by Penny Simkin, PT, CD(DONA)

Today, a long awaited report written by Dr. Sarah Buckley, 'Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care' is being released by Childbirth Connection. In this valuable report, Dr. Buckley gathers the most current research and provides the definitive guide for the role of hormones in normal, natural birth. Esteemed childbirth educator, doula and author/filmmaker Penny Simkin has reviewed Dr. Buckley's latest offering and shares today on Science & Sensibility how childbirth educators, doulas and other birth professionals can use this information to inform parents on how best to support the physiological process of childbirth. In coordination with this research report, Dr. Buckley and Childbirth Connection are releasing a consumer booklet geared for families and consumers as well as other material, including infographics in support of this report. On Thursday, Lamaze International Past President Michele Ondeck will share her interview with Dr. Buckley. In that interview, S&S readers can get the full story directly from Dr. Buckley, on just what it took to create this remarkable tome. - Sharon Muza, Community Manager, Science & Sensibility.

© Childbirth Connection

Introduction

For many of us who work in the maternity field, Sarah Buckley's fine work is well-known. Her book, 'Gentle Birth, Gentle Mothering' (Buckley, 2009) has provided scholarly and enlightening guidance on natural childbirth and early parenting for many years. Her 16 page paper, 'Ecstatic Birth,' (Buckley, 2010) guides educators and doula trainers, who rely heavily on her explanations of hormonal physiology in childbearing, for teaching about labor physiology and psychology and the impact of care practices.

Her newest publication, 'Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care,' (Buckley, 2015) is a gift to us all. It represents a massive scholarly effort, a review of all the related scientific literature on the topic. With 1141 references, most of which were published in recent years, Dr. Buckley's overview provides the transparency to allow readers to trace her statements to the evidence on which they are based. She exercises caution in drawing concrete conclusions when the evidence is insufficient; she presents such information as theory (rather than fact), and points out when more research is necessary for concrete conclusions. The 'theory' that undisturbed birth is safest and healthiest for most mothers and babies most of the time is impressively supported by her exhaustive review, as stated in the conclusion (Buckley, 2015):

'According to the evidence summarized in this report, the innate hormonal physiology of mothers and babies - when promoted, supported, and protected - has significant benefits for both during the critical transitions of labor, birth, and the early postpartum and newborn periods, likely extending into the future by optimizing breastfeeding and attachment. While beneficial in selected circumstances, maternity care interventions may disrupt these beneficial processes. Because of the possibility of enduring effects, including via epigenetics, the Precautionary Principle suggests caution in deviating from these healthy physiologic processes in childbearing.'

The Precautionary Principle, to which she refers, has been stated as follows:

'When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof. . . . It (the activity) must also involve an examination of the full range of alternatives, including no action.' (Science and Environmental Health Network, 1998).

In other words, when applied to maternity care, The Precautionary Principle states that when a practice, action, or policy may raise threats of harm to mother, baby, or family, the burden of proof that it will result in more good than harm falls on those who wish to adopt it - the policy maker, caregiver, or administrator, not on the pregnant person.

© Sarah Buckley

What's new in this document and how might you use it and apply it in your classroom or practice?

This document represents the 'State of the Science' regarding hormonal physiology of childbirth (HPOC). It should be the starting point for consideration of proposed changes in maternity care management and education. The question, 'How might this policy, practice, or new information impact the HPOC and subsequent outcomes for mother and/or baby?' should be asked and answered about both existing and proposed interventions.

Sarah Buckley has asked and answered this question, and reveals the unintended consequences of numerous widespread practices, including scheduled birth - induced labor or planned cesarean; disturbance and excessive stress during labor; synthetic oxytocin (Pitocin); opioids and epidural analgesia for labor pain; early separation of mother from infant or wrapping the infant in a blanket to be held (i.e., no skin-to-skin contact); breastmilk substitutes, and many more. All of these practices cause more harm than good, except in unusual or abnormal circumstances.

One of the greatest contributions of this book is showing that hormonal physiology is affected by virtually every intervention 'major and minor ' and understanding this is the key to appropriate maternity care. The topic is complex and not nearly fully understood, but Sarah Buckley has pulled together just about everything that is now known on this topic. If you're a maternity care practitioner or student, who wants to approach the care you give from a physiological perspective, or want information on the impact of common interventions on the physiological process, it's all here. If you're a researcher interested in studying some aspect of HPOC, your literature search has already been done for you and you can discover the many areas that have been insufficiently studied and plan where to go from there.

