Ep 75: Benefits Risks and Ethical Considerations of Newborn Male Circumcision

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I have received quite a few requests to talk about newborn male circumcision on the podcast, so in this episode I'm walking through what circumcision is, the benefits and risks of the procedure, and the reasons why some families might decide to have this elective procedure performed on their babies.

Newborn male circumcision has been the norm in the United States for a while, but is on the decline. There are a lot of opinions about circumcision out there, so this can sometimes be a controversial topic. 

In this episode, you'll learn about different tools and techniques for circumcision, which medical providers perform circumcisions, and the circumstances in which your provider may recommend against circumcision for your newborn son. There are also some ethical questions you may want to consider before choosing to have your baby circumcised, so I talk about those too. And I share a little bit about how my own thinking around this procedure has changed over time. 

In this Episode, You’ll Learn About:

  • What circumcision is and why it is considered an elective procedure rather than a necessary one
  • Some of the health and social reasons why some families choose circumcision for their sons
  • The medical and health risks, benefits, and potential complications associated with newborn circumcision
  • Which medical providers are trained to perform circumcisions and what techniques they may use
  • Reasons why a medical provider may recommend against newborn circumcision
  • Ethical questions about circumcision to consider
  • My thoughts on circumcision, from the perspective of a provider and from the perspective of a parent

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Speaker 1: In this episode, I'm talking about newborn circumcision. This is a bit more of a mature topic. So use your discretion about having children around while listening.

: Welcome to the All About Pregnancy & Birth. Hi, I'm Dr. Nicole Calloway Rankins, a practicing board certified OB GYN who's had the privilege of helping hundreds of moms bring their babies into this world. I'm here to help you be knowledgeable, prepared, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer, at www.ncrcoaching.com/disclaimer. Now let's get to it.

Speaker 1: Hello and welcome to another episode of the podcast. This is episode number 75. I am so glad that you are here with me today. So in this episode, I'm talking about male newborn circumcision. This is a topic that can be somewhat controversial as well as emotional for some. There are people who have really strong beliefs about circumcision. And I also know that there are a lot of folks that have questions about it. I've certainly had a few people reach out to me and request to do this as a topic for a podcast episode. So what I'm going to do in this episode is really just present factual information so that you can make a decision about whether or not you think newborn circumcision is right for your son. So I'm going to share with you what circumcision is, how it's done, you'll learn the benefits, the risks, and some other things that people consider before they make a decision about circumcision. I'll also add some tidbits of information, my own personal perspective related to circumcision that a lot of people don't necessarily know. And then I will end with some ethical concerns about male newborn circumcision.

: Now, before we get into the episode, let me do a listener shout out. This is from Mrs. BNJC Wilson, and the title of the review, and this was left in Apple podcast, says Just As Informative As it is Calming. And the review says, "Dr. Rankins has such a soothing presence. I love hearing her share information and helping parents as well as birth pros like myself stay up to date on the best practices for labor and birth. As a doula, I especially appreciate her OB GYN perspective and that she is fully supportive of birth options. Thank you." Well, thank you for that lovely and kind review and for taking the time to leave that for me, I'm a big supporter of doulas.

Speaker 1: I have a doula as the community manager for both of my Facebook groups, the free Facebook group, All About Pregnancy and Birth community, as well as the Facebook group that comes with the all access level of The Birth Preparation Course. We've actually started giving away hour long consults in both of those groups with Keisha. Keisha is the community manager. So if you're not a part of the free Facebook group, then definitely check it out. It's called All About Pregnancy and Birth on Facebook. It's just a supportive community where there are lots of pregnant mamas and you can get your questions answered and connect with other women. The group is over a thousand strong now, so really great place, nonjudgmental. So do check that out. I'll link to it in the show notes, of course.

: And then Keisha is also the community manager for The Birth Preparation Course private community for the all access level of a course. I am in that group as well. I do regular live sessions in that group. And if you don't know, The Birth Preparation Course is my online childbirth education class. It uses my unique, beautiful birth prep process to ensure you are knowledgeable, prepared, confident, and empowered to have a beautiful birth. And right now that all access level with the private course community is very heavily discounted because of COVID. I want the course to be accessible to as many women as possible. So you can check out all the details of The Birth Preparation Course at www.ncrncrcoaching.com/enroll. Women have truly found it invaluable right now when in-person childbirth education classes have been canceled. So again, that's www.ncrcoaching.com/enroll.

