maralyn foureur 2011 home birth conference

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TOMORROW’S PARENTS

Home Birth Aotearoa National Conference

October 28-30 2011

Creating Optimal Birth Space

MARALYN FOUREURPROFESSOR OF MIDWIFERY

UNIVERSITY OF TECHNOLOGY SYDNEY

EPIGENETICS, OVERWEIGHT AND OBESITY

Maralyn FoureurProfessor of Midwifery

University of Technology Sydney

AIM:

To explore how the birth environment influences childbirth, parenting and our

future health

THIS REQUIRES US TO ENGAGE WITH…

Research evidence from cross disciplinary scientific traditions (behavioural & biological sciences)

Research conducted across species Rodents – mice, prairie voles, rats Sheep Primates Humans

Using a range of research methods Aided by new tools such as fMRI, PET scans & the New Science of Epigenetics

IDENTIFYING PATTERNS

Developing Theory Hypothesis generating Research stimulus

Putting together pieces of a puzzle (Product warning – allresearch has limitations)

Optimal Birth Environment

Relationship based maternity care

Calm & Connect System

Optimal Oxytocin

Lowers BP, Heart

rate, decreases pain

Normal Birth

+

OPTIMISING BIRTH PHYSIOLOGY

3 stories1. Epigenetics2. Oxytocin3. Our need to feel safe

RECENT REVOLUTION IN SCIENCETHE CENTRAL DOGMA OF MOST SCIENTIFIC ACTIVITY FOR THE LAST 150 YEARS HAS BEEN CHALLENGED…

Darwin’s Theory of Evolution … we inherit all of our characteristics from our parents… Is NOT entirely right!

THE REVOLUTION BEGAN WITH THE DISCOVERY OF DNA

Watson & Crick 1953

DNA Controls All of life – genes are subunits of strands of DNA

A PARADIGM SHIFT BEGAN IN 1980S Human Genome

Project Looked for

120,000 genes to account for all the complexity & diversity of life

But found human genome only consists of 30,000 genes

About the same as a fruit fly

Forced to conclude that genes do NOT control life- so what does????

Genes are being switched on or silenced by signals from outside the genes-from the environment

Through a process called Methylation or Demethylation ++

EPIGENETICS DESCRIBES A CONTROL - ABOVE THE GENES Environmental

influences including:

Stress = Feeling unsafe/threatened

Emotions Nutrition Toxins

Can modify genes without changing their basic blueprint

EVIDENCE FROM PERINATAL RESEARCH

1. The Agouti Mouse2. Stressed Pregnant Rats3. Genetically Engineered Mice

Large population based Studies in Humans

STUDY 1: THE AGOUTI MOUSE

Prone to Obesity, Diabetes, Cancer, Early Death

THE AGOUTI GENE CAN BE SILENCED…

Pregnant Agouti fed a diet rich in soy extract, folate, B12…

-will have babies who still have the agouti gene but are otherwise normal

STUDY 2: STRESSED PREGNANT RATS…

Abused and neglected their pups

Pups developed epigenetic modifications to their DNA

Pups grew up to be poor mothers

3RD GENERATION EFFECTS

And passed on these changes to the next generation of offspring

STUDY 3: ITS NOT ALL BAD NEWS…TRANS-GENERATIONAL EFFECTS ON BRAIN’S PLASTICITY

1. Mice genetically engineered to have a memory defect

2. Placed in an enriched environment

Memory improved

3. Offspring of those mice - who had the same memory defective gene - also had an improved memory

SO WHAT HAVE WE ENCOUNTERED SO FAR? Gene mutation can

cause obesity, diabetes and cancer

Changes to diet can silence the gene mutation from being expressed

Maternal Stress during pregnancy can alter the structure of the DNA (gene expression) in the unborn offspring

The changes to the gene expression result in behavioural changes in the offspring

Changes to the gene expression can continue to occur across generations

An enriched environment can overcome changes in the genes

EPIGENETICS = CONTROL ABOVE THE GENES Environmental

influences including:

Stress = Feeling unsafe/threatened

Emotions Nutrition Toxins

Can modify genes without changing their basic blueprint

ASSOCIATIONS BETWEEN STRESSFUL PERINATAL EXPERIENCES AND LATER LIFE EVENTS

Identified in population based studies with humans

naturally occurring experiments

Obesity Diabetes Cardio vascular

disease Autism spectrum

disorders Schizophrenia Psychotic disorders Drug Dependency Suicidality

Therefore we need to pay attention to the birth environment…

Giving birth is a feat of almost cataclysmic stress

Mediated by Endogenous Oxytocin

2 MAIN REASONS FOR ALL INTERVENTION DURING CHILDBIRTH-ONCE LABOUR HAS BEGUN

Uterine inertia (failure to progress) Fetal distress

Why is this so???

