 Maite timatatanga kote kori Te po nui Te po roa Te po pā mā mā Te ao Te ao Te aoa tea Ti hei mōri ora In the beginning there was the nothingness The dark, the surrounding blackness The void, then there's light The dawn, the world of light The first breath of life Nau mai haere mai Ngā tangata ngā haw e whā Hite tūpheratanga o te wananga Mo te ra o ngā kaiwhaka whānau o te ao 2000 te kaumārima It is my privilege and honour to welcome you all to the International Day of the Midwife Virtual Conference 2015 I have begun with a karanga The traditional Māori welcome and it was followed by an ancient chant depicting a Māori worldview of the beginning of life Kō rāpaki, kitēwai pounamu to kuturanga waiwai Kō kaitahu te iwi, ko tumanako to ku ingua Hitoura kaiwhaka whānau o Kia ora, my name is Tumanako Stone Howard and I am a Māori Midwifery student from Aotearoa, New Zealand My family come from Rāpaki and my tribe is Kaitahu Nō reira tēnā koutou, tēnā koutou, tēnā koutou katoa Welcome and warm greetings to one and all It's a childbirth and the knowledge that what we do is really profoundly important So welcome one and all and I hope you enjoy the conference Thank you Deb This is Linda Wiley speaking now as the chair of this session Before we start, can I just check with Sarah that she's got sound Can you speak to Sarah? Yes, good morning, good afternoon, good evening Fabulous, that's absolutely fine then I'll just say very little we'll get cracking because obviously we've been a bit delayed It's all these time zones they kept us all muckled up periodically Welcome to the virtual international Day of the Midwife Sarah Buckley is a doctor from New Zealand a doctor who was trained in New Zealand and she's got a great interest in my favourite topic which is oxytocin and I'm going to say no more than that I'll let her introduce herself and I'll just quickly run through these initial slides so we can get to Sarah's presentation So, we've said all this already hoping that you've all had a chance to set yourself up for this meeting There is an audio setup wizard at the top if you fancy speaking later on and asking some questions You have to work through the audio setup in order to speak We do have the chat window which we have been using in our time of waiting here and you'll be aware that you can use this but try not to say to talk away from the topic once Sarah starts her presentation You can give us feedback by using the status symbols you'll see at the top of the screen the little man with his hand up use him and there's a variety of feedback mechanisms there that you can use I've already made comments about that If you want to make your... If we give you permission to use your microphone you'll need to click the little green thing well it can be white at the moment the green thing at the top of the screen you may need to adjust your microphone We'll discuss that in the chat box if it comes to anything We're already recording this session Can I just hand over to Sarah then with delight that she's managed to make it with our time differences and let you introduce yourself Sarah Thank you very much Thank you very much Linda What a pleasure it is to be here and to be opening the virtual International Day of Midwives because midwives are my heroes I've discovered through my interest and research and hormonal physiology is that midwives are heroes of hormonal physiology so that's what we're talking about today Now this presentation is based on my report called Hormonal Physiology of Child Bearing Evidence and Implications for Women, Babies and Maternity Care Published back in January through Child Birth Connection and the National Partnership for Women and Families Can you put your hand up if you've read this report Beautiful Let's have a look Can you put up your hand if you intend to read this report I'm not seeing that there Linda can you just message me what we're getting there Beautiful, thank you My intention is that by the end of my presentation you'll all be intending to read this report because it really is a great resource for midwives and for midwifery and this is what it looks like so you'll recognise it that URL is on the next slide too but if you search Hormonal Physiology online so the intentions of my presentation is to honour acknowledge and applaud midwives from over here in Brisbane there's a big round of applause because I really think that what you do has enormous implications not just for the mother and baby in your care but for that mother and baby on goingly probably the rest of their lives from a Hormonal Physiology perspective and also for society as a whole so thank you so much for what you do in the world of the work that you do I also want to provide some midwifery focused highlights of the report and that'll be obvious and to stimulate your interest to read more in the report and to share because as I said it really is a great resource it's the evidence that underpins so much of what you do and what you know and that's really been my passion for a number of years now so a little bit more about me I'm a GP or family physician I have a diploma of obstetrics and I have an article Ecstatic Birth and Nature's Hormonal Blueprint for Labour which was published in Mothering magazine and that article was written for parents so it's a little bit technical but it's understandable by anyone with a lay background and you can go to my website sarahbuckley.com and