: All right, so let's talk about circumcision. So circumcision in the male refers to the surgical removal of the fore skin of the penis. The procedure has actually been around for centuries, mostly related to religious traditions in the Jewish culture and, for Muslim babies as well. And it still continues to be performed for religious reasons, cultural reasons, and very rarely for medical reasons. Now the US is the only developed nation where circumcision is done routinely for non religious reasons. Actually in Europe, most men are not circumcised.

Speaker 2: And it's thought that circumcision came to be more prevalent in the US because there was in the early 1900's a movement to stop boys from masturbating, like an anti masturbation movement. And one of the people who was the big proponent of that was John Harvey Kellogg, the founder of Kellogg, like Kellogg's cornflakes. He was actually a physician and he believed that circumcision was an important treatment to keep boys from masturbating. So that's part of why it came to be routinely used in the US. Now today, roughly 70 to 80% of all men in the US are circumcised. That number is actually on the decline and there are some regional, as well as racial and ethnic differences in the rate of circumcision. Circumcision rates are highest in the Midwest where about 74% of men are circumcised, followed by the Northeast with about 67%, Southern states 60%, and then lowest in Western States where it's quite a bit lower, only 30%.

Speaker 1: It's also highest in non Hispanic, white males. About 90% in this country are circumcised and then followed by non Hispanic, black male, 76%, and then Hispanic males, 40 ish percent. And as I said, that number is declining. In 2010, the last year that we have data available about 60% of newborn males were circumcised. And all of this information comes from the Centers for Disease Control. So circumcision is done in the newborn period because it's fairly easy to do it. It's a quick short procedure. The recovery is very quick and it's thought to be less painful. It's also convenient because the baby's still in the hospital and it can be done without much interruption for the parents in getting used to having a newborn baby. On the flip side circumcision performed in adults does have greater risk. It does have greater cost. Also it may have more discomfort afterwards.

Speaker 1: And I don't know if that's because it's actually more uncomfortable or because adults of course can tell us about their discomfort, whereas babies can't. And there's also a longer recovery period. Now, it doesn't mean that circumcision can't be done when boys get older, it certainly can be. It's just a bit more involved and requires more anesthesia. Now, as far as when we do it in the hospital, we usually do it before the baby goes home. We wait for at least 24 hours after birth, make sure the baby is stable. Make sure there are no issues with the baby's anatomy. And then after 24 hours, it may be done that next day. It may be done right before baby goes home. After that, there's no necessary best time that it has to be done, but usually we wait at least 24 hours. And then it can be done actually up to six weeks in that newborn period where you have like the lesser risk of complications and where you don't need more anesthesia. So the same procedure that's done in the hospital can be done up to about six weeks in the office.

: Now there are different techniques for doing a circumcision. The main three, there are three different types of clamps. One is a gomco clamp. One is a plastybill, and one is a mogan that helped to do the procedure and remove the foreskin. And I will link videos of those in the show notes. Fair warning, it can be a bit graphic and it's actual depictions of the medical procedures. So if that's going to be a bit much for you, then I'd suggest you don't watch the videos, but I will link those. If you are curious about what the procedure actually looks like now, as far as one technique being better than another, there's not one that's been shown to be better than another.

Speaker 1: There actually isn't a lot of like data at all, or randomized trials about comparing different methods of circumcision or whether or not circumcision is warranted or not warranted, but there's definitely not any data that one technique works better than another in terms of results for the procedure, they each have their own benefits and risks. The main thing is that whoever is doing it is comfortable with whatever technique that they're using. So you just want the person to be skilled in doing circumcision and whatever instrument they use, that they are comfortable with using that instrument. Now, when circumcision is done routinely, there is pain control provided because as you might imagine, it's going to be painful to have skin cut off your body.

: Now, some effective techniques that are used, and this also depends on the comfort level or what the provider I should say is used to, and then what the hospital has. Some folks use a topical agent like a numbing cream that has to go on for a little bit and sit before the procedure. Some people do nerve blocks where you inject pain medication, lidocane around the base of the penis in order to numb it up. That's what I personally did when I did do circumcisions. I don't do them anymore. And I'll talk about why towards the end. No technique for pain medication is superior. It really, again, just depends on what the clinician is comfortable with. We also do some non-pharmacologic things to help with pain. So in addition to either the cream or injecting the medication, sometimes like non-nutritive sucking. So sucking on a pacifier or sucking on a glove finger can be soothing for the baby. Or sometimes we give the baby a little bit of oral sugar solution.

