Dear Anatomy & Physiology Professor

Yesterday I finished a 12 week anatomy and physiology 2 part course. At the end I posted my professor a note in the discussion area.

I have enjoyed both Anatomy classes and have learned lots of information valuable for the various things I do. I am a birth doula, birth educator, La Leache League Leader, parent educator and more. I do have some ideas about the labor and birth chapter which I meant to contact you about. I'll still try to do that before the discussion areas get closed. 

Thank you,

Jennifer

The professor responded, "I'm glad you enjoyed the course and look forward to your input!"

So I spent a considerable amount of time yesterday going carefully through her lectures and formulating my response. I posted it into the discussion area as I had no other way to connect with her. I found out this morning that she took it down and sent me this reply, 

"To Jennifer,

Thank you for the information.  I am not able to keep that type of post up in the Discussion Area, but I read it carefully and copied and pasted it into a Word document for further review.  I am looking forward to checking out the references you included.  I think the pendulum has swung some on medication during childbirth.  When I was having my children (my oldest is 33 and my youngest is 18), women were encouraged to avoid medication if possible, while women in my mother's generation were significantly medicated.  Now, it seems that epidurals are used almost routinely, rather than reserved for special situations.

http://americanpregnancy.org/labornbirth/epidural.html

I think it's very important for women and their partners to learn as much as they can about pregnancy and childbirth, understand the pros and cons of different types of pain relief, think about their ideal situation for labor and delivery, and then discuss their wishes and concerns with a physician who comes highly recommended and who they trust.  

Thanks again for the info!"

I couldn't agree more. Women should learn all about the pros and cons, safety and risks of ALL medical procedures before they give birth but NOT in an anatomy and physiology class. In an anatomy and physiology class they should learn how a woman's body works without any outside interference. How her musculoskeletal, integumentary, sensory, hormonal, chemical and nervous systems work in concert to bring a baby into this world. 

Here is what I posted on the discussion board:

I have some thoughts about the sections in your lectures which cover normal vaginal birth. Let me explain my background. I have been a doula for over 20 years. In case you aren't familiar with this profession, a doula supports couples during the entire birth process and into the early postpartum period as well. I have been at over 100 births. Some have happened in homes and birth centers, but the majority of my clients have chosen to birth in a hospital setting. I have seen lots of babies come into this world vaginally and some via cesarean section. Along with this I am a birth educator and La Leche League Leader. La Leche League International has been educating and supporting breastfeeding women for over 50 years. They have the most up to date information and studies on lactation, breast milk, and breastfeeding. As a Leader I am trained to support mothers who desire to breastfeed through facilitating meetings and providing one-on-one support.

Throughout your classes I have been impressed with how well you explain the body's systems both anatomically and physiologically. The more I know about the human body the more amazing its abilities seem to me. I am very passionate about women, birth and families. It is very important to me that women are given accurate information about their body's birthing and breastfeeding abilities. Unfortunately in our culture women know very little about birth and what they are told is not at all from an anatomical and physiological stand point. Instead it is heavily mixed with cultural beliefs with no regard for science. Unfortunately I believe your section on birth is skewed in this manner. Women need to know how we were designed to give birth. If they then choose to use medical and pharmacological props or interventions that will be an educated cultural choice. As this is an anatomy and physiology course, I am hoping you will consider taking a more physiologic approach to how you present birth to women. Please understand I am NOT advocating women should birth without skilled help at the ready. How much they use or need that help will depend on their unique situation. I want them to learn what their bodies are capable of doing. 

