These things kept cesarean numbers low for most of the
Speaker 1: twentieth century. Between eighteen thirty eight and eighteen seventy eight,
Speaker 1: eighty nine c sections were performed in the US, sixty
Speaker 1: two percent of mothers died, sixty percent of babies died.
Speaker 1: One obstetrician from this era said, there is nothing in
Speaker 1: surgery about which the surgeon is so timid as a
Speaker 1: cesarean operation, and nothing in obstetric of which this obstetrician
Speaker 1: stands so much in dread.
Speaker 2: Yeah, okay.
Speaker 1: For the sentiment to change going into the twentieth century,
Speaker 1: four developments needed to take place. Anesthesia, antisepsis, blood transfusions,
Speaker 1: and surgical technique okay. Practicing primarily on women of color,
Speaker 1: poor women, disabled women, other women viewed as second class citizens,
Speaker 1: surgeons honed their approach to cesareans. Eduardo Poro introduced the
Speaker 1: Poro technique in eighteen seventy eight, which involved amputating the
Speaker 1: uterus at the cervix and suturing the cervix into the
Speaker 1: abdominal wall. Oh yeah, this actually did reduce infection and hemorrhage,
Speaker 1: brought the survival rate up to forty four percent. Max
Speaker 1: Sanger used silver wire in uterine sutures beginning in the
Speaker 1: late eighteen eighties, further improving survival rate. I think previously
Speaker 1: they were like, should we even suture the uterus back together?
Speaker 1: Because what infection was so bad? Yeah. By the nineteen tens,
Speaker 1: the overall maternal mortality rate for cesareans dropped to eight
Speaker 1: point one percent wow, which is lower than the fifty
Speaker 1: six percent it was in the late eighteen hundreds, but
Speaker 1: still very high for a surgery, so its use was debated,
Speaker 1: with the decision to cut often influenced by the social
Speaker 1: standing of the mother, which opened the door to eugenics, right,
Speaker 1: So the risk of a negative outcome was perceived to
Speaker 1: be lower in cases where you didn't care whether or
Speaker 1: not mother and baby lived.
Speaker 2: Oh my god, Okay, yeah.
Speaker 1: Inductions were often used as a way to prevent what
Speaker 1: was seen as an extremely risky procedure. But over the
Speaker 1: first they were like, well, we'll just in case we
Speaker 1: don't want to we want to avoid a cesareans, we'll
Speaker 1: just induce you. So that became very, very popular, But
Speaker 1: over the first seven decades of the twentieth century, that
Speaker 1: perception of risk would change. What started out as a
Speaker 1: surgery to be avoided at all costs, turned into something
Speaker 1: that you only did in extreme circumstances, then something to
Speaker 1: do in certain situations, and then only at the discretion
Speaker 1: the physician, to finally something that was routine. The reasons
Speaker 1: for this shift included those I mentioned earlier, transfusions, antsepsis
Speaker 1: anesthesia technique plus antibiotics introduced in the nineteen forties, and
Speaker 1: a gradual decline in maternal mortality from other causes. So
Speaker 1: as obstetricians got better at recognizing and treating or preventing
Speaker 1: complications for mom during pregnancy and childbirth, the focus then
Speaker 1: shifted to seeing a similar decrease in neonatal and perinatal mortality.
Speaker 2: Okay, because previously it had always been about maternal mortality
Speaker 2: and trying to reduce that, and the baby was always secondary. Yes,
Speaker 2: And then as we got better at reducing maternal mortality,
Speaker 2: now we said, okay, can we save these babies? Yes, exactly,
Speaker 2: got it, yep, yep.
Speaker 1: And so then we started to develop things like diagnostic
Speaker 1: tools Apgar score, the Freedman curve to measure how labor
Speaker 1: is progressing, X rays, ultrasound, and the electronic fetal monitor,
Speaker 1: which was introduced in the nineteen fifties, or a lot
Speaker 1: of these were were established by the nineteen fifties and
Speaker 1: nineteen sixties. Obviously, X rays were a long time previous
Speaker 1: to that, but these different diagnostic tools captured what seemed
Speaker 1: like more and more risk during childbirth, and thus more
Speaker 1: and more reason to do a sea section or placental
Speaker 1: issues pelvis size, estimated baby size, uterine rupture, pre eclampsy,
Speaker 1: et cetera. We got better at detecting those and measuring
Speaker 1: those and being like, well, we should can.
Speaker 2: We prevent the risk? So how can we not do
Speaker 2: something about it?
Speaker 1: Yes, exactly, that's what exactly?
Speaker 2: Yeah, okay.
Speaker 1: But in another way, what these instruments were doing, in part,
Speaker 1: was confirming what early male physicians involved in childbirth believed
Speaker 1: that pregnancy and childbirth were pathological processes in themselves.
Speaker 2: Oh I know, okay, yeah.
Speaker 1: By the nineteen seventies, the tides had fully turned and
Speaker 1: C sections were about to skyrocket, at least here in
Speaker 1: the US. To give give you some idea of this
Speaker 1: massive change, let me throw some numbers at you please.
Speaker 1: Until nineteen seventy, the US C section rate was five
Speaker 1: point five percent.
Speaker 2: Wow. Okay.
Speaker 1: Between nineteen sixty five and nineteen eighty seven, the rate
Speaker 1: of C sections grew four hundred and fifty five percent.
Speaker 2: In I'm sorry, that is such a short I think
Speaker 2: what I didn't realize about looking at these numbers is
Speaker 2: how short that timeframe was. When it just boomed.
Speaker 1: Yeah, electronic fetal monitoring was a big okay.
Speaker 2: Yeah. Oh that's really interesting, especially in the context of
Speaker 2: like today. Yep, okay, interesting.
Speaker 1: Yeah, and it became like it just there are so
Speaker 1: many different dynamics to this as well. Yeah. So in
Speaker 1: nineteen sixty five the rate was like four and a
Speaker 1: half percent. In nineteen eighty seven it was twenty five percent,
Speaker 1: which is also lower than it is today.
Speaker 2: Yeah.
Speaker 1: Articles or stories that referenced C sections of the nineteen
Speaker 1: sixties still in who did a definition of the procedure?
Speaker 2: Wow?
Speaker 1: Yeah okay, And those published after nineteen seventy didn't have to.
Speaker 1: And the shift wasn't entirely welcomed by all obstetricians, many
Speaker 1: of whom saw cesareans as requiring much less skill than
Speaker 1: assisting in vaginal birth interesting and were against expanding criteria
Speaker 1: for the procedure because they were afraid of their own marginalization.
Speaker 2: In part, interesting, the.
Speaker 1: Skills that had taken them years to learn and perfect
Speaker 1: would be pointless with a surgical technique that took a
Speaker 1: few weeks to learn.
Speaker 2: Interesting.
Speaker 1: Yeah, this is not unfounded, right. Few physicians today have
Speaker 1: ever attended a vaginal breach birth, and watching a monitor
Speaker 1: is no substitute for interacting with a patient and becoming
Speaker 1: familiar with the varied rhythms of labor and that patient
Speaker 1: themselves like the person who they are. The natural birth movement,
Speaker 1: beginning in the nineteen seventies was in part a reaction
Speaker 1: to the increasing medicalization of pregnancy and childbirth, which included
Speaker 1: su sections, and this, combined with the push for vaginal
Speaker 1: birth after c section v back in the nineteen eighties,
Speaker 1: led to a brief dip in C section rates in
Speaker 1: the US, but that decline was short lived as resistance
Speaker 1: to v backs grew among doctors, as insurance companies hiked
Speaker 1: up malpractice insurance rates for doctors who performed v backs,
Speaker 1: and as hospitals just began to forbade it as an option.
Speaker 2: Yeah, wow, hospital administration making decisions. Cool cool, cool, cool
Speaker 2: cool cool insurance love it?
Speaker 1: I mean I do think this is probably like a
Speaker 1: global issue.
Speaker 2: Obviously some degree based on this.
Speaker 1: These are US numbers for sure. Yeah. The one acessarean
Speaker 1: always a cesarean adage that was first popularized by Edwin
Speaker 1: Cragan in nineteen sixteen still holds sway nineteen sixteen. Yeah,
Speaker 1: the perception of risk had shifted. Before the nineteen seventies,
Speaker 1: c sections themselves were seen as the risk, and after
Speaker 1: not performing the procedure was the risk. Medical malpractice suits
Speaker 1: on failure to perform a sea section reinforce this, okay,
Speaker 1: But what seems to have gotten lost as cesareans became
Speaker 1: more normalized is that the procedure does carry with it
Speaker 1: substantial risk, which can be compounded in subsequent sea sections.
Speaker 1: I know you'll talk a little bit more about this, Aaron,
Speaker 1: but high rates of blood transfusions, emergency hysterectomies, postpartum depression,
Speaker 1: difficulty breastfeeding, newborn lung conditions, and in subsequent pregnancies, still birth,
Speaker 1: uterine ruptures, placental anomalies such as placenta acreda. We can
Speaker 1: see the impact of sea sections on placenta acreda by
Speaker 1: looking at rates over time from the nineteen thirties to
Speaker 1: the nineteen fifties, placenta acreda occurred in less than one
Speaker 1: in thirty thousand berths.
Speaker 2: Oh my gosh.
Speaker 1: By twenty sixteen, that number was down to one in
Speaker 1: two hundred and seventy two. Yeah, in large part due
Speaker 1: to sea sections.
Speaker 2: Right. Placenta acreda is when the placenta grows two deeply
Speaker 2: into the myometrium. In some cases it can actually go
Speaker 2: all the way through the myometrium and be adherent to
Speaker 2: like the outside wall or even into the abdominal cavity.
Speaker 2: It's a spectrum of disorders depending on how deep it is,
Speaker 2: and if it can be identified prior to delivery, then
Speaker 2: generally a sasarean section is necessary to be able to
Speaker 2: ensure that you can remove all of the placental tissue because,
Speaker 2: as we'll talk about, it's really important that the whole
Speaker 2: placenta comes out, but sometimes it's not identified and so
Speaker 2: then it can result in increased risk of hemorrhage and
Speaker 2: things like that. Yeah.
Speaker 1: And it's like, from my understanding is that risk of
Speaker 1: placenta accreta increases with every sea section because the potential
Speaker 1: for just the lack of like decidua that can form
Speaker 1: exactly where the previous scar is.
Speaker 2: Exactly because of the Cesaian scar.
