Ep 170 Pregnancy: Act 3

Episode Transcript
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Speaker 1 (00:00):
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.

Speaker 2 (00:17):
Hi.

Speaker 3 (00:17):
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

(00:38):
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.

(01:01):
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

(01:22):
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

(01:43):
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

(02:05):
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

(02:27):
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.

Speaker 4 (02:46):
Hi.

Speaker 5 (02:47):
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.

(03:11):
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

(03:34):
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

(03:55):
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

(04:18):
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,

(04:40):
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,

(05:03):
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

(05:26):
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

(05:50):
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.

Speaker 1 (06:46):
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,

(07:08):
and so throughout this episode and the next episode, the
last episode in our series, you will hear more first
hand accounts.

Speaker 2 (07:15):
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.

Speaker 1 (07:30):
So thank you eternally grateful. Is yeah. Yeah, Hi, I'm.

Speaker 2 (07:37):
Erin Welsh and I'm erin alman.

Speaker 1 (07:39):
Update and this is this podcast will kill.

Speaker 2 (07:41):
You, coming to you from the exactly right studios to
record the third episode about pregnancy I know in our
four episode series.

Speaker 1 (07:52):
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.

Speaker 2 (08:12):
Head to YouTube. I have some really good props for
this episode, guys. I made them myself.

Speaker 1 (08:19):
The last episode two tennis ball.

Speaker 2 (08:21):
Yeah, that was the first episode.

Speaker 4 (08:24):
I know.

Speaker 2 (08:24):
It was a lot.

Speaker 1 (08:25):
Yeah my mind, it was great. Oh the placenta ye, yeah,
that was good.

Speaker 2 (08:31):
Okay, So it's going to be a fun day today.

Speaker 1 (08:35):
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

(08:57):
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

(09:17):
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

(09:38):
the future.

Speaker 2 (09:38):
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

(09:59):
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

(10:19):
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.

Speaker 1 (10:36):
And our most recent episode, last episode, our second episode,
we talked about the amazing organ that is the placenta.

Speaker 2 (10:44):
We love it. Do you love it?

Speaker 3 (10:45):
Now?

Speaker 2 (10:46):
Have you listened to that episode? You?

Speaker 1 (10:48):
Once you do, you will love it.

Speaker 2 (10:49):
You will love it. I feel confident in that. Absolutely
pretty phenomenal.

Speaker 1 (10:54):
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.

Speaker 2 (11:05):
Which I guess might make you not like the placenta
a little bit too.

Speaker 1 (11:09):
It's a complicated you know, we have complicated feelings about
the placenta, but we also appreciate its amazingness.

Speaker 2 (11:15):
It's amazingness.

Speaker 1 (11:16):
Yeah.

Speaker 2 (11:16):
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.

Speaker 1 (11:28):
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

(11:53):
how we moved childbirth from the home to hospital and
some of the consequences of that.

Speaker 2 (12:00):
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,

(12:22):
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.

Speaker 1 (12:37):
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

(12:58):
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.

Speaker 2 (13:07):
Right exactly. Okay, there's a lot o disclaimers and information and.

Speaker 1 (13:13):
Thanks for thanks for sticking with us.

Speaker 2 (13:17):
I'm really excited about today.

Speaker 1 (13:19):
But first but first I almost forgot er. I was like,
let's get started.

Speaker 2 (13:24):
It's quarantining that it is.

Speaker 1 (13:26):
Well, what are we drinking this week?

Speaker 2 (13:28):
We're drinking the same thing. We are great expected. We're
not actually drinking it right now, but we have drunk it.

Speaker 1 (13:34):
It is so good.

Speaker 2 (13:35):
It is better than we expected.

Speaker 1 (13:38):
We can't reveal our secrets, our lack of confidence and
our recipe making.

Speaker 2 (13:44):
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.

Speaker 1 (13:57):
It was really fun.

