OSTETRICIA E GINECOLOGIA CANOSA

Vendola a Canosa nel Marzo 2009 "Inaugurato il reparto di Ostetricia e Ginecologia"

2011-12-22T03:03:00.000-08:00

IL NOSTRO PUNTO NASCITA
DATI DEL 2011

TOT. PARTI 541

TASSO DI CESAREI 33.1% (180 T.C.)
NULLIPARE 248
CLASSE 1° e 2° DI ROBSON 25.3%
PARTI OPERATIVI 3 (0.5%)

TOTALE IVG 311
IVG FARMACOLOGICHE (RU486) 232 (74.5%)

AMBULATORIO OSTETRICO
2441 ECOGRAFIE
2009 VISITE SPECIALISTICHE

Ru486 L'Esperienza del nostro reparto

View more presentations from antoniobelpiede
La Riorganizzazione dei Punti Nascita in Puglia

Nel giugno del 2011 il prof. Tommaso Fiore, assessore regionale alle politiche della salute, convocò a Bari tutti i Direttori delle U.O. complesse di Ostetricia e Ginecologia e di Pediatria della Regione Puglia. L'ordine del giorno era "La riorganizzazione dei punti nascita nella nostra regione". Questa lodevole iniziativa, purtroppo, non ha avuto seguito e non si è sviluppato un dibattito, su un tema così importante come la Nascita che, a mio parere, dovrebbe coinvolgere, oltre gli operatori sanitari, tutta la società civile e soprattutto le donne e le organizzazioni femminili.

L'accordo Stato Regioni del 16 Dicembre 2010, recepito anche dalla nostra Regione, impone una razionalizzazione e riduzione dei punti nascita secondo criteri che perseguano 3 obiettivi:

Riduzione degli sprechi
Sicurezza
Umanità

In Puglia i punti nascita sono 42 mentre in regioni come l'Emilia Romagna. la Toscana e il Piemonte, oscillano tra i 20 e i 23!

Siamo tutti convinti che ci debba essere una svolta:

i punti nascita con meno di 500 parti/anno devono chiudere, con poche eccezioni determinate da ragioni logistiche e non lobbistiche (dovrebbero già essere stati chiusi al 31/12/2011)
i punti nascita con 500-1000 parti/anno devono essere "accorpati" tra di loro perseguendo i tre obiettivi prima citati.

La riduzione degli sprechi, secondo criteri di economicità, è automatica, nel momento in cui si accorpano 2 reparti; anche la sicurezza è sicuramente maggiore se l'accorpamento avviene nelle strutture con paletti di sicurezza già esistenti (Rianimazione materna, Centro trasfusionale etc.), mentre per le moderne esigenze di “umanità” i criteri sono meno definiti.

Su quest'ultimo obiettivo è necessario fare chiarezza.

Umanità significa "ambienti adeguati" che non disturbino i processi fisiologici del parto, significa assistenza "one to one": una ostetrica vicino ad ogni singola donna, in una sala parto-travaglio, dove può essere accolto il marito o la madre o la persona desiderata dalla partoriente. Questa è l'unica strategia efficace nella riduzione dei tagli cesarei (evidenza scientifica di livello 1A). Altre misure, farmacologiche o di altra natura, si sono dimostrate inefficaci.

Il tasso di cesarei, che, se elevato, è un indicatore del degrado organizzativo e assistenziale, va preso in seria considerazione per non ripetere esperienze già vissute in altri paesi Europei. In Inghilterra, a Londra, tre anni fa, hanno inaugurato, con una spesa di circa 12 milioni di sterline, il "Barkantine Birth Centre" una casa del parto con circa 600 parti /anno, a 12 minuti di ambulanza dal Royal Hopital. Questo per correre ai ripari dopo gli accorpamenti selvaggi che avevano prodotto una diminuzione dei parti fisiologici. Un aumento del tasso di cesarei in Puglia, che già sfiora il 50%, avrebbe effetti catastrofici, con ricadute anche economiche, come ben sa l'assessore Fiore. E' necessaria, quindi, una attenta ricognizione delle risorse umane e di quelle strutturali già esistenti. Dobbiamo sapere che in un reparto ostetrico con 1500 parti sono necessarie 3-4 sale parto-travaglio perchè non è proponibile una assistenza in cui ci siano contemporaneamente più donne in travaglio in una stessa stanza (vecchia sala travaglio). Torneremmo, per quella che è la nostra esperienza, ad una sorta di "medioevo assistenziale".

Non è, quindi, sufficiente nel decidere gli accorpamenti, il parametro "numero di parti" , ma anche il tasso di cesarei insieme all’esistenza di strutture adeguate. Oltre alle sale travaglio-parto, quante sale operatorie dedicate (cioè ubicate accanto alle sale parto) esistono nei punti nascita pugliesi? Sono anche queste previste dall'Accordo Stato-Regioni. Dovremmo riflettere sull’esigenza attualissima di dividere la popolazione di donne gravide a rischio dalle donne portatrici di gravidanze fisiologiche.

Credo che le difficoltà economiche che attraversiamo debbano farci fare scelte coraggiose, ma nella furia di risparmiare e “rientrare” nell’immediato, si rischia di “sprecare” le risorse umane e strutturali che già abbiamo, con un danno economico maggiore in tempi lunghi. Lo sforzo deve essere quello di dare o meglio di ridare, dignità alla nascita che rimane il primo segno di civiltà e non si deve fare confusione tra “la chiusura”dei piccoli ospedali inefficienti e la riorganizzazione dei punti nascita nella nostra Regione.

Antonio Belpiede, M.D.

Direttore U.O. Ostetricia e Ginecologia

Canosa di Puglia

http://ostetriciaeginecologiacanosa.blogspot.com/

L'attività del nostro reparto nel 2011

michael stark a canosa il 20 Marzo 2010

2009-11-21T07:49:00.000-08:00

Prof Michael Stark from Berlin, the “father” of the simplified, fast and easy technique of caesarean, and as the founder of the “New European Surgical Academy”

Prof. Michael Stark da Berlino, il padre del cesareo semplice veloce e agevole, fondatore del “New European Surgical Academy”, che parlerà della fisiologia del parto

“The delivery room in the 21st century - Humanity and Safety”

birth physiology, the place of the caesarean and the results of unnecessary interventions which might be destructive (like Kristeller manoeuvre, episiotomy etc)
the importance of the follow-up in light of the understanding of physiology.

la sala parto del 21° secolo: umanità e sicurezza

ore 9 Saluto delle autorità

Nichi Vendola Presidente Regione Puglia

Tommaso Fiore Assessore Politiche della Salute Regione Puglia

Francesco Ventola Sindaco di Canosa di Puglia

Rocco Canosa Direttore Generale Asl Bat

Franco Polemio Direttore Sanitario Asl Bat

1° PARTE

fisiologia del parto

ruolo del cesareo

tecnica ottimale del cesareo aggiornata al 2010

11.30- 12.30 tavola rotonda

12.30 -13.30 brunch

2° PARTE

risultati di interventi che possono avere conseguenze distruttive ( Kristeller, episiotomia, etc)

L'importanza del follow-up alla luce della comprensione della fisiologia.

15.45-17.00 tavola rotonda

CHIUSURA DEI LAVORI

Tavola Rotonda con:

dott. Silvio Anastasio

dott. Mariano Cantatore

prof. Ettore Cicinelli

prof. Pantaleo Greco

prof. Giuseppe Loverro

dott. Antonio Malvasi

dott. Sergio Sabatelli

prof. Sergio Schonauer

prof. Luigi Selvaggi

dott. Lorenzo Torciano

I lavori si terranno c/o "Il Giardino del Mago" - via Corsica 138- Canosa di Puglia

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RICERCA IN SALUTE PRIMALE

UNA NUOVA ERA NELLA RICERCA SULLA SALUTE

Pubblicazione quadrimestrale del Centro di Ricerca in Salute Primale

Charity No.328090

72, Savernake Road, London NW3 2JR

michelodent@googlemail.com

Autunno 2009 Vol 17. No2

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http://www.primalhealthresearch.com/

(Accesso gratuito alla Primal Health Research Data Bank)

www.wombecology.com

(informazioni aggiornate sul Convegno Mittelatlantico sulla Nascita e sulla Ricerca in Salute Primale)

LA NASCITA NEL PAESE DI UTOPIA

GENNAIO 2031

Come tutti sanno, il nostro paese – Utopia – è un territorio indipendente.

Anche se abbiamo raggiunto un elevato livello scientifico e tecnologico, siamo riusciti a conservare e perfino a coltivare alcune caratteristiche fondamentali della nostra cultura. In particolare, abbiamo sviluppato la capacità di concepire progetti irrealistici e di oltrepassare il limite della correttezza politica. Prenderemo ad esempio la storia della nascita per illustrare in dettaglio le caratteristiche di un 'Utopiano'.

Nel 2010 due donne famose di Utopia decisero di partorire con il cesareo. Per questo motivo, di colpo, la nascita divenne uno degli temi principali riportati dai media. Tutti si resero conto che il tasso di cesarei stava aumentando di anno in anno. L'opinione pubblica era tuttavia d'accordo con le severe linee guida promosse dalla OUS, l'Organizzazione Utopiana della Sanità. Per far fronte a quella situazione senza precedenti, il vertice dell'OUS decise di indirre un incontro multidisciplinare.

Il primo a parlare fu un esperto di statistica, che presentò dei grafici impressionanti sull'andamento del tasso di cesarei a partire dal 1950, momento in cui la tecnica del segmento inferiore sostituì quella classica. Secondo la sua estrapolazione, era assai probabile che dopo il 2020 il cesareo sarebbe diventato il modo più comune di partorire. Un emerito medico ostetrico si sentì in dovere di commentare immediatamente quei dati, sostenendo che, di quel nuovo fenomeno, andavano considerati anche gli aspetti positivi. Egli spiegò come il cesareo fosse divenuto un'operazione facile, rapida e sicura. Era convinto che, in un futuro prossimo, la maggior parte delle donne avrebbero preferito evitare i rischi associati al parto per via vaginale. A conferma della sua opinione, presentò uno studio canadese, pubblicato nel 2007, in cui non si era riscontrato neanche un caso di morte materna, su più di 46.000 cesarei elettivi per presentazione podalica alla 39.a settimana di gestazione. Fece riferimento anche a un successivo studio statunitense, pubblicato nel 2009, con un solo caso di morte neonatale su 24.000 cesarei ripetuti. Secondo lui, in molti casi, il cesareo elettivo prima dell'inizio spontaneo del travaglio era in assoluto il modo più sicuro di partorire. L'espressione sul viso di un'ostetrica alle sue parole conclusive '...non è possibile fermare il progresso...', tuttavia, suggeriva che al medico potesse sfuggire qualche dettaglio.

La presidentessa del BWL ('association for Birth With Love', associazione per la nascita con amore) reagì prontamente alla conclusione del medico. Innanzitutto, gli chiese quali criteri avesse usato per valutare il grado di sicurezza del cesareo. Com'era prevedibile, lui menzionò unicamente la mortalità e la morbilità, sia perinatali che materne. A quel punto la presidentessa del BWL spiegò che quella limitata lista di criteri era stata fissata in passato, prima del 21^o secolo, mentre ora numerose discipline scientifiche in pieno sviluppo indicavano la necessità di una lista di criteri nuovi per la valutazione delle pratiche ostetriche. Questa considerazione costituì il punto di svolta di questo storico incontro multidisciplinare.

Un professore di endocrinologia fece subito eco a questo commento eloquente e convincente. Dopo aver fatto riferimento all'accumularsi di dati sugli effetti comportamentali degli ormoni implicati nella nascita, poté facilmente convincere la platea del fatto che la donna, per avere un bambino, è stata programmata a rilasciare un vero e proprio 'cocktail di ormoni dell'amore'. Sottolineò che, nell'ora che segue la nascita, gli ormoni della madre e del feto, liberati durante il processo del parto, non sono ancora stati eliminati e che ognuno di loro ha un ruolo specifico da giocare nell'interazione tra madre e neonato. In altre parole, aggiunse, grazie alla prospettiva ormonale, ora siamo in grado di interpretare il concetto di periodo critico introdotto dagli etologi: alcuni pionieri in questo campo, già nella metà del ventesimo secolo, avevano compreso che, in tutti i mammiferi, immediatamente dopo la nascita, si osserva un momento transitorio che non si ripeterà mai più, critico per quel che riguarda l'attaccamento madre-cucciolo. Mettendo a confronto i dati da lui esposti con gli innumerevoli studi epidemiologici che suggeriscono come il modo in cui veniamo al mondo abbia conseguenze per tutta la vita, emergeva chiaramente che la capacità di amare si sviluppa in gran parte nel periodo perinatale. Il medico ostetrico era stupito, alle sue parole.

Al termine di quell'intervento, il direttore del dipartimento di epidemiologia del OUS , che era particolarmente interessato alla 'Ricerca in Salute Primale', non poté più restare in silenzio. Egli aveva raccolto centinaia di pubblicazioni sui fattori di rischio, nel periodo perinatale, per un gran numero di diverse condizioni patologiche tipiche dell'età adulta, dell'adolescenza o dell'infanzia. Si soffermò sugli studi più validi, quelli che avevano preso in considerazione un enorme numero di soggetti, e poté riassumere molto facilmente il risultato della sua inchiesta: quando i ricercatori prendono in esame, nell'ottica della Ricerca in Salute Primale, condizioni patologiche che possono essere interpretate come varianti diverse di una ridotta capacità di amare (gli altri o se stessi), individuano sempre fattori di rischio nel periodo perinatale. Egli sottolineò la necessità di pensare a lungo termine, riallacciandosi al commento della presidentessa del BWL in merito all'introduzione di criteri nuovi per valutare le pratiche ostetriche. Infine presentò la Banca Dati sulla Ricerca in Salute Primale come uno strumento adatto ad allenarsi a pensare a lungo termine.

A quel punto alzò la mano con impazienza una professoressa di genetica, che introdusse il concetto di ‘gene expression’ (espressione dei geni), visto come un ulteriore modo per interpretare le conseguenze a lungo termine delle esperienze pre- e perinatali. Illustrò come, di tutto il materiale genetico ricevuto al momento del concepimento, alcuni geni diventino silenti, senza peraltro scomparire nel nulla. Il fenomeno di espressione dei geni è influenzato, in particolar modo, dai fattori ambientali nel periodo pre- e perinatale. Il medico ostetrico si fece sempre più attento e curioso, come se stesse scoprendo argomenti nuovi. Una delle sue pertinenti domande sulla genesi di condizioni patologiche e di tratti caratteriali offrì alla professoressa di genetica l'opportunità di spiegare che la natura del fattore ambientale spesso è meno importante del momento in cui avviene l'interazione, e di esporre quindi il concetto di periodo critico per l'interazione tra gene e ambiente. L'intervento della professoressa di genetica ispirò una fruttuosa conversazione multidisciplinare. L'epidemiologo rispose di getto alla domanda sollevata da un medico generico e fornì ulteriori dettagli su una delle nuove funzioni della Banca Dati sulla Ricerca in Salute Primale: quella di raccogliere dati sul periodo critico per l'interazione tra geni e ambiente, per quel che concerne condizioni patologiche o tratti di personalità.

Un batteriologo, che fino a quel momento non era intervenuto alla discussione, sottolineò come i minuti che seguono la nascita siano critici anche dalla sua prospettiva. In passato, solo in pochi avevano compreso che al momento preciso della nascita il neonato è privo di germi, mentre poche ore dopo il suo corpo è stato colonizzato da milioni di microbi. Dato che gli anticorpi IgG oltrepassano facilmente la barriera placentare, spiegò, i microbi familiari alla madre sono già familiari (e di conseguenza, amichevoli) al neonato al momento della nascita, quando è ancora privo di germi. Se il bambino è immediatamente invaso da germi amichevoli portati dalla madre, viene protetto da microbi a lui estranei e, pertanto, potenzialmente pericolosi. Egli aggiunse che, quando un bambino nasce attraverso il perineo, è garantito che venga contaminato innanzitutto da una gran quantità di germi portati dalla madre, se paragonato a un bambino nato con il cesareo. Per evidenziare l'importanza di questo aspetto, egli menzionò che la flora batterica si forma in gran parte nei primi minuti che seguono la nascita. Sono considerazioni utili, in un'epoca in cui si sta scoprendo che la flora batterica intestinale rappresenta l'80% del sistema immunitario.

