MAYD to Birth: At Your Doorstep

Promoting gentle, empowering mother journies…

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Clamping Umbilical Cords

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Umbilical cords…most people know very little about them.  They probably know that they used to have one…and probably know that it made their belly button.  They may know that it was once attached to a placenta…but beyond that, most people can’t understand why I admire umbilical cords.

Let me try and explain it to you.

* * * * * * *

One of my most popular blog posts is this one on umbilical cords…

Magic Umbilical Cords

In case you haven’t seen it yet – it is one of my shortest blog posts, yet has become one of my most shared and well known. I have had an interest in the umbilical cord and our rush to clamp it for a while, and had previously looked for pictures to demonstrate the changes that the cord goes through from immediately after birth until it is no longer functional. Imagine my surprise when I couldn’t find the desired pictures even when looking through google images!! Billions of images shared, but that one eluded me. So one morning I watched a friend (whom I had watched birth her first baby) push her second baby out into the world – and was struck by the beauty of this thick, blue, pulsing umbilical cord. I asked the mother if I could take pictures of the cord to use for educational purposes, and she said yes. I asked my student if she could grab the camera and take some pictures for me…and she took those amazing pictures that I was then given permission to share in the hopes of educating others as to the importance of respecting the function of the cord.

(sidenote – lesson learned…next time I will watermark the images after editing them)

I knew that I loved the pictures and have a respect for the umbilical cord, but I guess I didn’t realize how popular that blog post would become or I would have seized the opportunity to educate more on the wonders of this cord that connects baby to mother. Here are some really interesting facts that you may or may not know about the umbilical cord.

IT PROTECTS BABIES’ BRAINS

The debate is far from over – should we clamp the umbilical cord immediately at birth, or should we wait until it has stopped pulsing or the placenta is delivered?  Those advocating that we delay cord clamping often say that doing so would allow oxygen to continue to be delivered to the baby until baby begins breathing – but the truth is that it does even more than deliver oxygen, it delivers blood.  At first glance that might seem like the same thing – but perfusion of blood can be more important in the immediate protection of brain function than oxygen levels.

babies-brain-742

What causes brain damage in a person? If I asked that question to a classroom of students most of their hands would go up and I would easily get the correct answer of “Lack of oxygen!” That is correct. In a person, lack of oxygen (otherwise known as hypoxia) eventually causes brain damage. Usually the cause of the hypoxia is respiratory depression or heart failure. In other words…. the reason that they would be without oxygen long enough to cause brain damage is that they have stopped breathing or their heart stopped pumping the blood.

What would cause a neonate (newly born baby) to be hypoxic? It’s not the lungs or the heart that had a problem – it’s the cord. The solution is to protect the return of the function of the cord, thus correcting the problem. If the cord was the problem, then the cord is the solution.

Here is something that not everyone understands – perfusion of blood to the brain has more immediate repercussions to its function than oxygen level of that blood. Babies in utero grow and thrive in an oxygen level much lower than ours. Oxygenated blood comes through the umbilical cord, mixes in the inferior vena cava and in the heart with DE-OXYGENATED blood from the inferior+superior vena cava….and that mixed, lower oxygenated blood is then circulated throughout the baby.  Even with lower oxygen levels, they thrive.  Their skin is purple, but their system is perfused with blood that is lower in oxygen than ours. This offers protection from hypoxic injury…as long as organ and placental perfusion are good.

Adult brains and organs aren’t much different….an adult can survive without oxygen of any sort (ie. breathing pure nitrogen) for 5 minutes and, while they will lose consciousness, will suffer no long-term effects. No brain damage. However, if you occlude the cerebral artery (stop blood flow to the brain), brain damage begins almost instantly. Losing perfusion of the blood to the brain is much more damaging to the tissue than losing the oxygen to the brain.

It is understandable, then, that our primary goal for the depressed neonate should be allowing the placenta and cord to re-perfuse the baby and his/her organs immediately after birth!  If baby’s system has been compromised of blood supply, then it is imperative that we do not remove that cord until perfusion has been re-established.  Providing that baby with oxygen via a mask with positive-pressure-ventilation to resuscitate doesn’t address the PROBLEM – which is the perfusion of blood to the baby’s system at the moment of birth.

functioningcord

A fully functioning cord…this baby was born at home. His mother is snuggling this baby, oblivious of the gifts this cord is providing her baby.

attached

The same baby baby, now snuggled with his daddy…while still attached to the placenta that is in the bowl. Notice that his cord, previously thick and purple, is now thin and opaque white.