Speaker 2 (13:58):
It was really fun, and George to hard Stark provided
a wonderful quarantine eye for us to go with this episode.

Speaker 1 (14:05):
So that is available on YouTube teeny it has.

Speaker 2 (14:08):
A name now.

Speaker 1 (14:09):
It's very cute. Oh my god, it's so much fun.

Speaker 2 (14:11):
It's really fun.

Speaker 1 (14:12):
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.

Speaker 2 (14:23):
Third time and we sent it to me.

Speaker 1 (14:25):
I can say it's on our website.

Speaker 2 (14:26):
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

(14:50):
and a first hand account form.

Speaker 1 (14:53):
There's probably more.

Speaker 2 (14:55):
All of the sources from each and every one of
our episodes.

Speaker 1 (14:57):
Yeah, there, and there might be more. Tell us what
we missed. Go check out our website.

Speaker 2 (15:01):
Go check out our website. Like what you meant me?
And I was like, I don't know what I meant, Darren.

Speaker 1 (15:08):
This podcast will kill You dot dot com.

Speaker 2 (15:11):
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.

Speaker 1 (15:30):
I love that plan. Let's take a quick break and
then we'll really get started.

Speaker 6 (15:34):
Okay, Hi, I'm Laura, and this is my pregnancy story.

Speaker 7 (15:53):
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

(16:13):
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

(16:36):
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

(16:57):
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,

(17:19):
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

(17:42):
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,

(18:03):
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.

Speaker 8 (18:24):
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

(18:45):
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

(19:07):
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

(19:29):
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.

Speaker 1 (20:16):
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.

Speaker 2 (20:32):
Largely is an understatement, and they are entirely, entirely helpless.

Speaker 1 (20:37):
And these human experiences are exceptional compared to most, but
not all, other mammalian or primate species.

Speaker 2 (20:45):
Why Why?

Speaker 1 (20:46):
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?

Speaker 5 (21:03):
Why?

Speaker 1 (21:04):
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.

Speaker 2 (21:23):
Our pelvis are pelvis.

Speaker 1 (21:25):
And at some point after these anatomical changes, head size
in our ancestors also grew as we got.

Speaker 2 (21:31):
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.

Speaker 1 (21:43):
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.

Speaker 2 (21:56):
Affect our fitness somehow affect our fitness.

Speaker 1 (21:58):
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.

Speaker 4 (22:05):
You know.

Speaker 1 (22:06):
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.

Speaker 2 (22:23):
I love thinking of evolution in this very inaccurate way
of giving it like agency. Yeah.

Speaker 1 (22:29):
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.

Speaker 2 (22:41):
It's a good way to just think, like in your
mind frame it it's just yeah, it's.

Speaker 1 (22:46):
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

(23:08):
proportion of all primates.

Speaker 2 (23:09):
Like it is, oh, of all primate of all primates. Okay, interesting? Interesting, Yeah,
so other primates, their brains come out already bigger.

Speaker 1 (23:17):
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.

Speaker 2 (23:33):
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.

Speaker 1 (23:41):
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.

Speaker 2 (23:59):
No, thank you.

Speaker 1 (24:00):
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

(24:23):
balance to strike with extremely high costs if things go awry.
How have we dealt with this over human history?

Speaker 2 (24:30):
Tell me?

Speaker 1 (24:31):
One way is through cooperation.

Speaker 2 (24:33):
Oh, I know, humans and our cooperation and we are
capable of it.

Speaker 1 (24:38):
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

(25:01):
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

(25:23):
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

(25:44):
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

(26:06):
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

(26:26):
that how it's always been? That's a really difficult question
to answer.

Speaker 2 (26:29):
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.

Speaker 1 (26:39):
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

(27:01):
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.

Speaker 2 (27:13):
Right, and we talk a lot about that in our episode.

Speaker 1 (27:15):
On Selvis and people fever.

