Dr Sarah Buckley

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Epidurals in Labour (Part 2)

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What do you know about epidurals and their risk and benefits?  In this blog (Part 2), Dr Buckley explores the impacts of epidural on the hormones of labour and birth , and what this might mean for mothers and babies in the short and longer-terms. (You can read Part 1 here)

Like all interventions in labour and birth, epidurals have benefits and risks for mothers and babies. Part 1 explores how epidurals work; the role of stress in labour (its not all bad!); epidural side-effects, including impacts on oxytocin systems; and why epidurals usually slow labour.

In this Part 2, we will look in more depth at the hormones, and what research tells us about epidural impacts, including on the longer-term hormonal processes of breastfeeding and bonding.

These FAQs are intended to help you to balance the benefits and risks of epidurals for yourself and your own unique situation, so that you can make the choices that are right for you, your baby and your family.

How do epidurals impact oxytocin in labour?

As described in detail in Part 1, the sensations of labour provide feedback to the brain to increase oxytocin release. This leads to stronger contractions, more sensations, and more oxytocin release. This positive feedback cycle drives labour progress, as shown in the diagram.

Labour progress usually slows or stops after epidural administration because of the lack of sensation and sensory feedback to the brain. This also reduces oxytocin release within the brain

Why is oxytocin doing in the labouring mother’s brain, anyway?

While oxytocin is most famous in childbirth for causing the contractions of labour, it has many other beneficial effects that depend on its release in the brain. Oxytocin has pain-relieving and stress-reducing effects that are welcome in labour. Oxytocin also activates brain pleasure and reward centres that contribute to post-birth euphoria.

Reward centre activation  happens for all mammals as mothers meet their newborns for the first time. This imprints pleasure in relation to infant contact, and ensures that mothers will be rewarded and motivated to give the dedicated care that all mammalian newborns require. This is why dog, cow, or elephant mamas will devotedly care for their babies (and butt or bite you if you try to interfere!) without ever going to a prenatal class or reading a book.

Natural birth pioneer Michel Odent calls this phase,”The beginning of a great love affair.” The oxytocin peaks in the brain from release during labour and birth, and heightened further by first contact, ensure that mother and baby will have the best first date ever! (See more in my Ecstatic Birth ebook here).

How does oxytocin help with breastfeeding?

Oxytocin is also the hormone that causes the let-down, or milk-ejection reflex during breastfeeding. Stimulation of the nursing mother’s nipple (or sometimes just the thought of her baby) causes a surge of oxytocin to be released from her brain into her body. This activates milk ducts that push milk to the suckling baby. In addition, nursing-related pulses of oxytocin stimulate the release of prolactin, which promotes milk production in the longer-term.

At the same time, oxytocin released into the mother’s brain reinforces pleasure and reward, so that she will enjoy contact with, and breastfeeding, her baby . The baby also receives oxytocin with suckling, with digesting, and through the milk, so that both will benefit from oxytocin’s relaxing, “calm and connection,” and “hormone of love” effects.

Could epidurals affect breastfeeding?

There are several ways that epidurals could affect breastfeeding. First, the numbing local anaesthetic and sedating opioid drugs used in epidurals all cross into the baby’s body. These drugs have been found in newborn urine even 1-3 days after birth. Opioid drugs such as fentanyl could affect the newborns ability to establish breastfeeding, as some studies have found.

The negative effects of epidurals on maternal oxytocin could also affect breastfeeding. Studies have found disruptions to oxytocin release during early breastfeeding among women exposed to epidurals, along with synthetic oxytocin, in labour. This could also reduce prolactin release, and disrupt future milk production.

Possible longer-term effects of epidurals on breastfeeding have not been studied in high-quality research. See below for more about supporting breastfeeding when an epidural is needed.

How does oxytocin help with bonding

As discussed above, oxytocin released into the mother’s brain during labor and birth activates maternal circuits that switch on instinctive mothering. Powerful activation of reward and pleasure centres at this time ensures that the mother finds her offspring pleasurable and rewarding.

In addition, human studies have found that new mothers experience changes in personality following physiologic birth, making them more relaxed and interactive, which also helps with enjoying her baby.

Could epidurals affect bonding?

This area has not been well researched. Some studies have shown impacts such as more negative descriptions of the baby at one month among women exposed to labour epidurals, which might reflect disruption to the activation of reward systems. In addition, the usual postpartum personality changes described above are not seen in women who have had an epidural, which could also make the transition to motherhood more difficult.

Note that these studies do not imply that women who have had epidurals (or other interventions) will love their babies less, or be negatively impacted in their mothering. However, having an epidural may reduce the ‘head start’ that Mother Nature  provides through the peaks of oxytocin and other hormones in physiologic labour and birth. The resulting ‘hormonal gap’ may take some effort to fill.

What can we do to help mothers and babies to fill in these “hormonal gaps”? 