 



AND IT’S NOT JUST THE BRAIN

Perfusion of the liver helps the baby maintain glucose levels as the baby now needs to tap into their own glycogen stores in the liver to maintain glucose levels. The liver is also responsible for processing bilirubin and preventing jaundice. While it is understandable that one could think that having a higher blood volume at birth could contribute to physiological jaundice of the newborn, having a liver that is properly perfused could actually assist in preventing jaundice.
Perfusion to the kidneys is necessary to maintain blood pressure which is required for fluid, electrolyte, and acid-base regulation after birth.
Perfusion of the lungs “erects” the alveoli and initiated respiration – with perfusion resulting in lung aeration before respiratory efforts even start. Respiration is a reflex controlled through the central nervous system which needs copious perfusion of the reflex circuit and well as the respiratory muscles for it to function. A large portion of the blood volume given by the unclamped cord at birth goes towards establishing the pulmonary (lung) blood flow.

This is usually where I take a moment to reflect in the awesomeness that happens in that moment of birth…when the cord is blue and pulsing, when baby is changing from purple to pink – when this cord, that has supported this baby their entire life, gives its final gift before it will collapse, almost as if it has given its life for this baby.

IT PROTECTS THEM UNTIL THEY START TO BREATHE

The moment of birth is dramatic…for no one more than for the baby. The umbilical cord words to make this sensitive time easier by protecting the baby on many levels.

First, it protects their temperature.  Until the cord stops functioning, it is pumping mother-heated blood from inside her body (the placenta) through the cord into the baby – thus acting like a circulating heater keeping baby’s temperature stable until baby can be snuggled into mother’s warm arms.  I’ve seen nurses, doctors, and midwives rush immediately to rub baby with towels, drying baby off, slipping a hat on their head…all in an effort to maintain baby’s body temperature.  The truth is that for the minutes that the cord is functional, there is really no reason for any of that yet.  Once in mother’s arms, her body heat will adjust to maintain the baby’s body temperature perfectly.

clampsSecond, it gives the baby a grace period by providing oxygen (along with blood, see above), giving the baby time to initiate respiratory efforts.  I’ve heard medical care providers say that a depressed newborn (one with low APGAR scores – or one who isn’t breathing and responsive immediately) is one of the instances in which delayed cord clamping can not be accomplished as the baby needs medical attention in a warmer where the neonatal team has full access to that baby. Proponents of delayed cord clamping state that a depressed newborn is when it is most crucial that we don’t clamp that umbilical cord in order to support the baby until respiration is established.

The truth is that in 1957 (over 50 years ago!) a paper published in the Lancet demonstrated just how dramatic the support and protection of the cord can be for a baby. In the report, the medical team tracked the weight of a newborn who was wrapped immediately at birth in warm cloth and placed on a scale near mother’s vagina. Baby didn’t start breathing for 10 full minutes. For 10 minutes they watched the baby and recorded it kicking the bed (at 4 minutes), recorded the baby’s weight as it changed with uterine contractions that pushed blood into the baby….and finally recorded the baby’s weight surge immediately after the baby began breathing (as a full 100ml [.42 cup] of blood was pushed into baby from the placenta), finally stabilizing after the cord stopped functioning. The baby was never in any danger even though it took 10 minutes to establish respiration.

Gunther

Initially at birth, the placenta and umbilical cord continue to function similarly to how they did in utero. After birth as it is exposed to temperature change, the gelatinous substance in the cord (Wharton’s Jelly) that was firm and thick and protected the integrity of the two arteries and single vein inside the cord….begins to chemically change, liquefying, collapsing the cord and restricting the vessels it contains. As the Wharton’s jelly begins to collapse, it first restricts the smaller arteries (that bring blood from baby to the placenta) before finally collapsing the larger umbilical vein (that brings blood from the placenta to the baby. Clamping the cord prematurely interrupts this process and demands immediate respiration from the newborn as well as possible severe repercussions if that doesn’t occur.

HOW MUCH BLOOD DOES BABY GET?

