Our Active Birth Workshop or Antenatal Private Session is led by advanced childbirth educator and senior yoga teacher, Suzanne Swan. Suzanne has been doing this work for over eighteen years and her experience affirms that having the partner involved in the birth process, working hands on as a team with the mother, promotes a positive birth experience and enhances family bonding.
Undisturbed Birth- Nature’s Blueprint for Ease and Ecstasy
by Dr Sarah Buckley
The term undisturbed birth came to have great meaning for me when I gave birth to my fourth baby, unassisted (and unexpectedly breech) at home. It describes well this beautiful experience which awakened me anew to the ecstasy of birth, and I realised that the process of birth can be very simple, if we avoid disturbing it. Comparing this birth to my three previous midwife-assisted home births, and to home and hospital births that I had attended, I saw also how ingrained is our habit of disturbance, and that our need to ‘do something’ so often becomes self-fulfilling in the birth room.
I realised that birth is also very complex, and that the process is exquisitely sensitive to outside influences. The parallels between making love and giving birth became very clear to me, not only in terms of passion and love, but also because we need essentially the same conditions for both experiences- to feel private, safe and unobserved. Yet the conditions that we provide for birthing women are almost diametrically opposed to these- no wonder giving birth is so difficult for most women today.
What Disturbs Birth?
As I imply, anything that disturbs a labouring woman’s sense of safety and privacy will disrupt the birth process. This definition covers most of modern obstetrics, which has created an entire industry around the observation and monitoring of pregnant and birthing women. Some of the techniques used are painful or uncomfortable, most involve some transgression of bodily and/or social boundaries and almost all are performed by people who are essentially strangers to the woman herself. All of these factors are disruptive to pregnant and birthing women.
Underlying these procedures, is a deep distrust of women’s bodies, and of the natural processes of gestation and birth, and this attitude in itself has a strong nocebo, or noxious effect.
On top of this, is another obstetric layer devoted to correcting the ‘dysfunctional labour’ that such disruption is likely to produce. The resulting distortion of the process of birth- what we might call ‘disturbed birth’-has come to be what women expect when they have a baby and perhaps, in a strange circularity, it works. Under this model, women are almost certain to ‘need’ the interventions that the medical model promotes, and to come away grateful to be ‘saved’, no matter how difficult or traumatic their experience.
These disturbances are counterproductive for midwives also. When a midwife’s time and focus is taken up with monitoring and recording, she is less able to be ‘with women’ as the guardian of natural birth. When her intuitive skills and simple ways of knowing have been buried in service to the system, more and more invasive procedures will be needed to get information that, in other times, a midwife’s heart and hands would have illuminated. And when a woman misses out on the joy and ecstasy of birth, so does her midwife, which will influence her expectations of birth, as well as her job satisfaction.
However our women’s bodies have their own wisdom, and our innate system of birth, refined over 100,000 generations, is not so easily overpowered. This system- what I am calling undisturbed birth- has the evolutionary stamp of approval, not only because it is safe and efficient for the vast majority of mothers and babies, but also because it incorporates our hormonal blueprint for ecstasy in birth.
When birth is undisturbed, our birthing hormones can take us into ecstasy- outside (ec) our usual state (stasis)- so that we enter motherhood awakened and transformed. This is not just a good feeling; the post-birth hormones that suffuse the brains of a new mother and her baby also catalyse profound neurological, or brain changes. These changes give the new mother personal empowerment, physical strength and an intuitive sense of her baby’s needs (Pearce 1995), and prepare both partners for the pleasurable mutual dependency that will ensure a mother’s care and protection, and her baby’s survival.
Undisturbed birth, then, represents the smoothest hormonal orchestration of the birth process, and therefore the easiest transition possible- physiologically, hormonally, psychologically and emotionally- from pregnancy and birth to new motherhood and lactation for each woman. When a mother’s hormonal orchestration is undisturbed, her baby’s safety is also enhanced, not only during labour and delivery but also in the critical transition from intra- to extra-uterine life. Furthermore, the optimal expression of a woman’s ‘motherhood hormones’ will ensure that her growing child is well nurtured, adding another layer of evolutionary ‘fitness’ to the process of undisturbed birth.
Undisturbed birth does not mean unsupported birth. Some anthropologists believe that human females have sought assistance in birth since we began to walk on two legs. The change in our pelvic shape that accompanied our upright stance added uniquely complex twists and turns to our babies’ journeys during birth, making assistance more necessary than for other mammals (Rosenberg 2001). It does mean having supporters who we have specifically chosen as our familiar and loving companions; who are confident in our abilities, and who will intervene as little and as gently as possible.
Undisturbed birth does not mean painless birth. Giving birth is a huge event, physically and psychologically, and makes demands on the body which are hormonally equivalent to endurance athletics(Goland 1984). But when a woman feels confident in her body, well supported, and able to express herself without inhibition, any painful feelings can become just one part of the process and something that she can respond to instinctively from her own resources using, for example, breath, sound and movement.