Il batteriologo era completamente d'accordo con una consulente in allattamento, la quale aveva aggiunto che, se madre e neonato non vengono affatto separati, è grande la probabilità che il bambino trovi il seno nella prima ora che segue la nascita e consumi precocemente il colostro, ricco di batteri benefici, di specifici anticorpi locali e di sostanze anti-infettive. L'assunzione precoce del colostro, probabilmente, ha conseguenze a lungo termine, perlomeno a causa della sua influenza sul modo in cui si forma la flora batterica.

Il vertice dell'OUS, ovviamente, era lieto dello sviluppo dell'incontro interdisciplinare che aveva organizzato. L'intervento conclusivo fu affidato a un anziano filosofo, considerato un grande saggio dall'intera comunità. Egli spiegò che la dimensione specificatamente umana non dovrebbe essere ignorata e che bisognerebbe, innanzitutto e soprattutto, ragionare in termini di civiltà. Fece riferimento ai dati presentati dall'epidemiologo: “Negli studi citati, spesso era stato necessario prendere in considerazione un numero enorme di casi, prima di poter individuare tendenze ed effetti statisticamente significativi. Ciò ci ricorda che, spesso, quando si tratta dell'essere umano, bisogna dimenticare il singolo individuo, gli aneddoti e i casi particolari, a favore di una dimensione collettiva e, pertanto, culturale. Dagli interventi di quest'incontro, emerge chiaramente che l'umanità si trova in una situazione senza precedenti, che può essere riassunta in un modo molto conciso. Al giorno d'oggi”, disse, “il numero di donne, che dà alla luce il proprio bambino e la placenta grazie al rilascio di un vero e proprio cocktail di ormoni dell'amore, si sta avvicinando allo zero. Che cosa succederà, in termini di civiltà, se proseguiamo per questa strada? Che cosa succederà, tra due o tre generazioni, se gli ormoni dell'amore saranno resi inutili nel periodo critico attorno alla nascita?”

Al termine dell'eloquente conclusione, il vertice dell'OUS chiese cosa ne pensassero i partecipanti della necessità di tenere sotto controllo il tasso di cesarei. Tutti, incluso il medico ostetrico, ritennero che fosse necessario, perfino urgente, passare all'azione.

Pertanto venne indetto un secondo incontro, con l'obiettivo di individuare soluzioni efficaci.

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All'inizio del secondo incontro, il vertice dell'OUS domandò ai partecipanti quali soluzioni proponessero, per contenere il tasso di cesarei e di interventi ostetrici. Il medico ostetrico presentò un progetto per 'misurare l'efficacia di una strategia multi-articolata per la valutazione della pertinenza delle indicazioni per un cesareo'. Nessuno vi prestò attenzione. Un giovane medico appena laureato parlò della necessità di aggiornare i corsi di laurea in medicina e ostetricia. Il direttore della Scuola di Ostetricia replicò immediatamente, affermando che in tutto il mondo vi sono stati diversi tentativi di rinnovare la formazione delle ostetriche e dei medici, inclusi i medici specialisti, senza alcun effetto positivo sugli esiti del parto. Diversi partecipanti suggerirono un incentivo economico per abbassare il tasso di interventi ostetrici. Il vertice dell'OUS prese la parola, per puntualizzare che questa soluzione era stata già tentata in svariati paesi, senza successo, e che, inoltre, il tasso di cesarei stavano aumentando dappertutto a prescindere dal tipo di sistema sanitario: pertanto andrebbero presi in considerazione altri fattori. Aggiunse che si correrebbe il rischio di aumentare l'incidenza di parti per via vaginale lunghi e difficili e l'abuso di sostituti farmacologici degli ormoni naturali. Sarebbe un effetto inaccettabile, in un'epoca in cui il cesareo è divenuta un'operazione talmente semplice e rapida. La priorità dovrebbe essere prima di tutto quella di cercare di rendere il parto il più facile possibile, allo scopo di ridurre la necessità di interventi ostetrici in generale.

In modo del tutto inaspettato, la discussione si sviluppò una nuova direzione quando prese la parola, per la prima volta, una neurofisiologa, nota a livello internazionale per le sue ricerche sul comportamento della mantide religiosa. Ella spiegò che, mettendo a confronto le sue ricerche con la sua esperienza personale di madre, aveva acquisito una comprensione chiara dei bisogni di base della donna quando partorisce. In linea generale, disse, i messaggi inviati dal sistema nervoso centrale alle zone genitali sono di tipo inibitorio. Aveva compreso questa semplice regola studiando il comportamento della mantide religiosa durante l'accoppiamento. Al momento della copula, la femmina spesso divora la testa del maschio, una maniera alquanto radicale di eliminare ogni messaggio inibitorio! A quel punto, l'attività sessuale del maschio diviene molto più intensa e aumenta la probabilità di concepire una discendenza. Quella ricercatrice aveva compreso che l'effetto inibitorio del sistema nervoso centrale in tutti gli eventi della vita sessuale è una regola generale. In molte occasioni aveva potuto confermare questa regola e, guarda caso, aveva compreso tutto ciò ancora meglio dopo aver partorito il primogenito. La neurofisiologa era convinta che il motivo principale per cui quella nascita era stata così facile e veloce andava cercato nella riduzione della sua attività neocorticale. Ne approfittò per ricordare che l'essere umano è caratterizzato da uno sviluppo enorme di quella parte del sistema nervoso centrale denominata neocorteccia. La sua neocorteccia, senza dubbio, si era messa completamente a riposo quando era iniziato il travaglio vero e proprio, visto che aveva completamente dimenticato molti dettagli del luogo in cui aveva partorito. Ricordava vagamente che si trovava in un luogo piuttosto buio e che non c'era nessuno accanto a lei, eccetto un'ostetrica seduta in un angolo a sferruzzare. Ricordava, inoltre, di aver vomitato a un certo punto del travaglio, ma l'ostetrica le disse soltanto: 'È successo anche a me, quando è nato mio figlio, è normale'. Anche se non lo ricorda con grande precisione, è convinta che quel commento discreto, espresso sottovoce da una voce materna, avesse favorito il progredire del parto. Si era sentita completamente al sicuro assieme a quella donna materna, calma ed esperta. A posteriori, ora si rende conto che in quel contesto tutte le condizioni adatte a una riduzione dell'attività della neocorteccia erano state soddisfatte. Si era potuta sentire al sicuro, senza sentirsi osservata, in un ambiente poco illuminato e silenzioso. Di conseguenza, dopo aver integrato ciò che aveva appreso come neurobiologa con quello che aveva appreso in qualità di madre, il suo suggerimento era di rimettere in discussione i criteri utilizzati per selezionare le future ostetriche. In un futuro, per essere ammesse a una Scuola di Ostetricia, sarà necessario aver partorito senza alcun intervento medico, conservando un ricordo piacevole dell'esperienza vissuta.

Di fronte a questa proposta, il medico ostetrico si trovava visibilmente a disagio e protestava, affermando di aver lavorato assieme a ostetriche meravigliose, pur non essendo madri. La direttrice della Scuola di Ostetricia replicò che tutti conoscono brave ostetriche senza figli, tuttavia lei aveva il dovere di garantire che le ostetriche diplomate presso la sua Scuola siano tutte accomunate da una predisposizione caratteriale: quella di saper stare accanto a una partoriente disturbando il meno possibile il decorso del travaglio. Per questo motivo, non potrebbe immaginarsi un criterio migliore di quello suggerito dalla neurofisiologa. Dato che la proposta non poteva essere affatto considerata politicamente corretta, quasi tutti i presenti valutarono su piè pari che poteva essere accettata a Utopia.

A quel punto si levò una voce maschile da un angolo della sala. Era il giovane tecnico incaricato della registrazione dell'incontro: “Considerato che non ne so nulla di questi argomenti, posso porre una domanda ingenua? Cosa succederebbe se anche un medico, per intraprendere la specializzazione in ostetricia, dovesse avere un'esperienza personale positiva di parto, senza alcun intervento medico?”

La sua domanda fu seguita da un'indimenticabile ovazione entusiastica, come se tutti si ritrovassero nella medesima situazione di Archimede quando esclamò 'Eureka!'. A tutti i partecipanti apparve evidente che un simile progetto era abbastanza irrealistico da poter essere adottato nel paese di Utopia immediatamente, senza ulteriori discussioni.

Venne nominato subito un comitato con il compito di organizzare un periodo di transizione della durata di 15 anni.

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Il periodo di transizione si è concluso nel 2024 e, oggi, nel gennaio del 2031, siamo in grado di fornire dati statistici affidabili. Si tratta di dati impressionanti.

Il tasso di mortalità perinatale è estremamente basso, pari a quello di tutti gli altri paesi con un simile standard di vita. Il tasso di trasferimento nelle unità pediatriche neonatali è diminuito drasticamente. Negli ultimi quattro anni, non c'è stato un solo caso di uso del forcipe. Dato che la priorità è quella di evitare parti lunghi e difficili per via vaginale, il ricorso alla ventosa o ai farmaci è diventato eccezionalmente raro. Ciò che è ancora più importante, il tasso di cesarei è pari un terzo di quello riscontrato nel periodo di transizione. Il tasso di allattamento al seno a sei mesi d'età supera il 90%. Un pedopsichiatra ha già riportato che l'autismo è meno diffuso che in passato. Se il famoso filosofo – il saggio della comunità – fosse ancora vivo, potrebbe dichiarare che, ora, nel paese di Utopia, la maggior parte delle donne danno alla luce sia il bambino che la placenta grazie al rilascio di un 'cocktail di ormoni dell'amore'.

Il nuovo vertice dell'OUS e varie commissioni stanno stilando comunicati stampa da inviare a tutti canali mediatici internazionali. È stato indetto un concorso, per trovare uno slogan di 5 parole, adatto a diffondere rapidamente in tutto il mondo, in modo conciso e efficace, l'importante messaggio. Ecco lo slogan prescelto:

SOLO UTOPIA PUÒ SALVARE L'UMANITÀ!

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GRAN CANARIA

Un passo verso Utopia.

Come Thomas More già sapeva 500 anni fa, Utopia è un'isola dell'Atlantico.

Non perdere il

CONGRESSO MITTELATLANTICO

SULLA NASCITA & SULLA RICERCA IN SALUTE PRIMALE

Las Palmas, 26-28 febbraio 2010

Dalla prestigiosa Sala sinfonica del Centro Congressi delle Isole Canarie a 1656 posti, vedrai l'oceano. Sognerai la Rinascita della Dea dell'Amore, che fu generata 'dalla schiuma del mare'.

Con l'obiettivo di prepararci al futuro, in questo congresso si offrirà una panoramica dei recenti spettacolari progressi, in campo sia scientifico che tecnico, che influenzeranno la storia della nascita.

La presenza di Michael Stark, il padre della tecnica di cesareo rapida, semplificata e sicura, simboleggerà i progressi tecnici, mentre quella di Kerstin Uvnäs-Moberg, esperta mondiale degli effetti comportamentali dell'ossitocina, simboleggerà i progressi scientifici. La necessità di passare all'azione sarà evidenziata dalla partecipazione di Anthony Costello, professore di salute internazionale presso l'Istituto di Salute Infantile a Londra, e di Mario Merialdi, coordinatore per la salute materna e perinatale all'OMS.

Un'accurata selezione di medici e di 'utopiani' è stata convocata per proferire l'ultima parola.

Ognuno può partecipare attivamente al congresso presentando un poster, partecipando a 3 dei 27 worskshops previsti e a uno dei due forum plenari.

http://www.wombecology.com/

il programma completo in inglese e spagnolo

Il congresso è aperto a tutti coloro che sono interessati al futuro dell'Umanità

DIVULGA L'INFORMAZIONE A TUTTI!

Vendola "Questa è la sanità che funziona" vedi video su you tube http://www.youtube.com/watch?v=YeGT8IZHJzg

2009-06-28T05:47:00.000-07:00

SIMPLIFIED STRATEGIES IN THE AGE OF SIMPLIFIED CAESAREAN TECHNIQUES

2009-03-25T10:50:00.000-07:00

SIMPLIFIED STRATEGIES IN THE AGE OF SIMPLIFIED CAESAREAN TECHNIQUES

The history of caesarean sections offers a typical example of the ineluctable gaps between technical and conceptual advances. Spectacular technical and organisational advances have created a recent milestone where the safety of the caesarean, in developed countries, can be compared with the safety of vaginal route. This new step in the history of childbirth should lead us to reconsider traditional strategies in obstetrics.

SITUATIONS TO AVOID

Since the caesarean has become a simple, fast and safe operation in well-organised maternity units, we must first wonder what scenarios should be imperatively avoided. When considering common reasons for transfer to an intensive care unit and also the data provided by the “Primal Health Research Data Bank”, it seems clear that in the future the priority should be to avoid instrumental deliveries by the vaginal route after long hours of augmentation with synthetic oxytocin. The ‘Primal Health Research Data Bank’ (www.birthworks.org/primalhealth) compiles studies exploring correlations between the ‘primal period’ (which includes the perinatal period) and what happens later on in life in terms of health, behaviour, and personality traits. Such studies are difficult to trace in the medical and scientific literature, because they are unrelated according to current classifications. To link relevant data, the database can be explored prospectively (for example via keywords such as ‘birth complications’, ‘birth optimality’, ‘caesarean’, ‘labour induction’, ‘breech presentation’, ‘cephalhaematoma’, ‘forceps’, ‘ventouse’, ‘hypoxia’, ‘neonatal pulmonary hypertension’, etc.), or retrospectively (for example via key words such as ‘asthma’, ‘juvenile criminality’, ‘suicide’, ‘drug addiction’, ‘anorexia nervosa’, ‘autism’, etc.).

An overview of the database suggests that instrumental deliveries by the vaginal route should become gradually obsolete in such an unprecedented technical context.
Similar conclusions can be drawn from the abundant literature on perineal damage after childbirth. We can conclude that the most dangerous scenario is a forceps delivery following a long, arduous labour. This is the main lesson of a British study about tears involving the anal sphincter. More than 8000 women who had given birth vaginally were included in the study (Sultan et al 1994). This is also the main lesson of an Australian study that investigated, thanks to a translabial ultrasound technique, the effect of childbirth on pelvic organ mobility.(Dietz & Bennett 2003) They measured in particular the ‘bladder neck descent’ when the woman was asked to forcibly breathe out while keeping her mouth and nose closed. The mean bladder neck descent is spectacular after a forceps delivery (14.5 mm), compared with vacuum (9 mm), ‘normal’ vaginal delivery (7.2 mm), caesarean during the second stage (4mm) and caesarean during the first stage (2.6 mm).

