Antonín Pařízek is one of the most well-known obstetricians in this country. Chief physician of the perinatology center and deputy head of the Department of Gynecology and Obstetrics of the General University Hospital in Prague and the Charles University 1st Faculty of Medicine. Because November is the lung month, the professor talked in an interview for LP-Life.com not only about the problems of today's pregnant women, but also about the importance of breathing during pregnancy and childbirth.
November is upon is, which is the month of the lungs. How would you describe breathing in pregnant women? What problems do they tend to have during pregnancy?
Significant anatomical and functional changes occur in a woman's respiratory system during pregnancy. These changes are necessary mainly due to the growing oxygen demand of the mother and the fetus. Respiration adaptation occurs in the first weeks after pregnancy. Changes are mainly controlled hormonally. During pregnancy, there is also a change in the anatomy of the woman's chest. The chest cavity expands to the sides. At the end of pregnancy, due to the growing uterus, the position of the diaphragm (main respiratory muscle, editor's note) rises by about 4 centimeters, and although it presses mechanically on the lungs, the vital capacity of the lungs does not change during pregnancy.
Breathing during childbirth is very important. Oxygen supply is required to maintain oxygenated blood flow to all of the mother's organs. The flow of oxygenated blood through the uterus and placenta plays a key role in the successful management of not only pregnancy, but especially childbirth. On the other hand, breathing training in antenatal classes is traditionally overestimated. It is often even incorrect. The activity of the respiratory muscles, diaphragm and auxiliary respiratory muscles can consume a large amount of energy, which the woman usually needs at the end of childbirth when expelling the fetus (professionally second stage of parturition). If the mother breathes technically incorrectly during childbirth, it can not only paradoxically cause a disturbance in the distribution of oxygen to the fetus, but she can also deplete her energy. The correct way of breathing in the first stage of labor (dilation, which lasts 8-12 hours), during labor pains (professionally uterine contractions) is only to take deep and relaxed inhales and exhales. The incorrect "breathing like a dog" training is not appropriate in this case. This way of breathing (professionally free / intentional hyperventilation) is not even needed by many mothers at birth. However, women do not have to worry about ignorance of the correct breathing technique during childbirth. An experienced midwife can help a mother with breathing training during childbirth in the span of 2-3 contractions. By the way, the right technique and concentration on breathing can distract a woman from labor pains. Breathing is therefore at the forefront of a non-pharmacological approach to relieving labor pains. However, if women are giving birth with bronchitis or an upper respiratory tract infection, they should be offered epidural analgesia during childbirth. It helps to protect the mother from the excessive exertion caused by hyperventilation, which occurs during pain from uterine contractions. In these cases, epidural analgesia may help to prevent acute deterioration of lung function.
We must be able to help these women too. At the "U Apolináře" maternity hospital, we have a sophisticated system of antenatal courses, during which our most experienced midwives prepare future mothers and their partners for childbirth. The courses take place in a part of the building called the AVE Center. In the vast majority of cases, even women who'd been set up this way manage to calm down and prepare well for childbirth. If even this approach does not help, we still have the help in the form of a clinical psychologist in reserve.
On the contrary, more and more older women are giving birth to their first baby. The average age of first-time mothers in Prague has already exceeded 30 years. The task of doctors is to warn the general public that the pregnancy in an older woman does not bring any biological benefits at all. However, it does depend on whether the woman gives birth at the age of 35, or at the age of 45 or even after the age of 50. Medicine can handle even the most complex cases, but common clinical practice shows that older women often suffer mentally rather than physically. Postpartum convalescence, getting up at night, breastfeeding, caring for a child are factors that make women far more exhausted than if they were under 30 years of age.
In recent years, even such a conservative field as obstetrics has not remained unchanged. Previously commonly used automatisms, often even paternalism, have disappeared. The field has become more open. Midwives and doctors individualize their approach to pregnant women and try to meet the wishes of mothers and their partners. Pregnant women and women in labor have become partners for the health professionals. Safety for both mother and child has increased and it is possible to observe greater satisfaction of new parents with the provided services. In the Czech Republic, we have never achieved better obstetric results in history than we do at present. In other words, our country has ranked at the forefront of the world in terms of safety for mother and child at birth. These are the positives.
