Dr Sarah Buckley

Sarah Buckley

Covid-19 virus: Q&A for expectant families (Part 1)

by

(Published April 2 2020, most recently updated 10 June

These are certainly intense times for all of us worldwide, with the Covid-19 pandemic.

I send my love and prayers to each and every one of you, wherever you are globally: mothers, babies, fathers, partners, children, families and all who care for them. May you, your loved ones and communities stay safe.

This new virus brings many implications and new situations for us all. Here is some basic information and some responses to your questions, as well as useful links. 

Please note that much is still unknown, as the spread has been so fast that there has not yet been time to perform studies. Healthcare systems are making the best decisions and policies they can, in the absence of good evidence, to protect birthing women, families and their front-line staff, who are very much as risk.

A special thank you to all who are working with birthing families in clinics, hospitals and homes right now.

Also, this situation is evolving rapidly, and information and policies are also likely to change. I will keep these updated with new information as far as possible. 

Note that I am trained as a GP (family physician) and not an obstetrician or public health physician, although I have some public health training. I am providing general information for you to take into account in your decision-making. At this time, there may not be certainty or simple answers, or one right thing to do, even in the most simple areas. (A bit like parenting!) 

Update- see my webinar for expectant families! Covid-19 Virus: Your hormones are your helpers

Q: Should I be worried about this virus? 

The SARS-COV-2 virus is a type of coronavirus that can cause COVID-19 illness. This is a new infection that humans have not encountered before, therefore none of us have immunity. In addition, it seems to be able to spread more widely than other cold or influenza viruses.

For example, just one infected person could pass the virus to more than 400 people within a month, unless they take precautions. (More info) These factors mean that many people will eventually be exposed to this virus. 

It is important that we all take this seriously. Each of us must take precautions to reduce the spread, including washing hands, avoiding close physical contact and staying home. See World Health Organisation (WHO) recommendations, and also your own local recommendations. This will help to keep you and your family safe as well.  

Sign up to my newsletter to get notified for Part 2: Covid-19 Q&A for labour and birth

Q: Am I at risk of catching Covid-19?

This depends on your situation. You are more likely to catch Covid-19 if you have had contact with someone infected with the virus, or with someone who has had contact with an infected person. 

Generally, this means close contact e.g. having a face-to-face conversation for 15 minutes or more, or being in the same space for more than 2 hours Those who have been travelled internationally recently, including on planes and cruise ships, and their close contacts are also at greater risk. 

You are also at greater risk if there is more community infection and spread in your area- more good reasons to stay home, as far as possible! 

Spread within the community also means that people working with the public are at higher risk. Health care workers on the front lines treating infected people are at high risk and require effective personal protective equipment (PPE- gowns, gloves and masks) to work safely.

Q: What are the symptoms?

The main symptoms of Covid-19 are 

  • fever (88% of infected people have fever)
  • dry cough (68%)
  • fatigue (38%) 
  • short of breath (19%) 

New research suggests that loss of smell and taste are also very common. More info Many people will have only mild flu-like symptoms, but others may not have symptoms at all, especially if young and healthy. More info 

See this comparison of Covid-19 symptoms vs common cold or flu. If you are in doubt, phone your local or national hotline for advice (see below) and whether to have a test. 

If there is any possibility that you are infected, please avoid contact with others and take stringent protection measures (quarantine) for 14 days or until you have a negative test.  See CDC recommendations

Q: How will Covid-19 affect me and my family? 

According to the best information so far, based on experiences in China and other countries, around 80% of people who contract Covid-19 will have a mild flu-like illness, with a sore throat, fever and dry cough.

Around 20% will have a more severe illness, where the virus goes on to infect the lungs and causes pneumonia. This usually happens 5-7 days after first symptoms and likely requires hospital treatment and support, although there are no specific drugs to treat or cure this virus right now. 

Around 6% (based on worldwide figures) will become severely ill, requiring intensive care and even a machine (ventilator) to help them breathe. Between 1- 4% of infected people may die from the disease, according to current figures. Older people (over 65-70) and those with pre-existing illnesses are more vulnerable.

It seems that children under 18 are much more likely to have a mild illness, or even have no symptoms. Many younger healthy adults may also have no symptoms. However these populations may also transit the virus to more vulnerable people. There is much that remains poorly understood in relation to asymptomatic infections.

Q: How can I protect myself and my family?

Covid-19 is spread by the secretions from the respiratory tract of infected people- nose, throat, breathing passages and lungs. When people cough or sneeze, these secretions go into the air as droplets, which can travel 1-2 m (3-6 feet). For this reason, ‘social distancing’ rules are designed to keep people 1.5-2m (5-6 feet) apart.

If an infected person touches their mouth or nose, or coughs into their hands, and then touches another person, especially if that contact then touches their face, the virus could get into their respiratory tract and spread the infection

In addition, the virus can stay alive on some surfaces for hours to days, at least in theory. (More info) If an uninfected person touches a surface that has been contaminated by someone with the virus, and then touches their face, the virus could cause infection. Because of this risk, it is recommended that we all wash our hands frequently and especially avoid touching our faces when out in public.  

It is safest to presume that anyone you meet could be infected, especially because people can be contagious before they develop symptoms, and because some people will have very mild or no symptoms. 

