What is exactly the definition of a successfull birth for an obstetric suregon ?

Olivier Ami, obstetrician gynecologist qualified in radiodiagnosis, and Luka Velemir, obstetrician gynecologist, give us a forum on the contribution of modern obstetrics both in the monitoring of life in utero and in the transition to life ex utero and attachment between a child and his parents.

Knowledgeable people and the contribution of imagery

During training as a midwife, you will learn about the usefulness of obstetrical protocols, the use of many measuring instruments, the use of advanced techniques for imaging the fetus or treating patients, and the need to be available and organized to deal with emergencies, which can be extreme. After several thousand pregnancies and deliveries performed with her hands, this teaching allows us to approach another reality of modern obstetrics.

The fetus is not a human being in miniature. The brain (a complex organ, which surprises us every day when explored in adults) shows a sequence of development in utero that is surprisingly comparable from one individual to another. The conformity of this evolution is monitored every trimester by so-called “morphological” ultrasounds.

Thus, we observe the appearance in the embryo of specialized cells along the notochord, which will give rise to the brain and the spinal cord with a segmentation of the peripheral nerves by territories, destined to form as many afferences [1] as efferences [2]. The fetal brain will present a gray matter, which includes the cell bodies performing integration and calculation operations, as well as a white matter, which groups all the nerve passageways. The gray matter will organize itself into cortex and gray nuclei, while the white matter will offer an architecture of fibers allowing communication between the different areas of the brain. The growth of the cerebral cortex and the establishment of its gyration are also monitored in the fetus, which will allow it to learn skills by transforming the data perceived from the real world into data that can be used by the body. This innate container will thus allow the unborn child to accumulate experiences and to favor the emergence of a symbolic processing.

Plunged into darkness at the dawn of its extra-uterine life, the child perceives stimuli as soon as these nerves are in place, but cannot yet interpret them as an adult would. A learning phase is necessary, which will pass by a labeling in which the parents and their substitutes will play a primordial role during the early childhood.

Studies on the development of fetal brain anatomy, carried out with the help of MRI at the University of Paris-Sud XI, have made it possible to explore and visualize this process for two years. It was thus possible to measure the densification of cerebral fibers, to follow the establishment of information pathways and to detect the appearance of connections between neurons in the cortex.

Fetal neurophysiology remains a vast continent to be discovered and this becomes possible thanks to imaging. Beyond volume images and 3D simulation, it also offers the opportunity to determine the molecular composition of tissues, fluid movements, elasticity, temperature…

Births and the passage to life ex utero

In the amniotic sac, the unborn child generally lacks nothing: a stable temperature of 37°C, breathing and nutrition via the placenta, shock absorption by the uterine muscle and the amniotic fluid, acoustic attenuation thanks to the fluids and the wall.

At the same time, her senses are stimulated: touch from inside the uterus (of her own face, the umbilical cord, her other limbs, the vessels running on the surface of a placenta that is a little softer than the rest of the uterine wall) or from outside (the mother caressing her belly, the father looking for a reaction, the sonographer handling the baby) ; sounds, in particular the maternal voice, transmitted through the body and not subject to acoustic attenuation like other noises; the taste of the amniotic fluid; proprioception during limb movements; and, finally, gravity or acceleration.

These felt variables give every human being reference for his brain cells, which pick up these signals and integrate them at their own pace. These founding experiences are similar in nature on a collective scale and, at the same time, different for each individual.

But what about the variations? What about the presence of a twin in utero, a premature birth or unusual experiences? This is a very broad field of investigation for scientific research in the antenatal field, at the crossroads of psychology, neurology, neonatology and gynecology-obstetrics.

Thanks to MRI, the birth process has been studied at the University of Clermont Auvergne, not without the hope of modeling more accurately the obstetrical biomechanics of normal childbirth. The first observations allowed to discover the mechanisms presiding over the skull shaping sequence and the temporary cerebral deformation that accompanies it: the cerebrospinal fluid migrating to the posterior fossa, the scythe of the brain and the tent of the cerebellum that provide a complex system of internal constraints to the architecture of the skull bones, which are not fused at this age and will be able to overlap, making the “tectonics” of skull shaping an illustration of the intelligence of nature and the processes put in place over millions of years to facilitate this passage to life ex utero.

Parents and the attachment process

One of the most moving phenomena that can be witnessed at every birth is the attachment process between the child and its parents in the first minutes and hours of life. The conditions of a normal birth, with immediate skin-to-skin contact to promote the encounter between parents and child, must become a goal in itself. More and more teams are choosing to make these conditions, which medical protocols do not always allow, a priority for the good of all.

Thus, inspired by the conditions of physiological childbirth, in the case of caesarean section for example, it is very important that the patient’s choice to welcome the child immediately be respected. It is therefore necessary that the team be organized to welcome a companion at the side of the woman during the operation, that the anesthetic and obstetrical teams accept this presence and that they give it sufficient space. This includes the placement of arms that should not be tied, drapes that are glued lower on the belly to free up space upstairs, a chair with wheels for the attendant, and a blanket suitable for skin-to-skin in the OR where the temperature is generally lower, a forced-air heating system for the mother, the need to avoid the mirror effect via the orientation of the surgical light which can reflect the whole operating field, the fact of lowering the sound of the electric scalpel, of clamping the suction and avoiding stressful noises… In short, it is all these attentions that can be imagined to reduce stress and improve the conditions of comfort of the birth. Without forgetting the role of the midwife, who welcomes the child with the parents, who must ensure that there is no need for immediate care, who can restore speech during the entire procedure and who ensures that the medical procedures are carried out correctly, all the while encouraging this moment of attachment. Also, the pediatric team can facilitate this process, either by participating in it or by delegating it to the midwife.

Finally, these principles can be applied to all births, whether scheduled or emergency, vaginal or cesarean. Provided, of course, that the emergency does not reach the point of “saving” the mother and/or the child in “code red”.

Whenever possible, modern obstetrics must offer, in addition to respecting the mother’s perineal capital and the child’s neurological capital, comfortable reception conditions, with the least possible stress, to favor the success of this encounter. This is the equation with three unknowns, represented by the parents, the births and the knowers, that must be solved during the supervision of a birth, whether it is planned or unplanned. And there is a kind of urgency to rethink this triptych in order to move towards a new ecology of birth.

[1] Sensory nerves allowing to bring information concerning stimuli from the periphery to the central nervous system

[2] Motor and effector nerves, which carry information intended to produce a response, such as a muscular movement