Undisturbed birth does not guarantee an easy birth. There are many layers, both individual and cultural, that can impede us at birth. But when we approach birth with the intention of minimum disturbance, we are optimising the functioning of our birth hormones. This, coupled with our unparalleled levels of hygiene and nutrition, gives us a better chance of an easy and safe birth than any of our foremothers, from whom we have also inherited, through natural selection, the female anatomy and physiology that births most easily and efficiently.
The hormones of birth
The hormonal orchestration of birth, to which I refer, is exceedingly complex and our understanding of it is limited and based mainly on studies in other mammals. New hormones and endocrine factors are being described, and inter-species differences elucidated, by researchers all over the world but many fundamental processes are still unknown.
In this paper, I will be primarily discussing the hormones oxytocin; beta endorphin; the catecholamines adrenalin and noradrenaline (epinephrine and norepinephrine) and prolactin. As the hormones of love, transcendence, excitement and stress, and mothering, respectively, these hormones are the major components of an ecstatic cocktail of hormones that nature prescribes to aid birthing mothers of all mammalian species.
All of these are produced primarily in the middle or mammalian brain, also called the limbic system. and their levels build during an undisturbed labour, peaking around the time of birth for both mother and baby, and subsiding or reorganising over the subsequent hours or days.
For birth to proceed optimally, this more ‘primitive’ part of the brain needs to take precedence over our neo-cortex- our ‘new brain’-that is the seat of our rational mind. This shift is aided by, and also aids, the release of birthing hormones such as beta-endorphin, and is inhibited by disturbances such as bright lighting, conversation, and expectations of rationality.
If we were to consider giving birth as the deepest meditation possible, and to accord birthing women the commensurate respect,
support and lack of disturbance, we would provide the most physiological conditions for birth. This optimal hormonal orchestration, as I discuss, provides ease, ecstasy and safety for mother and baby, and, conversely, interference with this process will also disrupt this hormonal process.
Mother Nature’s pragmatic and efficient principles dictate that these hormones should also help the baby at birth, and this is increasingly being ratified by scientific research. This hormonal interdependence contradicts the oft-repeated obstetric response to natural birth as the mother prizing her experience over her baby’s safety, and underlines the mutual dependency of mother and baby, even as they begin their physical separation.
I begin with a brief discussion of the role of our archetypal female hormones, oestrogen and progesterone, in the birth process.
Oestrogen and progesterone
In our current understanding, the prime movers- the hormones which are involved in setting the scene, including activating, inhibiting and reorganising other hormone systems- are the sex steroids progesterone and oestrogen, (of which there are three distinct types). In pregnancy, progesterone production by the placenta increases 10 to 18 times, while placental production of oestriol- the dominant pregnancy estrogen- rises more than 1000 times.(Russell 2001)
These hormones are thought to play a critical but complex role in the initiation of labour, most likely through changes in their levels and/or ratios (Weiss 2000). Oestrogen also increases the number of uterine oxytocin receptors (Jackson 1998).and gap junctions (Petrocelli 1993) in late pregnancy , effectively ‘wiring up’ the uterus for co-ordinated contractions in labour.
Oestrogen and progesterone together also activate opiate pain-killing pathways in the brain and spinal cord in preparation for labour (Russell 2001).
Oxytocin has been called the hormone of love, because of its connection with sexual activity, orgasm, birth and breastfeeding. As well as this, oxytocin is produced in social situations such as sharing a meal (Verbalis 1986) making it a hormone of altruism, or, Michel Odent suggests, of ‘forgetting oneself’.
Oxytocin is made in the hypothalamus, the master gland of the limbic system, and released in pulses from the posterior pituatary into the bloodstream. Levels are difficult to measure in the human because of its pulsatile pattern of release and its half-life of only 3 minutes (Fuchs 1984).The number of oxytocin receptors in a woman’s uterus increases substantially late in pregnancy, increasing her sensitivity to oxytocin; circulating levels do not actually rise until late in labour, as below (Steer 1990).
Oxytocin is thought to be the prime initiator of the rhythmic uterine contractions of labour, although it is not the only hormonal system involved- mice who have had their oxytocin gene inactivated are still able to deliver- but not breastfeed-their young (Young 1996). It has been hypothesised that prostaglandins- especially prostaglandin F2alpha- take over this ‘uterotonic’ role later in labour (Fuchs 1984). Oxytocin has also been shown to have a pain killing effect in pregnant rats and mice (Lundeberg 1994).
The baby also releases large amounts of oxytocin from the pituatary during labour, and there is evidence that this oxytocin is transported back through the placenta (Fuchs 1984). Oxytocin is also produced by the placenta and fetal membranes, as well as being present in amniotic fluid (Fuchs 1984). Some researchers have therefore suggested that fetal oxytocin may directly stimulate the uterine muscle, perhaps even initiating labour (Chard 1971).
Oxytocin catalyses the final powerful uterine contractions at the end of an undisturbed birth, sometimes called the fetal ejection reflex, that birth the baby quickly and easily. At this time, the baby’s descending head stimulates ‘stretch receptors’ in a woman’s lower vagina, giving positive feedback to pituatary oxytocin neurones and releasing oxytocin in large quantities (Dawood 1978). This is also called the Ferguson reflex.