In the Gunther study mentioned above, they found a 100ml surge within one minute of the baby beginning to breathe. That may not seem like much until you think of it this way…

* the estimated blood volume of a baby is determined as 85ml for every kilogram of full term baby.
* the average baby weighs approximately 7.5 pounds. Converting that to kilograms is approximately 3.5 kg (approximating for simplicity)
* using these calculations – the average blood volume of a newborn baby is approximately 297.5 ml.

OLYMPUS DIGITAL CAMERA

A fully functional umbilical cord being clamped by the physician immediately at birth. Baby was then immediately taken over to a warmer, rubbed down, and kept for almost half an hour.

While they did not mention the size of the newborn studied….if it was an average sized baby, he or she would have received approximately 1/3 their total blood volume FOLLOWING the initiation of respiration. Studies have shown that it can be even more significant – up to 50%. If you or I lost 30-50% of our blood volume, we would be in stage 3 or 4 (out of 4) hypovolemic (low blood volume) shock. We usually are symptomatic and in the beginning stages of hypovolemic shock at only 15% blood loss. A loss of 50% usually requires severe intervention to prevent death.

 

CONCLUSION

The more I learn of the umbilical cord and its function, the more I am in awe at its incredible abilities to protect our babies both inside and out of the womb. I have yet to see ANY compelling arguments that would convince me that we should do anything in that immediate postpartum period that would interrupt the function of the cord – especially if baby is compromised. In fact, I believe strongly that to do so is to put that baby at significant risk – and as health care practitioners, how can we justify that? The only logical approach is to leave the cord alone until the placenta has delivered, only clamping before then in extreme circumstances and after exhausting all other options.

Practice Description

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Based on the current direction of my practice, I have updated my practice description:

Denise Punger MD IBCLC is a family physician who has very specialized interests and skills. Although she continues to do ‘regular’ family medicine: school physicals, routine checks, and treat common infections, new patients come to her because of her unique gift and love for breastfeeding medicine, minimally-invasive well-baby care, appreciation for birth plans, attachment-parenting philosophy, and selective vaccination schedules. She has been evaluating newborns with tongue-tie and preforming office frenotomies for over 15 years to preserve the nursing relationship. She supports prevention through nutrition, respects food sensitivities, and understands how hormone balance influence mood and overall well-being in the adult. She’s been prescribing bio-identicals over 8 years. She is the author of Permission to Mother and she has a strong online presence and welcomes contact from patients and potential patients through the social media and the website. Patients travel, e-mail, and call for consults from all over.

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I haven’t been blogging much (or at all). I do have some topics I would like to write about that take up more space than facebook. So, I may be back…. It seems I can’t keep up with the changes on the blog and it is hard for readers to leave blog comments. I am active on my personal facebook profile and my business profile (Punger Family Medicine). I have a “Permission to Mother” facebook page, also. They all kind of overlap. I post at Instagram. I have a Pinterest Account; one day I will start pinning. Thank you for your continued interest in following me.
Permission to Mother now available on Kindle!

Rodeo Beach Hike — A Beautiful Day!

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Thank you so much to the Peppers, Holly, Mark and Beckett, for leading the first ever hike of the 2013 Wisewoman Childbirth Traditions Fitness Program. We had a beautiful day in the Marin Headlands, hiking up and around for about 2 and a half hours. We had a great time hearing Holly’s birth story and the stories of her pregnancy adventures.
This was the first of a monthly series of hikes that will be led by mentor parents (basically anyone who wants to lead the hike and has a story to tell!) The fitness program also includes a monthly Nutrition class. You can read about our first class here. The first class was all about gluten and why being gluten free might be the right thing for many of us. The Fitness program will include shorter group walks as well as a free Zumba class on Fridays. We are gonna be fit in 2013!!
And thank you so much, Holly for the yummy coconut treats! You will have to send the recipe so that I can put it up on Wisewoman Food!

Birth is empowering!

AZ Midwives – Scope of Practice

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Background: Arizona midwives are in transition right now – where the state of midwifery ends up at the end of this transition will affect thousands of mothers, fathers, and their babies for so many years to come.

Arizona has had licensed midwives since 1978 (yes, they have only been legally recognized for 35 years) and there is a VERY LONG list of rules and regulations (R/R) that govern those midwives who are licensed. This list of R/R is what states what a midwife is allowed to do as a midwife…but, equally as important, it states what licensed midwifes (LMs) may NOT do as an LM.