In summary 

  • Keep a safe distance from others 
  • Avoid touching surfaces when out in public as far as possible
  • Wash hands frequently : see this video for effective technique 
  • Stay home as far as possible 

Q: Help! I’m pregnant! 

Update- see my webinar for expectant families! Covid-19 Virus: Your hormones are your helpers

Covid-19 does not seem to cause more severe illness in pregnant women compared to the general population and does not seem (from what we know so far) to cross from mother to baby during pregnancy, also called ‘vertical transmission.’ The virus has not been found in breastmilk. 

It is still possible that an infected mother could pass the virus to her breastfeeding baby, but the evidence so far has found that babies and young children are much more likely to have a mild illness, compared to adults, or even have no symptoms.

However, there are many implications for your care in pregnancy. Because of the increasing spread, it is sensible to keep healthy pregnant women away from risky places such as hospitals and clinics. Therefore, many care-providers are moving to tele-health appointments, where you talk by phone or computer and have simple tests done by yourself (eg taking your own blood pressure or having your own urine dip-sticks ) or your pharmacist.

There are many more questions, and uncertain information, in relation to labour and birth, whether or not you are personally at risk or infected with Covid-19. Also see below for some resources

Sign up to my newsletter to get notified for Part 2: Covid-19 Q&A for labour and birth

Q: What about breastfeeding?

Breastfeeding is very beneficial to our babies’ immune systems. In general, a breastfeeding mother passes immune factors (antibodies) through breastmilk that protect her baby from diseases that mother or baby encounter. More info 

Continuing breastfeeding is recommended, even if mother or baby develop Covid-19 illness. The World Health Organisation recommends that infected breastfeeding mothers take some precautions;

  • Practice respiratory hygiene during feeding, wearing a mask where available; 
  • Wash hands before and after touching the baby;
  • Routinely clean and disinfect surfaces they have touched

More links and resources for breastfeeding below

Q: How do I take care of myself and my children, while they are off school?

In many places, schools are closing, and parents may also choose to keep children home to reduce their chance of catching and spreading this virus, including to grandparents and other vulnerable loved ones.

At the same time, offices are closing and many parents are now working from home. How can we educate our children- or at least, keep them out of trouble!- and fulfil out own responsibilities?

Educating your children can seem like a huge task. A reassuring personal note here: I have had a variety of educational experiences, including home-schooling, with my 4 children who are now happy healthy well educated adults! I personally chose a relaxed, unstructured approach (structure can be great in some families!) and allowed my children to follow their interests, including time for play, friends (perhaps on Skype right now!) and some computer/TV times too. 

In relation to activities, there are learning opportunities everywhere, from what you eat for breakfast to why the sky is blue. As one wise Mama advised “provide a rich environment, involve children in everyday living, and help find answers to their questions.” I learned a lot from our home-schooling years too! 

Here are some resources and info to start you off

Update- see my webinar for expectant families! Covid-19 Virus: Your hormones are your helpers

Sign up to my newsletter to get notified for Part 2: Covid-19 Q&A for labour and birth

Resources:

Official COVID-19 sites -updated regularly

General COVID-19 information

COVID-19 for pregnancy, labour, birth and breastfeeding

World Health Organisation on pregnancy labour and birth

Evidence-based birth —summaries and great resources

Great guidelines from Queensland Health (Australia)

CDC –Coronavirus and pregnancy (includes breastfeeding and infant care)

Canadian recommendations for pregnancy birth and infant care

Info hub for pregnancy and Covid-19 here

Professional statements-

Breastfeeding organisations- see also above

La Leche League multi-language updated statements resources and links

Australian Breastfeeding Association (ABA) statement

Free online breastfeeding resources from Lactation Ireland

Covid-19 research and interesting studies

Labour Induction: Making Choices

by

So many are being offered induction of labour, often without a good medical reason. This blog article will help you to make sense- and make informed choices- in this complex and controversial area.

So many inductions

In  Australia (2020) labour was induced in more than  1 in 3 pregnancies (35.5%), including almost half (45.8%) of first-time pregnancies. The US Vital Statistics (2021) reports 32.1% induction (2021), although women themselves report higher induction rates- as reported in the Listening to Mothers surveys. Rates are high in many other countries, suggesting that maternity-care interventions are being applied ‘too much, too soon’.

Why am I being offered an induction?

 If you have been offered an induction of labour without  a medical reason, especially in your first pregnancy, it is likely because of the 2019 ARRIVE trial.

This study found that routinely inducing labour at 39 weeks in a healthy, low-risk first-time pregnancy reduced the caesarean rate from 22.2% to 18.6% (16% reduction) with no other signficant benefits. (See my blog critique here and note the even greater reduction in caesareans- 25%-  from doula care.)

The ARRIVE trial has influenced practice world-wide because it provides supposedly the best evidence- a randomised controlled trial (RCT)- in this controversial area. However, RCTs have strict criteria for inclusion and treatment, and results may be different in real-life situations, outside experimental conditions. This problem is called ‘external validity.’ (See this discussion of the external validity of the ARRIVE trial.)

In fact, many studies have found that, in everyday practice settings, induction has minimal or even negative effects on caesarean rates, and may increase other risks. See this large study,  this study  and this high-quality review.  This is a controversial  area and results depend on the groups compared,  the timing of induction and the rates of induction in the group who were not initially induced  (‘expectantly managed.’) 