After the birth, ongoing high levels of oxytocin, augmented by more pulses released as the baby touches, licks and nuzzles the breast (Matthiesen 2001), help to keep the new mothers uterus contracted and so protect her against post partum haemorrhage. Skin-to-skin and eye-to-eye contact between mother and baby are also thought to optimise oxytocin release. Oxytocin levels peak with the delivery of the placenta and subside over about 60 minutes. (Nissen 1995)
Newborn oxytocin levels peak at around 30 minutes after birth (Leake 1981) so that during the first hour after birth, both mother and baby are bathed in an ecstatic cocktail of hormones, including oxytocin, the hormone of love. Newborn babies have elevated levels of oxytocin for at least 4 days after birth (Leake 1981).
Oxytocin is also involved with the olfactory system, which is known to play an important role in mammalian birth. In labour, the olfactory sense (smell) augments oxytocin release, and after the birth, this is thought to be important in the establishment of mothering behaviour (Russell 2001). For example, one study found that monkeys delivered by caesarean rejected their offspring unless the babies were swabbed with secretions from the mother’s vagina (Lundblad 1980). The large number of human genes which are involved with smell- 1-2% of the total (Axel 1995)- suggests that smell is of evolutionary importance in mother-infant bonding in our species also.
As well as reaching peak levels after birth, oxytocin is secreted in large amounts in pregnancy, when it acts to enhance nutrient absorption, and conserve energy by making us more sleepy (Uvnas Moberg 1998).The well-documented suppression of the HPA/stress axis during pregnancy and lactation, which makes pregnant and breastfeeding mothers more relaxed, more resistant to stress and experience more positive mood states, may be due, at least in part, to oxytocin. (Russell 2001)
During breastfeeding, oxytocin mediates the milk-ejection, or ‘let down’ reflex and is released in pulses as the baby suckles. During the months and years of lactation, oxytocin continues to act to keep the mother relaxed and well nourished. One researcher calls it “a very efficient anti-stress situation which prevents a lot of disease later on.” In her study, mothers who breastfed for more than seven weeks were calmer when their babies were six months old than mothers who did not breastfeed at all (Uvnas Moberg 1998).
The oxytocin system has also been implicated in aggressive-defensive behaviour in lactating females (Giovenardi 1988), although opiate mechanisms are also known to be involved (Kinsley 1986).
Other studies indicate that oxytocin is also involved in cognition, tolerance and adaptation, and researchers have recently found that oxytocin also acts as a cardiovascular hormone, with effects such as slowing the heart rate and reducing blood pressure (Gutkowska 2000).
Another researcher has ascribed a ‘relaxation and growth response’ to oxytocin release, contrasting this physiologically with the body’s fight-or-flight stress response (Uvnas Moberg 1997). Malfunctions of the oxytocin system have been implicated in conditions such as schizophrenia (Feifal 1999) autism (Insel 1999), cardiovascular disease (Knox 1998) and drug dependency (Sarnyai 1994), and it has been suggested that oxytocin may mediate the antidepressant effect of drugs such as Prozac (Uvnas Moberg 1999).
Beta endorphin is one of a group of naturally-occurring opiates, with properties similar to meperidine (pethidine, demorol), morphine, and heroin, and has been shown to work on the same receptors of the brain. It is secreted from the pituatary gland under conditions of pain and stress, and high levels are present in pregnancy, birth and lactation.
Beta endorphin acts as a natural pain killer, and causes an increasing tolerance to pain in pregnant rats (Laaitikainen 1991). Beta endorphin also suppresses that immune system, which may be important in preventing a pregnant mother’s immune system from acting against her baby, whose genetic material is foreign to hers.
Like the addictive opiates, beta-endorphin induces feelings of pleasure, euphoria, and dependency or, with a partner, mutual dependency. Beta-endorphin levels increase throughout labour, (Brinsmead 1985) when levels of beta-endorphin and CRH (another stress hormone) reach those found in male endurance athletes during maximal exercise on a treadmill (Goland 1984). Levels peak at the time of birth and subside slowly, reaching normal levels one to three days after birth.(Bacigalupo 1990).
Such high levels help a labouring woman to transmute pain and enter the altered state of consciousness that characterises an undisturbed birth.
The baby also secretes beta endorphin during labour from the fetal pituatary (Fachinetti 1989) as well as directly from placental tissue and membranes (Fachinetti 1990) and levels in the placenta at birth are even higher than those in maternal blood (Jevremovich 1991). Kimball (1979) speculated that early cord cutting may “…deprive mothers and infants of placental opiod molecules designed to induce interdependency of mothers and infants.”
Beta-endorphin has complex and incompletely understood relationships with other hormonal systems (Laatikainen 1991); for example high levels of beta endorphin inhibit oxytocin release. It makes sense that when pain or stress levels are very high, contractions will slow, thus “rationing labour according to both physiological and psychological stress.”(Jowitt 1993), and this effect may also be involved in inhibiting the action of oxytocin before labour begins (Douglas 1995). Beta-endorphin also facilitates the release of prolactin during labour (Rivier 1976), which prepares the mother’s breasts for lactation and also aids in lung maturation for the baby (Parker 1989).
