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Dr. Jones: Natural child birth, what is that? No woman wants an unnatural birth. But let's talk about normal labor or physiologic labor and how we can support it. This is Dr. Kirtly Jones from obstetrics-gynecology at University of Utah Health and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Today in The Scope studio, we're talking about normal or physiologic birth with Celeste Thomas, a certified nurse midwife and clinical director of birth care health care with the University of Utah College of Nursing. Welcome Celeste. So we all want a normal birth, but humans have these big babies and as a former of OB, all births looked a little risky to me, so let's talk about normal vaginal birth, or you use the word physiologic birth.

Celeste: Yeah, I prefer physiologic, because all birth is normal, right?

Dr. Jones: Yeah. Sort of.

Celeste: I mean, kind of. I mean, for us humans you're right, we do have big brains and so we have to come out sooner than a lot of mammals have to. So let's talk about physiologic birth though, right? Because when we talk about physiologic birth, we're talking about the things that drive birth, which are the hormones.

Dr. Jones: Oh, I'm all about hormones. Go for it.

Celeste: Right? So we're always about hormones at many different parts of our lives. So a lot of this stuff about keeping the room calm or comfortable sounds really nice, right? But it also serves a physiologic end, which is that when hormones are doing what they need to do, then birth runs more smoothly. We know this, because we know that there are things like: prostaglandins, oxytocin, beta endorphins, catecholamines, norepinephrine, epinephrine. All of these things actually build up and change as birth gets nearer, as spontaneous labor gets nearer, and they really serve good purposes. So we know for instance that epinephrine and norepinephrine and cortisol have effects on the fetal brain, pre-labor effects, so things that happen in the brain that are prepping that baby's brain for birth itself.

Dr. Jones: You mean like for getting squeezed?

Celeste: Yeah, for dealing with less oxygen.

Dr. Jones: Wow. I'd always wondered that we aren't weren't born with traumatic brain injury.

Celeste: Yeah. So they have preparations that happen in the fetal brain for dealing with less oxygen, because birth does lead to decreased oxygen for most babies just in the normal process and babies' brains ideally need to withstand that. And we know that there are synthetic versions of things that we use. For instance oxytocin, we will sometimes use a synthetic version called Pitocin, that's in the hospital, but we know also that the synthetic version of oxytocin doesn't necessarily act in the exact same way as naturally occurring oxytocin.

For instance, the synthetic version of oxytocin which causes contractions doesn't easily cross the blood-brain barrier. So this barrier to get into the brain in the same way that naturally occurring oxytocin that comes from the mother does. So there are things about that that are not exactly the same. So I think that the question is, what in the process . . . So sometimes there are ways to kind of safeguard the physiologic process even when things don't go exactly in the way that we were hoping, right, or even when things kind of go differently.

So some of the ways though that we can safeguard that process and allow these hormones to do what they need to do is we can allow labor to begin on its own when we are able to. We can allow labor to begin that way. And that means that we get this pre-labor up regulation in the uterus and allows that uterus to contract more efficiently with the oxytocin. We can get that pre-labor up regulation in the baby's brain as well to withstand decreased oxygen during labor. It also means we want to avoid excessive stress in labor. So a certain amount of stress in labor is normal and can actually beneficial but if that stress reaches a level that is excessive we've seen in a lot of studies that labor can actually shut down.

Dr. Jones: Well, so there's some good reason for that. I mean when you think about how long labors can be in humans. And maybe the tigers are coming or maybe you need to run away. And the fact that you could actually in early labor run away if you were afraid or if you weren't safe or if your baby wasn't safe, you could run away. Maybe it's a hurricane coming. Well, that's a long time to put it off. But we've known in women if they have a big scary thing, their labor can stop and then you end up having to start it up with external hormones and things like that.

Celeste: Absolutely. And sometimes even just going to the hospital, the smells of the hospital, the people talking to you, the bright lights, that can sometimes slow labor down. And we'll see that sometimes when a woman will get to the hospital and her contractions were two minutes apart at home, but now they're 10 minutes apart and kind of sluggish and not really picking up. So keeping the lights low, making sure she has the people around her that feel safe and comfortable to her. Keeping the questions to minimum, just whatever you need to know but not being excessive with that. Making sure that she has access to a doula which is a trained birth support person. Allowing her to move and eat as she needs to. These things are going to decrease those stress hormones and hopefully keep them in that optimal range.

Dr. Jones: Well, so let's back up just a sec, because certainly I could be in clinic and one in five women in the last couple of weeks of pregnancy will say, "Can't you just induce my labor? I just don't want to be pregnant anymore." That's a common . . . now on the one hand some of them say, "No, no, no, I don't want an induction," meaning start the synthetic hormones. But many women assume that doctors want to induce their labor. And maybe they live far away and they're afraid they won't get there on time, or maybe their husband's leaving to be deployed. I mean, there are thousands of reasons, and we've tried to do fewer and fewer inductions. And I think we're really dropping the number of inductions that we're doing. But women ask for it.

Celeste: Yeah, absolutely. I mean it's hard to say . . .

Dr. Jones: I want to tape your comments and say, "Oh no, your baby's brain isn't ready."

Celeste: Yeah. I mean, there are sometimes really good reasons to induce. We have to weigh the risks and benefits. But when we don't have a really good reason to do it, we need to talk with women about what the risks are. So maybe a baby's brain who isn't as primed to go without oxygen, maybe the baby's brain is not going to do us well in labor as the baby whose brain is primed. So it's something to talk about and really discuss with women, and let them know about the research that we have and the outcomes. They're better for spontaneous labor.

Dr. Jones: Well also women are given this due date which, not necessarily your patients, but mine used to think it was their God-given right to deliver by their due date, and so I'd say, "Here's an approximation. Here's your due date, but it could be a couple weeks on either side. So don't start counting down until it's a week or two after this date that we've given you."

Celeste: I almost feel that we kind of give women a disservice, by not giving them a range and just saying, "You could have your baby between this and this."

Dr. Jones: Right.

Celeste: And that would be totally normal, right? Dr. Jones: Right. Well, what are other good ways to support physiologic birth?