download that as an e-book and then Gentle Birth, Gentle Mothering is my book from 2009 that has even more about Hormonal Physiology so it really was very exciting for me to do this report which is expanding that knowledge even more. The report's over 200 pages we've got over 1100 studies in there so really a lot of evidence and a lot of what we know but also as you read the report you'll find some of the most important things is what we don't know so we'll talk a little about that in this presentation as well so my first question is how are midwives heroic why do I say that well I only need to look as far as the traumatic review midwife led continuity models versus other models of care for childbearing women and authors of that conclude that continuity of midwifery care has significant benefits for mothers and babies and these are just some of them fewer epidurals, fewer instrumental births more spontaneous vaginal, vaginal births fewer episiotomies and more maternal satisfaction and I could probably do a whole lecture on each of those points in relation to hormonal physiology but I'm just going to pick out a few of those I also really recommend this paper here which was published in the Lancet series last year about midwifery midwifery and quality care findings from a new evidence informed framework from maternal and newborn care and this study by Mary Renfrew and colleagues looks more widely at the research on midwifery and its impacts on mothers and babies and there's some really great findings in there it's a really great summary so that's the how midwifery is one of the top five heroes of hormonal physiology we just want to start by looking a little bit wider and say that midwifery is a heroic because you have a salutogenic approach to childbearing now if you don't know that term salutogenic I recommend that you take it up and use it liberally because salutogenic means promoting positive health and well-being and that really is the cornerstone of what you do promoting positive health and well-being in relation to pregnancy in relation to postpartum for mothers and babies and by the way the report is a PDF document we don't actually have an index but what you do is you use the PDF finder and if you search for example type in the term salutogenic you can find out everything I have to say about salutogenic in the report now midwives are also heroic because you value physiologic childbearing and we define physiologic childbearing as childbearing conforming to healthy biologic processes in our definitions of that we don't say this and not that but what we say is that physiologic childbearing is a continuum and there's obviously full physiology at one end and minimal physiology at another end and the aim really of the report and the recommendations is to encourage people to think from a physiologic from a hormonal physiology perspective move women along how can we add more hormonal physiology for mothers and babies in this situation whether it's a pre-labour caesarian physiologic labour and birth and you also know I hope that you're very skilled in non-pharmacological approaches to labour pain and progress and of course those are the two things where there's most intervention and where the hormonal physiology ends up being substantially disrupted often as we'll find out so being skilled in non-pharmacological approaches really avoids lots of disruptions and we'll touch on that as we go through here so you optimise hormonal physiology for my perspective and that's talking about these four hormone systems so the hormone systems and I say they're not just hormones they're hormone systems that includes what regulates those hormones how those hormones act in the body what increases them, what decreases them what happens and they lead up to labour and their receptor systems as well because as you probably know a hormone is a chemical made in one part of the body that travels to another part where it has effects and it's radiating with binding with receptor systems which sends a signal into the cell and has an effect so we'll touch a little bit on that as well but we focus on these hormone hormone systems oxytocin, beta endorphins epinephrine nor epinephrine and related stress hormones and prolactin there's a chapter on each of those hormone systems in the report and we focus on those in relation to child bearing and I'm going to say a little bit about that we're not just talking about child birth child bearing which also includes pregnancy which also includes postpartum and particularly as we'll talk a little bit about here includes breastfeeding and attachment so oxytocin I'm going to summarise about a hundred and something pages in the report down to four slides they might have to hang on this is a bit of a quick ride, a quick romp through hormonal physiology but I just want to make sure you've got a little bit of background before we add in some more things so oxytocin our most famous breast hormone is the hormone of sexual activity labour birth lactation and attachment and it has effects both in the body and in the mind and you can see that there that's actually me breastfeeding my daughter Maya when she was three and you can see that little oxytocin love bubble and you can also see that lactation is happening so oxytocin has effects by reducing fear and stress and our physiologic responses to fear and stress and what that means in a sense is that increases activity