These R/R have not been updated in about 15 years and therefore have not kept current with evidence-based practice in obstetrics – haven’t been fluid enough to conform to new ideas and discoveries.

To put it simply….the fact that the R/R are being revisited in Arizona is a BIG DEAL. It means that consumers (mothers) and midwives are fighting to expand our scope of practice, and the medical community is coming out in force to try and restrict the LMs in Arizona.

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My Summary of Last Night’s Advisory Committee Meeting

WillHumble

Will Humble, Director of the AZ Dept of Health

First I’d like to give a big thumbs up to Director Will Humble – who gently guided the meeting with respect as he listened to both sides present their findings, concerns, and opinions.

 

The main portion of the meeting began, and they didn’t get two slides into their powerpoint before it was effectively brought to a screeching halt. The largest controversy was the proposed expansion of the R/R to allow for LMs to legally attend the homebirth of VBACs (Vaginal Births after previous Cesarean Section), twins, and breeches. The proposed draft suggested implementing a requirement that each mother wishing to have a homebirth VBAC be required to consult with an OB and get a form (provided by the state) filled out and signed as proof that they visited with the OB and therefore understand the decision they are making.

Consumers on the panel argued it was insulting to require them to get this form as it’s insinuating that they aren’t bright enough to do their own research and make their own decisions. Besides, they have a care provider (LM) who can provide the same level of informed consent (education) that an OB would be able to provide.
Midwives on the panel argued that it’s an unobtainable requirement as no OB will ever sign that form due to liability concerns – therefore it continues to render VBACs illegal for LMs to attend.
OBs on the panel argued that VBACs can go tragically wrong very quickly and should always be done in a hospital regardless – and the fact that the birth certificates submitted by homebirth midwives shows that most of their clients are “self-pay” demonstrates that they are probably less educated, less professional, and less likely to be able to understand the research as well as the two consumer members of the panel who are educated professionals.

This type of lively discussion continued for well over an hour. Very little was agreed upon.

Finally, Director Will Humble opened the meeting to public comments (for those who had indicated upon entering that they wished to speak and submitted the form for it). Again, the division was clear…medical representative, one after the other, proudly stating they are the director of this group or the chairman of that medical group, stood to say that they have seen HORRIBLE things at the hospital, and if you’ve just seen these terrible things you’d know that births belong in hospitals!

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MY RESPONSE

I didn’t get a chance to speak, so I share my response here.

First and foremost, it greatly disturbs me how we so easily fall into the “us vs. them” division. Ladies and gentlemen – OBs, nurses, CNMs, LMs, Neonatologists, Perinatologists, NDs, DOs, MDs……..we are on the same team!! Do we not all have the same goal here? The best outcomes for moms and babies? If you think anything else, then please step back as I think you need to reapproach this topic from a completely different angle. Midwives don’t want emergencies or bad outcomes…neither do doctors.  Most importantly, neither do mothers!

Irestrictionst is being argued by the medical establishment, homebirth isn’t safe. Their answer to this problem – is to make it less safe by imposing greater restrictions as to what midwives can do. Do you really believe that restricting our access to emergency medication is in the patient’s best interest? Do you really think that making transporting to the hospital challenging and adversarial is in the patient’s best interest? Do you think that you are protecting women by making LMs unable to attend VBACs at home? Do you think that the choice here is homebirth or hospital birth? It is NOT! That is not the choice that this group of expectant mothers are considering!! They are considering an LM assisted homebirth VBAC or an UNASSISTED VBAC. Are you really arguing that if someone makes the decision to have a VBAC at home – because you disagree with it then you will make it your mission to make it as dangerous as you possibly can by removing a medical professional who can monitor heart tones, who can resuscitate a baby, who is trained to recognize the signs of problems…? That it is in THEIR best interest to ensure they have an unassisted birth rather than a midwife assisted birth?

Time and time again the medical community stood and described tragic outcomes they have seen, emergency situations that have occurred on their watch in the blink of the eye and how this demonstrates that births belong in hospitals – especially VBACs.

To all of those who stood I would ask this simple question: Have you ever seen a homebirth?

*crickets*
Why not?

Let’s compare and contrast for a moment…please. Indulge me.

Hospital births – deal with inductions, analgesics, anesthesia (epidurals), and many routine interventions that hinder the birthing process such as routine vaginal exams and in-and-out care providers as they care for 2-6 patients at a time.