Celeste: The other things that are really important have to do a lot with the postpartum period. So when babies come out, making sure that as little as possible there is as little disruption to the process of baby being on the mother's skin as possible. And this is really interesting too because there are things about that postpartum period that we kind of tend to rush in the hospital. And I'm saying this because I've seen it and I've done it too. Where it's like, that baby is on her chest and it's kind of bobbing around and you're just like, "Baby go to the breast. It's over there." But it takes baby a while to get there.

Dr. Jones: But baby's got a headache.

Celeste: And sometimes baby has a headache. But that, it's interesting in the studies looking at babies who bob and are kind of looking around and don't necessarily get the breast in their mouth yet.

The mother's oxytocin goes much high than babies who are just latched on right away. So there seems to be some reason why these things are happening, so as much as possible to kind of watch for those danger signs of course and make sure mom's not bleeding too much or doing those things. But really allowing mom and baby in that little ecosystem, right? That's really important to a baby survival, allowing that to happen.

And the really interesting thing about these things is that, let's say you end up with a C-section. Well guess what? There's physiologic things we can support even in a C-section. We can allow skin to skin. We've been doing that in the operating room, right? So you can do skin to skin. There's a lot of studies now going on with the vaginal microbes.

Dr. Jones: Oh, we did a study. Listeners, you can actually tune in on that.

Celeste: Yeah. So again, there's a lot of stuff we don't know, but there's a lot of things that we can see physiologically that happen in nature that we can try to really safeguard.

Dr. Jones: Yeah. Well I always liked doing deliveries in the almost dark and especially after the baby was born, to turn off the lights so the mom and the baby aren't squinting. The poor baby, the lights are too bright. All I need is a spot at the other end so I can make sure the bleeding isn't happening and get the placenta delivered and let the mom and the baby be in the dark and quiet. And it gives me a chance for my blood pressure to come down as well, as the deliverer, so until the baby is out my blood pressure is up. So I like the dark.

Celeste: Yeah. Absolutely, and I tend to do a kind of mindfulness exercise when I'm even in that second stage when she is pushing, so I really feel my feet on the ground, I want to stay really present, I don't want to get too anxious, want to kind of create that space for her. But also be vigilant, of course.

Dr. Jones: The other thing is that I've often seen and I can't say I've participated because I'm not a yelling person. But when women are pushing and people want them to push firmly, although I don't think there's any evidence that they have to push hard. The body will make them push hard. But they start yelling at someone to push. And you see this on TV. "Push, push." And I'd rather be sweet talked. So talk about your own practice in this regard.

Celeste: Well, think about it. I mean, in the physiology about birth, they actually call it the fetal ejection reflex. So in some ways it's like a reflex, in that when the baby's head reaches a certain point, you will push, and if you can feel it, you will push. So especially with a woman who doesn't have an epidural, you don't need to . . .

Dr. Jones: It's uncontrollable.

Celeste: Yeah, it's uncontrollable. If you have a woman with an epidural, they do some times need a little more guidance, but again, they'll get the hang of it. And really having to direct them in pushing, there's no evidence that that is beneficial.

Dr. Jones: I just don't think it's beneficial at 60 decibels or 80 decibels. I think you could probably coach someone. But when you watch it on TV, they're kind of yelling at the mom to push, and can't you sweet talk that baby out?

Celeste: Yeah, and it's a less like a sport and more like a bowel movement than anything else, right? I mean it's like there is a certain amount of . . .

Dr. Jones: We'll hold that thought. Let's just hold that thought. Well as we put things together, I want to briefly talk about home births and the safety of home births and some studies from Europe and compare the European experience with the American experience.

Celeste: Yeah. Absolutely. So there's been a number of studies on out of hospital birth, especially home birth in the Netherlands, in the United Kingdom for low risk women. And this is an option that's completely integrated into their health system, meaning these are midwives who work with the National Health Service. They have a set criteria of risk that they look at to see if someone is eligible for an out of hospital birth and they have set criteria for transferring when they need to.

Dr. Jones: And the transfer time is short. They're not a hundred miles from the hospital.

Celeste: Yeah. They actually have to be within about 15 minutes I think it is. So in that scenario, home birth can be a really safe option for low risk women. If you look here in the United States, we have a different health system. It's not comprehensive. It can be rather fractured. And so this ability to kind of transfer seamlessly into the hospital when you're having a home birth is not as smooth. And so there are some challenges that way. When you look at outcomes you can see that Cesarean rate for low risk women is lower when they are out of the hospital. And that's true regardless of if it's a birth center or if it's a home birth. The Cesarean rate is lower for low risk women than low risk women who are having their babies in the hospital.

Dr. Jones: Right, and that the women who aren't transferred. And clearly when get transferred the story is over in terms of . . .

Celeste: But you still need to follow those women, those transferred women, and that's something we're actually doing here in the state of Utah, is that we are now capturing the women who transferred in to see what are their outcomes like? And to be expected, the outcomes are not as good, right? If you transfer.

Dr. Jones: Right. But once you've gone from low risk to high risk at home, then that ends up being a bigger problem than going from low risk to high risk in the hospital.

Celeste: Absolutely.

Dr. Jones: But birth is a physiologic phenomenon and there are many, many of us on the planet, so we must be doing it pretty well. Even though the stories from 150 years ago are heartbreaking with the number of moms and babies that we lost, I think that we really do very well in various settings with people who are informed and supported. The biggest issue is supported. And we all want the safest and most comfortable birthing experiences for mom and we offer options that let women make some choices in their birthing experience. And thanks for joining us on The Scope.

Announcer: Want The Scope delivered straight to your inbox? Enter your e-mail address at thescoperadio.com and click "Sign me up" for updates on our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Dr. Jones: "I don't know nothin' about birthin' babies, Miss Scarlett." That is something no mother should ever hear, except on the big screen. Trained midwives have helped women and their babies safely through birth for a long time here in the West. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Utah Health. No, it's not "Gone With The Wind."

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Building on the rich tradition of midwifery in the intermountain west, the Certified Nurse Midwifery program at the University of Utah is one of the top 10 programs in the U.S. Certified nurse midwives at the University of Utah help women with their choices in their birthing experience. Today in the Scope studio we're talking with Celeste Thomas, a certified nurse midwife and Clinical Director of Birth Care Healthcare at the University of Utah College of Nursing. Welcome, Celeste.