In summary, epidurals can create a hormonal gap for the new mother (and the baby, directly or indirectly) in relation to oxytocin. This could impact the initiation of breastfeeding for mother and/or newborn, and potentially disrupt the pleasure and reward she experiences with her baby.

These hormonal gaps can be filled, but more effort will be needed outside of the biologically ‘sensitive period’ of labour and birth. For example hormone receptor numbers reach peak levels at physiologic labour onset, making hormonal systems maximally sensitive and most easily activated through to the early postpartum period.

Human studies show maximal oxytocin receptor numbers in the uterus, and animal studies (impossible to do on women) show maximal brain and mammary gland receptors for oxytocin and prolactin.

Filling in hormonal gaps means supporting activities that stimulate hormonal release for mother and baby. The most powerful of these are skin-to-skin contact and breastfeeding.

Practically, this would mean promoting early and ongoing skin to skin contact, with liberal opportunities for newborn-initiated breastfeeding, along with extra breastfeeding help if needed, eg lactation consultant support. These practices feature prominently in epidural studies that show good outcomes for breastfeeding.

Want to know more?

Ecstatic Birth: Nature’s Hormonal Blueprint for Labour (free ebook)

Hormonal Physiology of Childbearing Report, see especially section 3.2.5

Epidurals and breastfeeding review and study on fentanyl 

Impacts of epidurals on breastfeeding hormones and personality changes

Epidural drugs in the newborn e.g. here and here

My whole-day Undisturbed Birth workshop on DVD  You can attend my acclaimed workshop in the comfort of your own home!

  • Learn all about the ecstatic hormones of labour and birth, and how to make the most of them
  • Find out how maternity-care interventions including epidurals can impact these delicate hormonal systems.
  • Discover the hormonal magic of the hour after birth, and how to give your newborn the best start with cord clamping.

This DVD workshop is suitable for interested parents as well as birth professionals, with free  postage worldwide.

 

 

Epidurals in Labour (Part 1)

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What do you know about epidurals and their risk and benefits?  In this blog (Part 1) , Dr Buckley explores the impacts of epidural on oxytocin and the flow of labour, and what this might mean for mothers and babies.

Epidurals are a very effective method of pain relief for labouring women, and are often encouraged by caregivers, even before labour begins.

Like all interventions, epidurals have benefits and risks for mothers and babies. Possible risks include the potential to disrupt the processes of labour for mother and baby. There are also unanswered questions about possible impacts through to motherhood, including effects on breastfeeding and bonding.

These FAQs will help you to balance the benefits and risks of epidurals for yourself and your own unique situation, so that you can make the choices that are right for you, your baby and your family.

What is an epidural?

Epidural analgesia involves an injection into the lower back that pierces the outer coverings (”epi-dura”) of the spinal cord. Drugs are injected close to the nerves as they come out from the spinal cord. Usually this involves a “local anaesthetic” (LA) drug such as bupivacaine, along with an “opiate” drug (related to morphine, pethidine/meperidine etc) such as Fentanyl. Epidurals are used in many types of surgery and procedures, and also sometimes administered to relieve pain outside of childbirth.

How do epidurals work?

Just like a dental anaesthetic, LA drugs block the sensory nerves, causing numbness, and also inevitably block the motor nerves, giving some degree of paralysis. Opiate drugs are added to an epidural to increase the effectiveness of the LA, so that there will be good pain relief with less motor block.

What are the benefits of epidurals?

Obviously, the main benefit of an epidural is the very effective pain relief that most women experience. Because of this effective analgesia, epidurals also reduce stress, and stress hormones, in labour. This can be beneficial when women are experiencing very high levels of stress and pain, which can slow labour progress.

Is labour stress harmful?

It is important to realise that some degree of stress is inevitable in labour, and actually beneficial for mother and baby. For example, high levels of the stress hormone cortisol contribute to a new mother’s euphoria, and help with bonding with her newborn. For the baby, the “stress of being born” switches on biologic processes that help with breathing at birth, among other adaptations. (See below for references)

Are epidurals good if I need a caesarean?

Epidurals also allow you to be awake and alert, but pain free, when procedures such as caesareans are needed. You will be able to see and hold your baby soon afterwards. In this situation, you and your baby will also be exposed to lower levels of drugs than a “general anaesthetic.”

What are the side-effects of epidurals?

Many of the side-effects of epidurals are due to effects on your  birthing hormones. These are the calming, pain relieving, and stress-reducing chemicals that your body naturally produces to make labour as easy, safe and rewarding as possible. (See my Ecstatic Birth ebook for more info).

How do hormones help in labour?

The hormone oxytocin is particularly important because it causes the uterine contractions that drive labour and birth.

During a natural (physiological) labour and birth, the sensations of uterine contractions are transmitted to the labouring woman’s brain, and drive the oxytocin “positive feedback cycle” (Ferguson reflex). Within this cycle, uterine sensations trigger oxytocin release, more contractions, more sensations, and more oxytocin release. This strengthens labour and also helps the baby to be born quickly and easily.

