On shouting, "SEED MY BABY WITH MY VAGINAL MICROBES!"

Co-authored by Emily Pereira, Anthropology major, University of Rhode Island

When I was pregnant, the human microbiome was hot. And news about the microbiomes of newborns was even hotter, at least to my eyes and ears because I was on the verge of having one.

This was in 2014. Studies were starting to find that babies born via c-section have different microbiomes than babies born vaginally. These findings were being interpretively linked to health problems down the road. 

Here’s a write-up of one study of a few 4-month-olds that I came across while pregnant: “Infant gut microbiota influenced by cesarean section and breastfeeding practices; may impact long-term health”

And today studies continue to pop-up that find differences in baby microbial composition and then suggest those differences may be linked to future health problems. For example, here’s a recent one from 2016 in JAMA Pediatrics: 

“CONCLUSIONS AND RELEVANCE The infant intestinal microbiome at approximately 6 weeks of age is significantly associated with both delivery mode and feeding method, and the supplementation of breast milk feeding with formula is associated with a microbiome composition that resembles that of infants who are exclusively formula fed. These results may inform feeding choices and shed light on the mechanisms behind the lifelong health consequences of delivery and infant feeding modalities.”

These discoveries about c-sections seem important because microbes are now famous for being linked to all kinds of health troubles. 

According to the American Microbiome Institute... 

“studies are finding that our bacteria (or lack thereof) can be linked to or associated with: obesity, malnutrition, heart disease, diabetes, celiac disease, eczema, asthma, multiple sclerosis, colitis, some cancers, and even autism.”

And of course many of those same things have been epidemiologically traced back to birth by c-section. Here’s a report on one study, “published in the British Medical Journal, [that] found that newborns delivered by C-section are more likely to develop obesity, asthma, and type 1 diabetes when they get older.”

Another found that, “people born by C-section, more often suffer from chronic disorders such as asthma, rheumatism, allergies, bowel disorders, and leukaemia than people born naturally."

One can’t help but assume it’s all connected. If microbes are to blame for this list of problems and if c-sections are too and if c-sections are causing babies to have different microbiomes, then the following conclusion seems like a no-brainer: we need to be wiping c-sected babies with their mother’s vaginal juices.

So although I did basically nothing to prepare for a c-section (d’oh!), I imagined that if my childbirth came to surgery, that it would be really easy to avoid the risks to my baby's health by simply wiping him down with something soaked in my lady fluids.

I had even caught wind of a trial of this procedure, written-up somewhere, and so I mentioned it to my OB at a prenatal visit. She said she’d heard of it and that there was a term for it but the term escaped her. The idea excited her, but it wasn’t even remotely close to being part of regular clinical practice yet. Remember, this was summer 2014. Sensing it was too soon and out of reach, I changed the subject of conversation. Yet, I continued to believe that someone would just help me out with the whole vaginal swabbing thing if need be. It seemed simple enough. No biggie.

At the time, I didn’t Google around for tips or instructions so I don’t know what the Internet was offering up to would-be mothers/vaginal-microbe believers like me. But today it’s quite easy to find encouragement to D-I-Y transform your kid’s c-sected microbiome into a naturally-born one.

Here, let Mama Seeds explain:

“In the event of a c-section, be proactive. Mamas, we know this recommendation is not without its “icky-factor," but WOW it makes perfect sense when you think about it, and some believe it will be a standard recommendation in the future. Here goes: if your baby is born via c-section, consider taking a swab of your vaginal secretions and rubbing it on your baby’s skin and in her/his mouth. I know, ick. But when babies traverse the birth canal, they are coated in and swallowing those secretions/bacteria in a health-promoting way, so all you’re doing is mimicking that exposure. Don’t be afraid to ask your midwife or OB to help you collect the vaginal swabs—or do it yourself, if you’re comfortable. You have all the available evidence on your side.” - Michelle Bennett, MD is a full-time pediatrician, a Fellow of the American Academy of Pediatrics, a mother of two, and a founder of Mama Seeds.

Like I said, I didn’t have Mama Seeds. But I didn’t need Mama Seeds. While I was being wheeled into emergency cesarean surgery, I still shouted “SEED MY BABY WITH MY VAGINAL MICROBES!”

The reaction from the hospital staff? There was no reaction and, surprise surprise, there was no artificial seeding of my baby’s microbiome.

And that’s good. That’s how it should have gone down because my request was not based on scientific thinking. I hope you'll forgive me. I was pregnant. I wasn’t myself.

Slowly I’m becoming myself again, though, and thanks to a keen student, Emma Pereira, this post’s co-author, I’ve learned quite a bit about the science behind whether I should have seeded my newborn with my vaginal microbes. And the answer to anyone who’s wondering is a resounding NO. At least for now.

Here’s why.