Celeste: Thank you so much.

Dr. Jones: So are there other kinds of midwives who practice in Utah?

Celeste: Yeah, so there are three types of midwives here in Utah. I am a certified nurse midwife, so I have gone through a master's or doctoral program after becoming a registered nurse to become a certified nurse midwife, and that's similar to a nurse practitioner.

And there are also midwives who are licensed by the state of Utah that are called licensed direct entry midwives. These are midwives that primarily do out of hospital births, so that would be home and birth center births. And they are also licensed by the State of Utah, and they usually go through an educational program but can also do a portfolio-based apprentice program as well in order to sit for their board exams. And then there are midwives who are not licensed in the state of Utah, and Utah allows midwives to practice even if they are not licensed. It's one of the few states that does that.

Dr. Jones: So your training, as you mentioned, was you had an undergraduate degree and then you got a nursing, an RN.

Celeste: I got an RN.

Dr. Jones: And then a special extra three or four or five or however many years it might be with a lot of hands-on training. I'd see the midwives in our program on labor and delivery at the U pretty frequently.

Celeste: Yeah, and a lot of their training is hands on. About half, 50% of their training is hands on and the other 50% is didactic or in the classroom.

Dr. Jones: Well, let's talk about that hands-on part. There are some aspects of the natural birth experience that women are kind of afraid of. Many women are worried about their bottoms. Getting a baby through there's no small task, and they might be choosing a midwife for many reasons, but one might be that they don't want an episiotomy, a cut that makes their vaginal opening a little larger. Now as we OBs don't commonly do episiotomy for a normal vaginal birth, but even we think that midwives might have a knack for getting the baby out without a tear. What is your magic?

Celeste: Oh, well, it's not magic. It's research.

Dr. Jones: Okay. Tell me about the research. You mean, you don't pass it down from midwife to midwife for the last 300 years?

Celeste: Well, it is very interesting. Maybe 20 years ago a lot of OBs were still doing episiotomies, and as the research came around to show that that was really not helpful to keeping that perineum, which is that skin between the vagina and the anus intact, that really has fallen out of favor and it's pretty rare to find an OB nowadays who does an episiotomy. Now as midwives, we rarely did episitomies, so we just kept rarely doing them and that's worked for us.

Dr. Jones: Oh. That was your knack?

Celeste: But the other things that we know about keeping the perineum intact, there are some things that we know in the research do work. So one is perineal massage. So this sounds really lovely, like massage.

Dr. Jones: Well, it sounds a little X-rated.

Celeste: It might. It really is gentle stretching. And doing that before you go into labor in the studies has been shown to decrease the number of tears, especially for moms who are having a baby for the first time.

Dr. Jones: So moms do it at home?

Celeste: Moms do it at home and with their partner. This does not have to be done by a health provider. So starting at 35 weeks and they only have to do it about once or twice a week. It doesn't have to be all the time in order for it to have the benefit.

Dr. Jones: Oh, well, that's good news.

Celeste: Yeah, so that's something kind of easy they can do.

Dr. Jones: Well, when you think about how much stretching actually, and often it happens over a period of just maybe 15 or 20 minutes. And for someone who hasn't had a baby to see where they are before and then see what has to happen, you're amazed that that tissue can stretch so easily and then come back to its almost before state.

Celeste: It's pretty miraculous, but we like to help it out if you're a first-time mom. And the research is pretty strong on that one too.

Dr. Jones: Okay, now let's talk about water birth. What is that?

Celeste: Well, water birth, it has been getting more popular recently, and really women laboring in water is the thing that seems to be supported in the research. So we know from the research that women who labor in the water have shorter labors. They have less need for any medications or an epidural, and they have greater satisfaction and greater mobility to be able to move, because as you know when you have a baby inside you, it can be difficult to kind of get into certain positions, right? It's hard enough just tying your own shoe.

So being able to move in the water is really lovely. And for a lot of women who don't want to use medication, being in the water during labor is really beneficial. The question is then when the baby comes out, is there a benefit to being under water? And from what we can see in the research there is no benefit.

Dr. Jones: But there's no harm either?

Celeste: For low-risk women, we don't have a lot of evidence, but from what we have there doesn't seem to be a lot of harm. We have a study ongoing here at the University of Utah about water births specifically to look at potential harms. But yes, it is a good option as far as we know for low-risk women, and a lot of women just don't want to get out in that really intense moment when the baby's head is kind of maximally stretching things.

Dr. Jones: How deep is the tub?

Celeste: So the tub in order for it to have its benefit needs to be at least 27 inches deep.

Dr. Jones: I would think it'd have to be deeper if you really want to have some buoyancy.

Celeste: You have to at least be immersed usually up to your chest in order to have those benefits.

Dr. Jones: Okay. Now the next question is, do you have to come as the midwife in your bathing togs, or do you have to just get your scrubs right in there or you just bend over and get back pain? How do you get in there?

Celeste: This is a good question. So body mechanics is important. The thing to remember is that you don't have to support the baby's body in the same way as you do when baby's born with gravity. So when you have a woman who's delivering, it's important to be able to get to the baby if you need to, but you're watching for that baby and you really are not doing a lot of hands-on in that moment when the baby's coming out. You just need to be able to reach the baby and bring the baby up above the water when the baby comes out.

Dr. Jones: Well, I was thinking again, if we go back to the episiotomy question when we are delivering a woman in a bed, this is OBs, we're careful to kind of support the head and make sure it doesn't come out too fast and gentle the head out. But that's kind of a low position to be in in the tub.

Celeste: Which is why we don't get into that position in the tub. It's pretty hard to get there, and depending on the mom's position. We do try to coach her through that crowning process so that she does it nice and slowly.

Dr. Jones: Crowning, when the baby's head is just about to be born but isn't it quite born yet.

Celeste: Yes. But in general she is letting the baby out, and then we are bringing the baby up to the surface when baby comes out.

Dr. Jones: Okay. But you don't get to have an epidural in the tub?

