 And now, it's my great pleasure to introduce tonight's speaker, Margaret Giant. Margaret first delved into the physiology of birth for her 1993 book, Childbirth Unmasked, which made the scientific case for minimizing avoidable stress in labour. For her master's degree, she looked at women's experience of birth, interviewing mothers, and comparing notes of home and hospital birth. Control, that's the key really, declared one home birth mother. Margaret edited Midwifery Matters, the magazine of the Association of Radical Midwives for nearly 20 years, moving on to devote more time and develop a kneeling chair for obstetric units. Her book Dynamic Positions in Birth provides a theoretical underpinning for the importance of freedom of movement in labour. And her next book, The Natural Science of Birth, will explore the biomechanics of uterine function. Without further ado, let me make Margaret the presenter and hand over to Margaret. Margaret, you have the controls on your laptop and you can speak through your tablet. Yes, good. Have you got my voice? Yes, we have. Thank you. Good. We do have your voice. That's wonderful. I'm so glad. Yes, I see you have now. Right, I can cut my first paragraph. You've just said it for me. I would just like to say Mary Cronk. Our beloved Mary Cronk did me the utmost honour of forgetting that I wasn't a midwife once. So, I'm not a midwife, but perhaps I could be an honour. Anyway, my research at Keele was based on the assumption that stress hormones might in any trend. And I had to learn how the uterus worked in order to know physically how they did. And that was a 25-year journey, which has led me to a radically new model of uterine function that fits so very well with what mothers and midwives know about birth. The British Journal of Obstongyne published a pretty of my new model. You can Google Jowit, B-Jog, 2018 to find it. But not just yet, please. You get a better version here. Gosh, I'm sorry about my nerves. Anyway, before looking at the dosage, we need to take a close look at physiology and biomechanics. Basically, I've found that the textbooks have left out half the picture. They've left out most of the biomechanics of the uterus, and they practically ignore the baby. They call him a passenger. I believe that my new model explains how the baby and the uterus interact with each other during labour. That's the dance of the birth. I'll do these slides. Next one. Hold that way. Slide 14. Right, so the uterus has got two opposites, and even contradictory functions. First of all, the uterus is a sanctuary for a growing human. It's an incubator, nurturing the embryo as it turns into a fetus, keeping it safely inside, fed, water, waste disposed of, all over the centre. And then, towards the end of pregnancy, the uterus gradually transforms into an ejection seat. A really horrible, quite funny baby, but it is the most powerful muscle in the body, and it's capable of pushing out a four kilo baby into the world, or by itself. Even paralysed mothers can give birth. Come on, slide, move. Right, the biomechanics. The wounds are ballooned. My new model is easy to explain because if an everyday object that is a near-perfect analogy for the uterus, the properties of a party balloon depend entirely upon its shape, its strength, and the material it's made of. It's pear shaped. A hollow elastic bag, which grows, is under pressure, has elastic memory, and reverts nearly to its original size when popped. Fragile, yet strong. Tides shut after such performance and urgency. Right, this is the bit the textbooks do tell you, so I won't spend too much time on this. During pregnancy, the uterus keeps the uterus quiet. Progesterone stocks strong contracts. In nearly all other placental mammals, high levels of progesterone are stopped by uterus from laboring. Estrogen encourages the uterus to grow to become about 20 times its original size. And after the uterus has stopped growing, the fetus carries on growing, and the uterus stretches and stretches to contain it. And please, you must remember this, there's a huge amount of stretch. I have it not. Change slide please. The slides are being very slow. It's coming along. Right, going in. Am I speaking before the slide comes? Perhaps you can see it. The uterus has to remodel itself from an incubator into an ejective feed. Part of this transformation is the result of changes in the biomechanical measurements of the uterus. Raised estrogen increases the number of oxytocin receptors so that the same small amount of circulating oxytocin has more places where it can act as the uterus. That makes it lively. Raised estrogen also increases the number of electrical gap junctions. Muscle cells communicate using electrical signals just like nerves do. Polyconnexin43 links up the muscle cells of the uterus electrically so that they