1.   We don’t know if it’s necessary. Despite the increasing numbers of studies, no one to our knowledge has looked longitudinally at the microbiomes of humans born via c-section to find out if the changes detected (in very small samples) early on in these studies actually last, let alone if they can be causally linked to differences in health. It seems like the money and the technology is there to identify (via genetic sequencing) myriad microbial species, but the time and energy just isn’t there to do much else. So, although there is a growing literature, the dots aren’t connected yet. A graphic may help explain what we've learned: 

2.  You could actually harm your baby. Because there is currently no known good to come of seeding one’s c-sected baby with one’s vaginal microbes, there can only be bad. Yes, authors of this study published recently in Nature Medicine took a bunch of gauze that had been sitting in the mother’s vagina for an hour and swabbed 4 babies for a duration of about 15 seconds right after their birth by c-section and then found a significant difference in their microbiome at 30 days-old compared to babies who weren’t treated.  The microbiome wasn’t identical to vaginally born babies, but at least it wasn’t identical to those poor c-sected controls who didn’t get swabbed, right? Well, maybe wrong. First, please revisit number 1. And, second, maybe causing a baby to have a c-sected microbiome is not worse than seeding a baby with genital herpes, which is a very real possibility in practice, outside of these early, highly controlled pilot studies. As reported in Should C-section babies get wiped down with vagina microbes?, “the procedure could unknowingly expose newborns to dangerous bugs, pathogens that babies born by C-section usually avoid. Group B streptococcus, which is carried by about 30 percent of women, can trigger meningitis and fatal septicemia... Herpes simplex virus can lead to death and disability in newborns. And chlamydia and gonorrhea can cause severe eye infections.”

So, again, as of right now, there is no reason to seed one's c-sected baby with one's vaginal microbes. And there are very good reasons not to! 

We think that the temptation to blame the rise of numerous complex health problems to something as simple (and easily knowable) as the way we’re born is similar to the temptation to reduce these very same complexities to what’s coded in the genome. For some people, maybe even many, it may turn out to be this simple! But we’re far from knowing whether that’s true. 

Spare your baby from meddling with his microbes until the evidence is there. 

When evolutionary-minded medicine gets it (possibly) wrong about childbirth interventions

No one is saying that medicine isn't brilliant and hasn't saved lives. But it does intervene more than necessary when it comes to pregnancy and childbirth.

Part of that unnecessary intervention is driven by lack of experience. Part is an economically-driven disrespect for time. (Give childbirth some motherlovin' time.) Another part, related very much to experience, is how difficult it is to decide when intervention is and isn't necessary, especially when things are heating up. But another part of the trouble actually lies in the evolutionary perspective. Unfortunately it's not all rainbows and unicorns when M.D.s embrace evolution. Instead, evolutionary thinking is biasing some medical professionals into believing that, for example, birth by surgical caesarean is an "evolutionary imperative."

Here's one recent example in The American Journal of Obstetrics & Gynecology of how the evolutionary perspective is (mis)guiding arguments for increased medical intervention in childbirth.

link to paper

It's a fairly straight-forward study of over 22,000 birth records at a hospital in Jerusalem. The authors ask whether birth weight (BW) or head circumference (HC) is more of a driver of childbirth interventions (instrumental delivery and unplanned caesareans) than the other. Of course, the focus is on the biggest babies with the biggest heads causing all the trouble, so the authors narrow the data down to the 95th percentile for both. Presumably they're asking this question about BW and HC because both can be estimated with prenatal screening. So there's the hope of improving delivery outcomes here. And, of course, the reason they ask whether head size or body mass is more of a problem is because of evolution. They anticipate that they'll discover that heads are a bigger problem than bodies because of the well-known "obstetrical dilemma" (OD) hypothesis in anthropology.

OD thinking goes like this: Big heads and small birth canals are adaptive for our species' cognition and locomotion, respectively, but the two traits cause a problem at birth, which is not only difficult but results in our species' peculiar brand of useless babies. (But see and see.)

So, since we're on the OD train, it's no surprise when we read how the authors demonstrate and, thus, conclude that indeed HC (head circumference) is more strongly associated with childbirth interventions than BW (birth weight), at least when we're up in the 95th percentile of BW and HC. Okay.

They use this finding to advocate for prenatal estimation of head size to prepare for any difficulties a mother and her fetus may be facing soon. Okay.

Sounds good. Sounds really good if you support healthy moms and babies. But it also sounds really good if you already see these risks to childbirth through the lens of the "obstetrical dilemma" with that OD thinking helping you to support "the evolutionary imperative" of the c-section. Okay.

Too many "Okays" you're thinking? You're right. There's a catch.

When you dig into the paper you see that "large HC" heads are usually about an inch (~ 2.5 cm) greater in circumference than "normal HC" ones. (Nevermind that we chopped up a continuum of quantitative variation to put heads in arbitrary categories for statistical analysis.) And when you calculate the head diameter based on the head circumference, there is less than 1 cm difference between "large" and "normal" neonatal heads in diameter. That doesn't seem like a whole lot considering how women's bony pelvic dimensions can vary more than that.  Still, these data suggest that the difference between a  relatively low risk of having a c-section and a relatively high risk of having a c-section amounts to less than a centimeter in fetal head diameter. And maybe it does. Nobody's saying that big heads aren't a major problem sometimes! But maybe there's something else to consider that the paper absolutely didn't.