Today it is commonplace to claim that the rising caesareans rates worldwide are a cause for concern. In fact we might claim that the first cause for concern should be stable or even increasing rates of instrumental vaginal deliveries in the age of the safe caesarean.(Odent 2004) In the USA the rates of operative deliveries have increased recently, if we consider both forceps deliveries and vacuum extractions.( Kozak & Weeks 2002, Poma 1999) In the United Kingdom, the rates of instrumental deliveries have remained fairly constant (between 10% and 15%), although there has been a change in preference of instruments.(Thomas & Paranjothy 2001; www.show.scot.nhs.uk/isd/sexual_health), Even among a Brazilian population of women giving birth in private institutions, the rate of forceps delivery can still be 3%, despite the fact that at 72% the abdominal route is the most frequent mode of delivery (Potter et al 2001)

There are also serious reasons to avoid real emergency caesareans, when there the surgical team races to rescue a life-threatening situation. Emergency c-sections should not be confused with intrapartum c-sections. A retrospective study of a population born by c-section between 1952 and 1954, after prolonged active labour (more than 12 hours), found that the average IQ (intellectual quotient) was low, compared with a control group including siblings and other family members.(Roemer et al 1991)) Furthermore the risks of intraoperative complications are higher in a situation of critical emergency: cervical dilation of 9 or 10 cm at the time of operation and general anaesthesia have been identified as independent risk factors.(Hager et al 2004)

Pre-labour elective caesareans, I dare to suggest, are among the situations that should be avoided, wherever possible. Although the exact mechanisms involved in the initiation of human parturition have yet to be fully understood, and whatever the name of the mediators and cytokines involved, we are in a position to claim that the fetus participates in the initiation of labour by sending information about the maturation of its lungs and other vital organs. Furthermore a pre-labour c-section prevents the surge in endogenous steroids and catecholamines that accompanies term gestation and spontaneous vaginal delivery and which is partly responsible for the clearance of fetal lung fluid. (Jain 2006, Vogl 2006) Disrupting this process can lead to the retention of fluid in air spaces, setting the stage for alveolar hypoventilation. Such theoretical considerations are supported by an accumulation of clinical data confirming that positive pressure ventilation resuscitation risk is comparatively high among infants born by elective pre-labour cesarean section. (Zanardo et al 2004) In addition to respiratory distress syndrome, elective pre-labour cesarean sections may contribute to transient tachypnea of the newborn. (Hook et al 1997, Shearer 1993) A Norwegian prospective study comparing 17,828 planned vaginal births and 825 elective C-sections confirmed the significantly higher rates of pulmonary disorders (and also of hypoglycemia and anemia) among the infants born by elective pre-labour caesarean.(Saugstad 2006)

ACCEPTABLE BY A FEW

Finally, when considering all the situations we should try to avoid in the age of the safe caesarean, it appears that we are evolving towards a simplified strategy, which is valid for most obstetrical cases: either the birth process is straightforward and the vaginal route is considered a wise option; or it is not, and an intrapartum non-emergency caesarean is the best solution.

If such futuristic strategies were adopted overnight the global caesarean rates worldwide would climb dramatically, probably passing the 50 per cent mark in most developed countries. Certain medical circles would accept and even welcome this new step in the history of obstetrics. As early as 1998, in an editorial of ‘The British Journal of Obstetrics and Gynaecology’, Philip Steer anticipated that in the future the unpredictable risks of labour would no longer be justified for most women.(Steer 1998) He considered the c-section to be an ‘evolving procedure’, that is a technological solution to ‘the conflict between the need to think and the need to run’: if the abdominal route does become the norm, average birth weight will no longer be restricted by the constraints of maternal pelvic size so that eventually caesarean birth will become necessary for the majority. This point of view is implicitly shared by the many female obstetricians who choose the abdominal route for the birth at term of their own babies.(Al-Mufti et al 1997, Gabbe & Holzman 2001).Such ways of thinking are understandable if one just takes into account conventional criteria to evaluate the practices of obstetrics and midwifery, such as perinatal mortality and morbidity rates, maternal morbidity and cost effectiveness.

UNACCEPTABLE BY OTHERS

However many others will claim that the abdominal route cannot be accepted as the norm. The opposite point of view can simply be based on the intuition that this new stage in the lifestyle of human populations would be a risky irreversible jump into a “Brave New World”. Some will support their intuition with rational considerations. It is easy to use an accumulation of published data to demonstrate that, in general, a caesarean born baby (particularly a baby born after a non-labour caesarean) is physiologically different from a baby born by the vaginal route. His lungs and his heart do not work in the same way; (Lundell et al 1984) his glucose levels tend to be lower(Hagnevik et al 1984); babies born by elective caesarean tend to have a lower body temperature during the first 90 minutes following birth, compared with babies born by the vaginal route or by caesarean during labour(Christensson et al 1993); immune responses are different(Thilaganathan et al 1991, Molloy et al 2004, Gronlund et al 1999, Gasparani et al 1992); the systems controlling blood pressure work differently(Fujimura et al 1990, Gemelli et al 1992); erythropoietin levels and blood cells mass tend to be lower among cesarean born babies (Steverson et al 1986, Lubetzky et al 2000); progesterone levels are also lower(Asien 1994); the level of the hormone that regulates thyroid activity is also lower(Lao & Panesar 1989); the levels of liver enzymes are different (Mongelli et al 2000; finally, neonatal gastric acidity is also different (Miclat et al 1972).

All these differences may be considered acceptable as long as the abdominal route is an occasional way to rescue babies in danger; it is another matter if it becomes the norm. To the many inescapable differences between vaginally born and caesarean born neonates, we might add that the body of the vaginally born neonate is immediately colonized by germs from maternal origins, which is an important event in the human species, where the transfer of maternal IgG by the placenta is particularly intense from 38 weeks onward.(Cederqvist et al 1978) The body of the caesarean born, on the other hand, is first colonized by unfamiliar hospital germs. From a bacteriological point of view, there is an inherent and fundamental difference between a vaginal birth and a caesarean birth

There are consequently several reasons why the establishment of the gut flora during the hours following birth is highly influenced by the birth route. In particular, the connections between birth physiology and the physiology of lactation and therefore the way the initiation of lactation occurs in relation to how the baby was born. These connections are easy to explain in the current scientific climate. For example it is well known today that the maternal beta-endorphins released in the perinatal period stimulate the secretion of prolactin (Rivier et al 1977); a Swedish study found that when a two days old baby is at the breast, women who gave birth vaginally released oxytocin in a pulsatile - and therefore effective – way, compared with women who gave birth by caesarean (Nissen et al 1996); according to an Italian study, the amount of endorphins in the milk during the first days is much higher among mothers who gave birth vaginally(Zanardo etal 2001); in general it is easy to explain that the first time when the human neonate is able to find the breast (Odent 1977), the behaviour of mother and baby is influenced by the numerous hormones they released during labour and delivery (Odent 1999). These different hormones are still present or rebound during the hour following birth, and all of them play a specific role in the interaction between mother and baby and therefore the initiation of lactation.

The fact that the initiation of lactation cannot be dissociated from the birth process suggests that caesarean born neonates might have difficulty to consume a significant amount of colostrum… another way to refer to the establishment of the gut flora during the hours following birth, which is related to the consumption of early colostrum, with its IgA and other anti infectious substances, and also its friendly germs. Let us add that to be born is to ‘enter the world of odours’ and that the sense of smell of the newborn baby is probably one of the main guides towards the nipple: the early expression of the rooting reflex is highly dependent on environmental factors. There are countless reasons why the initiation of breastfeeding has to overcome well defined handicaps in a caesarean born population.

Others will rationally justify their intuition by focusing on what we are learning today about the long-term consequences of intrapartum events and therefore by explaining the need to think long-term. Data provided by primal health research suggest that new criteria are needed to evaluate the practices of obstetrics and midwifery. For example the most authoritative studies about breech presentation at term lead to the apparently undisputable conclusion that a prelabour elective c-section is wiser than a trial of labour (Hannah et al 2000, Krebs & Langhoff-Roos 2003). However such a conclusion must be reconsidered when data provided by the Primal Health Research Data Bank are taken into account. There is a Norwegian study, for example, which looks at intellectual performance at age 18 in a nationwide population enquiry (Eide et al 2005). The researchers looked at 8,738 male infants in breech and 384,832 males in cephalic presentation registered at the Medical Birth Registry of Norway, between 1967 and 1979, and linked these data to the data registered at the National Conscript Service, covering the period 1984-1999. Scores of intelligence testing at the time of conscription were presented as “standard nine scores”. Breech-presented infants had significantly lower mean scores if born by caesarean compared with vaginal breech birth.

In fact the most powerful warning is offered by “The Scientification of Love”: when combining data provided by ethology, animal experiments, studies of the behavioural effects of hormones involved in childbirth, and “Primal Health Research”, it seems clear that the perinatal period is critical in the development of the capacity to love. (Odent 1999)

There are therefore pressing reasons for trying to control and even moderate the caesarean rates, at the very time when there are also serious reasons to enlarge the indications of the abdominal route.

MAIN CHALLENGE FOR MODERN MIDWIFERY AND OBSTETRICS

How to reduce the incidence of an operation which is safer and safer? This is an unprecedented challenge for midwifery and obstetrics. To face this challenge we must first realize that, after thousands of years of culturally controlled childbirth, the basic needs of labouring women and newborn babies have been forgotten. We are in a position to claim that all the reasons usually given to explain the increasing caesarean rates are - apart from the safety of the operation - the direct or indirect consequences of a deep-rooted, widespread, and even cultural ignorance of such basic needs. This ignorance has been reinforced during the second half of the twentieth century by a proliferation of theories that are at the root of different schools of “natural childbirth” and that are unacceptable in the current scientific context. It has been commonplace to focus on limited negative questions such as how to eliminate the pain, or the fear, or the violence. Today, at a turning point in the history of childbirth, we must go back to square one, and start from the most fundamental positive and paradoxically new simple question: “what are the basic needs of a labouring woman?”

To provide answers to this question, we cannot rely on any cultural model, since all societies we know about have interfered with the physiological processes, often via authoritarian and invasive birth attendants transmitting beliefs and rituals. This is why we must use the perspective and the language of physiologists, keeping in mind what we can learn from practical experience, particularly from easy and fast labours and deliveries. Physiologists study what is universal and cross-cultural. The word “physiological” should not be confused with the word “normal”, which contains a cultural connotation. It does not mean “it should be exactly like that”. It is a reference point we should constantly be aware of.

The most recent advances in birth physiology are related to a new generation of research about the behavioural effects of hormones involved in childbirth.(Odent 2001) This new generation of research was initiated by the historical experiment by Prange and Pedersen in 1979: they thought of injecting oxytocin directly into the cerebral ventricles of virgin rats as a way of inducing maternal behaviour. (Pedersen 1979) When injections were intravenous or intramuscular only the peripheral and mechanical effects were demonstrated. It is well understood today that the nonapeptide oxytocin cannot cross the blood-brain barrier and therefore cannot reach the brain receptors.

The explosion of research triggered by such an animal experiment is illustrated by the publication by the New York Academy of Sciences, as early as 1992, of a 500-page book including 53 articles on the behavioural effects of oxytocin.(Pedersen 1992) The general conclusion of this generation of research is that ‘oxytocin is the hormone of love’. It is noticeable that, whatever the facet of love we consider, oxytocin is involved. For example, it is involved in lactation, and during intercourse, when both partners – male and female – release it. The media started to be interested in the behavioural effects of oxytocin in 2005 after the publication in Nature of a study of the biological basis of trust. (Kosfeld 2005) At the same time there has been an accumulation of data regarding other hormones involved in parturition, particularly endogenous opiates, prolactin (the motherhood hormone), and vasopressin (Thompson 2006). In such a context we can visualize in a new way the process of parturition among mammals, by claiming that during the birth process archaic mammalian brain structures (i.e.hypothalamus, pituitary gland) have been programmed to release a complex cocktail of ‘love hormones’. This leads to a practical question: ‘which factors can facilitate or inhibit the release of this flow of hormones?’ In other words: ‘What are the basic needs of human mammals when they are giving birth?’

BASIC MAMMALIAN NEEDS

Our current understanding of birth physiology is based on the adrenaline–oxytocin antagonism: when mammals release adrenaline they cannot release oxytocin. We use the word ‘adrenaline’ as a simplified way to refer to the ‘fight and flight system’. Such an antagonism has been understood for a long time and evaluated in relation to myometrial response (Pose 1962, Zuspan 1962) and milk ejection response (Whittlestone 1954). The first data have been confirmed by clinical studies among humans(Lederman 1977, Lederman 1978). Today oxytocin is often presented as ‘the mirror image of adrenaline’. (Uvnas-Moberg 2003).

It is well known that mammals (including humans) release adrenaline in situations such as being scared, feeling observed, or being cold. We can therefore draw the preliminary conclusion that in order to give birth a woman needs to feel secure, without feeling observed, in a warm enough place.

Although the adrenaline-oxytocin antagonism is theoretically established, it is not well-digested knowledge. It disagrees with deep-rooted beliefs. It is still commonplace, in natural childbirth circles, to include recommendations based on the simplistic idea that walking and using the force of gravity will make labour easier. Finding these recommendations strange is not new. As early as 1833, William DeWees wrote that ‘the preposterous custom of obliging her (the labouring woman) to walk the floor with a view to increase the pains when tardy should be preremptorily forbidden’(DeWees 1833) Today scientific evidence tends to support De Wees’ point of view. Since the prerequisite for labour to establish itself properly is a low level of adrenaline, it is a good sign when a labouring woman does not feel the need to stand up and walk. During the first stage of an easy and fast birth, women are often passive, for example on all fours or lying down. To suggest any sort of muscular activity at that phase can be counter-productive, even cruel.

This belief that a woman in labour should walk can still influence medical circles as well. This is how we can explain the popularity of the term ‘walking epidural’ and also the publication of randomised controlled trials to evaluate the effect of walking on labour and delivery. Of course none of the studies could demonstrate any effect (Hemminki 1983, McMnus 1978, Bloom 1998) It is significant that, in the most authoritative of these studies, 22% of the women who were assigned to walking stayed in bed.(Bloom 1998)
In natural childbirth circles, labouring women are also often compared with athletes who are advised to consume large amount of carbohydrates before starting extreme physical exertion, such as running a marathon.(Odent 1994) Authors of articles about nutrition during labour have suggested that we should learn from sports medicine(Cram Elsberry 1993). Many birth attendants are influenced by these comparisons and encourage women to eat food such as pasta at the onset of labour, and to drink something sweet when labour is established: ‘You need energy!’.

These ideas about nutrition are also in contradiction with our current understanding of the adrenaline-oxytocin antagonism. A low level of adrenaline and good progress in the first stage imply that the striated muscles are at rest. When a birth is as physiological as possible, the labouring woman has a tendency to be immobile during the first stage. When all the skeletal muscles are at rest, such as when the mother is lying on her side or is on all-fours, energy expended is insignificant, and the need for carbohydrates is minimal, insofar as glucose is the favourite fuel of skeletal muscles. The energy expenditure of the uterine muscle is insignificant. Smooth muscles are between 20 and 400 times more energy efficient than skeletal muscles. Furthermore they can easily use fatty acids (rather than glucose) as fuel. In practice there is no risk of fuel shortage for the smooth muscles. The observations by Paterson and colleagues are highly significant.(Paterson et al 1967) They found that ketone levels were higher in women who had been starved for twelve hours before an elective caesarean under general anaesthesia than they were for women who had been in labour. This confirms that labouring women spend less energy than those who are only waiting for an operation without being in labour.

Comparing labouring women to marathon runners is misleading and potentially dangerous. The side effects of sugar during labour are well documented.(Lawrence et al 1982). There is evidence that when the mother has been given an infusion containing glucose, the risk of lactic acidosis in the fetus is increased (Singhi et al 1982) and the intensity of jaundice in the neonate is greater (Kenepp et al 1982).

These theoretical considerations are supported by what we can learn from observation. Mammals in general do not eat during the process of parturition. For several decades, either in a hospital or at home, I have learned from thousands of women who were neither encouraged nor discouraged to eat and drink in labour. Although there are always exceptions, it is possible to summarize several simple observations. The first point is that labour rarely starts when a pregnant woman is hungry. This makes sense since hunger tends to increase the level of catecholamines. Second, when labour is really well established, women do not feel the need to eat.

OVERCOMING THE SPECIFICALLY HUMAN HANDICAP

A specifically human handicap during the process of parturition is the huge development of the neocortex in our species. During the birth process (or during any sort of sexual experience) most inhibitions are related to neocortical activity. In general rational control of the procreative drives is a byproduct of human brain evolution.

The evolutionary process found a way of overcoming this vulnerability. Neocortical activity simply becomes reduced during the birth process. This had not been understood by the Pavlovian physiologists whose theories are, directly or indirectly, at the root of most current schools of ‘natural childbirth’. It is, on the other hand, easily interpreted by those who have the experience of undisturbed, unmanaged and “uncoached” births. When a woman is giving birth easily, without any interference, there is a time when she seems to cut herself off from our world. She becomes indifferent to what is happening around her. She tends to forget her plans and received ideas. She behaves in a way that would be considered unacceptable in the daily life of a civilized woman. When, for example, she dares to scream, or to swear, or to be impolite, it means that there is reduction in neocortical control. She can find herself in the most bizarre, unexpected, and often primitive, quadrupedal and typically mammalian postures. She seems to be “on another planet”. This reduction of neocortical activity is an essential aspect of birth physiology among humans. It implies that labouring women need to be protected against any sort of neocortical stimulation. We must remember the main stimulants of the human neocortex are, if we are to avoid such stimulations.