Here is what I have learned from watching women, keeping up with the latest science, and opening my mind to see past our current birth culture. Women are designed anatomically to labor and birth in upright positions. Left to their own instincts it is very rare indeed for a woman to choose to lie down to birth, especially on her back. Imagine a woman choosing to lie flat on her back to defecate or urinate. Most un-medicated women will choose to stand, semi-squat, full squat or be on their hands and knees. Unfortunately all of your graphics clearly show the supine position. This position is brought about through the use of pain medication and for doctor and hospital convenience. It is considered normal only because of cultural influences on the physiologic birth process. Anatomically it flattens the pelvis and doesn't allow for the sacrum and coccyx to move out of the way of the descending head. It also immobilizes both of the illiac bones making it harder for them to spread laterally giving the additional space needed for the baby. You mention the doctor placing the woman in a semi upright position but as long as her bottom is against the surface of a bed she will be hampered in her abilities to birth unassisted, but unassisted is what we are anatomically and physiologically designed to do.

In your course you say the doctor will tell the mother when second stage has begun. But anatomically when a mother is un-medicated she does not need to be told when to begin pushing. When the baby descends to a certain point in the pelvis he naturally triggers the fetal ejection reflex in mom. Just as when you need to vomit you know you are about to vomit. No one needs to tell you it is time or how to do it. No one needs to say how long each vomiting session should last. This is exactly like the 2nd stage of labor. The mother, even a first time mother, will spontaneously begin to push with her diaphragm and abdominal muscles. She will not be able to help it. She will not be able to stop herself. She will naturally tend to push 3 times during each contraction for approximately 6 seconds. This amount of time works physiologically for the baby. When a mother is pushing she tends to hold her breath to bear down. This breath holding reduces the available oxygen to the baby. Six seconds is an amount of time that babies tolerate well. Longer than that can cause a drop in oxygenated blood with a corresponding rise in fetal heart rate as they physiologically struggle for homeostasis. 

The un-medicated mother will know when she is crowning from the burning sensations she will feel. Most mothers stop pushing and cry out. This releases the vaginal muscles and allows for the last stretching. I agree with you that it can be helpful for a provider to gently put counter pressure on the head to keep it from coming so quickly mom’s vaginal tissues tear but this is not how the system was designed. It was designed for the mother to birth like other mammals, without assistance. Further there have been many studies done that show that an episiotomy does not keep a woman from tearing. As a matter of fact they all agree that a woman is more likely to have a 3rd or 4th degree tear if she has an episiotomy. Currently most doctors only do an episiotomy if the baby's heart rate is dropping into the danger zone. In this situation it can be life-saving.  

When the baby's head appears the supine or semi-reclined position necessitates a care provider to hold the head so the head doesn't flop backward, hyper extending the baby's neck. When a mother births in a squat the head stays perfectly in line with the body as it hangs down. In your lecture you say the doctor will rotate the baby's shoulders but most babies rotate without any assistance. It is part of the anatomical fit between mother and baby that causes them to sort of cork screw out. It is only if their shoulder is stuck under the pubic bone that this doesn't happen. Finally rather than a doctor needing to catch the baby as you suggest, the mother is capable of reaching down and catching the baby as it pops out after the body rotates into position. I have witnessed this. 

As to the physiological process, you mentioned the hormones oxytocin and prostaglandin but equally important in the process are dopamine and endorphins. This combination of dopamine, endorphin and oxytocin is the same combo released during orgasm which causes intense pleasure and a feeling of floating. In labor this powerful chemical combination changes the laboring woman's perception of the pain allowing her to endure much more than she would otherwise. On top of that she is chemically driven to bond with her new baby as soon as he or she emerges. This is a very important feed-back loop which pitocin and an epidural disrupt. It has consequences for the next phase, mothering the baby outside the uterus.