Speaker 1: And that's because we usually like to do it when babies are, right before they need to be fed. We don't want them to have a full stomach because when we do the procedure, they have to be strapped down. So if the baby is moving his arms and legs, then he risks being hurt during the course of the procedure or us not being able to do it. So they do have to be strapped down. So because they're strapped down, we don't want their little stomachs to be full. Cause if they vomit, we don't want them to potentially aspirate. So sometimes we use some of those nonpharmacologic things to help soothe them. Cause they may just be hungry while they're doing the procedure and the sucking can help them feel better.

: Now I've occasionally had families ask for someone to be present during the circumcision procedure. And in the end, I've never had anybody actually decide to go forward with being present. I know some colleagues have had folks be present and I don't think there's anything wrong with that. I do think it can be, like I said, a tough procedure to kind of watch because it is a baby being strapped down and sometimes they do cry and they may be crying because they're hungry, they may be crying because they're feeling discomfort, but some obstetricians certainly have let family members watch some obstetricians. I would dare even say most don't let family members watch. Because again, it can just be a little bit challenging to watch if you are not familiar with medical procedures, but that's certainly something if you want to do, you could ask. And then afterwards the care is pretty straightforward and simple. There's not like a standardized way to care for it. Most of us do petroleum jelly with diaper changes for a couple of weeks as the area heals and then just keeping it clean and as dry as possible. Nothing major or difficult to care for the circumcision site afterwards.

: Okay. So let's get into some of the benefits and risk of circumcision. I want to be clear up front that circumcision is what's called an elective procedure, meaning that it is not something that is considered medically necessary. It's something that parents can choose to have done for their son. There aren't enough benefits that it's something that any group universally recommends that needs to happen, it's elective. So you can make a decision about whether or not you think it's best for your son. So as far as the benefits, there are some benefits to circumcision. And I should say that most of these benefits come from looking at what we call observational studies or looking back in time and evaluating data.

Speaker 1: There's not like super strong research studies about this topic, just because it's hard to sort of randomize. Oh, you get a circumcision, oh, you don't get a circumcision. And then you would have to follow babies for a really long time to see if there's any changes in their health. I mean, you have to follow them into adulthood. So that type of study would take years and years and years. So really all of the information we have is based on looking back, and there's definitely a reduced risk of an infection for babies that are circumcised. So there's a reduced risk of urinary tract infection. There's a reduced risk of transmitting sexually transmitted infections, including HIV. So what happens is in the uncircumcised male, the space underneath that foreskin provides a warm, moist environment that can trap bacteria. It can trap bodily secretions, and then that makes it a favorable environment for those bacteria to survive and replicate. And also the foreskin area itself is susceptible to tiny tears that we call micro abrasions and can help facilitate infection as well.

: In contrast, when the glans of the penis is exposed, so in the circumcised male, when the glans is exposed, it actually forms a little bit of roughness around it and kind of scar a little bit on it. And that can create an unfavorable environment for bacteria to grow. Now, men who are circumcised also have a reduced risk of penile cancer, but penile cancer is very rare to begin with. So it's estimated that in order to prevent one case of penile cancer between 900 and 322,000 circumcisions would need to be done in order to prevent one case of penile cancer. So that's not really a terribly strong benefit. It also reduces the risk of penile inflammation and what's called retractile disorders, which are basically the shape of the penis can turn into a curvature sort of shape and that can be uncomfortable. And then the last thing is most people will say that a circumcised penis is a lot easier to clean. You really have to be diligent about pulling back the Foreskin on an uncircumcised penis to keep the area clean.

: So let's move on to some of the complications that can come or risks, I should say, from circumcision. Complications are actually very rare. Circumcision is a safe procedure. There are complications that only happen, we estimate in roughly 0.2% of cases. So complications are very rare, rare that they happen, but they can happen. The biggest or most common I would say is that it's a surgical procedure. So there's a risk of bleeding and a risk of infection. In my experience when I was doing circumcisions, probably the biggest thing that I would see is sometimes it can be bleeding and normally it's very easy to get it to stop, but rarely it can be pretty significant and it doesn't take babies much time to lose a lot of blood cause they're tiny anyway, they don't have the whole lot of blood circulating in their system. So bleeding is a possibility as well as infection.