Speaker 2 (27:19):
Yeah yeah, just like which episode was that, because I
know we covered it in detail.

Speaker 1 (27:23):
A long time, but yeah, yeah, But the specter of
infectious disease during childbirth maybe a more recent development, relatively speaking.

Speaker 2 (27:32):
Some researchers have suggested.

Speaker 1 (27:33):
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.

Speaker 2 (27:49):
So it used to just be that if we were
limited by nutrition, then your huh, I mean maybe maybe maybe,
who knows?

Speaker 1 (27:55):
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

(28:17):
WHO today roughly estimates that five percent of births with
labor starting spontaneously develop complications.

Speaker 2 (28:25):
Okay, five percent percent.

Speaker 1 (28:28):
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.

Speaker 2 (28:41):
Interesting, that five.

Speaker 1 (28:43):
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.

Speaker 2 (29:02):
How does it and what is different? What is defined right.

Speaker 1 (29:05):
Exactly requiring intervention? Then? What is requiring intervention? How do
we make those decisions?

Speaker 2 (29:11):
Yeah?

Speaker 1 (29:11):
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

(29:34):
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.

Speaker 2 (29:53):
Eighty four percent.

Speaker 1 (29:55):
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

(30:17):
the US and around the world. What period and all
surgery right, including like tonsilectomies, appendectomy replacements?

Speaker 2 (30:24):
Right?

Speaker 1 (30:27):
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?

Speaker 2 (30:40):
Yeah?

Speaker 1 (30:40):
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

(31:04):
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

(31:25):
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.

Speaker 2 (31:49):
Wonderful.

Speaker 1 (31:49):
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.

Speaker 2 (31:55):
Every meds street listening that's about to start their obed
an rotation is thrilled.

Speaker 1 (32:00):
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

(32:23):
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

(32:44):
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.

Speaker 2 (33:02):
Yep, yeah, wholly accurate.

Speaker 1 (33:04):
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.

Speaker 2 (33:14):
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.

Speaker 1 (33:25):
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.

Speaker 2 (33:37):
Wow. Yeah, I feel like those were not good ones.

Speaker 1 (33:41):
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

(34:02):
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

(34:24):
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.

Speaker 2 (34:41):
Oh okay.

Speaker 1 (34:43):
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

(35:07):
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

(35:29):
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

(35:52):
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

(36:13):
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

(36:35):
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

(36:57):
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

(37:18):
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

(37:40):
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.

Speaker 2 (37:56):
Oh interesting.

Speaker 1 (37:58):
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

(38:21):
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,

(38:42):
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.

Speaker 2 (39:04):
Yeah, okay.

Speaker 1 (39:06):
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

(39:29):
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

(39:51):
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,

(40:13):
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.

Speaker 2 (40:26):
Oh my god, Okay, yeah.

Speaker 1 (40:28):
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

(40:48):
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

(41:13):
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.

Speaker 2 (41:30):
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.

Speaker 1 (41:46):
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

(42:06):
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.

Speaker 2 (42:27):
We prevent the risk? So how can we not do
something about it?

Speaker 1 (42:31):
Yes, exactly, that's what exactly?

Speaker 2 (42:33):
Yeah, okay.

Speaker 1 (42:34):
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.

Speaker 2 (42:49):
Oh I know, okay, yeah.

Speaker 1 (42:52):
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.

Speaker 2 (43:09):
Wow. Okay.

Speaker 1 (43:11):
Between nineteen sixty five and nineteen eighty seven, the rate
of C sections grew four hundred and fifty five percent.

Speaker 2 (43:19):
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.

Speaker 1 (43:31):
Yeah, electronic fetal monitoring was a big okay.

Speaker 2 (43:34):
Yeah. Oh that's really interesting, especially in the context of
like today. Yep, okay, interesting.

Speaker 1 (43:40):
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.

Speaker 2 (43:54):
Yeah.

