#40 | Q&A: The Placenta & Advanced Maternal Age; COVID-19 Silver Lining ; Chapped Nipples & Poor Latch; Who Can Have a Natural Birth; Pitocin Postpartum; Unsolicated Family Advice

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Hello.

Hi, how are you today? I'm great. Well, I thought before we begin, we could talk about something that just came through my inbox that I thought was kind of interesting and worthwhile to share with our community. Because obviously, this has been a long, hard road for pregnant women during this pandemic and all that, and it just so happened that an email came to me today that was discussing the potential silver linings of COVID-19 for pregnant women. Okay, what's the silver lining, there's some good stuff. This this information actually came from 100 different birth providers who were surveyed. And they found that women are having much more rapid births. Because there are fewer people around that they're much more focused. Also that women are staying home longer before they come to the hospital. So they're entering that hospital much further along in labor, which we already know, increases your chance of having your birth go the way you want kind of the later you enter the hospital.

So it's interesting if that's what it's saying, because time and time again, what we see is that what women feel emotionally during their birth has a biophysical response on their birth. So you're saying the article indicates that they're having faster births, and they are pointing to the fact that they're the women are just not being bothered as much.

They're not being disturbed as their births are being less disturbed. And what we know is that women who are left undisturbed birth is more successful birth, it's you're more likely to have a vaginal birth, you're more likely to not need pain, medication or other types of interventions, you're less likely to set off that cascade of interventions that can lead to you know, less than desirable outcomes. But they're not only seeing improved birth outcomes are also seeing improved breastfeeding rates, less formula use, and Better skin to skin bonding with mothers and babies. Because, again, you don't have visitors coming in and passing the baby around. Because so many women are choosing to give birth out of the hospital, the nursing to patient ratio is improved. And so nurses are also more present and available. And actually they also said one statistic that stuck in my head 46% decrease into C- sections in India. Really 46% decrease?

So this is what I'm wondering, is everyone going to go back to their old ways after this? Well, I hope we learn something. I mean, we wait but yeah, but we've all known this for a long time. We've all known that this is what women need. They need to go to the hospitals later that's on the women as long as the providers and saying Come on down. Right. They often encourage women to come down too early. But why does it have to take something like this, they're probably also encouraging women to stay home longer because they have right you know, fewer spaces available. This happened so far. Frequently that so often we see the outcomes supporting the evidence that has been there for a long time. But real change is not happening,
because so rarely do we actually get this kind of mass data. So now we'll have a chance to look at it. I don't know, I just, it's good to see this. I'm just going to feel very discouraged if in the near future, they're all reverting to their old practices, you know, but right now, it's anecdotal, right? They're just starting that this is just anecdotal. This is just anecdotal. Yes. And I mean, we have to remember that hospitals are financially incentivized. So having fewer C-sections isn't helpful for their bottom line. And even though we have this evidence, it doesn't mean that they're going to pay attention to it or use it.

We're the only industrialized nation since 1987, or from around the mid 80s, whose outcomes have grown significantly worse, and every single other industrialized nation does Have them have significantly improved outcomes. They're just all sloping sloping down on the maternal mortality chart, and ours is shooting up in the exact opposite direction. And that is the that's the differentiator that you just mentioned that there are financial incentives here and not anywhere else. It's just a different model. And it's that model that we're up against. It's not people we're up against. It's the system. This is what we mean, when we talk about the healthcare system. We're up against that model of healthcare. Right? It's, it's well, well, I mean, it's good news. And I don't mean to interpret it like it's, it's discouraging, it's good news. But it does make you think like, Well, can we hope now that someone's going to pay attention to this or do some studies that maybe apply what we're learning? I hope so.

The first thing is to notice it, right? That's the first step. And then the second thing is to start talking about it. And now at least it's being talked about and hopefully by someone other than just us, right? Hey, but its a start. Thank you for sharing that.