Speaker 1: Yeah yeah, yeah, Okay, now that we've like talked about
Speaker 1: some of the negative things, I do want to just
Speaker 1: emphasize that sea sections are absolutely a life saving procedure.
Speaker 1: They really are, and they are incredibly safe.
Speaker 6: Yeah.
Speaker 1: I don't want to give the impression that they aren't.
Speaker 1: That's not the point I'm trying to make. The point
Speaker 1: is that while there are risks inherent in this procedure,
Speaker 1: risks that are worth it if it means a healthy
Speaker 1: mother and baby, these risks aren't always adequately communicated, whether
Speaker 1: in planned cesarean sections, unplanned ones, or in many what
Speaker 1: to expect while you're expecting books. The decision to conduct
Speaker 1: an unplanned cesarean isn't always explained to the person in labor, who,
Speaker 1: in their state of anxiety, pain, worry, doesn't feel like
Speaker 1: they can ask questions or be listened to.
Speaker 2: Or can't understand like everything that's happening all at once
Speaker 2: because it can change on a dime, exactly.
Speaker 1: Yeah.
Speaker 4: Yeah.
Speaker 1: Being in a room surrounded by people for whom this
Speaker 1: is an everyday occurrence seems like it should be reassuring,
Speaker 1: but what it can often be is silencing and isolating.
Speaker 1: Your fears are dismissed because oh, it's fine, we do
Speaker 1: this all the time, don't worry about it. Your questions
Speaker 1: aren't answered because the doctor is telling you there's no time,
Speaker 1: we have to do this now. And this crowded labor
Speaker 1: room filled with capable hands provides no comfort because most
Speaker 1: of them are strangers. They don't know you, you don't know them.
Speaker 1: This feeling of a loss of control might not be
Speaker 1: unique to sea sections, but it is something that gets
Speaker 1: minimized both during and after childbirth, both of which carries
Speaker 1: significant rates of emotional trauma. One study I saw reported
Speaker 1: forty five percent. The message is, well, you've got a
Speaker 1: healthy baby, what do you have to complain about?
Speaker 2: Get over it, you know, like, just enjoy your baby. Yeah,
Speaker 2: so they're screaming all the time.
Speaker 1: You enjoy. But this no big deal sentiment carries over
Speaker 1: into the physical trauma of sea sections, which are treated
Speaker 1: like the world's most minor surgery instead of the major
Speaker 1: abdominal surgery that they are.
Speaker 2: I do find that so interesting.
Speaker 1: Yeah, it's like, oh so serian, Oh my god, It's like, yeah,
Speaker 1: it must be nice for you. Yeah right, it's like what, like,
Speaker 1: how are you expected to carry your newborn to their
Speaker 1: first doctor's appointment when you aren't supposed to lift anything
Speaker 1: because your muscles have just undergone significant trauma.
Speaker 2: Yeah, and even if your newborn is only like six
Speaker 2: or seven pounds, your course's twelve. Then so now you're
Speaker 2: right your twenty pound max.
Speaker 4: Right?
Speaker 1: Great? And then how long? How long does that?
Speaker 2: You know?
Speaker 1: In the famous pregnancy book What to Expect While You're Expecting,
Speaker 1: You know this book. Everyone never read book? Okay, yeah,
Speaker 1: I haven't either, but I did come across this description
Speaker 1: of c sections in one edition. Instead of huffing, puffing
Speaker 1: and pushing your baby into the world, you'll get to
Speaker 1: lie back and let everyone else do the heavy lifting.
Speaker 2: I hope that was I don't even know what I
Speaker 2: hope about that.
Speaker 1: Discussion, because I, oh gosh. My charitable take is that
Speaker 1: maybe it was meant to be reassuring, reassuring and like,
Speaker 1: don't worry about it. This is something that you know,
Speaker 1: you don't have to stress about this major surgery.
Speaker 2: It's not helpful for either side because it makes it
Speaker 2: seem like a vaginal birth is like the worst possible
Speaker 2: thing in it so hard, and then it makes it
Speaker 2: seem like a cesarean section is so easy, and like
Speaker 2: neither one of those things are exactly true. Yeah, it's
Speaker 2: all still childbirth.
Speaker 1: It's all childbirth. Yeah yeah, yeah, ah it's and the
Speaker 1: thing is too. I also I also want to acknowledge
Speaker 1: it that might be someone's experience like that maybe maybe
Speaker 1: I don't. I don't want to say like everyone who
Speaker 1: has c sections had it's a horrible time, because maybe
Speaker 1: they didn't.
Speaker 2: Maybe it was like this is maybe it is totally fine,
Speaker 2: scheduled procedure and it goes exactly as planned and it
Speaker 2: was very relaxing and your recovery is easy and that's phenomenal.
Speaker 1: Right, or even if it was unplanned, and it's like yeah.
Speaker 2: And but the same can also be true for a vaginal.
Speaker 1: Delivery for sure. Yeah yeah, but I feel like, yeah,
Speaker 1: this this saying that way, describing it that way is
Speaker 1: so dismissive.
Speaker 2: Right, It's one way that it will go, yes, yeah, yeah.
Speaker 1: And it also sort of like is like, well, if
Speaker 1: you felt any any other way, then that's your that's
Speaker 1: on you, right, right. And this perception of c sections
Speaker 1: as being either like the easy way out or a
Speaker 1: vanity procedure, which is we'll get into that, yeah, or not.
Speaker 1: Real birth so incredibly harmful. And I feel like this
Speaker 1: idea of natural birth or the term natural birth implies
Speaker 1: unnatural birth, right, and that can be so othering, right
Speaker 1: that along with a million different books and articles and
Speaker 1: forums saying you should do this and you shouldn't do that.
Speaker 1: If you do this, you're a good mother. If you
Speaker 1: don't do this, then you're a bad mind. Like that
Speaker 1: sort of thing.
Speaker 2: Right, It compares and contrast in this way, right.
Speaker 1: The focus on skin to skin bonding in the minutes
Speaker 1: right after birth, what happens if you're under anesthesia or
Speaker 1: if baby is rushed away for extra care. That's okay,
Speaker 1: everything will be okay. But that message gets lost. Women
Speaker 1: who have c sections often have a more difficult time breastfeeding,
Speaker 1: which can then lead to shaming because that's not the
Speaker 1: way you're supposed to do it, when in reality, a
Speaker 1: fed baby is the best baby. The moral superiority tied
Speaker 1: to so much of pregnancy and childbirth can be crushing
Speaker 1: and isolating, especially when things are out of your control.
Speaker 1: Even the language that we use to describe reasons for
Speaker 1: seas sections shows this.
Speaker 2: Oh my gosh, I talk about this nail.
Speaker 1: You're to progress incompetent cervix, inefficient contractions, uterine dysfunction. Some
Speaker 1: women are told, you're not trying hard enough. I know,
Speaker 1: you're not strong enough. Yes, like you're you're not even
Speaker 1: you're not even pushing. What are you doing? Do you
Speaker 1: do you want to have a C section?
Speaker 2: You know?
Speaker 1: Sorry to I know, I know, yeah, but it's that
Speaker 1: all places the blame on them making the sea section
Speaker 1: solely their decision rather than what the doctor instructed. And
Speaker 1: it's so difficult to know, Like you, you have this plan,
Speaker 1: you you want to your birst to go a certain way,
Speaker 1: and then something goes not according to plan. What do
Speaker 1: you do? Do you feel like it's your fault? It's
Speaker 1: it's really complicated.
Speaker 2: And that I mean, that is the truth of our
Speaker 2: entire lives, right, Yeah, like you, we cannot plan everything.
Speaker 2: But I do think that, especially today, there is very
Speaker 2: much an emphasis on like having a plan and then
Speaker 2: things if things do not go accord to that plan,
Speaker 2: it makes it seem like you did something wrong, right
Speaker 2: when that's not reality.
Speaker 1: It's not reality. So it's really hard Yeah, it is
Speaker 1: really hard, and I think that what it does is
Speaker 1: sort of shift the attention away from where I think
Speaker 1: we need to be more like, have more discussions about
Speaker 1: you know, what are these drivers for this thirty three
Speaker 1: percent rate of C sections at the provider level, at
Speaker 1: the institutional level, at the systemic level. One overlooked aspect
Speaker 1: is the individual provider's reasons for deciding on a sea section.
Speaker 1: Trauma during childbirth is not exclusive to the mother, and
Speaker 1: as a provider, if you attend a traumatic vaginal birth,
Speaker 1: you might be more likely to suggest a sea section
Speaker 1: than your other colleagues.
Speaker 2: Every provider has seen traumatic everything. Yeah, and the things
Speaker 2: that obstetric providers see on a daily basis are trauma exactly.
Speaker 1: Yeah. Some hospitals I found this fascinating took to publishing
Speaker 1: or displaying each physician's cesarean rates and that led to
Speaker 1: them plummeting.
Speaker 2: Interesting wow, which suggests that maybe risk tolerance for vaginal
Speaker 2: birth is lower than physicians think it should be.
Speaker 1: And so I don't know what to make of that,
Speaker 1: but I do think that's that is Yeah, And then
Speaker 1: there's implicit bias. Black mothers are more likely to have
Speaker 1: SEE sections than white mothers, even if risk factors are similar.
Speaker 1: Does this suggest that non white mothers can't be trusted
Speaker 1: to give birth without medical intervention? Which is also then
Speaker 1: funny because it's like, but we're also you have pain,
Speaker 1: I don't believe you. Yeah. Other research shows that female
Speaker 1: obgui ns and maternal fetal medicine specialists are more likely
Speaker 1: to opt for an elective CESAIAN for themselves rather than
Speaker 1: low risk vaginal birth twenty one to thirty one percent
Speaker 1: preferred elective cesarean. So how does that personal preference bleed
Speaker 1: into their practice? Along with these individual drivers? What about
Speaker 1: the US medical system as a whole, driven by profits,
Speaker 1: fear of litigation? How do these things impact rates? And finally,
Speaker 1: how much of this rise in c sections is due
Speaker 1: to a corresponding rise in the actual risk factors for
Speaker 1: the procedure, like older age during pregnancy or higher rates
Speaker 1: of preeclampsia in recent decades. How appropriate is a comparison
Speaker 1: between historical and modern rates of difficult labor? Do these
Speaker 1: historical metrics capture neonatal or perinatal mortality injuries during childbirth?
