Group B Strep Positive = Antibiotics During Labor... Evidence Based?

This review finds that giving antibiotics is not supported by conclusive evidence. The review identified four trials involving 852 GBS positive women. Three trials, which were around 20 years old, compared ampicillin or penicillin to no treatment and found no clear differences in newborn deaths although the occurrence of early GBS infection in the newborn was reduced with antibiotics. "Intrapartum antibiotics for known maternal Group B streptococcal colonization"

Anyone that has been pregnant knows that at around 35-36 weeks gestation, your OB tests you to find out of you are "GBS+" or Group B Strep positive. This involves a swab of the vagina and usually the rectum and it is sent off for analysis and culture. If the results show that you are GBS+, antibiotics are required during labor to keep the baby from contracting the infection.... or will they?

A new study by the Cochrane Reviews shows that giving antibiotics made no clear difference in the instance of GBS infections.

So, yet again, ACOG and its members are practicing medicine that is not evidence based. At the very least, I would like to see OB's using antibiotics on a case by case basis.

There are symptoms that can indicate that you are at a higher risk of delivering a baby with GBS...

* Labor or rupture of membranes before 37 weeks
* Rupture of membranes 18 hours or more before delivery
* Fever during labor
* A urinary tract infection as a result of GBS during your pregnancy
* A previous baby with GBS disease

Shouldn't we be looking more at these risk factors and treating mindfully, rather then assuming that yet another one-size fits all way of practicing is best?

Looking for some alternative treatment options? http://www.givingbirthnaturally.com/group-b-streptococcus.html

The Experience of Birth

Wiregrass Birth Network

The Wiregrass Birth Network is a non-profit organization committed to helping women and families have a safe & fulfilling pregnancy and birth experience.

Our goal is to empower women in their roles as health care consumers. We promote an awareness of evidence-based care and informed decision making through advocacy, education and support.

Visit the new site at: http://wiregrassbirthnetwork.webs.com/

Pregnant Woman = Doormat?

So, I've been reading a lot of articles and stories lately about women who have been treated badly during labor and birth.

Here are just a few:

Skol v. Pierce Update: Doctor Fined and Placed on Probation

New Jersey Cesarean Refusal Case: The "System" is Schizophrenic

Since when did pregnant women become doormats? No one, especially a woman in labor, deserves to be treated like this.

This all has me thinking.

A pregnant woman, like any other competent adult, has certain basic rights. She has the right (for any or no reason) to decline medical treatment. This has long been recognized by the common law in the United States, Canada, England and Australia. (from Childbirth and the law; By John A. Seymour)

It amazes me that in this country you can actually choose to have an abortion, yet you (obviously) can't choose to refuse a cesarean. And while I don't want to open a can of worms in regards to abortion, we need to sort out some facts.

An abortion is the termination of a pregnancy by the removal or expulsion from the uterus of a fetus/embryo, resulting in or caused by its death. (from Wikipedia)

So, an abortion ends in the death of the fetus (or embryo as the case may be), and it is a deliberate act. And if we take into consideration that there are a few doctors in this country that still do LATE term abortions, we can factually say that some abortions are performed on viable fetuses. So, we are legally allowed to cause death deliberately to a potentially viable baby, but we are not allowed to refuse a cesarean (even when fetal distress is the reason given for it).

Abortion = Deliberate Death = OK
Cesarean Refusal = Possible Death = Not OK

Now, I am not advocating for women to refuse cesareans if their baby is in true distress. And I think that most women are smart enough and brave enough to admit that cesareans are a wonderful live-saving tool and a benefit when used judiciously. But to tell a woman that she must sacrifice her bodily integrity to potentially save the fetus's life seems out of line.

Lets talk a bit about fetal monitoring for a moment.