Language is a specifically human stimulant of the neocortex. When we communicate with language we process what we perceive with our neocortex. This implies, for example, that if there is a birth attendant, one of her main qualities is her capacity to keep a low profile and to remain silent, to avoid in particular asking precise questions. It will probably take a long time for people to realize that a birth attendant must remain as silent as possible. It is difficult to get rid of the after-effects of the Pavlovian theories. Velvovski and other Pavlovian theoreticians had understood the neocortical origins of inhibitions during human parturition.(Velvovski 1950) However, probably because they were not practitioners directly involved in childbirth, they ignored the reduction of neocortical control as an essential aspect of birth physiology in our species. They assumed that the practical objective should be to ‘recondition’ women in order to eliminate the inhibitions and to make childbirth painless. From their point of view labour pain is a conditioned reflex, and therefore cultural. Such theories lead to the concept of ‘verbal analgesia’. After visiting the Pavlovian theoreticians in Russia in 1951, Lamaze introduced their concepts in Western countries. This is how the birth attendants started to overuse language and became invasive guides, helpers and even ‘coaches’.
Light is another well-known stimulant of the human neocortex. Electroencephalographers know that the trace exploring neocortical activity is influenced by visual stimulation. We usually close the curtains and switch off the lights when we want to reduce the activity of our intellect in order to go to sleep. This implies that, from a physiological perspective, a dim light should in general facilitate the birth process. These are important considerations in the age of electricity, when we have the power to switch on a bright light simply by pressing a button. It is noticeable that as soon as a labouring woman is on ‘another planet’ she is spontaneously driven towards postures that tend to protect her against all sorts of visual stimulations. For example she may be on all fours, as if praying. Apart from reducing the back pain, this common posture (with many asymmetrical variants) has several positive effects, such as eliminating the main reason for fetal distress (no compression of the vena cava), influencing the process of rotation, and therefore minimizing the mechanical difficulties that characterize human parturition.

Feeling observed is a situation associated with neocortical stimulation. When we feel observed, we tend in return to observe ourselves and to correct our attitude. This is another way to interpret the importance of privacy (i.e. not to feel observed) as a basic need during labour. Understanding the need for privacy makes us anticipate, for example, that there is a difference between a midwife staying in front of a labouring woman and watching her, and another one sitting in a corner. It might also make us anticipate that devices that are perceived by the labouring woman as observing tools (such as a camera or an electronic fetal monitor) should be introduced with extreme caution in a birthing place. The surprise produced by the results of randomized controlled trials comparing the effects on statistics of electronic fetal monitoring versus intermittent auscultation is a symptom of a lack of understanding of birth physiology. It might have been anticipated that the only fact that a labouring woman knows that her body functions are continuously monitored tends to stimulate her neocortex. Stimulating the neocortex risks making the labour longer, more difficult, and therefore more dangerous so that more babies must be rescued via the abdominal route. Photos in books for the general public and videos shown in conferences constitute proof that the need for privacy is not understood by the natural childbirth movements: it is commonplace to see a woman in labour surrounded by several people watching her.
The perception of danger is another possible stimulant of the neocortex. Since in situations of danger it is an advantage to be alert and attentive, neocortical activity is an appropriate response. Analyzing such a situation is another way to consider the need to feel secure as basic during human parturition.

Understanding the solution the evolutionary process found in order to overcome the specifically human handicap in parturition appears today to be a necessary step towards rediscovering the basic needs of labouring women.

BASIC NEEDS DURING THE THIRD STAGE OF LABOUR

Provided there have been no major deviations from the physiological reference during the previous phases of labour, mother and baby share similar basic needs during the third stage. From a physiological perspective there is a key event between the birth of the baby and the delivery of the placenta. It is the high peak of oxytocin that human mothers have the capacity to release immediately after the birth, which is arguably the highest level of oxytocin a woman can reach during her whole life. (Nissen 1995) This peak of oxytocin is vital, since it is necessary for a safe and bloodless delivery of the placenta, and since oxytocin is the main component of the 'cocktail of love hormones' that is supposed to be released in the perinatal period.

Whatever the circumstances, a release of oxytocin is highly influenced by the environment. We must therefore look at the factors that can have a positive or negative effect at the beginning of the mother-newborn interaction. By mixing theoretical considerations and clinical observations we can identify two main groups of factors. At this phase of labour, the vulnerability of mothers to an inappropriate ambient temperature is well known. This is why shivering (a sign of adrenaline release) is a frequent physiological response to an insufficiently high room temperature. In fact, just after the birth of the baby, mothers never complain because the place is too hot, while nonverbally they often indicate that it is not warm enough. The concept of adrenaline-oxytocin antagonism, alongside clinical observation, must bring us to the conclusion that, as soon as the baby is born, the thermo-regulation of the mother must be at rest. In other words, maintaining an appropriate ambient temperature should be the first preoccupation.
An undisturbed interaction between mother and newborn is another factor facilitating oxytocin release. During the third stage of labour an appropriate maternal hormonal balance is more easily obtained if, in an atmosphere of privacy, the mother can feel the skin-to-skin contact, can try to establish eye-to-eye contact, and can smell the odour of her baby…without any distractions. Eliminating any distractions is difficult: as soon as a baby is born, there is always an irrational need for activity around; there is always somebody who wants to do something or to say something. This need for activity has been ritualized in many societies. It is impossible to offer an exhaustive catalogue of all the possible ways to interfere with the mother-newborn intimacy. Let us imagine, for example, that a mother is still in such a state of consciousness that she has forgotten the rest of the world while discovering her baby; suddenly somebody appears with two clamps and a pair of scissors in order to cut the cord. This distraction is a dangerous interference with the physiological processes.

At the very time when we are starting to understand the importance of the third stage for the ‘development of the capacity to love’, we have to realize that this particular phase of labour has been dramatically disturbed by all cultural milieus via a great diversity of beliefs and rituals. Furthermore we have to realize that, in the age of the safe caesarean, this phase of labour can be purely and simply eliminated for the first time in the history of mankind.

REDISCOVERING AUTHENTIC MIDWIFERY

Rediscovering the basic needs of labouring women and newborn babies after thousands of years of culturally controlled childbirth would lead us to rediscover “authentic midwifery”. The main lesson of the physiological approach is that to give birth a woman needs to feel secure, without feeling observed. It is probable that during a certain phase of the history of mankind, the universal mammalian need for privacy prevailed. We must keep in mind that the concept of a birth attendant is probably more recent than commonly believed. Films among the Eipos in New Guinea (Schiefenhovel 1978), written documents about pre-agricultural societies such as, for example, the !Kung San (Eaton 1998), and word-of-mouth reports from Amazonian ethnic groups suggest that there has been a phase in the history of humanity when women used to isolate themselves when giving birth, like all mammals. We can also guess that, in certain situations, being not too far from an adult might have been an advantage. This person would need to have been the prototype of the person with whom the labouring woman could feel secure, without feeling observed or judged: she was undoubtedly the mother, or an experienced mother or grandmother in the community. This is how we can interpret the root of and the reason for midwifery.

Rediscovering the specific role of authentic midwifery appears to be a necessary step in the age of the safe caesarean. The elimination of midwives in places as diverse as Chinese, Indian, or Latin American cities is a symptom of a widespread deep-rooted lack of understanding of the physiology of parturition. The fact that in many countries the midwife became one member of a medical team suggests the same lack of understanding. The vocabulary commonly used in the natural childbirth movements when referring to the birth attendant also transmits a lack of understanding of the physiological processes. A “coach” cannot facilitate an involuntary process. The primary objective in modern midwifery schools is not to select women of a peaceful nature, who can easily play the roles of mother figures.
Not only can the physiological approach help us to rediscover the reason for midwifery, it can also identify the main preoccupations an authentic midwife has. An authentic midwife has an intuitive or/and scientific knowledge of the adrenaline – oxytocin antagonism. Furthermore she knows how contagious an adrenaline release is. This has been studied among mammals in general. It is the same among humans: one cannot be in a state of complete relaxation when close to a tense person. One of the main preoccupations of an authentic midwife is therefore to make sure, when a woman is in labour, that there is nobody around releasing adrenaline. This implies that her duty is first to keep her own level of stress hormones as low as possible. When addressing this issue I cannot help thinking of the six months I spent as an “externe” in a Paris maternity unit during the winter 1953-1954. At that time the midwife was a woman who spent her life knitting. She was more often than not the only person staying not far from the labouring woman. This situation was obviously compatible with easy births.(Odent 1996) It is fruitful to reinterpret such a scene in the scientific context of the twenty first century. At the April 2004 British Psychological Society conference, Dr Emily Holmes, from Cambridge University, presented her studies on the effects of repetitive tasks, such as knitting. The author concluded from such studies that repetitive tasks are extremely effective means of reducing tension. We might translate such findings in physiological language and realize that when midwives are knitting, their own levels of adrenaline are kept as low as possible. Let us add that the capacity to spend hours and hours knitting is probably associated with personality traits that include the capacity to maintain a low level of stress hormones.

FETUS EJECTION REFLEX AND ART OF MIDWIFERY

Re-examining the tenets of midwifery lead us to reconsider our current understanding of the different phases of labour. Today the different phases of labour are defined in the context of “managed” or “coached” births. The main criteria are the objective data provided by vaginal examinations. Complete dilation of the cervix is usually considered the boundary between first and second stage. However, a real ‘fetus ejection reflex’ can occur among humans, provided that the activity of the neocortex is dramatically reduced, so that our human handicap can be overcome. The term “fetus ejection reflex” was originally used by Niles Newton, when she was studying the effect of the environment on the birth of mice (Newton et al 1967)—mice are mammals that do not have a neocortex as powerful as ours. I found it necessary in the 1980s to rescue the term from oblivion and to use it for humans as well (Odent 1987). Today I consider this "reflex" as a necessary physiological reference from which one should try not to deviate too much. During the powerful and irresistible contractions of an authentic ejection reflex there is no room for voluntary movements. A cultural misunderstanding of birth physiology is the main reason why the birth of a baby is usually preceded by a second stage, with voluntary movements.

The vocabulary originally used by Niles Newton helps us to understand that sexuality must be considered a whole. Today it is artificial to study the episodes that are essential for the survival of the species in isolation. The same hormones are involved. Similar scenarios are reproduced. So there is always a final ejection reflex: milk ejection reflex, sperm ejection reflex, fetus ejection reflex…(Newton 1987),

The concept of the ejection reflex is not easily understood today because the passage towards the reflex is inhibited by any interference with the state of privacy. It does not occur if there is a birth attendant who behaves like a "coach", or an observer, or a helper, or a guide, or a "support person"(Odent 1996). It can be inhibited by vaginal exams, by eye-to-eye contact, or by the imposition of a change in the environment. It does not occur if the intellect of the labouring woman is stimulated by a rational language ("Now you are completely dilated; you must push"). It does not occur if the woman is given instructions of this or any type. It does not occur if the room is not warm enough or if there are bright lights.

A typical fetus ejection reflex is easy to recognize. It can be preceded by a sudden and transitory fear expressed in an irrational way ( “kill me”, “let me die”, etc.). In such a situation the worst approach is to reassure the woman with words (Odent 1991). This short and transitory expression of fear can be interpreted as a reliable sign of a spectacular increase in hormonal release, including adrenaline. It should be immediately followed by a series of irresistible contractions. During the powerful last contractions the mother-to-be seems to be suddenly full of energy, with a need to grasp something. The maternal body has a sudden tendency to be upright. For example, if the woman was previously on her hands and knees, her chest will tend to be vertical. Other women stand up to give birth, more often than not leaning on the edge of a piece of furniture. A fetus ejection reflex is usually associated with a bending forward posture. When a woman is bending, the mechanism of the opening of the vulva is different from what it is in other positions. The risk of dangerous tears is eliminated. After a typical ejection reflex, the placenta is often separated within a few minutes, if the mother-newborn interaction is not disturbed, and if the place is a warm enough.

I have interpreted this reflex as the effect of a sudden spectacular reduction in neocortical activity, associated with the release of a complex hormonal cocktail, including hormones of the adrenaline family. The release of a high peak of oxytocin is of course suggested by the sudden power and efficiency of the uterine contractions. The ecstatic state of the mother at this time, which is also typical after a fetus ejection reflex, suggests that the hormonal cocktail includes morphine-like hormones.

The fetus ejection reflex should not be confused with the well- known Ferguson’s reflex.(Ferguson 1941) The Ferguson’s reflex is related to mechanical conditions: the pressure of the presenting part on the perineal muscles. A real fetus ejection reflex can occur long before the descent of the presenting part, or long after. It can start before complete dilation, or after. Usually it does not occur at all because the prerequisite is complete privacy. In the context of homebirth, I am familiar with this reflex when I follow the progress of labor from another room through the sound the woman is making, while her husband or partner goes shopping and there is nobody else around other than an experienced, motherly, silent and low-profile doula. An authentic reflex is exceptionally rare in the presence of the baby’s father.

Being familiar with the fetus ejection reflex lead me to “restudy” the “paradoxical oxytocic effects of adrenaline”, which has been rarely mentioned since the reports by Zuspan, Cibil and Pose were published in 1962 (Pose et al 1962,Zuspan et al 1962). Before that time the authors who studied uterine contractility after the administration of adrenaline or noradrenaline stressed either the excitatory responses (Miller et al 1937, Brown et al 1943, Kelly 1962) or the inhibitory responses (Rudolph & Ivy 1930, Ivy et al 1931, Woodbury et al 1938). Since then, there has been a tendency to consider only the inhibitory effects of adrenaline. The complex effects of adrenaline might become less mysterious in the context of recent advances in human physiology.

I became aware of this complexity in precise circumstances. When we introduced the concept of birthing pools, in the 1970s, our prime objective was to facilitate the birth process by reducing the level of catecholamines. We observed that often, in this environment, the labour stops progressing at the end of the first stage. This is the time when many women leave the bath spontaneously. As soon as they return to a cool atmosphere it is as if the different ambient temperature triggers some major contractions and the delivery is fast. This is typical when goose bumps and other symptoms of a surge of adrenaline are obviously compatible with strong and efficient contractions. It is in such circumstances that I found the term “fetus ejection reflex” relevant to human beings as well (Odent 1983). A rapid expulsive stage of delivery triggered by fear is another example of a situation in which efficient contractions seem to be associated with increased levels of adrenaline. There are countless anecdotes reported by birth attendants, sometimes in extreme circumstances like bombardments or earthquakes. There has also been the well-known practice of saying or doing something frightening as a way of occasionally avoiding the use of forceps. Besides, anthropological documents suggest that, at a certain stage of labour, in some very precise circumstances, fear has been used to trigger the birth.

It is significant that after a typical fetus ejection reflex the mother usually remains alert for 5 to 10 minutes, tending to keep her trunk vertical whilst making her first contact with the newborn baby, as if her levels of adrenaline had not yet dropped. This is in accordance with the findings of R. Lederman et al. regarding the circulating plasma catecholamines: the level of adrenaline returns to normal within 3 – 21 minutes after delivery (Lederman et al 1977).

These phenomena have obvious evolutionary advantages (Newton et al 1968). If anything threatening should occur at the beginning of labour there is an advantage in postponing the birth and being in a state of muscular activity. On the other hand, having passed the point of no return in labour, it is an advantage to give birth as quickly as possible and to be alert during the minutes around birth: “being aroused and ready to interact at birth is more adaptative than being sluggish and unaware”(Lagercrantz & Slotkin 1986).