Speaker 1: Disability caused by a difficult labor? I mean reiterate again,
Speaker 1: c sections are life saving in generally extremely safe procedure,
Speaker 1: but in order to reach the Who's recommended ideal C
Speaker 1: section rate of ten to fifteen percent, we really need
Speaker 1: to reassess the metrics that we use to make decisions
Speaker 1: about interventions. How are we measuring risk? How accurate are
Speaker 1: these measurements are the risk factors themselves? Increasing medical advancements
Speaker 1: have saved the lives of so many mothers and babies,
Speaker 1: but in our reliance on diagnostic tools and technologies, we've
Speaker 1: left something else behind, and that is the comfort that
Speaker 1: community can bring to pregnancy, childbirth, and child rearing, which
Speaker 1: is in part what I'll be talking about next a week.
Speaker 2: Excited next episode, But.
Speaker 1: For now, Aaron, I want to turn it over to
Speaker 1: you to tell me all everything about labor and delivery.
Speaker 2: I'm not going to tell you everything, but I'll cover
Speaker 2: a lot right after a short break.
Speaker 9: Yeah, it was in March of twenty twenty three that
Speaker 9: we lost our first baby to miscarriage. We've been trying
Speaker 9: to conceive for quite some time and were absolutely esthetic
Speaker 9: to become parents, but we ended up in the act
Speaker 9: in an emergency department following some bleeding. I remember getting
Speaker 9: the news and just completely breaking down. It was a
Speaker 9: really busy Friday night, and we were told that we
Speaker 9: should go home and come back the next day for
Speaker 9: a transvaginal ultrasound.
Speaker 2: When we were in that.
Speaker 9: Waiting room, we already knew that we had lost our baby,
Speaker 9: but we were surrounded by excited, happy parents who were
Speaker 9: waiting to get their own scans, and it just felt
Speaker 9: like such a lonely and isolating experience. Once they had
Speaker 9: done the scan to confirm that it wasn't an ectopic
Speaker 9: pregnancy that needed further intervention, we were told we should
Speaker 9: go home and wait for the fecal matter to pass
Speaker 9: on its own. It was a really bizarre situation where
Speaker 9: literally being told to flush your hopes and dreams down
Speaker 9: a toilet. It felt very cold and clinical. I never
Speaker 9: truly appreciated that so many pregnancies end in miscarriage. I
Speaker 9: think it's about one in four is the statistic, which
Speaker 9: is so many people who were affected by baby loss.
Speaker 9: To further this, I felt like I couldn't take any
Speaker 9: time off from work and that I was a failure
Speaker 9: in some ways, which I know, having spoken to other women,
Speaker 9: is something that I'm not alone with. It wasn't just
Speaker 9: the physical pain of having the miscarriage, but the emotional
Speaker 9: told that it took on me and my partner as well.
Speaker 9: Growing up, you're always told that if you have sex,
Speaker 9: you'll get pregnant, and obviously pregnancy equals a baby, but
Speaker 9: that is so not the case for so many people. Sadly,
Speaker 9: we were one of the unlucky few couples that go
Speaker 9: on to have reoccurrent miscourages, so that sort of feeling
Speaker 9: of isolation and loneliness has happened time and time again
Speaker 9: for us. Each time I felt like I should just
Speaker 9: get over it. There was lots of support when we
Speaker 9: had that first miscarriage, but after the second one, it
Speaker 9: sort of starts to dwindle, particularly with people in the workplace.
Speaker 9: In the UK, currently there's no paid time off, no
Speaker 9: legal right to have paid time off if you lose
Speaker 9: a baby under twenty four weeks of gestation. So I've
Speaker 9: actually been campaigning to introduce that. I'm really pleased to
Speaker 9: say that most recently we've managed to do that in
Speaker 9: my workplace and we're one of the first people within
Speaker 9: our industry to actually introduce paid time off for bereaved
Speaker 9: parents who lose a baby for miscarriage or for termination
Speaker 9: for medical reasons under twenty four weeks, and I hope
Speaker 9: that my story can empower other people to campaign for
Speaker 9: the same in their workplaces and to feel less alone.
Speaker 4: I am My name's Kate from Western Australia and I'm
Speaker 4: the mother of two pre term babies. After a fairly
Speaker 4: smooth pregnancy at the age of twenty eight, I gave
Speaker 4: birth to my son at just thirty weeks in five days.
Speaker 4: He was thirteen hundred and seventy five grams or about
Speaker 4: three pounds. Went to hospital after a really bad cramping,
Speaker 4: backache and bleeding and I was advised I was in
Speaker 4: pre term labor. It was given steroids for his lungs.
Speaker 4: Because he was so early, we had to be transferred
Speaker 4: to the public hospital, and by the time I had
Speaker 4: been embittered, they rushed me in for an emergency cesarean
Speaker 4: as they could feel his little feet poking out. I
Speaker 4: was completely terrified, with my teeth chattering uncontrollably from the
Speaker 4: epidural a. Some was lifted out onto a warming bed
Speaker 4: and given oxygen. To our relief. He cried, but I
Speaker 4: only got a glimpse of him as he was taken
Speaker 4: to the ICU to be intubated and placed in a
Speaker 4: HUMI crib. He then spent a day or so in
Speaker 4: the ICU on oxygen. He was then put on a
Speaker 4: sea pat machine and moved to the neonatal ward, where
Speaker 4: I was able to hold him for the first time.
Speaker 4: I remember the nurse tucking him under my singlet the
Speaker 4: skinned skin, which was such a surreal and amazing moment
Speaker 4: for me. To many ups and downs, Jimmy was discharged
Speaker 4: from hospital after nine long weeks, but he is now
Speaker 4: a pats turn fifteen years old. Two and a half
Speaker 4: years later, his sister was born when I was thirty
Speaker 4: two weeks and five days. I had the same cramping,
Speaker 4: the same back ache, but I got to hospital much earlier.
Speaker 4: This time. I was given steroids. They tried to slow
Speaker 4: everything down, which they did for a few hours, but
Speaker 4: she was also determined to make an early entrance. As
Speaker 4: she was head down and quite small in size, we
Speaker 4: decided I was safe to deliver vaginally. Evie was born
Speaker 4: at eighteen hundred and seventy five grams, which is about
Speaker 4: four pounds. She was breathing on her own and I
Speaker 4: was able to hold her almost straight after. The extra
Speaker 4: time and the pressure from the vaginal birth ensured that
Speaker 4: steroids worked on her lungs, which made such a huge difference.
Speaker 4: Evie came home with us just four weeks later. Having
Speaker 4: to leave your new baby to go home every day
Speaker 4: is so incredibly hard. So thank you so much, the
Speaker 4: nurses at king Edwary Memorial. You made it bearable and
Speaker 4: you were all so kind and so caring. Thank you.
Speaker 2: So by the end of the last episode, episode two,
Speaker 2: by the end of my section, I made it like
Speaker 2: most of the way through pregnancy, and I stopped just
Speaker 2: before the big event, delivery. And of course, Aaron, you
Speaker 2: beautifully walked us through some parts of delivery, especially see
Speaker 2: sections and how those go. But I'm going to focus
Speaker 2: a little bit on what most people because even at
Speaker 2: thirty three percent, most people, a lot of people, even
Speaker 2: in that thirty three percent of cesarean sections, go through
Speaker 2: some part of labor beforehand. So what the heck is that?
Speaker 1: What is that? What is labor?
Speaker 2: Can't wait to tell you? So I'm going to go
Speaker 2: through what we know about the biology of labor and
Speaker 2: then walk through delivery modes, methods, a little bit more
Speaker 2: on sea sections and vaginal deliveries. It's gonna be great.
Speaker 2: So what is labor? Yeah, okay, during our whole pregnancy,
Speaker 2: all of the hormones jutting around that we've talked about, progesterone,
Speaker 2: prosscline and blah blah blah, all these things, what they
Speaker 2: do is help to keep our uterus relatively quiescent, relatively relaxed. Okay, Often,
Speaker 2: especially late in pregnancy, we might see this irregular contractility.
Speaker 2: So anyone who has experienced what they call Braxton Hicks
Speaker 2: contractions knows what those are. It's basically just your uterus.
Speaker 2: Sometimes people describe it as getting ready for birth. I
Speaker 2: don't know that that's accurate, but it's just your uterus
Speaker 2: every once in a while is still going to have
Speaker 2: these contractions.
Speaker 1: What just what is a contraction?
Speaker 2: Yes, it is actually because your uterus has like the
Speaker 2: inner lining right the endometrium. But then it's a huge muscle. Yeah,
Speaker 2: and so it is the fibers contracting literally like like
Speaker 2: your biceps contracts.
Speaker 1: But I mean, like, what, what what is it?
Speaker 3: Like?
Speaker 1: How long does it contract? We're gonna get the no, no,
Speaker 1: we'll get there. But Braxton Hicks.
Speaker 2: Like Braxton Hicks contractions, are defined as Okay, so to
Speaker 2: kind of define that, we have to define what what
Speaker 2: do we mean by labor? Like how are you defining
Speaker 2: those contractions and what's the difference there? And that is
Speaker 2: what what they are doing. So the onset of labor
Speaker 2: is defined as when there is a switch in the
Speaker 2: contractions to where they are resulting in dilation and effacement
Speaker 2: of the cervix. Okay, So contractions that are happening where
Speaker 2: you're having perhaps pain sometimes they're painful, where your uterus
Speaker 2: is contracting, but there's no change in your cervix, those
Speaker 2: contractions are not considered labor contractions it So what we
Speaker 2: see with the onset of labor is that these contractions
Speaker 2: increase in frequency and intensity and they become regular, which
Speaker 2: means that they're occurring at regular intervals. What that interval
Speaker 2: is is going to vary. Right later on in labor,
Speaker 2: they're much closer together, maybe a minute or two, but
Speaker 2: at the start they could be like ten, fifteen, even
Speaker 2: twenty minutes apart. If they are causing cervical change, then
Speaker 2: they are considered labor contractions.
Speaker 1: Okay, did you say, like which hormones are causing this yet?
Speaker 2: Did I say what triggers labor. No, I did not
Speaker 2: error because we don't know what we don't.
Speaker 1: Know, I can't be right. Check your notes again.
Speaker 2: We don't know. I said what triggers labor to begin?
Speaker 2: What an excellent question. It is hypothesized. We think that labor,
Speaker 2: the onset of labor, is triggered by the fetus or
Speaker 2: the placenta, the feto placental unit. We think that because
Speaker 2: that is what happens in like sheep and cows and
Speaker 2: in those other animals. Know what enzymes are involved, we
Speaker 2: know like the specific hormonal triggers, but we do not
Speaker 2: know that in humans, and if we did, it would
Speaker 2: be so much easier to induce labor.