Has this improved outcomes?

Have the increasing numbers of inductions improved outcomes, as the ARRIVE trial suggested?

This study used US data to compare the outcomes for healthy, low-risk, first-time pregnancies before (2015-7) and after (2019) publication of the ARRIVE trial. Induction rates increased from 30% to 36% in this population, but their CS rate decreased only 0.6%. In addition, there were higher risks of some concerning outcomes in the induced groups, including more serious postpartum haemorrhage, lower newborn APGAR scores and more newborn breathing difficulties.

Could induction disrupt hormonal processes?

There are very complex and precise processes that lead to the physiological (spontaneous) onset of labour. These processes ensure that mother and baby are both perfectly prepared for an effective labour, birth and postpartum/newborn transitions, including breastfeeding and bonding. By definition, this readiness is not complete when birth is scheduled by induction or prelabour CS.

For a detailed review of the processes involved with the physiological onset of labour, see Chapter 2 , ‘Physiologic Onset of Labor and Scheduled Birth’ in my 2015 Hormonal Physiology report, linked from my website here and a more recent article here.

In addition, the method of induction may disrupt the natural hormonal flow of labour. As part of my PhD, I’ve been publishing studies with EU colleagues looking at oxytocin levels in women and babies in labour and the effects of interventions. Our upcoming reviews include studies of prostaglandins and rupture of membranes.

(To keep updated with my research, make sure to  sign up to my newsletter)

Oxytocin and Induction: My PhD research

In our most recent publication we summarised all the studies that measured plasma (blood) oxytocin levels in women receiving synthetic oxytocin (Pitocin, Syntocinon).

We found that, even with the highest doses in labour, maternal oxytocin levels were maximum 3-4 times higher than levels in physiological labour. This is not high enough to cross the placenta or into the maternal brain and cause direct harm. (However, indirect effects are possible, including effects from the additional stress and pain of induction- see our discussion here)

We also found that newborn babies have naturally high oxytocin levels in labour, likely due to the stress and massage-like effects of uterine contractions. These high oxytocin levels help the baby cope with labour and adapt to life outside the womb. Being exposed to synthetic oxytocin did not further increase newborn oxytocin levels, indicating that synthetic oxytocin does not cross to the baby in labour.

My next blog will discuss these findings further- stay tuned! We are also researching the effects of epidural, opioids and prostaglandins in upcoming publications.

Another important question is: could labour induction-whether with synthetic oxytocin or other methods- affect longer-term outcomes such as breastfeeding, bonding and postpartum depression?  These outcomes have not been well studied in the highest-quality randomised trials and are part of my PhD studies.

(To keep updated with my research, make sure to  sign up to my newsletter)

Brain development in the womb

There are also a growing number of studies suggesting worse development and educational outcomes in children born at shorter gestation, even at 39 vs 40 or 41 weeks. This is not surprising when we consider that the unborn baby’s brain is growing at a very fast rate at the end of pregnancy, making those last weeks of brain development very precious. (See Every Week Counts) Shortening gestation with induction could limit full brain development.  See also my discussion here.

However, some studies looking at induction and longer-term offspring outcomes have not found negative effects. Induction rates in the expectant groups are an important consideration in these studies. It is also important to note that these population-wide studies do not mean that being induced will have effects on individual children.

Are there benefits from labour induction?

There is no doubt that induction of labour reduces the chances of stillbirth. Babies that have been induced and born are obviously not at risk of stillbirth. This has been a major motivation for induction past 40-41 weeks, although the actual risks (and therefore benefits of induction) are small.

Some babies that are overdue do not cope as well with labour. This has been used to disallow access to midwifery care in birth centres or homebirth past 41 or 42 weeks. However, again the risks are small. If you are labouring after 41-42 weeks, your care provider or midwife may want to monitor you more closely.

Based on these considerations, induction at 41-42 weeks may prevent 2 perinatal deaths (around the time of birth) per 1000 babies. Looked at another way, 544 inductions would be needed to prevent the death of one baby.  This information may be helpful if you are overdue and offered an induction of labour.

The best decision 

Ultimately the best decision is one you make with your heart and womb, connected to your baby, as well as with the information from here and the resources below.  

(To keep updated with my research, make sure to  sign up to my newsletter)

More induction resources:

Postdates induction of labour- balancing risks Rachel Reed- Midwife thinking

Ten things I wish women knew about induction- Sarah Wickham  and her books 

Induction of labour (Podcast)- Melanie the Midwife with Hannah Dahlen in The Great Birth Rebellion 

Inducing for due dates Evidence based birth   

Induction of labour articles Henci Goer  

Myth of the aging placenta –Sophie Messager 

Preventative induction of labor- does Mother Nature know best? (ARRIVE trial)  Lamaze international

Your body, your baby, your choice: Chapter 4 in  Gentle Birth, Gentle Mothering by Dr Sarah Buckley 

Acknowledgements:

Some of this information comes from a new publication as part of my PhD research: Maternal and newborn plasma oxytocin levels in response to maternal synthetic oxytocin administration during labour, birth and postpartum – a systematic review with implications for the function of the oxytocinergic system This was written with the good work and dedication of my colleagues Kerstin Uvnäs-Moberg, Zada Pajalic, Karolina Luegmair, Anette Ekström-Bergström, Anna Dencker, Claudia Massarotti, Alicja Kotlowska, Leonie Callaway, Sandra Morano, Ibone Olza & Claudia Meier Magistretti. This work was initiated within  EU COST IS1405 BIRTH: Building intrapartum research through health. 