Beta-endorphin is also important in breastfeeding. Levels peak in the mother at 20 minutes (Franceschini 1989) and beta-endorphin is also present in breastmilk, (Zanardo 2001) inducing a pleasurable mutual dependency for both mother and baby in their ongoing relationship.
The fight-or-flight hormones adrenaline and noradrenaline (epinephrine and norepinephrine), are, along with dopamine, known as the catecholamines, and are produced by the body in response to stresses such as hunger, fear and cold. Together they stimulate the sympathetic nervous system for fight or flight.
Catecholamine levels rise during an undisturbed labour; research indicates that adrenaline levels are more responsive to psychological stresses such as pain and anxiety, with noradrenaline increasing in response to the physiological work of labour (Costa 1988).
Very high adrenaline levels in the first stage of labour will inhibit oxytocin release, therefore slowing or stopping labour. Adrenaline also acts to reduce blood flow to the uterus, placenta and therefore to the baby. This makes sense for mammals birthing in the wild, where the presence of danger would activate this fight or flight response, inhibiting labor and diverting blood to the major muscle groups so that the mother can flee to safety. In humans, high levels of adrenaline have been associated with longer labour and adverse fetal heart rate patterns (Lederman 1985).
After an undisturbed labour, however, when the moment of birth is imminent, these hormones act in a different way. There is a sudden increase in CA levels, especially noradrenaline, which activates the fetal ejection reflex. The mother experiences a sudden rush of energy; she will be upright and alert, with a dry mouth and shallow breathing and perhaps the urge to grasp something. She may express fear, anger, or excitement, and the CA rush will produce, in concert with oxytocin, several very strong contractions, which will birth the baby quickly and easily.
Some birth attendants have made good use of this reflex when a woman is having difficulties in the second stage of labour. For example, one anthropologist working with an indigenous Canadian tribe recorded that when a woman was having difficulty in birth, the young people of the village would gather together to help. They would suddenly and unexpectedly shout out close to her, with the shock triggering her fetal ejection reflex and a quick birth (in Odent 1992).
After the birth, the new mother’s CA levels drop steeply, and she may feel shaky or cold as a consequence. A warm atmosphere is important, as ongoing high CA levels will inhibit oxytocin and therefore increase the risk of postpartum haemorrhage (Saito 1991).
Noradrenaline, as part of the ecstatic cocktail, is also implicated in instinctive mothering behaviour. Mice bred to be deficient in noradrenaline will not care for their young after birth unless noradrenaline is injected back into their system (Thomas 1997).
For the baby also, labour is an exciting and stressful event, reflected in increasing CA levels and the baby also experiences a marked CA surge, especially of noradrenaline, at the time of birth (Elliot 1980, Lagercrantz 1977). In labour these hormones have a very beneficial effect, and protect the baby against the effects of hypoxia (lack of oxygen) and subsequent acidosis by redistributing cardiac output (Philippe 1983) and by increasing the capacity for anaerobic glycolysis- ie metabolism of glucose at low oxygen levels (Irestedt 1984).
This ‘catecholamine surge’ also plays a very important role in the newborn’s adaptation of extra-uterine life. It aids newborn metabolism by increasing levels of glucose and free fatty acids (Hagnevik 1984) which protect the brain from the low blood sugar that naturally occurs in the early newborn period (Colson 2002).
In addition, catecholamines enhance respiratory adaptation to extra-utero life by increasing the absorption of amniotic fluid from the lungs and stimulating surfactant release (Irestedt 1984). They also assist with the necessary newborn shift to non-shivering thermogenesis (heat production) (Lowe 1996), increase cardiac contractility, stimulate breathing and enhance irritability and tone in the newborn (Irestedt 1984).
High CA levels at birth also ensure that the baby is wide-eyed and alert at first contact with the mother. The baby’s CA levels also drop steeply after an undisturbed birth, being soothed by contact with the mother, but remain significantly elevated for the first 12 hours (Elliot 1980).
Prolactin is known as the mothering hormone and it is regarded as “a key player in the organisation and coordination of the neuroendocrine and behavioural adaptations of the maternal brain” (Grattan 2001). Prolactin is also the major hormone of milk synthesis and breastfeeding.
Prolactin levels rise progressively during pregnancy but its actions on the breast are inhibited, until delivery of the placenta, by high levels of progesterone. All mammalian species also produce a placental hormone with lactogenic effects- in the human this is human placental lactogen (hPL), which parallels prolactin in its increase throughout pregnancy, illustrating the baby’s active role in organising the mother’s brain for maternity (Grattan 2001).
Like the other hormones discussed, prolactin levels rise in labour, peaking at birth and then subsiding. During lactation, prolactin levels are directly related to the suckling intensity, duration and frequency (Grattan 2001).
Known effects of prolactin on the mammalian brain include- induction of maternal behaviour; increase in appetite and food intake; suppression of fertility; stimulation of motor and grooming activity; reduction of the stress response; stimulation of oxytocin secretion and opioid activity; alteration of the sleep-wake cycle and increase in REM sleep; reduction in body temperature and stimulation of natural analgesia (Grattan 2001).