Yeah. Let's go into our q&a is I know that you said right before we started recording today, you've just got one in from Instagram. So do you want to just do that one before we get to the ones we had prepared from the past few days? Yeah. Oh, yeah. Yes, I did. Exactly. Thank you. Okay. The question is, it was little quick response to your Instagram story. How does advanced maternal age impact placental performance? Which sounds like a pretty sophisticated question from somebody who's been doing their research? Yeah, because most women think advanced maternal age is just a matter of genetic deficiencies, or they just think it's like, quote, unquote, more dangerous and they don't really understand why but it does tend to point to the placenta most of the time, doesn't it?

Yes. I think the general thinking for women who are older is that they're just their bodies aren't as good at growing a baby or managing pregnancy or just not as not as not as resilient but it really does have a lot to do with the placenta and the placental function. So when we're talking about risks of being older or advanced maternal age, we are talking about how the placenta function changes with age and also length of pregnancy. Some of the things that older women can experience with the placenta is higher rates of fetal growth restriction, higher rates of stillbirth, and higher rates of preeclampsia.

You can't put all 35 year olds into the same bucket. If people are abusing their bodies or not eating well or they're smoking or doing drugs or drinking an inordinate amount of alcohol in their lives. They are literally aging their cells. And if you're eating well and taking care of yourself, you're keeping your cells young. So we have no way to track health other than to put everyone in a category based on age. But I just think it serves all of us to totally reject that. Because we can live our lives really afraid thinking like oh gosh, now I'm 40. And I'm at risk of this kind of breast cancer. And I'm 60. And I'm at this risk of heart disease. And we need to just say wait a second, that's we really can hardly scratched the surface on understanding health, even our stress levels and how we take care of ourselves emotionally. So that's the first thing I think anyone needs to think about. Don't worry so much about these broad categories of women based on age, and in other countries. They're not looking at this at all. They're not doing this at all. This is a cultural thing, even if there's some merit to it, even if there's some statistics behind it. This is still very cultural. And I think the second thing is this is always my concern with a client who's older, I am always concerned that she will be pressured into induction because of that slightly increased risk of stillbirth and then what do you do with all of these women over whatever the defined advanced maternal ages seems to move around sometimes? What do you do with all these women now that you're inducing, when it's not necessarily what has to be done in each individual case?

As far as advanced, maternal Age goes, I think it's also important to point out that it isn't a threshold that isn't like at 35 years olds, suddenly things are way worse, you're at much higher risk and your body isn't capable of doing this, we actually have slightly, I mean, these risks all go up slightly, slightly from even 25 on.  AMA came about, because age 35 was the point at which certain tests became worthwhile to do to pick up on a subset of people that might be at higher risk. And that's kind of how that age came along. So if you're 35 versus 45, those are very different scenarios. So I think it's really important for a lot of women who are having babies in their mid to late 30s, because that is so much more common now, to not feel that they've passed this threshold like they've walked off the edge of the cliff and everything is, you know, really high Risk now. That's not the case. I mean, you can't really know if a placenta has those calcifications or insufficiencies or the anatomy of a placenta until after the baby's born. I mean, some. I think ultrasound technology today can pick up on certain things. But like intrauterine growth restriction is one of the ways that they assess placental function, or even fluid levels. That's why that biophysical profile in late pregnancy is gives a lot of important information about how the placenta is functioning.

I think the best we can do for any mom is just have her focus on what she can control, which is a her own health, emotional and physical health, and be her relationship with her provider. And the one thing I just want to remind women of is, if you're not comfortable with how one provider handles your conditions or situation, you very likely will find another provider in your area who handles it differently. And they both might be legitimate approaches, but you really have to find the right partner for you and your birth. So always Be willing to shop around.