Speaker 1: Also, sheep and cows have less invasive placentas.
Speaker 2: I know, I know, so it's different. It's not the
Speaker 2: same in us.
Speaker 1: But I mean, we have we have animal models that
Speaker 1: we understand.
Speaker 2: That we under the process of labor the trigger the trigger,
Speaker 2: and so in us we don't have that trigger. We
Speaker 2: know that A really important thing is that oxytocin yep,
Speaker 2: which is a hormone that the like synthetic version of
Speaker 2: it is called pittocine, that triggers unine contractions but what
Speaker 2: triggers in someone who spontaneously goes into labor, what triggers that,
Speaker 2: because it's not just like just oxytocin is something else
Speaker 2: has to trigger the production of that. Yeah, we don't
Speaker 2: know what that is, okay.
Speaker 1: And then for the for the regularity of these contractions,
Speaker 1: like how is it just the speed at which it's
Speaker 1: being oxytocin is being released? What what is?
Speaker 2: Don't know?
Speaker 1: Okay, So like we don't know why. I mean, we
Speaker 1: know why they speed up, like the purpose of speeding it.
Speaker 2: Right, we know what they're doing, but we do not
Speaker 2: know very much about the physiology of what is triggering it.
Speaker 2: But we do know a lot about how labor progresses.
Speaker 2: So what I'm going to go through are the different
Speaker 2: stages of labor. There are three. The first stage has
Speaker 2: two different phases. So we'll talk about all of that.
Speaker 2: And to do that, I did bring some props. Yay,
Speaker 2: this is the Balloon's there something in? Don't worry, we'll
Speaker 2: get there. This is a balloon that is going to
Speaker 2: represent our uterus. So if you're just listening, imagine a balloon.
Speaker 2: It's inflated, okay, but it's not tied off at the bottom.
Speaker 2: All right, So this is a uterus and this part
Speaker 2: down here, like the part that you would blow into
Speaker 2: of a balloon, is the surfix during pregnancy. I spent
Speaker 2: so long I practiced at home and everything. It's helped me.
Speaker 2: It's great. So this part is the cervix, the part
Speaker 2: that you would blow into of the balloon during pregnancy
Speaker 2: and outside of pregnancy. It's long and it's firm. It
Speaker 2: kind of feels like the tip of your nose if
Speaker 2: you were to touch it. Okay, okay, and it is closed.
Speaker 2: So you see that there's no opening here. What is that?
Speaker 8: I mean?
Speaker 1: Like, but what is that the for you?
Speaker 2: It is a little puffball okay, craft puffball?
Speaker 1: And what is it representing.
Speaker 2: It is representing the mucus plug. So during pregnancy, your
Speaker 2: cervix is closed with a mucus plug. And so one
Speaker 2: of the first steps of labor is that this mucus
Speaker 2: plug is shed. So exciting, thank you. And then through
Speaker 2: the power of these contractions, these contractions that are regular
Speaker 2: that increase in frequency and it's not going to pop
Speaker 2: I've practiced. The cervix has to do two things. It
Speaker 2: has to dilate and it has to efface. Okay, So
Speaker 2: die means that it has to go from closed to open.
Speaker 2: It's not going to pop up aiming, and so it
Speaker 2: has to go from a state of being completely closed
Speaker 2: to about ten centimeters open in diameter. Okay's that is
Speaker 2: fully dilated. But it also, as you can see as
Speaker 2: I'm like, if I'm squeezing this, it's also getting thinner, right,
Speaker 2: it's not as deep. That's called effacement. So it has
Speaker 2: to go from like several centimeters kind of like thick
Speaker 2: and deep basically paper thin tissue.
Speaker 1: Got it. So it's just yeah, yeah, it's just.
Speaker 2: Smoothing out and kind of being coming more of a
Speaker 2: part of the actual uterus itself. Cool. Cool. So that
Speaker 2: happens all through the power of contractions. The first stage
Speaker 2: of labor. This is all part of the first stage
Speaker 2: of labor, dilation and effacement. It's divided into two parts,
Speaker 2: latent labor and active labor. And these definitions vary a
Speaker 2: little bit place to place, So just for transparency, I'm
Speaker 2: using US definitions from the American College of Obstetrics and Gynecology.
Speaker 2: They define latent labor as the phase from when the
Speaker 2: cervix is completely closed until six centimeters dilated, okay. And
Speaker 2: we have found through lots of studies on people's labor
Speaker 2: progression those labor curves, that six centimeters is kind of
Speaker 2: this magic number where after that point, the regularity with
Speaker 2: which you dilate can be predictable. Up until six centimeters,
Speaker 2: someone might have very very very slow change, So they
Speaker 2: might have a latent phase of labor that is many, many,
Speaker 2: many hours long, if those contractions are still happening at
Speaker 2: a regular interval. Even if again that interval is like
Speaker 2: ten fifteen to twenty minutes, if they're still having cervical change,
Speaker 2: albeit slow, that would still be considered labor just latent.
Speaker 2: There is estimates on how long does lay labor last,
Speaker 2: What is quote unquote normal, what is outside of the
Speaker 2: range of normal, And that is a little bit up
Speaker 2: in the air, okay, because latent labor can really vary.
Speaker 2: And most of the data that we have is the
Speaker 2: time between admission to the hospital and the onset of
Speaker 2: active labor. But that doesn't necessarily mean that your labor
Speaker 2: started when you entered the hospital. But that number is
Speaker 2: about sixteen hours. Wow, is the like ninety fifth percentile?
Speaker 2: Now that's not the average, that's like the long end.
Speaker 2: Oh okay, okay, but again that's that's gonna depend very
Speaker 2: much person to person. So latent labor is the time
Speaker 2: that like really really can vary. After you get to
Speaker 2: six centimeters, that is when you are now considered to
Speaker 2: be an active labor, and that is the time at
Speaker 2: which the cervical change should speed up to a predictable
Speaker 2: interval of about one centimeter every two hours, okay or
Speaker 2: less faster, it's totally fine. Sorry, that's a six okay,
Speaker 2: So to go for six to ten, you've got like
Speaker 2: eight hours, got it before a provider is going to
Speaker 2: be like this is taking too long, okay, okay, okay, ten,
Speaker 2: But ten is the fully fully dilated yeah, okay, okay.
Speaker 2: Questions about any of that, Yeah.
Speaker 1: Okay, So the active labor part is more.
Speaker 2: Predictable, more predictable.
Speaker 1: But then not everyone progresses through active labor, yeah the
Speaker 1: same way.
Speaker 2: Yeah, Well you mean through like that from six to
Speaker 2: ten centimeters, Yeah, in eight hours or whatever. Yeah, And
Speaker 2: so if they don't a few things might be the case.
Speaker 2: So one thing that should usually happen at some point
Speaker 2: prior to that, probably is that your water should break.
Speaker 2: If your water didn't break, on its own, then a
Speaker 2: provider might say, we should break it for you. This
Speaker 2: is a cruchet hook, which looks exactly like it does
Speaker 2: look exactly like an amni hook. This is the actual hook.
Speaker 2: You can see. It looks exactly identical it does. Yeah,
Speaker 2: it's just longer and not round and not round you.
Speaker 1: I wouldn't want to crouchet with that.
Speaker 2: No, yeah, yeah, yeah, But this is used to break
Speaker 2: somebody's water. Now. The reason that that's important is because
Speaker 2: the baby's head, which is hopefully down, exerts pressure on
Speaker 2: that cervix. If there is a bag of fluid there,
Speaker 2: then that might limit the amount of pressure that's being
Speaker 2: exerted and might make it so that your cervix is
Speaker 2: not dilating the way that it should. So that's the
Speaker 2: reason that a lot of times, if water hasn't broken
Speaker 2: on its own, that will be like an intervention that's
Speaker 2: recommended to help speed up the process of labor.
Speaker 1: What determines how much I was going to how much fluid?
Speaker 2: Oh yes, I was going to do it, but I
Speaker 2: think it actually might make a mess, So I'm going
Speaker 2: to stop that. I had a baby in there too.
Speaker 1: I'm envisioning the water going everywhere make a mess. Yeah.
Speaker 1: What determines how much liquid? How much amniotic fluid is
Speaker 1: in there?
Speaker 2: Big question? So AMIEC fluid is P? It's a fetus P.
Speaker 1: Yeah.
Speaker 2: So it depends on how much the fetus is peeing
Speaker 2: and whether or not their kidneys are working directly, and
Speaker 2: also how much they because then they drink that pea
Speaker 2: and so that it's like a whole thing. It's fetal development.
Speaker 2: I'm not going to get into it.
Speaker 1: Yeah, okay, So I.
Speaker 2: Don't have an answer for you. And what determines whether
Speaker 2: or not what determines whether or not it breaks spontaneously
Speaker 2: or has to be broken? Who knows what.
Speaker 1: What percentage breaks spontaneously?
Speaker 2: I don't ask question. Listen, In any case, at some
Speaker 2: point the water is likely going to break. Sometimes it doesn't.
Speaker 2: Babies can be born just fine. In call it's called amatic.
Speaker 2: There's a whole history we could talk about, beautiful. But
Speaker 2: in any case, when it does break, that allows for
Speaker 2: the fetal head to engage lower down in the pelvis,
Speaker 2: putting more pressure on the cervix and helping to ensure
Speaker 2: that you're getting adequate dilation and effacement.
Speaker 1: What I have a question, it might be it might
Speaker 1: be jumping ahead breach number one number two, which which
Speaker 1: how is what facing facing babyhead?
Speaker 2: I have a baby? Do you want me to show you? Yes,
Speaker 2: I love that I have a baby. Here. Most of
Speaker 2: the time a baby should be facing We like for
Speaker 2: them to be facing like this. If this is my body,
Speaker 2: so that they are facing down, their face is facing
Speaker 2: maternal backside, and their oxaput, which is the back part
Speaker 2: of their head, is anterior, meaning facing up towards my
Speaker 2: belly button. Okay, that is the easiest way for a
Speaker 2: baby to come out. They have to do some rotations
Speaker 2: within the pelvis in order to get there, which is
Speaker 2: very interesting. If a baby is facing the other way,
Speaker 2: so head up, which is how I was born, eyes
Speaker 2: up and open to the world, then it's a little
Speaker 2: bit harder because this forehead is wider, so it's just
Speaker 2: harder to push that through the canal first.