: The other thing that's a possibility is that either not enough skin is removed or too much skin is removed. And that may necessitate that the baby has to have corrective procedures later in the future. That happened to one of my friends where her son had to have the circumcision revised when he was older, like between the ages of three and four, just because of too much skin being removed before sometimes adhesions can form that scar tissue. So you just have to be careful about making sure that scar tissue doesn't form cause that's gonna be painful. And then in rare cases, it can lead to injury of the penis. And in super rare cases, amputation of part of the penis. One of the clamps, since you used called a mogan clamp, and again, I'll link to those videos with the different methods in the show notes, that particular clamp has the highest risk of amputation just because of the way that it's used. And again, that's very rare, rare, but the makers of that clamp have been sued a couple of times because of amputation of part of the penis.

: Now, complications are more common among preemie babies, among babies that have been born with congenital anomalies, and then circumcisions that are performed beyond that six week period. And then probably the biggest risk is a circumcision being done by someone who is not trained well or is poorly trained to do it. So those are the things that increase the risk of complications, preemie babies and done later, so after that six weeks, and then someone who's not well trained to do it. Now, there is something that's not necessarily a risk, but I'll mention, but there is some thought that circumcision may reduce sexual pleasure because the foreskin has a lot of nerve endings, but that is really, really difficult to prove because you'd have to take someone who's older and then, you know, circumcise and not circumcise and compare and see how things feel. So there are some theoretical risks that that may be the case, but hard to prove.

: All right. So let's move on and talk about some other things or just a couple other things that people may consider when they're making a decision about whether or not to circumcise their son. So one of the things that people do think about is the father's circumcision status. For some families, it's important that fathers and sons are similar in that regard and that they look similar. Another thing that may be a concern is social conformity, meaning that it's just something that's been done in your family. It's been something that's been done in your partner's family and you just kind of keep that going because that's what your family has always done.

: Now, some people have said things like they worry that a boy might be bullied if he's not circumcised, but everybody else around him is circumcised. I think that's theoretical and not necessarily reality. And I believe that that's also less of a concern because as I said, it's on the decline. So there are fewer boys who are circumcised. So I think bullying, teasing is not necessarily a strong reason to circumcise or not circumcise. Now, as far as some sort of lesser known tidbits of information about circumcision, they have traditionally been done by OB GYN because we do more procedures and we are in the hospital and we're there. So it kind of came to be a part of training for OB GYN, however, OB GYN, aren't the only people that do circumcisions and not all OB GYN do circumcisions. So in some places, GYN actually are not trained to do circumcisions because in the hospital, it's the pediatrician who actually does circumcision. So there are many places where a pediatrician may do circumcisions either in the hospital or they may do them in the office.

Speaker 1: So within that first six weeks of life, and there are a few OB GYN who may do circumcisions in the office, but that's pretty rare, but there're definitely pediatricians that do them in the hospital or who will do them in the office. And there are also pediatric urologist who do neonatal or newborn circumcisions. And a urologist is a doctor who specializes in the male urinary and reproductive system. So they are quite familiar with circumcision. As a matter of fact, more familiar with that area than OB GYN are. I've always thought it was kind of weird that OB GYN did circumcisions because we don't take care of males otherwise. So pediatric urologists will also do infant circumcisions as well. Now, most often they do not come to the hospital to do them. If it's a pediatric urologist, they do them in their office once the baby gets discharged.

Speaker 1: And often at least I've seen in my area a couple folks, I know it tends to be like a cash only kind of thing. And you pay for it out of pocket and you can get reimbursed from your insurance if you want, but it tends to be, they do it in the office, kind of a cash only sort of thing. And then the last thing, and this one kinda throws people off sometimes, especially if they're expecting that a circumcision is going to be done, is that circumcision might not be able to be done while your baby's in the hospital. It might not be the right thing to do. Sometimes the penis isn't big enough yet. Sometimes it just is on the smaller side. And you don't want to take off too much skin. So the baby may need to get bigger. And by the way, if the doctor tells you that the penis is small, it doesn't mean that that's a longterm prediction of what it'll be.

