 So, today we'll be listening to a presentation from Margaret Jewitt on baby-led birth. Margaret first delved into the physiology of birth for a 1993 book called Child Birth on Marks, which made the scientific case for minimizing avoidable stress in labor. For a master's degree, Margaret looked at women's experiences of birth, interviewing mothers and comparing notes of home and hospital birth. Margaret edited Midwifery Matters, the magazine of theization of radical midwives for nearly 20 years. She moved on to devote more time and develop a kneeling chair for obstetric units. A book, Dynamic Positions in Birth, provides the theoretical underpinning for the importance of freedom of movement in labor. Our next book, The Natural Science of Birth, will explore the bowmanics of uterine function. You are so very much welcome, Margaret. I'm going to give you the presentation right now, and we are looking forward, very much forward to hear about your study. Thank you very much for allowing me to speak at this year's conference. Even though I'm not a midwife, I'm just a birth nerd, and I'm a psychologist really, and the cats just come to join me, so if anything happens, blame the cat. Today, I want us to rethink physiology and the biomechanics and the Meccano biology, the science of how the body works in birth. But I want to roll back about 500 years when the anatomists of the 16th century decided that the uterus owned all the power of birth. Right, I've got a quote here. I'm going to read it out from a little book from a study day from 1969, a lecture by Carl Wood, who was a physiologist. Hippocrates considered that at the appointed hour, the fetus put its feet against the fundus and pushed. The fetus was, in fact, held responsible for its own birth well into the 16th century, when Fabricius Ab Aquapedente, an Italian anatomist, put forward the idea, amidst great opposition, that the chief agent concerned in parturition, in childbirth, was the muscular action of the uterus itself. And that has been the case ever since. The mother and the baby are left out of the picture, the uterus does all of that, according to the obstetricians. 1969 was virtually the last time when most obstetricians and physiologists were still interested enough in each other's work to attend the same conferences. When Cesarean section became safer and obstetricians learned what to do with artificial oxytocin, they seemed to lose interest in physiology and they have tended to stick with the outdated powers passenger-passage model of labour. They've used ever since invented by Samuel Reynolds in the 1940s, who was a renowned physiologist. But I really hate to think of the baby as a passenger. I'm going to call the fetus, the baby, because I want to give him personhood. I want to give him agency, the ability to do things, to decide when he's ready to be born and to participate in his own birth. I'm talking about him as a he, just to distinguish him from his female mother. In what you could call the natural environment, the nearest that we have today is the mother's own home. In the natural environment, the baby is anything but a passenger. He has the role to play in every stage of labour. In this talk, I'm going to talk mostly about the first and second stages. When he can be, if conditions allow, he has his most active. So, the start of labour. How does the baby participate? How does, in the start of labour, the onset of labour? Well, he's got a special part in his paternity grant called the intermediate zone, which secretes a hormone, D-H-E-S, which the placenta converts to estrogen, which is then sent to the mother, and the mother makes collagenase, a hormone called MMP, which can break down membranes at the cervix and at the uterus. We know that the cervix changes before labour because we've got a score for it, the Bishop score. And we know that this is called remodelling, and it changes the quality of the cervix. It has a loss of its tensile strength. It stops being such a good stopper, and it becomes less stiff. It breaks down. The estrogen also leads to an increase in oxytocin receptors at the uterus. So, there's a little oxytocin goes a far longer way. Oxytocin has more sites to act at the uterus, so it has a greater effect. And the other thing that estrogen does, it starts a process of creating gap junctions, which are electrical connections between muscle cells, so that the uterus can start to act as a whole. Instead of contractions being restricted to the single site of initiation. Come back to that later. And at the bottom of this slide, I've put inflammation. Premature rupture of the membranes can lead to premature birth. And one of the mechanisms is inflammation. Inflammation is the body's response to detecting a foreign body. Right, the baby starts labour by making his presence felt as a foreign body, and by making his mother recognise him as a foreign body. All this biochemistry, all this endocrinology, transforms the uterus from fortress to lobby, to anti-room, to starting to become the way out. It transforms it from an incubator to an ejector seat. And it transforms it from a sealed room to a passageway out of the body. Right, the very final stage is when the cervix starts to open. It turns a closed system, a sealed room, into a room with a door, which is starting to inch forward. The uterus has to change its very substance, its physical properties, which is mainly its ability to stretch and its ability to resist stretch. It's transformed. And the physiologists call this process remodelling, and it seems to take place starting over the last weeks of pregnancy, as far as we can tell. It's been completely neglected by most, if not all, researchers. I have come across midwives