Neonatal heads get squeezed and molded into interesting shapes in the birth canal.

The data say that normal HC babies get born vaginally more often than large HC ones. But this is based on the head measures of babies who are already born! If we're pitting head circumference (HC) of babies plucked from the uterus against the HC of babies who've been through hello! then of course the vaginally delivered ones could have smaller HCs.

C-sected babies tend to have rounder heads than the ones squeezed by the birth canal. It's impossible to know but I'm fairly confident about this, at least for a subsample of a population: Birth the same baby from the same mother both ways, vaginally and surgically, and its head after c-section will have a larger HC than its squeezed conehead will after natural birth.

Measuring newborn head circumference (HC). source

When we're talking about roughly 2.5 cm difference in circumference or less than 1 cm difference in diameter, then I'd say it's possible that neonatal cranial plasticity is mucking up these data; we're sending c-sected babies over into the "large HC" part of the story just because they were c-sected in the first place. So without accounting for this phenomenon, the claim that large head circumference is more of a cause of birth intervention, of unplanned c-sections, than large body mass isn't as believable.

If these thoughts about neonatal cranial molding are worthwhile, then here we have a seemingly useful and very high-profile professional study, grounded in the popular but deeply flawed obstetrical dilemma hypothesis, that is arguing for medical intervention in childbirth based solely on the difference in head size measures induced by those very medical interventions. 

The circle of life!

Why is the human vagina so big?

We are obsessed with penis and testicle size. Yet, we can barely say "vagina" and when we do we're usually talking about the vulva.

Everyone's come across some article somewhere on-line that is thrilled to share how big human penises really are, for primates, and to explain why they evolved to be so big. It's not really the length, but the girth. Alan Dixson is your go-to on this. He's conservative in his assessment of the literature on penis size and even he concedes that human penis "circumference is unusual when compared to the penes of other hominoids (apes)" (p. 65 in Sexual Selection and the Origins of Human Mating Systems).

A favorite explanation for the big phallus is female mate choice, that females selectively make babies with males who have larger and, presumably, more pleasurable semen delivery devices. This is backed up by studies. When life size projections of naked men are shown to female subjects, they say they find the ones with bigger ones to be more attractive. [This is exactly how mate choice works where I live, how about you?]

Other explanations include male competition. If you can deliver your package to the front yard but the other guy can deliver to the front door, his is more likely to be carried inside the house first. Or, if he can steal away what you just delivered, then, again, his package has yours beat. Thanks to his big penis he's more likely to pass on his winning penis genes than you are to pass on your loser penis genes. Loser.

All this is just terribly fun to write about and I'm not even going nuts (gah) like they do. And they do. They really do. And all over the Internet they do: "Evolution of human penis" gets 53,000 hits just on scholar.google alone, and about 832,000 on Google.

But doesn't it make sense that for a penis to be somewhat useful it has to be somewhat correlated to vagina size?

I'm talking about all penises in the universe and all vaginas too. Sure there's variation, but a penis can't be too wide. It helps to be long, probably, but it can't be too long.

So neither pleasure nor psychology need matter at all, just function associated with some sort of fit. Pleasure and psychology are never invoked to explain penis morphology in other animals. If anything, it's the cornucopia of horrifying, not pleasing, animal penises that begs for evolutionary explanations.

Wouldn't you explain the size and shape of the key by the size and shape of the lock? So wouldn't it be a little more scientifically sound to hypothesize that the human penis is sized and shaped like that because it fits well into the human vagina?

Sure, it gets chicken-and-eggy or turtles-all-the-way-downy, but c'mon. Isn't it a bit obvious that the privates that fit inside the other privates are probably correlated? You'd think that even the people who have never had intercourse would default to this explanation for the evolution of the human penis.

Figure 2. Examples of genital covariation in waterfowl.

(A) Harlequin duck (Histrionicus histrionicus) and (B) African goose (Anser cygnoides), two species with a short phallus and no forced copulations, in which females have simple vaginas as in Fig 1a. (C) Long-tailed duck (Clangula hyemalis), and (D) MallardAnas platyrhynchos two species with a long phallus and high levels of forced copulations, in which females have very elaborate vaginas (size bars = 2 cm). ] = Phallus, * = Testis, ★ = Muscular base of the male phallus, ▹ = upper and lower limits of the vagina.

doi:10.1371/journal.pone.0000418.g002

But we're rarely, if ever, told that human penises are relatively girthy because human vaginas are. It's always about male competition or female preference.

Sure, we may be a little weird compared to our close relatives for not having a baculum (penis bone), and maybe that's the sort of thing you want to explain for whatever reason, but does human penis size and shape need a uniquely human story?