can act as a network. And the signals can pass from one muscle bundle to another muscle bundle. Potentially all over the uterus. So it connects it all up to become an integrated whole. And your... I won't waste time on that now. Oh, in the cervix. You can read that bit. Next slide, it's slow. Come on. Slide 18. So... Oh, no. I don't want to join the audience. I'm sorry about that. Go for 18. I think, Chris, I want you to do my slides for me. Okay, I will do that. I will do that. It's being slow. Right. So it should be slide 18 now. Yeah, it is. Lovely. Stretch leads to contraction. Now, one of the physiology midwifery textbooks says that it doesn't. But it does, let me tell you. I say more about how the uterus works. It isn't just hormones that initiate contractions. It's stretch. The uterus is made of smooth muscle. And stretching smooth muscle is the body's way of moving stuff around. A process known as peristalsis. Hollow organs, made of smooth muscle, tend to contract as a whole. The four chambers of the heart contract as a whole each once. You can't see my hand moving. Sorry about that. Anyway, the uterus is made of smooth muscle. And yet, it stretches and stretches and stretches as the baby gets bigger. So why doesn't stretch lead to contraction in pregnancy? Gesturone alone is not enough to stop contraction for humans. It doesn't prevent premature labor. Well, the doctors would use it all the time. Next slide, please. Now, the next one. I added a bit to my balloon, which I hope is going to come up soon. Right. We have a constrained balloon. We can skip back to the balloon analogy. So at this time, we put the balloon into a stiffish net. This one had some garlic in it, I think. Remember? The net in this picture is about the right size to contain a balloon. I blew up the balloon inside the net. And the net stopped the balloon getting any larger. The net limited the stretch. The mammalian equivalent of the net is connected tissue. You may already know that the cervix is 90% collagen and only 10% muscle. It's this collagen that breaks down to ripen the cervix before labor. You all know about that. What I didn't know until about five years ago now is that all smooth muscle needs a scaffolding of connected tissue, mainly collagen and elastin, to keep its shape. The muscle alone is too sloppy a material. Collagen stiffens it. So the muscle of the uterus is constrained in a network of collagen and elastin, not so much as the cervix, but 40% a significant amount. And I think that this network serves exactly the same purpose in the uterus as it does at the cervix. Constrain movement and deplace limits on the ability of the uterus to be stretched. Next slide, please. In pregnancy, stretch and estrogen leads to growth. Progesterone limits contraction. And also, this is the new bit, the collagen network also limits contraction. Next slide, please. It's a bit more fun than just words, I think. Because for humans, next slide, please. Well, it hasn't come off on mine. Perhaps it has on yours. I'm going to wait. Oh, right. Yes, okay. Well, and another one. This is the rubber bulb. A rubber bulb makes a dent. I've skipped a bit. All right. Just deep breathing. And the next slide, please. I make it more fun. You might have missed the slide. That's right. Because for humans, that'll be thanks, Chris. For humans, progesterone by itself isn't enough to stop the contractions caused by stretch. Why? Because of gravity. You can see the gravity by the little arrow. Our habit of upright walking puts immense strain on the uterus. In four-legged animals, the weight of the fetus is slung in a hammock suspended between the animal's four legs. The calf can't just drop out. It would have to defy gravity. You have to go uphill. But there's no premature delivery problem for the heifer. But in humans, the weight of the fetus is directly above the exit. The human uterus has to work much harder to defy gravity. Hence, there needs to be a much longer college and network. Is there? That's something for the analytic physiologists. And it's difficult getting your hands on uterus term. But what I do know is that we do have a greater supply of an enzyme which breaks down collagen. Collagenase. Otherwise known as... Physiologists who have analysed this tissue from Slytherin's Pagans to their sense find more collagen when it was in the electrosis area before labour. So the electros sections, the uterus hasn't started to break down that network. Next slide, please. Chris, next slide, please. Right. The collagen, this slide, is put in to show you the effect for network of constraining material. If you imagine yourself squeezing a rubber bulb on the picture, it goes in and back out again. Okay, the uterus isn't exactly like the rubber bulb. It stretches evenly instead of making a dent. But the stretch doesn't