|July 9, 1999|
Volume 1, Issue 28
|Midwifery Today E-News|
“Group B Strep”
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In This Week's Issue:
1) Quote of the Week
1) Quote of the Week:
"In a garden we do not 'grow' flowers, we create the conditions in which flowers can grow."
- Ram Dass
2) The Art of Midwifery
Early childbirth classes offer parents a network of peer support throughout pregnancy. Such support might extend more readily into the postpartum/breastfeeding period than is currently the case with classes that begin in the third trimester. Women might decide to team up for walking or doing yoga. Men might understand a lot earlier and therefore a lot better, about their partners' changing feelings. Some of the emotional support the midwife would otherwise provide could be gained through peer support. This can be empowering for her clients. It would free up her time and might be more cost effective than increasing midwifery care alone.
- Anabeth Karson, excerpted from Wisdom of the Midwives: Tricks of the Trade Vol. 2, a Midwifery Today book
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3) News Flashes
During the last few years there has been a noticeable increase in cases where the uterus has ruptured during labor. Commonly, the woman has had a previous cesarean. In almost all the rupture cases we see, the woman has had prostaglandin pessaries or gel inserted into the vagina. This has the effect of both softening and ripening the cervix and causing contractions, but the amount of time this may take and the strength of the response can vary. A second, then a third dose can be given before the previous dose has been given full opportunity to work. Then an oxytocin drip is added, which further stimulates the uterus. The woman is given an epidural for the pain this causes, but the epidural can mask or reduce the pain of rupture. The combination of scarred uterus, prostaglandins and/or oxytocin requires constant monitoring from staff. Training or retraining of staff on recognition of signs of possible rupture is recommended. Prostaglandins and/or oxytocin should be used only when really necessary on women with scarred uteri or women at other risk of rupture.
- AIMS Journal, Vol. 7 No. 1, Spring 1995
4) Group B Strep
Different Beta-strep (group B) serotypes are recognized based on chemical differences in the Beta-strep organism; serotypes Ia, Ia/c, Ib, II and III are most problematic during pregnancy. Group B causes a less severe form of childbed fever than type A. It can also lead to inflammation of the amniotic sac, the uterine lining or the urinary tract in the mother. Beta-strep is the most common cause of life-threatening bacterial infection in the newborn. It produces both early (first 7 days) and late onset (8 days to 3 months) neonatal infection. Early onset neonatal infection without meningitis is divided equally among types I, II and III. Eight percent of early onset neonatal infection with meningitis is associated with type III.
Six percent to 25% of all women have asymptomatic GBS in their yoni [vagina] which may appear and disappear regardless of treatment. Colonization is evenly divided among groups I, II and III. Predisposing factors to colonization include age over 20, low parity, colonization with Candida sp., multiple sexual partners in the previous 12 months, external genital erythema and scaling, use of tampons, purulent yoni discharge and yoni pH over 5.
Mothers who have heavy colonization, especially those with Beta-strep in multiple sites, have an 87.8% chance of colonizing their newborns. Moderately colonized women have a 50% transmission rate; the rate is 30% for lightly colonized women. As many as 50% to 75% of babies exposed to intrayoni GBS become colonized. The overall rate of early onset sepsis is about 1 to 2 per 1,000, 10 per 1,000 for babies born to colonized mothers and approaches 40 per 1,000 for preterm babies or those with risk factors such as rupture of membranes greater than 18 hours, maternal GBS urinary tract infection, internal fetal monitoring for over 12 hours [see text for complete list]. Although preterm babies are at higher risk, over half the cases of sepsis occur in term babies. Early onset infections account for about 80% of all neonatal infections. Neurologic compromise occurs in about 15% to 30% of meningitis survivors. Overall, 1 to 2% of all infants born to colonized mothers will develop early onset invasive disease.
