Empowering Birth Blog

Delayed Cord Clamping

A MUST READ article with all the evidence you need to support delayed cord clamping:

http://academicobgyn.com/2009/12/03/delayed-cord-clamping-should-be-standard-practice-in-obstetrics/

Written by Dr. Nicholas Fogelson.

Thaddeus Arrives Face First

If my 37^th year had a theme, it would be the year God reminded me at every turn that I am not in control; the birth of Thaddeus was no exception.  Thankfully I had gotten the message loud and clear and so while I had a pretty clear picture of his birth (middle of the night, in the birth pool, easing baby out and catching him/her myself, surrounded by family with my fellow student midwife/future midwifery partner quietly in the corner and supervising midwife nearby) as I neared 40 weeks I also knew that birth, like life, cannot be controlled.   And so I made sure to double make the bed, placing my extra polk a dot shower curtain for protection underneath the top sheet, just in case I had the baby on the bed.

The first surprise was that I did not go into hard labor after the kids were neatly tucked into bed, as I did with my second and third babies, but in the early evening.  I hoped for a Sunday birth.  It was the last chance my baby had to meet my sister as a newborn.  My sis was coming up Monday morning in order to say goodbye before flying back to New Mexico.  She was in Williamsburg on Sunday celebrating my Dad’s 75^th birthday.  Since it was HOT and I had a baby that kept trying to slide into a posterior position (swimming helps encourage an anterior position) I decided to spend Sunday afternoon at the pool with the kids.  At the pool, I noticed that my warm-up contractions (I had been having strong warm up contractions from about 34 weeks on) were 8-10 minutes a part, but this was nothing new for this pregnancy.   Swimming, I palpated my relaxed belly and confirmed what I suspected, baby was definitely facing posterior (also known as sunny side up). After the swim, it became slightly uncomfortable to walk through contractions and, though this wasn’t new either, it was time to go home.  We gathered the kids, and climbed in the car.  In the car I had a contraction that was very uncomfortable in my sitting position and I thought, hmm, tonight is the night.  It was 5pm and I texted my midwives, to let them know that if this labor was anything like my last labors, baby was coming tonight.

We arrived home at about 5:15pm.  Dinner wasn’t made, the kids were starving and tired from sun and swimming and the birth pool needed filling.   Before we could get started, Matt announced he needed to go to the hardware store to buy an extra connection in order to fill up the birth pool. Things were chaotic and at 5:50pm, realizing that Matt could not get everything done by himself and realizing that I needed to make space for active labor to start, I called Mimi and asked if she could come over to help Matt.  She came over shortly after 6, and together Matt and Mimi were able to feed the kids and get the birth pool set up while I moved into active labor.  I am not sure when that move came, let’s say 6:15pm.  By 6:35pm, when Liz called to see if she should head up to Baltimore and drop off her partner or come straight to my house, I was no longer interested in talking to anyone and had shut myself in the basement bathroom.   Thankfully Mimi took the call, updated Liz on the situation and they decided Liz should come right away.

Liz arrived at 7pm and mentioned she wanted to start setting up so I asked her to call Mairi.  Mairi, who lives in Takoma Park as well, was quickly on her way.  At some point things became more intense and it was time to turn on the CD of gospel music I had prepared for the birth.  I headed upstairs, where I would remain for the birth. The music deepened my connection to the spiritual nature of birth and opened my awareness of the unfolding miracle.  I am again and again awed by the spiritual power of birth and felt my body flood with the intense energy of the Spirit.  I needed all the help I could get as this was my hardest labor, probably because it moved so quickly.  In barely over an hour I went from thinking I might be in early labor to having intense ctx 3 minutes a part. 

As soon as the tub filled up I climbed in (7:45pm) and sang and labored, grateful for the water’s soothing warmth.   Sometime after 8pm I checked myself and felt a very bulging bag of waters and a very soft and stretchy cervix.  It is hard to check yourself when you have short fingers so I have no idea how far dilated I was nor did I care.  Sometime later I felt the need for a position change and climbed out of the water thinking I might go downstairs and sit on the toilet.  Standing by the side of the tub, my water broke and I stood frozen for minutes watching the spreading pool of fluid, unsure of what to do next.  I climbed back in the tub and noticed that my uterus was pushing; I watched it rise up and move down with incredible force, encouraging baby to move on out.  I felt baby wiggling and squirming and kicking inside me. The thing is, while my body was pushing, something didn’t feel right and I was resisting.  I didn’t have trouble pushing with Nettie or Fen and even enjoyed second stage…  Since I had checked myself only a little over 30 minutes ago and felt cervix, I thought, I must not be fully dilated and that is why this feels so different from pushing Fen and Nettie out.  I called Liz to check me but realized “I can check myself.”  I slipped in a finger to feel a hard palate, then a mouth sucking on my finger!  Imagine my surprise! 

