|March 29, 2017|
Volume 19, Issue 7
|Midwifery Today E-News|
“Group B Strep”
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In This Week’s Issue
Understanding Diagnostic Tests by Anne Frye will give you a holistic perspective on test results. The 7th edition is updated and expanded by around 395 pages, to give you 1365 pages packed with valuable information. To order
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Quote of the Week
Humanity shares a common ancestry with all living things on Earth. We often share especially close intimacies with the microbial world. In fact, only a small percentage of the cells in the human body are human at all. Yet, the common biology and biochemistry that unites us also makes us susceptible to contracting and transmitting infectious disease.
— Brenda Wilmoth Lerner, Infectious Diseases: In Context
The Art of Midwifery
Fish oil reduces the incidence of preterm delivery by increasing the length of gestation, on average, by eight days. Although very little research exists on this topic, one study of 142 women who ate DHA-rich eggs found that the women had an increased pregnancy of six days.… Clients in a climate of high postdates induction rates … could elect to reduce their oral fish oil intake at 38 weeks and insert [evening primrose oil] vaginally (usually 1000 mg) to encourage topical absorption on the cervix to promote ripening. Do not apply fish oil topically because the smell is unpleasant.
Midwifery Today Conferences
There’s still time to attend our conference in Eugene, Oregon, this April!
You will be able to choose from classes such as Hemorrhage and Estimating Blood Loss, Research in Midwifery and Using Gentle Tools (Our Hands) for Ideal Positioning. There will also be a two-day Midwifery Issues and Skills class. Planned teachers include Penny Simkin (pictured), Gail Hart, Fernando Molina, Sister MorningStar and Carol Gautschi. Plan to register in person at the conference.
Join us in May for a one-day conference on the East Coast USA!
Jan Tritten (pictured), Gail Hart and Eneyda Spradlin-Ramos will discuss topics such as New and Old: Techniques for Controlling and Preventing Hemorrhage, Resolving Shoulder Dystocia and Our Eyes and Non-verbal Communication. There will also be a Tricks of the Trade sharing session. You may choose from three locations: Myrtle Beach, South Carolina; the Boston area; and New York City.
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GBS: Common Sense for Midwifery Practice
[Editor’s note: This issue contains a special guest editorial by Jane Beal.]
When is GBS primarily going to be an issue? When a woman has PROM or a prolonged labor after ROM (18 hours or more) and one or more cervical checks. It’s a good idea to screen prenatally, with both a double-tipped swab (one tip vaginal, the other tip rectal) and a urine culture, because if a woman has GBS, her midwife should know so she can help prevent chorioamnionitis in the mama or sepsis in the babe by taking steps prenatally, in labor and, if necessary, during postpartum.
Prenatally, if she cultures positive at 35 weeks, she can be treated (with oral antibiotics, Hibiclens (chlorhexidine), probiotics and/or grapefruit seed extract) and be re-screened within two weeks—hopefully before going into labor. It is possible to do a rapid GBS screen for a woman in labor who presents with unknown GBS status if you have such a screening test with you. Although not considered as sensitive as a prenatal culture, I would prefer this to not knowing her status or to treating her with antibiotics prophylactically (especially if she does not have GBS and has no symptoms of infection).
If a woman is GBS-positive in labor, there should be no cervical checks in early labor and only a check in active labor if it slows or an assessment is needed (as when you need to determine if there is an OP baby or an anterior lip)—and then only with a sterile glove. You can use Hibiclens on the glove rather than gel to avoid creating an easy medium for GBS to advance up the vagina to the cervix. If the woman is in good health and has had good nutrition overall, she is at less risk. If she enters labor with a cough, cold or other illness, or if she becomes greatly fatigued in labor, her body is more vulnerable to a developing infection.
In labor, with GBS and broken waters, monitor the woman’s temp (concern starts between 99.1° and 100.4°F and rises significantly at 101°F) and make sure she does not feel a stinging sensation when urinating. If chorio develops, it has a distinct smell; you will notice it. The infection should be treated in labor and/or in postpartum. Oral or IV antibiotics can be an effective option for treatment. If many doses are given, the mama is at risk of getting a secondary infection in postpartum (such as mastitis), so help her with her diet. Include probiotics to lay down good bacteria in the gut.
If maternal chorio develops, that does not necessarily mean the baby is infected, but the baby’s best hope is to be born quickly and breastfeed. The mother’s colostrum will contain the antibodies to quickly heal the baby. If the mother has GBS and the baby is born in the caul, or soon after waters break, the risk to mother and baby is minimal.
— Jane Beal, PhD, is a writer, educator and midwife. She has served with homebirth practices in the Chicago, Denver and San Francisco metro areas and in birth centers in the US, Uganda and the Philippine Islands. She is the author of Epiphany: Birth Poems and Transfiguration: A Midwife’s Birth Poems. She currently teaches at UC Davis. To learn more, please visit sanctuarypoet.net and christianmidwife.wordpress.com.
Editor’s note: This is an excerpt from an article that will be in the Summer 2017 issue of Midwifery Today magazine. Subscribe or renew now and make sure you receive this issue.
Research in Midwifery Class at Eugene Conference
Midwifery Today’s The Heart and Science of Birth conference in Eugene, Oregon, is only a week away! As the team at Midwifery Today prepares to welcome practitioners from all over the world from April 5–9 to learn, connect, share and grow, I am amazed to see the diversity of attendees who will be joining us. Equally amazing is the roster of speakers who will lead sessions that truly reflect both the heart and science of birth.
