Ep 170 Pregnancy: Act 3

This is exactly right

on Fox One.

You can stream your favorite news, sports, and entertainment live, all in one app.

It's fing roll and unfiltered.

This is the best thing ever.

Watch breaking news as it breaks.

Breaking tonight, we're following two major stories.

And catch history in the making.

Gibby, meet Freddy.

Debates,

drama, touchdown.

It's all here, baby.

Fox One.

We live for live.

Streaming now.

Hi, I'm Morgan Sung, host of Close All Tabs from KQED, where every week we reveal how the online world collides with everyday life.

There was the six-foot cartoon otter who came out from behind a curtain.

It actually really matters that driverless cars are going to mess up in ways that humans wouldn't.

Should I be telling this thing all about my love life?

I think we will see a Twitch stream or president, maybe within our lifetimes.

You can find Close All Tabs wherever you listen to podcasts.

Today's episode is brought to you by Toyota.

The Toyota Certified Used Vehicle Sales Event is full of great surprises, like a wide selection of low-mileage models all backed by Toyota, with warranties that start on the date of purchase.

Because when it comes to quality, the best new cars make the best used cars.

So don't miss your chance.

Find your certified Toyota today.

But hurry, these great offers end November 3rd.

Toyota Certified Used Vehicles Sales Event, where every surprise is a great one.

Inventory may vary by dealer, participating dealers only, comprehensive in Powertrain or limited warranties.

See TCUV warranty supplement, ToyotaCertified.com or your Toyota dealer for details.

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.

Hi, my name is 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 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 36 week appointment if they had any idea how big she was going to be.

I had 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 very large.

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 40 weeks and 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 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 glucose 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 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 vacuum assist delivery, which is where they literally use a suction cup to suction to the baby's head to help you pull them out.

And there's some complications that can come with that.

So, you know, they brought in some extra hands and it was a little nerve-wracking.

And I was actually able to push her out on my very last push before they were going to start the vacuum vacuum assist.

Everybody was all in their sterile field and everything.

And I was able to push her out.

And I ended up having a 10-pound, 0.01-ounce baby girl who was 96 percentile for weight and 91st percentile for height.

And to this day, she's three and a half and she's still at the very top of her growth curve.

She's probably almost 45 pounds and she's over three feet tall.

She's a very tall girl.

So we're going to 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 assist and a surprise 10-pound baby.

Hi, 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 best 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 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 meconium aspiration syndrome, or MAS.

After 27 hours of labor, I had no choice but to undergo a C-section.

Exhausted, scared, and devastated, I was ripped away from my husband and Doula and wheeled into the operating room.

During the C-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 and with an iron grip on the umbilical 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 NICU.

My husband went with her.

It was basically my worst nightmare of birth.

Thankfully, after some initial help breathing and five days in the NICU, 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 grieve for the birth experience I imagined, for the initial bonding time I'd missed, for my baby's first cry, 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, C-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 unequipped to hear anything that wasn't sunshine and rainbows instead of an adult human who, best case scenario, was about to go through vaginal labor and delivery.

I wish I had fought through the patronizing rhetoric, did more C-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 C-section discussion.

Every case, every 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 you failed.

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.

And so throughout this episode and the next episode, the last episode in our series, you will hear more first-hand accounts.

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 are eternally grateful.

They really do mean the world to us.

And we listened to and read every single one.

So thank you.

Eternally grateful is

very accurate.

Yeah, very accurate.

Hi, I'm Erin Welsh.

And I'm Erin Allman Updike.

And this is this podcast will kill you.

Coming to you from the exactly right studios

to record the third episode about pregnancy

in our four episode series.

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.

So

we get some props,

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.

Head to YouTube.

I have some really good props for this episode, guys.

I made them myself.

Shit, the last episode, too.

I did.

There's the tennis ball.

Yeah.

No, that was the first episode.

Oh, actually, I know.

It was a lot.

Yeah.

My mind was.

The placenta.

It was great.

Oh, the placenta.

Yeah, yeah, yeah.

Yeah, that was good.

Okay.

So it's going to be a fun day today, Aaron.

It is.

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 first or second episode in this series, this is all gonna sound familiar to you.

But in case this is your first time tuning in, welcome.

And we've got a few things that we wanna share.

So we're gonna talk about what we will cover in each of 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 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 the future.

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 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 has roughly corresponded to each trimester.

Very roughly, but.

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.

And our most recent episode, last episode, our second episode, we talked about the amazing organ that is the placenta.

We love it.

Do you love it now?

Have you listened to that episode?

If you, once you do, you will love it.

I will love it.

I feel confident in that.

Absolutely.

Yeah, I agree.

It's pretty phenomenal.

And then we also talked about some of these broad system body changes that happen during pregnancy, system by system, and including focusing on some complications that can arise, which I guess might make you not like the placenta a little bit, too.

It's a complicated feeling, you know, we have complicated feelings about the placenta, but we also appreciate appreciate its amazingness.

Its amazingness.

Yeah.

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 ring.

Oh my gosh, there is so much to cover.

I'm literally so excited.

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 this big picture history of how we moved childbirth from the home to hospital and some of the consequences of that.

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 historically and in present day is a result of gender discrimination and racism.

So in those contexts we may also use the term woman or women and throughout these episodes we'll be using terms like mother or maternal and paternal as these are what are used in the scientific and medical literature.

We also want to acknowledge that there is no such thing as a normal pregnancy.

There's not just one.

There's not just one.

There's not just one textbook example of 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 understand when things kind of maybe go outside of those boundaries and then what happens.

And this kind of helps us to understand what complication actually means.

Right, exactly.

Okay, that was a lot.

All of our disclaimers and information.

And

Thanks for sticking with us.

I'm really excited about today, but first.

But first, I almost forgot, Erin.

I was like, let's get started.

It's quarantining time.

It is.

Well, what are we drinking this week?

We're drinking the same thing.

We are.

Great expectation.

We're not actually drinking it right now, but we have drunk it.

It is so good.

It is better than we expected.

We can't reveal our secrets, our lack of confidence in our recipe making.

It is very good and we made a placebarita with blackberry, ginger, ale, lemon, mint, mint.

There's a video on YouTube of us making it, which was very fun to make.

It was really fun.

It was really fun.

And Georgia Hardstark provided a wonderful quarantine for us to go with this episode.

So that is available on YouTube today.

Antini.

Santini.

It has a name now.

It's very cute.

Oh my God.

It was so much fun.

It was really fun.

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, thispodcastwillKillyou.com.

It's the third time in a recipe.

You haven't sent it to me.

I can say what's on our website.

Let me do it.

Ready?

On our website, thispodcastwillKillyou.com, you can find incredible things such as merch.

You can find links to our bookshop.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

Blood Mobile, who who does the music for every one of our episodes.

Thank you, panicked.

You can find a contact us form and a first-hand account form.