Home births – one care provider (midwife) in constant presence with one patient in an unhindered unaugmented birth without interventions that increase risk.

OB_Epidural

An epidural – way too dangerous to do in a homebirth! But dangerous enough to restrict a woman’s right to choose one?

With all due respect to the members of the medical community who stood to speak out about the dangerous of homebirth because of what you’ve seen at your hospitals…. I agree with you!  The births as they occur in hospitals…I agree that *those births* are too dangerous to do at home!! That is why that is not our model of care. We aren’t bringing the risks into the home – we keep it as low risk as possible. Elective induction increases risk. (if it’s for medical reasons then it doesn’t matter where she intended to birth…she’d be in a hospital) Epidurals increase risk. Augmentation of the labor increases risk. (again, if it’s for medical reasons then the original intended place of birth is irrelevant as she’d be in the hospital being augmented) Having one care provider responsible for 3-4-5-6 people at the same time increases risk.  I think that the types of births you are used to would be INCREDIBLY dangerous to attempt at home!!

That is not what these mothers are doing.

I actually think that this argument is missing the point, however. We can argue all day about where it’s safest to give birth – but that diverts us from what I feel should be the TRUE discussion I think we need to be having….that is: when should a woman be allowed to choose risk? Do we respect woman’s autonomy when it comes to her body and her birth or not? She’s smart enough to choose an epidural and understand the risks/benefits that may come with that…but not smart enough to choose a VBAC and all of the risks/benefits that may come with that. We respect her enough to allow her to induce her 39 week pregnancy because her husband is being deployed overseas and wants to meet his baby before he leaves….but we don’t respect her enough to allow her to have a homebirth VBAC in the name of safety (and then will make it less safe by refusing to allow a care provider to be with her).

She can choose to ‘labor at home as long as possible”….but the thought of doing so with a midwife is somehow scary to them? Many CNMs and OBs have told VBAC mothers to just labor at home as long as possible to avoid many of the interventions of the hospital that they are hoping to avoid….so they are okay with that mother not getting to the hospital until pushing, but aren’t okay with that mother being monitored at home and just birthing at home because the risk of a catastrophic rupture is too great?

There seems to be this misconception in the medical community that what they see in hospitals is equal to what we are seeing in homebirths….and it’s simply not accurate. There are increased risks at every turn at the hospital, and we decrease those risks to the barest minimum at home. Lower infections due to less antibiotic resistant strains around a person’s home. Lower infections due to fewer invasive procedures like vaginal exams, breaking their water, episiotomies, and c-sections. Lower risk by providing one on one care. Lower risk by not introducing drugs into the process – either to induce or augment, or to provide pain relief.  We simply aren’t doing hospital births at home.

What you see at a hospital is NOT what we see at home…and our outcomes show that.

While I criticize you for not having any experience in homebirths before passing judgment – let me state that for 12 years I witnessed births exclusively in hospital settings. For 12 years I saw us introduce risk, then try and minimize what we just did. I’ve seen the hospital side and can truly understand why, if that’s all someone has seen, that they would be scared when they think of THOSE births being done in the home! But I would bet money that not a single “medical professional” who stood up to speak at the meeting had ever seen a homebirth.

ER2I also heard time and time again how hard it is on the medical professionals to receive the homebirthers who transfer to the hospital…how hard it is to see these “trainwrecks” (derogatory term, btw) come in ‘off the street’ and have to care for them. I ask you this….what other area of medicine has this complaint? Are there doctors in the ER complaining that they only see car drivers when they wreck? That they wish that the skier had called before taking to the slopes and not wait until they actually broke their leg? In what other area of medicine do they get upset at receiving the patient when there’s a problem?

None.

0NDRI4XH1emergencyEvery other area of medicine is expected to ONLY be there when there IS a problem! Obstetrics is the only time in our lives that we are expected to check ourselves into the hospital while totally healthy…the only area of medicine in which they complain when something goes wrong that you should have already been in the hospital. And that only happens during labor…because presenting to the hospital at 32 weeks for preterm labor doesn’t make them mad. Presenting to the hospital at 34 weeks because you are throwing up and can’t stop doesn’t make them mad. Presenting to the hospital at ANY OTHER TIME IN OUR LIVES when there is a problem doesn’t get them upset. The one instance is in labor. If you are in labor and present to the hospital because you have a problem then and only then they get upset because you should have been there sooner.

