vaginal birth

More on the Microbiome, Birth and How To Get Your Baby The Good Goop That Live On You

Here’s another great piece about the way childbirth affects a baby’s microbiome (the bacteria that live on and in her), this time an essay by a microbiologist who was all prepared to “inoculate” her newborn if a c-section was necessary.  Inoculate, here, means:  ”take some vaginal discharge and swab the baby’s mouth and nose with it to try to replicate what the baby would have been exposed to during birth.” Check it out.  For more on this topic, see here and here.

The Straight Poop

I’m sharing today’s post from Brain, Child’s new blog for several reasons:

  1. Because it is a hilarious short piece about pooping during childbirth, which also involves a brief misunderstanding about whether the author’s midwife reached orgasm during the labor.
  2. Because Brain, Child is an excellent magazine you should all subscribe to if you are interested in thinking and parenthood.  (I thought this long, long before I had an essay published in it).
  3. Because it fascinates me that this woman took a childbirth class where Pooping During Pushing only came up incidentally and quietly and kind of indirectly.  Did her teacher say “fecal matter”? Ladies, come to my class and we will be real and talk about All The Things. 
  4. Speaking of which, here’s the real scoop on the poop: 

 If you’re pushing something large down the birth canal (i.e. your baby), in all likelihood you’ll also push some stool out, too.  The same muscle groups control all the exits down there. You’ll probably squeeze some pee out, too, while we’re mentioning Things. 

You might not even know it happens:  If you have pain medication, you won’t feel it; if you don’t have pain medication, you may have so much sensation that you don’t particularly register a bit of poo on top of everything else.  In both cases, if your partner isn’t looking, s/he may not see your midwife or doctor wipe it away briskly.  She will wipe it away quickly because she, like the rest of us, does not want to hang around beside a steaming pile of poo while we wait for the rest of your baby to emerge.  This may be what happened in the author’s first two births. 

The thing is, it’s really all OK.  This is not a parenting fail, at all.  At all.  In fact, to the contrary: I hate to gross you all out even more, but it’s actually really OK if a tiny bit of poo is on your baby.  Think about it people:

  • lets say no actual visible turd emerges.  Do you really think that your anus is sterile?  If your baby is born with her nose essentially pressed against your butt hole, she is going to get some particles of poo on her no matter what you do.
  • What is in that poop?  A whole lot of your gut bacteria.  And yes, it goes up your baby’s nose and possibly into her mouth, and from there it gets into her gut.  And that (plus her trip through the birth canal, where, to be clear, your vaginal microbes get on and into her) is what helps “colonize the infant gut with protective microbes” (translation: all the good-guy germs that live inside your tush and vagina go into her nose and mouth and then start growing inside her). And this, despite the lemon face you may have just made, is a very good thing. These great, helpful, protective gut bacteria keep her healthy, protect her against infection, regulate the immune system, and neural development, and apparently affect her metabolism for the rest of her life.  In short, it may be one of the best things you ever do for her!

As my great friend, certified childbirth educator Ceridwen Morris says, “It’s not a mistake that human babies are born with their face an inch away from their mother’s asshole.”  Chew on that for a while.

UPDATE, 5/16/13:  This excellent article in this weekend’s NY Times Magazine discusses the importance of gut bacteria and the “fine patina” of poop that, for better or for worse, coats basically everything.  It’s an awesome piece, but even the intrepid Michael Pollan glosses over the birth-poop-connection.  He says:

Most of the microbes that make up a baby’s gut community are acquired during birth — a microbially rich and messy process that exposes the baby to a whole suite of maternal microbes. Babies born by Caesarean, however, a comparatively sterile procedure, do not acquire their mother’s vaginal and intestinal microbes at birth.”  

It’s a funny world when you can have a feature article about how important your poop-bacteria are, but not be clear that Vadge-And-Butt-To-Nose-Transfer is where it all begins.

More about germs! Yay germs!

Yesterday I blogged about the importance of gut microbes, and recent news showing that birth mode (vaginal vs c-section) and infant feeding (breastmilk vs formula) affect babies’ development of good bacteria for long term health.  Today there’s another piece about this in the Times.  The article covers a Canadian study which found, again, that babies born by c-section and those who don’t have a breast milk diet have less protective gut bacteria at four months old, and more of the harmful germs that make you sick.  The authors of the study believe that this is a pathway for various autoimmune problems in older people.  