Assuming it's correlated to the vagina like it probably is in many other species,* then no it doesn't... unless the size and shape of the human vagina has an exceptional story.

Does it? We wouldn't know. There are zero (look!) articles titled "Why is the human vagina so big?"

Until right now.

Here we go. If we were going to answer it the same way we've long explained the human penis, and other animal penis shapes, then we've got a few ideas...

Because walking upright made the vagina conspicuous and males thought a bigger vagina was better. Because big vaginas outcompete small ones at catching sperm. Because of male pleasure from coitus with a big vagina. Because of heat dissipation or thermoregulation. Because of a tradeoff with brain size.

And of course, we'd need to demonstrate that the human vagina is in fact larger, relative to body size, than the vaginas of other primates. Regardless, a sound answer to the question of vagina size and shape focuses on childbirth, wouldn't you say? She's got to be big enough to push out a baby and, for humans, it's a great big baby. 

So if there's an exceptionally human story for the great big human penis, that exceptional story originates not in a woman's orgasms, not in her pornographic thoughts or her lustful eyes, but in her decidedly unsexy "birth canal."

And I dug up a nice little note to explain this to us all written by Dr. Bowman, a gynecologist, back in 2008 for the Archives of Sexual Behavior

That note is magnificent. It starts out giving the only vagina-size-based, not to mention childbirth-based, explanation for human penises that I can find in the literature (which is thankfully cited by Dixson in his book mentioned above). But it still manages to bring the explanation beyond the vagina and onto another proud triumph: "In sum, man’s larger penis is a consequence of his larger brain."

After you clean up the coffee you just spat onto your computer screen, you can read it all for yourself up there in the figure.

Guess who didn't read it? That study in PNAS, mentioned above, that showed women naked penises, got a high attractive score for the big ones, and thinks that's evidence for mate choice now, today, let alone back when (I'm going to speculate that) women had a tiny bit less of it.

Point is, the literature rages on with the special explanations for the big penis with nary a big vagina in sight.

But you heard it here, at least.

Childbirth is why the human vagina is so big and, consequently, why the male penis is so big. It's pretty straightforward. Yet we're still left scratching our heads as to why the penis question endures.

Is evolutionary science averse to big vaginas?

Does nobody love a big vagina?

Because that's just ridiculous. Everybody came from one.



*Unfortunately a few scholar.google searches led me to find no cross-species comparisons of mammalian vagina lengths or any vaginal measures. It may be out there, but I haven' t found it. I found some measures for bitches... DOGS! And some heifers... COWS! So I've got to compile some data if I'm to do this properly. Baby size might be a way to do this.

**UPDATE. p. 73 in Dixson has Figure 4.3 with nine primate species' penile and vaginal lengths plotted. Thanks Patrick C for reminding me where I'd seen something like this and where to point readers!

Marshawn Lynch's extra placenta feeds the curiosity

The most important sporting event in the universe will take place Sunday night and that's partly why one of the players, Marshawn Lynch, has been in the spotlight. But it's not entirely why.

Marshawn Lynch, running back for the Seattle Seahawks.

He's an interesting guy, and in more ways than his mesmerizing moves, broken tackles, and bizarre locker room interviews, as Andrew Sharp writes:

After his mother gave birth to him 28 years ago, the midwife told her that she may have had a twin that died in utero.“They just knew that Marshawn was living off two placentas,” his mother told USA Today. “She told me that with that, he may be an amazingly strong child.”

We all have origin stories, some more elaborate or more epic than others. And when someone is notable or special or revered or freakish, we certainly pile it on. You can't just be born if you're somebody. You have to emerge under a full moon at the very least, but even better under a meteor shower, and best while Halley's comet's in sight.

Siddhartha was talking and walking right out of the birth canal. And you know who he became? The Buddha.

Marshawn Lynch was feasting from not one but two placentas. And you know who he became? Beast Mode.

Right. But if you've ever read this blog before you're probably wondering the same thing I'm wondering: Is it even possible for a fetus to be nourished from two placentas? Like with two umbilical cords or a bifurcated one?

I'm going to offer that yes, it's possible; to say otherwise is as arrogant as that semicolon. But hell no I don't know of an instance to share with you. And hell yes I think it's highly unlikely that Lynch was living off two placentas. What's more, even if he was, it wouldn't necessarily have anything biologically to do with Beast Mode. I just can't see how. But I'm not exactly the Beast Mode of placentology so take that for what you will.

Lately, however, I am the Beast Mode of new motherhood so I adore how the midwife and the family interpreted the two placenta event. This is what makes humans a riot. This is why they're my new favorite species. Spin a tale about the start of a precious life, the kind of tale that sets dreams afloat... the sky's the limit for this kid and nobody better get in the way of that.