If you're a childbirth educator seeking to give accurate information to expectant parents about how normal childbirth unfolds and how it can be altered (for better or worse) with common procedures and medications, you can learn it here. If you're a doula who wants to understand how your presence and actions may contribute to normalcy, you can learn it here. If you're an expectant parent who wants to make choices that maintain or improve the pregnant person and infant's well-being, you can learn it here or access the consumer guide.

Organization of the Chapters

This book, with its numerous references, sheer number of pages, level of detail and broad scope, may seem daunting at first. However, if you take some time to familiarize yourself with the layout of the book before plunging in, you will find that the material in each chapter is arranged so that readers can explore each topic at varying levels of detail.

The book begins with a very helpful 10 page executive summary of the contents. There are then two chapters introducing concepts relevant to HPOC, and on the physiologic vs. scheduled onset of birth (induction and planned cesarean birth). The 7 chapters are organized with topics and subtopics. The first paragraph beneath the headings for each topic or sub-topic briefly and clearly summarizes the information in that section in italics, so that you can skim each topic by reading only the italicized summary. If you wish to investigate some subtopics more deeply, you can read everything included on those topics. Each chapter also ends with a summary of the entire chapter. Chapters 3, 4, 5, and 6 (Chapter 3 - 'Oxytocin;' 4 - 'Beta-Endorphins;' 5 - 'Epinephrine-Norepinephrine and Related Stress Hormones;' ; and 6 - 'Prolactin') follow the same outline of topics and subtopics.

Using Chapter 6 ('Prolactin') as an example, here is the outline:

• 6.1 Normal physiology of prolactin
  • 6.1.1 Introduction: Prolactin
  • 6.1.2 Prolactin in pregnancy
  • 6.1.3 Prolactin in labor and birth
  • 6.1.4 Prolactin after birth
• 6.2 Maternity care practices that may impact the physiology of prolactin
  • 6.2.1 Possible impacts of maternity care provider and birth environment on prolactin
  • 6.2.2 Prostaglandins for cervical ripening and labor induction: possible impacts on prolactin
  • 6.2.3 Synthetic Oxytocin in labor for induction, augmentation, and postpartum care: possible impacts on prolactin
  • 6.2.4 Opioid analgesic drugs: possible impacts on physiology of prolactin
  • 6.2.5 Epidural analgesia: possible impacts on physiology of prolactin
  • 6.2.6 Cesarean section: possible impacts on physiology of prolactin
  • 6.2.7 Early separation of healthy mothers and newborns: possible impact on physiology of prolactin
• 6.3 Summary of all findings on prolactin

For childbirth educators: how might we use this information to benefit our students?

I especially appreciate that Dr. Buckley begins every section with a description of the relevant physiology. In order to be truly effective, we educators should do the same in our classes, to ensure that our students understand how and when their care is consistent with physiological childbearing and when (and why) it is not. ''Physiological childbearing' refers to childbearing conforming to healthy biological processes,' (Buckley, 2015, page 11) as opposed to what many might refer to as 'medicalized childbearing,' in which the physiologic process is altered or replaced with interventions and medications.

© Childbirth Connection

Childbirth education should be designed to allay the pregnant person's anxiety, not by avoiding mention of potentially troubling labor situations, or minimizing concerns mentioned by the students, but rather by giving realistic portrayals of birth, encouraging expression of feelings, and dealing with them by informing, reframing, desensitizing, and strategizing ways to handle troubling situations. Following is an example of how an educator might include hormonal physiology of childbearing to teach about one critical topic - Physiologic Onset of Labor, which is Lamaze International's First Healthy Birth Practice.

Let labor begin on its own: How to teach from the standpoint of HPOC

Chapter 2 in HPOC , 'Physiologic Onset of Labor and Scheduled Birth,' details the 'highly complex orchestrated events that lead to full readiness for labor, birth and the critical postpartum transitions of mother and baby.' (Buckley, 2015). As educators, we should try to convey this information, in simplified form, to help our students appreciate the beauty and connectedness of the whole mother-baby dyad. They need to understand the consequences of interrupting the chain of events that usually result in optimal timing of birth. Most parents (and many caregivers as well) have no idea that the fetus determines the onset of labor. Nor do they know that fetal readiness for labor (including protection against hypoxia and readiness for newborn transitions after birth) is coordinated with preparation of the mother's body for labor, breastfeeding and mother-infant attachment. Once students have some grasp of these processes, they appreciate and want to protect them from interruption or replacement by medical means. As we know, most inductions and many planned cesareans are done without medical reason (ACOG, 2014). Out of ignorance and/or misinformation from their caregivers, parents often agree or even ask for these procedures.