I asked Liz to check me to confirm a face presentation and she thought she felt a nose but couldn't be 100% sure (Is anyone 100% sure when they feel a face?  Our fingers expect to feel heads...).  I called “Mairi!” and Liz and I agreed I would get out of the tub so that Mairi could check me on the bed. (Mairi had been just downstairs listening and holding the space, ready to help if needed, as I wanted as few people upstairs as possible until the birth.  For much of the labor it was me with Liz quietly sitting nearby).  I asked to hear to heart tones (my request had been no heart tones unless necessary knowing that if mom knows baby is moving well, baby is ok) because I was concerned by a face presentation and I felt a change in baby's pattern of movement.  I thought baby was posterior and remembered something that was not at all good about the combination of posterior and face (in labor, your brain doesn’t work so well, after birth, I remembered that it is a posterior chin that is not good, not a posterior baby, a baby with a posterior chin should not be born vaginally while a posterior baby with an anterior chin can).  The pain was too much to bear for a vaginal exam on my back so I asked Mairi to check me on all fours, half leaning on the bed.  

Heart tones at some point dropped.  While I didn’t have a watch, as a student midwife, I know the sound of poor heart tones.  I looked at Liz and Mairi, unsure of what to do next.  This is why we have midwives.  When you are in labor land, things can get very fuzzy.   A woman in labor shouldn’t have to think and I needed direction. Mairi said “I think you need to push your baby out now, it would help if you got into McRoberts to flex the head,” and my body moved quickly into McRoberts where I started pushing with all my might.   (While I started pushing, my husband quickly ran downstairs to get the kids.) I think I had about one contraction the entire time I was pushing.  The rest of the time I was bearing down, thinking of the thunk, thunk, I heard on the Doppler and knowing it was time for baby to come out.  I moved Thaddeus swiftly under my pubic bone and heart tones came back up and he started to pink up.  I took a breath and continued to push him out, giving an extra strong push to birth the shoulders.   I didn’t catch my baby as planned.  The effort required to push my baby out without contractions while lying on my back required one-pointed focus.  I paused a second to touch his emerging face but I wasn’t able to focus on how my pushing was progressing and when I would need to catch him.  At 9:06pm, a short 16 minutes after I first felt him sucking on my finger inside me, Thaddeus was born.  He was caught with lots of love and by my request, no gloves, by my future midwifery partner, my loving preceptor midwife standing by and surrounded by the love of my life and our three amazing kids.  My friend Mimi, who was such a help to Matt during the birth, was an incredible help to me during pushing and immediately after the birth. 

Pushing Thaddeus out was HARD and having a circle of support while doing it made it easier.  Thaddeus arrived, face first, with only a bit of bruising around the eyes.  Mimi, a gifted cranio-sacral therapist helped Thaddeus release the intensity of the experience caused by his unusual position and helped me relax my sacrum so that I could eventually sink back into pillows with Thaddeus resting on my chest.  While the birth of Thaddeus was certainly a surprise, I think the biggest surprise came at the end of the newborn exam.  Thaddeus weighed in at 8 pounds 9 ounces, a full 1.3 pounds bigger then my biggest baby!  Not to mention that the presenting diameter of his face was not small at all.  And I thought I made small babies!  

There is much more to the story, this is only a small snap shot.  There were friends downstairs that I was not aware of, silent helpers, there to be with the kids, to hand off from one friend to the other as needed, so that Matt was always free to be with me if called, my unseen village supporting me.  But I have gone on long enough.  Much love to you Thaddeus from your mom, dad and three siblings!!!!

*A note on face first babies, Anne Frye (Holistic Midwifery Volume II, pg. 121) notes that they are unusual, averaging about 1 in every 545 births.

 

 

 

I saw my midwife in chains

Seeing a loved one shackled is probably the worst nightmare of many and something I had hoped never to see.  Isn't it enough to shoulder the burden of awareness that women, men and children are unjustly hauled off to jail on a regular basis in the U.S. and worldwide?

And then it happened.  I stood in the courtroom and watched my beloved midwife enter in a pink jumpsuit.  I don't know why I expected them to make an exception for her...  I suppose that is what every parent/friend thinks as they watch a loved one enter in shackles, not my baby/friend/lover...  But there she was, handcuffs around her wrists, ankles, and a rope of chain around her waist...  Hands that had helped so many babies safely enter this world, hands that reassuringly stroked and held women in the throws of doubt during a long labor, a waist often seen from behind as Karen kneeled next to an emerging baby, feet that slipped quietly out of bed in the middle of the night, on their way in service to women...

My midwife is being prosecuted for manslaughter. A disheartening investigation ensued after the tragic death of a client’s baby. Karen is being charged with involuntary manslaughter and other felonies for her role as a homebirth midwife.  She will be on trial for these charges beginning June 7^th and is facing up to 30 years in jail.

Did you know that charges are regularly brought against midwives in the United States?  Charges are often brought because it is illegal for them to practice the profession they are thoroughly trained to practice (see The Big Push, an organization working to change this).  I have noticed that charges are also brought when, instead of following the medical model, the midwife honors the informed choice of a family (even when the informed choice is evidence based). If you have ever been urged to be induced or scared into a c-section for a "big baby" or heard of court-ordered cesarean-section (see National Advocates for Pregnant Women, for example), you know that the medical community is not always a strong supporter of informed choice in practice, even when it is evidence-based.  

In 2005, I was pregnant with my second and hungering for a vaginal birth after cesarean (VBAC).  I was told that if I gave birth in a hospital, I would need to be hooked up to a continuous fetal monitor.  As someone who believes firmly that hospitals are only for the sick and is a do it myself/on my own terms kind of girl when it comes to birth, I knew that being tethered to a monitor in an unfamiliar, rather then intimate, environment, would mostly likely lead to a second cesarean.  I was told I was not a birth center candidate since I had had a cesarean with my first baby and a recent insurance change prohibited birth centers from attending VBAC clients.  

