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"Normalising birth with complicated pregnancy and labour
Dr. Amali Lokugamage, Consultant Obstetrician and Gynaecologist, Whittington Hospital, Whittington Health NHS Health Trust
We should attempt to normalize complicated births to give mothers and babies the advantages of bonding and breastfeeding, that parental nurturing received during the neonatal period and infancy. the eventual adult social competence of babies depends importantly on the quality and quantity of maternal care; the later ability to cope with stress, aggressiveness, even preference for addictive substances is also believed to benefit from the cerebral oxytocin generated in normal birth. Furthermore social neurobiologists credit this with how we behave toward society, and show loyalty to the social group and its culture. If maternal care is compromised problems may arise with forming interpersonal relationships, commitment to societal and cultural values, and reduced constraint around violating the trust of others.
The framework for normalization, depending as it does on the physical and emotional power derived from oxytocin, needs support for the mother, which suggests that a midwife who promotes physiological birth with continuity of care, or a doula, should be included in the high risk team. Nowadays the human side to the consultation is being increasingly marginalized by the advent of more and more technology and the sheer volume of patients who need to be seen, and is left to midwives. Being an obstetrician, “one of them”, I was consigned to the continuous care of a consultant during my pregnancy, and would have had little contact with a midwife had I not asked for one. Then I came to love my midwife's antenatal checks, which helped me to address some very basic “new mum” queries.
That was the Power aspect of the process. Now comes the Passage. Again I have personal experience with perineal myofascial release, a DIY method of stretching the outlet. Research into the benefits of nutrition in pregnancy is overdue; some recommend eliminating gluten from the diet, and incorporating herbs such as raspberry leaf tea. We should perhaps look at the advice of western herbalists, which fits the normal birth agenda. Relaxation can be induced in various ways – Yoga, autohypnosis, acupuncture. I used a visualisation of breathing into my vagina, to relax the outlet while breathing out (avoiding the possible harm of pushing with valsalva). There is also help for the Passenger: avoiding obesity with resulting macrosomia, and optimising the position of the fetus with intrapartum acupuncture, Yoga, Rebozo scarves (which relieve the mother of some of her weight):
It is often possible to improve the birthing environment for women who have complicated pregnancies in many of the ways of normal birth: not starving them in labour, permitting an upright and mobile position, non-threatening and non-intrusive monitoring, helping carers who are anxious, quietness, privacy, and low lighting. Also non-directive pushing, availability of hydrotherapy, hoists for the overweight, and intermittent fetal heart auscultation or continuous remote telemetry which can be helpful. In these days epidural analgesia need not prevent some of this optimisation. Normalizing birth for most of these women reduces risk. As for the partogram, the Cochrane database shows that there is no evidence that it is useful for following progress in labour, surprising information which I have accepted in advance of my obstetric colleagues.
Why can't labour wards look more like birth centres? I felt edgy, admitted as a patient to the labour ward, and I realised that if a woman was in labour in hospital, aiming for a comfortable, safe environment to enable her body to work with nature, the agitated atmosphere in the labour ward would expose her to the antithesis of this, and would trigger the release of her “fight or flight” body chemicals, adrenaline and noradrenalin. These chemicals would slow down contractions, disturbing the natural rhythms set up by her own body. I realized that if it felt that way for me as a doctor, in a familiar setting, surrounded by known and trusted colleagues, it must be far worse for the women for whom we care.
There are obstetricians who dislike the “gentle caesarian” – a sympathetic, communicative team, dim lighting, delayed cord clamping and early skin to skin contact – despite the typical gratitude of mothers who have experienced it. That vital early bonding need not be completely disturbed; it is usually unnecessary to separate mother and baby even for resuscitation, which can be done with the cord still attached (delayed clamping reducing the baby's blood loss), while close contact, breast feeding and midwife support are all possible. When interventions such as inductions and emergencies are unavoidable we can still try to rescue as many elements of physiological birth as are reasonable, and in any case good birth preparation including autohypnosis with its known benefits can be helpful.
Unfortunately doctors get very little education on the behavioural aspects of birth, and normal birth hardly impacts on public health and society, leaving people blind to the basics of physiological birthing and to much that may go wrong and require any of a number of interventions. We professionals have not infrequently to face stress inducing problems, and the difficulty of explaining them to others.
Fear can affect all the actors in the drama of birth, and it is aggravated by the influence of television programmes on the subject; fathers, mothers, midwives and obstetricians, all may have to face fear. But all the means of support which have been covered by the previous speakers, and permitting the mothers and partners to be loving and sensual, promote the generation of cerebral oxytocin, which in its turn promotes glucocorticoids, active in tissue healing, serotonin and pain relieving opioids. Medication for posttraumatic stress disorder (PTSD) may occasionally be useful.