Hormonal Physiology, Oxytocin and More

by

When we interact with our babiesSince the publication of her 2015 report Hormonal Physiology of Childbearing (more info and links here) Dr Buckley has continued to research and write about the hormones of physiological labour and the impacts of interventions.

She is currently a PhD candidate at the University of Queensland (Brisbane, Australia) studying oxytocin in childbearing.

This page lists the publications Sarah has co-authored, with links and descriptions. You can receive information about new publications by signing up to Sarah’s newsletters. 

Maternal and newborn plasma oxytocin levels in response to maternal synthetic oxytocin administration during labour, birth and postpartum – a systematic review with implications for the function of the oxytocinergic system. Buckley S, Uvnäs-Moberg K, Pajalic Z, Luegmair K, Ekström-Bergström A, Dencker A,Massarotti, C. Kotlovska, A Callaway, L Morano S, Olza Fernandez I, Meier-Magistretti C. BMC Pregnancy Childbirth. 2023;23(1):137. Full text here 

Maternal plasma levels of oxytocin during physiological childbirth – a systematic review with implications for uterine contractions and central actions of oxytocin. Uvnas-Moberg, K., A. Ekstrom-Bergstrom, M. Berg, S. Buckley, Z. Pajalic, E. Hadjigeorgiou, A. Kotlowska, L. Lengler, B. Kielbratowska, F. Leon-Larios, C. M. Magistretti, S. Downe, B. Lindstrom and A. Dencker (2019).  BMC Pregnancy Childbirth 19(1): 285  Full text here

Maternal plasma levels of oxytocin during breastfeeding-A systematic review. Uvnäs Moberg, K., A. Ekström-Bergström, S. Buckley, C. Massarotti, Z. Pajalic, K. Luegmair, A. Kotlowska, L. Lengler, I. Olza, S. Grylka-Baeschlin, P. Leahy-Warren, E. Hadjigeorgiu, S. Villarmea and A. Dencker (2020). PLoS One 15(8): e0235806. More info and full text links here

Birth as a neuro-psycho-social event: An integrative model of maternal experiences and their relation to neurohormonal events during childbirth. Olza, I., K. Uvnas-Moberg, A. Ekström-Bergström, P. Leahy-Warren, S. I. Karlsdottir, M. Nieuwenhuijze, S. Villarmea, E. Hadjigeorgiou, M. Kazmierczak, A. Spyridou and S. Buckley (2020) PLoS One 15(7): e0230992. More info and full text links here  

Nature and consequences of oxytocin and other neurohormones during the perinatal period.Buckley S, Uvnäs Moberg K Chapter in: Downe S, Byron S, editors. Squaring the Circle: Normal birth research, theory and practice in a technological age. London: Pinter and Martin; 2019. p. 19-31 More info and links to purchase this book here 

The initiation of labour at term gestation: Physiology and Practice implications. Hundley, V., S. Downe and S. J. Buckley (2020). Best Pract Res Clin Obstet Gynaecol Aug; 67:4-18  More info (This article is only available via subscription or payment

Physiologic Basis of Pain in Labour and Delivery: An Evidence-Based Approach to its Management. Practice Guideline No. 355 Bonapace, J., G. P. Gagne, N. Chaillet, R. Gagnon, E. Hebert and S. Buckley (2018). J Obstet Gynaecol Can 40(2): 2 DOI: 10.1016/j.jogc.2017.08.003  More info (This article is only available via subscription or payment

You can find more of Sarah’s science and wisdom in her  blogs  podcast interviews and books and DVDs

Synthetic Oxytocin (Pitocin, Syntocinon): Unpacking the myths and side-effects

by


Synthetic oxytocin (Pitocin, Syntocinon) is widely used in maternity care around the world. It is commonly administered to induce or to speed up (augment) labour, and to prevent or treat bleeding after birth (postpartum haemorrhage).

Like all maternity-care interventions, synthetic oxytocin may be beneficial, even life-saving, for mothers and babies in some situations. However, because of its widespread use, including in many healthy mothers and babies, it is important to understand the possible risks and side-effects.

This blog explores some important questions, including:

  • Is synthetic oxytocin harmless because it mimics the natural oxytocin that women release during labour?
  • Do high doses of synthetic oxytocin impact the mother’s own natural oxytocin release in labour?

In upcoming blog posts: (from mid-2023, make sure to sign up to my newsletter) 

  • Does synthetic oxytocin cross into the brain during labour?
  • Could synthetic oxytocin affect breastfeeding or bonding?
  • Does synthetic oxytocin cross to the baby?
  • Could synthetic oxytocin impact the baby’s developing oxytocin system, as found in animal studies?
  • Could synthetic oxytocin even cause autism? (Also see this blog)

This information in this blog comes from a recent publication on Maternal oxytocin levels during physiological childbirth, which Dr Buckley is a co-author (more details below) and a new review from Dr Buckley and colleagues of oxytocin levels in women and newborns following maternal  synthetic oxytocin administration.

Is synthetic oxytocin harmless, because it mimics the natural oxytocin that women release during labour?