Celeste: No epidurals in the tub, no.

Dr. Jones: Okay. No narcotics in the tub?

Celeste: No narcotics in the tub because of the risk of dizziness. And currently at the University of Utah we also don't allow people to have nitrous gas also in the tub because of that risk of dizziness.

Dr. Jones: Right, right. Well, we have tubs at the U.

Celeste: We do. We have four rooms with tubs, but only one of them is technically deep enough to push your baby out under water. But you can absolutely use them . . .

Dr. Jones: For laboring.

Celeste: . . . and sit in the tub for labor, and that really is where the benefits come from.

Dr. Jones: Right. So getting back briefly to certified nurse-midwives, you primarily practice inside the hospital but create an environment which we'll talk about a little bit more that you think is as homey as you can be, given that you're close to all the other things that a hospital can offer.

Celeste: Yeah, so the majority of certified nurse-midwives give birth in hospitals, but there are certified nurse-midwives who do home birth and birth center births as well. We can catch a baby anywhere.

Dr. Jones: Oh, you can catch a baby anywhere. I'm glad to hear that.

Well, so whether you choose a physician, a certified nurse midwife, or a team of both, because sometimes people have complications, they need the entire team to be with them. For your OB care and delivery, our goal is to provide the safest and most comfortable passage for moms and their babies through pregnancy and birth. And thanks for joining us on The Scope. Thanks, Celeste.

Celeste: Thank you.

Announcer: Want the scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign me up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Interviewer: Have you ever watched those movies or TV shows where there's a woman in an elevator about to give birth and the elevator is stuck and you're stuck in there with her and you're panicking and you don't know what to do? We're going to tell you next on The Scope.

Announcer: Covering all aspects of women's health. This is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Interviewer: We're talking today with Dr. Kirtly Parker Jones. Dr. Jones, I've never been in the situation and I hope I never have to be. But in case I ever do come across it, if I'm stuck in an elevator with a woman about to go into labor or if we're stuck on the highway and the ambulance isn't coming in time and I'm a bystander and I want to help, what are things I need to be doing? What advice do you have for somebody that's just standing there, panicking?

Dr. Jones: First of all don't panic.

Interviewer: Don't panic.

Dr. Jones: Don't panic. Well I'll tell you a story. Some years ago and it was probably late in night. I was on labor and delivery as the attending physician and the elevator door actually opens and it's an orthopedic resident and a woman who actually has given birth in the elevator. So she walked into the front door of the hospital, which is not really close to labor and delivery and was close to delivering. And she didn't know where to go and he took her, as he should, to the elevator and things then happened pretty quickly.

So he was strutting around. He was so proud that he had delivered the baby. But when we actually got to the woman her panties weren't really even off, so I don't think he did anything. So when he said, "I delivered this baby." I said "I think she delivered this baby." And in fact that's what you need to remember. If the baby's coming that fast you just stand back.

So you stand back, you can make sure that the mom maybe is on the ground so the baby isn't going to fall and you want to make sure that the baby if anything, if the baby comes out that the baby's put next to the moms chest. The baby needs to be warm.

Interviewer: Okay.

Dr. Jones: You do not have to cut the cord. Somebody else can do that. If you're in the elevator you can wait for that but mostly . . .

Interviewer: It's not an emergency.

Dr. Jones: It's not an emergency. You keep your hands off.

Interviewer: Keep your hands to yourself.

Dr. Jones: Keep your hands to yourself.

Interviewer: Got you. Okay.

Dr. Jones: If the baby's coming that fast and the woman is on the ground so the baby's not going to fall. Then all you do is you wait. If you have something that's relatively clean so that you can wipe off the baby's face and mouth and then put the baby on the mom's bare chest so that skin to skin so the baby can stay warm. Cover them up. Don't feel like you have to cut anything. You can just wait.

Interviewer: And the mom will be okay.

Dr. Jones: Yeah. The mom's going to be okay. Now the biggest risk to the mom who's having birth that fast is not the baby coming out, because the baby's coming out, it's, is the placenta going to come out. And normally the placenta comes out on its own. The uterus continues to contract after the birth and usually then it's expelled.

But if it doesn't come all the way out then the placenta separates and the mom can hemorrhage. That's where you need to make sure that you're getting help. So if the mom is hemorrhaging and you just see blood everywhere, the best thing you can do is put your hand on her tummy, below her belly button and try to massage this lump that's there and that's the uterus, so that the uterus will contract well.

Most people aren't going to feel comfortable doing that because they don't know what a uterus is. But after baby is born if the placenta isn't out yet, the uterus is still moderately big. It's below the belly button. It maybe just feel like a chubby tummy until you rub on it and then it should contract and become a hard ball-like melon size ball and keep massaging it so the uterus can contract. But hopefully someone's called for some help.

Interviewer: Right.

Dr. Jones: But remember women all over the world deliver their baby's by themselves. If it's coming that fast you don't need to put your hands in anywhere.

Now there is the baby coming that fast and its feet first and that's going to be difficult. My guess is if you have absolutely no experience, you should probably let things go and not tug on the feet.

Interviewer: Okay.

Dr. Jones: But if the head comes out first, that's the way it's supposed to and that's the biggest part of the body so if the head can fit, everything else is going to fit. If the feet come out first then the head may not come out and that can be a problem. But an inexperienced person should not be pulling.

Interviewer: So the rule of . . . Keep your hands to yourself still applies?

Dr. Jones: Right. So it's not like pulling a calf. Just put the baby skin to skin next to the mom and hopefully somebody will get in there who knows what they're doing.

Interviewer: So the takeaway is if you are bystander to a delivery, a birth delivery, keep your hands to yourself.

Dr. Jones: Right. Get the mom down on the ground. You can support her shoulders or head. She will push. If it's coming that fast her body will do the right thing. You don't know what size the baby is.

Interviewer: Stay above her head pretty much.

Dr. Jones: So stay above her head and then if someone can keep an eye so that when the baby does come all the way out that you wipe the baby's face a little, you can blow into the baby's face and make sure it takes a little breath. But then put the baby skin to skin next to the mom. The umbilical chord is still attached. Hopefully everything will go okay with the umbilical cord because that's the next risky time. But don't put your hands in there if you don't know what you're doing.