THE FEAR CASCADETHEORY

Oxytocin

Catecholamines

Uterine contractions

Catecholamines

Uterine inertia Fetal Distress

Constricts blood vesselsdecreases

Uterine blood flowPlacental perfusionFetal oxygentation

Feeling Unsafe

Stress

IS THERE ANY EVIDENCE TO SUPPORT (OR CHALLENGE) THE THEORY…

Sosa, Klaus and Kennel 1986 Social Security Hospital-Guatemala Continuous presence of supportive

companion = shorter labour & less intervention

? Oxytocin secretion not disrupted by fear induced adrenaline

PERINATAL ENVIRONMENTAL DISTURBANCE

Research conducted on the mouse!

1968Niles Newton

1968

LABOURING UNDISTURBED – A SERIES OF EXPERIMENTS

Created hostile birth environment Significantly fewer mice give birth

in hostile environments Disturbed mice have longer

labours Delivery initially slows - then

becomes precipitous to empty the birth canal

Pups of continuously disturbed mice more likely to be found dead-suggests fetal damage occurred in utero

•“...are mammals with more highly developed nervous systems than the mouse equally sensitive to perinatal environmental disturbance?

•...what effect if any do variations between home and hospital environments have on the course of labour and on perinatal mortality?”

Studies in primates

CATECHOLAMINE RESEARCH

Injected adrenaline directly through the mother’s abdomen into the fetus - had no effect other than increased

heart rate

However when injected into the mother - Induced fetal asphyxia and acidosis

Postulated this was due to vasoconstrictor effect of adrenaline leading to impaired uterine blood flow

More recent studies in pregnant women

MATERNAL ANXIETY ALTERS THE BABY’S

INTRA-UTERINE ENVIRONMENT

Anxiety is associated with increases in uterine artery resistance index

Blood flow to baby is reduced May effect fetal development May initiate premature birth Associated with baby who is small

for gestational age Possibly alters neuro anatomy &

impacts later behaviour

FEAR CASCADE IS PLAUSIBLE…THE ANSWER IS TO PREVENT IT BY…

Providing women with continuous labour support so that fear does not take hold…

Providing women with fear reducing birth environments that…

Prevent disruption to oxytocin secretion = normal labour will happen

THIS WAS ONLY PART OF THE PUZZLE…CATECHOLAMINES & OXYTOCIN HAVE MUCH MORE COMPLEX ROLES TO PLAY…

New scientific discoveries have now made it possible

to understand more…

BIAS IN STUDIES OF STRESS REVEALED…

Most research conducted with male subjects

Studies with females yields inconsistent data

? Cyclical variation in neuro-endocrine response the only reason.

Studies of oxytocin reveal another explanation

OUR BODY HAS THREE PHYSIOLOGICAL BALANCING SYSTEMS

•Fight OR Flight

•Freeze System

•Calm and Connect

OPPOSITE REACTIONS Fight, flight Increased heart

rate Elevated BP

Increased blood to muscles

Extra fuel from release of glucose from liver

Higher level of stress hormones

Calm & Connect Lowered heart

rate Lowered BP Increased

circulation to skin (rosy cheeks)

More effective digestion, nutritional uptake and storage

Lower levels of stress hormones

FEMALE RESPONSE TO STRESS DIFFERS FROM MEN!

Not predominantly - fight or flight or freeze

More likely to be the oxytocin mediated - calm and connection/tend and befriend response (a desire to affiliate with others -more adaptive)

Taylor, Klein et al, 2000

OXYTOCIN

Is the key to the calm and connect system Involved in much more than contractions of the uterus and in breastfeeding Oxytocin is the major orchestrator of the neuro-endocrine system

We are just beginning to discover how important it is and why protecting & promoting normal birth is essential for our survival

OXYTOCIN

Is a neuro-hormone Secreted by the BRAIN as well as in

different sites in the body Influences BEHAVIOUR generally - as well

as having localised impact on different body systems

NILES NEWTON DESCRIBED OXYTOCIN AS...

The love hormone

Much research has confirmed this – starting with...

The Prairie Vole

OXYTOCIN HARD TO DO RESEARCH ON – DOES NOT CROSS BLOOD BRAIN BARRIER

Need to access oxytocin in the brain Can be blocked by antagonists injected into

the prairie vole brain Stops taking care of its pups – stops

breastfeeding- rejects its mate Remove the antagonists – starts nesting

again

PRAIRIE VOLE & OXYTOCIN

Oxytocin – secreted during sexual activity

Female and male orgasm Labour Birth-fetal ejection reflex Placental ejection reflex Breastfeeding Touch- massage and stroking Eating

OXYTOCIN INITIATES LOVE

The Ewe and the Lamb….