It is true that the chemical structure of synthetic oxytocin is identical to the chemical structure of the natural (endogenous) oxytocin that our bodies produce during labour, as shown in this picture.

However, our own natural (endogenous) oxytocin is made in the brain and is released during labour into both the body, where pulses of oxytocin reach the uterus and promote the rhythmic contractions of labour, and also locally into the brain, where it has calming and pain-relieving effects.

As labour progresses, high oxytocin levels released within the brain help to counter the stress and pain of the strengthening contractions, which are caused by oxytocin stimulating the labouring female’s uterus. At the same time, oxytocin is activating her brain’s pleasure and reward centres in preparation for bonding with her newborn baby. (This process assists all mammals during labour, birth and postpartum )

In contrast, synthetic oxytocin is administered by intravenous (IV) infusion and in constant, high doses rather than in lower-levels and pulses. This can lead to maternal plasma oxytocin levels that are more than double those in a natural (physiological) labour, as measured in the blood. (See Oxytocin levels during physiological childbirth)

For these reasons, IV synthetic oxytocin causes contractions that are stronger and closer together than natural contractions, especially in early labour.

In addition, because synthetic oxytocin is administered into the body and not into the brain, it does not have the brain-based benefits of countering labour stress and pain, as natural oxytocin does. (See Oxytocin levels during physiological childbirth.) Therefore, the stress system may be more activated with high doses of synthetic oxytocin in labour, compared to physiological labour.

Those who are administered synthetic oxytocin also commonly receive epidurals to counter the increased pain, and epidurals reduce the natural release of oxytocin, as explained below and in this blog, which increases the need for synthetic oxytocin to fill the ‘hormonal gap.’

With this combination of epidural with synthetic oxytocin in labour, the natural stress-reducing benefits of endogenous oxytocin can be reduced or absent. (More about this below.) This combination might also explain some of the longer-term effects that have been reported for synthetic oxytocin, to be discussed in upcoming blog posts.Image used with permission

For the baby, the stronger and more frequent contractions will inevitably reduce blood and oxygen supply more than during physiological labour, increasing the risks of hypoxia (low oxygen), which is especially risky for the baby’s brain at this time. For this reason, administration of synthetic oxytocin in labour always requires monitoring of the baby’s heart rate to check for indications of hypoxia.

Some studies suggest extra risks of hypoxia and its possible long-term consequences for babies exposed to synthetic oxytocin in labour, although this area is not well studied. (See studies below.)

Synthetic oxytocin may also reduce activity in the uterine oxytocin receptors, although the mechanisms is not certain. This can decrease the effectiveness of oxytocin (natural or synthetic) to cause strong contractions, including after the birth. This explains why receiving synthetic oxytocin in labour increases the chance of postpartum haemorrhage and requires extra medications (including more synthetic oxytocin) to counter this risk. (More discussion of the possible mechanisms in upcoming posts.)

(For more great articles like this, make sure to  sign up to my newsletter)

Do high doses of synthetic oxytocin impact the natural oxytocin release in labour?

It is sometimes presumed that administering high doses of synthetic oxytocin in labour will reduce maternal natural (endogenous) oxytocin production. This is not likely, according to our current understandings, although this is very hard to measure as natural and synthetic oxytocin can’t be differentiated in the blood.

It is important to understand that oxytocin release from the brain in labour is not controlled by the usual ‘negative feedback’ systems, whereby high levels of a hormone or biological marker lead to feedback that reduces levels. For example, our heart rate and blood pressure are controlled such that a sudden increases are detected by our body systems and lead to changes that bring them back down to what is normal for each of us. This negative feedback is operative in most biological systems, and contributes to homeostasis- the maintaining of physiological stability in the face of external (or internal) changes.

However, labour is not a homeostatic process! In labour, contractions need to strengthen rather than remain stable, and eventually be strong enough to push the baby from the mother’s uterus. This strengthening requires positive, rather than negative, feedback systems, also called ‘feed-forward cycles.’

This diagram shows one feed-forward cycle in labour, where strong uterine contractions cause pressure on the cervix area  and generate sensory feedback to the brain that increases brain  oxytocin release, including release to the uterus. This causes even stronger contractions and sensations, more sensory feedback and more oxytocin release.

This feed-forward cycle, also known as the Ferguson reflex, provides the high levels of oxytocin (average 3-4-fold increased at birth) that are needed for the birthing mother to have an effective pushing stage.(See Oxytocin levels during physiological childbirth)

The administration of synthetic oxytocin (without epidurals) will not reduce this cycle, or the stimulation of natural oxytocin release. In fact, in some circumstances, synthetic oxytocin may even accelerate this feed-forward cycle (and increase brain oxytocin) by causing stronger contractions with greater sensations. (More details in upcoming blog posts.)

However, when epidurals are co-administered, the sensations from contractions, which fuel this feed-forward cycle, are abolished, which slows or even stops the cycle, and consequently slows or stops oxytocin release, as described in this blog.

The combination of epidurals with high doses of synthetic oxytocin can therefore increase physiological stress in labour but reduce oxytocin release, including within the brain, which would usually counteract this stress in labour.

In summary

Synthetic oxytocin is chemically identical to the natural oxytocin released in labour and birth. However it has different effects because it is administered IV rather than into the brain.