You can read the full study here.  I don’t love this study because the total number of infants is low.  More importantly, it, like so many studies that start to examine the nursing relationship, doesn’t really clarify what “breastfeeding” means.  They differentiate “formula feeding” from “exclusive breastfeeding” and “partial breastfeeding” at the time they took the samples, but there’s no apparent guidance about how to use those terms. My concern is that without good definitions, we can’t properly interpret the results. For instance: if a baby was given one bottle of formula on day 1 in the hospital (as so many are) but went on to have nothing but breast milk for the next many months, is that baby “exclusively” or “partially” breastfed?  If we are looking at the effect of early exposure to nonnatural microbes, it seems wrong to compare that baby to one who has had nothing but breast milk from birth.  But if we are looking at whether a protective effect of breast milk is dose-dependent, it seems wrong to lump that baby in as “partially” breastfed with another who has had half breast milk and half formula for four months. These distinctions are rarely made in studies that purport to look at the ways infant feeding affects health outcomes.  But if we’re going to learn anything real, we need to look closely at what it is we’re trying to study. “Breastfeeding” isn’t just one thing.

Germs are Great

If you’ve talked to me in real life for more than five minutes this year, you already know that I am currently obsessed with bacteria.  

I’m not a germophobe — quite the contrary: a host of new research shows that “good guy” bacteria — and there are billions of them on us — are extremely important in keeping us healthy.  I blogged about this  about a year ago after a report came out indicating that babies born by c-section are twice as likely to be overweight later in childhood.  Apparently, the difference is that since those babies didn’t go through the birth canal, they weren’t exposed to the good bacteria that live there, which “paint” a newborn’s skin, and get into her nose and mouth (and down into her gut) in a vaginal birth.

More recently, an article in the New York Times outlined how bacteria may also explain why breast-feeding may be protective against celiac disease and gluten intolerance:  probiotics (“good guy bacteria”) in breast milk, and pre-biotic oligosaccharides in breast milk (sugars in breast milk that exist not to feed the baby but to feed the good-guy bacteria that live in her gut) apparently help protect an infant’s gut from developing an inflammatory autoimmune response to gluten.

So, and here, today is another good piece, at Double X Science, called The Vaginal Ecosystem, which talks about changes in the bacteria that live in your birth canal during pregnancy.  The plain language explanation is:  the goo that lives in you changes while you’re pregnant because your body knows that a baby will be passing through and he’ll need to get a good coating of all your good gunk to get the best start in the world.

I guess the idea that you’re covered in germs (and that that’s a good good thing) is gross to some folks, but I think it’s awesome.  Truly, you’re the Mother Ship, and your crew are the billion germs that keep you in good condition. Go hug and kiss your kid: he’ll be all gooped up with your protective good-guys!

Why The C-Section/Obesity Study Makes Me Feel Reverence for Bodies and Bacteria and Even, Kind of, Poop

In the past few years, I’ve become fascinated with “good guy” bacteria — the bugs that live on and inside us, and keep us safe from disease and infection.  It’s kind of awesome that we’re home to zillions of microbes.  You’re a walking Starship Enterprise and the crew is doing maintenance and defense work on you even as we speak!

(Let me pause and say that if that concept make you a little squeamish, you may find the rest of this blog post grody).

Along these lines, I was fascinated to read of a recent study which concluded that gut bacteria may be the reason that babies born by c-section are twice as likely to be overweight later in childhood, compared with babies born vaginally.  The study, in the Archives of Disease in Childhood, found a large disparity in childhood obesity rates between kids born by c-sec and those born vaginally, even after considering other factors such as mother’s weight, baby’s size and the length of time they were breastfed.  

We already knew that babies born by c-section have an increased risk of post-birth infection vs. babies born vaginally, in part because of good-guy bacteria:  as babies travel through the birth canal, and all the good bacteria that live there (yes, your vagina is filled with bacteria! It protects you from illness) coat the baby’s skin, providing your baby with an initial coating of anti-germ protection even as he’s being born.  (A baby born by c-section on the other hand, comes out of the sterile amniotic sac, directly into a germ-filled operating room.  Germs that cause illness have the opportunity to colonize his skin before mom’s good anti-sick bacteria can colonize and protect him.  This is why skin-to-skin contact is especially important for babies born surgically — frequent contact helps the baby get a nice coating of protective bacteria from the “Mother Ship.”)