There's probably more.

All of the sources from each and every one of our episodes.

Yeah.

And there might be more.

Tell us what we missed.

Go check out our website.

Go check out our website.

I thought you meant me.

And I was like, I don't know what I missed, Aaron.

This podcast will kill you.com.

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.

Yeah.

Thanks for listening.

Let's stop talking so that we can start talking.

I love that plan.

Let's take a quick break and then we'll really get started.

Okay.

Be honest.

How many tabs do you have open right now?

Too many?

Sounds like you need close all tabs from KQED, where I, Morgan Sung, Doom Scroll so you don't have to.

Every week, we scour the internet to bring you deep dives that explain how the digital world connects and divides us all.

Everyone's cooped up in their house.

I will talk to this robot.

If you're a truly engaged activist, the government already has data on you.

Driverless cars are going to mess up in ways that humans wouldn't.

Listen to Close All Tabs, wherever you get your podcasts.

Betrayal Weekly is back for season two with brand new stories.

The detective comes driving up fast and just like screeches right in the parking lot.

I swear I'm not crazy, but I think he poisoned me.

I feel trapped.

My breathing changes.

More money, more money, more money.

And I went white.

I realize, wow, like he is not a mentor.

He's pretty much a monster.

New stories, new voices, and shocking manipulations.

This didn't just happen to me.

It happened to hundreds of other people.

But these aren't just stories of destruction.

They're stories of survival, of people picking up the pieces and daring to tell the truth.

I'm going to tell my story and I'm going to hold my head up.

Listen to Betrayal Weekly on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

Hi, it's Jemis Begg, host of the Psychology of Your 20s.

Remember when you used to have science week at school?

Well, if you loved that, how would you feel about a full psychology month?

This September at the Psychology of Your Twenties, we're breaking down the interesting ways psychology applies to real life, like how our pets actually change our brain chemistry, the psychology of office politics, whether happiness is even a real emotion, and my favourite episode, Why Do We All Secretly Crave External Validation?

It's so interesting to me that we are so quick to believe others' judgments of us and not our own.

I found a study that said not being liked actually creates similar levels of pain as physical pain.

Like, no wonder we care so much.

So, the secret is: if you want to be okay with not being liked, you have to know why your brain craves it in the first place.

Learn more about the psychology of external validation, everyday life, and of course, your 20s.

This September, listen to the psychology of your 20s on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

Hi, I'm Laura and this is my pregnancy story.

To begin, we've got to rewind briefly to April 2018.

I was 27 and diagnosed with HER2 positive breast 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 preserve my fertility, which put me into essentially early menopause.

I did chemo through the summer and fall and then opted for a double mastectomy 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 2021, 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 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 food concoctions, but I really wanted a turkey sub 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, but ultimately I'm happy with my decision.

So now it's July 5th, 2022.

I'm 39 weeks pregnant, it's 11 p.m., and I'd finally laid down for bed after nesting and cleaning my whole house that day, even being sick with COVID.

I'd just tested positive the day before.

I got up because I felt the urge to pee and in true dramatic fashion, just like the movies, my water broke in a huge gush.

Of course, my hospital 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 easy or fun to breathe through contractions with a mask on.

I did my whole labor that way for nearly 30 hours.

Then it was time to push.

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 at 2.38 in the morning on July 7th.

She's my lucky 7-7 post-cancer miracle baby.

Today my daughter is 2.5 and 1 wild redhead little girl.

I'm six years cancer-free and we're living our best life.

My name is Jaden and I found out I was pregnant in January of 2024.

Overall, it was a very normal pregnancy.

However, at week 20, 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 39 weeks.

However, a week after that, there was a large increase in amniotic fluid, so we elected to schedule an induction for 38 weeks for polyhydromniose.

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 14 hours.

Because there was so much fluid, my 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 18 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 the same position.

Because of this failure to descend and she was not yet in distress, we decided to go in for a C-section.

The C-section was uncomplicated and my baby girl was born at 38 weeks and 2 days at 7 pounds 15 ounces.

She is now a very healthy 4.5 month old.

Childbirth in humans is difficult.

It is long.

It is painful.

It carries with it significant risks to mother and baby.

Afterbirth comes with its own set of challenges.

Caring for a newborn that is largely helpless can be overwhelming.

Largely is an understatement.

They are entirely helpless.

Entirely helpless.

And these human experiences are exceptional compared to most, but not all, other mammalian or primate species.

Why?

Why?

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 hominin ancestors evolved bipedalism, being able to move around on two feet rather than four.

Why?

I just keep going why, why, why?

But why?

Because maybe it allowed us to live in more varied habitats or acquire more varied food sources or 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.

Our pelvis, our body.

Our pelvis.

And at some point, after these anatomical changes, head size in our ancestors also grew as we got 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.

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.

Maybe affect our fitness somehow.

Affect our fitness, yeah.

I mean, it's like,

if we needed the pelvis to expand, then we would lose the ability to like the balance and the movement and the running.

You know, it's like, yeah.

Trade-offs.

Trade-offs.

That's the thing.

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.

I love thinking of evolution in this very inaccurate way of giving it like agency.

Yeah.

Oh, yeah.

No, I know.

I think evolutionary biologists are like, what are you doing?

Sorry.

Evolution does not have agency.

It's, yeah, yeah.

But I mean, that's, that is how I'm going to present it.

I love it.

So that's, you know, it's fine.

It's a good way to just think like in your mind, frame it.

It's just, yeah, it's fine.

The end result is the same.

Exactly.

This is what happened.

This is what happened.

And, but this long period of neurodevelopment after birth might be what allows us to learn more and have flexibility in our learning.

Okay.

So at birth, the brain size of a neonate is about 25% of what it'll be as an adult.

Wow.

Which is the smallest neonate adult proportion of all primates.

Like it is, oh, of all primates.

Of all primates.

Okay, interesting, interesting.

Yeah.

So other primates, their brains come out already bigger.

Already bigger compared to their adult brain size.

Okay, interesting.

And compared to other primates, our newborns seem especially helpless.

I 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.

And you think of like the baby monkeys who can just go

and hold on so well.

Yeah.

And ours can just do this palm or grass reflex.

And you're like, thank you.

Good job.

You're working hard.

I know.

We do work hard.

It's true.

Some researchers suggest that to match the developmental stage of other apes right after birth, humans would have gestation seven to 12 months longer than our nine-month gestation.

No, thank you.

There is some current debate on this point.

Like, Like, yeah, there's nuance, there's papers.

Okay.

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 balance to strike with extremely high costs if things go awry.

How have we dealt with this over human history?

Tell me.

One way is through cooperation.

I know.

Humans and our cooperation.

We are capable of it.

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?

Interesting.

We don't know.

We probably hardly

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 the burden of care falling to one or two people.

This is far removed from how our ancestors would have experienced child rearing in a cooperative social group.