But here comes science. The parsimonious placental tale would be that Beast Mode's twin died in utero, but the placenta stayed around (boring!). I gather from a brief Google search that this happens occasionally, or that this is how the presence of two placentas (or one placenta that looks like it has two parts) is normally explained.

But see, now we've done it. The science killjoys have ruined another beautiful legend. If the Lynch family has already been fed that boring scientific explanation, or if they read it here just now, and feel like their story might no longer have legs, we can help. Let's put some stardust back into it, but with different science.

If there was a twin, then the fact that Marshawn Lynch survived the same experience that his twin couldn't, well, that might speak volumes about his strength. 

There. It's not a far-fetched story, as-is, already. And that's lovely. But we can do better.

If Marshawn Lynch was born with teeth--which the Buddha probably had too if he could speak so well at birth--then maybe Lynch didn't just merely out-survive his twin. Maybe he went full Beast Mode in utero, just like the sand tiger shark where one vicious shark blasts through the other eleven. No kidding. This shark has to prey upon its siblings in the womb if it is going to be born, and the one born is not only strong but stronger for it.

Feeding from two placentas? Never heard of it.

But feeding off your embryonic kin? Yeah.

'Obstetric dilemma' skeptic has c-section and remains skeptical ... & ... Why my c-section was natural childbirth

This is a new kind of Tale for me. The rock'n'roll's turned way up, and every couple sentences I have to stop typing to twirl a blue hound dog, a bear holding an umbrella, a Flying Spaghetti Monster, and other oddities that I strung up to hypnotize this little guy into letting me type one thought at a time:

The thing that needs to be hypnotized.
Or the three wise monkeys say: The thing that makes it impossible to create or to dwell on the negative. (e.g. his birth by c-section)

That young primate's the reason I've been quiet for a while here on the MT. And he's the reason I'm a bit more emotional and I cry harder than usual at Rise of the Planet of the Apes (those poor apes!), Cujo (that poor dog!), and other tearjerkers. But he's also the reason my new favorite animal is plain old, fascinating, and dropdead adorable Homo sapiens.

In anthropological terms, he's the reason I'm overwhelmed, not just in love but in new thinking and new questions about the evolution of human life history and reproduction, and then what culture's got to do with it and with our reconstruction of it.

Some context would help, probably.

For the past few years I've been challenging the 'obstetric dilemma' hypothesis--the idea that hominin mothers' bipedal pelves have shortened our species' gestation length and caused infant helplessness, and that antagonistic selection between big-brained babies and constrained bipedal mothers' pelves explains childbirth difficulty too.

[For background see here or here or here or here.]

As part of all that, I've been arguing that the historically recent surge of c-sections and our misguided assumptions about childbirth difficulty and mortality have muddled our thinking about human evolution.

So, once I was pregnant, you might imagine how anxious I was to experience labor and childbirth for myself, to feel what the onset of labor was like, and to feel that notorious "crunch" that is our species's particular brand of childbirth. Luckily I was not anxious about much else the future might hold because modern medicine, paid for by my ample health insurance, would always be there to make it all okay. After a long pregnancy that I didn't enjoy (and am astonished by people who do) I was very much looking forward to experiencing childbirth. In the end, however, my labor was induced and I had a bleeping c-section.

But my bleeping c-section's only worth cussing over for academic reasons because the outcome has been marvelous, and the experience itself was out of this world.

We'll get to the reasons for my c-section in a second, but before that, here are the not-reasons...

First of all, I did not have a c-section because I fell out of a tree with a full bladder.

Second of all, shut your mouth... a c-section was not inevitable because of my hips.

Okay, you got me. I've never been even remotely described as built for babymaking. My hips are only eye-catching in their asymmetry. One side flares out. It might be because when I was 15 years old I walked bent-kneed for a few months pre- and post-ACL reconstruction. That leg's iliac crest may have formed differently under those abnormal forces because, at 15, it probably wasn't fused and done growing yet. If you like thinking in paleoanthropological terms like I do, then my left side is so Lucy.

Anyway. I'm not wide-hipped. However, guess how many nurses, doctors, or midwives who were involved in our baby's birth think my pelvis was a note-worthy factor in my c-section? Not one.

Hips do lie! Inside mine there's plenty of room to birth a large baby. Two independent pelvic exams from different midwives (who knew nothing of my research interests at the time) told me so, and it sounded like routine news to boot. Although one midwife asked me "do you wear size nine and a half shoes?" (no, I wear 8) which was her way of saying, "Girl, you're running a big-and-tall business. You got this."

What you probably know from being alive and knowing other people who were also born and who are alive (or what you might hear if you ask a health professional in the childbirth biz) is that most women are able to birth babies vaginally, even larger-than-average babies. And that goes for most women who have ever lived. Today, "most women" includes many who have c-sections because not all c-sections are performed because of tight fit between mother's birth canal and baby's size. As I understand it, once the kid's started down into the birth canal and gets stuck, a c-section's no longer in the cards. So performing c-sections for tight fit is a preventative measure based on a probability, not a reflection of an actual tight fit. In the mid 20th century, tight fit used to be estimated by x-raying pregnant women and their fetuses. Can you imagine? And this was right about the time the obstetric dilemma hypothesis was born. I don't think that's a coincidence.