travel very far. Just enough to cause a contraction to fold the baby back into the fetal position. And of course we could stretch those things from the outside, but the baby stretches it from inside. Right, Nick. We're going to have a recapitulation of going into labour. We'll just remind ourselves of the whole set of labour. First, an increase in oxytocin receptors so that oxytocin can act in more places. Secondly, a new network of junctions, wiring up the uterus altogether. And now to add to that picture, we have matrix metalloprotein, MMP, which starts to break down the network of collagen so that, like the cervix, we use more stretchy. And as it becomes more stretchy, it becomes more active because stretch leads to contractions. This is what it feels like for me to give birth. What labour feels like for me. Contractions change. Right, sorry, I just added that bit. Now, we all know that after birth, the uterus gets smaller. It reverts to near its previous size. Discharge from the vagina after birth is different from menstrual blood because it contains the breakdown products of the uterus itself. It's a different colour. All that I am proposing in this new model of mine is that the uterus starts this breakdown process before labour rather than after. And this leads to a difference in the material properties of the substance of the uterus. It is less rigid, more stretchy. And stretch initiates contractions. I haven't got time to go into quite how and how they get timed. You'll have to wait for the next slide please, Chris. Right. Slide. Inflammation. I don't know which one it is. Labour is said to be an inflammatory event. And on this slide, I can't see it, but perhaps you can. There we are. I've listed some of the biochemicals involved in inflammation. Prostaglandins, interleukinate, MNP, white blood cells. They all co-operate to digest the collagen. Next slide please. It's taking back control of her body. Could you have the next slide please? Perhaps it's there. I'll carry on talking. If you think about it, all the way through pregnancy, the mother has been protecting and nurturing a small human with half of its DNA alien to her. Scientists such as Sabita Medaway, who researched skin transplants for burns patients during World War II, discovered that the body rejects and breaks down alien tissue. During pregnancy, the fetus is hidden from the mother's immune system. What would it be that the mother goes into labour when she finally recognises that she harbours a foreign body? This would make labour the natural bodily response to foreign tissue. I'll go back to you quickly. It's okay, people can go back and look at these slides later once they're up on YouTube. Okay, so what is the next one? The next one is the two balloons again, isn't it? The next slide, that's right. Yes, so all I've done on this one, you see I've chopped the knot on the balloon on the right. You couldn't do that to a real balloon because you could see the air would just come rushing straight out. That's basically what happens. Take away the net and take away the knot. And labour becomes inevitable. I think that my new model solves some of the mysteries of labour. Now, the next four slides, I think it's four, 27 to 32 might be five, are from an animation that a friend of mine, Pete Bradley, made to illustrate the new model of labour. I do wish we'd been clever enough to put the baby inside the balloon and to have shown his movements if we need more work. But then we will. You can access the main through my website, which is birth upright or one word.co.uk. Now, Chris, can you slide through to the last balloon picture? I'll read it out as you go. The uterus is essentially a balloon shaped elastic bag. The stiff surface is not the balloon. Next slide. I've got a picture of this. It is being very slow, isn't it? You can all see it. I'll show you the picture. The network has a way in that one and the balloon is contracting down and always and if you imagine that baby, you've got to get out of that service, which is opening up. I think that's the last in that section. I don't know why it's got 19 minor on it. That's not far, I think. That's okay. Next slide, please. I hope you get the picture. Anyway, you can watch all that on my website. But, as I said, we left out a vital piece of information. The baby. It was just too complicated to manage each time and to be honest, it still is. I need help. But the baby is really the first smoother in all of this because what is most likely to cause this uterus? Baby, of course. We can see it. We have seen it. Does the baby kick-start later? I can't find one text, though, saying the baby is a uterus and that's, I think, I don't know if you've just faced it about 1960s. Of course it's straight from uterus. The baby has to be children. Right. Why does this matter? This