OXYTOCIN INTEGRAL TO ATTACHMENT Sheep bond like glue within one hour of

birth if separated at this time – will not ever bond

Introduce oxytocin directly into the brain – the ewe will bond instantly with any lamb it is shown-

or use vaginal stretching –’dildo’ – stimulates oxytocin release = bonding!

Epiduralised ewe will not bond with lamb

THE BRAIN AND THE GUT ARE LINKED

Suckling releases oxytocin in the lamb’s brain and cholecystokinin in the lamb’s gut

Block either oxytocin or cholecystokinin and you interfere with the lamb’s ability to bond to its mother

KERSTIN UVNAS-MOBERG - SWEDEN

Research with pregnant and lactating women/babies and their midwives

Karolinska Institute

OXYTOCIN IS ANXIOLYTIC – CALMING AND INCREASES SOCIAL INTERACTION

Breastfeeding women more social and less anxious than non breastfeeding

Personality changes persist up to 6 months after birth

Onset is more rapid in multiparous Higher the level of oxytocin the more

calm and social the mother BP lowered short/long term depends

on length of time spent breastfeeding

OXYTOCIN IMPACTS ON EVERY AREA OF THE BRAIN

Enhances nutrient absorption Reduces stress-anxiolytic Increases pain threshold Conserves energy –Induces sleep Reduces blood pressure and heart rate –

short and long term Balances body temperature Enhances social memory Improves learning ability Facilitates affiliative behaviour – love and

altruism - attachment

ENDOGENOUS OXYTOCIN CAN BE INDUCED…

In social situations by tone of voice By a pleasant approach/ authentic smiles

with crinkled skin around the eyes Caring/Comfort Touch, hugging, cuddling, grooming By having a meal with friends-around a

table By Imagining pleasant things By viewing nature and scenes/objects of

beauty Involves every sense modality, smell,

taste, sight, hearing, feeling, dreaming

TOUCH ACTIVATES OXYTOCIN Mothers secrete oxytocin when they stroke

their babies Rhythmically – 40 beats per minute Animals lick at the rate of 40 bpm Warm pulsing water has the same effect Underlying physiology of kangaroo care Skin to skin contact increases rate of

growth of neonate Oral simulation-internal touch (non nutritive

sucking) – activates oxytocin - calming

DISTURB OXYTOCIN - CONSEQUENCES Epidural – mother less calm & less close

to baby at least one day after birth Large amount oxytocin to induce labour

stimulates vasopressin has anti-diuretic effect = fluid retention

risk of pph increases breastfeeding impaired In the long term suppresses

endogenous oxytocin

Animal studies have found artificial oxytocin alters neuro-anatomy and subsequent behaviour

PATTERNS EMERGING Women with high anxiety levels Have low oxytocin levels

Children with recurrent abdominal pain have extremely low oxytocin levels

Recurrent abdominal pain is a classic symptom of anxiety in children

BIOLOGY IS NOT DESTINY

Genetic blueprint is plastic Environmental variations switch on

and/or off parts of the genome resulting in a variety of outcomes

Oxytocin, endogenous opioid mechanisms & estrogen are not the only neuro-hormones that play a role in behaviour – future research will reveal more

COMPLEX INTERPLAY BETWEEN GENES AND LIFE EXPERIENCES

Disturbing normal neuro-hormonal responses during labour –disruption to endogenous oxytocin MAY have epigenetic consequences

WE NEED TO CREATE ENVIRONMENTS WHERE-

Women feel connected to their careproviders, calm, confident in themselves, have trust in- and- are trusted by, their caregivers

Spaces where women feel SAFE

WE NEED TO CREATE ENVIRONMENTS THAT…

Prevent disruption to normal oxytocin secretion

Decrease maternal anxiety

Increase likelihood of normal birth

Increase likelihood of long term health of baby

WHERE WOMEN FEEL WELCOMED…

AN INVITING COMFORTABLE ROOM: ‘LIKE A CAVE’

WHERE WOMEN ARE INVITED TO BE ACTIVE

....AND TAKE UP A VARIETY OF POSITIONS

OPTIMAL BIRTH ENVIRONMENTS DEMONSTRATE…

Attention paid to every aspect of the environment and how it impacts the emotional mindbody through our senses

Smell Touch (feeling and moving) Hearing Seeing Tasting Dreaming

Optimal Birth Environment

Relationship based maternity care

Calm & Connect System

Optimal Oxytocin

Lowers BP, Heart

rate, decreases pain

Normal Birth

+

OPTIMISING BIRTH PHYSIOLOGY