Speaker 1 (43:55):
Articles or stories that referenced C sections of the nineteen
sixties still in who did a definition of the procedure?

Speaker 2 (44:02):
Wow?

Speaker 1 (44:03):
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.

Speaker 2 (44:22):
In part, interesting, the.

Speaker 1 (44:24):
Skills that had taken them years to learn and perfect
would be pointless with a surgical technique that took a
few weeks to learn.

Speaker 2 (44:33):
Interesting.

Speaker 1 (44:33):
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

(44:55):
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

(45:15):
up malpractice insurance rates for doctors who performed v backs,
and as hospitals just began to forbade it as an option.

Speaker 2 (45:22):
Yeah, wow, hospital administration making decisions. Cool cool, cool, cool
cool cool insurance love it?

Speaker 1 (45:33):
I mean I do think this is probably like a
global issue.

Speaker 2 (45:36):
Obviously some degree based on this.

Speaker 1 (45:38):
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

(46:00):
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,

(46:22):
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

(46:42):
the nineteen fifties, placenta acreda occurred in less than one
in thirty thousand berths.

Speaker 2 (46:48):
Oh my gosh.

Speaker 1 (46:49):
By twenty sixteen, that number was down to one in
two hundred and seventy two. Yeah, in large part due
to sea sections.

Speaker 2 (46:55):
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

(47:17):
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.

Speaker 1 (47:32):
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.

Speaker 2 (47:43):
Exactly because of the Cesaian scar.

Speaker 1 (47:45):
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.

Speaker 6 (47:59):
Yeah.

Speaker 1 (47:59):
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

(48:19):
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.

Speaker 2 (48:33):
Or can't understand like everything that's happening all at once
because it can change on a dime, exactly.

Speaker 1 (48:39):
Yeah.

Speaker 4 (48:39):
Yeah.

Speaker 1 (48:40):
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

(49:00):
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

(49:23):
healthy baby, what do you have to complain about?

Speaker 2 (49:25):
Get over it, you know, like, just enjoy your baby. Yeah,
so they're screaming all the time.

Speaker 1 (49:31):
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.

Speaker 2 (49:42):
I do find that so interesting.

Speaker 1 (49:45):
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.

Speaker 2 (49:59):
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.

Speaker 4 (50:04):
Right?

Speaker 1 (50:05):
Great? And then how long? How long does that?

Speaker 2 (50:07):
You know?

Speaker 1 (50:09):
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.

Speaker 2 (50:32):
I hope that was I don't even know what I
hope about that.

Speaker 1 (50:35):
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.

Speaker 2 (50:49):
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.

Speaker 1 (51:03):
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.

Speaker 2 (51:19):
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.

Speaker 1 (51:26):
Right, or even if it was unplanned, and it's like yeah.

Speaker 2 (51:30):
And but the same can also be true for a vaginal.

Speaker 1 (51:32):
Delivery for sure. Yeah yeah, but I feel like, yeah,
this this saying that way, describing it that way is
so dismissive.

Speaker 2 (51:39):
Right, It's one way that it will go, yes, yeah, yeah.

Speaker 1 (51:42):
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

(52:02):
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.

Speaker 2 (52:23):
Right, It compares and contrast in this way, right.

Speaker 1 (52:25):
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

(52:46):
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.

Speaker 2 (53:01):
Oh my gosh, I talk about this nail.

Speaker 1 (53:02):
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?

Speaker 2 (53:20):
You know?

Speaker 1 (53:21):
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

(53:42):
you do? Do you feel like it's your fault? It's
it's really complicated.

Speaker 2 (53:45):
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.

Speaker 1 (54:06):
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

(54:27):
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.

Speaker 2 (54:47):
Every provider has seen traumatic everything. Yeah, and the things
that obstetric providers see on a daily basis are trauma exactly.

Speaker 1 (54:56):
Yeah. Some hospitals I found this fascinating took to publishing
or displaying each physician's cesarean rates and that led to
them plummeting.