It is worth mentioning that I have never had to repair the perineum after a real, undisturbed fetus ejection reflex. One of the many reasons may be that in such a context of privacy, the mother is more often than not bending forward, for example on hands and knees. In such postures, the mechanism of vulva opening is different from what it is in other postures. First, the anterior part of the vulva opens more quickly; then the deflexion of the head tends to be delayed and, when the face is coming out, the chin is in a more lateral position.

It is tempting to try to explain the paradoxical oxytocic effects of adrenaline in the light of physiological data that were not available a few decades ago. The first explanation one can propose is related to the lipolytic effect of adrenaline (Qvisth et al 2006). An adrenaline drip triggers a release of free fatty acids and, in particular, of arachidonic acid (AA), the most common of the three precursors of prostaglandins in tissue lipids (Hansen 1983). (The metabolites of AA synthesized in amnion and decidua vera are stimulants of uterine contractions). The process of lipolysis is over before the end of the drip (Havel & Goldfien 1959) and the half life of prostaglandins is half a minute (Hansen 1983). In other words any rush of adrenaline triggers a transitory release of prostaglandins of the 2-family. The main effect of a sudden lipolysis on uterine contractility should be excitatory in so far as there are also increases of plasma levels of cortisol during labour (Carr & Parker 1981), and that cortisol electively blocks the biosynthesis of the inhibitory myometrial prostaglandins (prostacyclin or Pgi2) (Casey !985).

The second explanation one can propose takes into account the complexity of the system of α and β receptors in smooth muscles. The activation of α receptors in smooth muscles is usually excitatory while the activation of β receptors is usually inhibitory. It is likely that above a certain threshold the effects on α receptors are predominant. This explanation is supported by the different patterns of birth process where low weight babies are concerned. A fast end of delivery is common in the case of a small for dates baby at term while the end of delivery has a tendency to be longer and more difficult in the case of a premature birth. It is worth recalling that the ratio is increasing between α and β uterine receptors at the end of pregnancy. The complexity of the effects of catecholamines on uterine activity might also be related to various responses of the different regions of the myometrium and, in particular, to responses specific to cervical portion (Bonnycastle & Ferguson 1941). The ratio of adrenaline to noradrenaline is also a factor to consider.

These considerations about the concept of ejection reflex are necessary steps at a time when the specific role of the midwife must be rationally explained. Is it premature to claim that the art of midwifery is the art of creating the conditions for a fetus ejection reflex and a “placenta ejection reflex”?

PARTICULAR SITUATIONS

Rediscovering the basic needs of labouring women and understanding the fetus ejection reflex would force us to reconsider many contemporary practices that are based on data established in the age of “managed” childbirth. We can take as an example the particular case of a breech birth at term. From my personal experience of about 300 breech births by the vaginal route (including three home births) I can conclude that the risks are significantly reduced when the first stage has been easy and is followed by a powerful fetus ejection reflex. We can take as another example the issue of shoulder dystocia. This complication of “managed” or “coached” birth does not occur if the conditions for a powerful ejection reflex are met.

We must add that a genuine fetus ejection reflex seems to be the main factor facilitating the rotation of the presenting part of the fetus. In other words it is the physiological way of overcoming the specifically human mechanical difficulties during the birth process. (Odent 2005) We have confirmation today that fetal position changes are common during labour, with the final position established close to delivery. This is the conclusion of a prospective study of 1562 women which aimed to evaluate changes in fetal position during labor by using serial ultrasound examination.(Lieberman 2005) Among babies who were posterior late in labor, only 20.7% appeared to be posterior at delivery. Finally, when the mother had no epidural, the overall rate of posterior position at delivery was only 3.3%, although this study was conducted in conventional departments of obstetrics, where the basic needs of birthing women could not easily be met. The rate was 12.9% in the epidural group. These data are reinforced by the results of a large Australian randomized controlled trial involving 2547 pregnant women. It appeared that hands and knees exercise with pelvic rocking from 37 weeks’ gestation until the onset of labor does not influence the incidence of persistent occiput posterior position at birth.(Kariminia 2004)

MATERNAL EMOTIONAL STATES

Apart from some anecdotes of accidental privacy when giving birth, an authentic fetus ejection reflex is so rare that it cannot be easily studied from a subjective perspective. However we can anticipate that understanding the conditions for a fetus ejection reflex would help us to become more familiar with the concepts of ‘orgasmic states’ and ‘ecstatic states’ associated with childbirth. There is also an obvious association between fetus ejection reflex and, afterwards, the expression of pure joy.

WHEN SIMPLIFIED STRATEGIES BECOME REALISTIC

It is only when the basic needs of labouring women and newborn babies are rediscovered that simplified strategies may be considered. We should not aim specifically to reduce the caesarean rates: we need first to improve our understanding of the physiological processes. In hospitals where the watchword is to reduce the rates of c-sections, the first effect is usually an increased number of difficult births by the vaginal route and of dangerous last-minute emergency caesareans. This is exactly what we should avoid in the age of the safe caesarean.

The only factor that might be influenced almost overnight is the current dominant attitude regarding prolonged pregnancies. The epidemic of labour induction is usually considered a factor that tends to increase the rates of c-sections (Seyb 1999, Edris 2006), in spite of a small number of contradictory data (Caughey 2006). The usual attitude (routine induction when the pregnancy has reached a certain number of weeks) might be replaced by a selective attitude. Above a certain number of weeks of gestation it should be easy to assess the well being of the fetus on a day-to-day basis. It should be possible, in particular, to combine ultrasonic evaluations of the amniotic fluid index and evaluations of the levels of placental hormones in the urine. Such laboratory tests would become cheap and easy to obtain if the demand was increasing. In most cases an expectative attitude would become advisable. When the first signs of an altered placental activity would be detected, an elective caesarean would be preferred. There is strong evidence that maternal morbidity is significantly reduced when the intention to treat is elective c-section, compared with labour induction.(Allen 2006) In the case of prolonged pregnancy, a selective attitude would lead obstetrical teams to replace a great number of emergency caesareans by a small number of elective c-sections.

Meanwhile, before rediscovering the meaning of privacy and silence and the reason for midwifery, we must already prepare for binary strategies, with two basic scenarios. Either the birth process is straightforward by the vaginal route, or it is not. This would lead to an in-labour non-emergency caesarean. The key is to decide early enough during the first stage of labour when a caesarean is indicated. We need new tests to do this effectively, i.e. tests which are adapted to twenty-first century strategies. Scores associating a great number of criteria have already been designed in order to detect early on in the birth process those women who are destined to have a caesarean.(Wilkes et al 2003)
Up to the mid-1970s I had used what I called ‘lumbar reflexotherapy’ as a test in order to decide early enough, in difficult cases, if a caesarean is necessary. In this technique, one or two intracutaneous injections of sterile water are made in the back, on each side of the spine, at the level of the muscular depression which is just below the last rib. This reflexotherapy is efficient when the dilation has reached 5 cm and only when the contractions are felt as unbearable lumbar pains. As soon as the lumbar pains have gone, only a discomfort above the pubic bone continues while cervical dilation is progressing. When the dilation does not progress in spite of privacy, it means that there is probably a major mechanical obstacle. I dared to publish my observations in a medical journal in 1975, when we heard of the ‘gate control theory of pain’. It became plausible that painful fleeting stimulations of the area of the skin served by the posterior branch of the 12th dorsal nerve can compete at the level of the spinal posterior horn with painful messages coming from the uterus. (Odent 1975)

After we had introduced a birthing pool in our maternity unit in the late 1970s, I had a tendency to forget the use of lumbar reflexotherapy. Immersion in water at the temperature of the body in hard labour is usually followed by a spectacular progress of cervical dilation during a limited length of time that is in the region of an hour or two.(Odent 1983). If, after two hours of immersion, and in spite of privacy (no camera!), the dilation has not progressed, one can expect the usual range of drugs preceding an emergency caesarean. This is the basis of the ”birthing pool test”(Odent 2004), which can be useful when the dilation does not progress beyond five centimetres in spite of strong contractions. The birthing pool test implies that an internal exam has been performed just before immersion so that, if necessary, a comparison becomes possible after an hour or two. This is an important practical detail, because midwives who are familiar with undisturbed and unguided births in silence, semi-darkness and privacy usually can follow the progress of labour without repeated evaluation of the dilation of the cervix.

Today our primary objective should be to make such simplified binary strategies realistic, that is to say compatible with moderate rates of caesareans. We must prepare for the day when technical advances will be matched by conceptual advances.

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Index: proposal

adrenaline, anorexia nervosa, asthma, autism, birthing pool, catecholamines, cost-effectiveness, criminality, drug addiction, endorphins, fatty acids, fetus ejection reflex, forceps, glucose, gut flora, induction (of labour), instrumental deliveries, knitting, lactation, love, lumbar reflexotherapy, midwifery, neocortex, noradrenaline, odours, oxytocin, pelvic size, perinatal morbidity, perinatal mortality, perineal damage, primal health research, privacy, prolactin, prostaglandins, silence, ventouse.
WHAT IS THE FUTURE OF A CIVILISATION BORN BY CAESAREAN?

There are several reasons to consider this unusual question at the dawn of the new millennium.

A SPECIFICALLY HUMAN DIMENSION

First, as human beings, we are endowed with gregarious tendency. Like most other primates we need to live in groups. Since we are also endowed with the capacity to communicate in sophisticated ways, particularly through language, we create cultural milieus and civilizations. This is why the effects of widespread interferences with the physiological processes, particularly in the perinatal period, must be considered in terms of civilization. The effects of new aspects of lifestyle are not easily detected at an individual level. In this regard humans are special, compared with other mammals. When a woman knows that she is pregnant, she can anticipate displaying some maternal behaviour, while pregnant non-human mammals must entirely rely on the behavioural effects of the flow of hormones associated with the process of parturition.

From non-human to human mammals

We do not need to mention many examples of animal experiments and observations by veterinarians and primate-using scientists to convince anyone that the maternal behaviour of non-human mammals is altered by a caesarean. Their maternal behaviour can be dramatically disturbed by the mere anaesthesia. Almost a century ago, in South Africa, Eugene Marais was making experiments to confirm his intuition as a poet that a connection exists between the pain of birth and maternal love.(Marais 1937) He studied a group of sixty Kaffir Bucks, knowing that there had not been a single instance of a buck mother in the herd rejecting her young in the previous fifteen years. He proceeded to give the birthing females a few puffs of chloroform and ether, and noticed that the mothers refused to accept their newborn lambs afterwards. In the 1980s, Krehbiel and Poindron studied the effects of epidural anaesthesia among ewes giving birth.(Krehbiel 1987) The results of this study are easily summarized: when ewes give birth with an epidural anaesthesia, they don’t take care of their lambs.

Today, caesarean sections are common in veterinary medicine, particularly among dogs. This is possible as long as human beings compensate for a frequently inadequate maternal behaviour, assist the process of nursing and provide, if necessary, commercial canine milk replacers. The effects of a caesarean on the maternal behaviour of primates are also well documented, because several species of monkeys are routinely used as laboratory animals. This is the case of the ‘crab-eating macaques’ and the rhesus monkeys.(Lundbland 1980) In these species the mothers do not take care of their baby after a caesarean; laboratory personnel must multiply artifices, such as spreading vaginal secretions on the baby’s body, in order to try to induce a mother interest for her newborn.
The immediate and spectacular responses of animals to anaesthesia and caesarean operations indicate the questions we should raise where our species is concerned. We just need to include terms such as ‘civilisation’ or ‘culture’.(Odent 2004) For example, if non-human primates do not take care of their babies after being delivered by c-section, the appropriate question is: “What is the future of a civilisation born by caesarean?”

Obstacles

Several obstacles must be overcome before we develop our capacity to think in terms of civilisation. For centuries doctors have been working within Hippocratic principles of ethics. Traditional Hippocratic medicine only considers the perspective of individual patients. There is no mention in the Hippocratic Oath of the doctor’s societal responsibilities. As for the midwife, she is traditionally in intimate communication – in communion – with the labouring woman, sharing her priorities. Finally, doctors and midwives are not in a position to think in terms of civilization. Pregnant women and young mothers are also not in a position to think in terms of civilization. They have other understandable vital and immediate priorities. When a woman is pregnant, her main preoccupation is usually the health and wellbeing of her own baby. After the birth, the behaviour of a mother tends to be more than ever under the control of her ‘selfish genes’.

THE AGE OF THE “SCIENTIFICATION OF LOVE”

The age of the safe caesarean is also the age of the “scientification of love”.(Odent 1999) The concept of the scientification of love also forces us to think in terms of civilisation. Until recently love was the realm of poets, novelists and philosophers. Today it is studied from a variety of scientific perspectives. It is easy to miss the importance of the phenomenon because there is a multitude of specialised approaches to exploring the nature of love. Genuine scientific advances always lead to new questions being raised or to the reformulation of old questions. It is as if these scientific advances provide answers to questions that had never been properly formulated. This is the case with the scientification of love, which prompts us to ask simple and paradoxically new questions, such as ‘How does the capacity to love develop?’. Today all scientific data converge to emphasize the importance to early experiences, particularly in the perinatal period. During millennia the widespread promotion of love had bypassed this basic question.

Ethologists as pioneers

The legendary observation by Konrad Lorenz, in the 1930s, symbolizes this new scientific era. The founder of modern ethology reported that one day he had interposed himself between newly hatched ducklings and their mother and then imitated the mother duck's quacking sounds. These ducklings became attached to Lorenz for the rest of their lives, following him when he walked in the garden, for example. This is how the concept of a sensitive period in the process of forming attachment came to be introduced. Since that time there have been countless studies involving a great diversity of mammals, including primates. All ethologists seem to have come to a tacit agreement that the attachment between mother and baby constitutes the prototypical form of love. It is interesting that pioneering ethologists such a Lorenz (who studied ducks and geese) and Harlow (who studied primates) did not hesitate to introduce the word ‘love’ into the scientific vocabulary. From studies among mammals as diverse as rats, hamsters, sheep, goats, and monkeys one can conclude, in spite of differences between species, that there is always, immediately after birth, a short period which will never be repeated, and which is critical in mother-baby attachment.

Understanding the cocktails of “love hormones”

The study of the behavioural effects of hormones involved in parturition started in the 1960s.ThenTerkel and Rosenblatt injected virgin rats with blood taken from mother rats within 48 hours of parturition (Terkel 1968). The virgin rats displayed maternal behavior. This historical experiment was followed in the 1970s by a great number of other experimental studies exploring the behavioral effects of hormones whose levels fluctuate in the perinatal period (estrogens, prolactin, progesterone).

A new era of research started in 1979 when Prange and Pedersen published the results of their historical experiment. Instead of injecting oxytocin intravenously, they thought of injecting this hormone directly into the cerebral ventricles of virgin rats.(Pedersen 1979) About half of the rats developed the full spectrum of nurturing behaviour exhibited by rat mothers in less than one hour after treatment. Interestingly the rats that responded to oxytocin with maternal behaviour were in stages of the oestrus cycle associated with rising, elevated, or recently elevated oestrogens. The authors had demonstrated that oxytocin has behavioural effects and also that these effects are influenced by other hormones.