I believe in multidisciplinary training in normalizing birth additional to skills and drills, and hope that the RCOG will incorporate such a programme. It might include biobehavioural aspects of birth, the impact on public health, the microbiome (http://en.wikipedia.org/wiki/Microbiome), life-course epidemiology, images and videos of positive birth (I subject my students to one on orgasmic birth monthly!), home birth and birth centre experiences, and the notion of childbirth human rights.
We are part of the start of life, and must contribute to the building of loving families and societal health. And that's why it's so important to normalize complicated birth.
Uvnas-Moberg, K.(2003) The oxytocin factor tapping the hormone of calm, love, and healing. Cambridge, Mass: Da Capo Press.
Lokugamage, A. (2011). The Heart in the Womb: An exploration of the roots of love and social cohesion. Docamali Ltd..
Ivan Illich/social iatrogenesis relating to birth. http://midwifery.megtaylor.co.uk/index.php?option=com_content&view=article&id=21:social-iatrogenesis-and-tokophobia&catid=1:midwifery&Itemid=2
Observing and interacting with the newborn using the Brazelton approach.
Dr. Joanna Hawthorne PhD., Psychologist and Director, Brazelton Centre in Great Britain (www.brazelton.co.uk).
Babies are incredibly capable interactive partners.
At the Brazelton Centre we work antenatally, talking about baby behaviour with families, and from birth to three months, with the early minutes, hours and days the most important.
Here's a baby. What's he thinking, feeling, at two days old? (Alert, but some strain after an assessment). Another baby, at two weeks enjoying play. The language of a baby is his behaviour. He is ready to interact at birth, and we health professionals need to form a relationship with the parents through the baby, sharing our observations with them. It's the interactions which lead to attachment, which will be secure for at least 60%.
Now the parents learn how to read the baby's cues and so to understand them: “What's he saying, what does he want? What do I do now?” We facilitate the parent-baby relationship, helping the child and the caregiver to learn how to adapt to each other. (Als et al. 2004; Meisels and Shonkoff, 1990; Nugent and Brazelton, 2000; Shonkoff and Phillips, 2000). The Brazelton approach is about understanding the baby, while observing the parents' reactions.
Beatrice Beebe in the USA has shown us that the interaction of 4 month-old babies with their mothers is predictive of attachment at 1 year and 4 years, and that facial mirroring and vocalisations predict social and cognitive outcomes at 4 years old. Also 'chase and dodge' interactive behaviours predict resistant attachment; the baby's reaction to intrusive behaviour is to avoid eye contact, and he's taking a break. Dr Ed Tronick's still-face experiment tells us that the observed, tested, and proven danger of prolonged negative interactions (“ugly”, as he expressed them) initiated by the mother—whether due to post-partum depression, drug abuse, child abuse, or neglect—is that over time the infant's social-emotional development may fail and lead to aberrant brain pathways. Tragically, the infant may feel helpless and become apathetic, withdrawn, and depressed. Others may become angry, hyper-vigilant, and emotionally brittle. (http://www.umb.edu/academics/cla/faculty/edward_tronick). And we know that depressed mothers often experience a profound sense of emptiness, including a loss of interest and pleasure in being with the baby. Postnatal depression can compromise their ability to respond to the infant's cues and to engage in affectionate responsive interactions with him.
It's not long since we began to think of a baby as more than a 'blank slate', thanks to three decades of research. He is competent, using all five senses, and organized, with a system of behaviours enabling him to affect the behaviour of his parents and to be affected in turn by them. He is an individual with likes and dislikes and sensitivities. Meanwhile he is learning fast; his brain's development, structure, and functions are affected by his early experiences and environment. Baby behaviour means something: no behaviour is random; behaviour has a meaning – it's the baby's language, and he has an excellent memory.
The mother is wondering what her newborn is doing. He is learning. To imitate, and to understand the minds of others; to make some meaning of his world; to predict what will happen next, based on previous experiences. He is learning about his emotional states and those of others; about his familiar people; and importantly, how to regulate himself. What he wants, his signals, the built in behaviours, need to be seen in context, learning and looking. His whole body is involved in his responses, and to understand these we use video, enabling a micro-analysis of mother-infant interaction. This is the only way to see touch, distance, fleeting facial expressions, behaviours which are often subtle. The same kinds of interactions are seen in mothers and babies, monkeys and their young, and lovers on benches in the park (Beebe 2013).