As the diagram shows, this positive feedback cycle also increases oxytocin release into the brain, where it has calming and pain relieving effects. (Very welcome in labour!)  Oxytocin also turns on reward and pleasure centres in the brain during labour and birth, in preparation for mothering. (More about this in part 2)

Why do epidurals slow labour?

With an epidural, your labour sensations will usually be completely abolished. This means that there is no sensation to drive this oxytocin feedback cycle, and your oxytocin levels will decline.

This explains why labour usually slows, and sometimes even stops, in the hours following epidural administration. You will probably require an infusion of synthetic oxytocin (Pitocin, Syntocinon) to compensate for the loss of your own oxytocin, and to strengthen labour again.

More epidural resources

Epidural FAQs part 2.

What are the consequences of missing the oxytocin peaks for mothers, babies, breastfeeding and bonding? How can we fill in the hormone gaps when epidurals are needed? Part 2 Coming soon!

Epidurals: Risks and Concerns for Mothers and Babies Chapter from Gentle Birth, Gentle Mothering (2005)

Undisturbed Birth DVD Dr Buckley’s workshop on DVD. Discover the “ecstatic hormones” of labour and birth and the impacts of interventions, including epidurals

Hormonal Physiology of Childbearing Dr Buckley’s in-depth report (2015) has all the scientific detail and studies. See particularly sections 3.2.5, 4.2.5, 5.2.6 and 6.2.5 .

2017: Reasons for Hope

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From the personal and local, to the national and global, things seem to be getting more extreme and polarised, and it can be easy to sink into despair and hopelessness. Please remember that we have been here before, (the Cold War for example), and we got through that too.

Maybe these collectively intense experiences are necessary to wake us up before it is too late. Or, as one environmental campaigner put it, “The best time to take action on climate change was 30 years ago. The second best time is now.”

But it’s is not just about taking direct political or environmental actions. Those of you who are busy (very busy!) with young children, please know that your contributions are critical to our collective future. Those small daily actions that we take as parents can add up to a transformation on Planet Earth.

Parenting gently and mindfully; raising our children—our future citizens—with love and connection; caring for ourselves and our communities, as best we can; these are huge investments in a peaceful and sustainable future.

As my friend and colleague Robin Grille explains in his exceptional talk for Unicef, our parenting can either promote the release of oxytocin—the hormone of love, calm and connection—or the stress hormone cortisol, in our children’s brains. Repeated experiences of oxytocin, via connection and nurturance, or cortisol, via stress and separation (which is interpreted as a life-threatening stress for a young child), can shape our children’s developing brains towards peaceful cooperation, or aggression and competition.

This makes evolutionary sense. In an environment of scarcity, stress is likely to lead to less attentive, or even harsh, parenting, and orient offspring brain development towards the aggressive, competitive behaviours that will promote individual survival in this situation.

Similarly, cultural norms that promote a more punitive, separating, and/or harsh style of child-rearing may influence whole societies towards more aggressive and competitive interactions, as occurred in pre-Nazi Germany. (See below and also Robin Grille’s book Parenting for a Peaceful World for more about child-rearing norms in relation to world events.)

In this situation, parents can also miss the calming, connecting and health-enhancing effects that come from oxytocin-rich experiences, such as holding, carrying, breastfeeding and co-sleeping with our babies and children.  For example, one randomised study found that women who had daily skin-to-skin contact in the first month had lower cortisol levels and lower maternal postpartum depression scores, compared to unexposed women (see below.)

What is revolutionary, and potentially transformational, about these understandings is that they involve epigenetic processes—switching our genes on and off–and can produce changes in a single lifetime.

The radical implication is that human aggression is not inevitably programmed into our genetics, but can be moulded by our earliest experiences. 

For example, studies have demonstrated epigenetic changes in the brain oxytocin systems of animal offspring who receive high levels of nurturing in infancy. The “well-mothered “ adults are less susceptible to stress, and females grow up to become highly nurturing mothers themselves, even when genetically predisposed to be less nurturing.

The potential for parenting nurturance to produce epigenetic brain changes that enhance social behaviours in humans has been called “Neurosocial Evolution.” According to Robin Grille, this process has been gathering pace for some time, associated with widespread shifts in parenting norms and laws that increasingly promote children’s wellbeing.

For example, a growing number of countries are now giving children the same legal protection against physical violence as adults by outlawing spanking and other physical punishments.  And the UN-endorsed Declaration of Rights of the Child (1959) would have been unthinkable 100 years previous.

In parallel with this evolution in parenting attitudes and practices, global violence and wars have reduced, even in the last 100 years. For example, research shows that in 1950, 250 people per million died as a result of war, compared to 10 per million in 2007.

Globally we have become more empathetic, peaceful, and democratic.