who say that they can feel it, and I'm longing to talk to an obstetrician, preferably one who turns rich babies, perhaps they will be able to feel this change in the uterus, in the function of the uterus. Now, my main contribution, I think, to this, is that I think that this process actually carries on throughout labour itself, that the uterus becomes more and more stretchy and more and more reactive as the labour progresses. It fits in with what midwives say. It fits in with mother's birth stories. And the process hasn't been studied much, because it's so difficult to look at human processes. We can't open women up and look and see what's happening. We can only guess what's happening, and the obstetricians have stopped being interested in what's happening. A few people have looked. The only time a sample of the uterus has been taken is at Caesarean section. And when people have looked, they find that there is less collagen in a myometrial strip taken when the woman's labour has started spontaneously, but her uterus is more transformed during spontaneous labour than in a labour that was started artificially. So I've got a great big way of induction in capital letters. I think this is the main reason why inductions either fail or they lead to dysfunctional painful labour, because the uterus simply isn't ready to labour, because the uterus hasn't received the signals from the baby. And I want, we have to stop this tide of inductions, this flood of inductions, because it's dangerous. Right. Okay. This is the difference. I've got little things that can move this. This is what I think the transformation of the uterus is about. And if we compare it to the change in the cervix, on the left you can see a rubber bulb, the sort of rubber bulb at the top of a pipette, or a turkey baster or something. It's stiff and you can squeeze it, but it'll pop straight back. And this represents, if we think about the cervix, which we could, a bishop's score of naught. And the one on the right is a blown-up balloon, and I've cut its knot off, because it doesn't really have a tied knot like balloons do. But the one on the right represents a bishop's score of 13, which is as ready to go as you can be. But I think it applies to the uterus as well as to the cervix. But we can't measure it. We can't measure it at the uterus. We can at the cervix. Although there is a new ultrasound technique that measures stretch. And I'm trying to find a university that knows how to do this so that we can start having a look, because it's non-invasive. Ultrasound is used a lot at the end of pregnancy anyway. And we might be able to find whether this theory of the transformation of the uterus is... would give it support. Right. So it all sounds very complicated. Collagen and collagenase, and stiffness, and estrogen and oxytocinase, and progesterone, and all the other things. But it's easy if you consider the physical effect of the biochemistry on the tissue of the body. The way the stuff of the uterus behaves. I'm a psychologist. I'm interested in behavior. And I came to the uterus through psychology, through wondering what stress hormones did to the uterus. And as you will all know, they stopped contractions. That was my way into the fascination of the uterus as I have now. The other thing that has come to light is that there are so many genes and proteins affecting it. Hundreds of genes of which about 80% ought to do with immunology and inflammation. Which I don't know whether any of you will have realized that inflammation is crucial for labor. But the biochemists have proved beyond doubt that labor is an inflammatory process. But they do seem to be stuck in their own silo. They don't seem to consider what those processes, what those proteins actually do. If you consider it from a material point of view to me, it's starting to look much easier. Inflammation is tissue, tissue breaking down. And I think that's the very process of labor, prostaglandins, breaking down tissue, breaking down collagen, making the uterus less stiff, making it more reactive. And it's a snowball effect process. You'll have to write it or a book and you'll have to buy the book. Oh my gosh, I'm running out of time. Now the important thing about this is because what initiates contractions is stretch. And during pregnancy, stretch is constrained. But for about week 36, it starts to prepare for labor by becoming more stretchy. We get Brax and Hicks contractions. What's doing the stretching? The baby's doing the stretching. After I published my first book, Sheila Kitzinger rang me up in great excitement and said, had I heard about the neonatal reflexes? Well, I had because I'm a psychologist and I did child development and neonatal reflexes are part of that. But she said the Italian neurologist, Milano Comperetti, said that he thought that the reflexes, the neonatal reflexes were involved in birth and that the baby is searching for the invitation of softness. The cervix becoming softer, the baby trying to find his way out. So the baby is not being a passenger. He's no longer constrained. He can find his own way out. And Jane Evans, a midwife who was in ARM, talked about the concept of cervical weeping, which is a discharge often mistaken for amniotic fluid, but actually it's breakdown of collagen. It's the cervix breaking down and releasing its stiffness. Oh, this stuff is just so wonderful. I love it. And I just wish I could find other people. To share it with. Right. How does the baby find his way out? Now, this is a picture from my first book about trampolines. Trampolines, you jump on a trampoline and if you jump in the middle, you'll be pushed. The trampoline will push you straight back up in the air again. Here's my red. Can