On the other hand, I would mention the present negatives. Women give birth at an advanced age, have a number of associated diseases, problems are beginning to stem from obesity in pregnancy. A mother weighing over 100 kg is no rarity today, my personal record is the delivery of a woman weighing 200 kg. And last but not least, social media. Nowadays, especially on social media, the field of obstetrics is subjected to serious stress tests. Some authors of hoaxes and fake news seem to be deliberately abusing the vulnerable mental state of pregnant women. Under the guise of so-called good advice, we can come across a sea of nonsense and sometimes even dangerous recommendations. People who do not have a medical education, not even in any similar field, have also learned to speak on the field. I am convinced that this wave will be swept away by the spread of critical thinking of the general public, and that the situation will certainly return to normal in the future.
When the first lockdown happened, many couples stayed together at home, some divorced and others spent quarantine having sex. Does it show on the numbers? Will we have a generation of coronavirus children?
Currently, there are no data that would clearly indicate whether the spring lockdown will contribute to increased birth rates in our country. We won't know that until the turn of the year.
We are very lucky at the maternity hospital "U Apolináře". The building of the former Zemská maternity hospital was designed by the leading Czech architect and builder Josef Hlávka. He constructed a building consisting of six pavilions with eleven tracts. It is the pavilion system that still makes it possible, to close off individual parts of the building if necessary and thus prevent the spread of infection. We currently have isolation sites for pregnant women and new mothers both in quarantine and Covid positive. We currently have enough protective equipment, techniques and technologies. Since the spring, our clinic has had its own crisis staff, which responds flexibly by adjusting operations according to the current epidemiological situation and individual cases. Unlike in the spring, women giving birth can be accompanied by their partners during childbirth, even in the case of a caesarean section, if they are under regional anesthesia. Children are not separated from mothers. Bonding and breastfeeding is also recommended for Covid-positive women if hygiene rules are followed. If the health and condition of the mother and child allow, it is possible to release them earlier. Organizationally, everything is fine at first glance. But obstetrics is a field that cannot be stopped or even reduced under any circumstances. Doctors, midwives, and nurses have not been able to rest properly since spring. Some could not even take time off for summer holidays. The staff therefore works in the state of fatigue and often under great stress. Few can imagine caring for pregnant women and mothers with COVID-19. Personnel must work in a special isolation mode. Healthcare professionals must protect themselves in contact with a COVID-positive woman - protective clothing (commonly hazmat suit), a respirator, goggles, shoe covers, several layers of gloves, when a spontaneous delivery lasts 8-12 hours. The "U Apolináře" maternity hospital is the one perinatological center for the Central Bohemian Region. We help twelve maternity hospitals in the region mainly with care for women going into premature labor before the 32nd week of pregnancy. The often highly qualified work of paramedics in maternity hospitals deserves great admiration.
Having a partner present at childbirth is currently a common practice in Czech maternity hospitals. In the "U Apolináře" maternity hospital, we were historically the third maternity hospital in the country which began to allow the father to be present at the birth in the early 1990s. We therefore welcome the presence of a partner at the birth. On the other hand, it was the spring lockdown that banned not only visits to maternity facilities, but even fathers at childbirth. The ministerial measure has been widely criticized. In this context, we conducted a study on a large group of women from more than a third of obstetric facilities in the Czech Republic, the results of which clearly show that without a partner in childbirth there was no deterioration in obstetric parameters, and that a certain number of professional midwives were stressing women out needlessly, especially those who were waiting for their first birth.
Please talk about premature births, how are we doing on those? These days, you can save even those nearly beyond saving.
Today's perinatology manages to keep the number of premature births in our country at a very low rate, and most importantly consistently on the same level. About 7% of women in the Czech Republic give birth before their due date, and there are about 8,000 premature babies born annually. Colleagues from our nearest field, which is neonatology, are able to handle even the most difficult cases brilliantly. Together, we not only save the lives of premature babies, but also contribute to high quality of their life. In the "U Apolináře" maternity hospital, a team of obstetricians and neonatologists specializes in premature births in the so-called gray zone, where we approach the very limit of the viability of premature babies. This is a very complicated issue, both medically but also ethically. Here, more than ever, we are very sensitive in communication not only with the woman who is expecting a premature birth, but also with her partner and often with the whole family. If such a family is interested in saving the child at all costs, we respect their decision and our teams try to meet the wishes as much as possible. By the way, we have currently introduced a program in the "U Apolináře" maternity hospital, with the help of which we can predict the degree of probability of a premature birth occuring. Screening the risk of premature birth using the QUIPP program is free for all women from the Czech Republic. For more information, just visit www.predcaasnyporod.eu.