Here's a list of reasons for c-sections. Tight fit is included in the first bullet point. Tight fit is one of the few quantifiable childbirth risks. No wonder it's so prominent in our minds. That list excludes "elective" ones which can be done, at least in Rhode Island, if they check the box that says "fear of childbirth". And that's not even close to a list of reasons why women around the world and throughout history have died during or as a result of childbirth. For example, about a hundred years ago women were dying all over the place because of childbed fever.

Anyway, we should assume that I am like most women and expect that I could have given birth the way Mother Nature intended: through my birth canal and with the participation of other humans. Oh yeah, when it comes to humans, social behavior and received knowledge are part of natural childbirth. Even this natural childbirth (which has inspired a forthcoming reality television show featuring women giving birth in the wild!) involves the supportive and beneficial presence of other humans as well as the culture that the mother brings to the experience.

But a c-section's just culture too, so could it be part of "natural" childbirth, then?

I'm inclined to blurt out yes, of course! because I don't support calling anything that humans do "unnatural." But I know that's not something everyone agrees with. It's politics. For example, many of you out there don't flinch an inch at the subtitle of Elizabeth Kolbert's book, "The Sixth Extinction: An Unnatural History."  And given the present energetic movement against childbirth interventions, describing c-sections as "unnatural" as climate change could help minimize unnecessary ones for those who wish to give birth vaginally.

So there we have it. These are the two enormous issues raised by my own little c-section: What can it teach us about the evolution of gestation length, infant helplessness, and childbirth difficulty? And could it be considered natural?

One way for me to get at these questions is to try to understand why I experienced "unnatural" childbirth in the first place. So here goes.

Here's why I think I had to have a c-section:

1. My pregnancy ran into overtime.

This is expected for nulliparous mothers. I visited one of my OBs on my due date. He put his finger on the calendar on the Friday that was two weeks out and joked, "Here's when we all go to jail." Then he asked me, "Who do you want to deliver your baby? I'll see when they're on call before that Friday and schedule your induction then." And I chose my favorite midwife and he scheduled the induction.

All right so I was running late compared to most women, but that's still natural, normal. But it also means risks are ever-increasing by the day. And no matter how small, that the professionals know how to mitigate the biggest risks of all, *deaths*, means that they try to do that. They're on alert already as it is, and then they're even moreso on edge when you're overdue. Especially when it's your first baby and you're a geezer, over 35 years of age.

Now, does going overdue mean the baby keeps growing? Maybe, but not necessarily and not necessarily substantially. Both of us, together, should have been reaching our maximum, metabolically. There's only so much growing a fetus can do inside a mother.

When I approached my due date, and then once I went past it, I tried to eat fewer sweets to make it less comfortable in my womb. I also went back to taking long, hard walks, five milers, even though it was hard on my bladder because I thought that might help kick him out too. I even ran the last of my five miles the day before my induction, to no avail other than the mood boost it gave me.

2. I didn't go into labor naturally by my due date or by my induction date 11 days later. 

Although my cervix was ripening, when I went in to be induced I was only dilated 0-1 cm. I had 9+ more to go before the kid could get out at 10. So a balloon catheter was inserted and filled with water, and I had to tug on the tail of it, which tugged the balloon, which put pressure on the cervix. It dilated enough that it fell out several hours into the process, and by morning I was dilated 3-4 cm. This was exactly the goal of the catheter, this many centimeters. All was going well. However, that the cervix did not open on its own is already a missing piece of going "natural," of having my own biology contribute to my childbirth experience. So starting this way is already derailing things, making it difficult for anything natural to follow, naturally.

3. The fetus's head was facing the hard way: sunnyside up.

This was assessed by the midwife and cradling my belly in a bedsheet, with me on all fours, she and I could not twist him into a better position. His head, she said, was probably why I did not dilate naturally. When I asked an OB during my postpartum check-up, "What dilates the cervix?", he said "We don't know. But I can tell you it's not with the head like it's a battering ram." Well, then... hmph. And then I asked him if women carrying breech fetuses have trouble dilating their cervixes, or going into labor naturally, and he said not necessarily. No. Hmph.

Regardless of what causes cervical dilation, if the head isn't facing the right direction, it's notoriously tough to get down into the birth canal, let alone through the birth canal. It's not impossible, not even close. But it's not looking good at this point either. Perhaps the contractions will jossle his head into a better position, they said. And the contractions should further dilate the cervix.

4. Contractions didn't get underway, naturally, after the catheter dilation, so the drug pitocin was used. 

Induction and pitocin increase the chances that a mother will ask for drugs to help with pain and that she will have interventions, like a c-section. See for example this paper. What the causes are, I'm not sure. But pointing out the correlation is useful at this point because at this point, without even getting into hard labor yet, and without finding out whether my cervix does its job, I'm more likely than ever to be going to the operating room.