Dr. Brazelton, a former paediatrician and paediatric psychiatrist now aged 95, recognized that babies could do more than feed, sleep and cry, and began to examine all their behaviours. He found that they are competent in taste, smell, touch, hearing and vision. His followers engaged in research in these areas, discovering in the babies they observed that they could visually track (Dannemiller and Friedland, 1991; LaPlante et al. 1996, Meltzoff and Moore, 1999), hear and locate sounds (Muir and Field, 1979; Moon and Fifer, 2000), and demonstrate becoming accustomed to stimuli (Hood et al, 1996; Slater et al. 1984). They can recognize the mother's voice and smell (deCasper and Spence, 1991; Schaal, 1998; Spence and Freeman, 1996), and discriminate her face from that of a stranger at four days of age (Pascalis et al. 1995). They can recognize emotional expressions (Field, 1984) and look significantly more at a face with direct gaze than at a face with averted gaze (Faroni et al (2001).
Newborns can orient towards a sound as early as age 10 minutes (Wertheimer, 1963); they can not only see but also have clear-cut visual preferences such as complex rather than simple patterns (Fantz, 1963). When a story was read to the baby in utero the baby sucked faster to hear the same story, not a different one, when one day old (DeCasper & Spence, 1986). A baby one hour old will copy as the experimenter holds up 1 to 3 fingers (Nagy, 2010).
Babies are primed to interact.
Our tools in the work of observation and its analysis are the Neonatal Behavioural Assessment Scale (NBAS, 1973) and the more user friendly Newborn Behavioural Observations (NBO, 2007). They are systematic observational and neurobehavioural interactive tools producing information about infant behaviour and promoting relationships from birth to 3 months old. They show the infant's reactions to stimulation, reflexes and social interaction, and study his habituation (sleep), state-regulation, self-quieting (from crying), and feeding.
Behavioural states form the basis of this work. Take sleep: State 3 is drowsy (semi-dozing, eyes opening, activity level variable, smooth movements). A well regulated baby who leaves State 1 (deep sleep - eyes closed/no eye movements, regular breathing, startles, jerky movements) and moves smoothly to State 4 (alert - bright-eyed; focuses attention; motor activity minimal) has parents who find him “easy”; a baby who moves from State 1 to crying (State6 - intense crying, difficult to break through; motor activity high), back to light sleep (State 2 - REM sleep, eyes closed/brief eye opening, some movements, startles, sucking on and off) then briefly to State 4 is more challenging to work with. He needs our help. We may notice that he is easily disturbed from his sleeping state; how is he to return to sleep? There are levels of states: a low level of alertness has the baby awake but not ready to play; they may even shut down, perhaps a way of disengaging which can appear to be sleep, a sign of stress, over stimulation, though parents dislike the word stress . We call a low level of State 6 fussing, a form of vocalising short of the continuous wail of real crying. A baby has many ways to help himself to stop crying: opening his eyes to distract himself with the environment; bringing the hands together across the chest or up to his mouth to suck; changing body position.
Parents can talk to help him stop crying, one of the forms of social interaction so essential for a baby's thriving, and there are numbers of other ways to help him to calm himself: just looking at him and while talking, placing a hand on his belly or his arms across his chest, picking him up and holding him calmly, perhaps with rocking, putting his hands to his mouth or a pacifier or parent's finger in his mouth, always calmly.
Our objective in making these observations is to set up a profile of the baby's way of managing his states and stimulation, his likes and dislikes. The parents learn from this and may themselves make additions based on there own observations. Thus we can design a scheme of support and recommendations for caregiving.
Research has shown that the use of the NBO results in mothers becoming more confident, more reponsive to their babies, playing with them more; fathers are more involved with their babies at age one month, preterm babies have higher cognitive scores, and babies of low birthweight have higher developmental scores. Other improvements are observed at age four years.
I repeat - the Brazelton approach is an excellent way to understand babies.
Barlow J and Svanberg PO (editors). Keeping the baby in mind. Routledge 2009
Brazelton TB and Cramer BG. The Earliest Relationship. Karnac Books, London 1991
Brazelton, TB and Nugent, JK. Neonatal Behavioral Assessment Scale, 4th edition. MacKeith Press, 2011
Nugent JK et al. Understanding newborn behavior and early relationships. Brookes, 2007
Stern, D. (1995) The Motherhood Constellation. New York: Basic Books
Trevarthen C et al. What infants' imitations communicate: with mothers, with fathers and with peers. In: Imitation in Infancy, Nadel J & Butterworth G (eds) Cambridge University Press 1999
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