So, but here’s how this plays out with the obesity thing.  Apparently the presence or absence of different gut bacteria play a role in how we use energy, respond to insulin and lay down fat.  And babies born by c-section have different gut bacteria than those born vaginally, even years later.  Why? 

Take a step back.  There’s bacteria in your gut, right?  What happens to it?  Mostly it lives inside you.  Also, some of it comes out when you poop.  So, you can find traces of it around your bottom.  Pan the camera back and let’s think for a minute about how babies born vaginally could come into contact with their mom’s gut bacteria?  As a another childbirth educator once quipped, “it’s not by accident that babies are born with their face an inch from your asshole.”  They’re designed, apparently, to meet that part of you first so they can get exposed to your gut bacteria and, yes, ingest some (microscopic) amount, so it can colonize their gut.  And that is apparently going to help them for the rest of their lives.  Next step for the newborn is to be placed on mom’s belly, where he can get colonized with her external, protective skin bacteria, and after that onto mom’s breast where the colostrum in her breasts is filled with immune factors so that with the first swallow her body tells him:  “all the stuff you were just exposed to is harmless for you, so don’t use your energy mount an immune response to any of it; you can use your energy to grow, stabilize temperature and sugar, and get acclimated, not for defense.”  Her breastmilk also contains pro- and pre-biotics to further colonize his gut and protect him from the inside.

I think this is kind of awesome.  Not the image of a baby with her nose in your rear end — sure, that’s kind of eww-y when you stop and think.  But what’s totally magnificent to me is the way our bodies are designed to do this right.  There are so many small things, invisible until we study them, which turn out to have tremendous lasting significance.  

What can you do?

Don’t feel bad if you had a c-section, that kind of backward-focus doesn’t help.  If you had a c-section, focus on behaviors that lean against any increased potential for obesity; we should all do that anyway.   C-section can be a very, very important surgery, and when it’s medically necessary, it is a tool we are very lucky to be able to use, and to have such phenomenally good results from most of the time.

But what we all can do, I think, is maintain a kind of reverence for the body, and remember that no matter how sophistocated we are, and how good our technology, how advanced our medications, and how grateful we are for the way they save lives, nothing we can invent compares to the complicated beauty and grace of a functioning human body. 

There is much we do not understand.  When it comes to a body that is healthy, we should be very reserved about elective surgeries.  And we ought to manage labors to minimize the likelihood of c-section, not just for all the reasons we know, but, even more, for the reasons we don’t know yet.  

UPDATE, 7/13/12:  Here’s a great article exploring the science of this issue, from Science and Sensibility.  

Consumer Reports: What To Reject When You're Expecting

This article from Consumer Reports is a great piece on the ten most “overused” procedures in childbirth:

1. C Section in low risk first birth

2. Automatic repeat C Section

3. Elective early delivery

4. Induction without medical reason

5. Ultrasound after 24 weeks

6. Early epidural

7. Continuous electronic fetal monitoring during labor

8. Routine artificial rupture of membranes (“breaking the bag of waters”)

9. Routine episiotomy

10. Sending baby to the nursery

The article, of course, goes into greater detail about how each of these is overused and what the alternatives are.  I like this piece because it’s a great reminder to everyone of a few really crucial points

1. When you’re there, in the hospital in labor?  You’re still a consumer, and entitled to excellent customer service.

2.  Health care is a product we pay for and it is important to think about whether each thing you do is necessary/worthwhile.

3.  You, as an adult, are competent to evaluate whether you need an induction/episiotomy/c-section/ultrasound, just like you evaluate whether you need the other things you pay for.  You don’t need to be a medical expert to do this.  You do need a medical expert *with you* to talk you through the benefits/risks/alternatives, but after that the decision is yours. 

4.  Not all of the things that doctors do routinely are helpful or necessary.

Ask questions.  Get to know your caregiver.  Be the customer.  Get good care.

Ina May: "I wasn't raised to think I was inferior to an animal"

Last night I went to a great event hosted by CEA/MNY — a discussion of modern maternity care between the awesome Jennifer Block and Ina May Gaskin.  