I had done the research and understood the evidence concluded that a vaginal birth after cesarean was safer then a repeat cesarean, especially if more children were planned (see, for example, Childbirth Connection).  As an informed consumer, I chose my best chance for a vaginal birth, a home birth with Karen Carr.  Karen put her neck out there for me and as a result, I found my full power as a woman and as a mother. As a result of that VBAC, I had a much higher chance of a healthy pregnancy and safe birth when I found out that I was pregnant with my third and now, with my fourth.

Karen needs your help.  Please visit In Service to Women and donate what you can, even if it is only $5. Please, join your local midwifery organization, if your state has one, or join Citizen's for Midwifery or the MAMA Campaign or...  Midwifery needs you.

 

Listen to Your Body!!

It is so important to listen to your body when you are pregnant, it will let you know if you are overdoing it.  Last week I went to two births, one of which was very long (I was at the long birth for 40 hours), and ended up sleeping only one night out of four nights.  Needless to say my body was screaming loudly.  I had a very crampy uterus and would have been more concerned if I didn't know that lots of rest should fix everything.  I put everything on hold except taking care of the kids and slept twelve hours at night with an hour to two hour nap during the day. It took me almost four days to fully regain my energy but I did!  That long birth was a good reminder for me in many ways.  One it reminded me that you can do EVERYTHING right and still get a doozy of a labor.  I think that sometimes I think that the natural birth world suggests that if you do the right things, you will have an easy (maybe even pain-free) birth.  NOT TRUE.  It also reminded me that you have to take excellent care of yourself as a midwife (student midwife) if you are going to be inflicting that kind of abuse (regular mostly sleepless nights) on your body.  And finally, it reminded me that I am NOT willing to be away from a little one for a long birth until he/she is at least 18 months.  That means I need to be ready to take it slow when the baby comes and leave a birth if necessary to go home and take care of my family.  One day at a time, that is my current mantra...

Sacred Mountain Midwifery

There is more news on the midwifery studies front.  I recently decided to attend Sacred Mountain Midwifery School in order to complete my didactic training as a midwife.  Over the past five years I have been reading midwifery texts and attending study groups and conferences, but when it was time to plan the completion of the PEP process for my CPM, I realized I wanted a concentrated review of all the skills I need to become a midwife, the things I have been studying on my own for the past few years.  I considered several programs and in the end chose Sacred Mountain Midwifery because I wanted extensive hands on experience (that is how I learn) and because I have been attending their yearly Women Helping Women Retreat and really enjoyed the teaching style of the co-founder Dr. Sarita Bennett (Ruth Ann is fabulous as well!).  In my search, I realized that I wanted to learn from a midwife who had been practicing for years and years (Sarita has almost thirty years of experience as a midwife) and (since my husband and I still plan to return to West Africa, hopefully Mali or Senegal) I wanted to learn from a midwife who practiced in a rural setting where immediate hospital transport was not always possible.  Sacred Mountain Midwifery seemed the perfect choice for me and after my first session there in October, I can hardly WAIT to go back.

Having a baby in May will make things a bit tricky.  I will be 38 and 1/2 weeks pregnant when I attend the May session and unless the baby comes early, I will most likely miss the June session.  My whole family will come for subsequent sessions and camp so that my husband can grab the baby if he/she is being fussy.  But it is a fabulous school and we are committed to working it out.  Anyone want to join me?  It isn't in the most practical location (a good four an a half hour drive from my house, a good bit winding through the mountains) but the setting is BREATH-TAKING and cell phones don't work (you can receive calls if you are on call and use their phone) which makes my weekends there a retreat as well as a learning experience.

Baby on the way!

It has been ages since I've blogged.  I took July and August off to focus on family, and then in September our family had some surprising news, and I didn't really feel like blogging until it was time to share the news.  You guessed it, we are expecting our fourth!  

Quite a surprise I must say.  I've been using Natural Family Planning, and apparently didn't realize the effects of possibly being close to Menopause (I am 37) and throwing my schedule off so drastically by attending births.  I hadn't had any real signs of Menopause, maybe a tiny variance in one cycle, but I know it can strike at any time.  It isn't like you get a notice in the mail announcing "Heads up Menopause is around the corner, expect cycle variations!"  When we had sex I had ZERO fertility signs, plus it was six days before the earliest I've ever ovulated.  I know NFP says seven days to be safe but I had been charting for quite awhile and never ovulated before day 19, and usually not until day 21, so I felt safe.  And six days should be ok, I mean sperm only lives 5 days (at best!).  But then I went to two crazy births, back to back, one of which was very long, and I noticed a shift in my cycle. This little person was determined to come into our lives, and we are excited to become a family of six!

