IF I WAS THE BABY…

Michel Odent 

All human beings are “endowed with reason”. This assumption is the basis of the Universal Declaration of Human Rights, as clearly expressed in its very first article. Obviously the authors of the declaration had not considered the particular case of the process of parturition, when there is no room for rational means of expression. One cannot interpret literally the irrational language of some women in hard labor, as soon as the neocortical control has been eliminated: “Kill me…shoot me…let me die…do anything…my bowels are getting out…etc”. On the other hand, for obvious reasons, the baby cannot rationally express his (her) point of view. However it happens frequently that decisions must be taken during childbirth. Who can take such decisions? On which criteria? 

A typical situation

I’ll take as an example a situation I often had to face in a hospital setting. The midwife on duty was calling me because she was pessimistic about the progress of labor, in spite of apparently suitable environmental conditions, in terms of privacy, temperature, etc. Should we go on by the vaginal route, starting with a drip of synthetic oxytocin, with the risk of finishing with forceps, ventouse, or hasty emergency c-section? Or, without waiting too long, should we prefer an “in-labor non-emergency c-section”? Since, in such situations, it was impossible to rely on the rationally expressed point of view of the two actors (mother and baby), I often took a decision after wondering: “If I was the baby, what my choice would be?”

Starting with such a question I developed gradually a tendency to try first to avoid long and difficult labors by the vaginal route. I can illustrate this tendency by recalling that the last time I have used the forceps was in February 1965. Of course in the 1960s, 1970s, and 1980s such attitudes could only be based on intuition and clinical observation. Then a visit of a pediatric unit could convince anyone that, apart from prematurity and intra uterine growth retardation, the most common reasons for transfer during the neonatal period was a birth after long and difficult labor by the vaginal route or after a hasty last minute emergency c-section.

Today a great diversity of scientific data can support this originally empiric strategy. When exploring the primal health research database (www.primalhealthresearch.com) keywords such as ‘forceps delivery’, ‘ventouse’, ‘cephalhematoma’, or ‘birth complications’ lead to studies that confirm the possible long-term negative consequences of difficult births by the vaginal route. On the other hand, thanks in particular to the work of Michael Stark, who developed the Misgav Ladach technique, the c-section has become an easy, fast, and comparatively safe operation.

The most common medical intervention in childbirth

However it is noticeable that the most common medical intervention used during the birth process is not taken into account in short-term and long-term birth statistics. Birth statistics contrast births by the vaginal route with or without the use of instruments (forceps or ventouse) and births by the abdominal route (pre-labor and in-labor c-sections). There have been some rare studies taking into account the use of epidural anesthesia. But the most common medical intervention is undoubtedly the use of drips of synthetic oxytocin. Most women who had a non-operative delivery by the vaginal route had a drip of oxytocin. Most women who had an operative delivery by the vaginal route also had hours of drip before the use of forceps or ventouse. Most women who had an in-labor c-section also had synthetic oxytocin before the operation was decided. Furthermore the rates of labor inductions are very high in many countries and, in practice, labor induction implies hours of intravenous drip.

A detail it is not worth mentioning in statistics

One should first wonder why the use of intravenous oxytocin during labor is perceived as a detail it is not worth mentioning in statistics. The main reason might be that the nonapeptide oxytocin is not considered a real medication because, from a chemical perspective, the synthetic form is not different from the natural hormone. Another reason might be that oxytocinases (enzymes that metabolize biologically active peptides) have been found in the placenta. This might had led to the hasty tacit conclusion that synthetic oxytocin does not cross the placenta.

On the day when we realize that most women, all over the world, receive synthetic oxytocin when giving birth, we’ll give a paramount importance to new questions, particularly about placental transfer of peptides. Paradoxically there is only one serious published article on this issue.1 After measuring concentrations of oxytocin in maternal blood, and also in the blood of the umbilical vein and of the umbilical arteries, and after perfusions of placental cotyledons, a team from Arkansas came to the conclusion that oxytocin crosses the placenta in both direction. More precisely the permeability is higher in the maternal to fetal than in the fetal to maternal transport direction. We must add that 80% of the blood reaching the fetus via the umbilical vein goes directly to the inferior vena cava via the ductus venosus, bypassing the liver, and therefore reaching immediately the brain: it is all the more direct since the shunts (foramen ovale and ductus arteriosus) are not yet closed.

Since there is a high probability that a significant amount of synthetic oxytocin can reach the brain of the fetus, we must raise questions regarding the permeability of the blood brain barrier at this phase of human development.  Australian researchers have presented evidence that the permeability to small lipid-insoluble molecules is greater in developing brain and that specific mechanisms, such as those involved in transfer of amino acids, develop sequentially as the brain grows.2 Furthermore it appears that the permeability of the blood brain barrier can increase in situations of oxidative stress3,4,5, a situation that is common when drips of synthetic oxytocin are used during labor.6 We have therefore serious reasons to be concerned if we take into account the widely documented concept of “oxytocin-induced desensitization of the oxytocin receptor”.7,8,9,10 In other words, it is probable that, at a quasi-global level, we routinely interfere with the development of the oxytocin system of human beings at a critical phase for gene-environment interaction. In such a new situation the priority is to phrase appropriate new questions at a cultural level…questions that would induce a new generation of research.