Childbirth was 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 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's just you or you and one other person continuously on call to take care of a newborn, that may emphasize the never-ending needs of that newborn.

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 that how it's always been?

That's a really difficult question to answer, 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.

We can know some things.

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 not has not been always in a positive direction.

Right.

For instance, in the 19th century, as more male physicians attended childbirth after receiving little, if any, education in 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.

Right.

And we talk a lot about that in our episode on

Semmelweis and pupil fever.

Yeah, yeah.

I was like, which episode was that?

Because I know we covered it in detail.

It was like a long time ago.

Yeah.

But the specter of infectious disease during childbirth may be a more recent development, relatively speaking.

Some researchers have suggested that early in our evolutionary history, birth might not have been as dangerous, but following the agricultural revolution around 20,000 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.

So it used to just be that if we were limited by nutrition, then you're, huh?

I mean, maybe.

Maybe, maybe.

Who knows?

Okay, okay.

The Industrial Revolution in the 18th and 19th centuries may have contributed to difficult childbirth in other other ways.

For instance, rickets caused by vitamin D deficiency, see our 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.

Ah, okay.

The WHO today roughly estimates that 5% of births with labor starting spontaneously develop complications.

Okay.

5%.

5%.

Birth records from a late 18th century midwife, Martha Ballard, the book, The Diary of a Midwife, it's based on her story, is incredible, suggested that 5.6% of births that she attended were difficult.

Interesting.

That 5% number for difficult labor or delivery pops up elsewhere throughout the 18th and 19th centuries until medical intervention increased, at which point then difficult increased as well.

And it's not clear what that 5% complications rate means for maternal or neonatal mortality historically.

How does it and what is different?

How is definitely defined?

Right, exactly.

Requiring intervention, then what is requiring intervention?

How do we make those decisions?

Yeah.

But those historic numbers, and often the ones today, these estimates, don't necessarily capture postnatal issues such as like prolapsed uterus or fistulas, something like that, which can be long-term permanent changes that

affect your morbidity over time.

But what strikes me is how different that 5% number is compared to the C-section rate, which here in the U.S.

is around 33%.

High, not the highest.

Brazil holds that title with 54% of births done by cesarean.

Wow.

Private hospitals have an 84% C-section rate in Brazil.

84%.

84%.

Yeah.

Wow.

Yeah.

Okay.

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 the U.S.

and around the world?

Like, period.

And that is of all surgeries.

Right, including like tonsillectomies, appendectomies.

Pain replacements.

Right.

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?

How do we get the answer to that?

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 C-sections, and how, 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.

Okay.

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 learn more.

So, one book is called Caesarean Section: An American History of Risk, Technology, and Consequence.

That's by Jacqueline Wolfe.

And another is called Invisible Labor, The Untold Story of the Caesarean Section by Rachel Summerstein.

Okay.

All right.

Are we ready to talk about C-section?

I'm literally so excited.

I want to start off by describing what happens during a C-section step by step.

Wonderful.

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.

Every median listening that's about to start their OBGYN rotation is thrilled.

Thank 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 mons pubis, slicing through layers of skin and fat and the fascia that covers the abdominal muscles.

The physician parts but does not cut the rectus abdominis muscles

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 C-section moms are told they might 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 sew it closed.

Then she sutures the other layers of the patient's abdominal wall and finally closes the topmost layer.

End quote.

Yep.

Yeah.

Hotly accurate.

But like it's amazing how you just think, like I feel like most people don't know the step by step.

No.

Which what's being cut, in what order, how do you get the placenta out, like all these different things.

Yeah.

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.

It's amazing.

And so this is the way that most C-sections are done today.

Most.

But this is not how they've always been done.

The earliest record of C-sections that we have dates back over 2,000 years.

Wow.

Yeah.

I feel like those were not good ones.

Well, the intention of C-section has changed a lot over time.

Okay.

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.

And so it was mostly like a last-ditch effort to save the baby or baptize the baby before it died.

Okay.

Or as a crucial step to prepare 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 Caesarean got its name.

Because it's not Julius Caesar.

Not Julius Caesar.

Yeah, so

a lot of stories go that, oh, the Caesarean got its name from Julius Caesar, the Roman emperor who was born via C-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.

Oh, okay.

Up until the 19th century, really, cesareans remained exceedingly rare, only performed in extreme instances, and the mother's life took precedence over the baby's.

Shockingly, there are cases where both mother and baby survived, the first being either in Prague in the 1300s or Switzerland in the 1500s.

Wow.

I know.

Wow.

I know.

Okay.

But overall, that outcome was like very, very rare.

Mostly a cesarean was viewed as a success if the mother survived.

Okay.

Regardless of the baby's status.

This would remain the case well into the 20th 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 the mother or the baby's.

Okay.

Anyone surviving a C-section was still so notable that it often made the history books, such as the case of Alice O'Neill, an Irish woman who had labored for 12 days until her midwife Mary Donnelly by her side, this was 1738, and then Mary, her midwife, was like, the only way to save Alice, Alice's baby had died during this long labor already, was to do a C-section.

And so Mary performed the C-section and Alice made a full recovery.

In England, the the first C-section where a mother survived took place in 1793.

And in the U.S., the year after, although this is somewhat disputed.

In the U.S.

case, there was a woman named Elizabeth Bennett, which is also, you're thinking Pride and Prejudice?

Okay, yeah.

So 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 forceps delivery didn't work and so Elizabeth's husband took matters into his own hands made an incision pulled out baby and 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

allegedly

yeah it's a little embellished like the telling of it so who knows if it's true and I want us to take all of these milestones with a 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 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 1880s, a British physician named Robert Falcon wrote about his experience in Uganda, where he observed cesarean sections being performed in the 1880s.

The surgery seemed not uncommon, was intended to save both mother and child, was often successful, and used anisepsis and pain treatment using banana wine.

Oh, interesting.

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.

Okay.

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 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 grim, dark, but realistic.

Yeah.

Yep.

These things kept cesarean numbers low for most of the 20th century.

Okay.

Between 1838 and 1878, 89 C-sections were performed in the U.S.

Okay.

62% of mothers died.

60% of babies died.

Okay.

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 obstetrics of which this obstetrician stands so much in dread.

Yeah.

Okay.

For the sentiment to change going into the 20th century, four developments needed to take place.

Anesthesia, anisepsis, 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 Poro technique in 1878, which involved amputating the uterus at the cervix and suturing the cervix into the abdominal wall.

Whoa.

Yeah.

This actually did reduce infection and hemorrhage, brought the survival rate up to 44%.

Okay.

Max Sanger used silver wire in uterine sutures beginning in the late 1880s, further improving survival rate.

I think previously they were like, should we even suture the uterus back together?

Oh, gosh, okay.

Because, well, infection was so bad.

Yeah.