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Interviewer: You are about to go into labor, your husband's nowhere to be found, you can't get to the hospital in time. What do you do? We'll tell you coming up next on The Scope.

Announcer: Covering all aspects of women's health this is The Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Interviewer: We're here with Dr. Kirtly Parker Jones. I'm sure that if you're about to give labor at home with nobody there to help you or you're stuck in an elevator or somewhere, you're not going to pull out the internet and listen to this podcast. You know, to conscience people, what can women do who are about to go into labor?

Dr. Jones: About to give birth.

Interviewer: About to give birth. There we go, labor's different. About to give birth, with nobody around to help or inexperienced people around how to help

Dr. Jones: There are those women who have very rapid labors and lucky for them, but it is a little scary. Some women who have 15 minute labors or they have their first contraction and then they have their second contraction and then all of a sudden they feel the baby coming. Now this is not something that usually happens to first time moms. It's more likely to happen to women who've given birth before, meaning the pathway through the pelvis has been stretched a little, the baby can come out a little faster.

Interviewer: Now you've mentioned that, I remember my mom because I was about six when she had my little baby brother and she literally had the baby, she literally had him in the elevator. But she was surrounded by people. They were rolling her into the delivery room and he just came out before they even got there.

Dr. Jones: You got her on a stretcher, so at least she's lying down. The baby is not going to fall on the floor.

Interviewer: Doctor's with her.

Dr. Jones: Let's say you have fast labors and you feel your water break and you have your first contraction and then you know the baby's coming. Maybe you have time to grab your phone for 911, but the first thing is, don't try to get in the car and drive. Just don't do that.

The first thing is to get at ground level. Could be a bed if you want to or it could be the floor. If you're going to give birth that fast, it's often that you've had a baby before and that's a good thing. The baby is not going to get stuck. If you feel the baby is coming, then the head is already on the pelvic floor. It is way down.

Interviewer: It is less pain for you.

Dr. Jones: You know have the urge to push, that baby is on its way. That's the good news and the urge to push is uncontrollable. What do you need to do? First of all, the baby is going to come out. The baby is coming out you can, when the baby is out, you'll know the baby is out. The placenta isn't out yet.

But what you really need to do is to have some kind of cloth or a towel so that you could wipe the baby dry because if it's chilly, and the baby is wet, which it will be, then it will get cold. You want to dry off the baby and then put the baby skin to skin with you. It is not your job and you should not pull on the placenta. Hopefully you're not going to be there by yourself for the next three days.

Interviewer: Hopefully not.

Dr. Jones: Hopefully that's not going to happen.

Interviewer: Maybe 30 minutes.

Dr. Jones: The placenta itself is a very risky time for mom. With the baby, it's risky for the mom and the baby if the baby gets stuck. But of course it's not getting stuck if the baby is on its way and then we worry about the placenta coming out. But the best thing to do would be to actually dry the baby off if you can.

If you've got a towel, put the baby skin to skin on your chest. If you want, you can put the baby to your breast. The baby, if he's breathing well or if she's breathing well, may actually grab onto a nipple and suck a little bit.

Interviewer: That early?

Dr. Jones: Yes, and that would be great because it will help your uterus contract. Stimulation of the nipple releases oxytocin, which makes your uterus contract. And that's really what you want to expel the placenta. You need to wipe the baby off, put it skin to skin. If the baby isn't breathing, then you can give a little spank if you want to.

Interviewer: Just to hear it cry.

Dr. Jones: You can give it a blow in the face, that sometimes can stimulate a baby to breathe. If the baby is really tiny then that's even more important that it keep warm. And you can breathe in the baby's nose or face, put your mouth over the baby's nose or face and give it a little breath if it's not breathing. But mostly the issue is getting it close and warm.

Get down, get comfortable. The baby's going to come, lucky you, unfortunately. Put the baby to breast if you can and that will help the uterus contract. People do this all over the world. Babies that come out too fast are probably better than babies that get stuck.

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Dr. Jones: Good bacteria and bad bacteria. We are being bombarded by information about the bacteria with which we share our bodies, but what about our babies? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Healthcare, and this is Babies and Good Bacteria on The Scope.

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Dr. Jones: We have previously talked about how babies benefit from exposure to different kinds of bacteria. Babies who have a wider exposure to bacteria may have less obesity, diabetes, asthma and autoimmune disease. So it is okay to put your baby on the floor, and it is okay, mostly, to let your dog lick your baby.

Now, a baby in the uterus the day before it is born is living in a mostly sterile environment. The passage through the mom's birth canal during labor allows mom's bacteria to colonise the baby, and breastfeeding allows some more.

The vaginal bacteria in healthy pregnant women are largely lactobacillus, which is a bacteria that can help babies metabolize milk, but what about babies that are born by cesarean section? There are some data to suggest that babies born by cesarean, and that is about 30% of babies in this country, may have more autoimmune diseases like asthma, type 1 diabetes and other conditions, and food allergies than babies that were squeezed out through the mom's vagina, especially babies that were born via cesarean, without moms having been in labor for a while.

Okay, so it isn't a huge difference in which babies get some diseases, but if you were planning a caesarean, could you do something about it? A short report has just been published in the Journal of Nature Medicine suggesting that you can. This was a very small study of 18 moms and their babies at the University of Puerto Rico in San Juan. Seven babies were born vaginally and 11 babies were born by elective cesarean section without labor.

Four women who were scheduled to have a caesarean had a bit of gauze put in their vagina, then removed and put in a sterile container before the cesarean was performed. A few minutes after the babies were born they were dried off and four of the babies had gauze wiped over their skin. Eleven other babies did not. Over the following month, the moms and their babies had their microbiome, their bacterial ecosystem, assessed. The babies who were treated with the gauze had skin bacteria more like their moms and more like the babies born vaginally. The babies born from cesarean who did not have the gauze treatment had bacteria more like that from the hospital environment, and less like their mom's vaginal environment.