- Anne Frye, Understanding Diagnostic Tests in the Childbearing Year 6th ed.,1997 Labrys Press
(Editor's note: Anne's book dedicates over ten pages to the subject of Group B strep, including useful charts on treatment protocols and clinical aspects for both infants and adults. This 900-page book, a must-have for practitioners of all kinds, is available for $43 plus shipping through Midwifery Today. E-mail email@example.com)
I handle GBS by giving women information on it regarding the risks, treatment, etc. and leave it up to them whether to culture or not. If they choose to culture, I do it at about 35 weeks. If the culture is positive, I give them the choice of herbal protocol and reculturing in two weeks to make sure the herbs worked. Or they can take antibiotics orally when labor starts.
The herbal protocol I recommend is as follows (it works for GBS, trichamonas, or chlamydia):
Add 1/2 teaspoon goldenseal tincture to 2 cups body temperature spring water. Add this to a douche bag and douche once a day for a week. Also take 500 mg. golden seal (or 1/4 tsp. tincture) orally TID. Then, use a lactobacillus implant daily for 2 weeks (a gelatin capsule of high quality lactobacillus inserted vaginally once or twice a day works well).
It is important to teach women how to douche properly. The bathtub with a towel to lie on is a good place to do it. She can put some pillows under her hips to elevate them. Make sure the tip of the douche is NOT inserted into the cervix. Have her undo the douche clip until the air is out of the line and reclip. As she slowly lets the fluid out, she should hold her labia closed with the fingers of one hand. This allows the vaginal tissues to expand and the fluid to wash over all the mucosa. As she holds her labia closed, her vaginal mucosa will balloon out. Some fluid will run out anyway, but keeping as much in as possible for at least a few minutes is recommended.
Be sure to reculture after the two weeks are up to make sure the GBS is gone. Then occasional douching, oral goldenseal tincture, and vaginal acidophillus is recommended so she doesn't recolonize. I don't have a definite routine on that.
If the pregnant woman chooses to use antibiotics, this is what was recommended to me by a University of California at Davis perinatologist: Amoxycillin 500 mg. Q4, beginning as soon as labor begins. The routine hospital protocol is IV ampicillin 2 grams, then 1 gram Q4 during labor, but I do not do IVs at home.
I would love to hear what other midwives are doing regarding GBS.
- Betty Idarius, L.M., C.Hom.
I do no vaginals--I really feel this is a causative problem of infection. I will watch for awhile and if after about 4 hours nothing is happening I will start the bag of tricks--herbs, homeopathy, castor oil and/or enemas.
- Ollie Anne Hamilton, LDEM, CPM
Someone asked why a patient is considered colonized when group B beta strep is found in the urine. My understanding is that because beta strep is normally only found in the colon/rectum and not in the bladder, when it IS found in the urine, that woman has a high probability that her vagina is colonized as well. If the organism was transferred from the rectum to the urethra, we know it encountered the vagina along the way too.
The recommendation from CDC in Atlanta, and followed by ACOG, is to recommend antibiotic prophylaxis to women at high risk of GBS disease. These include preterm delivery, fever in labor, prolonged ROM, positive vaginal culture at 36 weeks, GBS in the urine at any point during the pregnancy, and any previous baby affected by GBS infection. Remember that a negative vaginal culture does not mean the woman does not have the organism in her vagina, as it is possible to perform the culture ineffectively or to have a false negative for the usual variety of reasons.
I have a question for readers: I'm in a CNM group that offers clients information about the CDC information and the two ACOG guidelines, then allows the client to choose which guideline to follow. In other words, our clients decide whether to be cultured or not. We have a debate going on about how to advise women who have had a positive GBS vaginal culture in their previous pregnancy one or two years ago. Some people say "once a carrier always a carrier" and that we shouldn't even culture again during this pregnancy (at 36 weeks) because they should be assumed to be at risk still, and offered antibiotics in labor. Others say the organism comes and goes in humans, and that a new pregnancy should be treated as a clean slate, the woman should be considered neutral until and unless her 36-week culture in this pregnancy comes back positive (not including women with a previous GBS-affected baby). The CDC handout and literature don't seem to have addressed this. Any ideas/studies out there?
