EBB 304 – Q & A on PPD/Pitocin, Delayed Cord Clamping, Nubain, and Placental encapsulation

,Dr. Rebecca Dekker – 00:00:00: 


Hi, everyone. On today’s podcast, I’m going to do a mini Q&A for you all about pitocin and postpartum depression, delayed cord clamping, Nubain for pain relief during labor, and placenta encapsulation. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice see ebbirth.com/disclaimer for more details.  


Hi everyone, and welcome to today’s episode of the Evidence Based Birth® Podcast. My name is Dr. Rebecca Dekker, and I’ll be your teacher for today’s episode. Before we get started I have a quick announcement for you and that is the EBB conference is happening March 22 and 23 of 2024 and ticket sales closed last night but we are going to leave the doors open just for one more day. Today, March 13, you can still get tickets to the EBB conference if you go to evidencebasedbirth.com/conference we are leaving the doors open just for this final day in case you missed the final announcement last week about tickets closing. And now let’s get started with today’s episode.   


Today, I’m so excited to share with you some questions and answers that we have been asked this past year inside the Ask the Research Team Forum for evidence-based birth professional members. If you’ve ever wanted to ask me personally a research question, you know, you want my thoughts on something, or you wanna hear from the other researchers at Team EBB, you can do so inside the EBB Pro Membership, and you can learn more about that program at ebbirth.com/membership. Today, I’ve chosen four questions and answers from our forums to share publicly, and these questions have to do with pitocin and postpartum depression, delayed cord clamping, Nubain for pain relief during labor, and placenta encapsulation. And now, let’s get down to our Q&A. 


So the first question that was asked of me was, I was wondering what evidence you can find on the relation between synthetic oxytocin administration, also known as pitocin, either in labor or postpartum, and its relationship with postpartum mood disorders. This seems like a huge public health issue that is being ignored, and something that I see often anecdotally. Hoping there is more out there than just these two articles that I found. Thanks. So, postpartum depression (PPD) affects about 10 to 15% of postpartum people. Known risk factors for PPD include your genetics, personal past psychiatric history, adverse life events, and not having enough social support. There is mixed evidence, meaning some of the evidence supports and some of it does not support epigenetics, different neuroactive molecules, other health history, substance use, demographic factors such as poverty, nutrition, and birth outcomes. The evidence is still not confirmatory on those topics yet. There is some emerging research that if you have higher oxytocin levels, meaning your own endogenous or your body makes your own oxytocin, if those levels are higher in late pregnancy and postpartum, that that’s actually correlated with a better mood postpartum and less anxiety and less depression. This makes intuitive sense because oxytocin is one of the feel-good hormones. It’s sometimes called the love hormone. 


On the other hand, lower levels of oxytocin towards the end of pregnancy, so if your own natural oxytocin levels are low, that is correlated with higher levels of postpartum depression. Now, when you’re talking about synthetic oxytocin, this is chemically identical to our own natural oxytocin, but the main difference is synthetic oxytocin is given through your vein, so it does not pass through the blood-brain barrier into the brain, whereas your own natural oxytocin, sometimes called endogenous oxytocin, is produced and released from inside the brain, so it can have effects both in how you’re feeling as well as contractions. Now, most researchers and scientists think it’s really unlikely that synthetic oxytocin given in labor or immediately after you give birth could impact PPD, and the reason they think it’s unlikely is because it cannot cross that maternal blood-brain barrier, so it physically is not capable of getting into your brain. The person who asked this question did reference a systematic review published by Thull et al. in 2020, and that review was not able to find enough evidence to draw any conclusions on synthetic oxytocin in postpartum depression. 