What we already know

In the framework of accepted scientific knowledge we must include important functions of the oxytocin system, particularly its role in sociability, capacity to love (love of others and love of oneself) and potential for aggression (aggression towards oneself and towards others). We can also included in the same framework what we have recently learned from several disciplines about the importance of the period surrounding birth.11  For example we have learned from an overview of the Primal Health Research Database (www.primalhealthresearch.com) that when researchers explore  disorders that can be interpreted as alterations of the capacity to love (to love others and to love oneself) they always detect risk factors in the period surrounding birth. We have learned in particular that studies of disorders associated with documented alterations of the oxytocin system, such as autism12,13, and anorexia nervosa14, detect significant risk factors in the perinatal period.15  Is the widely use of synthetic oxytocin in obstetrics a key to interpret the rising incidence of such diseases? Is the widely use of synthetic oxytocin at the root of an unprecedented cultural revolution?

Meanwhile

All these questions should stimulate a new generation of research from both physiological and epidemiological perspectives. They should also dramatically influence obstetric strategies. Before we know more, it would be wise to make labor induction an exceptionally rare practice. In the case of prolonged pregnancy, it is possible to replace the routine standardized attitudes (induction at a certain number of weeks of gestation) by a selective attitude: checking on a day to day basis, through multiple methods, that the baby is in good shape, and waiting as long as there are no alarming signal.16

Furthermore, in the age of simplified techniques of caesarean, the priority should be to avoid long and difficult labors by the vaginal route, with hours of intravenous drips of synthetic oxytocin. If we add that there are multiple reasons to avoid pre-labor elective cesareans17, and also real emergency last minute c-sections, when there is a race between the surgeon and the progress of a fetal distress, we can anticipate a shift towards simplified strategies, based on clearly expressed objectives. One of the main objectives should be that as many women as possible, at a planetary level, give birth to babies and placentas thanks to the release of physiological cocktails of love hormones. The prerequisite is the rediscovery of the basic needs of laboring women after thousands of years of socialization of childbirth and powerful cultural interferences. This rediscovery is not unrealistic if we take advantage of basic physiological concepts such as catecholamines-oxytocin antagonism and neocortical inhibition. Finally we can anticipate a shift towards simplified binary obstetric strategies: either the progress of labor is straightforward and the vaginal route is possible without any medical interference; or the labor appears as long and difficult in spite of appropriate environmental conditions, and the best alternative might often be an in-labor non-emergency cesarean section.18     

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References:

1 - Malek A, Blann E, Mattison DR. Human placental transport of oxytocin. J Matern Fetal Med. 1996 Sep-Oct;5(5):245-55.

2 - Saunders NR, Habgood MD, Dziegielewska KM. Barrier mechanisms in the brain, II. immature brain. Clin. Exp. Pharmacol. Physiol. 1999;26(2):85–91

3 - Noseworthy M, Bray T. Effect of oxidative stress on brain damage detected by MRI and in vivo 31P-NMR. Free Rad. Biol. Med. 1998;24:942–951

 4 - Agnagnostakis D, Messaritakis J, Damianos D, Mandyla H. Blood-brain barrier permeability in healthy infected and stressed neonates. J. Pediatr. 1992;121:291–294.

5 - Noseworthy M, Bray T. Zinc deficiency execerbates loss in blood–brain barrier integrity induced by hyperoxia measured by dynamic MRI. PSEBM. 2000;231:175–182.

6 - Schneid-Kofman N, Silberstein T, Saphier O, Shai I, Tavor D, Burg A. Labor augmentation with oxytocin decreases glutathione level. Obstet Gynecol Int. 2009;2009:807659. Epub 2009 Apr 16.

7 -  Robinson C, Schumann R, Zhang P, Young R. Oxytocin-induced desensitization of the oxytocin receptor. Am. J. Obstet. Gynaecol. 2003;188:497–502.

8- Gimpl G, Fahrenholz F. The oxytocin receptor system: structure, function and regulation. Physiol. Rev. 2001;81:642–643.

9 - Phaneuf S, Rodríguez Liñares B, TambyRaja RL, MacKenzie IZ, López Bernal A. Loss of myometrial oxytocin receptors during oxytocin-induced and oxytocin-augmented labour. J Reprod Fertil. 2000 Sep;120(1):91-7.

10 - Phaneuf S, Asboth G, Carrasco M, Lineares B, Kimura T, Harris A, et al.  Desensitization of oxytocin receptors in human myometrium. Hum. Reprod. Update. 1998;4:625–633.

11 - Odent M. The Scientification of Love. Free Association Books. London 1999.

12 - Modahl C, Green L, et al. Plasma oxytocin levels in autistic children. Biol Psychiatry 1998; 43 (4): 270-7.

13- Green L, Fein D, et al. Oxytocin and autistic disorder: alterations in peptides forms. Biol Psychiatry 2001; 50 (8): 609-13.

14 - Demitrack MA, Lesem MD, Listwak SJ, et al. CSF oxytocin in anorexia.nervosa and bulimia nervosa: clinical and pathophysiologic considerations. Am J Psychiatry 1990 Jul;147(7):882-86

15 – Odent. Autism and anorexia nervosa: two facets of the same disease? Med Hypotheses 2010. doi:10.1016/j.mehy.2010.01.039.

16 - Odent M. The tree and the fruit. Routine versus selective strategies in postmaturity. Midwiferytoday 2004;72:18-19.

17 - George A. Macones. Elective delivery before 39 weeks: reason for caution
American Journal of Obstetrics & Gynecology.
March 2010 (Vol. 202, Issue 3, Page 208).

18 - Odent M. The Caesarean. Free Association Books. London 2004.