Prolactin is also a hormone of submission or surrender- in primate troupes, the dominant male has the lowest prolactin level- and also produces some anxiety. In the breastfeeding relationship, these effects activate a mother’s vigilance and help her to put her baby’s needs first (Odent 1992).
The baby produces prolactin in utero and prolactin is also present in breastmilk, with a significant amount being transferred intact into the newborn circulation, at least in the rat (Grosvenor 1983). According to one researcher, “… there is evidence that prolactin plays an important role in the development and maturation of the neonatal neuroendocrine [brain/hormone] system.” (Grattan 2001). As noted above, prolactin also plays a role in lung maturation in utero (Parker 1989).
The impact of obstetric interventions
I hope that I have conveyed, with the above discussion, the elegant and complex orchestration of birthing hormones in an undisturbed labour and birth, and their important roles in promoting optimal functioning in labour, birth and postnatal life for mother and baby.
In the next section, I discuss the deleterious effects of various drugs and interventions.
Induction and augmentation with synthetic oxytocin
Here in Australia, more than 25% of women have their labour induced and another 20% have an augmentation –stimulation or acceleration of labour- with synthetic oxytocin (syntocinon, pitocin) (AIHW 2001). In the US, figures are lower- 19.8% and 17.9% respectively (NCHS 2001) but adding up, in both countries, to large numbers of labouring women, and their babies, being exposed to unnaturally high levels of this hormone around the time of birth.
Synthetic oxytocin administered intravenously in labour acts very differently to a labouring woman’s intrinsic oxytocin. Firstly, the uterine contractions produced by iv syntocinon are different to natural contractions- possibly because syntocinon is administered continuously rather than in a pulsatile manner- and can cause detrimental effects to the baby in utero.
When synthetic oxytocin is administered, a woman’s uterine contractions can occur too close together, leaving insufficient time for the baby to recover from the loss of blood and oxygen that occurs when the placenta is compressed. Syntocinon also causes the resting tone of the uterus to increase (Friedman 1978). Such effects can produce abnormal fetal heart rate (FHR) patterns, fetal distress (leading to caesarean section) and even uterine rupture (Stubbs 2000).
Oxytocin augmentation stimulates uterine contraction but has minimal effects on cervical dilatation, compared to a natural labour (Bidgood 1987); this creates the possibility of ‘failed induction” where the cervix fails to dilate, and a caesarean becomes necessary.
Secondly, oxytocin, whether synthetic or not, cannot cross from the body back to the brain through the ‘blood-brain barrier’. This means that when it is administered in any way except directly into the brain, it can cause effects on the body, but it cannot act as the hormone of love. It does, however, generate ‘negative feedback’ – that is, receptors in the labouring woman’s body detect high levels of oxytocin and so signal her brain to reduce production.
We know that women who labour with an oxytocin infusion are at increased risk of post-partum haemorrhage (Gilbert 1987) because their own oxytocin production has been shut down. What we do not know, however, are the psychological, or psychoneuroendocrine, effects of giving birth without the peak levels of oxytocin that nature prescribes for all mammalian species.
In one study, women who had synthetic oxytocin augmentation did not experience an increase in beta endorphin levels in labour (Genazzani 1985), indicating the complexities that may result from interference with any of the hormonal systems in labour.
Other research has suggested that exogenous oxytocin may pass through the placenta unchanged (Dawood 1983), which implies that the fetal oxytocin system may also be disrupted by administration of synthetic oxytocin in labour.
Michel Odent notes that “Many experts believe that through participating in the initiation of his own birth, the fetus may be training himself to secrete his own love hormone…”(Odent 1992). Odent speaks passionately about our society’s deficits in our capacity to love self and others, and he traces these problems back to the time around birth, and especially to interference with the oxytocin system.
Pethidine (demerol, meperidine) is the usual opiate administered in Australian labour wards; in 1998 here in Queensland Australia, around a third of labouring women used this drug. In the US, other narcotics such as Nalbuphine (Nubain), butorphanol (Stadol), alphaprodine (Nisentil), hydromorphone (Dilaudid) and fentanyl citrate (Sublimaze) have been traditional mainstays of labour analgesia, but have now been largely replaced by epidural analgesia, which may also contain opiates (see below).
All opiates used in labour can cause side effects such as maternal nausea, vomiting, sedation, pruritus (itching), hypotension, respiratory depression; and for the baby, fetal heart rate (FHR) abnormalities, respiratory depression, impaired early breastfeeding and altered neonatal neurobehaviour (ACOG 1996).
As with oxytocin, use of these drugs will reduce a woman’s own opioid hormone production (Thomas 1982), which may be helpful if excessive levels are inhibiting labour. However the use of pethidine has been shown to slow labour, in a dose-response way (Thomson 1994); in one randomised trial,morphine (but not naloxone) administered in labour directly reduced oxytocin release (Lindow 1992)
And again, we must ask- what may be the effects for mother and baby of labouring and birthing without peak levels of these hormones of pleasure and transcendence ?
