Maralyn Foureur 2011 Home Birth Conference
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Transcript of Maralyn Foureur 2011 Home Birth Conference
TODAY’S CHOICES
TOMORROW’S PARENTS
Home Birth Aotearoa National Conference
October 28-30 2011
Creating Optimal Birth Space
MARALYN FOUREURPROFESSOR OF MIDWIFERY
UNIVERSITY OF TECHNOLOGY SYDNEY
EPIGENETICS, OVERWEIGHT AND OBESITY
Maralyn FoureurProfessor of Midwifery
University of Technology Sydney
AIM:
To explore how the birth environment influences childbirth, parenting and our
future health
THIS REQUIRES US TO ENGAGE WITH…
Research evidence from cross disciplinary scientific traditions (behavioural & biological sciences)
Research conducted across species Rodents – mice, prairie voles, rats Sheep Primates Humans
Using a range of research methods Aided by new tools such as fMRI, PET scans & the New Science of Epigenetics
IDENTIFYING PATTERNS
Developing Theory Hypothesis generating Research stimulus
Putting together pieces of a puzzle (Product warning – allresearch has limitations)
Optimal Birth Environment
Relationship based maternity care
Calm & Connect System
Optimal Oxytocin
Lowers BP, Heart
rate, decreases pain
Normal Birth
+
OPTIMISING BIRTH PHYSIOLOGY
3 stories1. Epigenetics2. Oxytocin3. Our need to feel safe
RECENT REVOLUTION IN SCIENCETHE CENTRAL DOGMA OF MOST SCIENTIFIC ACTIVITY FOR THE LAST 150 YEARS HAS BEEN CHALLENGED…
Darwin’s Theory of Evolution … we inherit all of our characteristics from our parents… Is NOT entirely right!
THE REVOLUTION BEGAN WITH THE DISCOVERY OF DNA
Watson & Crick 1953
DNA Controls All of life – genes are subunits of strands of DNA
A PARADIGM SHIFT BEGAN IN 1980S Human Genome
Project Looked for
120,000 genes to account for all the complexity & diversity of life
But found human genome only consists of 30,000 genes
About the same as a fruit fly
Forced to conclude that genes do NOT control life- so what does????
Genes are being switched on or silenced by signals from outside the genes-from the environment
Through a process called Methylation or Demethylation ++
EPIGENETICS DESCRIBES A CONTROL - ABOVE THE GENES Environmental
influences including:
Stress = Feeling unsafe/threatened
Emotions Nutrition Toxins
Can modify genes without changing their basic blueprint
EVIDENCE FROM PERINATAL RESEARCH
1. The Agouti Mouse2. Stressed Pregnant Rats3. Genetically Engineered Mice
Large population based Studies in Humans
STUDY 1: THE AGOUTI MOUSE
Prone to Obesity, Diabetes, Cancer, Early Death
THE AGOUTI GENE CAN BE SILENCED…
Pregnant Agouti fed a diet rich in soy extract, folate, B12…
-will have babies who still have the agouti gene but are otherwise normal
STUDY 2: STRESSED PREGNANT RATS…
Abused and neglected their pups
Pups developed epigenetic modifications to their DNA
Pups grew up to be poor mothers
3RD GENERATION EFFECTS
And passed on these changes to the next generation of offspring
STUDY 3: ITS NOT ALL BAD NEWS…TRANS-GENERATIONAL EFFECTS ON BRAIN’S PLASTICITY
1. Mice genetically engineered to have a memory defect
2. Placed in an enriched environment
Memory improved
3. Offspring of those mice - who had the same memory defective gene - also had an improved memory
SO WHAT HAVE WE ENCOUNTERED SO FAR? Gene mutation can
cause obesity, diabetes and cancer
Changes to diet can silence the gene mutation from being expressed
Maternal Stress during pregnancy can alter the structure of the DNA (gene expression) in the unborn offspring
The changes to the gene expression result in behavioural changes in the offspring
Changes to the gene expression can continue to occur across generations
An enriched environment can overcome changes in the genes
EPIGENETICS = CONTROL ABOVE THE GENES Environmental
influences including:
Stress = Feeling unsafe/threatened
Emotions Nutrition Toxins
Can modify genes without changing their basic blueprint
ASSOCIATIONS BETWEEN STRESSFUL PERINATAL EXPERIENCES AND LATER LIFE EVENTS
Identified in population based studies with humans
naturally occurring experiments
Obesity Diabetes Cardio vascular
disease Autism spectrum
disorders Schizophrenia Psychotic disorders Drug Dependency Suicidality
Therefore we need to pay attention to the birth environment…
Giving birth is a feat of almost cataclysmic stress
Mediated by Endogenous Oxytocin
2 MAIN REASONS FOR ALL INTERVENTION DURING CHILDBIRTH-ONCE LABOUR HAS BEGUN
Uterine inertia (failure to progress) Fetal distress
Why is this so???