(It is interesting to speculate whether parenting norms and laws in those places may be less supportive.)

The hormones of labour and birth play a role here too. Physiologic hormonal peaks saturate the brain of every new mammalian mother, activating brain pleasure and reward centres that will motivate and reward her to give the dedicated and physically close mothering that promotes survival of her offspring.(For the science behind, this, see section 3.1.4 my Hormonal Physiology of Childbearing report.)

This mammalian blueprint can benefit human mothers and babies. Full expression of our “ecstatic hormones” in labour and birth imprints our pleasure and reward centres in relation to newborn contact and care, giving us an ideal and pleasurable start to mothering.

Breastfeeding and holding our babies, especially skin-to-skin, also activates these pleasure circuits, reinforcing mothering that is attentive and physically close.

(For the science behind, this, see “Biological bonding” in my Hormonal Physiology of Childbearing report.)

Coming back to 2017, perhaps the most important question is: what will it take to transform ourselves into a peaceful and ecologically intelligent society?

Does it depend on the President we elect, or could this transformation be in our own hands, as mothers and fathers?

Could the hands that rock the cradle, actually transform the world?

More links

The Neurosocial Evolution of Humanity  (Robin Grille’s 1 hour talk for Unicef)

Parenting for a Peaceful World- Robin Grille’s heart-warming video  and book

Declaration of the Rights of the Child

Skin to skin mothering reduces postpartum depression (Study) 

52 countries that have so far outlawed physical punishment of children,

Recent reductions in global deaths from war (Study)

Ecstatic Birth: Nature’s Hormonal Blueprint for Labour (Free ebook)

Hormonal Physiology of Childbearing: Report and more

 

We were Made for These Times– Clarissa Pinkola Estes

 

Gentle, Natural, Mammalian Birth

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screen-shot-2016-11-22-at-1-21-31-pm-copy

In the festive season, we celebrate perhaps the most famous gentle, natural, birth in history.

Blessed Mary gave birth to her legendary baby in the most low-technology setting imaginable… and surrounded by mammals.

Could this be a powerful teaching to us, across time, about human birth?

As I emphasise in my lectures and  workshops, the core requirements for successful birth among all mammals are that the labouring female feels private, safe, and unobserved.

We are mammals too!

When we understand that we are mammals too, it becomes obvious that disturbance in birth—or any situation where the labouring woman does not feel private, safe, and unobserved—will interfere to some extent with the processes of labour.

Mary, for example, did not need to move to hospital mid-labour, and was not attended by strangers- definitely not workable for our mammalian cousins!

Disturbances such as shifting to an unfamiliar environment (especially home to hospital) can slow or even stop labour by disrupting our labour hormones. Labour disturbances can elevate adrenaline and noradrenaline, our “fight or flight” hormones, not only slowing labour, but also re-routing blood from the uterus and baby to the muscles, heart, and lungs in preparation for action.

Studies in animals show that labour disturbance can disrupt several other hormonal pathways as well (see my report Hormonal Physiology of Childbearing), emphasising the biological and evolutionary importance of a safe place to birth.

Private and safe

Our basic mammalian need to feel private and safe in labour is recognised in traditional systems of maternity care. Just like the circle of elephants that surround a labouring female in the wild, traditional caregivers know how to support the labouring woman so that she is as calm and comfortable as possible.

Individualised labour support (recognising that some women seek company in labour and others feel safer with more privacy) can help women to deal with the intensity of labour, aided of course by our natural pain and stress-relieving systems such as oxytocin and endorphins.

Well, most of us will not give birth in a stable this Christmas–or with a circle of elephants! So how can we make the most of our “Ecstatic hormones,” even in settings that may challenge or disturb us?

screen-shot-2016-11-22-at-3-10-34-pmHelping our hormones

This is a very big topic, but in a nutshell, here are my top 5 festive give-aways, for a gentle, natural, birth

1. Choose your maternity caregivers wisely

Labouring in a low-technology setting, such as homebirth or a birth centre, are safe options (see below) that are more likely to soothe your hormonal systems. Choosing lower-technology caregivers such as your own midwife or family physician will reduce your chances of maternity-care interventions such as epidurals and caesareans, which will can interefere with hormonal processes. You can always move up to higher levels of care, if needed, but it is difficult to move to lower technology care once labour begins.

(Its important to add that, in labour, it is your own perception of safety that matters. Choose the setting and caregivers that help you to feel private and safe! )

2. Choose your labour support team carefully

Who do you feel safe with? If you are a private person, you probably don’t want your whole family there. My best advice is to be flexible, so that you can see how you feel when you are actually in labour. Let your birth support team know that you may or may not call them, and you may even ask them to leave if you need privacy.

If you are giving birth in hospital, having your own midwife and/or doula (supportive birth companion) will reduce your chances of interventions such as epidurals and forceps, according to the best evidence (see below).