Until 1979 we knew only about the mechanical effects of oxytocin. It had been known for a long time that oxytocin is necessary to contract the uterus during parturition, and also to contract the myoepithelial cells of the breast for the milk ejection reflex. We have also known for a long time that it can induce uterine contractions, so as to facilitate the transportation of sperm towards the egg.(Egli 1961) Furthermore oxytocin’s mechanical effects on the prostate and the seminal vesicles have been well documented.(Sharaf 1992)
.It was also in 1979 that a Japanese team revealed that oestrogens affect both the release of and the response to oxytocin,(Yamaguchi 1979) while Melvyn Soloff and his team at the University of Texas showed that the response of an organ to oxytocin depends much more on the density of the receptors at the level of the target than on the blood concentrations of the hormone.(Soloff 1979)

After 1979 the way was open for an explosion of studies into oxytocin in “Maternal, Sexual and Social Behaviors” which led to the simplified conclusion that oxytocin is the primary “hormone of love”.(Pedersen 1992)
In the 1980s an accumulation of data confirmed that in mammals’ brains there are oxytocin receptors resembling those found in uterine and mammary glands.(Brinton 1984, Van Leeuwen 1985, De Kloet 1985, Freund-Mercier 1987, Insel 1986). Among rats there is an increased number of such receptors during birth in the “bed nucleus of the stria terminalis”. Because the experimental destruction of this zone inhibits maternal behaviour - without disturbing the births - it appears that the oxytocin receptors of that zone play an important role in maternal behaviour.(Pedersen 1992)

Since the early 1980s interest in oxytocin research has gradually increased. Its release and effects in a great variety of situations have been clarified.
Researchers from the Karolinska Institute, in Sweden, have contributed to a better understanding of the physiological processes in the perinatal period. Thanks to them we can claim that the highest peak of oxytocin a woman is able to reach in her entire life is just after the birth of a baby and that oxytocin returns to its pre-labour levels about an hour after birth.(Nissen 1995) This team of researchers also studied the patterns of oxytocin release at the beginning of lactation. Two days after birth, when the baby is at the breast, women who gave birth vaginally release their oxytocin in an effective way (rhythmically, in a pulsatile manner) while women who had a caesarean during labour release their oxytocin in a less pulsatile way, which is less effective.(Nissen 1996)
Oxytocin release has also been studied during sexual arousal and orgasm.(McNeilly 1972, Carmichael 1987) The system of oxytocin (and vasopressin) has been studied comparatively among polygamic and monogamic mammals.(Sapro 1992)
Oxytocin release has been studied in such a great diversity of situations that we can mention only some of them. For example sharing a meal with companions has been found to increase one’s blood level of oxytocin.(Verbalis 1986) According to the results of highly original studies originally presented by Paul Zak at the Society for Neuroscience’s annual meeting, people’s oxytocin levels rise when they receive a message of trust.(Zak 2003) These experiments were based on the physiological response to different situations of money transfer. The stronger the signal of trust, the more oxytocin increases. In addition, the more oxytocin increases, the more trustworthy people are.

We are are probably still in a preliminary phase of the history of our knowledge of the hormones released by the posterior pituitary gland. There is no contradiction between our current understanding of oxytocin as the hormone of love and the observations of those who have studied the effects of other sexual hormones, in particular estrogens and progesterone. Today it is well understood that estrogens activate the oxytocin and prolactin sensitive receptors. We must always think in terms of hormonal balance. For example, immediately after birth, oxytocin - an altruistic hormone - and prolactin - a mothering hormone - complement each other.
In the near future, we will have to take into account the complexity of the oxytocin system. In recent years it has become clear that oxytocin can appear in the brain in several forms. There is the nonapeptide oxytocin (OT) and the ‘C-terminal extended peptides’, which are described together as OT-X. The OT-X represent intermediate stages of oxytocin synthesis that accumulate in the case of an incomplete processing machinery. It has already been found that there was a decrease in blood OT, an increase in OT-X and an increase in the ratio of OT-X/OT among autistic prepubertal children.(Green 2001)

It was also in 1979 that the maternal release of beta-endorphins during labour and delivery was demonstrated. In the early 1980s we learnt that the fetus releases its own endorphins in the birth process and today, there is no doubt that, for a certain time following birth, both mother and neonate are impregnated with opiates. The ability of opiates to induce states of dependency is well known so it is easy to anticipate how the beginning of a "dependency" - an attachment - will be likely to develop.

Although the behavioural effects of the motherhood hormone prolactin (the levels of which tend to increase during the process of parturition) have been understood for a long time, one cannot ignore the Swedish studies using the ‘Karolinska Scales of Personality’ test. We should remember from such studies that, under the effects of prolactin, human beings are more prone to let the outside govern their actions, in other words to accept the laws of nature.(Uvnas-Moberg 1989)

Catecholamines also have a role to play in the interaction between mother and neonate immediately after birth. During the very last contractions before birth the maternal levels peak: as soon as the "fetus ejection reflex" begins, women tend to be upright, full of energy, with a sudden need to grasp something or someone; they often need to drink a glass of water, just as a speaker may do in front of a large audience. One of the effects of such a release of catecholamines is that the mother is alert when the baby is born. It is also well known that the fetus has its own survival mechanisms during the last strong, expulsive contractions, and releases its own catecholamines. The visible effect of this release of noradrenaline is that the baby is alert at birth, with eyes wide-open and pupils dilated. Human mothers are fascinated and delighted by the gaze of their newborn babies. It is as if the baby is giving a signal, and it certainly seems that the eye-to-eye contact typical of this time is an important feature of the beginning of the mother and baby relationship among humans.
The highly complex role of catecholamines in the interaction between mother and baby has not been studied for a long time. A small number of animal experiments open the way to further research. Mice who lack a gene responsible for the production of noradrenaline leave their pups scattered, unclean and unfed - unless they are injected with a noradrenaline-producing drug when giving birth. (Thomas 1997)

Our current knowledge about the behavioural effects of different hormones involved in the birth process helps us to interpret the concept of a sensitive period introduced by ethologists. It is clear that all the different hormones released by the mother and fetus during labor and delivery are not eliminated immediately. It is also clear that all of them have a specific role to play in the later interactions between mother and baby. For example, immediately after birth, when mother and neonate are still under the effect of endogenous opiates, one can assume that it is the beginning of a mutual dependency or, rather, an attachment.

The real importance of genuine scientific advances is usually ignored by those who live at that time. This is also the case with our new knowledge about the behavioural effects of hormones involved in parturition, lactation, and sexual intercourse. Few people have already realized how crucial it is to know that oxytocin, the hormone necessary for effective uterine contractions during parturition, is also the main hormone of love. The media started to be really interested in the behavioural effects of oxytocin in 2005 after the publication in Nature of the study of the biological basis of trust (Kosfeld 2005). Today we can simply claim that in order to give birth mammals have been programmed to release a complex cocktail of love hormones.

Primal Health Research

Among the scientific disciplines involved in the scientification of love, we include this branch of epidemiology I have termed primal health research.(Odent 1986) Many of the entries compiled in the Primal Health Research Database (www.birthworks.org/primalhealth) are related to various deviations from the usual gregarious human tendencies, or to self-destructive behaviours. An overview of the database must lead us to conclude that when researchers explore a behaviour, a personality trait, or a disease that can be interpreted as an ‘impaired capacity to love’, they always detect risks factors in the perinatal period. The term ‘impaired capacity to love’ is convenient because it can encompass self-destructive behaviours which are essentially an ‘impaired capacity to love oneself’.

Autism may be presented as a pathological deviation from the usual gregarious human tendency. Various research studies included in the database suggest that the timing of gene-environment interactions is different for autism than for schizophrenia. Several authoritative studies indicate the paramount importance of the perinatal period in the genesis of the various autistic spectrum disorders.
Niko Tinbergen - one of the founders of ethology, who shared the Nobel prize with Konrad Lorenz and Karl Von Frisch in 1973 – preceded modern epidemiologists in his study of autism from a primal health research perspective. As an ethologist familiar with the observation of animal behaviour, he researched the non-verbal behaviour of autistic children. As a "field ethologist" he studied the children in their home environment. Not only did he offer detailed descriptions of his observations, but he also came to the conclusion that there were risks factors in the perinatal period, such as labour induction and “deep forceps” delivery.(Tinbergen 1983) We must also save from oblivion a report by Ryoko Hattori, a psychiatrist from Kumamoto, Japan.(Hattori 1991) She evaluated the risks of becoming autistic according to the place of birth. Children born in a certain hospital were significantly more at risk. In that particular hospital, the routine was to induce labour a week before the expected date of birth and to administer a complex mixture of sedatives, anaesthesia agents and analgesics during labour.

Among the three recent large and authoritative studies of autism from a primal health research perspective, the Australian one will convince anyone that the risk factors in the perinatal period should be seriously considered.(Glasson 2004) The 465 subjects born in Western Australia between 1980 and 1995 diagnosed with an autism spectrum disorder by 1999 were compared with the birth records of 481 siblings of the cases, and with the records of 1313 controls. There were no difference in gestational age at birth (including the proportion of premature infants), weight for gestational age, head circumference, or length between cases and control subjects. Pre-eclampsia did not appear as a risk factor. These negative findings lend more importance to perinatal factors. Compared with their siblings, autism cases were more likely to have been induced, to have experienced fetal distress, and to have been born with a low Apgar score. Compared with control subjects, they were more likely to have been born after induction and to have been born by elective or emergency c-section.

Similar conclusions can be drawn from a study involving all Swedish children born from 1974 to 1993. No association was found between autism and head circumference, maternal diabetes, being a twin, or season of birth; however c-section did appear to be a risk factor.(Hultman 2002) This study could not consider labour induction as a possible risk factor, since this term did not appear in the Swedish birth registers until 1991. A recent report from Israel also found no prenatal differences between autistic children and controls, but the rates of birth complications were higher among the autistic population.(Stein 2006) In addition, we must consider data suggesting that anesthesia during labour is a risk factor for the development of dyskinesia among autistic children.(Armenteros 1995)

An overview of the database leads us to contrast autism and schizophrenia in terms of early risk factors. Many research studies suggest the importance of the ante partum environment in the genesis of schizophrenia (given the data about head circumference at birth, birth weight, frequency of association with minor physical anomalies, prenatal exposure to famine, bleeding in pregnancy, maternal diseases in pregnancy such as influenza, toxoplasmosis and pre-eclampsia, pharmaceutical drugs in pregnancy, stressful events in pregnancy etc). When researchers detect intrapartum complications as risk factors for schizophrenia, the inclusion of multiple variables usually suggests that these complications may be partly secondary to earlier events. The timing is apparently different where the genesis of autism is concerned: the focus is more often than not on the perinatal period.

Juvenile criminality can also be interpreted as a deviation from the usual human gregarious tendency. Raine and colleagues found that the main risk factor for being a violent criminal at age 18 was the association of birth complications, together with early separation from or rejection by the mother. Early separation-rejection by itself was not a risk factor(Raine 1994)..

All sorts of self destructive behaviour - such as suicide, drug abuse and anorexia nervosa - can be interpreted as an “impaired capacity to love oneself”. Teenage suicide, almost unknown fifty years ago, is an important issue specific to our time. Salk et al. found risk factors in the perinatal period for adolescent suicide victims who died before their 20th birthday (Salk 1985). One of the most significant factors was the fact of being resuscitated at birth. Jacobson focused on how people commit suicide. He found that suicides involving asphyxiation were closely associated with asphyxiation at birth; suicides by violent mechanical means were associated with mechanical birth trauma. In his last study, Jacobson confirmed that men (but not women) who had traumatic births are five times more at risk of committing suicide by violent means than others (Jacobson 1998). Jacobson compared the background of 242 adults who committed suicide by using a firearm, or by jumping from a height, or by jumping in front of a train, or by hanging, or by laceration, etc. with 403 siblings born during the same period and at the same group of hospitals. Many possible confounding factors were considered. The differences between men and women disappeared if their mothers had used analgesic drugs of the opiate family when in labor.

Jacobson and Nyberg found that if a mother had been given analgesic or sedative medication during labor (opiates, barbiturates or nitrous oxide), her child was statistically at increased risk of becoming drug-addicted in adolescence (Jacobson 1990). According to Nyberg et al.(Nyberg 2000)) adolescents who have been exposed in to 3 doses (or more) of opiates or barbiturates during the perinatal period had a risk of becoming drug addicted multiplied by 4.7 (95% CI = 1.00 – 44.1).

The largest study of anorexia nervosa included in our data bank detected correlations with the birth itself (Cnattingius 1999). A team of researchers had access to the birth records of all girls born in Sweden from 1973 to 1984. They also had access to the files of the 781 girls who had stayed in a Swedish hospital due to having anorexia nervosa between age 10 and age 21. For each anorexic girl there were five controls (non-anorexic girls born in the same hospital during the same year). Apart from being born before 32 weeks gestation, the most significant risk factor for anorexia nervosa was a cephalhematoma at birth. Forceps and ventouse deliveries were also risk factors. An Italian retrospective study of subjects with eating disorders found that the risk of developing anorexia nervosa increased with the total number of obstetric complications. In addition, an increasing number of complications significantly anticipated the age at onset of anorexia nervosa.(Favaro 2006)

This new generation of epidemiological research inspires several comments. It is noticeable that the studies we have mentioned - studies detecting correlations with intrapartum events - are related to highly topical issues. The incidence of autism, anorexia nervosa, drug addiction, suicide of adolescents and juvenile criminality has apparently increased during the past decades for reasons which are as yet unclear.. It is also noticeable that despite the publication of this research in authoritative medical or scientific journals, the findings are shunned by the medical community and the media. They are rarely quoted after publication. (Odent 2003) They belong to the framework of “cul-de-sac epidemiology”. (Odent 2000) At a time when new criteria must be taken into account to evaluate the practices of obstetrics and midwifery, the medical community should not ignore this developing branch of epidemiology.

Ethnology as a new scientific discipline

Ethnology has established itself as a science by publishing databases. Today its material on pregnancy, childbirth and the first days following birth are easily accessible. From an overview of the available data, one can first conclude that, one way or another, all cultures disturb the purely physiological processes in the perinatal period. One can also conclude that the greater the social need for aggression and an ability to destroy life, and therefore the greater the need to moderate the capacity to love, the more intrusive the perinatal rituals and beliefs. This is why I find it relevant to include ethnology among the disciplines that participate in the scientification of love.

This conclusion can be illustrated by taking as examples some extreme attitudes. In Sparta, in ancient Greece, there was a population of warriors. When a baby boy was born, he was thrown down on the floor. If he managed to survive, he was supposed to become a good warrior. By contrast, a very small number of pre-agricultural peoples were studied before they became extinct. Their strategy was to live in perfect harmony with the ecosystem; in such societies it was therefore an advantage to develop the particular form of love that involves a respect for Mother-Earth. The priority in these societies was not to develop the human potential for aggression. This was the case of the Efe Pygmies, for example, who were living in Zaire's Ituri Forest. They had a deeply rooted ecological instinct, and in particular an enormous respect for trees. It seems that they had no rituals or beliefs which disturbed the birth process (Hallet 1973). We also know about the "solitary and unaided births" among the African hunters and gatherers !Kung San. (Eaton 1988)

When considering the data provided by a range of disciplines involved in the scientification of love, we cannot help anticipating that the widespread use of simplified and safe techniques of caesarean will influence the evolution of our civilization.

PULVERIZED LIMITS TO BRAIN DEVELOPMENT

Until recently it was commonly accepted that, for obstetrical reasons, the development of the human brain has reached its limits. At term, the smaller diameter of the baby’s head (which is not exactly a sphere) is roughly the same as the larger diameter of the mother’s pelvis (which is not exactly a cone). The evolutionary process used a combination of solutions in order to reach the limits of what is possible.

Fetal head and maternal pelvis

All these apparently fixed limits to brain evolution are simply smashed with the advent of the safe caesarean. Until now babies who had too large a head to pass through the maternal pelvic opening did not survive birth and therefore could not transmit this tendency for larger brain size on to future generations. Today continued evolution of brain size is again possible.

Feeding the fetal brain

We must also take into account the fact that Homo Sapiens is to a large extent different from the other members of the chimpanzee family, in terms of fat metabolism. We are characterized by a huge capacity to transport fatty molecules to certain parts of the body, such as the brain. Humans are first and foremost characterized by a unique capacity to transport to the brain specific molecules of fatty acids that are necessary for its development. The developing brain has a real thirst for very long chain polyunsaturated fatty acids, particularly the one commonly called DHA : fifty percent of the molecules of fatty acids that incorporate into the developing brain are represented by DHA. This very long chain polyunsaturated molecule (22 carbons; 6 double bonds) of the omega 3 family is preformed and abundant in the sea food chain only. One of the keys to understanding human nature is to take into consideration the weakness of our delta-4 desaturation enzymes, taking into account that DHA is a product of this reaction. In other words human beings, who are characterized by an enormous brain, are not very effective at making a molecule that needs to be fed into the nervous system. This suggests that humans have evolved around a diet that included this molecule. In practice, this means access to seafood. Two studies have revealed that the mere fact of encouraging pregnant women to consume fish from the sea is followed by a significantly increased average head circumference (Odent 1996, Meeson 2006) It is therefore justified to claim that the transmission of the tendency for larger brains is suddenly made possible in the age of the safe caesarean, which is also a time when we start understanding the specific nutritional needs of the developing brain (and when aquaculture is the world’s fastest growing food-producing sector).