Looking back, I think this baby has many lessons for me, the biggest being that I can't plan everything.  I had neatly planned out the completion of the PEP process and the latest date I would take my NARM exam (I had planned to take it by August of 2012).  I was also going to finish my Birthing From Within certification.  Now everything is up in the air, and that is ok.  While I can, I am plowing full speed ahead with the PEP process.  I have been on a roll with daytime births (five in a row!) and at 13 weeks on Wednesday, I am feeling like I am about ready to handle an all-nighter again.  Finishing up the PEP process will depend on whether or not families are willing to let me attend their birth with a newborn for part of their labor.  I am just not willing to be away from a newborn for any length of time until they are at least 9 months.  And of course I will be taking four months off (my last 4 weeks of pregnancy, and the first three months).  So I might not take the NARM exam until February of 2013, and that is ok.  It is good to be forced to be flexible, I am learning my lesson (smile).

So I am "due" end May (my third May baby, although this one might come in June) and I am using my good friend and fellow student midwife as my midwife (with preceptor present of course so it counts!).  I think it might have just been my husband and I (with a knowledgable friend nearby if needed) if I wasn't a student midwife and 110% committed to students.  We NEED more midwives in our area and I will be honored to be submitted as a "Continuity of Care" birth (at least 3 of the births attended by CPMs need to be women that have been seen by the student over the course of a pregnancy for at least 4 prenatal visits).  Oh and of COURSE we are having the baby at home.

Last week I attended the birth of a ten pound baby, no suturing needed!  I have been at quite a few births with nuchal hands (left or right hand up by the face), in fact, I have been wondering what is up since we are not the only ones seeing so many nuchal hands.  Each birth I attend blows me away and reminds me how incredibly amazing women and their partners are.  It fires me up that CPMs are legally authorized to attend home births in only 27 states.  Women NEED access to midwives and home birth should be an option, in EVERY state.

Well, my little one calls so I must run.  We are in the process of weaning (she is two and a half, and I have a hard time nursing while pregnant), down to three nursings a day.  So I need to help her work through the fact that we no longer nurse after nap...  I hope that IF I have any regular readers left, that all are well.

Peace

 

Why I Need to be a Midwife

Hello all, I thought I would share a piece that I just wrote about why I need to be a midwife...

Revised 7/24/10 After a week in New Mexico

Why Do I Want to be A Midwife?

Why do I want to be a midwife?  How many times have I thought or written about this, each time going a bit deeper, peeling the layers of an onion, one thin and translucent layer at a time.

On a trip to New Mexico, standing half in the hot sun at Ohkay Owingeh festival, watching the Dance of the Deer, I achieved clarity on what I had always known but had not yet spoken or written.  I need to be a midwife because it is my connection to that which is sacred.

I thought being a midwife was about empowering women, or about organizing in my community, the community of women, (rather then as an outsider, organizing in another community), or about creating peace on earth.  It is about all those things but there is something deeper.  Being a midwife is about following my bliss, connecting to the sacred, a connection I believe every individual must find in order to be fully alive.

During the three years I spent in West Africa, I felt as close to God as I had ever been.  I  initially thought I was called to West Africa because I was angry with “white culture,” but now I know it was God calling me to truly taste what is sacred, in order to make me hunger for it in the years to come.  I think cultures closer to the earth embrace the sacred in daily moments, moments which can be few and far between in the U.S.  So few and far between that I had to travel to Mali to really understand the sacred.  Admittedly I caught the sacred here and there, a Cathedral in Paris, a sunrise on the Gulf of Mexico, and in Gospel Music (which is why I continue to sing and feel unrooted when I am not singing).  But standing in the half sun in New Mexico, I acknowledged that I find the sacred in every birth.

But there is more.  At the Georgia O’Keeffe museum in Santa Fe I read, “Singing has always seemed to me the most perfect means of expression.... It is so spontaneous....Since I cannot sing I paint.” (Georgia O’Keeffee 1922).  And my soul said YES and because I cannot sing or paint, I will midwife.  I do sing, with my gospel choir, but I don’t think that anyone will hear my voice, and soar to the heights that I have soared in Mali at a drumming circle, or at a birth, or when I listen to Kirk Franklin.  But maybe, just maybe, if I can hold the sacred space when I midwife, then the family will connect to the sacred, and then in the U.S. our connection to the sacred will deepen, one family at a time, one birth at a time, and there will be healing.

Part 2: So you've decided to test for GBS, you still have options

If you haven't already, you may want to read Part I of this post, which includes a fabulous article by Judy Slome Cohain, CNM.

***REMEMBER THAT NEITHER ANTIBIOTICS NOR HERBS, NOR CHLORHEXIDINE/HIBICLENS WILL GUARANTEE THAT YOUR BABY WILL BE GBS FREE.*** 

Babies born with GBS (from mom) have been shown to be protected from antibodies passed on by mom¹ (Please read this footnote.  It is very informative and also mentions that babies have less protection from E Coli then GBS.  Read below on why we should be concerned about E Coli).  Babies who get sick are babies whose moms lack the antibodies to the GBS bacteria. Even if you are treated with antibiotics in labor, your baby may still develop GBS disease (click here for a brief discussion of late-onset GBS disease including a potential connection between intrapartum antibiotics and increased rates of late on-set GBS).  In other words, there is no easy answer to the question, "I am positive for Group Beta Strep, what should I do?"

If you plan to test for GBS, you still have options...

The goal of treatment with antibiotics is to reduce the colony count in the vagina.  So why not try alternative methods to reduce the colony count before testing? Below are some options...