matter is rich. The uterus is poor. They all happen properly. I don't know what I'm talking about. Personally, induced labors are very different from physiological labors. If you are going to have to manage labors, you could wait to find the transformation first. Margaret, can I interrupt a second? To me, I don't know about the rest. Your sound has been to sound a bit different as if you're sitting slightly differently with your tablet. Aha! An earpiece fell out, which moved the microphone. Is that better? Yes, it is much better. Oh, brilliant. Okay. Right. We know about induction, don't you? I'm going to say. I'm repeating what's on the slide, but just expanding a bit, so you haven't really missed much. One midwife told me she could feel she was getting back against her hand when she palpated. This was at an ARM meeting six months ago or so. I was delighted it was evidence that the stretch of vaccination pleased more reports of this, anyone. We need more evidence than I have got at the moment. I've only got textbook biochemical evidence. We need some clinical, experiential evidence from midwives and from mothers. One more interruption, Margaret. We've got about 10 or 11 slides to get to your question slide, and you've got about seven or eight minutes if you want to allow time for Q&A. Okay, I'll speed up. I'll speed up. Right, so why does this matter? B, right. Next slide, please. It was not the only mammals to have one baby at a time. Let's say that the first stage of labour is for positioning the foal, and you can skip for the next one as well, which is a picture of for foals in the uterus. During pregnancy the foal lies with its heaviest part its spine slung in the hammock is the mare's belly. For stud vets, the repositioning of the foal is one of the first signs of labour. Look at the pictures, and look at the foal's back legs. The foal works with the mare's uterus to retain 180 degrees so it's fallen right side up. Our babies don't usually need to make such enormous changes in body positions, but they do need to fit themselves snugly into our tight pelvis in order to get themselves around the sacral promontory and to get themselves into the very best position to make the cardinal movements we learn about in the textbooks. Next slide, please. The foetus is not a passenger. The human foetus works with his mother's uterus to position himself optimally for the torturous journey through the bent human birth canal. He does this by using a combination of the stretch contract and his own neonatal reflex. Slide number 37 now, please. The uterus is a balloon shaped trampoline. And this is how the foetus of labor works. I know you've fallen for it. I'm sorry it's been so much science, but I think you can leave it. It took me a long time to understand and I hope I'm telling you all right. Right, we'll look at how the stretch contract reflex can move the baby. The technical term is mechanical and I've found only one textbook that even suggests that it might be the foetus that's doing the stretching, but that's okay. We all know that babies kick even if the sign doesn't. The center of each contraction is where the baby makes a large movement. Usually his feet, I think it could be his back. Can you just go up, back up a slide please, Chris. Sorry. That's the trampoline, that's all right. You look at the trampoline, there we are, that's right. I think the baby's using his feet. Look at the trampoline. If you bounce in the middle, it'll push you straight back up and up again. If you bounce to one side as in the right hand picture, it throws you back into the middle because of the way the elastic works and where the tension is and if you look at the bottom one, I've put a plank, underneath it, which is changing the center of the contraction and it's throwing the person now out from the center. This is what I think happens when the mother's lying on her back on the bed, her spine, even the contraction belts I haven't said could get in the way of being able to stretch where it wants to. Right, now we can have the next one. How does the baby do his stretching next slide? Do you want to go to see it? No, that's fine. This is the exciting bit. Sheila Kitzinger rang me up after my first book and told me about this. John Maconferretti with a father of pediatric neurology looked at the reflexes. He studied ultrasound of babies before birth and plotted a gestational timetable of the reflexes when they first appeared and when they faded and he concluded that some reflexes were used by the fetus to find what he called the invitation of softness. The softening and stretching lower segment of the uterus under the top of the cervix. My midwife friend, Joy Horner, and I got together over coffee to think about what reflexes might help with what movements and we came up with the following ideas which