Speaker 2 (55:04):
Interesting wow, which suggests that maybe risk tolerance for vaginal
birth is lower than physicians think it should be.

Speaker 1 (55:15):
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

(55:35):
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

(55:58):
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

(56:20):
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,

(56:42):
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

(57:03):
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.

Speaker 2 (57:21):
Excited next episode, But.

Speaker 1 (57:23):
For now, Aaron, I want to turn it over to
you to tell me all everything about labor and delivery.

Speaker 2 (57:28):
I'm not going to tell you everything, but I'll cover
a lot right after a short break.

Speaker 9 (57:35):
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

(57:57):
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.

Speaker 2 (58:13):
When we were in that.

Speaker 9 (58:14):
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

(58:34):
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

(58:54):
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,

(59:17):
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

(59:39):
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

(01:00:00):
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.

Speaker 4 (01:00:20):
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,

(01:00:41):
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

(01:01:04):
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

(01:01:26):
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

(01:01:46):
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

(01:02:08):
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.

(01:02:33):
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.

Speaker 2 (01:03:16):
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

(01:03:39):
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?

Speaker 1 (01:03:52):
What is that? What is labor?

Speaker 2 (01:03:54):
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,

(01:04:14):
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

(01:04:36):
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.

Speaker 1 (01:04:48):
What just what is a contraction?

Speaker 2 (01:04:51):
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.

Speaker 1 (01:05:04):
But I mean, like, what, what what is it?

Speaker 3 (01:05:06):
Like?

Speaker 1 (01:05:07):
How long does it contract? We're gonna get the no, no,
we'll get there. But Braxton Hicks.

Speaker 2 (01:05:11):
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

(01:05:35):
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

(01:05:57):
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

(01:06:18):
they are considered labor contractions.

Speaker 1 (01:06:20):
Okay, did you say, like which hormones are causing this yet?

Speaker 2 (01:06:25):
Did I say what triggers labor. No, I did not
error because we don't know what we don't.

Speaker 1 (01:06:32):
Know, I can't be right. Check your notes again.

Speaker 2 (01:06:37):
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

(01:06:57):
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.

Speaker 1 (01:07:09):
Also, sheep and cows have less invasive placentas.

Speaker 2 (01:07:13):
I know, I know, so it's different. It's not the
same in us.

Speaker 1 (01:07:15):
But I mean, we have we have animal models that
we understand.

Speaker 2 (01:07:18):
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

(01:07:40):
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.

Speaker 1 (01:07:51):
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?

Speaker 2 (01:08:00):
Don't know?

Speaker 1 (01:08:01):
Okay, So like we don't know why. I mean, we
know why they speed up, like the purpose of speeding it.

Speaker 2 (01:08:06):
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,

(01:08:30):
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

(01:08:50):
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

(01:09:12):
you were to touch it. Okay, okay, and it is closed.
So you see that there's no opening here. What is that?

Speaker 8 (01:09:20):
I mean?

Speaker 1 (01:09:21):
Like, but what is that the for you?

Speaker 2 (01:09:23):
It is a little puffball okay, craft puffball?

Speaker 1 (01:09:27):
And what is it representing.

Speaker 2 (01:09:29):
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

(01:09:52):
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

(01:10:14):
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.

Speaker 1 (01:10:32):
Got it. So it's just yeah, yeah, it's just.

Speaker 2 (01:10:34):
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

(01:10:55):
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

(01:11:18):
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,

(01:11:38):
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,

(01:12:00):
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

(01:12:23):
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

(01:12:44):
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,

(01:13:08):
But ten is the fully fully dilated yeah, okay, okay.
Questions about any of that, Yeah.

Speaker 1 (01:13:16):
Okay, So the active labor part is more.

Speaker 2 (01:13:18):
Predictable, more predictable.

Speaker 1 (01:13:20):
But then not everyone progresses through active labor, yeah the
same way.