Speaker 1: It just, maybe it's on the smaller side when they're born and the baby just needs a little bit more time to get bigger so that it's done safely. That can certainly be a risk with a preemie baby as well, but it can happen with full term babies as well. Also, if you declined the vitamin K injection, vitamin K is given in order to help prevent bleeding in babies. And if you decline the vitamin K injection for your baby, most doctors will not do circumcision because they won't don't want to run into that risk of bleeding. And then the final reason that it may not be done is for anomalies. So there's something wrong with the penis. I shouldn't say wrong, but there may be something with the penis that makes circumcision not quite right. So the most common thing is hypospadias or the opening to the penis is kind of on the underside and not at the very tip.

Speaker 1: And in that case we shouldn't do circumcision because the baby will need some corrective surgery later down the road. And they may want to use some of that skin in the corrective surgery. And I have had people actually get really angry at me for not doing their baby circumcision in the hospital. Probably the most common one is that I felt like it was too small and it wasn't safe for me to do it. But my thought and your thoughts should be too, is that your baby boy only has one penis. And do you really want someone doing a procedure if they're worried that it's not the right thing to do? Remember that this is an elective procedure, it is not something that has to be done. It's not something that's considered medically necessary. It's a choice that you're making. So we're under no circumstances required to do it before your baby goes home.

Speaker 1: So if you find that you're in that situation, you've decided that you wanted, but for some reason it can't happen, then please don't get angry. Remember that it's not something that has to be done. And if they have some concerns about doing it, where they don't feel comfortable doing it, that you don't want to press anybody to do something that they don't feel is the right thing to do. All right. So the last thing I'm going to talk about are some ethical considerations regarding male circumcision, and people have strong opinions about this on both sides. So there are some people who are in favor of routine circumcision because, and they believe that it should be kept available as the parent's ability to make that choice, because of those possible health benefits that I mentioned, and this kind of holds the view that that skin doesn't have much value in the sense that it's not missed.

Speaker 1: And we have evidence that men don't miss that skin. It's a simple procedure, it may reduce the risk of acquiring infections. Like I said, the benefits of reduced risk of urinary tract infections and sexually transmitted infections and HIV. And in some extreme, some folks believe that newborn circumcisions should be promoted, should be even required as a public health measure because of that. Now on the flip side, people argue that circumcision is a traumatic experience potentially for a baby boy, and that it is a violation of his right to bodily integrity, that we are removing this tissue from an intact sexual organ, without that baby's consent. It's something that's irreversible, meaning that once it's done, we can't go back and put it on. And really that baby boy should have autonomy and choice over what to do with his own body. So he should make the decision for himself when he's older about whether or not he wants to have circumcision, when he can understand the risks and benefits for himself.

Speaker 1: And the parents shouldn't make that decision about something in his body for him. And it's also argued that the health benefits of circumcision are minor. That they're outweighed by the risk and the benefits can be achieved by not doing the surgery. So just through great hygiene, through vaccinations, like penile cancer is most often caused by HPV. So getting the HPV vaccine will reduce that, safe sex practices, and those benefits don't justify having a surgery that is involuntary. And then some people just think that boys were born with it for a reason. So why are we removing it? And then even further, some people believe that you've been talking about circumcision as a health related decision for parents is actually normalizing what they believe to be an inethical practice and ignores the child's right to make a decision for themself about a private part of their body.

Speaker 1: For example, on the flip side, when we talk about female circumcision and we know that that's common in some cultures, we talk about removing female sexual organs at birth, we call it female genital mutilation. Whereas in this case, we call it circumcision and I'm not falling down one side or another. I'm just presenting kind of the argument for both sides. Now, when you look at what organizations say about circumcision, the American Academy of Pediatrics, that's the organization in the US that sets standards for pediatric care, their stance on circumcision is the following. The health benefits of newborn male circumcision outweigh the risk and the procedure benefits justify access to this procedure for families who choose it. However, health benefits are not great enough to recommend routine circumcision for all male newborns. That's the statement that they put out in 2012, it quote unquote expired in 2017.