Brain size and domestication

Homo sapiens may be classified as a highly domesticated primate, since cultural factors prescribe and proscribe behaviour. Norms become established which are enforced through social sanctions. This is a characteristic of our species one cannot ignore when discussing the evolutionary tendency in brain development. It is well known that a reduction in brain size is one of the long-term consequences of domestication. This has been demonstrated in species of mammals as diverse as pigs, sheep, dogs, cats, camels, ferrets and mink.(Kruska 1988) The changes in the brain of a wild creature into that of a highly domesticated strain happen very rapidly in terms of evolution: after only 120 years of domestication, a brain size reduction of about 20% has been observed in mink(Kruska 1996) This side effect of domestication seems to be a consequence of a lack of opportunities to take the initiative, to struggle for life and to compete. The evolution of human brain size and the evolution human domestication are two related issues. One cannot ignore these links when considering the future of our species.

What is at stake

We must emphasize that human-induced evolution of the brain would in fact result in human-induced neocortical development. Primitive brain structures are evolutionarily more stable. The neocortex was originally a sort of supercomputer at the service of vital archaic brain structures. The point is that this ‘new brain’ tends to wield most power and that it can inhibit the activity of the primitive one: a rational control of the urge toward survival is one of the by-products of brain evolution. One can anticipate that above a certain threshold of neocortical development the different aspects of the urge toward survival will be weakened. In other words, an excess of rationality might threaten our species. We must think at the same time of the urge for survival as individuals, as members of a group, and as members of a species.

The symptoms of a weakened urge for survival as individuals would be an increased incidence of depressive states and self-destructive behaviour. We must give real importance to data supporting De Catanzaro’s evolutionary theory of human suicide, according to which a threshold intelligence is necessary for self-damaging behaviour (which can be perceived as the expression of ‘impaired capacity to love oneself’). (De Catanzaro 1981) According to an ecological study comparing 85 countries, suicide rates are related to average intellectual development.(Voracek 2003) Furthermore, excess suicide prevalence has been observed in the highly gifted.
The symptoms of a weakened urge for survival for the group would theoretically be an increased incidence of antisocial behaviours. It is noticeable that deviations from the typical human gregarious tendency have been frequent among highly creative, legendary geniuses. Isaac Newton never married and lived most of his life alone. Albert Einstein had poor grooming and hygiene and well-documented interpersonal deficiencies. Bertrand Russell was an aloof, lonely, and somewhat insecure child, and later considered an unstable adult.

A weakened urge for survival through the species is likely to be characterized by a reduced libido, a reduced fertility, by the increased incidence of pathological pregnancies, and by a reduced capacity to give birth spontaneously and to breastfeed.
Once more the capacity to love (others and oneself) is a convenient term to summarize what is at stake.
It is paradoxical that we must rely on modern science to explain the dangers of an excess of rationality.

REASONS FOR PESSIMISM

The era of human-generated existential risks began some decades ago. Existential risks refer to events that would cause the extinction of our species or permanently cripple its potential.(Bostrom 2002) Non-anthropogenic factors have failed to annihilate the human species for millions of years. It seems unlikely that such factors will strike us down in the next few millennia. Before the recent advent of human-generated existential risks our intuitions and coping strategies were shaped by long experience of endurable and limited hazards such as, for example, dangerous animals, hostile individuals or tribes, poisonous food, volcanic eruptions, earthquakes and droughts.

Identifying extinction scenarios

Today we need to urgently identify and evaluate the global terminal risks created by modern civilisation. We need to invent coping strategies that are radically new. It is not yet known whether the human capacity to create problems is increasing at a faster or at a slower rate than our capacity to solve problems. We need to harmonize technological, scientific, and conceptual advances.

Meanwhile, several human extinction scenarios are already scrutinized in scientific circles. The use of nuclear energy, particularly for nuclear war, appeared as a human-generated global threat as early as the 1940s, and was soon followed by the fear of biological warfare. Today a great diversity of threats are mentioned with increasing frequency, particularly the destructive uses of nanotechnologies symbolised by the “gray goo scenario”, the malicious use of artificial intelligence, and the doomsday scenario in which high-energy physics experiments trigger the destruction of the Earth. The risks of a catastrophe after the deterioration of the planet’s ecosphere is now widely explored in mainstream scientific theorizing. There are many reasons for this sort of pessimism.
All the current attempts to evaluate these possible means of annihilation have ignored the probable fast evolution of Homo Sapiens in technological civilisations. We must remember that the evolution of technology and its use cannot be dissociated from the evolution of human beings.

At a time when we are learning that the pre- and perinatal periods are crucial in terms of gene–environment interactions, it seems obvious that the widespread use of the abdominal route for childbirth should be given first consideration among the lifestyle changes that are bound to modify human nature. The advent of the safe caesarean makes the release of specific hormonal agents useless during what appears to be a critical period in the development of the capacity to love. We might make similar comments about the effects of modern obstetrics in general, since today most women who give birth vaginally must rely on substitutes for natural hormones. For example they use drips of synthetic oxytocin that do not have the behavioural effects of the pituitary hormone, and they use analgesics via the epidural route that modify the whole hormonal balance of parturition and the postnatal period. Furthermore, the routine injection of uterotonic agents for the delivery of the placenta blocks the release of the peak of oxytocin during the third stage of labour, which occurs at the beginning of the mother-newborn interaction. It would be surprising if spectacular effects were not detectable within a short space of evolutionary time (e. g. a dozen generations). We must even start wondering if humanity can survive this turning point in the history of lifestyle changes. The emerging generation of scientifically literate philosophers who pronounce on the future of humanity must realize that the evolution of our capacity to love and our innate capacities for aggression should be given a prominent place in their thoughts, along with the development of our intellectual capacities.

Neutralising the laws of natural selection

We must add that the widespread use of the caesarean is a significant step in increasing the power modern medicine has already acquired to neutralise the laws of natural selection. While modern medicine has magnificent positive effects at an individual level, we prefer to ignore its long-term terrifying consequences at a collective level. From now on, the genetic predispositions to a great range of pathological conditions can be transmitted more easily than ever. If the current tendencies are not reversed, it should already be possible to predict the time when the greatest part of the global population will be chronically dependent on medical care. In the age of the safe caesarean, women who can give birth easily have the same number of children as other women. It is therefore probable that the tendency to have difficult births will be more easily transmitted. This will lead to more caesareans…so we need to consider how can we break this vicious circle.

In order to counteract the unprecedented negative effects of modern medicine on natural selection, there will be a temptation to think of gene therapy. But the current somatic gene therapy, that uses a viral vector to insert genetic material into cells of the recipient’s body, is non heritable. As for the heritable germ line therapy, performed on sperm or egg cells or on the early zygote, it is still experimental and, anyway, it cannot become a mass method.

The responsibility of pioneers

Since the famous ‘Einstein letter’ to President Roosevelt in October 1939 (in fact written by the Hungarian born physicist Leo Szilard and signed by Albert Einstein), the warnings about human-generated existential risks have been first expressed by those who had been in the forefront of the scientific or technical advances at the root of the threat. A recent example was the point of view of Bill Joy, the cofounder of Sun Microsystems, regarding the future of robotics, genetic engineering, and nanotechnology (GNR). In an article in ‘Wired Magazine’ entitled ‘Why the future does not need us’, he claimed that our most powerful 21st century technologies are threatening to make humans an endangered species and he advocated that we abandon GNR technology.

Today, in this book launched and edited by Michael Stark, it is our duty as members of the obstetric community to focus on threats that have not yet been perceived by scientifically and medically literate philosophers. The mere fact that Michael Stark asked me to write a chapter about the future of a civilisation born by caesarean is in itself a warning.

REASONS FOR OPTIMISM

While we must urgently identify and evaluate the global terminal risks created by modern civilisation, we should not ignore a few reasons for optimism. As early as 1934, at a time when he was in Beijing, Teilhard de Chardin prophetically anticipated the “scientification of love” and predicted a “rebound in human evolution and neo-cerebralization”. He wrote that, one day, after mastering the energies of space, winds, tides, and gravity, we would learn to master the energies of Love. Then, for the second time in the history of the World, Man will have discovered fire. (Teilhard de Chardin 1973).

Today our hope is not the advent of the sort of superhuman that is usually dreamt of in transhumanist circles: biological enhancement makes us think of genetic engineering for longer life, neuro-implants to assist our sensory organs, or drugs that improve memory and intellectual capacities. In the age of the scientification of love, what we need is superhuman intelligence in order to prioritise the development of a superhuman capacity to love. We might hope that Homo Sapiens, the only living creature intelligent enough to destroy the planet, will become intelligent enough to manipulate our evolution in order to manage existential risks.

If we are able to learn the lessons of the scientification of love soon enough, the human species in its current form will not represent the end of our development, but a rather comparatively early phase. Anyway humanity must invent radically new strategies for the survival of intelligent life, which will contrast with the strategies human groups have used until now for their own survival. The basic strategy for survival of most human groups is to dominate nature and to dominate other human groups. Civilisations have always had a tendency to dominate or eliminate other civilisations. Successful societies are those that develop and hand down ways of enhancing the strong innate capacities for aggression in our species. When the basic strategy for survival is to dominate nature and dominate other human groups, it is an advantage for a society to develop its capacity to destroy life. It is an advantage for it to moderate its capacity to love, including its respect for Mother Earth.(Odent 1979)

Today an emerging new awareness gives us cause for optimism. We are in the process of understanding the limits of the domination of nature. We are beginning to understand why we need to create a certain unity in our planetary village. To invent new strategies for survival, our priority must be to learn to develop the human potential for love, rather than our genetic propensity for aggression. Such an objective is not utopian in the age of the scientification of love.

A NECESSARY STEP

At a time when the perinatal period is considered critical in the development of the capacity to love, an overview of the documented rituals and beliefs whose effects are to disturb the physiological processes is a preliminary step to understanding the current turning point in the history of our species. It reveals the extent of what has been for millennia a cross-cultural phenomenon.

Interfering with parturition

Ritual female genital mutilation undoubtedly interferes with the birth process. It is said to have been practised worldwide at certain phases in history. Today its prevalence is largely observed in Africa, and in Europe among immigrant populations.(Momoh 2001) Its major form is infibulation (or pharaonic circumcision). Infibulation at present means the cutting off of the whole clitoris, the whole of the labia minora, and the adjacent parts of the labia majora, and stitching the two sides of the vulva, leaving a small opening for urination and menstruation. According to a World Health Organization study, female genital mutilation is estimated to lead to an extra one to two perinatal deaths per 100 deliveries, and risks are greater in the case of more extensive techniques.(Banks 2006) In Nigeria genital mutilation is often followed by the ‘Gishiri cut’. This operation is performed by a traditional birth attendant on women who have a prolonged labour. The birth attendant uses a knife to cut through the soft tissues for the purpose of enlarging the passage. The Gishiri cut is a major risk factor for perineal fistulas.(Ampofo 1990)

In general it is via a ‘coaching midwife’ that cultural milieus interfere with the physiological processes. The basic need of a labouring human mammal is privacy. Privacy may have to be protected. The need for protection was originally satisfied by the presence nearby of the mother of the birthing woman or by another familiar mother-figure in the community. This was the origin of midwifery. It seems that at a certain phase in history, in most societies, the midwife had a tendency to enlarge her role, to take power, and to become an active ‘coach’. In her study of 186 non-industrial societies, Betsy Lozoff found that in less than 2% of such societies does the woman routinely give birth alone, and in only another 2% is a woman permitted to give birth alone.(Lozoff 1982, Lozoff 1983) In 62% of the 71 societies on which she had valuable information, birth attendants try actively to influence women’s labour: manipulating, kneading, dilating the cervix manually, even bouncing on the abdomen, or simply, as reported by Brigitte Jordan when documenting the practices of the Maya people in the Yucatan, explaining the progress of labour.(Jordan 1983) In some cultures birth attendants have guided women in labour by telling them how to breathe. For example Sheila Kitzinger reported that in Jamaica women are told to breathe lightly in the late first stage as it is believed that the fetus can ascend into the mother’s chest.(Kitzinger 1982) These are some examples among many others of how birth attendants can play an active role.

Interfering with mother-newborn interaction

The third stage is the phase of labour which is routinely disturbed in all cultures. All societies we know about interfere in the interaction between mother and newborn and tend to postpone the initiation of breastfeeding via a great diversity of beliefs and rituals. We will focus on the quasi-universal negative attitude towards colostrum. Colostrum can be regarded as the symbol of the repression of instinctive forces insofar as the baby of civilised people is usually deprived of it.(Odent 1992)

In most traditional African cultures, colostrum is likened to pus, or poison, and it is therefore avoided. Some tribes employ a specific ritual to ensure that the absorption of colostrum is hampered or postponed. For example, in the Bemba tribe in Zambia, people put a small amount of gruel into the baby’s mouth: they say it is to open up the mouth. There has been a consensus of opinion in Asia that colostrum is bad. Indian Ayurvedic medicine recommended honey and clarified butter for the newborn, while colostrum was to be expressed and discarded.(Baumslag 1987) Babies in South India are usually given water, diluted cow’s milk, honey or dates.( Rao 1959) In Afghanistan the colostrum (called ‘fela’) was traditionally replaced by bitter herbs, sweets, and hyssop seeds. In Japan the elixir ‘Jumi Gokoto’ was given to the newborn. This was made from nuts and herbs, but the specific ingredients were determined by caste. In a field study of several villages in Matlab, Bangladesh, Lindenbaum reported that, for the first three to four days until milk production began, babies were given honey, mustard oil, or cow’s milk diluted with water – all fed to the child on the tip of the finger.( Huffman 1980) In old Siam the mother must eat boiled leaves of Cardiospermum halicacabum and Ipomsea aquatica in order to expel the bad ‘yellowish milk’ (i.e. the colostrum’), while waiting for the good ‘’white milk’.(Phya Anuman Rajadhon 1961) In China the routine is basically the same, with some local and regional variations. Negative attitudes towards colostrum are not uncommon in the American hemisphere either, and this has been noted particularly among the Indians of Guatemala. Anyway the documented perinatal rituals among American Indians would be incompatible with an early consumption of colostrum. We can make similar comments about births among the aborigines of Australia, as reported in particular by Annette Hamilton.

Western societies have always despised colostrum. In the sixth century BC., Prokopios reported the custom of nomadic people in the northern part of Sweden. There the newborn was immediately hung up in the trees, wrapped in fur skins, and given bone marrow to eat. In biblical times, colostrum was expressed and the baby given honey to cleanse the intestine before the proper milk was available. Greek doctors, Roman doctors, and Western European doctors have shared the same beliefs. In the Middle Ages, rosewater was commonly used as purgative. Sometimes the mother was given an older child who was considered capable of digesting colostrum. In Brittany, it was thought that the devil would enter the baby’s body along with the colostrum, had the mother given the breast before the baptism (three or four days after birth).
In Tudor and Stuart England, colostrum was openly regarded as a harmful substance, to be discarded.( Fildes V 1987) The mother was not permitted to give the breast until after a religious service of purification and thanksgiving called “churching”. Meanwhile the baby was given various types of purgative such as butter and honey or oil of sweet almonds, or sugar wine. Paintings from that time show the newborn infant fed with a spoon while the mother recovers in bed.

Beliefs cannot be dissociated from rituals. For example these negative beliefs about colostrum imply that the newborn baby must not be in the arms of its mother, but in the arms of another person. This leads people to cut the cord right away, which again is a widespread ritual. Several beliefs can reinforce each other. Among some African ethnic groups (particularly Benin), they also transmit the belief that the mother should not look at the baby’s eyes during the day following birth, so that the ‘bad spirits’ cannot penetrate the baby’s body. There is often a complex combination of beliefs and rituals. Among the Tagara, they think that the community of young children should welcome the newborn baby.(Sobonfu Somé 1999) When a woman is in labour, all the children are nearby. When they hear that the baby is born, they all enter the birthing place and shout out…a powerful way to distract the mother at the very time when she is supposed to release a vital peak of oxytocin.