If you need higher-level care because of a medical condition or complication, talk to your care provider about the benefits of taking your own doula.

3. Create your own privacy

How can you bring a sense of privacy and safety with you, into any setting? Controlling your sensory input can be enormously helpful.

For example shutting your eyes,  wearing an eye-mask, or focussing on a soothing object or image will reduce visual disturbance. Having ear plugs or headphones with soothing music, or having your beloved whispering encouraging words to you, will help control auditory input. And bringing familiar smells, e.g. essential oils, a T shirt from home, or your pillow to bury into, will reduce unfamiliar odours.

Hypnosis and hypnobirthing, relaxation tapes and techniques, and meditative practices, especially if you have used these in pregnancy, can also help to anchor you into a private  and safe state, amidst the intensity of labour.

4. Having a baby, making a baby

The hormones involved with having a baby are the same hormones involved with making a baby, and we need the same conditions (you guessed it!)- private, safe, and unobserved! This is a good rule of thumb to assess your “nest” in labour, especially if labour is stalling: Could I make a a baby in this situation?

You can also use this knowledge to help labour progress. Oxytocin, the hormone that gets labour going, is also a hormone of sexual activity and orgasm. Sexual activity in labour can be very effective for speeding labour– more natural (and more fun) than an IV drip with synthetic oxytocin!

5. Point of no return

There is a stage in labour when external disturbance does not slow labour down. In fact, for hormonal reasons, disturbance at the end of labour is more likely to speed things up. This is the ideal time to make your move to hospital.

How can you recognise this? I asked this question of participants in my Undisturbed Birth workshops, and one midwife commented,  “I know it is time to go to hospital when she can’t remember her own phone number!”

These wise words reflect the deep alteration in consciousness that accompanies a gentle, natural, physiologic birth, where activity in our rational brain subsides and our instinctive brain takes over. This can be a positive, even ecstatic experience. Hmm sounds a lot like… making a baby!

Find out more: 

*More about birth hormones in my free Ecstatic Birth ebook

*My whole-day Undisturbed Birth workshop on DVD You can attend my acclaimed workshop in the comfort of your own home!

  • Learn all about the ecstatic hormones, and how to make the most of them
  • Find out how maternity-care interventions can impact these delicate hormonal systems.
  • Discover the hormonal magic of the hour after birth, and how to give your newborn the best start with cord clamping.

This DVD workshop is suitable for interested parents as well as birth professionals, with free  postage worldwide.

*Watch online lectures about the ecstatic hormones, impacts of intervention and much more in my Gentle Natural Birth Professional program, also suitable for interested parents.

*All the science and citatations in my Hormonal Physiology of Childbearing report. (See especially Section 5.2.1 for research on the hormonal effects of labour stress.)

*Michel Odent discusses the mammalian need to feel private and safe in labour

*Elephant birth in the wild: circle of elephants

*More mammalian birth videos

Email us your favourite online animal birth video links!

Sexuality of labour and birth: www.orgasmicbirth.com 

*Best available evidence from the Cochrane Collaboration:

Normal Labour and Birth Conference, Sydney 2016: Science, Love and Dancing!

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The International Normal Labour and Birth Conference, downunder for the first time this October (2016), was, as one participant described, “A perfect blend of science, love, and dancing.”

It was a pleasure and privilege to participate, alongside stellar speakers, articulate advocates, refined researchers, and many, many, marvellous midwives (and midwifery students) from all over the world. All were passionate about mothers and babies, and the benefits of normal, natural birth. Thanks everyone for travelling so far to be with us!

There were many magical moments and powerful presentations, along with fun and frolicking, which midwives (and lawyers, doctors and others!) are equally good at- see the video links below.

I left the conference with huge gratitude to Soo Downe, Professor in Midwifery Studies at the University of Central Lancashire, who began NLBC in the UK in 2001, and to our own fabulous and prolific Hannah Dahlen, Professor of Midwifery  at the University Western Sydney, along with everyone who helped to bring this precious gathering to our shores.

For those who came (and just couldn’t choose which of the incredible concurrent sessions to attend); those who wanted to come but couldn’t make it (tickets sold out quickly); and/or anyone interested in the future of birth and the wellbeing of the planet,  here are some of my favourite presentations and take-aways:

  • Opening and warm welcome to country with our precious Aboriginal elder Aunty Millie
  • Soo Downe, just fresh off the plane from the UK (thanks Soo!), asked, “Who has mastery over safety and what it means in childbirth?”  Soo highlighted the recent Lancet series on midwifery that discriminates birth interventions that are “too little too late vs too much too soon.”
  • Caroline Homer gave a tour-de-force presentation on “Why normal birth matters in low and middle-income countries too.”  She included the WHO goal for universal health cover by 2030 and the beautiful quote in the image above by Aung San Su Kyi; “The birth of a baby is an occasion for weaving hopeful dreams about the future.”
  • “The only way we’ll get sustainable reforms in maternity care systems is to institutionalize the input of mothers’ experiences and attitudes into the process” Sobering conclusions from Eugene Declercq, Professor of Community Health Sciences at the Boston University School of Public Health, and author of the US Listening to Mothers surveys. Eugene generously shares his slides here and his presentation is here.
  • “The next decade is a crucial one to ‘save’ normal birth in the western world.”  Professor of Maternal-Fetal Medicine Alec Walsh, a strong supporter of midwifery care, with midwifery Professor Sally Tracy from the University of Sydney, who also discussed the M@ngo study, which found lower rates of intervention, lower costs and equivalent outcomes for women and babies randomised to continuity of midwifery vs usual care.
  • Saraswathi Vedam, Professor of Midwifery at the University of British Columbia and convenor of the exceptional annual multi-disciplinary homebirth summit, shared the summit consensus Homebirth referral guidelines. I recommend that you check out her fabulous TedX talk too. She also brought her beautiful daughter Zoe Miller-Vedam who is a human rights lawyer, also working for human rights in childbirth.
  • Obstetrician, breech birth expert– and midwifery supporter– Andrew Bisits, shared that, for him, every breech birth offers some insight into normal birth. He also took up the Q&A challenge to demonstrate how a breech baby gets itself out!
  • My friend, colleague–and my own childbirth educator back in 1995–Rhea Dempsey gave a standing-room-only workshop on Pain Dynamics and Physiologic Birth. The whole workshop is here part 1 and part 2 (scroll down)- Thanks Sheena for filming!
  • I gave a workshop on Hormonal Physiology of Childbearing, based on my report and with a special focus on the evolutionary roots of physiologic birth. My “triangle of reproductive success” emphasises that “The hormonally-mediated processes of successful lactation and maternal-infant attachment are intertwined and continuous with the biologic processes of parturition.” In other words, when we interfere with the hormones of labour and birth, we can inadvertently disrupt breastfeeding and mother-baby attachment. Watch this space for the whole workshop posted in my Gentle Natural Birth Professionals program!
  • “…it’s not just being friendly. It influences the physiology in a basic way.” Oxytocin guru Professor Kerstin Uvnas Moberg from Sweden, talking about the biologic benefits of having support–your own doula or midwife–in labour.
  •  Maralyn Foureur Professor of Midwifery at University of Technology Sydney, shared insights and some of her ground-breaking research on the impact of birth environment on women and care providers.
  • Proud and passionate indigenous midwives Renae Coleman and Leona McGrath, along with Professor of Midwifery at the University of Queensland Sue Kildea, spoke about the urgent need for  traditional birthing practices and for birthing “on country” Watch this space for opportunities to support.
  • “The right to autonomy includes the right to informed consent, to refuse medical treatment, and to make decisions for her unborn baby.” The wonderful Bashi Kumar Hazard spoke about Human Rights in Childbirth from her perspective as a HRIC board member and lawyer. Her full presentation is here.

All the abstracts here 

More fun:

More round-ups- thanks to all the bloggers!

  • Sydney Doula Ellen Croucher (lovely to meet you Ellen!) and her fabulous blogs about day 1, day 2, day 3

For the Mamas!

As the speakers at this conference emphasised again and agin, the best scientific research shows that having your own midwife will reduce your chance of unnecessary intervention, while giving the additional benefits of midwifery care. Having your own midwife may even reduce your chance of early stillbirth. Having a supportive birth companion (doula) will also increase the chances of a gentle natural birth and is a great option, especially if you are using an obstetrician as your main care provider

For more about the important decision of choosing your maternity care provider, see my Gentle Natural Birth Pregnancy program– great info for any stage of pregnancy too!

Photos and more 

Thanks to my friends, heroes and sheroes, including Pip Wynn Owen, Sheena Byrom and her lovely Paul (who together welcomed me at the airport) , Rhea Dempsey, Lesley Page, Kerstin Uvnas Moberg, Hannah Dahlen, Eugene Declercq,  Pat Brodie, Nicky Leap, Bashi Hazard, and all at #NLBC2016! More conference photos here. 

I missed lots of photo opportunities, including with my dear sister-in-law Sue Lennox, NZ midwife of 40 years+–and the reason we had our babies at home, which started all of this! Thanks Sue!

Ultrasound Scans in Pregnancy – Your Questions Answered!

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Having an ultrasound has become an expected part of pregnancy, and modern women may have many scans, sometimes beginning from the early weeks.

We are also lining up for “keepsake” scans, where we are paying hundreds of dollars for a scan with no medical need. We take home a blurry picture – or maybe a clear video – of our unborn baby to share with family and friends.

Ultrasound is an expensive and relatively new technology. Is it safe enough to be using routinely on all mothers and babies? Is it beneficial? What do you need to know to make (or facilitate) an informed choice?