you see my red? My blue spot. No, it's all you put a plank underneath and you jump in the middle. It's going to push you off to the side because it can't stretch where the plank is. You can only bounce where there's an elastic surface to bounce on. It has direction. The pushing has direction. If you jump to one side, it'll try and push you back to the middle. Now, the uterus is like a 3D trampoline, which steers the baby. The baby pushes and the uterus pushes back where the baby has kicked, where the baby has stretched it. We can't find a way of researching this. I've scratched my eyes asked so many people, can't do it. But it makes sense. It fits in with what we know. Oh, that's all right. I haven't got that much left. Right, so that's the physics of trampolining. The baby rotates and descends. Now, if you look at the obstetricians model of birth, they think it's just fundal pressure that the uterus pushes down from the top. If the uterus did just push down from the top, then all the baby could do would be to go down, go straight down in a line. But we know that he rotates as well as descends. In fact, one of the neonatal reflexes is even called the labyrinthine reflex. It's written into the very name of the reflex. What's it for? It's to negotiate a labyrinth, rotation and descent. And of course, the neonatal reflexes fade away after birth because they're not needed any longer. Right, I think I have missed another slide. Oh, we've got rotation and descent. That's all right. Right, okay. This is one of my bec noirs. This is the worst position to... I'm still in first stage. The worst position to have first stage in. Two tight belts stop the baby moving, even if he could. We've got the woman's spine underneath being another barrier, just like that plank on the trampoline. Just like that, that's her spine. The baby can't stretch that bit. We're immobilizing the baby if we put a woman on her back. And if we tie two straps tightly around her, we're immobilizing the baby again. He can't stretch where the bands are. So the CTG is worse than useless. It actually impedes the process of birth. The baby needs as much freedom of movement as possible. And this is achieved by allowing his mother freedom of movement so she can change her position at will. And now we're getting on to second stage because first stage has positioned the baby in the right place at the inlet in the best possible position to get through the pelvis that Molly was talking about earlier today. And second stage, he needs a big push to get out. And I believe that that big push comes from the baby impinging on the clitoris. We've only just discovered in the last 15, 20 years that there's a lot more to the clitoris than just this little bit. There's a whole body of it here. It's attached to the bottom of the synthesis pubis underneath the bones, what they call now. And the shaft, the body of the clitoris is up in the cartilaginous bit of the synthesis pubis. And that is the bit that the baby presses against. There's a lovely MRI. If you Google MRI, baby's birth, you'll see, look, there's this baby's head pressing against, that's the bone of the synthesis pubis. And the MRI, I can't do a video here, but the baby goes up and down and up and down just as if you were, and the baby is masturbating, the mother's clitoris basically. And what's going to happen then, she's going to have an orgasm. And you don't call it an orgasm in birth, we call it the fetal ejection reflex, or we call it Ferguson's reflex. I'm off-strip now because I'm running out of time. Ferguson didn't know that the clitoris existed, the internal clitoris existed when he put glass rods up a mouse and simulated the vagina and the cervix. The textbooks have got it wrong. It must be the clitoris. It makes sense. This is one of the things that happens when you stimulate a huge nerve on one side of the body, which has got connections to the other side of the body, you can have things like the movement of the rhombus of the chylis. The pelvis actually destabilizes to let the baby out. It's part of the fetal ejection reflex. I need someone to talk to about all this. It's just so fascinating and wonderful and the anatomy fits like a glove. But it doesn't get seen. Obstetricians never, ever see it. Well, I don't think, I don't know, I'd love to meet one who had. Next slide, because I'm running out of time. And I'm repeating a picture that Molly, Molly showed here. And again, we have got the back of the baby's head here, you see, pressing against the crura of the clitoris here. He's actually further out. The fetal ejection reflex has taken place here. It's beautiful. Birth is absolutely beautiful and the mechanics and the engineering of birth is so wonderful that I'm going to share it all with you in this book, The Natural Science of Birth. What's the next one? Oh, yeah, okay. I'm going to finish. Pause. This next slide is the baby participating in third stage. The baby elicits oxytocin from his mother as he suckles. And that suckling will send more oxytocin all around her body and shut off all those pesky blood vessels that otherwise might hemorrhage. Third stage, the baby's getting the oxytocin to flow by, by suckling his mother. Oh, right. Okay. So, the key to birth is freedom to move. And the freedom to move is not just the mother's freedom to move. The mother needs her freedom to move because she needs her baby to be free to move where he wants to move. It's not just a passenger. His reflexes, his hard-wired reflexes in his brain have told him what he needs to do to get out and his suckling reflex at the end. Baby needs freedom to move. His kicks cause the contractions. The center of the contraction is where he kicks. And, right, I've recently