Speaker 1: It's so interesting because I feel like you and I
Speaker 1: have talked about this, where like primates, depending on the
Speaker 1: primate species, there's like different directions that tend for you know,
Speaker 1: neoonates to be born right and often like why we
Speaker 1: think that human childbirth is a cooperative process is social
Speaker 1: process is because of the direction interesting and so it's
Speaker 1: like it can be more difficult to you can't do
Speaker 1: that yourself.
Speaker 2: It's harder to do yourself. And also when your baby
Speaker 2: is born facing down, you can't see their face to
Speaker 2: be able to do things like clean their eyes, clean
Speaker 2: their mouth, things like that, which other primemates can. Now,
Speaker 2: if a baby is breach, that means that some part
Speaker 2: of their bottom or feet is what is facing down
Speaker 2: towards the cervix. There's a lot of different types of breach,
Speaker 2: and I'm not an expert on it, so I don't
Speaker 2: remember like the different names for all of it, whether
Speaker 2: it's like complete breach or foot laning or blah blah blah.
Speaker 2: But yeah, it's usually some combination of either their bottom
Speaker 2: or their feet or one foot or something like that. Okay,
Speaker 2: breach babies are we'll talk a little bit more about this.
Speaker 2: But like you said, it is a slightly more difficult
Speaker 2: vaginal delivery, and so very very often, especially in the US,
Speaker 2: it is recommended that people have a c section. If
Speaker 2: baby is breached and won't be turned around.
Speaker 1: It won't be turned around, try to Okay.
Speaker 2: Yeah, and there's things that there's procedures that people can
Speaker 2: do to try and get baby to turn. It's called
Speaker 2: external cephalic version, where they basically push on the uterus
Speaker 2: and try They usually give medicines to relax the tone
Speaker 2: of the uterus first, Yeah, to try and induce that
Speaker 2: baby to turn. What about shoulders, shoulder dystotia. Okay, let's
Speaker 2: get We're still on the first stage of labor, Aaron,
Speaker 2: we haven't gotten there yet, but actively were erin. So
Speaker 2: that was all the first stage of labor. We skipped
Speaker 2: ahead a little bit with that delivery question. But once
Speaker 2: we've reached ten centimeters, I'm gonna treat this with more reverence.
Speaker 2: That is when we've entered the second stage of labor,
Speaker 2: which is delivery. Okay, and I guess I kind of
Speaker 2: already went through some of this, but essentially delivery is
Speaker 2: going to go one of two ways. It's going to
Speaker 2: go vaginally or it's not, in which case it's going
Speaker 2: to go to a C section. Right, So, how long
Speaker 2: one ends up having to push in order to deliver
Speaker 2: a baby vaginally totally depends. It can be a few minutes,
Speaker 2: it can be several hours. It does tend to be
Speaker 2: a little bit longer. That someone is pushing if they've
Speaker 2: had an epidural, And that's in part because it just
Speaker 2: makes it harder to know exactly where you are pushing
Speaker 2: because you can't feel as much because an epidural numbs you.
Speaker 8: Right.
Speaker 2: But that's the second stage of labor's delivery. Did I
Speaker 2: answer all of your questions about the modes?
Speaker 1: And I think so? I think so great.
Speaker 2: But I do want to spend a little bit more
Speaker 2: time here, not just talking about vaginal deliveries, but also talking,
Speaker 2: like you said erin, about cesarean sections, because sometimes we
Speaker 2: don't make it to this second stage of labor. Sometimes
Speaker 2: we don't make it all the way to ten centimeters.
Speaker 2: Sometimes we might not even make it to six centimeters.
Speaker 2: There's a lot of different things that can happen during
Speaker 2: that first stage of labor. So I want to take
Speaker 2: a minute to talk about c sections, not the steps,
Speaker 2: because you already did that, but about how it is
Speaker 2: often decided whether or not to proceed with a cesarean section.
Speaker 1: Could I before we do that, because I do realize
Speaker 1: I had a question about labor. How is that? Like
Speaker 1: who is keeping track? And what? Yeah? How is that?
Speaker 2: Then?
Speaker 1: Sort of yeah, these I guess leading into this question
Speaker 1: of C section.
Speaker 2: Yeah, so, I mean it is all going to depend
Speaker 2: on where you are and what your situation is. Right,
Speaker 2: If you're delivering at home, then it's just like you
Speaker 2: keeping track of the timing of your contractions, of how
Speaker 2: long those contractions are lasting, how frequently they're coming, and
Speaker 2: like maybe hopefully you have someone who's there with you
Speaker 2: who's checking your cervical dilation and effacement at regular intervals.
Speaker 2: If you're in the hospital, most of the time, you
Speaker 2: will be attached to an electronic fetal monitor, which is
Speaker 2: what you talked about, that's going to be monitoring your
Speaker 2: contractions so you can see them on the monitor so
Speaker 2: we know are they getting closer together. The external ones
Speaker 2: cannot tell us how strong a contraction is because they're
Speaker 2: just measuring tension externally. The only way that we can
Speaker 2: actually measure the pressure that's being exerted on the fetus
Speaker 2: is through an internal monitor, which we do have.
Speaker 1: Are those continuous or intermittent?
Speaker 2: They are continuous. Your water has to be broken to
Speaker 2: be able to get into the uterine cavity. But that's
Speaker 2: something that sometimes people end up having because let's say,
Speaker 2: for example, you're getting to that active phase of labor
Speaker 2: where we are expecting a certain amount of cervical change
Speaker 2: and it's not happening. So that might mean that even
Speaker 2: though you're contracting at intervals that seem regular, it might
Speaker 2: be that they're not strong enough to be inducing the
Speaker 2: cervical change. That might mean that we have medications that
Speaker 2: can help, because that's potocin or oxytocin is the one
Speaker 2: that we use most commonly because that is what stimulates
Speaker 2: contraction of the uterus, and so that's going to increase
Speaker 2: the power of those contractions to induce that cervical change.
Speaker 1: Are you going to talk about intermittent versus continuous feel monitoring?
Speaker 2: I mean those are two options for monitoring.
Speaker 1: Yeah, But in terms of like the decision making and
Speaker 1: what that tells us, it's.
Speaker 2: So variable that there's not like an easy answer that
Speaker 2: I have for that. It's going to very hospital to hospital,
Speaker 2: it's going to very provider to provider, and it's going
Speaker 2: to also depend on your individual risk situation, where most
Speaker 2: people if they have any kind of any degree of
Speaker 2: potential complications or like known complications. Let's say that you
Speaker 2: have preocclampsia or you have gestational hypertension or something like that,
Speaker 2: more likely that someone's going to be recommended to have
Speaker 2: continuous fetal monitoring rather than if you were considered a
Speaker 2: low risk pregnancy. Okay, and again that low to high
Speaker 2: risk can change very quickly, especially during labor. Yeah, it
Speaker 2: also is of course going to depend on whether you
Speaker 2: came into labor spontaneously or whether you came in to
Speaker 2: be induced for some reason or another. And one of
Speaker 2: the ways that I have seen most people talk about it,
Speaker 2: and one of the ways that I think about it
Speaker 2: that I think makes the most sense, is that any
Speaker 2: time that a medical provider is going to be doing
Speaker 2: an intervention, then they most likely will want to have
Speaker 2: continuous monitoring, at least for a time, because I'm doing
Speaker 2: something that's going to potentially affect you and your baby,
Speaker 2: so I want to know what effect that's having. Yea,
Speaker 2: if that makes sense, Yeah, that does so, but it
Speaker 2: totally varies place to place, Okay, So don't ask me statistics.
Speaker 2: I will tell you some statistics about sea sections unless
Speaker 2: you have more questions about.
Speaker 1: I'm sure that I will, but we'll give me the stats.
Speaker 2: Okay. So, globally, rates of sea sections are about twenty
Speaker 2: one percent on average global, but that, like you mentioned,
Speaker 2: AARIN is not at all homogeneous in places like Sub
Speaker 2: Saharan Africa. Sea section rates are around five percent. In
Speaker 2: Latin America and the Caribbean up to forty two percent,
Speaker 2: and like you said, AARON even higher in some private hospitals.
Speaker 2: In various places in Europe, we have huge variation depending
Speaker 2: on what geographic region, from like twenty four to thirty percent.
Speaker 2: All across Asia, things can vary from like twelve to
Speaker 2: thirty three percent. It's like huge, huge amounts of Australia
Speaker 2: and New Zealand are averaging around thirty three percent, and
Speaker 2: then we in the US are in the thirty percent
Speaker 2: range right now. It's up and down the last few years.
Speaker 2: And like you said, the World Health Organization has a
Speaker 2: recommendation that no more than fifteen percent of deliveries are
Speaker 2: by cesarean section. I don't know exactly how they came
Speaker 2: up with that number, but it's my understanding that that
Speaker 2: number is based on data to try and match the
Speaker 2: risk benefit ratio. How can we maximize health of both
Speaker 2: the mother and the baby and not increase the risks
Speaker 2: that we know are associated with cesarean section because there are,
Speaker 2: and there are without a doubt, circumstances where c section
Speaker 2: has and will continue to save the life of either
Speaker 2: mother or baby or both or both. Yeah, and there
Speaker 2: is no doubt about that. But deciding exactly when that
Speaker 2: point is can some be really tricky. There are some
Speaker 2: cases that pretty universally we think and we know that
Speaker 2: a c section is the most likely to save the
Speaker 2: life of mother and baby and is probably going to
Speaker 2: be recommended across the board always with like no gray
Speaker 2: areas ready for some of those factors that might be
Speaker 2: something like a placenta previa or a known placenta, a creed,
Speaker 2: a spectrum disorder like we talked about. Those are situations
Speaker 2: that Cisaian delivery is going to save the life of
Speaker 2: the baby and might also save the life of the
Speaker 2: mom because especially with placenta previa, which is where the
Speaker 2: placenta is covering the cervix, you can have significant hemorrhage
Speaker 2: which can be very dangerous for the mom as well
Speaker 2: as the baby. Another one that might happen during the
Speaker 2: course of labor after that amniotic fluid sac is broken,
Speaker 2: is called cord prolapse, and that is an absolute emergency
Speaker 2: where the umbilical cord comes out through the cervix before
Speaker 2: any part of the baby, and that is going to
Speaker 2: trap blood flow and block blood flow to the chord,
Speaker 2: which is extremely dangerous for the baby. So that is
Speaker 2: pretty universally an emergency sea section scenario. We also generally
Speaker 2: across the board recommend cesarean sections if there is a
Speaker 2: first time genital herpes outbreak or an active genital herpes infection,
Speaker 2: which people don't talk about that often, yeah they really don't,
Speaker 2: but that puts baby, if they're born vaginally, at a
Speaker 2: pretty high risk for herpes encephalitis, and so it's usually
Speaker 2: recommended to do a sea section if that is known
Speaker 2: to be happening, if somebody has had a prior uterine
Speaker 2: surgery like a very large fibroid removal, or a previous
Speaker 2: midline sea section, because most of the time, if we
Speaker 2: look at our uterus again here, most of the time
Speaker 2: these days, sea sections are done transverse, so they're cut
Speaker 2: across what's called the lower uterine segment, and that usually
Speaker 2: heals very well and a second pregnancy after that is
Speaker 2: at lower risk of uterine rupture, higher risk than with
Speaker 2: no surgery, but a mid line so an incision that
Speaker 2: goes from the top to the bottom of the uterus
Speaker 2: is a very high risk for uterine rupture with a
Speaker 2: next pregnancy.