By the 1910s, the overall maternal mortality rate for cesareans dropped to 8.1%.

Wow.

Which is lower than the 56% it was in the late 1800s, but still very high for a surgery.

So its use was debated.

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.

Oh my God.

Okay.

Yeah.

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 want to avoid a cesarean, so we'll just induce you.

So that became very, very popular.

But over the first seven decades of the 20th century, that perception of risk would change.

What started out as a 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 of the physician to finally something that was routine.

The reasons for this shift included those I mentioned earlier, transfusions, anisepisis, anesthesia technique, plus antibiotics introduced in the 1940s, and 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.

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.

And so then we started to develop things like diagnostic tools, Apgar score, the Friedman curve to measure how labor is progressing, x-rays, ultrasound, and the electronic fetal monitor,

which was introduced in the 1950s, or a lot of these were established by the 1950s and 1960s.

Obviously, x-rays were a long time previous 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 C-section

or placental issues, pelvis size, estimated baby size, uterine rupture, preeclampsia, et cetera.

We got better at detecting those and measuring those and being like, well, we should

see the risk, so how can we not do something about it?

Yes, exactly.

That's what it it is.

Exactly.

Yeah, okay.

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.

Oh, Aaron.

I know.

Okay.

Yep.

By the 1970s, the tides had fully turned and C-sections were about to skyrocket, at least here in the U.S.

To give you some idea of this massive change, let me throw throw some numbers at you.

Please.

Until 1970, the US C-section rate was 5.5%.

Wow.

Okay.

Between 1965 and 1987, the rate of C-sections grew 455%.

And 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.

Yeah.

Electronic fetal monitoring was a big okay.

Oh, that's really interesting, especially in the context of like today.

Yep.

Okay.

Interesting.

Yeah.

And it became like it just, there are so many different dynamics to this as well.

Yeah.

So in 1965, the rate was like 4.5%.

In 1987, it was 25%, which is also lower than it is today.

Yeah.

Articles or stories that referenced C-sections in the 1960s still included a definition of the procedure.

Wow.

Yeah.

Okay.

And those published after 1970 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 in part.

Interesting.

The skills that had taken them years to learn and perfect would be pointless with a surgical technique that took a few weeks to learn.

Interesting.

Yeah.

And 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 1970s was in part a reaction to the increasing medicalization of pregnancy and childbirth, which included C-sections.

And this combined with the push for vaginal birth after C-section, C-section, VBAC, in the 1980s led to a brief dip in C-section rates in the U.S.

Okay, okay.

But that decline was short-lived as resistance to VBACs grew among doctors, as insurance companies hiked up malpractice insurance rates for doctors who performed VBACs, and as hospitals just began to forbade it as an option.

Yeah.

Wow.

Hospital administration making decisions.

Cool, cool, cool, cool, cool, cool, cool, cool, cool, cool.

Insurance.

Yep.

Love it.

You

sweets.

Sorry.

do think this is probably like a global issue

to some degree.

Based on this data.

These are U.S.

numbers for sure.

Yeah.

The once a cesarean, always a cesarean adage that was first popularized by Edwin Craigen in 1916 still holds sway.

1916.

1916.

Yeah.

The perception of risk had shifted.

Before the 1970s, C-sections themselves were seen as the risk.

And after, not performing the procedure was was the risk.

Medical malpractice suits on failure to perform a c-section reinforce this.

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 C-sections.

I know you'll talk a little bit more about this, Erin, but high rates of blood transfusions, emergency hysterectomies, postpartum depression, difficulty breastfeeding, newborn lung conditions, and in subsequent pregnancies, stillbirth, uterine ruptures, ruptures, placental anomalies such as placenta accreta.

We can see the impact of C-sections on placenta accreta by looking at rates over time.

Yeah.

From the 1930s to the 1950s, placenta accreta occurred in less than 1 in 30,000 births.

Oh my gosh.

By 2016, that number was down to one in 272.

Yeah.

In large part due to C-sections.

Right.

Placenta accreta is when the placenta grows too 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 generally a cesarean 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 Yeah, and it's like from my understanding is that risk of placenta accreta increases with every C-section because there's a potential for just the lack of like decidua that can form where the previous scar is.

Exactly, because of the cesarean scar.

Yeah.

Yeah.

Yeah.

Okay, now that we've like talked about some of the negative things, I do want to just emphasize that C-sections are absolutely a life-saving procedure.

They really are.

And they are incredibly safe.

Yeah.

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 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.

Or can't understand like everything that's happening all at once because it can change on a dime.

Exactly.

Yeah.

Yeah.

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 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 C-sections, but it is something that gets minimized both during and after childbirth, both of which carry significant rates of emotional trauma.

One study I saw reported 45%.

The message is, well, you've got a healthy baby.

What do you have to complain about?

Get over it.

You know, like, just enjoy your baby.

Yeah.

Also, they're screaming all the time.

So it's hard to enjoy.

How can you enjoy?

But this no big deal sentiment carries over into the physical trauma of C-sections, which are treated like the world's most minor surgery instead of the major abdominal surgery that they are.

I do find that so interesting.

Yeah.

It's like, oh, cesarean.

Oh my God.

It was like, that must be nice for you.

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?

Yeah.

And even if your newborn is only like six or seven pounds, you're

12.

And so now you're at your 20-pound max.

Right.

Great.

And then how long?

How long does that go?

In the famous pregnancy book, What to Expect While You're Expecting, you know, this book, everyone knows.

I've never read it, though.

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.

I hope that was, I don't even know what I hope about that description because I,

oh, gosh.

My charitable take is that maybe it was meant to be reassuring.

Reassuring, sure.

And like, don't worry about it.

This is something that, you know, you don't have to stress about this major surgery.

It's not helpful for either side because it makes it seem like a vaginal birth is like the worst possible thing and it's 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.

It's all still childbirth.

It's all childbirth.

Yeah.

Yeah.

Yeah.

It's, and the thing is, too, I also, I also want to acknowledge that 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 a horrible time because maybe they didn't.

Maybe it was like, this is maybe it is totally fine.

It's a scheduled procedure and it goes exactly as planned and it was very relaxing and your recovery is easy and that's phenomenal.

Right.

Or even if it was unplanned and it's like, yeah.

And but the same can also be true for a vaginal delivery.

for sure yeah yeah but I feel like yeah this the saying it that way describing it that way is so dismissive right it's one way that it will go yes yeah yeah 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 is so incredibly harmful.

And I feel like this, this idea of natural birth or the term natural birth implies unnatural birth.

Right.

And that can be so othering, right?

That along with the 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 mother.

Like that sort of thing.

Right.

It compares and contrasts in this way.

Right.

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 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 C-sections shows this.

Oh my gosh, I talk about this in the middle.

In order 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 not even pushing.

What are you doing?

Do you want to have a C-section?

You know,

I know.

I know.