THE FEAR CASCADETHEORY
Oxytocin
Catecholamines
Uterine contractions
Catecholamines
Uterine inertia Fetal Distress
Constricts blood vesselsdecreases
Uterine blood flowPlacental perfusionFetal oxygentation
Feeling Unsafe
Stress
IS THERE ANY EVIDENCE TO SUPPORT (OR CHALLENGE) THE THEORY…
Sosa, Klaus and Kennel 1986 Social Security Hospital-Guatemala Continuous presence of supportive
companion = shorter labour & less intervention
? Oxytocin secretion not disrupted by fear induced adrenaline
PERINATAL ENVIRONMENTAL DISTURBANCE
Research conducted on the mouse!
1968Niles Newton
1968
LABOURING UNDISTURBED – A SERIES OF EXPERIMENTS
Created hostile birth environment Significantly fewer mice give birth
in hostile environments Disturbed mice have longer
labours Delivery initially slows - then
becomes precipitous to empty the birth canal
Pups of continuously disturbed mice more likely to be found dead-suggests fetal damage occurred in utero
•“...are mammals with more highly developed nervous systems than the mouse equally sensitive to perinatal environmental disturbance?
•...what effect if any do variations between home and hospital environments have on the course of labour and on perinatal mortality?”
Studies in primates
CATECHOLAMINE RESEARCH
Injected adrenaline directly through the mother’s abdomen into the fetus - had no effect other than increased
heart rate
However when injected into the mother - Induced fetal asphyxia and acidosis
Postulated this was due to vasoconstrictor effect of adrenaline leading to impaired uterine blood flow
More recent studies in pregnant women
MATERNAL ANXIETY ALTERS THE BABY’S
INTRA-UTERINE ENVIRONMENT
Anxiety is associated with increases in uterine artery resistance index
Blood flow to baby is reduced May effect fetal development May initiate premature birth Associated with baby who is small
for gestational age Possibly alters neuro anatomy &
impacts later behaviour
FEAR CASCADE IS PLAUSIBLE…THE ANSWER IS TO PREVENT IT BY…
Providing women with continuous labour support so that fear does not take hold…
Providing women with fear reducing birth environments that…
Prevent disruption to oxytocin secretion = normal labour will happen
THIS WAS ONLY PART OF THE PUZZLE…CATECHOLAMINES & OXYTOCIN HAVE MUCH MORE COMPLEX ROLES TO PLAY…
New scientific discoveries have now made it possible
to understand more…
BIAS IN STUDIES OF STRESS REVEALED…
Most research conducted with male subjects
Studies with females yields inconsistent data
? Cyclical variation in neuro-endocrine response the only reason.
Studies of oxytocin reveal another explanation
OUR BODY HAS THREE PHYSIOLOGICAL BALANCING SYSTEMS
•Fight OR Flight
•Freeze System
•Calm and Connect
OPPOSITE REACTIONS Fight, flight Increased heart
rate Elevated BP
Increased blood to muscles
Extra fuel from release of glucose from liver
Higher level of stress hormones
Calm & Connect Lowered heart
rate Lowered BP Increased
circulation to skin (rosy cheeks)
More effective digestion, nutritional uptake and storage
Lower levels of stress hormones
FEMALE RESPONSE TO STRESS DIFFERS FROM MEN!
Not predominantly - fight or flight or freeze
More likely to be the oxytocin mediated - calm and connection/tend and befriend response (a desire to affiliate with others -more adaptive)
Taylor, Klein et al, 2000
OXYTOCIN
Is the key to the calm and connect system Involved in much more than contractions of the uterus and in breastfeeding Oxytocin is the major orchestrator of the neuro-endocrine system
We are just beginning to discover how important it is and why protecting & promoting normal birth is essential for our survival
OXYTOCIN
Is a neuro-hormone Secreted by the BRAIN as well as in
different sites in the body Influences BEHAVIOUR generally - as well
as having localised impact on different body systems
NILES NEWTON DESCRIBED OXYTOCIN AS...
The love hormone
Much research has confirmed this – starting with...
The Prairie Vole
OXYTOCIN HARD TO DO RESEARCH ON – DOES NOT CROSS BLOOD BRAIN BARRIER
Need to access oxytocin in the brain Can be blocked by antagonists injected into
the prairie vole brain Stops taking care of its pups – stops
breastfeeding- rejects its mate Remove the antagonists – starts nesting
again
PRAIRIE VOLE & OXYTOCIN
Oxytocin – secreted during sexual activity
Female and male orgasm Labour Birth-fetal ejection reflex Placental ejection reflex Breastfeeding Touch- massage and stroking Eating
OXYTOCIN INITIATES LOVE
The Ewe and the Lamb….