Speaker 1: And so is the difference. So I know that today
Speaker 1: we do more transverse incisions, but historically we used to
Speaker 1: do midline. Are there is there any reason to do
Speaker 1: midline that like people do midline today.
Speaker 2: Usually it's if the baby is very small, so like
Speaker 2: very premature, then it might be really difficult to get
Speaker 2: to that lower uterine segment because it's just not up
Speaker 2: like above the pubic bone, so it's harder to access,
Speaker 2: and there might be other, like anatomic reasons that it
Speaker 2: has to be done. I'm not a surgeon, so that's
Speaker 2: not on me. That's a good question though, And so
Speaker 2: in those cases, people are usually scheduled for like a
Speaker 2: planned C section to that is, to avoid labor, because
Speaker 2: the contractions of labor can be very risky. Yeah, And
Speaker 2: like we talked about already, in most cases babies who
Speaker 2: are breach booty down or feet down instead of head down,
Speaker 2: sea section is often recommended. And it's not because it's
Speaker 2: impossible to deliver a vaginal breach delivery, but it's for
Speaker 2: a few reasons there's some data from a few studies
Speaker 2: in the US at least that it is studies that
Speaker 2: were looking at a planned cesarean delivery for a breach
Speaker 2: baby versus a planned vaginal delivery, whether or not that
Speaker 2: ended in a vaginal or a sea section, right, because
Speaker 2: you might plan for vaginal end up having a sea section.
Speaker 2: That data suggested that it was marginally safer to do
Speaker 2: a planned cesarean section in the immediate term, okay, And
Speaker 2: so because of that, for a while it was like
Speaker 2: kind of across the board recommended that you do see
Speaker 2: sections for breach deliveries if they cannot be rotated by
Speaker 2: that external cephalic version. And that recommendation plus the fact
Speaker 2: that breach deliveries are rare. I don't have an exact
Speaker 2: number on that, but most of the time babies end
Speaker 2: up head down, and so a breach presentation is relatively rare.
Speaker 2: And with those two things combined, less and less obstetricians
Speaker 2: and midwives have experience in vaginal breach deliveries, which then
Speaker 2: makes them riskier because if you haven't practiced that hands on,
Speaker 2: then you don't have as much experience with it. It's
Speaker 2: more likely that something is going to go wrong. So
Speaker 2: that is a big reason why most of the time
Speaker 2: people are recommended to get a C section if they're
Speaker 2: known to have a breach baby. Yep, So that makes.
Speaker 1: It, it does make sense. Yeah, I mean, it's like,
Speaker 1: it's a big part of just this is a tool
Speaker 1: that we use exactly, and so it's yeah, and so
Speaker 1: because we have this option exactly, we don't have to
Speaker 1: necessarily explore the option that is very risky.
Speaker 2: It is. It is, it absolutely is. And there might
Speaker 2: be others that I have missed in terms of what
Speaker 2: the more like clear cut recommendations are. But a lot
Speaker 2: of the sea sections that are done, and in a
Speaker 2: lot of cases in studies that have looked at this,
Speaker 2: and it really varies location to location, but in a
Speaker 2: lot of cases, most sea sections are not necessarily done
Speaker 2: for those reasons. They are done for reasons that fall
Speaker 2: more in this gray area in terms of who makes
Speaker 2: that decision and what point is that decision made, And
Speaker 2: those are for indications like failure to progress, failure of
Speaker 2: an induction of labor, a rest of descent so that
Speaker 2: means baby doesn't come all the way down the birth
Speaker 2: camel and get stuck, or fetal intolerance of labor, which
Speaker 2: means we're monitoring and we see that baby's heart rate
Speaker 2: is tanking and not coming back up. And so those
Speaker 2: are a lot of the main reasons that we see
Speaker 2: in studies that have looked at, like what are the
Speaker 2: indicant what are the reasons for surgery in these cases?
Speaker 2: Those are more gray areas, and in some of those
Speaker 2: cases it might be that we are saving lives, but
Speaker 2: who and when and why, Like it's it's just a
Speaker 2: harder place to make that decision, and it's much more
Speaker 2: an individual decision in that gray area, right.
Speaker 1: Like individual meaning dependent upon the specific situation, the.
Speaker 2: Specific situation the person who is in labor, the person
Speaker 2: who is going to be doing that C section or
Speaker 2: vaginal delivery, and like what their comfort level is, right,
Speaker 2: And so that's also I think when you see the
Speaker 2: most potential for trauma associated with it in terms of
Speaker 2: how I'm going to experience that because it is usually
Speaker 2: not planned in those scenarios.
Speaker 1: It's tough because whose responsibility is that? And then I
Speaker 1: feel like there's a lot of blame associated with it
Speaker 1: and a lot of trauma associated with like the questions
Speaker 1: why didn't I do this? Why didn't I ask this,
Speaker 1: Why didn't my doctor do this? Why didn't my doctor
Speaker 1: tell me this? And it's so like, how do we
Speaker 1: fix that even beyond making sure that we're eating fetal
Speaker 1: monitoring correctly right, or we're using continuous versus intribitten or
Speaker 1: what like, all of these indications, beyond measuring those, how
Speaker 1: do we then make sure that everyone, as much as
Speaker 1: we can, is okay with this decision?
Speaker 2: Right? I mean that comes down to communication, Aaron, Let's
Speaker 2: be honest.
Speaker 1: Yeah, it's a big part of it.
Speaker 2: It's a big part of it. But then there's another
Speaker 2: piece that we haven't really got into, and that is
Speaker 2: elective cesareans. Yes, and that can be a first time
Speaker 2: delivery with an elective cesarean or what's called sometimes an
Speaker 2: elective repeat cesarean. So say, whatever the reason was, you
Speaker 2: ended up with a C section your first time, and
Speaker 2: then you decide to schedule a C section for your
Speaker 2: second or third or whatever delivery. Now, I think that
Speaker 2: in this scenario, sometimes, just like with so many of
Speaker 2: the indications that we have, like, there is a lot
Speaker 2: of judgment that is placed on that and sometimes it
Speaker 2: can get to the point where we have to kind
Speaker 2: of take a step back and say, like you said,
Speaker 2: who is making this decision? If we believe, which I do,
Speaker 2: that somebody should have the right to decide whether or
Speaker 2: not they want to become pregnant or carry a pregnancy
Speaker 2: to term or not, then shouldn't they also have the
Speaker 2: right to decide whether or not they want to attempt
Speaker 2: a vaginal delivery or not? Is that a crazy concept today?
Speaker 1: It is, Yes, it.
Speaker 2: Can be, but said, I think that that part is
Speaker 2: often missing, honestly, And we can focus a lot on
Speaker 2: the potential risks of C section, and they do exist.
Speaker 2: There are also risks associated with vaginal deliveries, of course,
Speaker 2: and so I think that if we are not under
Speaker 2: selling the potential risks and complications of this major abdominal surgery,
Speaker 2: then it should be a person's right to decide what
Speaker 2: they do, yeah, and not be judged for that, and
Speaker 2: not be judged for that.
Speaker 1: Okay, do you remember Gilmore girls Sherry who is Christopher's
Speaker 1: wife vaguely yeah, yeah, yeah, And she was like very
Speaker 1: much like make the show was making fun of her
Speaker 1: because she had a planned, planned C section and then
Speaker 1: she ended up not like she ended up going into
Speaker 1: labor early and had a vaginal birth. I think that's
Speaker 1: what I remember.
Speaker 2: I remember that, but.
Speaker 1: Just like that alone, that representation of like, here's this
Speaker 1: ridiculous type a personality. Blah blah blah, she wants a
Speaker 1: see section. That is, who is electing for a sea section?
Speaker 1: And then the judgment.
Speaker 2: Judgment inherent to that. It's like, we just can't win.
Speaker 2: When if you plan that was delivery and then you
Speaker 2: had a C section, you you know, are you're getting
Speaker 2: judged for that or you feel judged for that. If
Speaker 2: you plan for a C section, you're judgement. We just
Speaker 2: can't win.
Speaker 1: We can't wine.
Speaker 2: Goodness, I know, Aaron, I want to move on, Okay,
Speaker 2: can we sure? Okay? Do you have any other questions?
Speaker 1: Probably?
Speaker 2: I have other things about sea sections, like the risk
Speaker 2: of this and like the effects on the child.
Speaker 1: I have a question about c section how we classify
Speaker 1: see sections because a lot of people use the phrase
Speaker 1: emergency C section? What is that? Is that unplanned? And
Speaker 1: then there's stages of unplanned that's like urgent, extra urgent,
Speaker 1: super urgent. Yeah.
Speaker 2: I tried to get you data on this. I read
Speaker 2: a whole paper that was about the classifications of how
Speaker 2: we classify a sea section. Yeah, it is a disaster,
Speaker 2: of course, both in terms of like sometimes they're just
Speaker 2: classified by indication, Like we talked about the indication for
Speaker 2: the C section was failure to progress or whatever. It
Speaker 2: was fetal intolerance of labor. Sometimes they're classified by urgency.
Speaker 2: This was an emergent. This was an urgent, This was
Speaker 2: a planned Okay. Sometimes they're classified by like the status
Speaker 2: of the pregnant person, so this was this was a
Speaker 2: person with preoclampsia, this was whatever this had. This paper
Speaker 2: alone had like twenty seven different systems of classification, So like,
Speaker 2: I don't know, Okay, I'm.
Speaker 1: Planned and unplanned plan big picture of breakdown.