But it's that all places the blame on them making the C-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 birth to go a certain way, and then something goes not according to plan.

What do you do?

Do you feel like it's your fault?

It's it's really complicated.

And that, I mean, that is the truth of our entire lives, right?

Is that 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 when things, if things do not go according to that plan, it makes it seem like you did something wrong.

Right.

When that's not reality.

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...

What are these drivers for this 33%

rate of C-sections at the provider level, at the institutional level, at the systemic level?

One overlooked aspect is the individual provider's reasons for deciding on a C-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 C-section than your other colleagues.

Every provider has seen traumatic.

Everything.

I mean, the things that obstetric providers see on a daily basis are trauma.

Exactly.

Yeah.

Some hospitals, I found this fascinating, took to publishing or displaying each physician's cesarean rates, and that led to them plummeting.

Interesting.

Wow.

So which suggests that maybe risk tolerance for vaginal birth is lower than physicians think it should be.

And so I don't know what to make of that.

But I do think that is, yeah.

And then there's implicit bias.

Black mothers are more likely to have C-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 funny because it's like, but we're also, you have pain.

I don't believe you.

Yeah.

Other research shows that female OBGYNs and maternal fetal medicine specialists are more likely to opt for an elective cesarean for themselves rather than low-risk vaginal birth.

21 to 31% preferred elective cesarean.

So how does that personal preference bleed into their practice?

Along with these individual drivers, what about the US medical system as a whole?

Oh, gosh.

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 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 difficult labor?

Let me reiterate again, C-sections are a life-saving and generally extremely safe procedure.

But in order to reach the WHO's recommended ideal C-section rate of 10 to 15%,

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 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 week.

I'm excited about it.

Next episode.

But for now, Erin, I want to turn it over to you to tell me all everything about labor and delivery.

I'm not going to tell you everything,

but I'll cover a lot right after a short break.

Yeah.

Hi, I'm Morgan Sung, host of Close All Tabs from KQED, where every week we reveal how the online world collides with everyday life.

There was the six-foot cartoon otter who came out from behind a curtain.

It actually really matters that driverless cars are going to mess up in ways that humans wouldn't.

Should I be telling this thing all about my loved life?

I think we will see a Twitch stream or president maybe within our lifetimes.

You can find Close All Tabs wherever you listen to podcasts.

Betrayal Weekly is back for season two with brand new stories.

The detective comes driving up fast and just like screeches right in the parking lot.

I swear I'm not crazy, but I think he poisoned me.

I feel trapped.

My breathing changes.

More money, more money, more money.

And I went white.

I realize, wow, like he is not a mentor.

He's pretty much a monster.

New stories, new voices, and shocking manipulations.

This didn't just happen to me.

It happened to hundreds of other people.

But these aren't just stories of destruction.

They're stories of survival, of people picking up the pieces and daring to tell the truth.

I'm going to tell my story and I'm going to hold my head up.

Listen to Betrayal Betrayal Weekly on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

Hi, it's Gemma Spegg, host of the Psychology of Your Twenties.

Remember when you used to have science week at school?

Well, if you loved that, how would you feel about a full psychology month?

This September at the Psychology of Your Twenties, we're breaking down the interesting ways psychology applies to real life, like how our pets actually change our brain chemistry, the psychology of office politics, whether happiness is even a real emotion, and my favorite episode, why do we all secretly crave external validation?

It's so interesting to me that we are so quick to believe others' judgments of us and not our own.

I found a study that said, not being liked actually creates similar levels of pain as physical pain.

Like, no wonder we care so much.

So the secret is, if you want to be okay with not being liked, you have to know why your brain craves it in the first place.

Learn more about the psychology of external validation, everyday life, and of course, your 20s.

This September, listen to the psychology of your 20s on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

It was in March of 2023 that we lost our first baby to miscarriage.

We'd been trying to conceive for quite some time and were absolutely ecstatic to become parents, but we ended up in the accident and 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.

When we were in that 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 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 is so many people who are affected by baby loss.

To further this, I felt like I couldn't really 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 toll that it took on me and my partner as well.

Growing up, you're always told that if you have sex, 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 recurrent miscarriages, 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 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 24 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 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 24 weeks.

And I hope that my story can empower other people to campaign for the same in their workplaces and to feel less alone.

Hi, my name's Kate from Western Australia and I'm the mother of two preterm babies.

After a fairly smooth pregnancy at the age of 28 I gave birth to my son at just 30 weeks and five days.

He was 1375 grams or about £3.

Went to hospital after really bad cramping, backache and bleeding and I was advised I was in pre-term labour.

I 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 admitted 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 epidural.

Our son 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 a day or so in the ICU on oxygen.

He was then put on a CPAP 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 for skin to skin, which was such a surreal and amazing moment for me.

After many ups and downs, Jimmy was discharged from hospital after nine long weeks.

But he is now about to turn 15 years old.

Two and a half years later, his sister was born.

When I was 32 weeks and five days I had the same cramping, the same backache, 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 she was head down and quite small in size, we decided I was safe to deliver vaginally.

Evie was born at 1875 grams, which is about 4 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.

Our 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 Edward Memorial.

You made it bearable, and you're all so kind and so caring.

Thank you.

So,

by the end of the last episode, 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 of delivery.

And of course, Erin, you beautifully walked us through some parts of delivery, especially C-sections and how those go.

But I'm going to focus a little bit on what most people, because even at 33%,

most people, a lot of people, even in that 33% of cesarean sections go through some part of labor beforehand.

So what what the heck is that?

What is that?

What is labor?

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 C-sections and vaginal deliveries.

It's going to be great.

So what is labor?

Yeah.

Okay.

During our whole pregnancy, All of the hormones jutting around that we've talked about, progesterone, prostaglandins, 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 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.

What just, what is a contraction?

Yeah.

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 muscle fibers contracting, literally, like your biceps contracts.

But I mean, like, what, what,

what is a, like, how long does it contract?

No, Aaron, we're going to get.

No, no, we'll get there.

But Braxton-Hicks.

So what are 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?

there?

And that is

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 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.

Got it.

So what we see with the onset of labor is that these contractions 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 10, 15, even 20 minutes apart.

If they are causing cervical change, then they are considered labor contractions.

Okay.

Did you say like which hormones are causing this yet?

Sorry.

Did I say what triggers labor?

No, I did not, Eric.

Okay.

Because we don't know.

What?

We don't know.

I can't be right.

Check your notes again.

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 fetoplacental unit.

Yeah.

We think that because that is what happens in like sheep and cows.

And in those other animals, we 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.

Also, sheep and cows have less invasive placentas.

I know, I know.

So it's different.

That's why it's not the same in us.

But I mean, we have animal models that we understand-by-step 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 pitocin yeah um that triggers uterine contractions

but what triggers in someone who spontaneously goes into labor what triggers that because it's not just like just oxytocin it something else has to trigger the production of that yeah we don't know what that is okay 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 is don't know?