But my bottom line is this:
OLYMPUS DIGITAL CAMERAshireen2

 

 

 

 

I support a woman’s autonomy and respect her intelligence. I think that the woman should have the right to determine what level of risk she wants to assume when it comes to her birth. I think that the woman should be able to choose an epidural on demand or a homebirth. She should be able to choose an elective repeat cesarean or a VBAC at home.

At the beginning of this blog post I stated that we are all on the same team! We all want a good outcome!
I also believe STRONGLY that nobody wants a good outcome more than the mother does. Nobody. If she makes a decision – whether I agree with it or not – it is her decision to make. Why punish her? It’s not our family, it’s not our baby, it’s not our body. We should be there to help her…and make whatever she chooses as safe as it can be for her and her baby. She wants an epidural? Fine – but ensure a sterile field, good training for anesthesiologists, training for nurses dealing with epidural labors. She wants a homebirth VBAC? Fine – but ensure she has a trained care provider with her, monitoring her and the baby.

Who is this about? Is this about the medical establishment? About the midwives? How very arrogant we are to take that approach.
It’s about mothers and babies and families and I implore everyone to keep that in mind. Lets keep safety and respect foremost in our minds as we proceed forward. If the OBs and midwives fight and argue over territory then I believe they are demonstrating the biggest problem in obstetrics today – it’s not our territory to fight over. It doesn’t belong to either one of us – it belongs to the mother. Please, lets work together to make it as safe as it can be for her.

Empowering VBAC

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I just read this fabulous story from a mom that I have been in touch with on her journey to Vaginal Birth After Cesarean or VBAC.  I asked her if I could share because it is truly an empowering story.  I love that this mama knew what she needed and didn't hesitate to advocate for it, even when it meant signing out against medical advice.

In her own words….

I had my 40 wk appointment with midwife on 2 january.  I was 2 cm, 50%, and she thought she cold feel the seam presenting OA.  She swept my membranes and we discussed 40-42 week  management plan.  

On the early morning of the 3rd around 2 am, my membranes released.  I was having very mild contractions so I put a pad on and tried to rest as much as I could.  Around 7-8 that morning, contractions were still intermittent and mild so we ate breakfast and went on a walk.  That helped a little but not a lot so we went back home, put away the christmas tree, vacuumed, ate lunch and  I decided to call to check in with l and d where I happened to know my midwife from the previous day was on.  I told her I still wanted to do early labor at home which she didn't have a problem with.  I didn't ask how long ;) but she did tell me once I checked in, the only way I could leave was against medical advice…  The entire time after rom, I monitored my temperature, fetal heartrate and movement, drank a lot of water to keep the amniotic fluid flowing, and checked fluid for any odor as a precaution…

That night when the OB's came on, they had the L and D Nurse call to advise me to come in… I was very non committal about coming in since at that point I knew the midwives were gone for the night and that I was on the Docs clock….

Contractions pretty much stopped that evening so my partner and I decided to get one more "good" nights rest and then go in the next morning since we would have been about 30 hours ruptured at that point, and most importantly shift change would be complete and there would be a midwife back again ;) .

We got to the hospital around 830, still very mild contractions so I decided we should go for a walk to relax and get mentally prepared.  I started having consistent, more intense contractions on the walk while listening to hypno babies birth day affirmations, and after an hour of walking we decided it was time to go in.  We checked in around 945, confirmed rom and consulted with the midwife who said "you don't look like you're in active labor" which was pretty funny. We discussed options for stimulating contractions but opted to start with a nst and check.  The nst was fine, I was having contractions and baby was fine, and I was 4cm, 75% effaced, the midwife was glad that I had made some progress from the previous day.  She advised that I should be admitted with continuous fetal monitoring then asked what I wanted to do.  I told her that I wanted to leave Against Medical Advice and keep walking since that had really been helping.

At that point I knew we'd just be walking around the hospital or outside but that I wanted to be moving, so we went downstairs and tried to walk to Starbucks but I could barely make it a minute without having to stop for intense contractions.   

We made it to the end of a hallway where I sat and leaned forward on another chair for about 45 min of super intense contraction where I was sweating, nauseous, and completely zoned out.  At that point we let our doula, know it was time to join us.  I wasn't coping very well with the intensity but my husband just kept reassuring me that I was doing it.  At a certain point I started vocalizing with the contractions and involuntarily pushing a bit so I told my husband it was time to go back to L and D.