One of the courses that presents a unique opportunity for learning the value, methods and various types of qualitative research and its importance within midwifery will be led by a premier researcher within the midwifery community in the US: Melissa Cheyney, PhD, CPM, LDM. It is Dr. Cheyney’s objective that upon completion, participants in the session, “Research in Midwifery,” will be able to:
Don’t miss out on learning more about the vital role research plays within the midwifery model of care worldwide and how you can best incorporate such research into your own practice.
— Midwifery Today’s Conference Coordinator Shea Baker, birth and postpartum doula
Keep up to date with conference news on Facebook: General conference news
GBS: Antibiotics or Not?
In newborns, GBS also infects the weak. Premature babies have a higher attack rate and a higher mortality rate than those born full term. The attack rate is higher with prolonged rupture of fetal membranes and the risk increases if infection of the amniotic fluid occurs (Woods 2014).
The argument of the CDC is persuasive that giving all pregnant women who test positive for GBS intrapartum antibiotics makes scientific sense and will save lives. Not everyone is convinced. The UK does not recommend the culture during pregnancy and treat with intrapartum antibiotics when the baby is premature or when there is prolonged rupture of membranes before birth or if there are other risk factors for infection. The Cochrane Review states that giving antibiotics is not supported by conclusive evidence.
The neonatal mortality rate per 1000 live births in 2013 was 3 in the UK; In the US, it was 4/1000.The policy of routinely giving preventive antibiotics in labor to up to 1/3 of all women, for a disease that will affect 1–2 babies out of 1000 culture-positive women with a treatable disease, which is rarely serious in low-risk, full-term babies, still might seem defensible until you begin to consider the information from the Microbiome Project.
This project, which took place from 2007 through 2012, involved 80 research centers (university and other) and over 200 major researchers in sequencing the genome of the bacteria, which live in and on the human body. A lot of the information learned still needs further study, but one thing is clear: Our personal microbiome, the bacterial community of our bodies, is important to our health, especially in the development of our immune systems. The microbiome starts with the mother, in the womb and in the birth process, and in early life with breastfeeding and a healthy lifestyle. The transmission of an intact microbiome from mother to baby may be inhibited by intrapartum antibiotics.
Dr. Martin Blaser, director of the Human Microbiome Program at New York University and former chair of medicine there, stated in an interview on National Public Radio that if a baby is born without a full and varied microbiome, either because of antibiotics or because of a cesarean birth, the development of the baby’s immune system can be affected, causing a vulnerability to many serious illnesses. Obesity, asthma, Crohn’s disease, eczema and juvenile diabetes are among them.
It would seem that with both potential harm and potential benefit to giving intrapartum antibiotics to women who test positive for group B strep, the choice should lie with the mother in consultation with her medical care providers and with her chosen care givers. The duty of the care providers could be to provide an informed choice counsel to the family, to give them their advice and to support them in their decision.
Woods, CJ. 2014. “Streptococcus Group B Infections.” Medscape. Accessed February 20, 2015. http://emedicine.medscape.com/article/229091-overview#a0101, 08/15/14.
Read this editorial by Jan Tritten from the newest issue of Midwifery Today, Spring 2017:
Q: How do you handle group B strep in your homebirth practice?
— Midwifery Today
A: I’m a bit biased because I was a GBS-septic baby and still have the chest tube scars. A friend also had GBS sepsis and NICU admission. I was a preemie; she was term. I offer GBS testing at 35–37 weeks and urine culture at first visit. I can do IV antibiotics or the lady can do Hibiclens (chlorhexidine). If she tests positive and chooses not to, or declines screening I have her notify her pediatric provider. She might want to see baby sooner. If the lady wants a course of oral antibiotics and rescreening she can also choose that. The midwife I trained with told me she used to do vaginal garlic but rescreening kept showing positive. I also impress the importance of prebiotics and probiotics when I review diet.
— Rachel Harris
A: We need to consider what is happening when women use natural remedies to treat GBS at the end of pregnancy. Are they actually clearing the infection, or knocking down the numbers for a bit and then having a resurgence of bacteria growth? I’m not saying we shouldn’t use natural things, however, I would advocate for their usage from the beginning in hopes of having healthy vaginal flora, rather than trying to treat it in the last few weeks before delivery and possibly getting a “false” negative.
— Julia Bailey
A: I have all my clients take probiotics daily. At 33 weeks I have them double up on the probiotics, and for three days prior to the test at 37 weeks; I have them do 1 g vitamin C, three times a day; echinacea tincture, 1 dropperful three times a day; and bee pollen, 1 dose four times a day—as per Anne Frye’s recommendation. At 37 weeks we do the swab. If it comes back positive I keep them on the probiotics, vitamin and supplements until I retest the next week. It usually clears GBS up, but just this past January one of the women tested positive both times. She kept taking everything until baby arrived. He was born at home and is doing well. Next week we’re doing his 6-week checkup.
— Linda Honey
A: I emphasize the importance of healthy diet and how that can improve gut flora and possibly reduce GBS colonization. I present the CDC guidelines as well as the handout from Evidence Based Birth. I do a urine culture at the beginning of pregnancy to see if she has GBS bacteriuria. If that’s positive, we talk about the increased risks for early-onset infection with GBS bacteriuria. I also do a vaginal culture at 35–37 weeks, except for people who have GBS bacteriuria at any point in their pregnancy. I offer the option of treating with IV antibiotics per CDC guidelines. If they choose another option, that’s up to them, but I consider that to be declining prophylaxis and base my recommendations for hospital transfer accordingly.
— Kim Pekin
A: Healthy diet, with live cultures, no routine testing. Testing for women with repeat UTIs only. In UK, we don’t offer routine testing.
— Anouk Lloyd
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