Speaker 2: But it is true that, like if you can think
Speaker 2: of some of the scenarios that I gave of, like
Speaker 2: this would one hundred percent of the time be recommended
Speaker 2: for C section, like a cord prolapse, that would be
Speaker 2: an emergency scenario because you have a cord that is
Speaker 2: being compressed. So yes, there are scenarios that are like, well,
Speaker 2: your baby is not looking great, so we might say
Speaker 2: let's do this urgently, but we're not like everyone's sprinting.
Speaker 2: And yeah, it's true that like there's a huge range.
Speaker 1: Yeah, there's a range.
Speaker 2: Yeah, there's also sometimes, and we kind of skipped over this,
Speaker 2: what are called operative vaginal deliveries, And that doesn't necessarily
Speaker 2: mean there's an operation, but it just might mean that
Speaker 2: somebody is having a vaginal delivery and the baby is
Speaker 2: having a hard time descending that birth canal. So there
Speaker 2: are things that can be done to help that process.
Speaker 2: Sometimes it's forceps.
Speaker 1: We still have still use percentage, and I'm sure there's
Speaker 1: various global blah blah blah.
Speaker 2: I don't have numbers on that because it also just
Speaker 2: varies hospital to hospital and training. How much training does
Speaker 2: it does an OBI get For the place forceps that
Speaker 2: I worked, there was someone who really was very adept
Speaker 2: at forceps and so would use them very frequently. So
Speaker 2: I know that the trainees there got a lot of
Speaker 2: training with forceps. At other places they might not. They
Speaker 2: might use what's called a vacuum. This is what it
Speaker 2: looks like if you're seeing this on video. It basically
Speaker 2: is a little disc, a plastic disc that sometimes has
Speaker 2: a bit of phone in the middle. This is placed
Speaker 2: on the baby's head here, yeah, and then you basically
Speaker 2: pump this up and it suctions itself to the baby's head,
Speaker 2: and then you're able to use that to pull the
Speaker 2: baby down to basically provide traction to help that baby descend.
Speaker 2: What about the soft spot so they can get a
Speaker 2: little bit of a hematoma there, Okay, yeah, but they
Speaker 2: usually do great.
Speaker 1: Wow.
Speaker 2: So yeah, So there's a lot of reasons why somebody
Speaker 2: might need a little bit of additional assistance, but not
Speaker 2: to the point of a C section. And it's all
Speaker 2: going to depend on the individual scenario and how how
Speaker 2: far you've progressed in labor up to that point. Okay, okay,
Speaker 2: but all of that was still just the second stage
Speaker 2: of labor. We have a whole nother stage to go.
Speaker 2: The third and final stage of labor is delivery of
Speaker 2: the placenta. Yeah, and that can take anywhere from like
Speaker 2: a couple of minutes to like a half an hour
Speaker 2: or so.
Speaker 1: Interesting.
Speaker 2: Most of the time the placenta detaches all on its own.
Speaker 2: Sometimes it doesn't, and it might get stuck, and then
Speaker 2: it might require manual removal, which can be quite uncomfortable.
Speaker 2: And then, like we talked kind of a lot about already,
Speaker 2: sometimes it might have gone too deep into the myometrium
Speaker 2: and actually have extended too far and might require surgery
Speaker 2: to remove, or in very extreme cases, it might require
Speaker 2: a hysterectomy.
Speaker 1: Okay.
Speaker 2: The reason that the removal of the placenta is so
Speaker 2: important is because without the placenta removed, you cannot stop
Speaker 2: the bleeding. So I want to talk about blood for
Speaker 2: a second. Yeah, I remember last episode. Our blood volume
Speaker 2: during pregnancy has increased by about fifty percent. At term,
Speaker 2: your uterus is receiving twelve to twenty percent, depending on
Speaker 2: which papers you read, of your total blood flow, your
Speaker 2: total cardiac output, which is like seven hundred milliliters every minute.
Speaker 2: That's wild. With every contraction, your uterus is shunting three
Speaker 2: hundred to five hundred milliliters of blood back into your
Speaker 2: circulation because it's just basically pushing out all of this
Speaker 2: blood like it's a sponge that you're ringing out. So
Speaker 2: immediately after delivery of the placenta, you have all of
Speaker 2: these spiral arteries in your uterus that have become enlarge
Speaker 2: in order to provide constant blood flow to the placenta.
Speaker 2: These have to find a way to stop because if
Speaker 2: they do not stop, then you are continuing to just bleed.
Speaker 2: So to do that, but your uterus has to clamp
Speaker 2: down very quickly, and it usually does, and it's phenomenal,
Speaker 2: Like after that placenta is out, your uterus goes from
Speaker 2: like the size of a watermelon, yeah, to like the
Speaker 2: size of a I don't know, miniature basketball, like yeah,
Speaker 2: very quickly. Yeah, but sometimes it doesn't. And postpartum hemorrhage,
Speaker 2: which is defined as the loss of more than one
Speaker 2: leader of blood okay, regardless of the method of delivery.
Speaker 2: It used to be defined differently for a C section
Speaker 2: versus a vaginal delivery. Okay, but it's not because now
Speaker 2: we know we can do se sections with very little
Speaker 2: blood loss. Yeah, postpartum hemorrhage one leader of blood. Even
Speaker 2: that much blood loss, a lot of times people are
Speaker 2: not symptomatic because of how much blood volume you have,
Speaker 2: which also means that people can lose a very significant
Speaker 2: amount of blood during the delivery process. Okay, Okay, let's
Speaker 2: go wrong.
Speaker 1: So because someone who is pregnant and at term has
Speaker 1: so much more blood than someone who is not pregnant.
Speaker 2: And so much blood is going to the uterus, yes.
Speaker 1: And so then that blood loss is not is not
Speaker 1: like as severe as it would be or like the
Speaker 1: consequence of it is not as severe as it would
Speaker 1: be if someone was the same amount of blood loss
Speaker 1: the same. Yeah, like because you have more blood to
Speaker 1: lose that you can live.
Speaker 2: You have more blood that you can lose, and you
Speaker 2: can lose way too much blood very quickly. Yes, So
Speaker 2: it's like both and yes, yes, yes, okay, And so
Speaker 2: that's why the limit is like one leader. One leader
Speaker 2: is a lot of leaders, a ton of blood, so
Speaker 2: much blood. But a lot of times people are maybe
Speaker 2: not symptomatic until they lose like one and a half
Speaker 2: liters or even two leaders of blood, which is like
Speaker 2: twenty five percent of your total bloodvaulume. It's a huge
Speaker 2: it's a huge amount of blood. So postpartum hemorrhage is
Speaker 2: estimated to effect anywhere from three to ten percent of deliveries,
Speaker 2: but it accounts for twenty percent of maternal deaths worldwide
Speaker 2: income countries. That number is less, in large part because
Speaker 2: we have really good options on how to stop postpartum hemorrhage.
Speaker 2: Though the rate of hemorrhage has been on the rise
Speaker 2: from in the US from nineteen ninety three to twenty fourteen,
Speaker 2: the rate of hemorrhage that required a blood transfusion, which
Speaker 2: is like not that means it's a pretty severe hemorrhage
Speaker 2: increased from eight per ten thousand deliveries to forty per
Speaker 2: ten thousand deliveries in the US. So why people are
Speaker 2: bleeding more in part probably because of other risk factors
Speaker 2: that are associated r like things like placenta accreda spectrum
Speaker 2: disorders which are on the rise, preaclampsia. A lot of
Speaker 2: these are risk factors for postpartum hemorrhage. There's four main
Speaker 2: things that we think of as like causal for postpartum hemorrhage.
Speaker 2: Most of the time it's because of uterine At me me,
Speaker 2: it's because of that uterus not clamping down to the
Speaker 2: size of a small basketball the way that it ought to,
Speaker 2: because then you just have so much blood being shunted
Speaker 2: to the uterus and it's just flowing down, blowing out
Speaker 2: because these arteries are not being clamped down. And the
Speaker 2: risks for having a uterus that has a hard time
Speaker 2: clamping down might be a retained placenta so a little
Speaker 2: piece of it that hasn't come off, or a prolonged
Speaker 2: labor Definitions vary on that. Gestational diabetes is a risk
Speaker 2: for this any kind of hypertensive disorders, and then there
Speaker 2: are probably other factors as well, But the other main
Speaker 2: factors that contribute to postpartum hemorrhage are things like trauma,
Speaker 2: so maybe lacerations, so that might not be even bleeding
Speaker 2: from the uterus, but just bleeding from elsewhere from lacerations,
Speaker 2: retain placenta or retain blood clots, even that can just
Speaker 2: prevent that uterus so it's like it's trying to clamp down,
Speaker 2: but there's something blocking it. And then also what they
Speaker 2: call thrombin or clotting factor deficiencies, which are not that uncommon,
Speaker 2: which is okay, like in general in general, because are
Speaker 2: like more like genetic susceptibilities, right, okay, Yeah, And there
Speaker 2: are a lot of different medications that we can now
Speaker 2: use to help stop the bleeding, to either induce contraction,
Speaker 2: and then also like devices like balloons and things like
Speaker 2: that that we can use to clamp down and block
Speaker 2: off those arteries, or in some cases people might need
Speaker 2: to have what's called a uterine artery embolization, so they
Speaker 2: put like a coil in to help block blood flow
Speaker 2: to the artery so you're not getting as much flow
Speaker 2: to that area. Okay, and that those kinds of developments
Speaker 2: are why we've seen a reduction in the mortality from hemorrhage.
Speaker 2: I see, even as we've seen an increase in the
Speaker 2: risk of hemorrhage. Okay, yeah, okay. But in the event
Speaker 2: that all of that happens well enough, and a baby
Speaker 2: is delivered one way or another, vaginally, spontaneously, vaginally, operatively
Speaker 2: so with assistance or a C section, after that third
Speaker 2: stage of labor, pregnancy is done.
Speaker 1: Or is it?
Speaker 2: Or is it? But that's where we'll pick up next week.
Speaker 3: Okay.
Speaker 1: I have a couple of questions that I jotted down.
Speaker 1: I saw you writing, Yeah, I didn't want to forget
Speaker 1: back labor.
Speaker 2: Ah, okay. So back labor just means that you're feeling
Speaker 2: the contractions primarily in your back rather than feeling them
Speaker 2: across your abdomen. Okay, why does it happen? I don't know.
Speaker 2: Is it just anatomic sometimes or et cetera. Sometimes people
Speaker 2: will say it's more based on position.
Speaker 1: Of the baby.