In contrast, natural oxytocin  is released from and into the brain in labour, and gives calming, pain relieving effects that counteract labour stress and pain. Within the brain, natural oxytocin also activates reward and pleasure centres in preparation for bonding with the newborn baby.

While synthetic oxytocin may not directly reduce the natural release of oxytocin, the common co-intervention of epidural analgesia does significantly reduce oxytocin release. Epidurals can slow labour and reduce oxytocin’s anti-stress, anti-inflammatory and anti-oxidant benefits. This combination might explain some of the longer-term effects that have been found for synthetic oxytocin, which will be discussed further in later blogs.

In addition,  prolonged, high doses of synthetic oxytocin increase the risk of bleeding after birth (postpartum haemorrhage). This likely reflects disruption to uterine oxytocin receptors, making the uterus less responsive to oxytocin and increasing the risk of bleeding, although the mechanism is debated.

Upcoming blog posts:

  • Does synthetic oxytocin cross into the brain during labour?
  • Could synthetic oxytocin interfere with the new mother’s ability to bond with her baby?
  • Could synthetic oxytocin impact breastfeeding success?
  • Does synthetic oxytocin cross to the baby?
  • Could synthetic oxytocin impact the baby’s developing oxytocin system, as found in animal studies?
  • Could synthetic oxytocin even cause autism? (Also see this blog)

(For more great articles like this, make sure to  sign up to my newsletter)

References and resources

Much of this information comes from a new publication on Maternal oxytocin levels during physiological childbirth: A systematic review with implications for uterine contractions and central actions of oxytocin  This was written with the good work and dedication of colleagues Kerstin Uvnas Moberg, Anette Ekstrom-Bergstrom  and other European co-authors. This work was partly funded by  EU COST IS1405 BIRTH: Building intrapartum research through health. 

Ecstatic Birth ebook

Hormonal Physiology of Childbearing report Sarah’s 2015 report with lots of information about oxytocin (Free download)

Sarah’s 2-part blog on epidural effects, including oxytocin

Impacts of synthetic oxytocin in labour:

Note that these studies are observational and do not imply causation. However, there is very little high-quality research available in this area. 

Bugg 13 : Augmentation with synthetic oxytocin has minimal benefits (Cochrane review)

Rahm 2012 : Epidurals reduce oxytocin 

How to Have the Best Cesarean

by


It’s true that our female bodies are superbly designed, and that gentle, natural birth is the best possible start. But birth is ultimately mysterious and unpredictable, and can sometimes take its own unexpected direction.

For example, the peaceful natural birth that you planned with a midwife, in a birth centre, or at home, may become less safe because of extra risks for you or your baby, or a situation can arise that sends you clearly towards a surgical birth. Or maybe you have known from the start that a cesarean is your best or only safe option.

What can you do to make the best of these circumstances? How can you compensate for the labour and birth that you and your baby will miss, to a greater or lesser extent, when a cesarean is needed? And how can you address the inevitable ‘hormonal gaps’ for you and your baby?

The answers can be surprisingly simple, from a hormonal perspective, and are important considerations, however you plan to give birth. (Personally I had a cesarean birth plan with each of my home births!)

(For more great articles like this, make sure to  sign up to my newsletter)

Hormonal gaps

Cesareans and other maternity-care interventions can be necessary, and even life-saving, for mother and/or baby in some situations. However, in these situations, there will inevitably be a gap between what our bodies and babies naturally expect in this major biological transition, and what actually happens.

Hormonal gaps occur because mother and baby miss significant and even vital processes. For example, if the cesarean occurs before labour onset (sometimes called a pre-labour, scheduled, or elective cesarean), mother and baby will not be fully ready for labour and the transitions of birth.

The baby can miss important preparations for the enormous transition to breathing, including hormonally-driven clearing of the lung fluid, which all babies have in the womb. This significantly contributes to newborn breathing difficulties, which are 2x more likely following a prelabour cesarean, even at 39 weeks, compared to vaginal birth (see study below). Breathing difficulties can necessitate separation and admission to special care facilities, and mother and baby will miss being together during the sensitive hours after birth.

Another hormonal gap for the caesarean newborn is lack of the ‘catecholamine surge.’ This huge in-labour increase in adrenaline and noradrenaline, the fight or flight or catecholamine hormones, activates the baby on every level as labour advances. The catecholamine surge also protects from low oxygen, further clears lung fluid, and ensures that the baby is wide-eyed and alert at birth, and ready to initiate breastfeeding. Babies born by cesarean and especially pre-labour cesarean, miss this activation and tend to be drowsy and not ready for interactions or feeding.

For the mother, the processes of labour activate her oxytocin system, in both body and brain. Her uterus will be sensitive and responsive to oxytocin, and capable of the strong postpartum contractions that prevent haemorrhage.  Oxytocin released in her brain also ensures that she will be calm and connected as she meets her baby for the first time.

Pleasure and reward

Oxytocin also acts on the mother’s brain reward centres, which are maximally sensitive at this time because of prelabour preparations. Her pre-labour preparations plus in-labour processes ensure full reward centre activation as she meets her baby for the first time. This produces the brain-based pleasure that is a critical part of bonding for all mammals, establishing irresistible brain pathways that will reward and motivate new mothers to give the dedicated care that all newborn mammals require for survival.