Option 1: Understanding that GBS comes and goes, you might follow an herbal regimen hoping to restore balance to your body (i.e. reduce GBS colonization) and then test, hoping for negative results. You continue  to maintain a diet that optimizes a healthy gut throughout the remainder of your pregnancy.  

Option 2: You can choose to wash with chlorhexidine/hibiclens and then test.

Option 3: Do nothing and test.  Understand that GBS comes and goes.

If You Test Positive:

You can take antibiotics (or use hibiclens) while in labor. Understand that neither of them completely remove the risk to your baby, that antibiotics are not without risk, and that hibiclens is a harsh substance.

If you test positive and are birthing at home with a midwife who will support your choice, you can repeat option 1 or 2 (above) and retest, hoping for a negative result. 

If you test positive you can do nothing, understanding that the risk to your newborn will increase with prolonged rupture of membranes and repeated vaginal exams.  

If you test positive, you can wait to use antibiotics or hibiclens after prolonged rupture of membranes.

Why Would You Want a Negative Test?

Why you may ask, is a negative test important?  A negative test means that if you birth in (or are transferred to) the hospital, your newborn will not be required to undergo a septic work up.  AND (perhaps more significant) a negative test means that if you are transferred to the hospital in labor, you will not automatically receive antibiotics.  Why should we be concerned about antibiotics?  Because research has shown that with the increase of intrapartum antibiotic prophylaxis (IAP) for GBS, there has been an increase in neonatal gram negative (e coli) sepsis which has led to an over all UNCHANGED rate of neonatal sepsis.  In addition, with the increase of IAP, there has been a corresponding increase in ampicillin resistant e coli (not a good thing!). As mentioned here, babies have less protection against E Coli. And remember, the Cochrane review has found no conclusive evidence to support giving antibiotics.

Herbal Protocols for Reducing GBS Colonization:

Midwife Judy Slome Cohain uses a Garlic Protocol.  If you are interested in garlic (and/or would like to learn more about GBS), it would be worth paying to download and read this research on GBS and garlic. Or read Judy's article on treating vaginal infections with garlic. 

From Midwife Maria Iorillo as found in Elizabeth Davis' Heart and Hands, 4th Edition:

Twice a day, with breakfast and dinner:

2 capsules lactobacillus acidophilus (2 billion per capsule- try Natures Plus)

1 capsule echinacea 350 mg

1 capsule garlic, 580mg

1 capsule or gel vitamin E, 500 mg

Also place one clove peeled, unnicked garlic in vagina every other night, remove in the morning

From midwife and herbalist Helena Wu:

I don't follow a specific herbal regimen but choose herbs that are mentioned in the books (Aviva Romm, Rosemary Gladstar, Amanda McQuade Crawford, Kathi Keville- well known experienced herbalists who have women/herbals written) for vaginal infections. Different ones work. I usually put in at least one that is anti-microbial, one to soothe. Also have mom eat yogurt with living cultures and put some in the vagina. You can make boluses (vaginal suppositories). It is messy but so far it has worked. On retest they are negative. Mom also should cut out sugars (simple carbs, juice, fruit). Do this for a week or two and retest.I give them all the options, antibiotics, hibiclens, herbal and let them choose.

Other Things You Can Do:

Avoid Vaginal Exams! 

Avoid hospital bugs (and frequent vaginal exams) by having your baby at home.

And of course the real question is why do we have such a high rate of GBS disease (as opposed to other countries) in the U.S?  Could it be that the American diet leads to low rates of antibody production in moms?  Of course that is another can of worms and not my area of expertise but as a huge fan/consumer of probiotics, I am a firm believer in maintaining a healthy gut.

1 Maternal Fetal & Neonatal Physiology A Clinical Perspective, by Susan Blackburn  http://books.google.com/books?id=2y6zOSQcn14C&pg=PA504&lpg=PA504&dq=GBS+mother+protection+antibodies+newborn&source=bl&ots=yHGbs78PKl&sig=4e9mDFgnBjEc0l-EzrpW3CZ4t2k&hl=en&ei=OEo-TN7rDcP88Aauq_SyBA&sa=X&oi=book_result&ct=result&resnum=1&ved=0CBYQ6AEwADgK#v=onepage&q=GBS%20mother%20protection%20antibodies%20newborn&f=false

2 Current Controversies in Midwifery Care, by Saraswathi Vedam, CNM, audio from 2009 MANA Conference 

Part I: GBS (Group Beta Strep)

I had been thinking it was best for moms to test for GBS at 36 weeks.  My rational was not driven by the belief that testing is necessary but rather by the wish to avoid the following scenario; if a mom enters a hospital in our area without a GBS negative result, even if the baby is asymptomatic, the baby will undergo a septic workup, often including a spinal tap, and the baby may be kept for observation and the mom sent home. 

Recently I have realized that the GBS  problem is much more complicated then merely testing and hoping for a negative result.  Testing can lead to a positive result which again leads to the scenario of the septic work up/spinal tap/separation. And testing can imply condoning the existing non-evidenced based GBS protocol (see for example the gold standard Cochrane review). 

You can argue that you should recommend GBS testing so that mom has more information, information that may influence how she care for herself in the last few weeks of her pregnancy.  But isn't that the mom's decision?  More information might be too information for the worry wort. I think the answer is to provide mom with the current research (which is full of gaps) and make space to let mom decide on her own the best path (isn't this always the best, empowering, course of action!). 