Now, synthetic oxytocin could theoretically send some feedback signals through something that we call down-regulation of receptors, although that would probably be a short-term effect. And the true answer is that we need more research on this subject, but so far it does not seem to be a quote-unquote cause of postpartum depression, and there’s no proof that it’s a cause of it. One study that people often will send to me and say, but what about this study, they said that there’s a link. This study is by Kroll-Disrosiers. It’s used as quote-unquote proof of a link between synthetic oxytocin and postpartum depression, and this study is of extremely poor quality. When I read that study, I was shocked by how bad it was. I couldn’t even believe it got past the peer review process, and I still can’t believe people are quoting it. So you cannot use that study. It was very low quality as proof of any kind. Now remember that both postpartum depression and pitocin or synthetic oxytocin are common, and just because pitocin was administered during labor or shortly after birth doesn’t mean that it caused the PPD. So you were mentioning anecdotal or individual stories that seem to line up to support this. This does not mean that one caused the other, and this is a really important lesson in philosophy that I learned in my philosophy class in college about all the different logical fallacies they call them or errors of thinking that we have. 


So a really common error in thinking is called if this, then that. Its technical name is post hoc ergo propter hoc. That’s Latin for after this, therefore, because of this. It’s a misperception that since event Y followed event X, event Y must have been caused by event X. And when we see anecdotes, they can be particularly tempting because they let you draw conclusions based solely on the order of the events. But you have to step back for a minute and remember that there could easily be other factors that are causing the postpartum depression. My favorite example, because it’s easy to remember, of an if this, then that logical fallacy. Was years ago, I read actually during the pandemic, I read Jessica Simpson’s autobiography, and she talked a lot about the story about how when her boyfriend at the time was playing for the Cowboys, when Jessica Simpson went to the Cowboys game and they lost, the media was all publishing these articles saying that Jessica caused the Cowboys to lose, which is a logical fallacy of if this, then that. It’s not necessarily true. There can be many other factors that can cause a football team to lose. And I’ll also link in the show notes to a funny cartoon from XKCD showing the if this, then that logical fallacy in action. But this is a common mistake that we make as humans. We assume that because one thing happened first and then something happened next, that the first thing caused the second thing. But that’s just not always the case. So hopefully that answers your question. I’ll put some links in the show notes to some articles about predictors of postpartum depression and also about oxytocin. 


All right, my next question comes from a member based in Canada. And she wrote, with the rise of delayed cord clamping and lotus birth, more families are requesting that the baby’s cord stay intact for a predetermined amount of time. Providers have different thresholds, especially MDs versus midwives for the neonatal transition to extrauterine life, with midwives here in Canada generally being more tolerant of a longer delay. The main issue here is that the doctors will push for early cord clamping and resuscitation, even when the baby is transitioning normally, according to the algorithms of neonatal resuscitation. Or we can see that Apgars are clearly fine and the baby is improving, and the baby would benefit from staying where they are skin to skin, but the doctors want to remove the baby, do early cord clamping and do some kind of resuscitation. She said, here we are entering an odd power dynamic where the physician is holding the clamp and makes an executive decision to clamp the cord without consulting the family while directing the nurse to take the baby to the warmer, even when the baby is doing well. So who does the umbilical cord belong to while the placenta is still attached to the uterus? Does it belong to the baby or the birthing person? Would this be considered assault or medical battery to either the parent or baby to violate consent when cutting the cord early? Is it legally similar to performing a medical procedure without consent? And this is a very complicated question. 


So thankfully, Sara Ailshire, a research fellow on our team here at EBB, agreed to kind of look into this question for our pro member. And so this was Sara’s response. Sara wrote, both parts of your question are legal in my nature. So my first and best response is that you may want to discuss this with a lawyer who specializes in the field of medical malpractice in Canada, particularly one who works in the field of birth injury. She wrote, a key element in establishing medical malpractice is whether the practitioner provided medical care and treatment that was A, below the standard of care, and B, that the breach of the standard of care caused an outcome or injury. If the standard of care is clamping after a certain amount of time, it may be difficult to assert that harm was done in a legal sense. And Sara found an article that can be useful for lay people who are trying to understand the legal situation in Canada. And I’ll put that link in the show notes. Sara also said, I wanted to look at what Canadian and American medical bodies say about cord clamping to see if there’s anything you could use as you help advocate for your patients. I’m sure much of this might be familiar to you, but because you’ve asked such a thought provoking question, I wanted to include some of the basics in case others are interested in this discussion and could use a primer or refresher. 