This process can be seen in mammalian mothers who adopt the babies of another species, if introduced during this biologically sensitive period. While human mothers can obviously bond with and love a baby that they have not birthed (or been with in this sensitive period) there can still be a hormonal gap in this ‘biological bonding,’ and  the pleasure (’reward salience’) that the mother receives from her baby can be reduced, even into the future.

Closing the gaps: in hospital

How can we close these hormonal gaps for mother and baby? An ideal solution is to allow labour to begin naturally, then perform an in-labour non-emergency cesarean. This ensures that the baby has maximum readiness, and may reduce the risk of newborn breathing difficulties (see study below). An in-labour, non-emergency cesarean is also ideal for maternal readiness, including maximising sensitivity to oxytocin in her uterus and brain.

If this is not possible, the major hormonal gaps involved in prelabour cesarean can be significantly addressed in the operating theatre. For the baby, the stress (and stress hormones) that accompany the sudden loss of the womb environment can be soothed by early–ideally immediate–skin-to-skin contact with the mother. This can occur even as the surgeon is finishing the operation. (Some surgeons have shown that the baby can even push itself out, with a little time and patience, and delayed clamping of the cord gives additional benefits- see Natural Caesarean study and video below.)

Ongoing, uninterrupted contact with the mother will help to switch on the baby’s ‘rest and digest’ system  and ability to initiate breastfeeding. Because of the hormonal gaps, it is necessary to be patient and allow the baby to come to the breast in their own time. The new mother’s breastfeeding and attachment hormones can also be affected by a cesarean, and liberal skin-to-skin and breastfeeding will help this as well.

If the baby cannot be placed on the mother’s chest, the ‘cheek-to-cheek’ position is recommended (see below). Any of these positions will begin to establish the biological bond between mother and baby. If this is not possible, skin-to-skin with father or partner is also valuable.

If mother and baby are separated, whether routinely or because of illness, skin-to-skin contact and breastfeeding as soon as possible, and as much as possible, is still the magic glue!

Closing the gaps: oxytocin and more oxytocin!

Breastfeeding is Mother Nature’s back-up system. Breastfeeding releases oxytocin and other feel-good hormones that reinforce pleasure and reward for both mother and baby. Early and frequent feeding will benefit the new mother, switching on her pleasure centres and reinforcing the bond with her baby with every episode.

Oxytocin released during breastfeeding also promotes wound healing and the immune system, reduces inflammation and has antioxidant properties, which are all beneficial in recovering from surgery. Oxytocin switches off stress and switches on relaxation and growth. Oxytocin will help you to relax and ease into new motherhood.

Liberal skin-to-skin contact also activates the oxytocin system and, according to one study, reduces the chance of postpartum depression in the early months. Soft carriers can be used under clothing so that mother and baby are skin-to-skin most of the time. Skin-to-skin is an ideal way to close hormonal gaps for the weeks and even months after a cesarean, and is particularly important if formula feeding or breast pumping.

Co-sleeping is our evolutionary norm, and maintains the continuum of mother-baby contact and hormonal release, as well as supporting breastfeeding- and gives mothers better sleep too!  (See below for safe co-sleeping guidelines)

(For more great articles like this, make sure to  sign up to my newsletter)

In summary

In summary, a cesarean birth creates significant gaps between the biological expectations for mother and baby and their experiences.

Mother-newborn skin-to-skin contact, beginning as early as possible after cesarean birth, will initiate and build the biological bonding that mother and baby may otherwise miss.  Early and liberal breastfeeding is Mother Nature’s back up system!

More resources

Ecstatic Birth ebook

Hormonal Physiology of Childbearing report Sarah’s 2015 report with lots of information about the hormones and caesareans (Free download)

Belly Belly: Mother-friendly caesarean.  

Belly Belly: Gentle C-sections for mothers and babies

American Pregnancy Positive caesarean

Childbirth connection Excellent information about all aspects of caesarean

Penny Simkin Best cesarean possible handout (under articles and handouts)

UK motherandbaby.co.uk, some good tips

Caesarean recovery https://www.mamanatural.com/c-section-recovery/

Cheek-to-cheek newborn contact post cesarean  (Questions 2.6 and 2.10)

Breastfeeding and cosleeping information

Safe cosleeping guidelines

Study: The natural caesarean: a woman-centred technique: a great article to give to your care provider from a OB team in the UK

Study: In labour caesarean benefits baby’s breathing

Study: Newborn breathing difficulties following cesarean 

Study: Skin-to-skin reduces postpartum depression

Videos

Natural caesarean UK, teaching; Includes good information for care providers: ‘walking the baby out,’ delayed cord clamping, immediate skin to skin contact, keeping the baby warm, and early breastfeeding

Skin to skin after CS (teaching)

One family’s gentle C-section with early skin to skin

 

 

Does Synthetic Oxytocin (Pitocin) Cause Autism?

by

Image courtesy of MyDvija https://mydvija.com

Does exposure in labour to synthetic oxytocin (Pitocin, Syntocinon) cause autism? Or could exposure at least increase the risks of an autism spectrum condition, including milder forms of autism, for genetically vulnerable children?

This question has been asked for many years, beginning with natural birth pioneer and surgeon Michel Odent in the 1980s. Dr Odent noted similarities between the social behaviours that autistic individuals tend to have (reduced eye contact and reading of  social cues) and the functions of our brain-based oxytocin system, which helps us with social behaviours, among other effects.