The recent Midwifery Today article by Judy Slome Cohain, CNM "Newborn Group B Strep Infection: Top Ten Reasons Not to Culture at 36 Weeks" (Issue 94, Summer 2010) prompted me to contact Judy.  She gave me permission to reprint her article below. I think it is fabulous food for thought as moms begin to navigate the decision making process of deciding whether or not to test.

GBS Disease of the Newborn in 2010:   Top 10 Lists: Things We Know and Things We Don't

By Judy Slome Cohain, reprinted with permission.

1. Culturing at 36 weeks and treating GBS positive women prophylactically in labor has not been shown to decrease newborn GBS disease by RCT study  (1).  The use of risk-based management results in  the same rate of GBS disease as culturing at 36 weeks and treating GBS positive women prophylactically in labor.  “Implementation of universal screening was expected to result in a 30% further decline in the incidence of EOD, with the most dramatic reductions anticipated among term infants, because screening is performed during 35-37 weeks of gestation....The overall EOD incidence rate showed an initial downward trend from 2000 to 2003 (0.52 to 0.31 cases per 1,000 live births), followed by an increase from 2003 to 2006 (0.31 to 0.40 cases per 1,000 live births.....This increase was not anticipated and cannot yet be explained.” (23)

2. Premise that GBS cultures are accurate for 5 weeks is based on a single study of 116 women.(2)  Larger studies failed to reproduce their results and have shown GBS cultures taken 24 hours before the woman gives birth are less than 30% accurate when compared to cultures taken at the time of birth.(3, 4)

3. Reports of Penicillin resistant GBS began to appear in 2007 (5). One study already found 10% of GBS cultured from women Pen-Resistant(6). If Pen-Resis GBS follows the evolution of Pen-Resis Strep pneumoniae which was first isolated in 1972(8),  in 2035, 50% of GBS will be unsusceptible to Penicillin(9). If the evolution of Pen Resistant GBS  were to resemble the development of MRSA, in 2055, 50% of GBS will be unsusceptible to Penicillin(7).   It is unknown whether giving 1 million American women per year mega doses of IV Penicillin in labor will speed the process of the evolution of Penicillin resistance in GBS. There is scant hope for miracle drugs as no new antibiotic families have been discovered since 1960. (10) 

4. 7%-10% of women cannot be given Penicillin due to allergic reactions.    The first line of alternatives is Clindamycin or Erythromycin, however about 50% of GBS is currently ‘resistant’ to the Clindamycin and/or Erythromycin. When the GBS is resistant to Clindamycin and Erythromycin, Vancomycin is given, often causing strong side effects like hypotension, RED MAN syndrome i.e. hives, histamine reaction and feeling lousy.

5. The 2002 CDC GBS protocols declared on page 16 that prophylactic antibiotics are only a temporary solution because of expectation that Penicillin resistant GBS will develop, however a definition for temporary was absent from the protocols.  The only alternative considered so far has been giving newborns routine antibiotics, which caused an increased death rate.

6. A GBS vaccine is never going to happen, because the surface antigens of GBS mutate too quickly to be effective as a vaccine given before pregnancy and the legal liability of giving pregnant women vaccines is too great.

7. 1 in 10,000 women have serious anaphylactic reactions to Penicillin (1)

8. Vaginal GBS is 2 to 3 times more prevalent in the USA than in third world countries (11)

9. Research conducted at NIH (13) found Penicillin use during labor was associated with a 2.6-fold increase in respiratory distress (nasal flaring, grunting, retraction or tachypnea (respiration rate =60 breaths/minute)  within 48 hours after birth in the absence of Early Onset GBS disease among 1,600 colonized newborns >32 weeks gestation.  95% were over 37 weeks gestation. Among colonized newborns of penicillin-treated mothers, 20.4% had respiratory distress compared with 6.9% of colonized newborns of untreated mothers.    In reaction to penicillin, Streptococcus mutans releases phospholipids immediately, which are known to cause pulmonary hypertension in experimental animals.  The increased respiratory distress in newborns colonized with GBS in which the mother was treated with Penicillin in labor may due to the phospholipids used by GBS as a defence to Penicillin. Being heavily or lightly colonized was not a significant factor in the development of early onset GBS or respiratory distress.  All antibiotics during pregnancy may increase allergies and asthma in children(14).

10. Telling 25% of pregnant women they are infected with a bacteria  that may be deadly to their fetus often has a terrifying psychological affect on the mother, which has unexplored affects on the fetus.

Top 10 things about GBS of the newborn for which there is a lack of research:

1.  How many full term babies are permanently injured (not  killed) from GBS disease of the newborn?  How many experience each of the various types (deafness, learning disabilities, CP) of morbidity?

2. Do prophylactic antibiotics to GBS positive women prevent or decrease long term GBS morbidity in full term newborns (vs. mortality)?

3. The presence of GBS antibodies in the mother has been shown to be protective against Newborn GBS(10).  Women with high titers of antibodies to GBS are thought to pass on immunity to GBS to their fetus and thereby have less GBS infected babies. Smokers, drug abusers, obese and immune suppressed women produce less antibodies.  Are they more likely to have a baby with GBS disease? Is some/most/all GBS disease of the newborn associated with women with low titers of antibodies to GBS?

