Blog

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

 

 

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.  

If you are pregnant right now, you can’t have missed it. For maternity care providers, it’s been the topic of the year.  Should healthy, low-risk women should be routinely induced at 39 weeks?

On August 9, the ARRIVE study (A Randomized Trial of Induction Versus Expectant Management) was finally published in full, reigniting a media storm on this topic.

But what is this based on? What are the benefits? And, most importantly, should we all be getting on the ‘induction express’?

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

The ARRIVE study was designed to test whether inducing healthy mothers in their first pregnancy was a benefit (or not) for themselves and their babies. Women were randomised to routine induction at 39 weeks or ‘expectant management’ (more about this below) and outcomes for women and babies were recorded and analysed.

Researchers found similar outcomes for both groups of mothers and babies, with somewhat lower caesarean rates in the induced women (18.6 vs 22.2%) as well as a slight reduction in late pregnancy complications such as high blood pressure. (This makes sense, as the induced women had a shorter time in late pregnancy to develop these complications.)

While overall this study was well funded and conducted, it raises many more questions than we currently have answers, and is certainly not a reason to start inducing every mother and baby.

Firstly, over 50 000 women were considered for this study but less than half were eligible because the definition of ‘low risk’ was very tight. Of these women, only 6 000 agreed to participate, suggesting that being randomly assigned to induction was not popular. Are these 6000 women representative enough of the general population that we can apply the findings to other low-risk, first-time mothers?

In addition, these 6000 women gave birth in well-resourced, high-level hospitals, where everyone was keen to apply the criteria and especially the strict protocols for induction. Would this apply to other maternity hospitals, with different protocols and less motivated staff?

And given that these women were generally low-risk enough to birth outside the hospital, there were some surprisingly poor outcomes. In both groups, around 1 in 9 babies were admitted to NICU and only 1 in 3 women were exclusively breastfeeding at 4-8 weeks. While the caesarean rate was lower for induced women, 18% is still quite high for such a low-risk group. If these women had planned to give birth at home, for example, the chance of caesarean would have been less than 10%.

It is possible that some of these poorer outcomes happened in both groups relatively equally because the groups were actually not so different. In this study, ‘expectant management’ included possible induction after 40 weeks and 5 days, which is actually shorter than the average gestation for first-time mothers – 41 weeks and 1 day, and all women in this expectant management group were required to be induced no later than 42 weeks and 2 days. Consequently, many women who were assigned to ’expectant management’ may later have been induced, although this number has not yet been revealed.

Women who were in the induced group spent many more hours in the labour and delivery unit (20 hours vs 14). This may reflect that women who were induced at 39 weeks were not as ready for labour, compared to the expectant group who would have given birth at a later gestation, even if induced. This means that their bodies (and babies) had greater readiness for labour.

It is likely that many care providers will now start to recommend routine induction at 39 weeks. You may have even been encouraged to accept induction, which is certainly more convenient for hospitals and care providers than waiting for labour to begin. However, this would put huge pressures on maternity care resources, and with the main benefit being possibly 4 fewer women per 100 having a caesarean.

In contrast, the best scientific studies that we have suggest that having your own supportive birth companion (doula) will reduce your need for a caesarean, while supporting, rather than disrupting, the natural processes for you and your baby. For example, the Cochrane systematic review for supportive birth companion (see links below) shows a 25% reduction in caesarean risk in women with continuous labour support vs a 16% reduction in this study.

In addition, choosing care with your own midwife, from pregnancy through labour and birth, lessens your need for analgesia, while also reducing risks of preterm birth and increasing satisfaction. (Midwifery care also decreased caesarean rates in most studies included in the Cochrane systematic review- see link below-but this was not statistically significant in the overall review- see below)

As I describe in my report, Hormonal Physiology of Childbearing, the natural (physiological) onset of labour is a pivotal time. While we don’t fully understand the processes that initiate human labour, we believe that the baby signals readiness for labour, birth and life outside the womb to the mother through placental hormones. These signals promote ‘prelabour physiologic preparations’ for mother and baby, which will make labour and birth as efficient, pleasurable, and safe as possible, for both.

Physiologic labour onset, by definition, allows the full maturity of the baby’s body and brain, which is also growing rapidly in the final weeks in the womb. Could disrupting these final weeks of brain development have longer-term effects? Several studies have found better developmental and academic outcomes for every extra week of pregnancy, even up to 41 weeks (see studies below).

You can read a lot more about this controversial study in the links below.

In the meantime, please don’t be swayed or scared into an unnecessary induction because of this study.

More Information and Resources

The ARRIVE Study: free abstract and accompanying editorial

Responses from maternity care providers and consumer groups

• “That’s a feminist issue!” from Milli Hill and Positive Birth (UK)
•  What women need to know from BellyBelly
• Great infographic from Mindful Childbirth Santa Cruz
• In-depth critique from Henci Goer in Science and Sensibility
• “Why Induction Matters” book and Midwife Thinking blog from Rachel Reed

Professional group responses:

• Response from Australian professionals in Women and Birth journal
• Response from the Society for Maternal-Fetal Medicine (US)
• Response from American College of Obstetricians and and Gynecologists (ACOG)
• Response from American College of Nurse-Midwives (ACNM)

Other research

• Hormonal Physiology of Childbearing
• Benefits of midwifery care
• Benefits of supportive birth companion (doula)
• benefits of home birth
• Benefits of longer gestation for academic achievement
  • Academic achievement varies with gestational age among children born at term
  • Gestational age and school achievement: a population study
  • A whole-of-population study of term and post-term gestational age at birth and children’s development

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