I can’t do justice to the whole event, which was so interesting, but I was particularly struck by the way Ina May described getting interested in birth in the first place.  She reported that when she was pregnant with her first child in the mid-1960s, she went to a doctor and was told she would have medication to knock her out, and a “forceps birth.”  When she asked why it was then-standard practice to extract all babies by forceps, the doctor told her that it was because “all” first-time moms had an “iron-hard” pelvic floor, which the baby would destroy like a “battering ram” unless a doctor cut her perineum and pulled the baby out.

A doctor who talks that way, whether it’s 1966 or 2012 is clearly trying to scare his patient out of further discussion, not provide guidance and counseling and safe, compassionate health care.  

Here was Ina May’s reaction at the time:

"I didn’t know about that.  But I did know I didn’t have any parts that were iron hard.  But I didn’t know that you could fire — should fire — a doctor who says something crazy."

Ina May was inspired by her own common sense — not at first (she did, apparently have the knocked-out-forceps birth that time), but later, after she became a mother, she became inspired to reevaluate the care she and others were receiving, and make dramatic changes.  

She began to think about medical advice and “what people said” about birth not only at face value, but in terms of whether it made sense to her.  She knew that “iron hard” does not sound like a description of any part of a woman’s body, and instead of concluding “I must be wrong about my body!” she began to explore the other possibility — maybe the person saying this is wrong, even though he is a doctor.  

And if so, then what?

The answer is, then I owe it to myself to to find (and ultimately, for Ina May, to provide) care that does make sense.

It’s inspiring.  At one point, Ina May added that another point of inspiration for her was that she had been “an English Major in college.”  Everyone laughed.  

She described how reading Tristram Shandy got her thinking about midwifery care.  Her point was not that reading 18th century literature is all you need to be a caregiver. Her point was that you don’t have to be a doctor to have a thinking cap.  Ina May felt confident that the intellectual gifts that served her in the rest of her life would help her understand enough about maternity care to make competent decisions for her own body’s care.  

You don’t have to become Ina May and start a Farm and catch 3000 babies in 40 years and become a birth guru.  But we can all take action in our own lives by insisting, with ourselves, that when it comes to the care of our bodies, that we use the common sense and intelligence we bring to everything else.  Birth (and breastfeeding, and motherhood) is not so haunted and mystical and weird and shameful that common sense and intelligence don’t apply. 

And when it feels too daunting to do that yourself, let that be a sign to you that you’re not supposed to figure all this out alone.  Childbirth classes, mother’s groups, breastfeeding support — all of these things exist to help you find the kind of care that will help you feel cared for while you do the transformative hard work of becoming a parent (or becoming a parent again!)

Childbirth is Natural

     Back in the 1970s, a lot of oat-filled snacks appeared in my lunch box, labelled: “all natural,” “naturally sweet” etc.  At the time, we all thought we were sort of virtuous and extra healthy for eating these. 

     The thing is, “natural” didn’t, apparently, mean anything on food labels; it was just a phrase marketers realized people like.  Granola bars had as much sugar as cookies, though we all thought of cookies as “dessert.”  When I learned that the phrase meant nothing, I felt a little cheated.  After all, the granola bars claimed to be from Nature’s Valley!  

     But then I thought — isn’t any valley just a natural formation between hills or mountains?  Are there unnatural valleys?

     The funny thing is, it’s the same thing with childbirth.  When I’m teaching, invariably a student will use the phrase “natural childbirth,” either to say, “I want a natural childbirth” or “I’m not interested in natural childbirth.”  

     We all know what it means.  And yet, it’s just as empty as the granola bar packaging, and I dislike it just as much, and I suggest we stop using it altogether.

     Because isn’t all childbirth natural?  

     What could be more natural than reproducing?  For adult women who like men, reproduction is so natural that you have to work to avoid it.  Whether you’re partnered or not, your body prepares for pregnancy a dozen times a year.  If you get pregnant, the natural culmination is birth.  Somehow, whether it’s a vaginal birth or a c-section, spontaneous labor or induction, pain medication or no, the natural conclusion of the labor is that the baby comes out.  

     I said “we all know what it means,” but that’s not exactly true either.  Sometimes people use “natural” childbirth to mean “no c-section,” and it’s just a way of avoiding the word “vaginal.”  