I chose a field that belongs to the most important fields of all medicine. It was some 100 years ago that the professor of obstetrics Ostrčil pointed out in his textbook that obstetrics is the most preventable field of medicine. In other words, we take part in the level of long-term (lifelong) quality of life of the people we help them come into the world. This brings a feeling of great responsibility and, on the other hand, great joy.
There are so many new things. All you have to do is sit down at a computer and surf the professional internet perinatology websites, and you will immediately discover a lot of interesting things that someone has recently discovered and published somewhere. Unfortunately, there is so much inspiration that one person's life can never be enough for everything.
Of course, I cannot answer this question. You have to ask the people from our very large team. We are one of the largest centers in the Czech Republic. The only thing I can note is that my ambition is to achieve the best possible perinatological results, in other words, to provide a system of care so that we achieve the highest possible safety for mother and child. At the same time, our services must be at such a level that we achieve the satisfaction of parents who choose our maternity hospital. Therefore, as a chief physician, I have to be adequately demanding of my co-workers, but also fair. I try to pass on my experience to younger colleagues and guide them in such a way that would make it important for them to work as conscientiously as possible, to achieve the best results, and most importantly, to have a desire to constantly improve.
I have two daughters and one son. Because the old wise rule is that a doctor should not treat members of his family, I asked my great colleagues for help when all three children were born.
Yes, I was contact tracked. I attended a professional meeting at which one of the participants later tested positive for COVID. Within the prescribed period, I took the test, which was positive. I was completely asymptomatic. I spent quarantine by doing a lot of sports around my temporary residence, cycling and running to burn the viruses in my upper respiratory tract, and I regularly had a sauna in the evening.
I also managed to get through remote learning. On the other hand, since spring, with regards to COVID-19, I have consistently told people not to panic, but at the same time to be humble and to observe appropriate hygienic and epidemiological measures. After all, we still don't know much about that Chinese stuff.
During the preparation of the text of this interview, I learned that due to my coronavirus exposure, I have a high titer. I decided to go donate plasma to help other seriously ill patients.
Honestly, Christmas doesn't mean much to me. If it weren't for the children, I would have passed on it personally. Consumerism bothers me, so I try to avoid it. I consider going to the theatre to be an ideal Christmas experience, and even better I would like to spend this time far away, somewhere by the sea abroad, which I have never succeeded in doing as an obstetrician. The maternity hospital does not stop operating during the Christmas holidays and, of course, there is also the obligation of night shifts. I remember that as a childless person I voluntarily and regularly chose the shift on Christmas Day. There was always a special calm and relaxed atmosphere in the maternity ward.
According to WHO, pain is defined as an unpleasant sensory and emotional experience associated with acute or potential tissue damage. Pain is always subjective. But labor pain is a special category of pain, it has a physiological origin. Childbirth is a physiological process and labor pain is a property of this natural process. Pain accompanies almost every birth. Childbirth has been shown to cause the greatest pain a person can face in life. On the other hand, during the course of pregnancy, mechanisms develop in a woman's body that increase her pain threshold and thus reduce the perception of painful sensations. Logically we can conclude that a man can never experience such a state.
Definitely a doctor's job again. I often thank the coincidental set of circumstances that fate forced me to study medicine. I don't know of a more beautiful field. I am very happy that both my daughters work in medicine. One is a neurologist and the other is just beginning to study medicine.
You treat pregnant women with myasthenia gravis - is it a problem for them to get pregnant, carry to term, give birth? How are their pregnancies handled?
Pregnancy care for women with myasthenia gravis requires very close cooperation, especially with neurologists who deal with the issue of myasthenia gravis. At the Department of Neurology of the First Medical Faculty of Charles University and the General University Hospital in Prague, such a department exists. Conception and pregnancy are different for each woman with myasthenia. Some women are treated conservatively, some require radical surgical treatment with thymus removal (professionally thymectomy). In most women, the result of thymectomy is very favorable. Surgery helps to get the disease under control in up to 90% of cases. The course of pregnancy is always monitored simultaneously with the obstetrician and the neurologist. If there is no other risk, then it is the neurologist who is proposing the method of delivery. If circumstances allow, natural delivery is always preferred. If there is a risk of neuromuscular exhaustion due to labor, there is no choice but to end the pregnancy by caesarean section. Here another expert, an anesthesiologist, joins the collaboration. Today the possibilities are such that even in women with myasthenia gravis, the results for both mother and child are similar to those of completely healthy women.