Some researchers have nominated our endogenous opiates as the reward system for reproductive acts– that is, the endorphin fix keeps us making babies, having babies and breastfeeding (Kimball 1979). Anecdotally, I notice that women who reap pleasure from these activities- eg homebirthers and la leche mothers- tend to have larger families. On a global scale, also, countries that have embraced the obstetric model of care, which prizes drugs and interventions above birthing pleasure and empowerment, have experienced steeply declining birth rates in recent years.
More serious are the implications of Swedish research into the use of opiates at birth, published in 1990 (Jacobsen 1990), and recently replicated with a prospective US population (Nyberg 2000). In the first study, researchers looked at the birth records of 200 opiate addicts born between 1945 and 1966, and compared them to their non-addicted siblings. Offspring whose mothers used analgesia in labour (opiates, barbiturates and nitrous oxide gas) were more likely to become addicted to drugs (opiates, amphetamines) as adults, especially when multiple doses were administered. For example, when a mother had received three doses of opiates in her labour, her child was 4.7 times more likely to become addicted to opiate drugs in adulthood.
Animal studies suggest a mechanism for such an effect. It seems that drugs administered chronically in late pregnancy can cause effects in brain structure and function (eg chemical and hormonal imbalance) in offspring which may not be obvious until young adulthood (Myerson 1985, Kellogg 1991, Liversay 1992, Mirmiran 1992). Whether such effects apply to human babies who are exposed for shorter periods around the time of birth is not known but, as one researcher warns “During this prenatal period of neuronal [brain cell] multiplication, migration and interconnection, the brain is most vulnerable to irreversible damage.”(Mirmiran 1992).
Epidural analgesia uses several types of drug, administered into the epidural space around the spinal cord. These include local anaesthetics (all cocaine derivatives, eg. bupivicaine/marcaine, ropivicaine, lidocaine), more recently combined with low-dose opiates as a ‘walking epidural’, and sometimes also catecholamines such as adrenaline. Spinal pain relief involves a single dose of the same drugs injected through the coverings of the spinal cord, and is usually short-acting unless given as a combined spinal-epidural (CSE).
Epidural pain relief has major effects on all of the above-mentioned hormones of labour. Epidurals inhibit beta-endorphin production (Bacigalupo 1990) and therefore also inhibit the shift in consciousness that is part of a normal labour. Their popularity may partly reflect the difficulty that we have allowing labouring women to enter an altered state of consciousness, and our lack of training and facilities to accommodate this most basic requirement for birth.
When an epidural is in place, the oxytocin peak that occurs at birth is also inhibited because the stretch receptors of a birthing woman’s lower vagina, which trigger this peak, are numbed. This effect probably persists even when the epidural has worn off and sensation has returned, because the nerve fibres involved are smaller than the sensory nerves and therefore more sensitive to drug effects (Goodfellow 1983).
A woman labouring with an epidural therefore misses out on the fetal ejection reflex, and must use her own effort, often against gravity, to compensate this loss. This explains the increased length of the second stage of labour and the extra need for forceps when an epidural is used (McRae-Bergeron 1998).
The use of epidurals also inhibits catecholamine release for both mother and baby (Jones 1985). This may be advantageous for the mother in the first stage of labour; close to the time of birth, however, a reduction in CA levels will inhibit the fetal ejection reflex and prolong the second stage.
The health of the newborn may be affected, to some extent, by the lack of catecholamines under epidural; for vulnerable babies, the loss of this protection could compromise cardiac, respiratory, metabolic and thermal adaptations at birth, as above.
Release of the important uterine stimulating hormone prostaglandin F2 alpha is also adversely affected by epidurals. This hormone, like the others that I have mentioned, rises during an undisturbed labour: however women with epidurals experience a decrease in PGF2 alpha, and a prolongation of labour (Behrens 1993). In this study average labour times were increased from 4.7 to 7.8 hours
Drugs administered by epidural enter the mother’s bloodstream immediately and go straight to the baby at equal, and sometimes greater, levels (Fernando 1995, Brinsmead 1987). Some drugs will be preferentially taken up into the baby’s brain (Hale 1998), and almost all will take longer to be eliminated from the baby’s immature system after the cord is cut. One researcher found bupivicaine and its breakdown products in the circulation of babies for the first three days (Belfrage 1975). (For more discussion of epidurals, see Buckley 1998)
Epidural anaesthesia, used for caesareans, has also been associated with more acidaemia (acid blood levels) in healthy newborn babies than general anaesthetic- an indication that epidurals can compromise fetal blood and oxygen supply, (Mueller 1997) possibly through a vasodilating effect, which causes a drop in the mother’s blood pressure.
Another indication that epidurals may have unintended side-effects for mothers and babies comes from French researchers who gave epidurals to labouring sheep (Krehbiel 1987). The ewes failed to display their normal mothering behaviour; this effect was especially marked for the ewes in their first lambing that were given epidurals early in labour. Seven out of eight of these mothers showed no interest in their offspring for at least 30 minutes.