Results were the same in all four studies: more electronically monitored women ended up...with Cesarean deliveries. Cesarean section rates ranged between 63% and 314% higher for electronically monitored women than manually monitored women. There was no improvement in perinatal outcome for the babies delivered by Cesarean section. The principal "reasons" alleged for these surgical deliveries--fetal distress and cephalopelvic disproportion (disproportion of head to pelvis)--cannot be proved or disproved. The real reasons, according to these studies, are attending physicians' impatience and nervousness. (Brackbill et al. 1984:10)

Ok, so according to 4 studies, the diagnosis of fetal distress via electronic fetal monitors which led to an implied life-saving cesarean, showed NO better outcome.

Forgive me, I am failing to see why a pregnant woman's autonomy should be violated...

VBAC

What is a VBAC? Simply put, it is a vaginal birth after cesarean. I talk to a lot of pregnant women. Most of the mother's I speak with who have had previous c-sections will express some interest in a VBAC, but won't follow through. This is unfortunate, because the risks associated with VBAC's are less than those of elective repeat c-sections.

And yes, I did say elective repeat c-sections. This is what they are... elective. You don't have to have one.

Risks to the baby from elective cesarean section:

* Babies delivered by elective cesarean have an increased risk of neonatal respiratory distress syndrome (RDS), a life-threatening condition,3-7 and other respiratory problems that may require NICU care.
* Babies delivered by elective cesarean have a five-fold increase in persistent pulmonary hypertension (PPH) over those born vaginally.6
* Babies delivered by elective cesarean are at increased risk of iatrogenic (physician-caused) prematurity, usually related to failure to conform to protocols for determining gestational age prior to delivery, or errors in estimating weeks of gestation even with the use of clinical data.7,8 Prematurity can have life-long effects on health and well-being, and even mild to moderate preterm births have serious health consequences.9
* Babies delivered by elective cesarean are cut by the surgeon’s scalpel from two to six percent of the time.10 Researchers believe these risks to be under reported.

Risks to the mother from elective cesarean section:

* Up to 30% of women who have a cesarean acquire a postpartum infection. Infections are the most common maternal complication after cesarean section and account for substantial postnatal morbidity and prolonged hospital stay.11
* Other serious complications for women undergoing cesarean include massive hemorrhage,12 transfusions,13 ureter injury,14 injury to bowels,15 and incisional endometriosis.16,17
* Women who undergo cesarean report much lower levels of health and well-being at seven weeks postpartum than women who have vaginal births.18
* Women who undergo cesarean section have twice the risk of rehospitalization for reasons such as infection, gallbladder disease, surgical wound complications, cardiopulmonary conditions, thromboembolic conditions, and appendicitis. Rehospitalization has a negative social and financial effect on the family.19
* Women who undergo cesarean section report less satisfaction than women having vaginal births.20,21
* Women undergoing cesarean are at increased risk of hysterectomy in both the current and future pregnancies.22,23
* The maternal death rate is twice as high for elective cesarean as for vaginal birth.24
* In subsequent pregnancies, women with a prior cesarean have higher rates of serious placental abnormalities which endanger the life and health of the baby and the mother.25-27 Women are rarely told that a cesarean places future babies at higher risk.
* After cesarean section, women face higher rates of secondary infertility as well as higher rates of miscarriage and ectopic pregnancy.28,29

