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