Some studies indicate that this disturbance may apply to humans also. Mothers given epidurals in one study spent less time with their babies in hospital, in inverse proportion to the dose of drugs they received and the length of the second stage of labour (Sepkoski 1992). In another study, mothers who had epidurals described their babies as more difficult to care for one month later (Murray 1981). Such subtle shifts in relationship and reciprocity may reflect hormonal dysfunctions and/or drug toxicity and/or the less-than-optimal circumstances that often accompany epidural births--long labours, forceps, and Caesareans.
Incredibly, there have been no good studies of the effects of epidurals on breastfeeding (see Walker 1997), although there is evidence that babies born after epidural have a diminished suckling reflexes and capacity (Riordan 2000, Ransjo-Arvidson 2001).
In the western world we are experiencing an epidemic of caesareans, and we have somehow come to believe that this is a safe- and perhaps even safer- way of delivering our babies. There is no evidence to support this assertion- caesarean section involves major abdominal surgery and increases the risk of maternal death by about four times (Enkin 2000). Mother and baby’s health may also be compromised in subsequent pregnancies because of the increased risk of placental abnormalities such as placenta praevia and placenta accreta (Hemminki 1996). Caesarean rates are currently 21.9 percent in Australia (AIHW 2001) and 22.9 percent--the highest level on record--in the U.S. (NCHS 2001).
Obviously with a caesarean there is an absent or curtailed labour, and the maternal hormonal peaks of oxytocin, endorphins, catecholamines, and prolactin are absent or reduced. Studies also show significantly lower levels of oxytocin (Marchini 1988), endorphins (Fanchinetti 1990), catecholamines (Jones 1982) and prolactin (Heasman 1997) in babies delivered by elective caesarean.
Some of the well-documented risks of ceasareans can be ascribed to these hormonal deficits, particularly, for the baby, to absence of the catecholamine surge. This means that babies born after Caesareans, are at increased risk of respiratory compromise (Faxelius 1983) as well as low blood sugar (Hagnevik 1984). Other effects may be more subtle, especially if brain and hormone systems are involved.
After a caesarean, mothers and babies are usually separated for some hours after birth, so the first breastfeed is usually delayed. Both will also be affected to some extent by the drugs used in the procedure (epidural, spinal, or general anaesthetic) and for post-operative pain relief.
The consequences of such radical departures from our maternal blueprint are suggested in the work of Australian researchers who interviewed 242 women in late pregnancy and again after birth. The 50 percent of women who had given spontaneous vaginal birth experienced, in general, a marked improvement in mood and an elevation of self-esteem after delivery. In comparison, the 17 percent who had caesarean surgery were more likely to experience a decline in mood and self-esteem. The remaining women had forceps or vacuum assistance, and their mood and self-esteem were, on average, unaltered (Fisher 1997).
Another study looked at the breastfeeding hormones prolactin and oxytocin on day two, comparing women who had given birth vaginally with women who had undergone emergency caesarean surgery. In the caesarean group, prolactin levels did not rise as expected with breastfeeding, and the oxytocin pulses were reduced or absent. In this study, first suckling had been at 240 minutes average for caesarean babies, and 75 minutes average for babies vaginally born. The authors of this study conclude; “These data indicate that early breastfeeding and physical closeness may be associated not only with more interaction between mother and child, but also with endocrine [hormonal] changes in the mother.”
Other research has shown that early and frequent suckling positively influences milk production and the duration of breastfeeding (Salariya 1978, De Chateau 1977). Most studies have shown significantly reduced breastfeeding rates after caesarean surgery (DiMattea 1996).
These studies not only indicate important links between birth,hormones and breastfeeding, but also show how an optimal birth experience is designed to enhance the long-term health of mother and baby. For example, successful and long-term breastfeeding confers advantages such as reduced risk of breast cancer and osteoporosis for the mother and increased intelligence, reduced risk of diabetes and less obesity long-term for the child- see 101 reasons to breastfeed for a comprehensive list of the benefits of breastfeeding. And enhanced self-esteem, which I see as nature’s blueprint for new mothers, gives us a solid base from which to begin our mothering.
The connections between events at birth and long-term health certainly deserve more study. (See Michel Odent’s Primal Health Database www.birthworks.org/primalhealth for a comprehensive listing of current research.) But we cannot afford to wait for years for researchers to ”prove” the benefits of an undisturbed birth. Perhaps the best we can do is trust our instincts and vote with our birthing bodies, choosing models of care that increase our chances of undisturbed birthing.
There are many animal studies that show that removing newborns from their mothers has deleterious effects on maternal-infant care and on the growing offspring. For some species, there is an inviolable need to lick and smell the offspring- without this, attachment will not occur. There seems also to be a critical period for mammals - the first hour or so after birth- when this process is most easily disrupted.
Human studies also support the importance of not disturbing this early contact. Swedish researchers noted that if an infant's lips touched the mother's nipple in the first hour of life, the mother kept her infant with her for an extra100 minutes every day compared to mothers who did not experience suckling until later (Widstrom 1990).