As a physician and mother, I have been researching and writing about prenatal ultrasound since my second pregnancy, more than 20 years ago. While my personal choice was to have no routine scans with any of my four children, I know that sometimes this technology can be immensely helpful.

I support parents, and their fundamental right to make the unique choices in pregnancy, birth and parenting that are right for themselves, their baby and their family.

This blog is based on common questions from childbearing families. You can learn more about ultrasound in my book Gentle Birth. Gentle Mothering. You will find more information and links at the end.

1.    What are the benefits of ultrasound?

Ultrasound is a powerful technology to see inside the womb and can give very useful information in some situations.

For example, a scan can see if your pregnancy has miscarried, measure your baby’s growth, and clarify baby’s position. It can also see if you are carrying more than one baby (although this has not been shown to improve the outcome, as multiple pregnancies are usually diagnosed before birth).

In relation to a routine ultrasound in pregnancy (where there is no other reason for a scan) the main benefit is to detect abnormalities in the baby. Around 1 in 50 babies have a significant abnormality at birth, and a scan can pick up around half of these (around 1 in 100).

A routine scan can also estimate your due date. This is most accurate early in pregnancy. By 18-20 weeks, the accuracy of a scan is one week either side. If your scan date is later than your own estimation, this may reduce your chance of being induced for going “overdue”.

It can also be exciting to see your baby on the screen, and to learn their sex before birth. In fact, many people are having “keepsake” scans for this reason. However, professional bodies urge caution with non-medical use of ultrasound, which gives us no medical benefit but possible risks.

2.    What if my baby is diagnosed with an abnormality on ultrasound?

Ultrasounds mainly detect “structural” abnormalities in the baby’s body, although there are also special scans (“nuchal translucency”) that can pick up increased risks of genetic conditions like Down syndrome.

If your baby is diagnosed with an abnormality, you should be offered expert help and counselling to decide what is right for you. Generally, the only treatment for major problems that are found on ultrasound is a pregnancy termination. It is extremely rare to be able to treat conditions in the womb, because fetal surgery generally causes labour to start.

For less severe abnormalities, e.g. cleft lip/palate, club-foot, there is nothing that can be done until after the baby is born. Some parents appreciate being fore-warned, but you might also consider that this knowledge will significantly impact your experience of pregnancy, may reduce your joy, and could adversely impact your relationship with your growing baby. (See this study)

There are also very few conditions where knowing the condition before birth might advantage your baby, also evidenced by the finding that routine scans do not reduce the chance of babies dying around the time of birth (“perinatal mortality”). (See this study)

In addition, a positive ultrasound diagnosis may be wrong for around one in 10 to 12 babies. (See this study )

3.    Is ultrasound safe?

The short answer to this question is, “We don’t know”.

We do not currently have any high-quality scientific studies that compare the development of children who were exposed and unexposed to modern high-powered ultrasound scans in the womb. (See this study)

There are two high-quality “randomised controlled trials” from the early 1980s in Sweden and Norway. These older machines had 10 to 20 times lower output, and in one of these studies, scans were only 3 minutes in duration. Follow up at school age showed a small increase in non-right-handedness, suggesting that ultrasound exposure could have impacts on brain development. Several other studies have also found this effect. (See this study)

Animal studies do show offspring effects from pregnancy ultrasound, including effects on brain development (this study) and social behaviours (this study). Note that two studies using older scanning machines did not find increased autism risks amongst children with greater ultrasound exposure (this study and here).

4.    Why does my doctor/sonographer tell me that ultrasound is safe?

Maternity care providers and practitioners all want the best for you and your baby, and many sincerely believe that scanning is not harmful. However, even the experts and organisations that are most involved in promoting and performing scans have accepted that there are unanswered questions about safety. (See this and this study for examples)

For these reasons, sonographers are recommended to use the ALARA principle – to limit exposure to “as low as reasonably achievable”. Modern ultrasound machines include output displays of exposure to help sonographers to limit exposure, but again, these are not well understood or used by most sonographers. (See this study)

If your doctor or sonographer tells you that ultrasound is unequivocally safe, or does not know how to limit exposure to ALARA for your baby, I recommend that you share this article.

5.    What about fetal heart rate monitors and hand-held Dopplers (“sonicaids”)?

Ultrasound is also used to hear your baby’s heart beat and measure the heart rate. The small hand-held machines (fetal Doppler, sonicaid), as well as the large “CTG” machines used to monitor the fetal heart in hospitals use a special form of ultrasound called Doppler.

Doppler ultrasound has generally higher exposure levels than the “pulsed” ultrasound that is used to picture your baby. Doppler uses constantly-emitted ultrasound waves rather than short pulses, and is especially good for showing blood flow and colour. Because of the constant waves, Doppler scans have higher tissue-heating effects, and caution is recommended with Doppler scans in early pregnancy. (See this study)

Handheld Dopplers have low ultrasound output compared to scans, and are generally used very briefly in pregnancy, which also reduces exposure. However, exposures may be higher when prolonged continuous monitoring is done for many hours in labour.