4. There is only one published study asking whether pregnant women who culture GBS positive in urine, also culture positive in rectovaginal culture.  Of 1036 assymptomatic women who underwent routine urine culture in pregnancy, 10.7% had GBS in their urine, of those 70% of those had <10,000 CFU (colony forming units) and 30% had >10,000 CFU which is considered highly colonized. Of the 111 women who had GBS in their urine (bacteriuria), 40% cultured negative for GBS on rectovaginal swabs. Women who were heavily colonized in urine were no more likely than those lightly colonized in urine to have  positive rectovaginal cultures. (16)

Approximately 11% of women colonized positive for GBS in urine and their healthy babies culture positive for GBS than other babies, however no one has ever documented higher rates of GBS DISEASE associated with maternal GBS bacteriuria. GBS in urine has been associated with chorioamnionitis- uterine infections in the mother- which is most closely associated with prolonged labors, as well as frequent vaginal exams, internal monitoring, prolonged ROM, cesareans, and teenage pregnancies,  but to date not documented to be associated with GBS disease of the newborn.

There are many claims that antibiotics during pregnancy given to women wiht GBS bacteriuria can prevent preterm birth, but this data is confounded by studying high risk populations. A RCT study contradicts this claim, found that women with GBS bacteriuria, additional exposure to antibiotics is associated with an increased, not decreased, risk of preterm birth.  In this study the rate of preterm birth for women with bacteriuria was 16% and without GBS bacteriuria was also 16% and 28% among women with GBS bacteriuria who received antibiotics. (17)  All three rates reflect outcomes only seen in extremely high risk populations. Healthy, well fed populations,   the preterm rate is 7%.   Asymptomatic  GBS bacteriuria may not have a role in preterm birth but rather may be a marker for low socioeconomic status which is associated with low birth weight. (18) The quality of even the best studies on asymptomatic bacteriuria in pregnancy is poor. (18)

The unanswered question is: Do heavily colonized full term women have more GBS newborn disease or perhaps less newborn GBS due to higher titers of antibodies against GBS that they pass to the fetus?  Are women who heavily colonized  with GBS, whether in urine or vagina,  more likely or less likely to have babies with GBS disease?  We dont know.

Does giving oral antibiotics to pregnant women with asymptomatic GBS bacteriuria decrease or increase the occurrence of GBS disease of newborn?  

5. 50% of GBS disease of the newborn occurs to babies of women with the following risk factors: Premature, IUGR, LBW, ROM > 18 hours, and fever.  The other 50% occurs to babies of women without those risk factors.  Of those women, how many had ROM between 2 and 17.9 hours?  Since prolonged ROM is known to increase the risk of GBS disease, how would eliminating AROM affect the occurrence of GBS disease of newborn? 

Is there a difference in the GBS disease among women with impressive, flowing ROM which fills up pads quickly and women who have a high leak that is leaks 1 to 2 cc per hour?  Is a high leak a risk of newborn GBS at all?

6. On page 11 of the 2002 CDC protocols appears one of several unqualified statement “GBS can cross intact amniotic membranes.”   A study of 550 babies born to GBS positive women, by CS without ROM, and without prophylaxis, demonstrated not a single case of GBS disease, where one would expected 5 sick newborn if GBS crossed membranes, supporting the theory that GBS either never crosses membranes. In vitro study has not been able to demonstrate GBS crossing membranes, even at concentrations of 1,000,000,000 CFU.  (20) Further investigation into how GBS could cross intact membranes demonstrated that GBS failed to invade amnion cells under a variety of assay conditions (21) and fetal membranes demonstrated an inhibitory effect on GBS. (22).  Cases of  colonized infants born by CS in the absence of ruptured membranes could be due to any number of other vectors other than the mother that come in contact with the baby.

7. Over 6 vaginal exams significantly increased rates of GBS disease(15).  Scalp electrodes double the risk of GBS colonization of amniotic fluid (19)

In my practice, with restricted AROM and Vaginal exams and no scalp electrodes, 3% of births the baby’s head comes out in the sac and never makes direct contact with the uterus, cervix or vaginal walls at all. How would restricted AROM, Vaginal exams and scalp electrodes affect GBS disease rates?.among low risk women? Among high risk women?

  

8. When does GBS cause disease? 99% of babies colonized with GBS, dont get GBS disease.  99.99% of women colonized with GBS, dont get GBS vaginitis. Why does GBS sometimes attack and sometimes live in ecological balance?   Why is GBS present in 2-3 times as many women in the USA than in Ireland, Cambodia, Taiwan, Philippines or Africa?  (11)  Why is long term (over 6 months duration) Symptomatic GBS Vulvovaginitis becoming more common in the western world? (12)

9.  How does GBS inhibit lactobacillus growth?

10. How many newborns will die of GBS disease in 10 years? 20 years? 40 years?

In the presence of so many unknowns, current protocols reflect an bias to take action in the presence of a lack of appreciation or humility for the complex habits of GBS and no consideration of the next generation of newborns. 

1. Ohlsson A, Shah VS. Intrapartum antibiotics for known maternal Group B streptococcal colonization. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD007467

2. Yancey MK, Schuchat A, Brown LK, Ventura VL, Markenson GR.The accuracy of late antenatal screening cultures in predicting genital group B streptococcal colonization at delivery. Obstet Gynecol 1996;88:811–5.