References:
1 Harer WB Jr. Patient choice cesarean. ACOG Clinical Rev 2000; 5(2).
2 Greene MF. Vaginal delivery after cesarean section - Is the risk acceptable? N Engl J Med 2001; 345(1): 54-5.
3 Bowers SK, MacDonald HM, Shapiro ED. Prevention of iatrogenic neonatal respiratory distress syndrome: Elective repeat cesarean section and spontaneous labor. Am J Obstet Gynecol 1982;143(2):186-9.
4 Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: Influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102:101-6.
5 Hales KA, Morgan MA, Thurnau GR. Influence of labor and route of delivery on the frequency of respiratory morbidity in term neonates. Int J Gynaecol Obstet 1993; 43(1):35-40.
6 Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42.
7 Parilla BV, Dooley SL, Jansen RD, and Socol ML. Iatrogenic respiratory distress syndrome following elective repeat cesarean delivery. Obstet Gynecol 1993; 81(3):392-5.
8 Hook, B et al. Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics 1997; 100(3):348-53.
9 Kramer MS, Demissie K, Yang H, Platt RW, Sauve R, Liston R. The contribution of mild and moderate preterm birth to infant mortality. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. J Amer Med Assoc 2000; 284(7):843-9.
10 Smith JF, Hernandez C, Wax JR. Fetal laceration injury at cesarean delivery. Obstet Gynecol 1997; 90(3): 344-6.
11 Henderson EJ & Love EJ. Incidence of hospital-acquired infections associated with cesarean section. J Hosp Infect 1995; 29: 245-255.
12 van Ham MA, van Dongen PW & Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997; 74: 1-6.
13 Naef RW III, Washburne JF, Martin RW et al. Hemorrhage associated with cesarean delivery: When is transfusion needed? J Perinatol 1995; 15: 32-35.
14 Eisenkop SM, Richman R, Platt LD & Paul RH. Urinary tract injury during cesarean section. Obstet Gynecol 1982; 60: 591-596.
15 Davis JD. Management of injuries to the urinary and gastrointestinal tract during cesarean section. Obstet Gynecol Clin North Am 1999; 26: 469-480.
16 Wolf Y, Haddad R, Werbin N, Skornick Y, Kaplan O. Endometriosis in abdominal scars: A diagnostic pitfall. Am Surg 1996; 62(12):1042-4.
17 Wolf GC, Singh KB. Cesarean scar endometriosis: A review. Obstet Gynecol Surv 1989; 44(2):89-95.
18 Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol. 2001 Jul;15(3):241-2.
19 Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. J Amer Med Assoc 2000; 283(18):2411-2416.
20 Fawcett J, Pollio N & Tully A. Women’s perceptions of cesarean and vaginal delivery: Another look. Res Nurs Health 1992; 15: 439-446.
21 Waldenstroem U. Experience of labor and birth in 1111 women. J Psychosom Res 1999;47: 471-482.
22 Stanco LM, Schrimmer DB, Paul RH, Mishell DR Jr. Emergency peripartum hysterectomy and associated risk factors. Am J Obstet Gynecol 1993; 168(3 Pt 1):879-83.
23 Bakshi S, Meyer BA. Indications for and outcomes of emergency peripartum hysterectomy. A five-year review. J Reprod Med 2000; 45(9):733-7.
24 Bewley S. Maternal mortality and mode of delivery. Lancet 1999; 354: 776.
25 Zaideh, SM et al. Placenta praevia and accreta: Analysis of a two-year experience. Gynecol Obstet Invest 1998; 46(2):96-8.
26 Ananth, CV et al. The association of placenta previa with history of cesarean delivery and abortion: A meta-analysis. Am J Obstet Gynecol 1997; 177(5):1071-78.
27 Miller DA, Chollet JA & Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997; 177: 210-214.
28 Hemminki, E and Merilainen, J. Long-term effects of cesarean sections: Ectopic pregnancies and placental problems. Am J Obstet Gynecol 1996; 174(5):1569-74.
29 Hall MH, Campbell DM, Fraser C & Lemon J. Mode of delivery and future fertility. Brit J Obstet Gynecol 1989; 96: 1297-1303.

© International Cesarean Awareness Network, Inc. All Rights Reserved.

The most serious risk of a VBAC is a uterine rupture. While this often sounds catastrophic, that is not always the case. Most uterine ruptures occur without symptoms and do not cause problems for the mother or baby. This mild type is usually only noticed when surgery is required for other reasons.

Researchers have shown that women attempting a VBAC and who have undergone a trial of labor have a 1.6 per thousand chance of uterine rupture or 0.16%.