He got me a wheelchair since I couldn't walk, and I kneeled on it backward as he pushed me through the hospital, moaning with each contraction (i would have loved to see people's reactions to that in hindsight).  We got back to L and D and they wheeled me straight back to a room.  They helped me undress and get on the bed in a inclined kneeling position where the midwife confirmed I was 10cm with a small lip and told me to keep pushing!  

Baby was born 25 minutes later and I got to pick her up put her straight to my chest where she immediately latched like a champ! There was never time to even get an IV started and the nurse held the heartrate monitor the entire time by hand.  All newborn procedures were delayed and there was no pressure to deviate from any of the things we wanted like delayed cord clamping and letting the placenta deliver naturally (which it did 21 min later).

The placenta looked great, no signs of infection and she had apgar scores of 9, 9.  The peds were concerned about risk of infection and were surprised we were "let" to go so long with rom but our baby passed every check with no issues.

We're home resting and nursing and enjoying quality family time which is wonderful.

Milk: Not Just from Moms, Not Just for Mammals

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I recently realized that you can’t really have a milk mustache if you don’t have lips. I guess that means we won’t be seeing pigeons in any upcoming dairy ad campaigns- even though they make “milk,” and it functions like the milk of mammals.

by L. Lan Danny

“Pigeon milk” was first systematically described in the 1930s and continues to intrigue dairy scientists through today. Pigeon chicks (known as squabs) hatch in a relatively undeveloped state, but during the first days after hatching, they show accelerated development. During this time, female and male pigeons shed “milk” from the epithelial cells in their crop, an enlarged compartment in the gullet in which food is stored prior to digestion. This chunky substance is rich in fats and proteins and is regurgitated to provision the squabs (Davies, 1939). Pigeon “lactation,” as well as parenting behavior, is hormonally regulated by prolactin, as is the case in mammals (reviewed in Horseman and Buntin, 1996).
Tibi Puiu
The time course of pigeon lactation also parallels many mammals. There is a period of exclusive milk feeding of squabs, and an increase in milk “volume” until mid-lactation is reached, after which production volume subsequently decreases (Vandeputte-Poma, 1980). Like mammals, the duration of lactation varies considerably between individuals. Moreover, just as in mammals, pigeon milk does not only contain macronutrients, but also immunofactors and bacteria (Goudswaard et al., 1979; Shetty et al., 1990).
photo by April 
Recently, Gillespie and colleagues reported an experimental model that demonstrated new functional properties of pigeon milk in the gut of baby chickens (2012). The gut associated lymphoid tissue (GALT) is a critical interface between the immune system and the gut bacteria. Additionally, the GALT produces a significant portion of immunoglobulin A (IgA). IgA is a major component ofthe immune system interfacing with “unfriendly” bacteria in your mucosal surfaces (think nose, mouth, gut, lady parts). Feeding pigeon milk to chickens significantly altered gene regulation in the GALT, up-regulating >1500 genes and downregulating ~600 genes. As a functional outcome, feeding chickens the pigeon milk resulted in significantly greater IgA expression in the gut compared to controls (Gillespie et al., 2012).
Moreover, intestinal microbial composition differed between chickens fed pigeon milk compared to controls. Chickens fed pigeon milk had a greater diversity of bacteria, determined using 16S amplification, at the levels of phylum, class, order, family, and genus compared to control subjects. Lactic acid bacteria, important for inhibiting the growth of “unfriendly” bacteria (Jin et al., 2011), were more diverse in the pigeon milk-fed chickens. Sixteen different species were present compared to 12 in the control chickens. 


Pigeon milk may contain prebiotics that support the colonization of beneficial gut bacteria, although the authors did not directly investigate such milk constituents. However, the researchers did examine the vertical transmission of bacteria through milk. The presence of bacteria in the pigeon milk was correlated with the presence of the same bacteria in the intestine of the chickens that were fed the pigeon milk, showing that bacterial inoculation occurs through milk feeding as in mammalian species (Martin and Sela, 2012).
Importantly, Gillespie and colleagues used chickens rather than pigeons because crop milk is necessary for pigeon squab survival. There are seemingly no artificial formula options at this time for squabs. There is no more compelling evidence, to my mind, that crop milk serves critical functions in the newly hatched pigeon squab. 

purely gratuitous photo of baby monkey & pigeon

Further experimental studies in other bird models will illuminate the mechanisms by which milk causes chicks to thrive beyond immune function and bacterial colonization- such as hormones digested through milk. One very interesting avenue is that in placental mammalian milks, prebiotic constituents are complex carbohydrates (oligosaccharides), but pigeon milk contains very low levels of carbohydrates (Davies, 1939). However, technological advances in detecting and quantifying milk constituents have improved our understanding of pigeon milk composition and oligosaccharides have been identified in crop milk (Shetty et al. 1994).  