There are no studies of the safety of hand-held Dopplers, and practitioners – myself included – have observed that babies tend to move away from the waves, suggesting an unpleasant effect. (See this study)

Maternity-care practitioners should be able to offer you the option of monitoring your baby’s heart via low technology methods such as Pinards stethoscope (see picture).

With a little practice, your friend or partner may be able to hear the low pitch of your baby’s heart (usually faster than yours, around 110-150 beats per minute) in late pregnancy by listening over your lower belly through a roll of cardboard or toilet roll.

6.    How can I reduce ultrasound exposure?

As a prospective parent you have the right to make an informed choice about medical tests and interventions for yourself and your baby (see this study). This includes accepting or refusing an ultrasound, and limiting your baby’s exposure.

Here are some suggestions:

  • Use the BRAIN model (considering Benefits, Risks, Alternatives, listening to your Intuition and doing Nothing), to decide what is right for you, your baby and family in relation to pregnancy ultrasound. (You will find this model really helpful in decision-making, from pregnancy through to parenting. You can get more help to “use your BRAIN” in book Gentle Birth, Gentle Mothering)
  • Choose a maternity caregiver who is respectful and open to your wishes and perspectives.
  • If you find that you are not able to negotiate this issue with your maternity caregiver, this may be a “red flag”. Consider whether you might also have trouble getting your needs and desires met later in pregnancy, and in labour and birth.
  • You could choose to avoid all ultrasounds unless you have a medical need. A good rule of thumb might be to ask, “Would we do anything differently after having this test?”
  • OR you could choose to selectively scan, requesting the lowest and shortest exposures possible. You would need to find a sonographer who is willing to help – see Q4 above.
  • My suggestion is that, when you ring to book your scan, you say something like, “I want to have a scan, but have some concerns about ultrasound safety. Can you book me with someone who I can talk about this with, and who will respect my wishes to have the lowest exposure possible for my baby?”
  • You might want to take this article to your doctor or sonographer. Note that the sonographer may not be able to exclude all possible conditions with a shorter scan. (However, even a comprehensive scan cannot pick up all conditions that your baby could have.)

7.    What do the experts say?

Here are some quotes by ultrasound experts:

“…ultrasound involves exposure to a form of energy, so there is the potential to initiate biological effects. Some of these effects might, under certain circumstances, be detrimental to the developing fetus.” (International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), 2009)

“Currently, there is no reliable evidence that ultrasound is harmful to a developing fetus. No links have been found between ultrasound and birth defects, childhood cancer, or developmental problems later in life. However, it is possible that effects could be identified in the future. For this reason, it is recommended that ultrasound exams be performed only for medical reasons by qualified health care providers” (American Congress of Obstetricians and Gynecologists, 2013)

“… it must once more be stressed that there has been no epidemiologic study published on populations scanned after 1992, when regulations were altered and the acoustic output of diagnostic instruments was permitted to reach levels many times higher than previously allowed (from 94 to 720 mW/cm2 spatial-peak temporal-average intensity for fetal applications). In several studies, levels reported by the manufacturers were no more than 1.5 W/cm2 spatial-peak temporal-peak intensity. There are no epidemiologic studies related to the output display standard (thermal and mechanical indices) and clinical outcomes. The safety of new technologies (harmonic imaging, Doppler imaging [spectral and color], 3-dimensional imaging, and the use of ultrasound contrast agents) as well as that of probe self-heating needs to be investigated.” (Abramowicz, 2008)

“Due to the exemption received by diagnostic ultrasound through the 510(k) process, there has been no extensive and planned investigation by independent laboratories into potential bioeffects risks of diagnostic ultrasound. Safety assurance rests on (1) an assumption of safety for pre-1976 ultrasound devices, (2) theoretical consideration of important bioeffects mechanisms and (3) interpretation of published research studies which may or may not have any relation to obstetrical ultrasound.” (Miller, 2008)

“Some non-imaging procedures, such as using Doppler ultrasound for fetal heart monitoring or peripheral pulse monitoring, use both continuous wave and pulsed low-power output levels that can cause tissue effects, although the exact mechanisms are still not completely understood. Low-intensity pulsed ultrasound effects, such as bone fracture repair reported in humans and repair of soft tissue damage and accelerated nerve regeneration in animal models, indicate a need for further research on potential fetal effects.” (Nelson, 2009)

“Pregnancy is not an exception to the rule that a decisionally capable patient has the right to refuse treatment. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.” (American Congress of Obstetricians and Gynecologists, 2016)

Scientific studies, reviews and comments

Links to Pubmed studies, with some free full-text articles available. (Click the top right image under “Full text links” to see if you can access the full article.)

Where can I learn more?

My book Gentle Birth, Gentle Mothering (2009) has an in-depth chapter on ultrasound designed to complement this updated information