Okay.

So like we don't know why.

I mean, we know why they speed up like the purpose of speeding up.

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.

This is a balloon.

Is there something in there?

Don't worry, we'll get there.

Oh, my God.

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 of a balloon, is the cervix.

During pregnancy, it's tired.

I spent so long I practiced this at home and everything.

My kids helped me.

It was 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 you were to touch it.

Okay.

Okay.

And it is closed.

So you see that there's no opening here.

Yeah, what is that?

What is that?

No, I mean, like, like, but what is that?

The free you?

It is a little puff ball.

Okay.

Craft puff ball.

And what is it representing?

It is representing the mucus plug.

Oh.

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 in terms of...

So nervous, it's going to It's not going to pop.

I've practiced.

The cervix has to do two things.

It has to dilate and it has to efface.

Okay.

So dilation means that it has to go from closed to open.

It's not going to pop on you.

You're aiming that at me.

And so it has to go from a state of being completely closed to about 10 centimeters open in diameter.

Okay.

That is fully dilated.

10 centimeters.

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.

Yeah.

That's called effacement.

So it has to go from like several centimeters, kind of like thick and deep to basically paper thin tissue.

Got it.

So it's just, yeah.

Yeah.

It's just smoothing out and kind of becoming 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 little bit place to place.

So, just for transparency, I'm using US definitions, like 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 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, many hours long.

Yeah.

If those contractions are still happening at a regular interval,

even if again, that interval is like 10, 15, 20 minutes, if they're still having cervical change, change, albeit slow, that would still be considered labor, just latent.

There is estimates on like how long does latent labor last?

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 about 16 hours.

Wow.

Is the like 95th percentile?

That's not the average.

That's like the long edge.

Oh, oh, oh, okay, okay.

Yeah.

But again,

that's going to depend very much person to person.

Yeah.

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 be in active labor.

And that is the time at which the cervical chain should speed up to a predictable interval of about one centimeter every two hours.

Okay.

Or less.

Faster is totally fine.

Sorry, that's a six to six.

Six or six inches.

Okay.

Yeah.

So to go from 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.

But 10 is the

fully dilated.

Yeah.

Okay.

Okay.

Questions about any of that?

Yeah.

Okay.

So the active labor part is more predictable.

More predictable.

But then

everyone progresses through active labor

the same way.

Yeah.

Well, you mean through like that, from six to 10 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 is a crochet hook that I brought, 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.

Like you wouldn't want to crochet with that.

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 like limit the amount of pressure that's being exerted and might make it so that your cervix is 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.

What determines how much

fluid?

Oh, yes.

I was going to do it, but I think it actually might make a mess.

So, I'm going to stop there.

I had a baby in there today.

I'm envisioning the water going everywhere.

It would make a mess.

Yeah,

what determines how much liquid, how much amniotic fluid is in there?

Big question.

So amniotic fluid is P.

It's a fetus P.

Yeah.

So it depends on how much the fetus is peeing and whether or not their kidneys are working correctly and also how much they, because then they drink that P.

And so that, it's like a whole thing.

It's fetal development.

I'm not going to get into it.

Yeah, but okay.

So I 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?

Right.

Who knows?

What percentage breaks spontaneously?

Don't ask me those questions.

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, or they're born in the amniotic.

There's a whole history we could talk about.

Call.

Beautiful.

Yeah.

But in any case, when it does break, that allows for the fetal head to engage lower down in the pelvis, putting more pressure on the cervix and helping to ensure that you're getting adequate dilation and effacement.

What?

I have a question.

What is your name?

It might be jumping ahead.

Breach, number one.

Okay.

Number two, which, which, how is, what's facing?

Ah, facing baby head.

I have a baby.

Do you want me to show you?

Yes, I would 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.

Okay.

So that they are facing down.

Their face is facing maternal backside.

Yeah.

And their occiput, which is the back part of their head, is anterior, meaning facing up towards my 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 harder to push that through the canal first.

That'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 like for you know, neonates to be born.

Right.

And often, like, why we think that human childbirth is a cooperative process, is a social, is a social process, is because of the direction.

Interesting.

And so, it's like you more, it can be more difficult to, you can't do that yourself.

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 primates 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, 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 footling 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 U.S., it is recommended that people have a C-section if baby is breached and won't be turned around.

It won't be turned around prior to.

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 to try and induce that baby to turn.

What about shoulders?

Shoulder dystocia?

Okay, let's get, we're still in the the first stage of labor, Aaron.

We haven't gotten there yet.

An act of labor, Aaron.

So that was all the first stage of labor.

I skipped ahead a little bit with that delivery question.

But once we've reached 10 centimeters, I'm going to 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.

Okay.

But essentially, delivery is 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 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.

Right.

But

that's the second stage of labor is delivery.

Did I answer all of your questions about the modes?

I think so.

I think so.

Great.

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 10 centimeters.

Sometimes we might not even make it to six centimeters.

There's a lot of different things that can happen during 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.

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 then sort of, yeah, these, I guess, leading into this question of C-section?

Yeah, so I mean, it is all going to depend on where you 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.

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 like tension

externally.

The only way that we can actually measure the pressure that's being exerted on the fetus is through an internal monitor, which we do have.

Are those continuous or intermittent?

They are continuous.

Your water has to be broken to be able to get into the uterine cavity.

But that's something that 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 be that they're not strong enough to be inducing this cervical change.

That might mean that we have medications that can help because that's pitocin 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.

Are you going to talk about intermittent versus continuous fetal monitoring?

I mean, those are two options for monitoring.

Yeah, but in terms of like the decision-making and what that tells us, it's so variable that there's not like an easy answer that I have for that.

It's going to vary hospital to hospital.

It's going to vary provider to provider.

And it's going to also depend on your individual risk situation.

Right.

Where most people, if they have any kind of any degree of potential complications or like known complications, let's say that you have preeclampsia or you have gestational hypertension or something like that, 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 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.

Yeah, yeah.

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 C-sections, unless you have more questions about I'm sure that I will, but let's

give me the stats.

Okay.

So globally, rates of C-sections are about 21% on average global.

But that, like you mentioned, Aaron, is not at all homogeneous.

In places like sub-Saharan Africa, C-section rates are around 5%.

In Latin America and the Caribbean, up to 42%.

And like you said, Erin, even higher in some private hospitals.

In various places in Europe, we have huge variation depending on what geographic region from like 24 to 30%.

All across Asia, things can vary from like 12 to 33 percent.

Wow.

It's like huge, huge amounts of variation.

Australia and New Zealand are averaging around 33%.

And then we in the U.S.

are in the 30% range right now.

It's been up and down the last few years.

And like you said, the World Health Organization has a recommendation that no more than 15% of deliveries are by cesarean section.

I don't know exactly how they came up with that number.

Yeah.