The babies who had the gauze treatment weren't exactly like babies born vaginally in that their gut bacteria weren't as varied and abundant as babies born vaginally. This could be for several reasons. One is the fact that moms getting a cesarean often get antibiotics to decrease the risk of infection in their cesarean incision or their uterus. Infection is relatively common in cesarean incisions, and that is why we give women antibiotics routinely who are having a cesarean.

So lots goes on in labor that involves moms exchanging bacteria with their babies. Now we don't know if these babies with the gauze treatment will grow up to be healthier or not. And we don't know if there are some moms with bacteria or viruses in their vagina that shouldn't be shared with their babies.

A bigger study is ongoing right now at New York Hospital. However, this idea is being disseminated in mothers' blogs and magazines, and women are asking for it. The professional medical organizations haven't recommended it yet, and I am pretty sure I would add the statement, "Don't do this at home," but if you're interested you should ask your OB.

There is so much to think about when you're going to be a new mom, and this wouldn't be number one on my list, but it is something to know as we learn more and more about the world in which we live and into which we bring our babies.

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Interviewer: Giving birth in water - is it something that you should consider? That's coming next on The Scope.

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Interviewer: It's a trend. It's like one of those popular things that expectant moms-to-be are just doing. It's giving birth in the water. We're talking today with Debra Penney. She is a certified nurse-midwife in the College of Nursing at the University of Utah. Is it, first of all, safe?

Debra: Yes. Actually, for low-risk women who have no medical problems who are expecting a normal progress in birth, it's very safe and it's very comfortable. It can relieve a lot of pain in labor as well.

Interviewer: Is that why a lot of women choose to give birth in the water, then, as opposed to the traditional way?

Debra: Yeah, many women find it very relaxing and pain relieving to be in the water during birth. It's warm water, it's clean, it's filtered as hours progress, and they find it very good to be buoyant and in the warm water.

Interviewer: Is this something that's done at home or is it also something you can do at a hospital?

Debra: Not every hospital offers this. Here at the University of Utah we are offering it, and yes, they can do it in the hospital. It's often done at home for home births as well.

Interviewer: And so I guess if it's safe, if it's comfortable for the mom, my next question is, what is the difference between giving birth in the water versus the traditional way? Is there a difference in why a mom would choose to give birth in the water instead?

Debra: Well, as midwives we like to give mothers choices, and we like to really consider the safety of those choices as well. So for the low-risk women we do some additional laboratory tests like hepatitis C for the mother because that can be transmitted in the water, and so if she's negative with that we can go ahead and anticipate a normal birth with her in the water. So the midwife traditionally can bring the baby to the surface at birth within five seconds. There's actually a protocol for safety, both for mom and baby with a water birth.

Interviewer: Are there any side effects or risk?

Debra: There's very few risks. If she's got a lot of meconium that shows up telling us the baby is stressed, we'll get her out. If for some reason labor doesn't progress, we'll get her out. And we always give women the choice to self-select when it comes time to push, and a lot of these women do get out to push the baby out and/or the placenta after the birth. But of all of the water births that have been done around the world, there's not a huge chance for infection or any of the other normal risks you would think of.

Interviewer: So it sounds like it's a pretty safe, natural process to give birth in the water. If it is a choice given to moms, then, is there a deciding factor, like, "Oh, I should be giving birth in the water versus in a hospital in the traditional way?"

Debra: It's really up to the woman, and some women come in wanting that straight from the beginning and we have not offered it until now. Some women just choose to labor in water and to get out when they're ready. So it's really up to the woman as far as what she wants, and having only one tub at the University will limit some of their choices. But it is sort of a trend these days.

Interviewer: So it's not really a "this is better than this" sort of a thing?

Debra: No, it's definitely not necessarily better. It's just a choice.

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Debra: If you've been to the dentist you may have heard of laughing gas. Did you also know that it's used for labor pains? Today we'll be talking about nitrous oxide on The Scope.

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Debra: I'm Debra Penney and I'm talking today with Michelle Collins, PhD. She's also a certified nurse midwife and the director at Vanderbilt University of the Nurse-Midwifery Program. First of all Michelle, what is nitrous oxide?

Michelle: A lot of people think of nitrous oxide as laughing gas because that's what they know it from the dentist. It is similar to what they use at the dentist, but it's a different concentration. A lower concentration when we use it in labor.

Debra: And tell me, how is it given to women in labor?

Michelle: They inhale it either through a mask or a mouthpiece. The mask goes over their mouth and nose, where the mouthpiece they purse their lips around.

Debra: And can she be up and mobile while she's taking this gas or does she have to be in bed? How does that work?

Michelle: It does allow for a woman to maintain her mobility. So she can be on her birth ball, on her hands and knees on her bed, doing slow dance with her partner, in the rocking chair, any position really.

Debra: What kind of affect does it have on her and does it have any side effects?

Michelle: Probably the largest side effect is about 10% of women will feel nauseous or need to vomit. But that's only 1 out of 10 women. That's probably the most prevalent. Some women get a little bit dizzy when they use it as well.

Debra: What about the baby? How much of this gets to the baby?

Michelle: So there has not been a great deal of research done on nitrous oxide, although we have a large body of what we call anecdotal evidence, meaning it's been used for almost a century in other countries. So we have lots of babies born over lots of years in lots of countries to look at and we've not seen it affect the baby at all after birth. In other words, we don't see sleepy babies or drug affected babies from mom using the Nitrous.

Debra: Well it sounds like a pretty good thing then. If it's that good why aren't we using more of it here in the US? I understand there are only about 100 hospitals that have it available to laboring women.

Michelle: It was actually used in the '50s, and then with the advent of the epidural anesthetic it kind of went out of favor as epidurals rose in popularity. Now in other countries the epidural rate is not what it is, not as high as it is in the United States, so they continue to use nitrous oxide widely. For instance some countries, like Great Britain, 60% of all women in labor use it. Some countries like Norway 80% of women use it in labor.

Debra: So does this nitrous oxide work for every woman?

Michelle: Not every woman is going to take the nitrous oxide just like not every woman likes an epidural or not every woman likes a narcotic. Some women will try it and not like it at all, feel it's not helpful, and move on to something else.

Debra: When hospitals use it, do they have some kind of guideline in place for how it's given, or who gives it?