- Kathleen Murray, CNM
Learn more from these Midwifery Today issues:
5) Question of the Week:
I would like more information about TENS (Transcutaneous Electrical Nerve Stimulation) for use in labor. The instructions on the units say "PREGNANCY: The safety of [TENS] for use during pregnancy or delivery has not been established. But I know it has been used for this purpose. Is there evidence that TENS works and is it safe?
- Jeanne Batacan, CMA, ICCE, CLE
Send your responses or submit a Question of the Week to firstname.lastname@example.org
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I need information on giving birth safely at home with a positive hepatitis B mom. Any information would be greatly appreciated.
It is my understanding that the symptoms of some autoimmune diseases may subside during pregnancy. Does anyone know what kind of response is present after the pregnancy ends? What about during breastfeeding?
- Tina Fleetwood
I am from Malta. I am a third year midwifery student moving into my final year and also working on my special project. The title is "Management of an Elective Caesarean Section"; the focus is postnatal psychological perspective. I would like to know where I could find some research and also any discussion lists or whatever that may help carry out a literature review.
- Alexia Callaby, Florida
California Association of Midwives sells a bumper sticker that reads "Dare to keep your baby off drugs. Have a homebirth." The cost is $2 each or six for $10. Send check payable to Fawn Gilbride, PO Box 15918, San Luis Obispo, CA 93406 or email email@example.com
In response to the issue on episiotomy [No. 24]: I have birthed three children. The first was born in hospital: I had a slight episiotomy. Healing took about one week. When sexual intercourse resumed I felt discomfort for about one year.
My second child was born in hospital; I had another episiotomy. It was slight and the baby was born with two pushes. There was almost no pain afterward and I even went on a two mile hike when he was less than 48 hours old. I had no pain with intercourse.
My third was born four months ago in hospital but was attended by a midwife. She did not believe in episiotomies. Crowning lasted 18 minutes and was incredibly painful. I kept begging for episiotomy and she said "you are doing fine." It didn't feel fine--I was in agony. The baby was finally birthed and I had almost fainted with the agony. I had two tears on my urethra area that stung for two weeks afterward when I urinated. My perinium was so torn (although I was told it wasn't torn in the least) that it was actually hanging outside my body for nearly three weeks. Sitting and getting up were agony. The wound felt raw and torn. There was frequent bleeding of the perinial area. After healing, the vaginal opening is tough and feels like scar tissue. This is around the entire vaginal opening. The perineal tissues are now inside my vaginal opening but are very loose and have no tone whatsoever (despite the use of kegals). Sexual intercourse is painful at the vaginal opening area, and not felt at all internally. I am told this is normal and that I have nothing to concern myself with (this from the midwife). This isn't satisfactory to me. I am young and the thought of living in this manner is not pleasant.
I also used evening primrose six weeks prior to birth to help soften the vaginal area. I don't think it helped. If I ever have another child I would prefer to use a midwife and either birth at home or just go to the hospital to deliver, but I will require an episiotomy. I believe this is the easiest and safest course. Any advice about the scar tissue or any further information would be valued. I feel somewhat lost in regard to an otherwise positive birth experience.
- J Hughes
I am presently going into my senior year at Lehigh University in Pennsylvania and will graduate in the spring of 2000 with a BS in psychology. For the past six years it has been my dream to become a CNM. I am going through the process of applying to schools and finding out what programs best fit my needs. I am currently a medical assistant for a very successful ob/gyn group that has three CNMs, but I am still looking for more midwives to talk to and ask all my questions. I really am trying to get all the information possible on this profession and stay updated because the times are changing quickly. I would like any advice on anything from current issues of the midwifery profession to whom I can possibly talk to. Email Heather Kramer at firstname.lastname@example.org or email@example.com
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Several other education related classes are planned. They include Midwifery Education, Tricks of the Trade, The Apprenticeship Model of Midwifery Education, Inquiry-based Learning and Mentorship, and Supporting Students.
Post-conference includes Evidence-Based Midwifery, a day-long workshop that will explore many of the emerging issues in this field including the diversity of evidence available to midwives and women, the ways in which we can use evidence to improve practice both locally and globally, and the need to evaluate and validate midwifery evidence.
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Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:
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