Speaker 2 (01:13:26):
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

(01:13:46):
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.

Speaker 1 (01:14:00):
I wouldn't want to crouchet with that.

Speaker 2 (01:14:01):
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

(01:14:22):
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.

Speaker 1 (01:14:32):
What determines how much I was going to how much fluid?

Speaker 2 (01:14:34):
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.

Speaker 1 (01:14:39):
I'm envisioning the water going everywhere make a mess. Yeah.
What determines how much liquid? How much amniotic fluid is
in there?

Speaker 2 (01:14:51):
Big question? So AMIEC fluid is P? It's a fetus P.

Speaker 1 (01:14:55):
Yeah.

Speaker 2 (01:14:55):
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.

Speaker 1 (01:15:07):
Yeah, okay, So I.

Speaker 2 (01:15:09):
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.

Speaker 1 (01:15:17):
What percentage breaks spontaneously?

Speaker 2 (01:15:19):
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,

(01:15:39):
putting more pressure on the cervix and helping to ensure
that you're getting adequate dilation and effacement.

Speaker 1 (01:15:46):
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?

Speaker 2 (01:15:57):
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

(01:16:19):
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

(01:16:42):
harder to push that through the canal first.

Speaker 1 (01:16:44):
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

(01:17:05):
like it can be more difficult to you can't do
that yourself.

Speaker 2 (01:17:08):
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,

(01:17:30):
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,

(01:17:54):
it is recommended that people have a c section. If
baby is breached and won't be turned around.

Speaker 1 (01:17:58):
It won't be turned around, try to Okay.

Speaker 2 (01:18:01):
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,

(01:18:22):
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

(01:18:43):
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

(01:19:06):
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.

Speaker 8 (01:19:16):
Right.

Speaker 2 (01:19:18):
But that's the second stage of labor's delivery. Did I
answer all of your questions about the modes?

Speaker 1 (01:19:24):
And I think so? I think so great.

Speaker 2 (01:19:28):
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

(01:19:49):
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.

Speaker 1 (01:20:04):
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?

Speaker 2 (01:20:13):
Then?

Speaker 1 (01:20:13):
Sort of yeah, these I guess leading into this question
of C section.

Speaker 2 (01:20:18):
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.

(01:20:41):
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

(01:21:06):
actually measure the pressure that's being exerted on the fetus
is through an internal monitor, which we do have.

Speaker 1 (01:21:13):
Are those continuous or intermittent?

Speaker 2 (01:21:14):
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

(01:21:37):
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.

Speaker 1 (01:21:56):
Are you going to talk about intermittent versus continuous feel monitoring?

Speaker 2 (01:21:59):
I mean those are two options for monitoring.

Speaker 1 (01:22:02):
Yeah, But in terms of like the decision making and
what that tells us, it's.

Speaker 2 (01:22:05):
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,

(01:22:28):
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

(01:22:51):
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,

(01:23:12):
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.

Speaker 1 (01:23:23):
I'm sure that I will, but we'll give me the stats.

Speaker 2 (01:23:26):
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.

(01:23:48):
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

(01:24:08):
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

(01:24:30):
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

(01:24:51):
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

(01:25:13):
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

(01:25:35):
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

(01:25:58):
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

(01:26:19):
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

(01:26:41):
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

(01:27:03):
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.

Speaker 1 (01:27:17):
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.

Speaker 2 (01:27:28):
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

(01:27:50):
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

(01:28:14):
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.

(01:28:37):
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

(01:29:01):
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

(01:29:21):
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.

Speaker 1 (01:29:40):
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.

Speaker 2 (01:29:54):
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

(01:30:16):
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

(01:30:36):
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?

(01:30:59):
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.

Speaker 1 (01:31:15):
Like individual meaning dependent upon the specific situation, the.

Speaker 2 (01:31:18):
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.