in what we call the parasympathetic nervous system remember your midwifery training it's the rest and digest, calm and connect, relaxation and growth system and reducing activity in this sympathetic which is the stress system the fight or flight system so it shifts our physiologic balance it also has intrinsic analgesic properties it's a pain relieving in its own right which is kind of useful in labour and birth and it also activates motivation and reward centres in the mother's brain or in the brain of anyone that's having oxytocin released and you'll see that that's a bit of a pain amongst all of these hormones so in a sense we could say it's giving rewarded through oxytocin but not only that but also rewarded through beta endorphins well thanks Linda I'll slow down a little bit so a second hormone system that we talk about is beta endorphins which are the body's stress system if you like we release them when we're under stress and pain and they act as analgesic or stress reducing hormones so you can see this beautiful picture of a woman her beta endorphin state but also like oxytocin they also activate motivation and reward centres so sometimes I say it's like mother nature patting us on the back saying you've done a good job do more of it make more babies have more babies breath feed and attach to your baby so these are really important hormones in relation to switching on those reward systems and those reward systems it's really one of the findings that surprised me in the research there's reward system and it's actually really important that switched on during labour and birth and particularly an hour after birth and then this turning on of those systems is activating then ongoing rewards the mother for contact with her baby and that of course is a substantial contribution to infant well-being and infant survival in all mammals but also including humans so our third hormone system that we talk about epinephrine nor epinephrine and noradrenaline we also talk about related stress hormones primarily cortisol so if you probably know they're released with phytoplite shifting blood away from the non-essential organs to the parts of the body we need for phytoplite so in childbearing that's really important because if we have a surge of epinephrine nor epinephrine that can decrease blood flow to our uterus it's a non-essential organ for phytoplite in this situation and they also have a direct effect on the labor on the labor muscle the uterine muscle of reducing labor contractions so they generally a surge of these hormones will switch labor off and give the mother that space for phytoplite however in late labor both mother and baby get a surge of these hormones and that has two important functions for the mother and for the baby it promotes effective pushing that's called the fetus ejection reflex and again if you want to know more about the fetus ejection reflex you can search for it in that little PDF search search window and also the late labor catecholamine surge as we call it it's really important for the baby it gives the baby protection from those long strong close together contractions and it also begins to prepare the baby for life outside the womb so that transition to life outside the womb is really optimised by the catecholamine surge for the baby cortisol also matures the fetal organs even before labor starts you probably know that because we give cortisol like drugs to mature the baby's lungs in the situation of threatened premature labor but that's what happens naturally in the lead up to labor preparing the baby for labor and for that transition of birth so our fourth hormone system that we talk about in the report and by the way oxytocin is chapter 3 4, 5, 6 so you can find all about prolactin in chapter 3 oxytocin chapter 3, beta endorphin chapter 4, epinephrin nor epinephrin chapter 5 prolactin chapter 6 so prolactin is a major hormone of breast milk synthesis and you probably know it's most famous role prolactation but it also promotes many physiologic adaptations to maternity in the mother's body for example nutrition fluid balance and in her brain as well it's a major hormone of maternal behaviours here we have again it's a hormone of sexual activity, labour birth lactation and attachment so there's quite a theme with these hormones as well and what they're involved with inside reproduction and also outside reproduction as well it's also been called the hormone of paternity because in any species where the father's involved in care of the young prolactin is involved okay so that's our sort of basic hormonal systems and I hope that you've got some of that under your belt as we begin to talk about how midwides are heroes of hormonal physiology and how you benefit hormonal physiology for mothers and babies so fewer epidurals under midwifery care and that's really significant because epidurals can impact all of our physiologic hormonal systems they reduce oxytocin and I'll talk a little more about that how that may happen they reduce beta endorphins because beta endorphins are hormones of stress and pain and if suddenly there's no stress and pain the body goes oh we don't need the beta endorphins they also unbalance we could say the epinephrine nor epinephrine system because they reduce epinephrine more than nor epinephrine and that explains some of the side effects that you'll know from epidurals and they also disrupt as far as we know prolactin