The Canadian Pediatric Society position statement on umbilical cord management recommends 60 seconds of delayed cord clamping for term infants and between 60 and 120 seconds for preterm infants. There are substantial benefits with delayed cord clamping for both preterm and term infants, as you well know. Better circulation, higher red blood cell volume, decreased need for blood transfusion, and lower incidence rates of some types of infections and even hemorrhage. The Evidence Based Birth® Signature Article on the third stage of labor, which we’ll link to in the show notes, also contains some information I think you might find useful. Here is a paragraph quoting from that Signature Article. A 2013 Cochrane review and meta-analysis that looked specifically at the timing of umbilical cord clamping included 15 randomized trials with nearly 4,000 mother-baby pairs who were assigned to early cord clamping. Defined as clamping within 60 seconds of birth, or delayed cord clamping, defined as clamping anywhere from one minute after the birth until the cord stopped pulsating. They concluded that delayed cord clamping offers significant advantages to the baby, such as higher birth weight, increased hemoglobin levels at birth, and increased iron stores in the first several months of life with no additional risk of postpartum hemorrhage or retained placenta for the birthing person. The overall rates of newborn jaundice were not different between the groups. There was one study that was an unpublished dissertation that found that fewer babies assigned to early clamping had light therapy for jaundice, 2.7% versus 4.4%. 


However, the study was never peer-reviewed, and they did not have an objective measurement of jaundice. So it’s been suggested by a different meta-analysis published in the Journal of the American Medical Association that we should not include this questionable study. And they did another analysis where they did not find any relationship between jaundice and delayed cord clamping. The concerns you usually hear around delayed cord clamping are mainly over the potential for an increased risk of jaundice in term infants. However, this risk is overstated and we really don’t have evidence to back it up. Something that Sara says she found interesting, and we think you will too, is that the newest evidence on delayed cord clamping and resuscitation is fascinating. There are currently large research trials where they’re doing infant resuscitation while keeping the cord intact. And these trials are either recently completed or they are close to finishing. And these trials are demonstrating that there is a benefit to delayed cord clamping in cases where the infant needs to be resuscitated. As well as among populations who are previously thought to be a poor fit for delayed cord clamping, such as growth-restricted infants, multiples, and some babies with cardiopulmonary congenital anomalies. There are also new types of resuscitation equipment for newborns that are in development that are designed to use when you’re keeping the baby’s cord intact. And there seems to be a new consensus forming, one that supports what so many midwives and birth workers and families have known for a long time. That the benefits of delayed cord clamping are worth the wait, especially or even if there is a situation where the baby needs resuscitation. Because that allows them to maintain their oxygen levels through the cord blood while they’re being resuscitated. So hopefully that is helpful, even if we couldn’t directly answer your legal questions. 


All right, third question is, I’m looking for research on the use of Nubain, spelled N-U-B-A-I-N, and its effects of stress on the baby when administered at the beginning of an induction. Many thanks. All right, this is a great question. So we do cover the evidence on injectable opioids in… an article in a YouTube video called the effects of IV opioids during labor. And that is applicable because Nubain is a type of opioid. In the United States, Nubain is approved by the FDA for pain management during labor. And we will link in the show notes to that FDA approval document. This same FDA approval document lists the known side effects of Nubain, which can include severe fetal bradycardia, which is a slowing of the baby’s heart rate in utero. They also state, quote, “The placental transfer of nalbuphine is high, rapid, and variable with a maternal to fetal ratio ranging from one to 0.37, all the way to one to six. Fetal and neonatal adverse effects that have been reported following the administration of nalbuphine to the mother during labor include fetal bradycardia, respiratory depression at birth, Apnea, which is not breathing, cyanosis, which is where your skin turns blue from lack of oxygen and hypotonia, which means your muscles are not contracting. Some of these events have been life-threatening. Maternal administration of naloxone during labor has normalized these effects in some cases. Severe and prolonged fetal bradycardia has been reported. Permanent neurological damage attributed to fetal bradycardia has occurred. A sinusoidal fetal heart rate pattern associated with the use of nalbuphine has also been reported.  Nubain should be used during labor and delivery only if clearly indicated and only if the potential benefits outweigh the risks to the infant. Newborns should be monitored for respiratory depression, apnea, bradycardia, and arrhythmias if Nubain has been used.”