Speaker 2: So if the baby is op so on the put
Speaker 2: back and face up, then sometimes people are more likely
Speaker 2: to have back labor. Doesn't necessarily mean baby will come
Speaker 2: out that way because they rotate this way quite a
Speaker 2: lot during labor and delivery. Spiral spiral. Yeah, they don't
Speaker 2: like tend to flip upside down, though sometimes they do.
Speaker 2: Sorry baby, Okay, back labor, Yes, back labor.
Speaker 1: Tearing. Let's talk about tearing. Okay, let's talk about episiotomies.
Speaker 2: I have a little bit of extra notes here just
Speaker 2: for you.
Speaker 1: You know me, I do know it.
Speaker 2: An episiotomy means that somebody makes a cut, makes an
Speaker 2: incision in the perineum, in the skin of the perineum,
Speaker 2: so that's the space of skin between the opening of
Speaker 2: the vagina and the opening of your anus. They have
Speaker 2: very much fallen out of favor. Yeah, they have. They
Speaker 2: used to be quite common.
Speaker 1: You know that no one did a study on them
Speaker 1: until the nineteen seventies about are these something we should
Speaker 1: be doing?
Speaker 2: Not surprised at all. I have had the fortune of
Speaker 2: working with some pretty phenomenal obgi ns in my training,
Speaker 2: and one that I worked with explained it to me
Speaker 2: very well. I think as an episiotomy is helping to
Speaker 2: increase soft tissue, right because it's basically it's only skin,
Speaker 2: so you're cutting in skin most of the time. If
Speaker 2: a baby is having trouble descending to the birth canal,
Speaker 2: Shall I get out my pelvis model?
Speaker 1: Yes?
Speaker 2: Please, I have a very large pelvist here. Most of
Speaker 2: the time, if a baby is having trouble descending the
Speaker 2: birth canal, it's not soft tissue of your paraneum that's
Speaker 2: causing the trouble, or even the tissue of the vaginal
Speaker 2: canal itself. It's your bones, right, So episiotomies don't help
Speaker 2: with any of that.
Speaker 1: It's our bipedalism.
Speaker 2: It's our bipedalism, and so because of that, they have
Speaker 2: very much fallen out of favor. They make it easier
Speaker 2: for somebody to use their hands in the vaginal canal
Speaker 2: to help in the case of a difficult delivery, so
Speaker 2: it's not that they're never done. They also increase the
Speaker 2: risk of fourth degree tears, which is a tear that
Speaker 2: goes all the way into the anal sphincter itself and
Speaker 2: can have severe longtime consequences like an increased risk of
Speaker 2: fecal incontinence, fiscilla formation, other things like that.
Speaker 1: Yeah, I mentioned fishila. What is official.
Speaker 2: Officila is any connection between two places that doesn't belong.
Speaker 2: So most often in the case of like after a
Speaker 2: vaginal delivery, you might have a fistulla into the anal
Speaker 2: canal or something like that, like from the from the
Speaker 2: a from the rectum into the vagina or something like that.
Speaker 2: Very very uncommon these days. Used to be much much
Speaker 2: more common, very very.
Speaker 1: Common instruments pessories that people There are hundreds of variations
Speaker 1: of these that people would use to prevent, you know,
Speaker 1: to different and also uterine prolapse and so on and
Speaker 1: so forth.
Speaker 2: It's just like, so, yes, c sections have definitely reduced
Speaker 2: the risk of those kinds of things. Yeah, for sure, yes,
Speaker 2: but yes, but some degree of tearing is often it's
Speaker 2: really common, and the we call them different degrees based
Speaker 2: on how deep they go. Essentially, so whether it's just
Speaker 2: a skin tear, like just a small superficial tear that's
Speaker 2: called the first degree, A second degree tear goes through
Speaker 2: into the perineum, so into that space between the opening
Speaker 2: of the vagina and the anus. A third degree will
Speaker 2: go into the muscle, but not all the way to
Speaker 2: the anal sphincter, and then a fourth degree goes off
Speaker 2: and by the way, okay, so episiotomies have definitely fallen
Speaker 2: out of favor, they're still used in some places. Yeah.
Speaker 1: I didn't even mention the husband's ditch, but we're not
Speaker 1: going to go there, we won't. You you can google
Speaker 1: that and be horrified.
Speaker 2: Other questions aarin, I don't think so, Okay, I think
Speaker 2: I us a lot. I probably could have covered even more,
Speaker 2: but listen, there's so much to cover. I didn't even
Speaker 2: talk about epidurals, but that's for a future episode.
Speaker 1: Yeah, we really need to do episodes. I want to
Speaker 1: talk about Twilight Sleep in more detail. I want to
Speaker 1: talk about the development of epidurals.
Speaker 2: Yeah, yeah, there's the future episode.
Speaker 4: It is.
Speaker 2: We have a lot that you can learn more about
Speaker 2: just by reading the sources that we read.
Speaker 1: We read some great sources, so let me shout out
Speaker 1: a few. I already mentioned the two books that I read,
Speaker 1: Invisible Labor by Rachel Summerstein and cesarean section by Jacqueline Wolf.
Speaker 1: But I also want to shout out a couple other
Speaker 1: papers here. One is by Dunsworth and Eccleston called the
Speaker 1: Evolution of Difficult Childbirth and Helpless Hominin Infants from twenty fifteen, Okay,
Speaker 1: and then a paper by Rosenberg and Trevathan titled Birth
Speaker 1: Obstetrics and a Human Evolution from two thousand and two.
Speaker 1: Interesting stuff, Okay.
Speaker 2: I had a number of papers for this, a few
Speaker 2: that I will shout out. One was just from the
Speaker 2: New England Journal Medicine from nineteen ninety nine called the
Speaker 2: Control of Labor pre basic but a good overview of
Speaker 2: labor and what we think we know about it. One
Speaker 2: that I loved was from the Journal of Perinatal Medicine
Speaker 2: called Cesarean Section one hundred years nineteen twenty to twenty twenty. Oh, good,
Speaker 2: bad and the ugly.
Speaker 1: I read that one.
Speaker 2: It was really good.
Speaker 1: Pezzone really loved it.
Speaker 2: A review of postpartum hemorrhage titled Postpartum Hemorrhage from the
Speaker 2: New England Journal of Medicine twenty twenty one. And then
Speaker 2: a paper that I didn't even get into this but
Speaker 2: is very interesting was from twenty eighteen in Plos Medicine
Speaker 2: plus Medicine called long Term Risks and Benefits associated with
Speaker 2: Cesarean Delivery for Mother Baby and Subsequent Pregnancies Systematic review
Speaker 2: and meta analysis. And I didn't get into it, but there
Speaker 2: is a lot most of the data on se sections
Speaker 2: really focuses on short term risks and benefits, and there's
Speaker 2: not as much known about long term risks and benefits,
Speaker 2: and so this paper was interesting for that perspective.
Speaker 1: Well, and that's something that I feel like I thought,
Speaker 1: I now I do have another question is like is
Speaker 1: this this aspect of short versus long term? Because I
Speaker 1: think one of the things that often gets mentioned is
Speaker 1: like vaginal microbiome and stuff like that, and it's like,
Speaker 1: what are the long term outcomes? We talk about, oh,
Speaker 1: well the risks and you're going on your notes.
Speaker 2: I keep going, I've got notes.
Speaker 1: Yes, we talk about okay, well are there long term
Speaker 1: associations with allergies, autommune disorders? Stuff like that that often
Speaker 1: gets linked but we don't is the how is the
Speaker 1: data create Aaron?
Speaker 2: Okay, So there is data to support the idea that
Speaker 2: C sections might be associated with a slightly increased risk
Speaker 2: of asthma and other atopic diseases for the baby during childhood.
Speaker 2: That data does, it's not super strong, like going all
Speaker 2: the way to adulthood, if that makes sense, where like
Speaker 2: adults are not necessarily at higher risk of asthma and
Speaker 2: allergies if they were born by C section. But it's
Speaker 2: also in part like we just don't have studies that
Speaker 2: show that this idea of like a microbiome association. People
Speaker 2: really like this idea. There is data that there is
Speaker 2: a shift in the microbiome of babies who are born
Speaker 2: via the abdominal root, so via a C section, compared
Speaker 2: to babies who are born via vaginal delivery, but we
Speaker 2: do not have data to show any long term effects
Speaker 2: of this. We don't know that that is why we
Speaker 2: see this slightly increased risk of atopic diseases. Like, there's
Speaker 2: no causal link that we have there, it's all correlation.
Speaker 2: And there is right now no data to suggest that
Speaker 2: vaginal seeding, so like taking swabs from the vagina and
Speaker 2: putting it on a baby who is born se section.
Speaker 2: That's not recommended, at least by ACOG. Right now, we
Speaker 2: do not have data that it is safe or effective.
Speaker 1: The microbiome is just one of those words that means
Speaker 1: many different things.
Speaker 2: Yeah, we just don't We just don't have data on it.
Speaker 1: We don't have data, and it's so complex to do
Speaker 1: the data.
Speaker 2: Yeah, right, and and again it's like you you also
Speaker 2: have to take into account the short term is and benefits,
Speaker 2: and you can't just only think about these long term
Speaker 2: things like it's it is all very nuanced and there's
Speaker 2: not like a right or a wrong or a whatever right.
Speaker 2: It is all it is all childbirth.
Speaker 1: It's all child birth. I mean, I think also the
Speaker 1: effect size is the other thing that we just don't
Speaker 1: have good handle on, right.
Speaker 2: Definitely, not definitely not definitely not so so.
Speaker 1: Yeah, I feel like I have more to say, but
Speaker 1: I guess there's one more episode to say.
Speaker 2: Let's say it next week.
Speaker 1: Yes, a big, huge thank you really like we don't
Speaker 1: we don't have the words to thank all of the
Speaker 1: providers of our first hand accounts. It really means the
Speaker 1: world to us, so holy share your stories.
Speaker 2: Thank you, thank you, thank you, thank you, thank you.
Speaker 2: Thank you also to everyone here at Exactly Right Studios.
Speaker 2: We've got Leon, We've got Jessica, We've got Brent, We've
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Speaker 1: Who's many amazing people.
Speaker 2: Thank you guys so much.
Speaker 1: Thank you. Thank you also to Bloodmobile for providing the
Speaker 1: music for this episode and.
Speaker 2: All of our episodes, and thank you to you listeners
Speaker 2: for listening. We've got a lot of fun doing these episodes.
Speaker 2: We've got one more still to come.
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Speaker 1: Until next time, wash your hands animals
Speaker 9: FU