3. Itakura A.Kurauchi O Morikawaa S, Matsuzawab K Mizutania S, Tomodaa Y. Variability of peripartum vaginal group B streptococcal colonization. International Journal of Gynecology & Obstetrics 55 (1996) 19-22.S

4. Tamerou Asrat, et.al.The accuracy of late third trimester antenatal screening for group B streptococcus in predicting GBS colonization at delivery American Journal of Obstetrics and Gynecology, Volume 195, Issue 6, Supplement 1, December 2006, Page S40

5. Chu YW, Tse C, Tsang GK, So DK, Fung JT, Lo JY. . Invasive group B Streptococcus isolates showing reduced susceptibility to penicillin in Hong Kong. Antimicrob Chemother. 2007 Dec;60(6):1407-9.

6.  Joachim A, Matee MI, Massawe FA, Lyamuya EF. Maternal and neonatal colonisation of group B streptococcus at Muhimbili National Hospital in Dar es Salaam, Tanzania: prevalence, risk factors and antimicrobial resistance. BMC Public Health.;2009: 9:437.

7. Klevens RM, Morrison MA, Nadle J, et al.Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007 Oct 17;298(15):1763-71.

8. Appelbaum, P. C. 1992. Antimicrobial resistance in Streptococcus pneumoniae: an overview. Clin. Infect. Dis. 15:77-83.

9. Jacobs, M. R., S. Bajaksouzian, A. Zilles, G. Lin, et al. 1999. Susceptibilities of Streptococcus pneumoniae and Haemophilus influenzae to 10 oral antimicrobial agents based on pharmacodynamic parameters: 1997 U.S. Surveillance study. Antimicrob. Agents Chemother. 43:1901-1908.

10. Walsh CT Fischbach MA New ways to squash superbugs. Scientific American, 2009. 301:32.

11. Whitney CG. et.al.The International Infections in Pregnancy Study: group B streptococcal colonization in pregnant women. The Journal of Maternal–Fetal and Neonatal Medicine 2004;15:267–274.

12. Cohain, JS. Long term Symptomatic GBS Vulvovaginitis – 8 cases resolved with freshly cut garlic. European Journal of OBGYN Reprod Biology. 2009;146(1):110-1. 

13.   Lin FY, Troendle JF. Hypothesis: Neonatal respiratory distress may be related to asymptomatic colonization with group B streptococci. Pediatr Infect Dis J. 2006 Oct;25(10):884-8.

14.  McKeever TM, Lewis SA, Smith C, Hubbard R. . The importance of prenatal exposures on the development of allergic disease: a birth cohort study using the West Midlands General Practice Database. Am J Respir Crit Care Med. 2002 Sep 15;166(6):827-32.

15.  P T Heath,1 G F Balfour,1 H Tighe,1 N Q Verlander,2 T L Lamagni,3 A Efstratiou Group B streptococcal disease in infants: a case control study. Arch Dis Child 2009 94: 674-680.

16. Centelles-Serrano MJ, Pérez-Moreno MO, Llovet-Lombarte MI, Cortell-Ortolá M, Jardí-Baiges AM, Buj-González JI.Effectiveness of systematic investigation for Group B Streptococcus in urine samples to identify colonized pregnant women. Enferm Infecc Microbiol Clin. 2009 Aug-Sep;27(7):394-8.

17. Anderson BL, Simhan HN, Simons K, Wiesenfeld HC. Additional antibiotic use and preterm birth among bacteriuric and nonbacteriuric pregnant women. Int J Gynaecol Obstet. 2008;102(2):141-5.

18 .  Smaill F, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev. 2007; 18;(2):CD000490.

19. Keski-Nisula L, Kirkinen P, Katila ML, Ollikainen M, Saarikoski S. Cesarean delivery. Microbial colonization in amniotic fluid.J Reprod Med. 1997;42(2):91-8.

20. Kjaergaard N, Helmig RB, Schønheyder HC, Uldbjerg N, Hansen ES, Madsen H. Chorioamniotic membranes constitute a competent barrier to group b streptococcus in vitro. Eur J Obstet Gynecol Reprod Biol. 1999 Apr;83(2):165-9.

21. Winram SB, Jonas M, Chi E, Rubens CE. Characterization of group B streptococcal invasion of human chorion and amnion epithelial cells In vitro. Infect Immun. 1998 Oct;66(10):4932-41.

22. Kjaergaard N, Hein M, Hyttel L, Helmig RB, Schønheyder HC, Uldbjerg N, Madsen H. Antibacterial properties of human amnion and chorion in vitro. Eur J Obstet Gynecol Reprod Biol. 2001;94(2):224-9.

23. Centers for Disease Control and Prevention (CDC). Trends in perinatal group B streptococcal disease - United States, 2000-2006. MMWR Morb Mortal Wkly Rep. 2009 Feb 13;58(5):109-12.

A big thank you to Judy Slome Cohain for giving me permission to reprint the above article. Stay tuned for more posts about GBS...

I suppose I will get a post up one of these days! In the meantime, have you read Orgasmic Birth? I've started and it is fabulous! And I have to brag for one second, both Fen and Nettie's stories are in it! Check it out!