Speaker 1: Like it was a five-year statement and they haven't updated it since then. The American College of OB GYN, obstetricians and gynecologists, our specialty organization endorses the conclusion of the American Academy of Pediatrics. And then the American Urological Association, believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risk. It is generally a safe procedure when performed by an experienced operator when circumcision is being discussed with parents and informed consent obtained, medical benefits and risk and ethnic cultural, religious, and individual preferences should be considered. The risks and disadvantages of circumcision are encountered early. Whereas the advantages and benefits are perspective. So they don't come down and say one way or another, that it should be recommended. Nope, no one does. No one has concluded that it should be a recommended procedure because of the benefits.

Speaker 1: So my own personal philosophy, I don't do circumcisions anymore. The biggest reason is because as a hospitalist, it's just infrequent. So I'm just not exposed to them enough, doing it like two or three times a year is not enough for me to keep my skills up. So I don't do them anymore. I also never really liked doing that. The biggest reason is because I felt like I couldn't handle the complications. So as OB GYN, we are trained early on female anatomy and taking care of women. So this one procedure, when there was ever any possible significant complication, we would have to call a specialist in. Now mind you that that doesn't happen very frequently, but that was always something that always made me feel a little uneasy, whereas with a complicated vaginal birth or cesarean, or when I was still doing gynecology care, I could handle those things, those issues that may come up, but for this one I couldn't.

Speaker 1: And then I have to be honest, I do have some concerns about doing a procedure that has limited benefit and the baby doesn't have a choice over what's happening in his own body. I do not know what I would have done if I had sons. I think today, if I had a son, I probably would not do circumcision, but I don't know, 12 years ago, 10 years ago, I probably would have. I think my thoughts on this have evolved over time. So in the end, you really just have to take all the information and then make a decision about what you think is best for you. Okay. So that is newborn male.

: Newborn circumcision, just to recap, circumcision is the removal of the foreskin of the penis. It's on the decline in the US, is typically done in the neonatal period, which is within the first six weeks of life. That's when it's safest, it can be done in the hospital by a pediatrician or a pediatric urologist. Benefits are that it decreases infection with urinary tract infections, sexually transmitted infections, HIV, penile cancer, and inflammatory disorders. The risks are bleeding, infection, scar tissue, taking too much, taking too little and rare cases, amputation. All of the specialty organizations, at least in the US pretty much say that the benefits outweigh the risk, but not so much though, that it needs to be a recommended procedure. There are some ethical considerations regarding circumcision, and that many believe that babies should have a choice over what happens over their own bodies. It's not considered medically necessary. Some people think it should be done as a public health measure. So the bottom line about circumcision is that you have to take in all of the evidence and what you think is best for your family.

Speaker 1: Perhaps you have religious considerations as well, and you have to do what you think is best. If you want to get even more information like the nitty gritty details of some of the research and studies that are available, then do check out the Evidence Based Birth article on circumcision by Rebecca Dekker. It's a very detailed dive into the minutia of circumcision, including the ethics surrounding it as well. So I will link to that in the show notes. I want to say it's www.evidencebasedbirth.com/circumcision. And she also had a podcast episode where she talked about as well. So I will link to that in the show notes too.

: So that's it for this episode of the podcast, be sure to subscribe to the podcast in Apple podcast or wherever you are listening to this podcast, Spotify, and a lot of folks listen in Spotify as well. Those reviews are particularly helpful in Apple podcasts. They help the show to grow. They help other women find the show. And then of course, I just love hearing what you think about the show. Also, don't forget to check out my free Facebook group, All About Pregnancy and Birth Facebook group. I'm sure we'll have some discussion about whether or not folks are circumcising their babies in the group after this podcast episode airs. You can search for that group All About Pregnancy and Birth on Facebook, and we will link to it in the show notes.

: And also check out The Birth Preparation Course, my online childbirth education class, which uses my beautiful birth prep process to ensure you are knowledgeable, prepared, confident, and empowered to have a beautiful birth. Currently quite discounted because COVID, you can check that out at www.ncrcoaching.com/enroll.

: Now next week on the podcast, I am interviewing a NICU doctor. It's going to be great information and episode. So do come on back next week. And until then, I wish you a beautiful pregnancy and birth.

: Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast. Head to my website at www.ncrcoaching.com to get even more great info, including free downloadable resources on how to manage pain in labor and warning signs to look out for after birth. You'll also find information on my free online class, on how to make a birth plan, as well as everything you need to know about The Birth Preparation Course. Again, that's www.ncrcoaching.com and I will see you next week.

Speaker 3: [inaudible].