Michelle: In most places in the US the midwife or obstetrician or family practitioner, or whoever is taking care of the mother, gives an order to the nurse, and the nurse initiates the nitrous oxide. In some hospitals only an anesthesia person initiates it. So it's dependent on the hospital. In birth centers there are only midwives and nurses so they would be the ones doing it at a birth center.

Debra: So it sounds like a pretty good option. What other kinds of affects, other than taking the pain away, does it have any other affects on the mom?

Michelle: It is really good for anxiolytic properties. What that means is it decreases one's anxiety. So for some women it's not the pain of labor that is intolerable, but the anxiety. They're so afraid of the birth process. So it can decrease their anxiety and help their labor along.

Debra: So apart from labor pain, say she's waiting for an epidural that's really her drug of choice, can she still use this nitrous oxide while she's waiting?

Michelle: Yes, that's a good use of it, is for the woman to inhale it while we're having her epidural placed. Helps with the pain, helps with her anxiety and generally gets her through that transition period until the epidural is working well.

Debra: Have you ever seen it abused in the hospital? Or heard of stories with it abused?

Michelle: That's a common misconception and it doesn't appear in the literature as any problem in the European hospitals and we've been using it at Vanderbilt for four years and have not had one instance of that happening.

Debra: So what if a woman tries it and finds out she doesn't really like it?

Michelle: If she inhales a few breaths, part of the advantage of using nitrous oxide is it's a very quick onset. Within about 30 seconds she'll feel an affect, and it also has a rapid offset. Meaning if she doesn't like it, she stops breathing it, takes a couple breaths, and the effect is gone. And that is really one of the advantages of using nitrous oxide.

Debra: What are some of the other advantages?

Michelle: Besides not affecting the baby at all, that we have seen in use, women can also control it themselves, so it's not strapped to their face where somebody else is controlling it. They are empowered to breathe it when they want and not breathe it when they don't want. This makes it a really attractive advantage, and hopefully it will be widely available to women in the US soon.

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Dr. Jones: When should a baby be born? It's sort of a Goldilocks problem isn't it? When is too early? When is too late? And when is just right? This is Dr Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care. Today we are talking about when should babies be born, on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Jones: So how do you know when an apple is ripe? Just right. By color? By size? By season? Do you pull it off the tree? But if you're wrong you can't put it back. Do you wait till it falls until the tree thinks it's ripe? Well then it might get bruised. So is it the number of days? How do you calculate them? When is too early? When is too late? What about babies? When do we know that the baby is ripe?

Today we're talking with Dr. Erin Clark a perintologist, that's someone who specializes in high risk pregnancy, about when is the baby just right. Welcome to The Scope Dr. Clark.

Dr. Clark: Thanks for having me.

Dr. Jones: So how do we know when a baby is ripe? Is it 40 weeks? Is it nine months exactly? Is it certain amount of days? And how do we get that number?

Dr. Clark: The formal definition of when a woman is due is 40 weeks from the first day of her last menstrual period. We know generally that that's the date because that's around the time when most people spontaneously go into labor. We have great respect for when Mother Nature does it right. Certainly Mother Nature doesn't always get it right and outcomes for moms and babies are not always good. Ten percent of babies in the United States are born too early, but most of the time delivery occurs about that 40 week mark.

Dr. Jones: So when is it too late?

Dr. Clark: It's a complicated question but if we look at outcomes for moms and outcomes for babies, a variety of outcomes. Stillbirth, c-section rate, the ability of a baby to breath and do well after delivery. If we look at all of those outcomes, the lowest risk time, the sweet spot, so to speak, that perfectly right apple seems to happen at 39 weeks give or take a week or so. So between 39 and 40 weeks appears to be the lowest risk time.

There's very good data that suggest if we go before 39 weeks electively, sometimes there's a very good medical reason to do that, but before 39 weeks babies have more difficulties after birth. They can have difficulty regulating their temperature, they can difficulty with eating, they can have difficulty with breathing. We know that in a well dated pregnancy at 39 weeks or beyond, babies do really well.

There is a point though at which pregnancies can go too far and it's a gradual increase in risk that happens after the due date which is at 40 weeks. So again that sweet spot appears to be 39 to 40. In general we try to get women delivered about a week past their due date at the latest because those risks start to climb.

Dr. Jones: So what are those risks?

Dr. Clark: For babies there is a risk of stillbirth that climbs over time. That's the biggest and scariest risk because a baby who has a stillbirth does not survive to have any of the other outcomes. But there's also a high rate of c-section because the placenta while it's miraculously marvelous organ, it has a life span. And after the due date it starts to baby and labor is a stressful process for babies and if that organ is not functioning optimally, we see signs in labor by watching the baby's heart rate that the baby is just not getting the oxygen and nutrients that are necessary and so the c-section rate is higher.

There is also some other risks that are higher for moms. The rate of hemorrhaging associated with delivery, the rate of having a baby that doesn't fit because of size. Those things go up over time too. So when we look at those myriad of complications, all of them are at their lowest risk at that 39 to 40 week mark.

Dr. Jones: But it's not always so easy. So if you decide 39 to 40 is a good number, how do we get the baby out then?

Dr. Clark: Maybe this is the apple and the worm analogy.

Dr. Jones: Okay.

Dr. Clark: There's very good data, 39 to 40 weeks baby is ready to come out beyond 39. But the other question that you're getting at is when is mom ready? Sometimes the two are not in sync. But what has been shown is that if you don't induce labor in a timely fashion after the due date has passed, actually the c-section rate goes up and not down. The cervix is like a fist, before labor starts, it's hard, it's somewhat unyielding and as preparations for labor happens it gets softer.

Dr. Jones: Well that's a good thing because we want to get the baby in for those 40 weeks or 39.

Dr. Clark: Correct. It's appropriately unyielding. But as preparations for labor made it gets soft, it get thinner, it starts to open. These are signs that we like to see as women get ready for labor and even in a patient who has a cervix who's not quite ready, if they're going past their due date especially a week or more, we know that their lowest risk are to induce labor rather than wait.