Several variants of the same ritual have been observed in places as far apart as New Guinea and Brazil. Margaret Mead provided detailed reports of childbirth among the mountain dwelling Arapesh in New Guinea.(Mead 1935) While his wife is in labour, the father waits within ear-shot until the baby’s gender is determined. When the father is informed about the baby’s gender, he laconically answers: “Wash it” or “Do not wash it”, which means that the child is or is not to be brought up. This clearly indicates that the baby is in the hands of the midwife, who is herself at the service of the father. Among the Myky from Mato Grosso, in Brazil, the mother is not authorized to touch the baby as long as the spiritual leader has not yet confirmed that this particular baby should survive. Among ethnic groups in Amazonia, it is only after the permission given by the godfather wearing his ceremony clothes that the mother can take care of her baby.
This is a relatively small sample of the data available on widespread beliefs and rituals. Man’s potential for meddling in the baby’s relationship with his or her mother is enormous. Baptism by immersion in cold water, “smoking the baby”(among the aborigines of Australia and still today among the Omanis), piercing the ears of the little girls during the hour following birth, opening the doors in cold countries, tight swaddling, foot binding: all these rituals have the same effects.

Lost evolutionary advantages

It is obvious that if these countless beliefs and rituals are so widespread, it is because until now they had evolutionary advantages, in spite of their cost. In reality, their cost is enormous, in terms of post-partum hemorrhage and maternal deaths: there are still hundreds of thousands maternal deaths a year related to hemorrhages, and a post partum hemorrhage is almost always the consequence of an inappropriate interference. While some of those who confuse science and technology claim that “The End of Science” has already arrived (Horgan 2003), in fact our hope is more than ever fed by the scientific pursuit of truth. Today we need authentic science not to challenge nature, but to challenge deep rooted beliefs that are losing their evolutionary advantages. This is a necessary step in order to rediscover - with the help of a physiological perspective - the basic needs of labouring women and newborn babies.

THE RIGHT QUESTION AT THE RIGHT TIME

Being aware of difficulties is not a reason for pessimism. A new awareness should rather urge us to analyze the main difficulties in order to overcome them. The main obstacle for rediscovering the basic needs of labouring women and newborn babies is that we are in the aftermath of the countless beliefs and rituals that have been transmitted from generation to generation for thousands of years. The current lack of understanding of birth physiology is cultural and shared by the natural childbirth establishment as well as by medical circles. As long as one of the aims of all cultures is to control the birth process, it is an advantage to disseminate the idea that a woman cannot give birth without being actively helped or guided by birth attendants. In most languages disempowering vocabulary tends to focus on the role of the birth attendant rather than on the needs of labouring women. Women do not give birth: somebody delivers them. The vocabulary suggests that a woman is unable to give birth without the help of a person bringing her expertise or her energy (in English the ‘coach’ is supposed to bring her expertise, while the ‘support person’ is supposed to bring her energy). In such a context it will take time to rediscover that privacy and silence are basic needs during the involuntary process of parturition.

It will also take a long time to eradicate the influence of all beliefs and rituals that for millennia have disturbed the first mother newborn interaction and the initiation of breastfeeding. Although we are now in a position to understand the vital significance of this short period of time, we still seem to constantly create new ‘excuses’ to interfere. Some of these excuses are rationalized by the medical institution. For example it is commonplace to rationalize cord clamping or cord cutting before the delivery of the placenta. Other excuses are rationalized by the natural childbirth circles. For example ignoring the importance of such vital events as the delivery of the placenta and the initiation of lactation led to a focus on the father-newborn ‘bonding’ immediately after the birth of the baby.

Among the difficulties we can anticipate we must emphasize the current lack of available criteria for comparative studies of the evolution of various cultural milieus in relation to the evolution of obstetrical practices. First, in the age of globalization, the differences between cultural milieus are gradually reduced. Furthermore, the practice of obstetrics and midwifery tends to be internationally standardized in the age of evidence-based medicine and computerized databases. However there are still huge differences when considering, in particular, the caesarean rates. It is not utopian to imagine specific criteria in order to follow up the evolution of the cultural characteristics of countries that are in extreme situations in terms of obstetrical practice. It would be possible, for example, to follow up the evolution of the Dutch culture (moderate rates of caesareans and high rates of home births), with the evolution of the Brazilian culture (high caesarean rates) and of the Irish culture (widespread use of synthetic oxytocin). It should be possible also to compare the evolution of the cultural characteristics of the Japanese culture (moderate rates of obstetric intervention) and the evolution of the Taiwanese and South Korean cultures (high rates of obstetric intervention). All these Asian populations, which are genetically almost similar, share comparable standards of living.

We must take into account the necessary delay for a new awareness to become widespread. However, at the dawn of this millennium, the powerful means of communication we have at our disposal can dramatically speed up the emergence and the development of new cultural values. The rate of change in our age is faster than ever before. It is noticeable that interpreting the causes of disasters has recently been the most powerful factor for new awareness (Odent 2002). Analyzing the real causes of mad cow disease and foot and mouth disease epidemics resulted in a sudden acceleration of the development of organic farming. Since the increased frequency of climatic disasters became obvious, the emission of greenhouse gases as an effect of uncontrolled industrial development appeared on the agenda of all politicians. We might wonder: “Which disaster might speed up the history of childbirth?”

Formulating the right question at the right time is another possible way of speeding up the emergence of a new awareness. Since nobody would dare to make pronouncements on the future of a civilisation born by caesarean, I am tempted to paraphrase the famous practical question publicly formulated by Stephen Hawking about how the human race might be able to survive the next hundred years. Let us ask: “How can the human race survive the safe caesarean?”

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Index: proposal:

Anorexia nervosa, antisocial behaviour, autism, beliefs, brain size, catecholamines, civilisation, colostrum, criminality, cul-de-sac epidemiology, culture, domestication, endorphins, ethnology, ethology, extinction scenarios, head circumference, hippocratic oath, love, maternal behaviour, natural selection, neocortex, noradrenaline, oxytocin, pelvic size, post-partum hemorrhage, pre-eclampsia, prolactin, primal health research, rationality, rituals, schizophrenia, self-destructive behaviour, suicide, veterinary medicine.

CURRICULUM VITAE

Michel Odent, MD

Born in France in 1930.
Medical studies at Paris University.
In charge of the surgical unit and the maternity unit at the Pithiviers state hospital (1962-1985). Founder of the Primal Health Research Centre (London).

- Introduced in the 1970s the concept of birthing pools in maternity hospitals. Author of the first article in the medical literature about the use of birthing pools (Odent M., Birth under water, Lancet 1983; i:1476-77).
- Introduced in the 1970s the concept of home-like birthing room in maternity hospitals (Jane Gillett, Childbirth in Pithiviers, France, Lancet 1979; i:894-96).
- Author of the first article in the medical literature about the initiation of lactation during the hour following birth (Odent M., The early expression of the rooting reflex, Proceedings of the 5th International Congress of Psychosomatic Obstetrics & Gynecology, Rome. London: Academic Press 1977: 1117-1119).
- Author of the first article applying the ‘Gate Control Theory of Pain’ to obstetrics (Odent M., La réflexotherapie lombaire, Nouvelle Presse Médicale 1975 (4):188)
- Founded the Primal Health Research Centre (London, UK). The objective is to test the assumption that human health is shaped during the ‘primal period’, which includes fetal life, perinatal period, and year following birth. (Michel Odent, Primal Health, London: Century Hutchinson, 1986)
- Created the Primal Health Research database, the only specialized database compiling studies that explore the long term consequences of what happened during the ‘Primal period’ (www.birthworks.org/primalhealth).
- Created the website www.wombecology.com, in order to convince anyone that the most vital form of human ecology is prenatal ecology (concept already included in Genèse de l’homme écologique, Paris Epi 1979)
- Studies in progress to evaluate the effects of encouraging pregnant women to consume sea fish (Odent M, McMillan L, Kimmel T., Prenatal care and sea fish, European Journal of Obstetrics & Gynecology 1996 (68):49-51 and Odent M., Plea for a new generation of research in eclampsia, Clinical effectiveness in nursing 2006; 952: e232-e237)
- Author of 11 books in 21 languages (in italiano: Abbracciamolo subito!, Red edizioni; L'ecologia della nascita, Red edizioni; L'agricoltore e il ginecologo, Leone Verde; La scientificazione dell'amore, Apogeo; Il cesareo, edizioni Blu)

In allegato:
- ultima breve pubblicazione su Lancet; Michel Odent è autore di un'ottantina di pubblicazioni su riviste scientifiche, tutte incluse sul sito Pubmed.
- in anteprima, l'originale inglese dei due capitoli conclusivi, redatti da Michel Odent, del libro a cura di Michael Stark sul cesareo, di prossima pubblicazione in lingua tedesca. Il Dr. Stark è il chirurgo che ha reso il taglio cesareo un'operazione rapida e sicura.

The Lancet, Current Issue, Volume 371, Number 9610, 2 February 2008

The Lancet 2008; 371:385-386
DOI:10.1016/S0140-6736(08)60198-1

Neonatal tetanus
Michel Odent a
In their Seminar about maternal and neonatal tetanus (Dec 8, p 1947),1 Martha Roper and colleagues present neonatal tetanus as a consequence of unsafe umbilical cord care practices. It should rather be presented as a complication of an intervention—ie, early cord cutting. If there is no rush to intervene, some hours later the cord is thin, dry, hard, and exsanguine. Then, it can be cut without any need for cord care practices. The risk of neonatal tetanus is eliminated.
We must keep in mind that cord cutting is originally a ritual inseparable from myths (eg, the widespread belief that the colostrum is harmful) that lead to early mother–newborn separation. If it were possible to neutralise the effects of such deep-rooted beliefs and rituals, there would be no excuse to separate the neonate from the mother. Apart from the prevention of neonatal tetanus, one might expect a cascade of secondary outcomes (higher haematocrit, immediate contamination of the neonate by germs satellite of the mother, early consumption of colostrum, effects on how the gut flora is established, etc).
At a time when global action is the watchword, one can wonder how cost effective it would be to teach the world that cutting the cord can wait many hours, that the neonate needs first its mother's arms and can find the breast during the hour after birth, and that the colostrum is precious. Our objective is not to discuss the particular case of wealthy countries where neonatal tetanus is almost unknown and drugless childbirth rare.
I declare that I have no conflict of interest.
References
1.Roper MH, Vandelaer JH, Gasse FL. Maternal and neonatal tetanus. Lancet 2007; 370: 1947-1959. Abstract | Full Text | Full-Text PDF (1020 KB)
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Affiliations

a. Primal Health Research Centre, London NW3 2JR, UK

MICHEL ODENT A CANOSA il 23 Marzo 2009 h. 9

2009-01-11T09:29:00.000-08:00

Michel Odent è autore di 12 libri tradotti in 21 lingue e di un'ottantina di articoli pubblicati da riviste scientifiche prestigiose. E' stato il primo medico ostetrico al mondo a parlare, a livello scientifico, dell'istinto del neonato a trovare da solo il seno della madre durante la prima ora dopo la nascita e a introdurre il concetto di riflesso di eiezione del feto. Ha appena finito di preparare il primo Convegno Internazionale sulla Salute Primale, vera e propria pietra miliare per la ricerca medica del futuro, che si terrà a Las Palmas di Gran Canaria il 26-28 febbraio 2010.
Il dott. Odent sarà accompagnato e tradotto dalla dott.ssa Clara Scropetta, a sua volta una sorta di pioniera italiana della cultura della maternità e del sostegno alla madre.

REGIONE PUGLIA ASL BAT COMUNE DI CANOSA DI PUGLIA

Coordinatore Scientifico
dott. Antonio Belpiede Dir. Ostetricia Ginecologia Canosa

info: 3358084820-Fax 0883641241
ostetriciaeginecologiacanosa.blogspot.com

Istituto Tecnico Commerciale "L. Einaudi" Via Settembrini, 160 Canosa di Puglia

"OSTETRICIA IERI OGGI E DOMANI" 23-Marzo-2009
l'approccio standardizzato e l'approccio selettivo

ore 9 Saluto delle autorità

Nichi Vendola Presidente Regione Puglia

Tommaso Fiore Assessore Politiche della Salute

Francesco Ventola Sindaco di Canosa di Puglia

Rocco Canosa Direttore Generale Asl Bat

Franco Polemio Direttore Sanitario Asl Bat

1° parte: l'approccio selettivo durante la gravidanza:

9.15-10.00 l'interpretazione dei dati clinici, l'ecografia, la valutazione della gravidanza a rischio e dell'età gestazionale

10.00-10.45 le visite prenatali e lo stato emotivo della gestante

10.45- 11.30 l'ecologia del grembo

11.30- 12.30 tavola rotonda

12.30 -13.30 brunch

2° parte: l'approccio selettivo durante il parto:

13.30-14.15 le fasi del parto: travaglio, riflesso di eiezione del feto, riflesso di eiezione della placenta e la prima ora dopo la nascita

14.15-15.00 l'influenza della somministrazione di preparati farmacologici, del monitoraggio e di alcune pratiche ostetriche sulla secrezione ormonale endogena

15.00- 15.45 riscoprire i bisogni fondamentali della partoriente e del neonato: l'emergere di una strategia binaria

15.45-17.00 tavola rotonda
CHIUSURA DEI LAVORI

Parteciperanno alla Tavola Rotonda:
dott. Silvio Anastasio, dott. Mariano Cantatore, dott. Nicola De Toma, dott. Benedetto Fucci, dott. Michele Grandolfo, prof. Pantaleo Greco, prof. Nicola Laforgia, dott. Sergio Sabatelli, ost. Maria P. Schiavelli, prof. Luigi Selvaggi, dott.Emilio Stola, dott. Ernesto Tajani, dott. Lorenzo Torciano

Sarà a Canosa prossimamente Michel Odent, medico ostetrico di fama internazionale, noto per aver introdotto il parto in acqua e le sale parto simili ad un ambiente domestico. Odent è considerato un pioniere nel suo campo e, lungi dall'essere un promotore del parto "naturale", è uno scienziato rigoroso che da decenni studia e osserva la fisiologia del parto. Secondo le sue ricerche, la salute si forma per la maggior parte in utero e viene fortemente influenzata dalle esperienze vissute alla nascita e nel primo anno di vita.

Odent arriva in Italia poco dopo l'uscita del libro "Der Kaiserschnitt" (il taglio cesareo), curato dal dott. Michael Stark, di cui ha redatto i due capitoli conclusivi. Si tratta di un'opera che farà indubbiamente parlare di sè. Il dott. Stark è, infatti, il chirurgo tedesco a cui si devono le innovazioni tecniche che hanno reso il taglio cesareo un'operazione rapida e sicura. Proprio lui lancia, ora, un appello all'intera classe medica: riconsiderare le condizioni in cui avviene la nascita in ospedale, affinchè il cesareo torni ad essere un'operazione d'emergenza. Egli ha chiesto a Odent di illustrare quali sono le conseguenze della medicalizzazione in ostetricia e quali le strategie atte a permettere un parto spontaneo.

In Italia, oramai, più di un bambino su tre nasce con il taglio cesareo (nel meridione uno su due) e i tassi di interventi medici in caso di parto per via vaginale sono moltoelevati. Si tratta quindi di un tema di scottante attualità.
Con semplicità, senso dell'umorismo e competenza, Odent illustrerà come il modo in cui si viene al mondo sia una questione di civiltà e si ripercuota sulla salute del singolo e della collettività.

La presentazione sarà seguita da una tavola rotonda con docenti universitari e i primari dei reparti di maternità e di neonatologia

Egli esporrà come facilitare il decorso fisiologico della gravidanza e del parto, rispettando le esigenze fondamentali della donna e del bambino e come integrare i risultati apportati da recenti studi epidemiologici nella pratica ospedaliera quotidiana, per migliorare la qualità e l'efficacia dell'assistenza.