not so much research on that but from the research that we have the pattern is disrupted so some of the epidural side effects for example the drop in blood pressure that inevitably happens for women when they're given an epidural it may not be obvious because most women are preloaded given a large amount of fluid beforehand but this is probably to do with the epinephrine nor epinephrine system also the uterine hyperactivity that happens for some women just after the epidural is put in place probably happens because of that sudden drop in pain and that sudden drop in epinephrine adrenaline we're talking about the fever side effects that can happen for some women with epidurals may be oxytocin oxytocin is actually a hormone that's involved in temperature regulation and also instrumental birth we know that that's the side effect of epidurals and it's probably to do with that reduction in oxytocin that the oxytocin is not there to give those powerful late labour contractions to help the mother to push her baby out quickly and easily so it also if it has impacts on all of these hormones could it also have impacts on these ongoing effects of the hormones so you have to go to the report to read how these hormones positively impact breastfeeding mother baby 1.4 that's oxytocin after the birth 4.1.4 beta endorphins after the birth all the 1.4 sections described the functions of these hormones after the birth so these hormones oxytocin beta endorphins prolactin as I mentioned are involved with breastfeeding so if we interfere with these hormone systems and epidurals could that interfere with breastfeeding it's a bit of a $6 million question highly debated in the literature but you can get my take on that by looking in section 3.2.5 all those sections down the bottom there they have the sections that look at the impact of epidurals on each of the hormone system some of the mother baby attachment similarly oxytocin beta endorphins nor epinephrens actually a hormone of mother baby attachment and prolactin and all of these hormones contribute to what I sometimes call an ecstatic euphoric feelings after the birth and maternal satisfaction ongoingly by switching on these reward systems so if those all the hormones are impacted is maternal satisfaction and even ongoing maternal reward going to be impacted and again that's another really important question that we haven't begun to look at in relation to hormonal physiology so you're also heroic because you have you increase the chance of spontaneous vaginal vaginal birth and why does that happen what's the mechanism by which that happens and my mechanism may be that it reduces the risk of epidurals maybe I also tend to work alternative settings which is associated with more spontaneous vaginal birth you also tend to help women to delay the admission until the active phase of labour and that's the subject of a Cochrane review that's Laoson 09 so you can look up that to look at all the evidence around that but that's important in relation to hormone physiology and we'll talk about that in a minute less augmentation in some studies of midwifery models of care and again if we're reducing augmentation and reducing women's exposure to synthetic oxytocin that may increase the risk of spontaneous vaginal birth and you also are masterful at attention to emotional well-being in labour in our current maternity care system that tends to be quite down on the list of priorities in labour but midwards you know how important emotional well-being is in labour because emotional well-being is about optimising the flow of those hormones which is going to promote hormonal physiology so I'm going to say something a little bit about how labour works and the positive feedback loops of cycles of active labour and what I describe the process of labour I say it's a bit like a snowball it starts small and it rolls and gets bigger and bigger and bigger and in the end becomes unstoppable so if we delay admission of women until they're in that active unstoppable part of labour then the processes of going to hospital and the stress that's involved in that isn't going to interfere with the flow of labour isn't going to stop the progress of labour whereas if we go earlier when labour is that small snowball if you like it's much more easily or easily disrupted and one of the reasons labour has this snowballing effect is because there's a lot of positive feedback cycles that progress labour and this is one of them if you look at that picture there you can see if you start in the top right hand corner that as labour goes on there's an increase in sensations and what happens is that those sensations are fed back into the brain and they actually increase the central release of oxytocin so more oxytocins are released more oxytocin goes to the uterus more contractions, more sensations more central oxytocin release so that's a positive feedback loop and that may be familiar to you that's actually the Ferguson reflex that we talk about that promotes the pushing stage of labour but what we think is that this positive feedback loop actually happens right the way through labour so central oxytocin release within the brain it also accelerates central oxytocin release is a positive feedback loop within the brain and those effects may be even greater for animals have given birth before I should say but probably explains why labour goes faster in women as well you also reduce if