OXYTOCIN INTEGRAL TO ATTACHMENT Sheep bond like glue within one hour of
birth if separated at this time – will not ever bond
Introduce oxytocin directly into the brain – the ewe will bond instantly with any lamb it is shown-
or use vaginal stretching –’dildo’ – stimulates oxytocin release = bonding!
Epiduralised ewe will not bond with lamb
THE BRAIN AND THE GUT ARE LINKED
Suckling releases oxytocin in the lamb’s brain and cholecystokinin in the lamb’s gut
Block either oxytocin or cholecystokinin and you interfere with the lamb’s ability to bond to its mother
KERSTIN UVNAS-MOBERG - SWEDEN
Research with pregnant and lactating women/babies and their midwives
Karolinska Institute
OXYTOCIN IS ANXIOLYTIC – CALMING AND INCREASES SOCIAL INTERACTION
Breastfeeding women more social and less anxious than non breastfeeding
Personality changes persist up to 6 months after birth
Onset is more rapid in multiparous Higher the level of oxytocin the more
calm and social the mother BP lowered short/long term depends
on length of time spent breastfeeding
OXYTOCIN IMPACTS ON EVERY AREA OF THE BRAIN
Enhances nutrient absorption Reduces stress-anxiolytic Increases pain threshold Conserves energy –Induces sleep Reduces blood pressure and heart rate –
short and long term Balances body temperature Enhances social memory Improves learning ability Facilitates affiliative behaviour – love and
altruism - attachment
ENDOGENOUS OXYTOCIN CAN BE INDUCED…
In social situations by tone of voice By a pleasant approach/ authentic smiles
with crinkled skin around the eyes Caring/Comfort Touch, hugging, cuddling, grooming By having a meal with friends-around a
table By Imagining pleasant things By viewing nature and scenes/objects of
beauty Involves every sense modality, smell,
taste, sight, hearing, feeling, dreaming
TOUCH ACTIVATES OXYTOCIN Mothers secrete oxytocin when they stroke
their babies Rhythmically – 40 beats per minute Animals lick at the rate of 40 bpm Warm pulsing water has the same effect Underlying physiology of kangaroo care Skin to skin contact increases rate of
growth of neonate Oral simulation-internal touch (non nutritive
sucking) – activates oxytocin - calming
DISTURB OXYTOCIN - CONSEQUENCES Epidural – mother less calm & less close
to baby at least one day after birth Large amount oxytocin to induce labour
stimulates vasopressin has anti-diuretic effect = fluid retention
risk of pph increases breastfeeding impaired In the long term suppresses
endogenous oxytocin
Animal studies have found artificial oxytocin alters neuro-anatomy and subsequent behaviour
PATTERNS EMERGING Women with high anxiety levels Have low oxytocin levels
Children with recurrent abdominal pain have extremely low oxytocin levels
Recurrent abdominal pain is a classic symptom of anxiety in children
BIOLOGY IS NOT DESTINY
Genetic blueprint is plastic Environmental variations switch on
and/or off parts of the genome resulting in a variety of outcomes
Oxytocin, endogenous opioid mechanisms & estrogen are not the only neuro-hormones that play a role in behaviour – future research will reveal more
COMPLEX INTERPLAY BETWEEN GENES AND LIFE EXPERIENCES
Disturbing normal neuro-hormonal responses during labour –disruption to endogenous oxytocin MAY have epigenetic consequences
WE NEED TO CREATE ENVIRONMENTS WHERE-
Women feel connected to their careproviders, calm, confident in themselves, have trust in- and- are trusted by, their caregivers
Spaces where women feel SAFE
WE NEED TO CREATE ENVIRONMENTS THAT…
Prevent disruption to normal oxytocin secretion
Decrease maternal anxiety
Increase likelihood of normal birth
Increase likelihood of long term health of baby
WHERE WOMEN FEEL WELCOMED…
AN INVITING COMFORTABLE ROOM: ‘LIKE A CAVE’
WHERE WOMEN ARE INVITED TO BE ACTIVE
....AND TAKE UP A VARIETY OF POSITIONS
OPTIMAL BIRTH ENVIRONMENTS DEMONSTRATE…
Attention paid to every aspect of the environment and how it impacts the emotional mindbody through our senses
Smell Touch (feeling and moving) Hearing Seeing Tasting Dreaming
Optimal Birth Environment
Relationship based maternity care
Calm & Connect System
Optimal Oxytocin
Lowers BP, Heart
rate, decreases pain
Normal Birth
+
OPTIMISING BIRTH PHYSIOLOGY