Speaker 1 (01:31:39):
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

(01:32:00):
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?

Speaker 2 (01:32:14):
Right? I mean that comes down to communication, Aaron, Let's
be honest.

Speaker 1 (01:32:17):
Yeah, it's a big part of it.

Speaker 2 (01:32:18):
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

(01:32:40):
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

(01:33:03):
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

(01:33:23):
a vaginal delivery or not? Is that a crazy concept today?

Speaker 1 (01:33:29):
It is, Yes, it.

Speaker 2 (01:33:30):
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

(01:33:54):
they do, yeah, and not be judged for that, and
not be judged for that.

Speaker 1 (01:33:58):
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

(01:34:18):
what I remember.

Speaker 2 (01:34:19):
I remember that, but.

Speaker 1 (01:34:19):
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.

Speaker 2 (01:34:30):
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.

Speaker 1 (01:34:45):
We can't wine.

Speaker 2 (01:34:46):
Goodness, I know, Aaron, I want to move on, Okay,
can we sure? Okay? Do you have any other questions?

Speaker 1 (01:34:54):
Probably?

Speaker 2 (01:34:54):
I have other things about sea sections, like the risk
of this and like the effects on the child.

Speaker 1 (01:35:01):
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.

Speaker 2 (01:35:14):
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.

(01:35:37):
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.

Speaker 1 (01:35:58):
Planned and unplanned plan big picture of breakdown.

Speaker 2 (01:36:02):
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.

(01:36:25):
And yeah, it's true that like there's a huge range.

Speaker 1 (01:36:27):
Yeah, there's a range.

Speaker 2 (01:36:28):
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.

(01:36:49):
Sometimes it's forceps.

Speaker 1 (01:36:51):
We still have still use percentage, and I'm sure there's
various global blah blah blah.

Speaker 2 (01:36:56):
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

(01:37:16):
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

(01:37:39):
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.

Speaker 1 (01:37:50):
Wow.

Speaker 2 (01:37:51):
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

(01:38:14):
the placenta. Yeah, and that can take anywhere from like
a couple of minutes to like a half an hour
or so.

Speaker 1 (01:38:21):
Interesting.

Speaker 2 (01:38:21):
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

(01:38:44):
a hysterectomy.

Speaker 1 (01:38:45):
Okay.

Speaker 2 (01:38:46):
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,

(01:39:08):
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

(01:39:29):
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.

(01:39:51):
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

(01:40:14):
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

(01:40:36):
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

(01:41:00):
go wrong.

Speaker 1 (01:41:01):
So because someone who is pregnant and at term has
so much more blood than someone who is not pregnant.

Speaker 2 (01:41:08):
And so much blood is going to the uterus, yes.

Speaker 1 (01:41:10):
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.

Speaker 2 (01:41:25):
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

(01:41:48):
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

(01:42:11):
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

(01:42:33):
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,

(01:42:55):
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

(01:43:17):
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

(01:43:40):
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

(01:44:02):
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

(01:44:23):
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

(01:44:45):
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.

Speaker 1 (01:45:00):
Or is it?

Speaker 2 (01:45:01):
Or is it? But that's where we'll pick up next week.

Speaker 3 (01:45:03):
Okay.

Speaker 1 (01:45:04):
I have a couple of questions that I jotted down.
I saw you writing, Yeah, I didn't want to forget
back labor.

Speaker 2 (01:45:10):
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.

Speaker 1 (01:45:27):
Of the baby.

Speaker 2 (01:45:28):
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.

Speaker 1 (01:45:49):
Tearing. Let's talk about tearing. Okay, let's talk about episiotomies.

Speaker 2 (01:45:54):
I have a little bit of extra notes here just
for you.

Speaker 1 (01:45:57):
You know me, I do know it.

Speaker 2 (01:46:00):
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.

Speaker 1 (01:46:21):
You know that no one did a study on them
until the nineteen seventies about are these something we should
be doing?