it's reducing the chance of augmentation in labour that's reducing exposure to synthetic oxytocin and I hope that you're familiar with this that prolonged exposure to constant high levels of synthetic oxytocin reduces a number of uterine oxytocin receptors if you don't believe me look in the package insert for your own particular version of synthetic oxytocin and if we reduce the number of uterine oxytocin receptors it reduces the sensitivity and effects of oxytocin so it could slow labour progress increase instrumental birth and increase postpartum hemorrhage and again I'll refer you to that section of the report to find out more about those things emotional well-being as I said that you know how important that is as mid-wise it's part of your job is to attend to women's emotional well-being and labour and there's a large section 5.2.1 stress can disrupt labour and there are several possible mechanisms that's not something that's well researched but excessive epinephrine nor epinephrine directly as I mentioned before reduces uterine contractions that may reduce the release of oxytocin as well excessive beta endorphins with stress in labour may reduce central oxytocin within the brain stress itself may reduce the pulsatile release of oxytocin and stress may also alter the patterns of prolactin relief so there's many mechanisms for how stress may impact labour progress but basically as I'm sure you know as mid-wise stress does impact labour progress so paying attention to women's emotional well-being and labour is really important so in summary you are a hero of hormonal physiology because you optimize hormonal physiology for mothers and babies which benefits labour and birth optimizes hormonal support for breastfeeding with ongoing and probably life-long effects again you can look at that in the report there's a lot actually in the report and I'm not mentioning it today about epigenetics so I really recommend you go into the search box and type epigenetics so optimizing hormonal support for that mother baby attachment again I talk a lot about that in the report search attachment, search bonding with ongoing and probably as far as we know life-long benefits for mothers and babies so thank you for listening for more information please access the report there it is again childbirthconnection.org website.org and I really recommend that you go and look at that there's also several women-friendly resources on there there's infographics there's actually a booklet explaining the hormonal physiology in simple language accessible to women as well so go to that website download the report it's all free I should have said that at the beginning 100% free 100% downloadable and use it for yourself to inform and resource your peers and the people you're working with tell the obstetricians about it it's really important information for them and that's the next stage of my the next stage of my birthing of this report is to write some papers, some articles in some of the peer review journals so I've got a big job ahead of me not just giving birth to this baby but also growing it up and really getting into the mainstream and I'd love you all as midwives around the world to partners in being heroes of hormonal physiology so that's my last slide and let's see what questions or comments you have about hormonal physiology thank you Sarah if anybody would like to verbally ask a question please just pop up your hand or if you want to ask questions in the box just as well doing it that way yes Holly it is fascinating that everything is linked and every action has a consequence and you know what I love when I present this material to midwives as I do in my workshops around the world it explains so much to be more easily attached to their babies more easily because what we think is happening in their brain and this is from animal studies and we obviously can't do this on women is the receptors in the brain that promote some of those positive feedback loops there's more receptors and more tipperous females and so that all those positive feedback loops go faster so really interesting and when you're next coming to the UK yes I was in the UK in 2011 2013 it's a long way 24 hours on a plane and also I've got to go for a few lengths of time and I'm a little bit well not constricted really but my youngest daughter is in senior high school now so I don't want to go away for prolonged periods of time for a couple of years still but definitely in the future so any of you are asking me do I think home birth optimises physiologic hormonal physiology well yes definitely because all those things that we talked about it reduces the chances of the interventions and you know we only talked about epidurals but other interventions like synthetic oxytocin there's a very long section about the impacts possible no one are known of synthetic oxytocin for mothers and babies I really recommend you read that that's a really important section reduces the chance of augmentation induction and induction has enormous consequences as well you know and again I'm going to refer you to chapter two which is called the physiologic onset of labour and schedule birth and I go through everything that happens before the onset of labour and then what happens when we disrupt the schedule birth and some of the important things that happen as far as we know mostly from animal studies some human studies is that the receptors for all these