A recent study, The Vermont/New Hampshire VBAC Project, reported that the overall risk of infant death from a VBAC attempt is 6 per 10,000 compared to 3 per 10,000 planned cesarean births.

The rate of uterine rupture rises when labor is induced with oxytocin, prostaglandin preparations, or misoprostol (Cytotec).

Women interested in attempting a VBAC should learn as much as possible about labor, childbirth, cesareans, informed consent and VBAC pros and cons. I also recommend looking into support groups like ICAN and getting the support of a doula or other support person with professional childbirth experience.

A VBAC can be a very emotionally charged and challenging event. But it is often an empowering and healing one as well.

Inductions

Ok, so I'm posting about inductions, again. Yes, I'm irritated about them, again. So, here are my lists.

Reasons to induce:

• Preeclampsia (or worsening preeclampsia/HELLP)
  
• Eclampsia (life threatening, usually means a c-section)
  
• Chronic high blood pressure that is difficult to keep under control or is affecting the baby's growth
  
• Intrauterine growth restriction
  
• Gestational diabetes - induction can be indicated at 40 weeks for this, to prevent complications related to the diabetes (risk for stillbirth goes up, blood glucose out of control)
  
• Mom has an illness or medical condition that continuing the pregnancy would make the condition worse, or could endanger mother or baby's health.
  
• Very low amniotic fluid levels (below 6) - usually confirmed by a 2nd ultrasound -- first ultrasound could have been wrong.
  
• Fetal distress or health concerns for the baby based on prenatal screenings (NSTs, biophysical profiles)
  
• Post dates (beyond 42+ weeks)
  
• Amniotic sac has ruptured but labor hasn't started within 24-48 hours.
  

NOT Reasons to Induce:

• Large for gestational age
  
• Maternal discomfort
  
• Hypothyroidism
  
• History of short labors
  
• Live more than 30 minutes from the hospital
  
• Family will be in town
  
• Want to pick the birth date
  
• Edema
  
• Tired of being pregnant
  
• Husband in the military
  
• Patient convenience
  
• Doctor convenience
  
• One or two days past your due date

About one out of every five pregnant women in the U.S. has their labor induced, according to the CDC. You can't honestly tell me that 1 in 5 women have the above medical indications for induction.

“It's really become an epidemic,” said Dr. Mildred Ramirez, an author of the American College of Obstetricians and Gynecologists guidelines and professor of ob-gyn at the University of Texas Medical School at Houston.

The overall induction rate doubled from 1999 to 2006.

Ladies!!! Wait it out. Be firm.

The Birth Survey

If you've given birth in the past 3 years, please take this survey!!!

www.thebirthsurvey.com

The purpose of The Birth Survey is to provide women with a venue to give feedback about their birth experiences with specific doctors, midwives, hospitals and birth centers, and to make this feedback available on this website as searchable reports. These reports currently include overall ratings but will over time expand to include detailed feedback. These searchable reports will be a resource to help other women and families to make more informed choices when choosing maternity care providers and birth settings and provide practitioners and institutions with feedback for quality of care improvement efforts.

Boring

So, I've been trying to decide what to blog about this evening. The kids are in bed, I have the house to myself and I've been searching the internet for some new piece of interesting information for an hour now. So far... nothing has hit me.

So maybe I'll just blog some random thoughts...

1. Every pregnant woman should read the book "Pushed" by Jennifer Block. It is a wonderful collection of information. Read it. Pass it on.

2. My daughter had a hard evening. She refused to take a nap this afternoon and by the time we arrived home around 6pm she was a mess. The screaming and crying ensued and I finally ended up giving her soup for dinner and sending her to bed at 7:30pm. She didn't even complain much. She was tired.

3. Cole has been an angel about sleeping since we got home from Jamaica. He has slept through the night since we got home. This morning I woke up to him standing next to my bed with his arms up. He wanted to nurse. So I changed him, and put him in bed with us and we snuggled and slept a bit longer. I'm going to miss these days.