Let's go on to the next one. Trisha. This question says my baby is two weeks old and my nipples are so sore, even sometimes bleeding after my baby nurses, what can I do to help them heal? I'm at the point where I get anxious when my baby is waking up because it will hurt so much. Is this normal? Or does it mean the latch is wrong? I've heard I just need to let them toughen up. But I'm not sure how I feel about that. And don't think I can do this much longer. Anyway, At this rate, I want to cry every time I feed my baby and I feel like I'm causing them causing him to get stressed out to it. Is that normal? Is that an indication of a latch? Oh, yeah, that's an indication of a latch two weeks out in that level of discomfort and yeah, I mean, I honestly hear this all the time as a lactation consultant. This is one of the main reasons people call lactation consultants because they can't take it anymore. And it's horrible to have to you know, sometimes babies are feeding 12 to 15 times a day into That you have to cringe and curl your toes and be in this horrible discomfort every time you have to feed your baby is so stressful and of course stress impacts oxytocin, so then that impacts your milk let down and then your baby gets stressed out because you're stressed out and then it's harder to latch them on. So this is not a good situation. And I definitely don't like to ever hear the advice given to women that your nipples just need to toughen up because they're not. They don't build calluses. They're not like our heels, you know, that get a little tough if we walk around barefoot, they don't toughen up. They're not meant to toughen up.  It's not a body part that's meant to toughen up. No. Okay. But do they get used to nursing a nursing baby? Yes, but they're not going to toughen up through like, getting damaged by Yeah, bye bye poor latch. So at two weeks, definitely if you're still feeling discomfort, there's there Problem with latch. Oh, also, if there's bleeding, yeah, there really should never be bleeding. That's a sign of, you know, cracks, nipples. Those are damaged nipples and that's also a way for a woman to get mastitis. I usually tell a woman that if she is sensitive to a towel after she gets out of the shower, or the shower water, or certainly if she's bleeding, or cringing during breastfeed, so that is absolutely reason to get help. And it may just be a very simple fix with positioning and how the baby's latching or it could be something more complicated like a baby might have a tongue tie. Certainly whatever the situation is, or until you can get to see a lactation consultant. It is best to actually stop breastfeeding and let the nipples heal. You can still have skin to skin contact and you can still pump and give your baby milk in a bottle. But to continue to breastfeed under those circumstances is going to make it very hard for the nipples to heal.

So Won't the pump hurt Or it just won't exacerbate the problem you're saying like you can pump and it might hurt but it won't make it worse but if you keep breastfeeding with a poor latch it will make it yes. so the pump should not have a poor latch effect on your nipples so yes, it's everything's going to hurt initially until they start to heal. But if you continue to nurse with a poor latched, those nipples are not going to heal. So yeah, get help, definitely get out and know and know that this is not a this is not a like a breastfeeding sentence that it's going to be this way this absolutely can, can be fixed and corrected and nursing should be easy, comfortable, carefree at once you get past the initial adjustment period, which is usually just a few days, maybe a week, but not this far out.

I think the next question is for you. Okay.

Hi, ladies. I love your podcast and never really considered a natural birth until recently. How do women do this? Just The thought of it makes me scared. But I asked this is my everyday life hearing women talking? Yes, for sure. But at least they're thinking about it right? Yeah, it's, ya know, like the whole scared part. Yes, of course, this is what it's all about. This is what we overcome, gone. What does it say? Just the thought of it makes me scared. But I also feel like when I, I also feel like I would love to avoid all the usual medical intervention if I can. Can you talk about how women build up the confidence to go for it? Okay, so the question is how to build up the confidence. This might be helpful. It's not really about building up confidence. You know, when I work with couples, it's not about giving them the right words and pep talk, or encouraging them even and having a natural birth. It's really something that you either feel a pull toward or you don't, but what I hope everyone can get on the same page with is having an informed birth and making sure every decision that takes place in that room came from you so we could make the decision to Happily relinquish to even a surgical birth when we know that we need one. So just trust yourself to make the right decisions once you are informed. And I think it's sometimes helpful to approach to approach your birth, in terms of recognizing that there are three things that will determine the outcome of your birth. And really what you want is to feel at peace with your birth, isn't it? I mean, you're asking about having a natural birth. But what I think we all have our deepest longing for is a birth we feel at peace with because when we don't feel at peace, we feel absolute anguish, and it can last for years that can stay with us. So my intention for everyone I work with and for whoever is listening is May you have a birth you feel at peace with so how do we go about this? The first part is to recognize that there are three things that will determine the outcome of your birth one is your provider. They are not all the same. The second is you right are you going to go through this Process keeping your cool keeping your breath allowing the oxytocin to flow, ensuring you have the support you need, or are you going to revert to what you've seen in the movies all these years by clenching your teeth and gripping the chair, oh my gosh, I'm having another one. And having that kind of reaction. So if you do that, it doesn't make it right or wrong. But if you do that, you are going to be tightening the cervix and secreting stress hormones instead. So you're the second thing you are the second thing that will determine the outcome of your birth. And the third is the position of your baby. And when you get these three things aligned, you can have the natural confidence that your birth is likely to go quite well. And then you just have your plan in case you need intervention. The only other thing involved in this process is to start asking yourself what you want for your birth. And when you ask most women this in their early pregnancy, they don't they don't know we tend to start off just knowing what we don't want. But as you get introduced to ideas, as get exposed to different places where you can give birth. As you become aware of evidence based birth, you start to form really strong opinions and desires about what you want. So just trust yourself to make the decision to get informed, and trust yourself to make the right decisions for yourself through this process. This is not about someone giving you the confidence. It's just about discovering yourself.