Fantastic Mr. Fox & Squab

These results from pigeons are similar to findings in mammals. Among mammals, mother’s milk influences intestinal immune development and influences microbial diversity directly through both the bacteria present in milk and containing constituents preferentially consumed by beneficial bacteria (Donovan et al., 2012, Neville et al., 2012, Martin and Sela, 2012). 

Taken together, the results from pigeon milk reveal what is known as “convergent evolution” between avian and mammalian milks. The production of milk independently arose after the divergence of avian and mammalian lineages over 300 million years ago. However, these milks seemingly serve the same function; body-nourishing, bacteria-innoculating, immune-programming substances produced by parents specifically to support offspring development. 
(possibly nsfw… depending on where you work)
CITATIONS

Davies WL. 1939. The composition of the crop milk of pigeons. Biochem J. 33(6):898-901.
Donovan SM, Wang M, Li M, Friedberg I, Schwartz SL, Chapkin RS. 2012. Host-microbe interactions in the neonatal intestine: role of human milk oligosaccharides. Adv Nutr. 3(3):450S-5S.
Gillespie MJ, Stanley D, Chen H, Donald JA, Nicholas KR, Moore RJ, Crowley TM. 2012. Functional Similarities between Pigeon ‘Milk’ and Mammalian Milk: Induction of Immune Gene Expression and Modification of the Microbiota. PLoS One. 7(10):e48363.
Goudswaard J, van der Donk JA, van der Gaag I, Noordzij A. 1979. Peculiar IgA transfer in the pigeon from mother to squab. Dev Comp Immunol. 3(2):307-19.
Horseman ND, Buntin JD. 1995. Regulation of pigeon cropmilk secretion and parental behaviors by prolactin. Annu Rev Nutr. 15:213-38.
Jin L, Hinde K, Tao L. 2011. Species diversity and relative abundance of lactic acid bacteria in the milk of rhesus monkeys (Macaca mulatta). J Med Primatol. 40(1):52-8.
Martin M, Sela D. 2012. Infant gut microbiota: developmental in fl uences and health outcomes? In: Clancy KBH, Hinde K, Rutherford JN (eds) Building babies: primate development in proximate and ultimate perspective. Springer, New York 233-258.
Neville MC, Anderson SM, McManaman JL, Badger TM, Bunik M, Contractor N, Crume T, Dabelea D, Donovan SM, Forman N, Frank DN, Friedman JE, German JB, Goldman A, Hadsell D, Hambidge M, Hinde K, Horseman ND, Hovey RC, Janoff E, Krebs NF, Lebrilla CB, Lemay DG, Maclean PS, Meier P, Morrow AL, Neu J, Nommsen-Rivers LA, Raiten DJ, Rijnkels M, Seewaldt V, Shur BD, Vanhouten J, Williamson P. 2012. Lactation and neonatal nutrition: defining and refining the critical questions. J Mammary Gland Biol Neoplasia. 17(2):167-88
Shetty S, Sridhar KR, Shenoy KB, Hegde SN. 1990. Observations on bacteria associated with pigeon crop. Folia Microbiol (Praha). 35(3):240-4.

Shetty S, Salimath PV, Hegde SN (1994) Carbohydrates of pigeon milk and
their changes in the first week of secretion. Arch Int Physiol Biochim Biophys
102: 277–280
Vandeputte-Poma J. 1980. Feeding, growth and metabolism of the pigeon, Columbia livia domesticus Journal of Comparative Physiology. 135: 97–99.

An earlier version of this post appeared in SPLASH! Milk Science Update.

I Gave Birth in an Airstream!

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Thank you so much to Mindy Poor for the link to her incredibly beautiful birth story in an Airstream Travel Trailer. She is my hero and fulfills the true meaning of homebirth!

Birth is empowering!