There's the other question though of when is the earliest that's safe to induce labor without a medical indication? And 39 weeks appears to be the earliest based on what we talked about as far as risk for baby go up if we go any sooner than that. In a woman whose had babies before who has a cervix that is soft and ready for labor and who is known solidly to be at least 39 weeks gestation, induction of labor electively is felt to be a very reasonably medically safe practice.

What is less well known and what we need research is what about the woman who has not had babies before? There's many advocates, experts across the nation who say because of this data that suggest that 39 weeks is that lowest risk spot, maybe that should be a policy. Maybe we should induce everybody between 39 and 40 weeks because we know we would see less stillbirths, we would see less pregnancy complications like preeclampsia. Maybe that's the right approach.

Clearly there's a lot of push back saying Mother Nature, Mother Nature. We should let most of these labors go on until there's an indication to intervene. But it's still a big question, and it won't be answered until we take a group of women who have not had a baby before and randomly assign them to either watchful waiting. Seeing if they go into labor on their own and intervening if there's a medical reason. Or another group of women where when they hit 39 weeks and we say it's time to have a baby and regardless of what your cervix says as far as readiness, we're going to give you the medications that will stimulate labor.

Dr. Jones: So this is study that's ongoing?

Dr. Clark: This is a current study. This is a national multi-site study. In Utah we have several participating sites one of which is The University of Utah, one of which is Intermountain Medical Center in Murray, LDS Hospital in Salt Lake City, Utah Valley Regional Hospital in Provo, and McKay-Dee Hospital in Ogden. We are trying to enroll 6,000 women across the nation for participation in the study.

Dr. Jones: Are ladies anxious to sign up? I am assuming randomization is 50/50.

Dr. Clark: It's 50/50.

Dr. Jones: When they randomized and they get not the arm they wanted, are they doing okay?

Dr. Clark: Yeah, we have two camps of women. One is very much wanting spontaneous labor to happen. They want that story of my water broke in bed one cold winter night. They can tell over and over again to this child forever. They want that natural course. And they're not interested in participating and that is totally fine.

There's another group of women who says for logistical reasons this would be a really nice thing to have a time delivery about a week before my due date and there's some enthusiasm there for participation. Remember this is a group of women who are not eligible otherwise to have an elective induction a week early who, yes, are very interested in participating. The ones who are very much often want to be in that induction of labor arm and there are sometimes tears when they randomize the other way but again it gives them a chance at that earlier intervention whereby they wouldn't otherwise. So for some women it is a very nice option.

Dr. Jones: To round up, it sounds like you want your baby just right and somewhere between 39 and 40 weeks is, we think for babies, just right. Up to 41 is kind of practice now but maybe sooner is better. People, if they're having their first baby and want to contribute and they deliver at those places can sign up and hopefully you'll have a perfect little apple for Thanksgiving.

Dr. Clark: Right. That's the goal.

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Dr. Jones: Okay, today is a quiz. True or false, question one, is a cesarean the safest way to deliver a baby? Question two, are there too many cesareans being done in the US?

Well, the answer to the first is true and false, about the safety of cesarean. But the answer to the second, are there too many cesarean deliveries done in the US, is very probably true. How many births in the US are done by cesarean? What was it in years past and why has it changed and what are the risks? This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care. How should your baby come out? And this is The Scope.

So, how many cesareans should be done for the safety of the baby and the mom? The United Nations world health report in 2010 suggested that a cesarean rate of about 15% should be about right. And Scandinavian countries with the best maternal and child mortality rates in the world--Iceland, Sweden, Norway--get it right at about 15-17%. The United Kingdom comes in at 22%, Canada at 28%, and the US comes in at 33%.

The UN calculates a cost of about $687 billion. Let me say that again, $687 billion extra dollars in US health care for what might be extra cesarean deliveries over 15%. In 1965, the C-section rate was about 4.5%, 17% in 1985, and now we're at 33%. Our maternal and baby health hasn't increased significantly since 1980 and the C-section rate has.

First of all, Utah is doing great. We have the third lowest rate of cesarean births in the United States at 23.1%. Good for us and our doctors and our mothers. Alaska has the lowest at 22.6%, closely followed by New Mexico at 22.8%. Kentucky comes in at the highest at 39.7%. Brazil comes in at 46% with 82% of women who live in Rio de Janeiro with health insurance being delivered by cesarean. What's up with that?

So, should we worry? Is cesarean safer? Certainly for some women and babies it is, and that's where the 15% comes from. Babies coming out sideways, babies that are too big, babies in fetal distress, moms who are very sick and need to get delivered right away. Okay, that's where the 15% are. But all things considered, a vaginal delivery is safer for the mom and not riskier for the baby. In fact, scheduled repeat cesarean sections may be done too early and the babies aren't ready yet. So, what are the risks of cesarean? Well, for the moms, slightly higher risk of hemorrhage and infection and severe illness and death. For the baby, it's the risk of being born too soon. And there's an increased risk of problems with the placenta in pregnancy after the one with the cesarean.

So, one-third of cesareans are done for what doctors have called labor arrest, meaning the mom isn't making progress quickly enough. So, the question is, fast enough for whom? The doctor? The mom? This is where we could make some changes. ACOG, the American College of OBGYN, recommends that the first part of labor, when the cervix is starting to open, should be extended to 6 centimeters. This is the time when normally labor takes a while, and we should just wait and let it happen if the mom and baby are okay.

Secondly, the pushing stage can go on longer. It used to be said that if a woman hadn't pushed her baby out in two hours, then you should consider a cesarean. This was never really true and if mom and baby are okay, this stage can do on for three hours or longer. Then, women with an epidural are going to take longer and moms and doctors should be patient. Lastly, but very importantly, induction of labor, labor that's started by the doctor, shouldn't happen except for good medical reasons. Labors that are induced take longer. Moms and doctors should be patient.

No mom wants to be pregnant one minute longer than necessary, but unless there are good medical reasons, moms and their doctors should wait until the body and the baby think it's time. A natural labor may go better. So, we should save cesarean operations for women and babies who really need it. Moms and doctors need to be patient. A scar on the uterus isn't the best thing for the next baby coming. This is Dr. Kirtly Jones and thank you for joining us on The Scope.

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