been in touch with one of these physiologists from back in the 1970s, Robert Garfield. He is the one who found gap junctions, which wire the uterus up for labor. And he participated in some research that involved an abdominal poke and the center of the contraction recorded on an electrohistogram was where he poked. Where you poke a uterus, it kicks back. Where the baby kicks the uterus from the inside, it pushes him back, it steers him. Right, okay. And the rest of the slide speaks for itself, I think. There we are, the dance of labor. We've got two bodies moving in relationship to each other. One body is moving out of the other's body to end up in her arms. And both mother and baby needs the freedom to move. And that's how we evolved to give birth. That's how we were designed. And please, if there's anyone else out there who loves this as much as I do and thinks it's as beautiful as I do, please get in touch because I feel it's such a lonely place. Because we can't do randomized controlled trials on this sort of stuff. And yet it's written in the anatomy. It's written in the material substances that make up our bodies. And if only we could let the world know about how these bodies works, then perhaps we wouldn't have all these inductions. Perhaps we wouldn't have women tied to the bed, tied to CTG machines. Perhaps we wouldn't have all this birth draw or all this postnatal depression, all this lack of bonding. And perhaps we could change birth. Peace on earth begins at birth. There we are, that'll do for now. Thank you very much, Margaret. Very interesting, exciting, fascinating piece of work. Thank you so much. I agree with you. 50 minutes is not enough to do justice to this fascinating insight that you have brought. And we're so much looking forward to the publication of your book, Natural Science of Birth, so that we can all share and explore these techniques of uterine function that you've described so eloquently. Thank you so much. There have been a lot of comments in the public chat. And you talked about people joining you. I can see a lot of collaborations forming. Names mentioned in the chat, Molly, Michael, Odend, and Betsy. All I've shown, I've talked about a lot of interest in exploring this further with you. So I want to encourage us to reach out to Margaret after this session to work together. Also, if you have maybe additional questions and comments. I can, there are some questions or comments that I've picked out. And one was from Molly who was talking about the need to have investigation, the initiation of labor that, as she said, remains a mystery. So it's well over time for us to have a better understanding of the process. There was a comment from Selin, and Selin was asking, what happens? How can you explain prematurity? And I don't know if I can add to that in the unfortunate event when the baby passes away, when the baby is there. So what happens to baby-led births? So I don't know if you can respond to that. Right. Yes. First, the prematurity is very, sometimes that will be due to information caused by infection. That infection is well known to cause prematurity. I think perhaps in about 50% of cases, that's the case. Now, when the baby has passed away, sadly, the baby still has a body and the baby doesn't have any reflexes anymore, but he still has a solid head. And we tend to induce labor, and we can use much more violent means of induction if we don't have to worry about baby anymore, so that larger doses of oxytocin can be used. The forceps aren't going to damage him. He's beyond that. So that's what I think. Now, some of this is a lot of it is speculation, but little bits of more and more information is coming to like this information business. But these scientists are all in their own little silos and they don't talk to each other, so that we've got... Roger Young is so interested in how the uterus works as a whole, but he's not talking to the biochemist interested in information. And the McCona biology people, they're all in their own little group and they're not talking to each other. And all I've done is pull in threads from lots of different disciplines and, well, made a tapestry, really. Jigsaw. It's like a jigsaw. I've been pulling bits from here and there and everywhere. Yes. Now, Molly, I see that. Linda says I should talk to Molly. Now, Molly's biomechanics are biomechanics of the pelvis. Most biomechanics is to do with bone. And, yes, Molly's work is fantastic and it's lovely. And I think what a lot of Molly's work does is to free up the uterus and therefore the baby to allow the baby, then the baby can move to influence the uterus. I think that's what's happening with these ligaments. I think letting the uterus hang free as in forward-leaning and things is doing that. But the thought of biomechanics I'm talking about is soft tissue biomechanics, which is a different field altogether. Sue Dan's group up in Lancashire is doing hard bony biomechanics, but it's skeletal. And they forget about gravity. Even though the baby is in a sack full of amniotic fluid, the baby has still got a weight to it. Coming back to the baby was passed away. There's still a physical force exerted by gravity by a hard object, inside a soft object, inside another hard object, the pelvis I suppose, if people can follow that rather convoluted talk. Thank you so much, Margaret. And thank you, everyone. There had been a lot and a lot of love shared in the public chat for you, Margaret. People say now much they love you. Listening to you is the idea. Thank you, Linda, for sharing Margaret's email address. There have been some requests for your email address. So I'll try and round up now. Thank you so much, everyone. Very, very insightful session.