4. I love my babies, even when they are horrible and run around car dealerships and stores and scream and don't listen and whine and cry and talk back. I still love them... even when I want to rip out my hair.

Ok, well, now I'm even more exhausted, so I'm going to bed.. early. YUM.

Pit to Distress

While I feel very lucky that all the births I've attended thus far have been induction and pitocin free, I know there will come a day when a client faces pitocin.

With all the birthy information that I read about or talk about on a daily basis, I have not heard of this. Honestly (and unfortunately), I am NOT surprised. The fact that there is even a need to inform women of this, disgusts me.

"Pit to Distress": Your Ticket to an "Emergency" Cesarean?

“Pit to distress.” How have I not heard about this? Apparently it’s quite en vogue in many hospitals these days. Googling the term brings up a number of pages discussing the practice, which entails administering the highest possible dosage of Pitocin in order to deliberately distress the fetus, so a C-section can be performed.

Yes folks, you read that right. All that Pit is not to coerce mom’s body into birthing ASAP so they can turn that moneymaking bed over, but to purposefully squeeze all the oxygen out of her baby so they can put on a concerned face and say, “Oh dear, looks like we’re heading to the OR!”

Ok, so here is my advice.

First, read the blog entry from Jill at Unnecesarean (above).

Next, read my blog on Labor Induction.

Next, don't induce unless it is medically necessary.

Finally, do some research on pit protocols and ask your doctor and hospital what their policy is. Do they jive? Does it sound like too much? Will they agree to a lower or slower pit induction?

If not... RUN.

Shame on OB's that practice this way.

Welcome Baby!

My client due 7/20 had her baby this morning. I'm so glad I got to attend this birth!

She was great. Very calm, very in control. She called me yesterday afternoon to check in after her OB appt and let me know that she was 3cm/100%/btw 0 & +1. WOW! She told me her back was hurting her a lot. I had a nervous feeling, but told her to try some pelvic rocks and hands & knees.

She called me back a few hours later around 6:30pm to ask if she was having contractions. From her description, I confirmed that she was probably in early labor and told her to go rest, take a bath, relax and to call me back in 2 hours to let me know if things had changed.

She called again at about 7pm, to say she was bleeding. She felt like it was a lot of bright red blood, so I told her to call her doctor and ask what he thought she should do. He wanted her to come and get it check out, just to make sure there wasn't a problem. She has a 45min drive to the hospital. I told her I would meet her at there.

I arrived at about 8pm. She was checked at 8:15pm and was 4cm/100%/0. The blood was just bloody show, although a lot of it. She was admitted and we were in a room around 9pm and her antibiotics were started (GBS+).

Around 10pm, her contractions were about 3 minutes apart, and long (double peaking). I got her in the tub and it spaced her contractions out a bit and they weren't as long, and she said she felt a lot better there. After about 30 minutes, she got out and back to the bed to lay down.

At 12am on 7/7, she was checked again and was 5cm, her contractions were long again (90+ seconds) and about 2 minutes apart. Around 2am she went to the bathroom and said she heard a pop and thought her water had broken. She laid back down on the bed and was immediately shaking and showing signs of transition. After saying she was feeling some pressure and grunting, she was checked and was 8cm.

The nurse left us alone (again) and we talked her out of giving up. Several times I looked up at the door wondering why no one was in here checking in. After several contractions of uncontrollable pushing during contractions, I paged the nurse to come. A different nurse comes in and I tell her that she is pushing a lot with each contraction. It's been about 20 minutes since she was last checked. She tells me she will tell her nurse, but not to push (as if I can hold her baby in or stop her). We work to get her to breathe out and that works a lot to keep her from pushing. Finally (at 3am) the nurse comes in and I give her a look... you know the she is ready to have a baby look, and she checks her (she's complete, duh!) and she calls the doctor, and tells her not to push (hah!). I tell her to blow out again, but I don't try and stop her from pushing. She's complete and whether he makes it or not, wasn't that important.