While many educators know and teach about the risks and benefits of induction and planned cesarean, they often don't convey the physiology on which the benefits and risks are based. It's all here in HPOC, and this information may inspire parents to question, seek alternatives or decline these procedures.

Over the years, I have wrestled with the challenge of conveying this information fairly simply and concisely, and now, with the help of Katie Rohs, developed a new animated PowerPoint slide, 'The Events of Late Pregnancy' (Simkin, 2013) that I use in class. You may access this animated slide and accompanying discussion points/teacher guide here.

© Penny Simkin

This is just one example of how we may shift our focus as teachers to incorporate basic hormonal physiology as a starting point. Dr. Buckley gives us a solid understanding of what is known about the key role the endocrine system plays in orchestrating the whole childbearing process, and why we shouldn't disrupt this elegant process without clear medical reasons. If we teachers and other birth workers incorporate this information in our practices and in our teaching, outcomes will improve.

'Hormonal Physiology of Childbearing' is surely the most extensive search ever done on this topic, and is a solid guide to learning this crucial information. Encyclopedic in its scope, and multi-layered in its depth, this book will be most useful as a reference text, rather than a book to read straight through. It is pretty dense reading, but when you have a question relating to reproductive physiology or the effects of interventions, you can search for well-explained answers. The evidence-based conclusions that Sarah Buckley has synthesized from an abundance of research (1141 references!) are authoritative and must be made accessible. This is truly 'State of the Science' on Hormonal Physiology of Childbearing.

Conclusion

Typical maternity care today has departed so far from physiology that in many cases it causes more harm than good, as borne out by Dr. Buckley's discussions throughout the book of the impact (i.e., unintended consequences) of common maternity care practices on hormonal physiology and mother-baby outcomes. Our job is to inform expectant parents of these things and help them translate information into preparedness and confident participation in their care. If we do our job well, our students will want to support, protect, and participate in the physiological process, which has yet to be improved upon. Parents and their babies will benefit! Our thanks should go out to Sarah Buckley and to Childbirth Connection for bringing this gift to us.

In conclusion, Sarah Buckley's 'Hormonal Physiology of Childbearing' is an impressive exploration of the major hormonal influences underlying all aspects of the labor and birth process. As we understand and incorporate the knowledge included in the book, the birth process will become safer, with effects lasting over the life span.

References

American College of Obstetricians and Gynecologists and Society of Maternal-Fetal Medicine, 2014. Safe Prevention of the Primary Cesarean Delivery. Obstetric Care Consensus Number 1. Obstet Gynecol ;123:693-711.

Buckley S. Ecstatic Birth. Nature's Hormonal Blueprint for Labor. 2010. www.sarahbuckley.com

Buckley S. 2009, Gentle Birth, Gentle Mothering: A Doctor's Guide to Natural Childbirth and Gentle Early Parenting Choices. Celestial Arts, Berkeley

Buckley S. 2015. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care. Childbirth Connection, New York

Science & Environmental Health Network. 1998. Wingspread Conference on the Precautionary Principle. Accessed Jan. 8, 2015, https://www.google.com/search?q=The+Precautionary+Principle&ie=utf-8&oe=utf-8.

Simkin P. 2013, Events of Late Pregnancy. Childbirth Education Handout and Slide Penny Simkin, Inc. Seattle. https://www.pennysimkin.com/events-powerpoint

About Penny Simkin

Penny Simkin is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 13,000 women, couples and siblings for childbirth, and has assisted hundreds of women or couples through childbirth as a doula. She has produced several birth-related films and is the author of many books and articles on birth for both parents and professionals. Her books include The Labor Progress Handbook (2011), with Ruth Ancheta, The Birth Partner(2013), and When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse of Childbearing Women (2004), with Phyllis Klaus. Penny and her husband have four adult children and eight grandchildren. Penny can be reached through her website.

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