But it's my understanding that that number is based on data to try and match the 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 mother or baby or both.

Or both, yeah.

And there is no doubt about that.

Yeah.

But deciding exactly when that point is can sometimes be really tricky.

Yeah.

There are

some cases that pretty universally we think and we know that a C-section is the most likely to save the life of mother and baby and is probably going to be recommended like across the board always with like no gray areas.

Yeah.

Ready for some of those factors?

Yeah, I am.

That might be something like a placenta previa or a known placenta accretive spectrum disorder like we talked about.

Those are situations that cesarean delivery is going to save the life of the baby and might also save the life of the 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 where the umbilical cord comes out through the cervix before any part of the baby.

Okay.

And that is going to trap blood flow and block blood flow to the cord, which is extremely dangerous for the baby.

So that is pretty universally an emergency C-section scenario.

We also generally 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 C-section if that is known to be happening.

If somebody has had a prior uterine surgery, like a very large fibroid removal or a previous midline C-section,

because most of the time, if we look at our uterus again here, most of the time these days, C-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 at lower risk of uterine rupture.

Yep.

Higher risk than with no surgery.

But a midline, so a

incision that goes from the top to the bottom of the uterus is at very high risk for uterine rupture with a next pregnancy.

And so is the difference, so I know that today we do more transverse

incisions, but historically we used to do midline.

Is there any reason to do midline that like people do midline today?

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.

Got it.

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.

It's a good question, though.

And so in those cases, people are usually scheduled for like a planned C-section to not, 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 breech, booty down or feet down instead of head down, C-section is often recommended.

And it's not because it's impossible to deliver a vaginal breach delivery.

But it's for a few reasons.

There's some data from a few studies in the U.S., 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 C-section, right?

Because you might plan for vaginal and end up having a C-section.

That data suggested that it was marginally safer to do a planned cesarean section in the like immediate term.

Okay.

And so because of that, for a while, it was like kind of across the board recommended that you do do C-sections for breach deliveries if they cannot be rotated by that external cephalic version.

And that recommendation plus the fact 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 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.

Does that make sense?

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,

we don't have to necessarily explore the option that that is very risky.

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.

Right.

But a lot of the C-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 C-sections are not necessarily done 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,

arrest of descent.

So that means baby doesn't come all the way down the birth canal 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 indicators, what are the reasons for surgery in these cases?

But 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?

Like individual meaning dependent upon the specific situation.

The 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.

Yeah.

Because it is usually not planned in those scenarios.

Right.

It's tough because who's...

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 yeah and it's so like how do we fix that even beyond making sure that we're reading fetal monitoring correctly right or we're using continuous versus intermittent 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 right i mean that comes down to communication aaron let's be honest it yeah it's a big part of it 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 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 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 a vaginal delivery or not?

Is that a crazy concept?

Today it is, yes.

It can be.

But I think that that part is often missing, honestly.

And like, 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 underselling the potential risks and complications of this major abdominal surgery, then it should be a person's right to decide what they do.

Yeah.

And not be judged for that.

And not be judged for that.

Okay, do you remember Gilmore girls, Sherry, who is Christopher's wife?

Oh, vaguely, yes.

Or something.

Yeah, yeah, yeah.

And she was like very much like make the show was making fun of her because she had a planned elective c-section.

Yeah.

And then she ended up not.

Like she ended up going into labor early and had a vaginal birth, I think, is what I remember.

I remember that.

But just like that alone, that representation of like, here's this ridiculous type A personality, blah, blah, blah.

She wants a C-section.

That is who is electing for a C-section.

And then the judgment inherent.

The judgment inherent to that.

It's like we just can't win when we're together.

No, if you plan for a vaginal delivery and then you had a C-section,

you, you know, are you getting judged for that, or you feel judged for that?

If you plan for a C-section, you're judged, we just can't win.

We can't win.

Yeah, goodness gracious.

I know.

Aaron.

Aaron.

I want to move on.

Okay.

Can we?

Sure.

Okay.

Do you have any other questions?

Probably.

I have other things about C-sections, like the risk of this and like the effects on the child.

I have a question about C-section, how we classify C-sections, because a lot of people use the phrase emergency C-section.

What is, is that, is that unplanned?

And then there are stages of unplanned that's like urgent, extra urgent, super urgent.

Yeah.

I tried to get.

you data on this.

I read a whole paper that was about the classifications of how we classify a C-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.

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 preeclampsia.

This was whatever.

This paper alone had like 27 different systems of classification.

So like, I don't know.

Okay.

I'm

not sure.

Planned and unplanned is like the general big, big picture breakdown.

But it is true that like, if you can think of some of the scenarios that I gave of like, this would 100% of the time be recommended for C-section, like a cord prolapse.

Yeah.

That would be an emergency scenario.

Yes.

Because you have a cord that is being compressed.

Right.

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.

Yeah.

And yeah, it's true that like there's just a huge range.

Yeah.

There's a range.

Yeah.

There's also sometimes, and we kind of skipped over this, what are called operative vaginal deliveries.

Oh, tell me what that means.

And that doesn't necessarily mean there's an operation.

Yeah.

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.

Okay.

Sometimes it's forceps.

We still have what we still use forceps.

Percentage, and I'm sure that's globally, blah, blah, blah.

Okay.

I don't have numbers on that because it also just varies hospital to hospital.

Like right and training.

How much training does an OB get for using 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 looks like.

If you're seeing this on video, it basically is a little disc, a plastic disc that sometimes has a bit of foam 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 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.

Wow.

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 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 the placenta.

Yeah.

And that can take anywhere from like a couple of minutes to like a half an hour or so.

Interesting.

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.

Okay.

Or in very extreme cases, it might require a hysterectomy.

Okay.

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.

If we remember last episode, our blood volume during pregnancy has increased by about 50%.

At term, your uterus is receiving 12 to 20%, depending on which papers you read, of your total blood flow, your total cardiac output, which is like 700 milliliters every minute.

That's wild.

With every contraction,

your uterus is shunting 300 to 500 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 wringing out.

So immediately after delivery of the placenta, you have all of these spiral arteries in your uterus that have become enlarged in order to provide constant blood flow to the placenta.

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, 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 to like the size of a, I don't know,

miniature basketball.

Like very quickly.

But sometimes it doesn't.

And postpartum hemorrhage, which is defined as the loss of more than one liter of blood,

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 we know we can do C-sections with very little blood loss.

Yeah.

Postpartum hemorrhage, one liter 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.

So because someone who is pregnant and at term has so much more blood than someone who is not pregnant.

And so much blood is going to the uterus.

Yes.

And so then the blood loss is not

is not like as severe as it would be or like the 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 lose.

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 liter.

One liter is a lot of blood.

One liter is 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 liters of blood, which is like 25% of your total blood volume.

It's a huge amount of blood.

It's a huge amount of blood.