The latest studies all show conclusively that immediate skin-to-skin contact is what we are physiologically designed for rather than taking the baby away even briefly and presenting it back to mother as a wrapped bundle. The mother and baby should continue to be considered one biologic unit. They share bacteria, hormones, body fluids, antibodies, fats and proteins. A neonate has no ability to self-regulate. He does this through his mother. Hearing the mother's heart beat and feeling the rise and fall of her breath regulates his heart rate and respiration. It keeps the levels of adrenalin and cortisol at their appropriate levels; enough to cause the baby to be hyper alert without causing him physical stress. Science has proven babies should not be taken away or wrapped in blankets. This is part of the WHO Baby Friendly Initiative. Their goal is to have all babies go immediately onto their mother’s abdomen or chest unless they need life saving measures. Normal suctioning doesn't count as life-saving. If needed this can be accomplished quite easily on the mother while baby remains skin-to-skin. They are to stay this way undisturbed for the first 2 hours of life so that all of the above sharing and regulation can occur. If you haven't watched a video on delivery self-attachment yet you will be amazed! We are much more like other mammals than we have given our babies credit. When un-medicated, undisturbed, and left skin-to-skin with mom they move themselves into position and find the nipple, latch on, and begin feeding. I just attended a conference where I was blown away by the latest info about epigenetics and breastfeeding. Breastmilk contains, histones, lepten, and microRNA, which all pass to the baby. They attach into their genes and change how the genes are expressed. This is an important further step in passing on genetic information from one generation to the next.  

The third stage is more easily accomplished if baby stays with mom. This triggers further oxytocin release, especially if the baby latches and begins to nurse, which stimulates the placenta to fully separate and then keeps blood flow to the amount which brings mom back to homeostasis. She loses the extra blood she created to maintain the pregnancy which she no longer needs. There is no need for "a little bit of pitocin" as you have taught unless the mom actually IS bleeding too much. Again our physiology is miraculously designed to take care of most contingencies. Only when it is not able to do its job successfully should we vary from this amazing design which you clearly have so much respect for.

Finally I want you to imagine what would physiologically occur if the mother and neonate were all alone immediately after birth. What would the mother do? Would she immediately clamp and cut the umbilical cord as you have stated the is done in our hospitals? Highly unlikely. Therefore what is supposed to occur? As you detailed so well, the baby's circulation and respiration have major changes that need to happen. These will generally take place quite peacefully without any gasping or stress to the baby. There is significant pressure around the baby's chest when it is squeezing through the vagina. When the baby is born there is therefore a significant drop in pressure which causes air to try to rush into the lungs. Also there are nerves in the skin of the neonates face which, when exposed to air for the first time, trigger him to breath in. This is why babies can be born under water and not drown. They do not attempt to breathe until their face is lifted out of the water. Further as long as the cord and placenta are intact and still pulsing the neonate continues to receive oxygenated blood from the mother through the placenta. The cord is covered with a substance called Warton's Jelly. When the air hits the cord it dries this out and triggers the cord to slowly stop pulsing. Meanwhile inside the baby his body is working to close the foramen ovale and reroute the blood. Most cords will pulse for 5 to 10 minutes after birth and placentas stay adhered to the wall for anywhere from 15 to 30 minutes. This gives the baby buffer time. I don't believe in this scenario there is a fall in blood PH, but I could be wrong. This also gives the mother/baby system time to bring their blood exchange into homeostasis with the neonate receiving exactly the right amount of blood. If you clamp the cord too soon you will leave 1/3 of the fetal blood in the placenta. This blood is needed by the neonate for many reasons. They are discussed in one of the links below. 

Thank you for listening and thank you for expanding and deepening my knowledge of the human body. I'm very glad I took this class. If you wish to ask me further questions about labor, birth or breastfeeding please email me at jenniferstoverdoula@gmail.com.

A standing unassisted birth video: https://www.youtube.com/watch?v=zFMHB4RqpjI  

An MRI study of Pelvimetry in 3 positions:

http://www.ajronline.org/doi/pdf/10.2214/ajr.179.4.1791063

Further explanation about up right positions: http://www.givingbirthnaturally.com/birth-positions.html

Discussion of labor hormones and how catecholamines disrupt the natural hormonal cascade:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595201/  

Fetal Ejection Reflex: http://www.wombecology.com/?pg=fetusejection

Delayed cord clamping: http://www.scienceandsensibility.org/?p=5730

The requirements for a hospital to become Baby Friendly certified:http://www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative/the-ten-steps

Importance of skin-to-skin contact: http://www.medscape.com/viewarticle/806325

Breast Crawl video: https://www.youtube.com/watch?v=zrwfIcPB1u4   

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