That's exactly right. And I think just to add to that, another another thing that is very helpful for women to do is to one look at their framework for how they see birth, like where that comes from, to their mother have a scary birth, their sister have a traumatic birth story or like Do they have these things in their head that are keeping them from seeing birth any differently so look at that, and then choose to surround yourself with people who have had the kind of birth that you're looking to have go find those people find that community? Read every positive birth story you possibly can get your hands on watch positive birth videos, not only informing and educating yourself about how to make good decisions about your own body and your birth, but take that in, get inspired, because that's how you change your belief.

Exactly. The first day of hypno birthing class, we talked about some attributes of neuroscience that impact how the brain works, and we cover just laws of the mind and one of them is called the law of harmonious attraction is it's exactly what Trisha is saying is just Trisha has instinct that totally understands this, but it's surround yourself with what you do want and avoid what you don't want. This goes for everything in your life. How many of you have been told a scary story since sharing that you're expecting?

It reminds me of a quote I love that says every cell in your body is eavesdropping on your thoughts. Everything we think is actually impacting our physical body. So if you're thinking, breech, baby, If you're thinking c section if you're thinking malposition, your body's listening Absolutely.

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The next one is a question that we have actually gotten from several people. So clearly this is kind of something people are really thinking about and talking about right now.
Yeah, this I'd love you to talk about this Trisha. It says I was told I'll be given a shot of pitocin right after I have the baby. This doesn't make sense to me because I thought pitocin is for speeding up labor. Why would anyone need this after the baby is born? Oh,  Because pitocin has only been FDA approved for postpartum hemorrhage and the medical induction of labor. It has not been FDA approved for speeding up labor as this woman says that's what we believe because that's how it's frequently used off label.

To me this is an indication that it is not being talked about in prenatal care that that after the birth of the baby pitocin is often given either IV or Im to prevent  bleeding.I mean intramuscular Yes, sorry, intravenous or intramuscular. And it's part of something called the active management of third stage, which is third stage is the birth of the placenta. And the fact that she said, why would anyone do this, and I've never heard of this is a good indication that, you know, this is a this is a procedure that requires informed consent. And that's not happening. So it certainly needs to be talked about. And we can talk about why this happens. And we can talk about whether or not it's effective. But I just wanted to make that point that, you know, she's right, hurtling. Are you aware how often this is happening that Trisha, it's happening to the like, almost? Yeah, right now. Yeah. I mean, well, first of all, if you're already have an IV because you've had your labor augmented, or you've gotten fluids, or you've just been admitted to the hospital, which generally means you're going to have an IV, then you know, it's easy if you don't, if you don't say no, if you allow it right on. Now, right? So yes, it's very easy to just administer this. And the reason that it's done is because there's a procedure called the active management of third stage of labor, which involves giving pitocin at the time of birth or just after it involves actively delivering the placenta by giving the pitocin using gentle cord traction, and clamping and cutting the cord. So when I was in midwifery school, this is the way we were taught to manage the birth of the placenta. That was a while ago, it's changed a little bit now. And there's many more people supporting delayed cord clamping, and letting the letting the placenta be birthed, naturally, but there still is a lot of use of pitocin.