So postpartum hemorrhage is estimated to affect anywhere from 3% to 10% of deliveries, but it accounts for 20% of maternal deaths worldwide.

In high-income countries, that number is less, in large part because we have really good options on how to stop postpartum hemorrhage.

Okay.

Though the rate of hemorrhage has been on the rise,

in the U.S., from 1993 to 2014, 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 10,000 deliveries to 40 per 10,000 deliveries in the U.S.

So why?

People are bleeding more in part probably because of other risk factors that are associated, right?

Like things like placenta accreta spectrum disorders, which are on the rise, preeclampsia.

A lot of these are risk factors for postpartum hemorrhage.

Okay.

There's four main things that we think of as like causal for postpartum hemorrhage.

Most of the time, it's because of uterine acne.

It's because of that uterus not clamping down to the size of a small basketball the way that it ought to.

Right.

Because then you just have so much blood being shunted to the uterus and it's just flowing 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 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 prevent that uterus.

So it's like it's trying to clamp down, but there's something blocking it.

And then also thromb, what they call thrombin or clotting factor deficiencies, which are not that uncommon.

Which is, okay, like in general.

In general.

Not okay.

Yeah, these are like more like genetic susceptibilities.

Right, okay.

Yeah.

And there are a lot of different medications that we can now 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 flow to the artery.

So you're not getting as much flow 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.

Prevalence.

Okay.

Yeah.

Okay.

But in the event that all of that happens well enough and a baby 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.

Or is it?

Or is it?

But that's where it will pick up next week.

Okay, I have a couple of questions that I jotted down.

I saw you writing.

Yeah.

I didn't want to forget.

Back labor.

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 etc.?

Sometimes people will say it's more based on position of the baby.

Okay.

So if the baby is OP, so occiput 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, they spiral.

Yeah, they don't like tend to flip upside down, though sometimes they do.

Sorry, baby.

Okay, back labor.

Yes, back labor.

Tearing.

Let's talk about tearing.

Okay.

Let's talk about episiotomies.

I have a little bit of extra notes here just for you, Erin.

You know me.

I do know you.

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.

You You know that no one did a study on them until the 1970s about are these something we should be doing?

Not surprised at all.

I have had the fortune of working with some pretty phenomenal OBGYNs 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.

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?

Yes, please.

I have a very large pelvis here.

Most of the time, if a baby is having trouble descending the birth canal, it's not soft tissue of your perineum that's causing the trouble or even the tissue of the vaginal canal itself.

Right.

It's your bones.

Yes.

Right.

So episiotomies don't help with any of that.

It's our bipedalism.

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 can have severe long-term consequences like an increased risk of

fecal incontinence, fistula formation, other things like that.

Yeah,

I mentioned fistula.

What is a fistula?

A fistula 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 fistula into the anal canal or something like that, like from the, from the annum into the vagina or something like that.

Very, very uncommon these days.

These days used to be much, much more common.

Very

uncommon.

These days, instruments, pessaries, that people would, there are hundreds of variations of these that people would use to prevent, you know, or to different, and also uterine prolapse and so on and so forth.

So it's just like.

So yes, C-sections have definitely reduced the risk of those kinds of things for sure.

Yes.

But yes, but some degree of tearing is often

it's really common.

And 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 a first degree.

A second degree tear goes through 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.

Got it.

And then a fourth degree goes all the way into the wood.

So episiotomies have definitely fallen out of favor.

They're still used in some places.

Yeah.

I didn't even mention the husband's ditch, but we're not going to go there.

No, we won't.

You can Google that and be horrified.

Other questions, Erin?

I don't think so.

I think I use 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.

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.

Yeah.

Yeah.

There's a lot of future episodes, Aaron.

It is.

We have a lot that you can learn more about just by reading the sources that we read.

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 Caesarean Section by Jacqueline Wolfe.

But I also want to shout out a couple other papers here.

One is by Dunsworth and Eccleston called The Evolution of Difficult Childbirth in Helpless Hominin Infants from 2015.

Okay.

And then a paper by Rosenberg and Trevathan titled Birth, Obstetrics, and Human Evolution from 2002.

Interesting stuff.

Okay.

I had a number of papers for this, a few that I will shout out.

One was just from the New England Journal of Medicine from 1999 called The Control of Labor.

Pretty 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 100 Years, 1920 to 2020.

The Bad and the Ugly.

I read that one.

It was really good.

It was a good one.

I really loved it.

A review of postpartum hemorrhage titled Postpartum Hemorrhage from the New England Journal of Medicine 2021.

And then a paper that I didn't even get into this, but is very interesting, was from 2018 in PLOS Medicine, PLOS Medicine, called Long-Term Risks and Benefits Associated with Cesarean Delivery for Mother, Baby, and Subsequent Pregnancies, Systematic Review and Meta-Analysis.

And I didn't get into it, but there is a lot.

Most of the data on C-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.

Well, and that's something that I feel like I thought, now I do have another question.

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 of C-section are going through.

Oh, you've got notes.

Keep going.

I've got notes.

Yeah.

Yeah.

So we talk about, okay, well,

are there long-term associations with allergies, autoimmune disorders, stuff like that?

That often gets linked, but we don't, is the, how is the data?

How is the data, Erin?

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 not, it's not super strong, like going all the way to adulthood, if that makes sense, where like 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 via the abdominal route, 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 vaginal seeding, so like taking swabs from the vagina and putting it on a baby who was born C-section, that's not recommended, at least by ACOG right now because we do not have data that it is safe or effective.

The microbiome is just one of those words that means many different things.

Yeah.

And we just don't, we just don't have data on it.

We don't have data.

And it's so complex to do the data.

Yeah.

Right.

And again, it's like you, you also have to take into account the short-term risks 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.

It's it is all

it is all childbirth.

It's all childbirth.

I mean, I think also the effect size is, is the other thing that we just don't have good handle on.

Right.

Definitely not.

Definitely not, definitely not.

So, yeah.

I feel like I have more to say, but I guess there's one more episode to say.

Let's say it next week.

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 to have you share your stories.

Thank you, thank you, thank you, thank you.

Thank you.

Thank you also to everyone here at Exactly Right Studios.

We've got Liana, we've got Jessica, we've got Brent, we've got Craig, we've got everyone who's been involved.

Many amazing people.

Thank you guys so much.

Thank you.

Thank you also to Blood Mobile for providing the music for this episode and all of our episodes.

And thank you to you, listeners.

For listening.

We've had a lot of fun doing these episodes.

We've got one more still to come.

Yeah.

We hope you learned something or something.

I don't know.

Yeah, tell us.

Yeah, tell us what you hated.

You loved it or hated it.

Okay.

Either way.

And a special thank you, as always, to our patrons.

Patrons.

Really, your support means so much to us.

We appreciate it.

Thank you.

Well, until next time, wash your hands.

Healthy animals.