I put in two slides. We need more practical research. This just represents our best guess and we have the next slide please, Chris. You've got to put a large question mark over the fourth column because this is joined and I'm guessing at what's happening. I'll just pick out one from each. The Moro reflex and if you allow the baby's head to fall back an inch the arms and legs first extend and then fall back towards the body well is this a baby getting into the pelvic inlet and tucking its chin in? I don't know. Next slide please, Chris and there's quite a lovely one on this. And it comes up the gallantry reflex stroke in the spine trunk and the hips move towards the side of the stimulus and we think that this might be the baby's spine going passing the sacral promontory and causing rotation into the mother's sacrum. Next slide please, Chris. Right, so I'm afraid that's about all the dance I can do but the dance floor is the wall of the uterus. It needs to be primed with the right hormones and it needs to be stretchy enough to contract when kicked. As the stiff network breaks and contractions become ever more powerful as women and midwives know them to be it's not just the quest chucking on the uterus and causing the whole thing to implode Sorry, I'm getting a bit political here. As for the dance movements this is very much working, Chris. It's why I desperately need a biomechanics lab that can study smooth muscle preferably with a baby inside I think if we found a mother having brachs and hips contractions we'd be able to do quite a lot and I also need someone with the right sort of brain to help map the fetal reflexes onto the cardinal I mean I'm sort of inching intuiting towards that way but my brain isn't quite good enough so I've left on with this once the lockdown is over Meanwhile, let's give the fetus all the room he needs let's let the uterus hang free so that the fetus can stretch it where he needs to stretch it to get into the best position for second stage and that means giving his mother freedom of movement off the bed unless she really wants to be on the bed I suppose she might do, she might want to be on her side forward leaning works best for me and it seems to work best for other mothers let's stop believing that the mother and baby can do nothing except accept their fate we really don't need to advise mothers to lie back and think of England we need to let mothers and babies follow their own instincts we need them to reclaim their bodies and to do what comes naturally and this is I think how birth works and the next slide please which is a picture of my kneeling chair I think it's slightly too you might see it have already oh gosh no I've got a blank screen on that blank screen there's pictures of my kneeling chair it goes into two positions my son calls it the flipping chair because you can get a high level and a low level you can have a seat bit you can even kneel on it and do a forward leaning inversion if you want it's to give really I decided for obstetric units to help nudge mothers off the bed and that's it and have we got time for questions gosh I've run over a bit sorry that's okay we've got time for a couple of questions I have one that I've noticed go through while you were talking and Buki from Nigeria asked for how long do you wait for transformation at EGA of 41 weeks I don't know I think that some labour doesn't happen because the fetus has got into a vision that he can't that he can't get out of and that a bit of ribosa has shifting the uterus about in a scarf imagine hands interlaced together underneath the uterus to try all fours kneeling I think I think there's an awful lot we still have to learn about this but I think that positioning might stop some labour happening so I can say I think for the moment in a time we've stopped okay don't worry and don't overdo it I've got time for one last question if someone would like to ask Margaret a question I want to our closing slides right I see someone said submitted to the Journal of Medical Hypothesis it has been published in the British Journal of Aesthetics and Gynecology in their debate section two years ago and I have not nobody had I had to praise it like mad to get it into 500 words but you've had an awful lot more than that today physiology didn't want it loads of people don't want it I'm a nobody, a lay person that's trouble so I want you all to start talking about it and think about it and thank you for coming here now and listening and well gosh Margaret thank you so much there weren't a huge amount of questions but you could see from the conversations and comments going through that people found that really really interesting I'm a knob midwife as we know from our conversations before but I found it really fascinating just from the time I've spent with the IDM so thank you very much