So does the evidence support a shot of pitocin after the birth doesn't really support it? Well, so this has taken a really long time for people to get clear on this. Okay. So I think it's I think it's kind of come down to To a mixed management strategy, which means give the pitocin delay the cord clamping and don't use the cord traction unless you need to. But the question still remains is is the pitocin necessary at all. But the evidence seems to suggest is that there is good quality evidence to say that giving pitocin at the time of birth will reduce the amount of bleeding a woman experiences after giving birth.
But I just want to say So what?

Yeah, exactly. So what does it actually really reduce the risk of postpartum hemorrhage in a woman or like, you know, the real morbidity or mortality from that for working mothers and the impact on babies and the evidence for that is very low quality, it does not seem to show that the question is, are we needing to do this because of all the things that we are doing to intervene in labor that may put a woman's uterus at risk of not clamping down properly? So the tosun is there to help the uterus clamp down more effectively after the birth of the baby because the biggest reason that a woman would have a postpartum hemorrhage is because the uterus becomes Boggy and tired after birth and it can't clamp down. So after that placenta separates from the uterine wall, you have, you have an open wound right inside the uterus that can bleed heavily and very quickly, and the uterus needs to continue to contract, contract contract releases the placenta, and as it contracts, it closes off all those blood vessels and the bleeding stops. But if a woman who has maybe had excessive amounts of pitocin in labor, or has a very long, or even sometimes a very rapid labor, or an infection or a uterus that's been overstretched because of multiple babies, or potentially, you know, too many babies, then that uterus might be at risk of not clamping down As well, putting them at higher risk of postpartum hemorrhage. So those are just thoughts. Those are some of the reasons that you might say, I am going to use active management of third stage. But in a low risk woman, there does not seem to be any benefit. And then there's still the question of does that use of synthetic oxytocin? Or pitocin, which is synthetic oxytocin? How does that impact a woman's immediate postpartum oxytocin natural oxytocin levels, which is the bonding hormone between her and her baby? So is that pitocin potentially interfering with the bonding because synthetic pitocin doesn't cross the blood brain barrier natural oxytocin does. And we need that oxytocin after the birth to be relaxed and calm and facilitate that early bonding.
So it's possible she'll get less of her own oxytocin if we're already flooding the body with a synthetic oxytocin right. So not only is it Not necessarily helpful for low risk women, but is it actually potentially a risk?
And it's going to affect virtually every woman? I mean, every woman has to really consider that this is a very, there's a very high likelihood that she's going to be confronted with this situation after she gives birth. What about women who have Syrian sections? Do they still do it then too? Or is that just a non issue? What is that? No is saying, I mean, women who have susteren sections tend to have more bleeding. So I think it's even more standard.

So the takeaway from this is really, that mothers need to be talking to their care providers about this prenatally and asking, you know, what is your procedure for delivering the placenta? And can we have the discussion now about not having the pitocin unless you feel that I'm bleeding excessively? I that's another point is that this is something that works very effectively to stop bleeding. So it is something that should always be available at a birth.

But even at a home birth, it's available hundred percent. Yes, I could never feel calm. Attending a birth without it. But does it mean should it be routine? Right doesn't need to be prophylactic? No, unless you determine that they are have these significant risk factors and you have the discussion with a mother and you decide that you feel it, the benefits outweigh the risks. Another downside of it is that women who receive at tend to have stronger after birth pains, which can be extremely uncomfortable. So after birth pains are basically like contractions of labor that you feel after the baby's born and they can last for 24 hours to you know, several days that they get less as the time goes on, but pitocin at the time of birth seems to increase those.

So the next question, you want to read it? Sure. Okay. Go ahead. All right. My mother in law keeps subtly hinting that I shouldn't hold the baby so much ettled. not so subtle. All right. It's never subtle. No matter how subtle you think you are, right? Okay. Continued subtle hinting is eventually not subtle anymore. Of course, and it's making me feel really self conscious. I know it's old fashioned to worry about spoiling the baby. But is there any other reason I should be careful about doing this? Can it impact how independent my baby will become in the next few years? Am I basically creating a bad habit for her or me, I would love to know your thoughts. It's the opposite of what she's afraid of exactly what she says about kind of impact how independent my baby will become in the next few years. I would say the more you hold your baby, the more strong that early bond is, the greater the attachment between mother and baby or father and baby in those early years. That's what leads to more independent children.