We also found a research article that states that after five minutes of administration to the birthing person, 3% of the initial dose is present in the fetus, and then 15 to 30 minutes after it was administered, about 10 to 16% of the dose is going to be in the circulation of the blood of the fetus. Some clinicians do not like to use Nubain in early labor because it can slow down the process and cause labor to stall out. At the same time, it’s also typically not given towards the end of labor because you don’t want to negatively affect the baby’s ability to breathe if it’s given shortly before the birth. So it tends to be used more in the middle of labor, not at the very beginning and not at the very end. There are, you know, there’s info, more info about the benefits and risks of opioids in labor. And like I said, check out that video we have on YouTube on this topic. All right. 


The fourth question I have is, hello, I’m looking for research on consuming the placenta, either dehydrated, freeze dried or raw. By the birthing person. Thank you. All right, and here’s my answer. I did a review of this in 2018. It was one of our very first podcast episodes here at EBB, and I will link to that episode in the show notes. So it’s been a while since I looked at the evidence. So I did a PubMed search to see if I could find any new research since 2018, and unfortunately, there was barely anything of substance. There was one new study where they were kind of surveying people to understand their motivations for consuming their placenta, and there was another new review published in 2020, but it doesn’t seem like they really covered any new research since I reviewed the research in 2018. And then I found another review published in 2023, but again, there was no new research for them to review. The same researchers who did the early randomized trials from the Western United States are continuing to publish results from the same original and very tiny studies that are being published in the United States. They’re not using new data. They’re just continuing to analyze different aspects of the data they collected. And their latest report found no benefits with newborn weight gain or prolactin levels in postpartum people. So, so far, we really don’t have evidence supporting the benefits of placenta encapsulation, but that doesn’t mean that people personally, you know, they still might find it helpful. And I’d highly encourage you to check out that earlier podcast episode that I did, because it is kind of interesting to see the theory of how people think it might work and the very little research that we have so far, so far not backing up some of those assumptions. And this kind of brings us back full circle to my first question where I was talking about the if this, then that fallacy, just because you take something and you feel better doesn’t necessarily mean it’s because of the placenta encapsulation, although it could be, but so far research has not backed that up yet. 


All right, everyone, I hope you enjoyed this mini Q&A talking about pitocin, postpartum depression, delayed cortisone. I hope you enjoyed this mini Q&A talking about pitocin, postpartum depression, delayed cortisone. I hope you enjoyed this mini Q&A talking about pitocin, postpartum depression, delayed cortisone. Thanks, everyone. Have a great rest of your week. Bye. Today’s podcast was brought to you by the Signature Articles at Evidence Space Birth. Did you know that we have more than 20 peer-reviewed articles summarizing the evidence on childbirth topics available for free at evidencebasebirth.com. It takes six to nine months on average for our research team to write an article from start to finish. And we then make those articles freely available to the public on our blog. Check out our topics ranging from advanced maternal age to circumcision, due dates, big babies, pitocin, vitamin K, and more. Our mission is to get research evidence on childbirth into the hands of families and communities around the world. Just go to evidencebasedbirth.com, click on blog. And click on the filter to look at just the EBB Signature Articles. 



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