OB comes in and asks how things are going. Watches her push a couple times and leaves. (This doc is kind of funny, he's sort of a interventionist, but he tries to be hands off) At about 3:30pm, she has moved the baby down to almost crowning and doc comes back in. The baby is born at 3:41am.

He is a cutie! Congratulations to the new mom and dad!

Sleep with your baby!

Ok! So how often have you heard this:

"Is your baby sleeping through the night yet?"

It is often (and unfortunately) the first question people ask a new parent.

The truth is that most babies do not sleep through the night, yet it is a myth that is perpetuated from generation to generation.

Ladies! It is ok! There is no reason for your baby to be sleeping through the night! The fact that they are not, shows that they are developing just as they should. They are bonding. They are attaching. They need you at night, just like they need you during the day.

Parents who are frustrated with frequent waking or who are sleep deprived may be tempted to try sleep training techniques that recommend letting a baby cry in an effort to "teach" him to "self-soothe". New research suggests that these techniques can have detrimental physiological effects on the baby by increasing the stress hormone cortisol in the brain, with potential long term effects to emotional regulation, sleep patterns and behavior. An infant is not neurologically or developmentally capable of calming or soothing himself to sleep in a way that is healthy. The part of the brain that helps with self-soothing isn't well developed until the child is two and a half to three years of age. Until that time, a child depends on his parents to help him calm down and learn to regulate his intense feelings.

Notice the bold that I added. Bet you didn't think about the neurological aspects of sleeping through the night!

The Case Against Solitary Sleep

It's important to note that infant solitary sleep is a relatively new practice that has evolved in the western world only within the last 100 years. Recently, there have been efforts by various medical and professional organizations to discourage parents from sleeping with their children for fear that it contributes to an increase in Sudden Infant Death Syndrome (SIDS). However, new research demonstrates that co-sleeping, when practiced by informed parents, can be safe and beneficial. In fact, many cultures where parents routinely sleep with their children report some of the lowest SIDS rates. In some of these cultures SIDS is non-existent.

In closing! Sleep with your baby! If you aren't comfortable with the baby in your bed, try a side-car arrangement or a bassinet next to your bed. If nothing else, keep the baby in your room! It will help your baby, and it will help you. If you have to get up in the middle of the night with your little one, at least you don't have to walk across the house in a haze.

Happy sleeping!

Ref: http://www.attachmentparenting.org/principles/night.php

Special Offers!

Ok, so I've got some special deals running right now. The economy being what it is, I thought I would try to offer what I could.

Check them out here!

Push Summit 2009 in Birmingham!

Push Summit 2009 in Birmingham!

The Big Push for Midwives, is holding “Push Summit 2009” in Birmingham from July 12-14. The nation’s best and brightest midwifery advocates will be convening to discuss state- and national-level strategies for licensure of Certified Professional Midwives.

The summit is expected to draw national media attention.

If you want to be more involved in our state’s licensing effort, this will be an informative event. You may register here.

Please note that they are offering a discounted rate for students who wish to attend.

2009/2010 Maternity Care Excellence Awards

HealthGrades recognized 145 hospitals with a 2009/2010 Maternity Care Excellence AwardTM. This places these hospitals among the top 10% of all hospitals nationwide for maternity care.

These best-performing hospitals consistently outperformed all other hospitals for maternal complication indicators as well as the weight-stratified neonatal mortality indicator (the number of newborns who died while in the hospital, examined by birth weight). Because of these vast quality differences, women should take care to research quality prior to choosing the hospital where they will deliver their baby.

Unfortunately, not a single hospital in Alabama received an award. In fact, the closest hospital that received the award is in Gainsville, FL, 240 miles away from Dothan. North Florida Regional Medical Center

AND... I am not incredibly happy with this study for its cesarean rates....

C-section rates average approximately 32% among the 19 states studied.

Obviously, a much lower c-section rate would be beneficial.

For a complete list of the hospitals, click here.