systems increase in the lead up to labour so that in the weeks and days and in animal studies even hours before the onset of labour all these things are getting set up to optimise the efficiency of labour and birth the efficiency of pushing the efficiency of contracting the uterus after birth to prevent postpartum hemorrhage and the efficiency of attachment and lactation and so you know you may be aware of all of the interest at the moment in elective induction should we be inducing women routinely to prevent still birth to reduce the risk of caesareans again and there's a few comments in my report about that but we haven't even begun to look at the hormonal physiology implications and missing out on those critical preparations and the lead up to labour and the studies that are happening right now the 35, 39 study and the arrive study they don't even measure breastfeeding as an outcome which is extraordinary and you can also read in the report there's lots of tips that's here prostaglandins we think that's an easy way of inducing women they actually have an anti-prolactin effect and they probably reduce in fact the one study that was done the the Welsh study the Carter study did show an impact of prostaglandins on the chance of successful breastfeeding at 48 hours so so many things that we're doing have um possible you know there's physiologic mechanisms whereby they probably do affect hormonal physiology but we haven't begun to look at that so yes definitely Anna and I think so you know the most effective way that we can enhance hormonal physiology is to put women in a setting where you know where the chance of these things is reduced and where as we talked about with stress where the chance of them being stressed and labour is reduced and that's going to optimise the flow of their hormones as well so yeah we talk so there's a section in there which is the 1.4 sections which is the time after birth if you're interested in the physiology of the hour after birth and how the interactions between mother and baby promote maternal oxytocin release even up to 10 times through those interactions with her baby so having mother and baby together increases her own flow of oxytocin which has all those benefits of contracting uterus and preventing hemorrhage and you know thank you to the New Zealand researchers as well for the work that you're doing in the chance of postpartum hemorrhage related to physiologic child bearing and there's really increasing evidence that physiologic child bearing if we're not interfering with the oxytocin system through some of these interventions especially for girls and synthetic oxytocin then the chance of bleeding after birth is normally it's not reduced so physiologic child bearing and physiologic third stage are eminently compatible in my word and we're getting increasingly evidence to support that so yeah the overuse of synthetic oxytocin Catherine definitely you know read that chapter I really haven't had a chance to talk about that but that's a big focus of the report and it's not very controversial but you know why aren't we looking at that why we know all about oxytocin outside reproduction why aren't we looking at the possible impacts and epigenetics in relation to its use in labour and birth yeah Well Catherine you're asking me a big question how do we address women's general social psyche emotional states in pregnancy you know an unwell emotional state and look I do there's actually section on stress and pregnancy which is a great systematic review of interventions to reduce stress and pregnancy so again I'm going to refer you back to the document to look at that obviously we can't change women's social situation to a large extent in pregnancy but there's things we can do there's tools that have been shown to be effective for reducing stress and pregnancy which as you say then goes on to impact stress and labour so again that section for 5.2.1 stress and pregnancy stress and labour so I'm going to ask you a final question so who's going to go out and read the report put your hand up for me I want to see everybody's hands up that's my intention okay I think we're out of time now so thank you all very much for coming along for your questions and stay tuned I'm going to my intention is to actually do a series of webinars later in the year looking at each of these subjects where you know I could do a whole webinar so if you want to find out more what's happening in hormonal physiology and how we're getting this work out and I'm also looking at putting a Facebook page together called Hormonal Physiology Revolution so let's get that happening but again go to my website and sign up for that so thank you so much for coming and I'll see you next time so thank you so much so thank you so much so thank you so much again go to my website and sign up for and you can find out all about that thank you Sarah there are a lot of people putting up their hands now Sarah and I'm sure that we will all be going to read more because this is the bed and butter of midwifery of course and we need someone who can explain all of this to us it's very complex but we know in our hearts we know instinctively as midwives the art of midwifery that you're talking about here letting women's own hormones do the work for them so thank you so very much for this rather quick journey through hormones and what we do my pleasure thank you we'll look forward to the webinars