Early breastfeeding also confers a lifelong benefit to the baby’s gut system. Uvnas Moberg has found that “ when the infant suckles from the breast, there is an outpouring of 19 different gastrointestinal hormones in both the mother and the infant, including insulin, cholesystokinin, and gastrin. Five of these hormones stimulate the growth of intestinal villi in the mother and the infant. As a result, with each feeding, there is an increased intestinal surface area for nutrient absorption. The hormonal release is stimulated by the touch of the mother's nipple by her infant's lips. This increases oxytocin in both the mother's brain and the infant's brain, which stimulates the vagus nerve, then causes the increase in the output of gastrointestinal hormones. Before the development of modern agriculture and grain storage 10 000 years ago, these responses in the infant and mother were essential for survival when famine was common.” (Uvnas Moberg 1989; quoted in Klaus 1998)
Undisturbed early contact- especially skin-to-skin- also fulfils the newborn’s physical needs, giving efficient temperature regulation easy access to the mother’s breast, and less crying than babies wrapped and placed in cots (Christenssen 1992).
Beyond the early hours, there is a ‘vulnerable period’ of several days when attachment is still developing; separation at this time also has negative long-term consequences for mammalian species. For example, Biagini (1998), showed that infant rats removed for 5 hours a day in the first week of life had increased responsiveness to stress in adulthood associated with alterations in HPA axis regulation.
In humans, extra contact ‘allowed’ in hospital decreases the risks of abandonment, abuse, neglect and failure to thrive in childhood (Klaus 1998). In one study, mothers who had experienced extra early contact with their babies spoke differently to their children at 2 years of age, using more questions, adjectives and words per proposition, and fewer commands and content words (Ringler 1975).
Michel Odent notes that almost every currently existing culture has rituals or practices that disturb the time immediately after birth, and believes that these disruptions to the mother-infant bond have predominated because they instil aggressive- and therefore more adaptive- traits in the offspring (Odent 1999). In western obstetrics, we also have a lot of unnecessary activity at this time, eg ‘active management of the third stage’- see Buckley (2000) for a fuller discussion. Even in gentle birth settings, it is unusual for the baby to remain in the mother’s arms for the first one to two hours.
The wisdom of undisturbed mother-baby contact after birth is well described by Joseph Chilton Pearce in his book Evolution’s End: Reclaiming the Potential of Our Intelligence (Pearce 1995). According to Pearce, when the newborn baby is in skin-to-skin contact, at the mother’s left breast -which is where new mothers in all cultures instinctively cradle their babies- and in contact with her heart rhythm, “a cascade of supportive confirmative information activates every sense, instinct and intelligence needed for the radical change of environment… Thus intelligent learning begins at birth.”
For the mother also, “A major block of dormant intelligences is activated…the mother then knows exactly what to do and can communicate with her baby on an intuitive level.” (Pearce 1995). Such intuitive capacities, which are almost certainly derived from hormonal reorganisation of the mother’s brain, are sorely needed in our human culture, where we rely on outside advice from books and 'experts' to tell us how to care for our babies.
According to Pearce, when these activations do not occur within about 45 minutes of birth, “…cut off from his mother’s nurturing and with none of the encoded expectancies met, the newborn’s adrenals continue to release steroids in the face of maximum fear and abandonment. The infant screams for a short time and then silence falls.”
The damage caused by separation, Pearce writes, is “massive and past the point of repair.” Like Odent, he believes that our current birth practices are psychologically crippling to babies, mothers, and society as a whole, and the evidence in his book is compelling.
How can we avoid disturbing the process of birth, and align our practices with our evolutionary blueprint? This can seem difficult in a culture where birth has been disturbed, one way or another, for many generations. Yet it is really very simple- if we were to provide conditions of privacy and a sense of safety for birthing women, as close as possible to the conditions necessary for sexual activity, most women would experience a spontaneous, ecstatic and relatively easy birth.
These are some suggestions for undisturbing birth.
· Take responsibility for your health, healing, and wholeness throughout the child-bearing years
· Choose a model of care that enhances the chance of a natural and undisturbed birth (eg home birth, birth centre, one-on-one midwifery care).
· Arrange support according to individual needs; trust, a loving relationship, and continuity of care with support people are important.
· Consider having an advocate at a hospital birth- eg private midwife or doula.
· Ensure an atmosphere where the labouring woman feels safe, unobserved, and free to follow her own instincts
· Reduce neocortical stimulation by- keeping lighting soft and reducing words to a minimum.
· Cover the clock and any other technical equipment.
· Avoid procedures (including obvious observations) unless absolutely necessary.
· Avoid giving ‘advice’ unless absolutely necessary.
· Avoid drugs unless absolutely necessary.
· Avoid caesarean surgery unless absolutely necessary.
· Don’t separate mother and baby for any reason, including resuscitation, which will be more effective with the cord still attached (see Buckley 2000)
· Breastfeed soon after birth, continue long-term, and enjoy it!
Sarah Buckley is trained as a GP (family MD), and is currently fully and deliciously occupied with mothering Emma, Zoe, Jacob and Maia Rose and writing about pregnancy, birth and parenting. She lives in Brisbane Australia with Nicholas, the love of her life.
For more articles go to http://sarahbuckley.com/articles