Speaker 2 (01:46:27):
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,

(01:46:48):
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?

Speaker 1 (01:46:57):
Yes?

Speaker 2 (01:46:57):
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.

Speaker 1 (01:47:16):
It's our bipedalism.

Speaker 2 (01:47:18):
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

(01:47:38):
can have severe longtime consequences like an increased risk of
fecal incontinence, fiscilla formation, other things like that.

Speaker 1 (01:47:47):
Yeah, I mentioned fishila. What is official.

Speaker 2 (01:47:51):
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

(01:48:11):
more common, very very.

Speaker 1 (01:48:14):
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.

Speaker 2 (01:48:26):
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

(01:48:49):
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.

Speaker 1 (01:49:08):
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.

Speaker 2 (01:49:15):
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.

Speaker 1 (01:49:26):
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.

Speaker 2 (01:49:34):
Yeah, yeah, there's the future episode.

Speaker 4 (01:49:35):
It is.

Speaker 2 (01:49:36):
We have a lot that you can learn more about
just by reading the sources that we read.

Speaker 1 (01:49:40):
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,

(01:50:00):
and then a paper by Rosenberg and Trevathan titled Birth
Obstetrics and a Human Evolution from two thousand and two.
Interesting stuff, Okay.

Speaker 2 (01:50:09):
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,

(01:50:31):
bad and the ugly.

Speaker 1 (01:50:32):
I read that one.

Speaker 2 (01:50:32):
It was really good.

Speaker 1 (01:50:33):
Pezzone really loved it.

Speaker 2 (01:50:35):
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

(01:50:55):
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.

Speaker 1 (01:51:09):
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.

Speaker 2 (01:51:30):
I keep going, I've got notes.

Speaker 1 (01:51:31):
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?

Speaker 2 (01:51:44):
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

(01:52:06):
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

(01:52:29):
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

(01:52:52):
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.

Speaker 1 (01:53:02):
The microbiome is just one of those words that means
many different things.

Speaker 2 (01:53:08):
Yeah, we just don't We just don't have data on it.

Speaker 1 (01:53:09):
We don't have data, and it's so complex to do
the data.

Speaker 2 (01:53:12):
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.

Speaker 1 (01:53:28):
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.

Speaker 2 (01:53:33):
Definitely, not definitely not definitely not so so.

Speaker 1 (01:53:36):
Yeah, I feel like I have more to say, but
I guess there's one more episode to say.

Speaker 2 (01:53:41):
Let's say it next week.

Speaker 1 (01:53:42):
Yes, a big, huge thank you really like we don't
we don't have the words to thank all of the
providers of our first hand accounts. It really means the
world to us, so holy share your stories.

Speaker 2 (01:53:53):
Thank you, thank you, thank you, thank you, thank you.
Thank you also to everyone here at Exactly Right Studios.
We've got Leon, We've got Jessica, We've got Brent, We've
got Craig, We've got everyone.

Speaker 1 (01:54:03):
Who's many amazing people.

Speaker 2 (01:54:06):
Thank you guys so much.

Speaker 1 (01:54:07):
Thank you. Thank you also to Bloodmobile for providing the
music for this episode and.

Speaker 2 (01:54:12):
All of our episodes, and thank you to you listeners
for listening. We've got a lot of fun doing these episodes.
We've got one more still to come.

Speaker 1 (01:54:19):
Yeah what we hope you learned something or something I
don't know.

Speaker 2 (01:54:23):
Yeah tell us, yeah, tell us we'd loved or hated
it okay either way. And especial thank you as always
to our trends.

Speaker 1 (01:54:31):
Really, your support means so much to us.

Speaker 2 (01:54:32):
We appreciate it. Thank you well.

Speaker 1 (01:54:35):
Until next time, wash your hands animals

Speaker 9 (01:55:02):
FU

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Erin Welsh

Erin Allmann Updyke

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