5. After six hours of easy labor and five hours of intense labor, my cervix never dilated past 5 cm.  

It needs to get to 10 cm to get the baby moving into the birth canal. Just like with due dates, I think that blanketly assigning this number to all women is probably not consistent with variable biology, but it's how it's currently done. And maybe any higher resolution, like "Sally's cervix needs to hit 9.7 cm", is pointless.

After several hours pitocin-induced contractions--which at first felt like the no-big-deal Braxton-Hicks ones I'd been having numerous times daily for the whole third trimester--I only dilated 1 cm more. That's even when they upped the pitocin to make them more intense.

But after they saw I'd made essentially no progress and that I was napping to save my energy for when things got bad, they woke me up and broke my bag. It would be nice if they could have let my labor progress slowly, if that's what my body wanted to do, but remember, my personal biology went out the window as soon as induction began. And then when that amniotic fluid oozed out of me, that's when bleep got real.

Every two minutes and then every one and a half, I grabbed Kevin's extended hand and breathed like an angry buffalo humping a locomotive. It was the worst pain of my life and I was afraid I'd never last to 10 cm, so I took the stadol when I told the nurse my pain was now at a 9 out of 10 (all previous answers to this question were no higher than 2). I was going to avoid the epidural no matter what, even at this point, because I was more afraid of the needle sticking out of my spine for hours of labor than I was afraid of these contractions. I have no idea if the stadol dulled any pain, because the pain just got worse, but it did help psychologically because it put me to sleep between contractions. There was no waiting with anxiety for the next one and time flew by. But after five hours of this, I had not dilated any more. But I had vomited plenty! And although I'd fended off the acupuncture (FFS!), I folded weakly and, for the peace of mind of a wonderfully caring nurse, I allowed a volunteer to perform reiki on me. And what a tragedy it was! Wherever she is, there's a good chance she gave up trying to help laboring women, and she may have given up reiki all-together.

The hard labor story ends at five hours because that's about when the nurse actually screamed into the intercom for the doctor. My contractions were sending the fetus into distress.

6. After five hours of intense labor, the fetus was experiencing "distress" at every contraction, as interpreted from his heart-rate monitor. 

Basically, he was bottoming out to a scary heart-rate and only very slowly coming back to a healthy heart-rate just in time to get nailed by another contraction. By the way, this is the official reason listed in my medical records for my c-section: fetal distress.

I know that a heart-rate monitor on the fetus is another one of those medical practices that increases the chances of an "unnatural" childbirth. That's probably because all fetuses are distressed during labor, but observing the horror, and then guessing whether it's safe to let it continue is seemingly impossible. So at some point, like with me and my fetus, they get alarmed and then how do you back down from that?  They gave me an oxygen mask which immediately helped the fetus a bit, but like I said, hackles were already up at this point. Soon thereafter we had a talk with the doctor about how I  could go several more hours like this and get absolutely nowhere with my cervix, and then there are those life and death matters. She never said c-section. I had to eek out between contractions, "So are you saying we need to perform a c-section?" and she said yes, and urgently. A c-section sounded like the only solution at this point both to battered, old me, to clear-minded Kevin, and clearly to the delivery team (and in hindsight, it still does to Kevin and me). Then, lickety-split, the anaesthesiologist arrived, got acquainted with our situation, and made me vomit more. And then like a whirlwind, Kevin's putting on scrubs, and we're told to kiss, and I'm jokingly protesting "I'm a doctor too!" while being wheeled into the operating room because I cannot walk through my contractions.

It's bright white, just like Monty Python said it would be. I sat on the crucifix-shaped operating table to receive all the numbing and pain killing agents through my spine. Somehow they pulled this off while I was still having massive contractions. Then I laid down, arms splayed out to the side, and they drew a curtain across my chest, a nurse told me how creepy it was about to be, and they got to work.

Although the c-section wasn't painful, I could feel everything. This was my childbirth experience. I felt the incision as if she was simply running her finger across my belly, and I felt the tugging and the pressure lifting from my back as they extracted my baby from me. After that, and after I got a short glimpse of him dangly over my left arm--"He's beautiful! He's perfect! He's got a dimple! He growled!"--I continued to feel many things, probably the birth of my placenta, etc...

But I didn't know what exactly I was feeling until I watched a video of a c-section on YouTube. Kevin helped fill in the details too. He had caught a naughty glimpse of the afterbirth scene before being chased back to his designated OR spot with the baby. Thanks to him (and that video) I know now that I was feeling my enormous muscular uterus and some of my intestines being yanked completely out of a small hole right above my pubic bones and then stuffed back in. For a few moments, it must have looked like I was getting re-inseminated by a red octopus.