They've done studies with rats where they give them food every time they press a lever, and like the rats all go crazy when they get the food. It's like a frenzy. But then when they like trust that it's always going to come out. They just relax. They go take a nap. They go get some food, they socialize. They go get some food. I don't know, sample of rats just came to me. But I think there's a link some study in my mind. Well, it's a really interesting study that goes further than that. But I think it I think somehow it's linked to that, that we're filling this need. And we're, we're filling them up. We're showing them your needs will be met, trust that your needs will be met in this world and I'm here to meet your needs and what I was wondering Yeah, go ahead. I think it's also really important to distinguish between spoiling and loving, not the same thing. Now giving your child attention, loving attention and support is not spoiling the spoiling his lack of discipline, lack of boundaries, that creates a dependent child. loving your child is deeply as you can bonding with them building that trust, knowing like you said that they you will be there to meet their every need, yet still setting the appropriate boundaries, through discipline. That's how you create independence. And that's how you create an a child who's going to grow into an adult who feels safe in the world.

Yeah, I think the bigger issue happening for this woman is how to manage the relationship with her mother in law. Because why does the mother in law feels she should hint, first of all, a direct conversation is better than hinting about anything. But it's difficult. And I can imagine it'll be difficult for all of us one day when we're grandparents, and we're seeing how our children or our children in law or are raising their children differently from how we might think is best. I think that would be extremely difficult, and I can understand that. But it might have to be hammered out a little bit. There does have to be that conversation like Look, you've you've had your turn. We're happy to have the conversation, but it kind of has to end after the conversation. Leave it back with us again, and we don't have to come to consensus on any decisions here.

There's some great research out there attachment parenting and by By Kendall and Klaus, you and I would both be in agreement that the more you wear your baby, the more you keep your baby close to you, the easier parenting is and the better off they will be as, as children and young adults.

I think the bottom line is follow your instinct if it feels right to love your baby, love your baby appeal, if it feels right to hold your baby to nurture your baby, just keep doing it. Don't second guess yourself that just paves the way towards suffering, your instincts are the best thing you have going for you. The same is true with the whole birth process. It's really about like, how do we get back to our instincts on all of this. We really do know how to do all of this. But everyone around us has a second guessing ourselves in questioning and we try to get into that conscious mind. But where we really belong is in that instinctual brain that's been doing this for millennia. Right? Just love your baby. You'll know when it's time to separate it will feel like the natural right thing to do. Your baby will go away from you. Rather than want to be in your arms, your baby won't want to be in your arms all the time, they'll push off of you and want to walk away at some point. And you will allow that. Right? It won't be healthy then to pull them back and cling to them. It's a natural progression to trust yourself, to know how this needs to play out.

And understand that bonding is not the same thing as spoiling. They're two totally different things that, you know, I'm going to change the subject and share a story about my dad. One of the best things my dad ever said to me. I was in college, and I had a new boyfriend that had been dating for like half a year. And I remember seeing my dad and we're hanging out minimum hours away from my boyfriend, and I was back with my family and I was with my dad. And I showed him a picture of my boyfriend. And I said, Dad, He's so nice. You really like him, dad. He's such a nice person. And my dad shook his head and smiled and said, Cynthia, you don't have to say another word if you picked him out. I already know. I mean, what do you think? To say, your child like you don't have to convince me so simple like if you picked him out, and he just gave me this message all the time to yourself that I made good decisions that I could trust myself. And that was enough for him. Wow. It's one of the most loving things I think a parent can possibly say to try. Yeah. And the lasting impact that had on you is profound. Was that it for the week? I think that's pretty good. I think yeah,

I think I think we covered them. That's a wrap.

All right. Thanks, everyone. Have a wonderful week. See you soon. See you next time.

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Transcribed by https://otter.ai