These concerns have been echoed by many researchers, who have wondered: Could exposure to synthetic oxytocin at this vulnerable time impact the baby’s developing oxytocin system? Could it disrupt oxytocin receptors, or mis-set the oxytocin system in other significant ways, with long-term effects? Could this even explain the worldwide increase in autism diagnosis among our children?

A recent study by Gustella and colleagues has addressed this question using a 20-year study that tracked children’s behavioural and emotional development. Researchers analysed this against the amount of synthetic oxytocin administered to their mothers during labour.

The overall finding was that there was no relationship between exposure to synthetic oxytocin in labour and autistic behaviours. This was also supported by the research finding that the dosage of synthetic oxytocin was not related to the presence or degree of autistic behaviours.(If synthetic oxytocin. really did cause autism, we would expect to get a ‘dose-response ‘effect, such that higher dosages would increase the risk and/or severity.)

(For more great articles like this, make sure to  sign up to my newsletter)

Researchers are obviously keen to find biological causes for autism, or at least factors that might increase the risks.  There are several other studies that have looked at exposure to synthetic oxytocin during labour and birth as a possible cause, with mixed results.

This is an important study because it has reliable data for the synthetic oxytocin dosage, which was extracted from hospital records, and  and for autism diagnosis, which is based on behavioural assessments at two or more times up to age 17.

Some of these concern about long-term effects of synthetic oxytocin comes from animal studies, particularly studies in prairie voles, which are small North American rodents with a complex oxytocin system not unlike ours. Researchers  have found effects on adult social and sexual behaviours, when newborn prairie voles are injected with synthetic oxytocin. However, it is important to consider that the dosage used in these newborn animals is 100 times or more higher than would be safe to give to a labouring woman. (In labour, a woman’s uterus is very sensitive to oxytocin. An excessive dose will cause overly strong contractions that will endanger her baby.)

In addition, there has been a debate about whether synthetic oxytocin- or the natural oxytocin that the mother releases in labour- can cross the placenta to the baby. Animal studies have found that maternal oxytocin does cross to the baby in labour and even reaches the baby’s brain, where it switches on factors that protect the brain from low oxygen.

However, human babies have a more mature brain at birth, and  actually produce their own oxytocin, so this mechanism is unlikely to affect human babies, (However there are many other factors that help to protect our baby’s brains- see my report below for more).

In addition, even if synthetic oxytocin administered in labour did reach the baby’s brain, levels would be very low– around 1/1000 of effective levels in the blood. Such low levels may be more beneficial than harmful. For example, low doses of synthetic oxytocin administered daily to newborn rats reduces their blood pressure and stress responses in adulthood.

However, its is also true that synthetic oxytocin could have detrimental effects for mothers and/or babies by other mechanisms.

If doses are too high and cause excessive contractions, there could be risks of too-low oxygen for the baby (hypoxia). This can cause long-term harms, including brain damage. However, this should  be detected by routine monitoring of the baby’s heart rate when synthetic oxytocin is given, and action quickly taken if needed.

Harms usually relate to poor monitoring and/or inadequate actions taken.Some hospitals and care provides have recognised these risks and have protocols for the safe administration of synthetic oxytocin, with dosages kept as low as possible to avoid such risks.

Synthetic oxytocin could also affect the baby indirectly, including via the mother. Stronger contractions cause more stress and pain, leading to more interventions for pain relief, including epidurals. which significantly affect the mother’s oxytocin system- see my blog here.

And because epidurals reduce the mothers own oxytocin production, labour tends to slow and women are often administered  synthetic oxytocin to speed labour. For these reasons,  it can be hard to separate the effects of epidurals and synthetic oxytocin for mothers and babies.

Synthetic oxytocin (and /or epidurals) could also impact breastfeeding success, which would impact the long-term health and wellbeing of the baby. (See review articles below) These have not been well studied, despite synthetic oxytocin being very widely used in labour, and also after birth.

(For more great articles like this, make sure to  sign up to my newsletter)

To conclude: the best evidence that we have does not show a connection between synthetic oxytocin in labour and autism. Synthetic oxytocin may have other negative impacts for mothers and/or babies that have not been well studied.

Supporting gentle, natural  birth is likely to be the safest long-term strategy to promote health and wellbeing for mothers, babies, fathers and families, with  extra support for those who require interventions.

More information and references

Gustella et al 2015 Does perinatal exposure to exogenous oxytocin influence child behavioural problems and autistic-like behaviours to 20 years of age?

Clark 2009 Oxytocin: New perspectives on an old drug. (Risks of synthetic oxytocin)

Erickson 2017 Breastfeeding Outcomes After Oxytocin Use During Childbirth: An Integrative Review

French 2016 Labor Epidural Analgesia and Breastfeeding: A Systematic Review

Petersson 2008 Postnatal oxytocin treatment of spontaneously hypertensive male rats decreases blood pressure and body weight in adulthood

Note for those who have read my 2015 Hormonal Physiology of Childbearing report. Some of this information, and my opinions, are different to my report, where I discuss possible mechanisms by which synthetic oxytocin might contribute to autism. This study was not published at that time, and I have also has the opportunity to read more about oxytocin for my my PhD studies, including discussion with my PhD advisor Professor Kerstin Uvnas Moberg.