I tell everyone that it was like going to outer space to give birth. And this, if you know me, is an exciting idea so my eyes are smiling and I sound dreamy when I say "it was like going to outer space to give birth!" I bet you're thinking it's the Prometheus influence, but you'd have the wrong movie. The correct one is Enemy Mine. And it's much more than that, actually. I was as jaw-dropped and awe-struck by humanity during my childbirth experience as I am by space exploration. The orchestration, the specialization, the patience, the years of study, of planning, the calculations, the dexterity. To boldly go. Wow. Like I said, humans are my new favorite animal.

I was back in our little room quicker than most pizza deliveries, where our bright red new baby was trying hard to nurse from his daddy. Then he nursed from me. And the story's all mushy weepy cuddly stuff from now on. So let's not. Let's remember what we're here for. Okay. Right.

7. The cord was wrapped twice around his neck. 

We found this out when he was cut out of me. That didn't help with moving him around in utero to a good position, nor did it help with oxygen flow during contractions! This would not have inhibited his safe vaginal birth, however, at least not necessarily.

8. He was enormous. His head was enormous too. 

He came out a whopping 9 pounds, 13 ounces, 22.25 inches long, with a head circumference of 15.5 inches. They say that's heavier than he'd be if born vaginally because he didn't get all the fluids squeezed out of him. But still, that's large. According to the CDC he was born as heavy as an average 3.5 month-old boy. His head was about the size of an average 2.5 month-old.

Red line is our baby's head circumference at birth. (source)

Way back at the mid-pregnancy ultra-sound, we knew he was going to be something. And then if you'd seen me by the end, like on my due date, you might have guessed I was carrying twins. I was so big that my mom joked she thought maybe a second fetus was hiding behind the other one, undetected.

Smiling on my due date because pregnancy was almost over. 
(By the way, I could still jog and I dressed weird while my body was weird.)

If I hadn't had the means to eat so much like I did during pregnancy, perhaps he wouldn't have grown so large inside me. If I hadn't lived such a relaxed lifestyle while pregnant, maybe he wouldn't have grown so large inside me. If I didn't have a medical safety net waiting for us at the end, perhaps I would have been scared into curbing my appetite from the get go. I gained 40 pounds. With this body, but in a different life, a different place, a different time, maybe I wouldn't have. Probably I wouldn't have.

His size has got to have influenced a few of those other contributors to my c-section. But clearly it's more complicated than his size. And this brings us back to the obstetric dilemma. Let's say he was too big or that his large size screwed everything up, even if he could technically fit through the birth canal. Well then, why didn't I go into labor? Labor triggers are, to me, a significant problem when it comes to explaining the evolution of gestation length in humans, and whether we have a unique problem at the end.

If our pregnancy length is determined by available energy, energy use, and metabolism (here and here) then women like me who go overdue, who are clearly not killing our babies inside us either, are just ... able to do that. But doing that clearly leads to problems in our species (one of the few known) that has such a tight fit to begin with.

If our pregnancy length is determined by our birth canal size, and any anatomical correlates, then why didn't I go into labor before my fetus got so big? What went wrong? What's frustrating too is, for my n of 1, we'll never know if I could have given birth vaginally because I never got the chance to try.

These seem like simple questions but they are deceptively complex. And I think there will be some exciting discoveries to come from medicine and anthropology in the coming decades to explain just how our reproduction works which will in turn help us reconstruct how it evolved.

What's my birth experience got to do with evolution? Why, everything. It's got everything to do with evolution, because if it's not evolution, it's magic.  And that's kind of where I'm coming from when I say that my c-section was still natural childbirth. It wasn't unnatural and it certainly wasn't supernatural. Sure, it's politics. I'm invested in the perspective that humans are part of the evolving, natural world and want others to see it that way or, simply, to understand how so many of us see it that way. But it's not just evolution that's got me enveloping culture into nature and that's got me all soft on the folks who drive fancy cars who cut my baby out of me.

Who knows what could have happened to my son or to me if we didn't have these people who know how to minimize the chances of our death? It's absolutely human to accumulate knowledge, like my nurses, midwives and doctors have about childbirth. Once learned, it's difficult for that knowledge to be unseen, unheard, unspoken, unknown. Why should we expect them to throw all that away so that we can experience some form of human being prior to that knowledge?

Nature vs. Culture? That's the wrong battle.
What matters is which one can fight hardest on my behalf against the unthinkable.

Maybe childbirth is so difficult because it can be. We've got all this culture to help out when things get dicey, with or without surgeons. On that note, maybe babies are so helpless because they can be. We've got all the anatomy and cognition to care for them and although the experiment would be impossible, it's doubtful any other species but ours could keep a human baby alive for very long. It could just be our dexterous hands and arms, but it could be so much more, like awareness of their vulnerability and their mortality,and (my favorite pet idea) awareness that they're related to us. Culture births and keeps human children alive with or without obstetricians. It's in our nature. Maybe it's time we let all this culture, our fundamental nature, extend into the operating room.