     Here’s the thing about that:  I do know that regular people who aren’t childbirth educators aren’t, usually, comfortable with the word “vagina.”  And I remember, when I was a lawyer, one time when the guy in the office next to me (who had overly-long greasy hair and a chronic post-nasal drip, so I’d hear him hawking phlegm, daily, as he berated first-year associates with the door open) told me about his wife’s birth and managed to say “vaginal” eight times, gratuitously in the span of two minutes.  

     The image of him schnuffling beside his wife and her vagina — eight times — was really gross, and I felt, distinctly, that the point of this, for him, was that he got to say “vagina” eight times to the cute, young associate next door, which pretty much sums up why I didn’t like the practice of law, butanyway.

     Still, in truth, if he’d said “natural” it wouldn’t have been much better.  My objection was to him and his slavering TMI, not to the word “vaginal.” 

     So, I get it on the “vaginal” birth thing, but, hey folks, get over it.  Say it quickly, or just say, “I gave birth,” and lets have that mean vaginal birth without having to talk about your Nether Regions.  It might help us remember that c-section is supposed to be a last resort.


     Some people use “natural” to mean “no pain medication,” but that’s tricky, too.  The idea is that a woman who relies on her own internal coping tools is closer to “nature” than someone who gets an infusion of chemicals injected into the epidural space.  But both women — all women in labor — naturally respond to pain by looking for *some* way to cope with it.  A woman who doesn’t use medication isn’t more stoic, she is just using different, non-chemical tools to get through the labor.  It is natural to look for pain relief.

     And the meds argument is tricky:  If you have Pitocin but no epidural, is it natural?  

     Suppose you have no medication at all, but you have IV fluids because you were dehydrated at the beginning of labor?  Natural? 

     Suppose you go into labor on your own labor at home in the tub and using massage and stuff, and, after 4 days of labor, are still a few centimeters dilated and request a c-section because you’re too exhausted to carry on?  Unnatural?  To me, the natural response to exhaustion is to look for something to help you deal.

     And, on the other hand:  suppose you planned to have an “all natural” birth but your placenta is completely previa and there’s no option besides surgical birth.  Do you lose your all-natural status?  Points for having wanted it?


     I hate the way “natural” can sound like a badge of honor: “She went all natural!  If “natural” is good, it seems like all the women whose labors don’t fit into the “natural” box are less entitled to bask in the accomplishment of having made it through a pregnancy and, somehow, gotten a baby out.   And that’s unfair.

     And I hate the way “natural” is, sometimes, a dis.  I don’t feel the need to do it all-natural,” some folks say, as though “natural” means “martyr.”  It’s not being a martyr to rely on non-medical tools for pain.  It’s not selfish.  It’s not a birth fetish.  It’s not crunchy/granola.  People have different ways to deal with pain, period.  


     In the end, though, it’s all meaningless – “natural” doesn’t mean any more in the birth world than it does in food labelling.  All valleys are natural, but that doesn’t mean you’re in the mood for a granola bar today, right?  Childbirth is natural too.  

      Here’s what’s unnatural:

  •  Being pregnant and not having any curiosity about what is going to happen at the end. 
  • A healthcare system that treats women like they can’t comprehend labor unless they are doctors, or probably aren’t smart enough to make good choices for themselves. 
  • Maternity care that is routinely managed in a way that leaves many women thinking their bodies don’t work properly. 


Instead of talking about “natural childbirth,” lets do this:

      When you’re pregnant, become educated about the physiology of labor, about medical tools available to address problem situations, and about all manner of ways to deal with pain.  You do not need an advanced degree; a high-quality prenatal class will suffice.  As you approach the birth, make sure you have access to at least one gentle, loving support person besides your caregiver, to be with you in labor and help you navigate your birth.  

      Afterwards, if you don’t feel like talking about the birth, don’t.  But if you do, I suggest that you say “I gave birth,” to mean a vaginal birth, or “I had a c-section,” if you did.  If you used pain medication and would like to talk about it, say, “I had an epidural,” (or fentanyl, or whatever), and if you didn’t use medication and would like to talk about it, you can say, “I didn’t use pain medication,” or “I had an unmedicated birth.”  If you’d like to add other info, you can do so specifically.  

      Does this sound wordy?  It is.  Childbirth is intimate and private and a big deal.  Your experience of bringing a child into the world and becoming a mother is more than can be captured in any two-word phrase.  You don’t need to tell anyone your personal business.  But if you want to, it’s OK to tell the story.