this is a photo of myself and my little Mikayla. Her sign says "I'm Improving Birth because I had a doula. This picture was taken at my first Improving Birth Rally in 2013. Last year Mikayla attended her third Improving Birth Rally with me and this picture was taken...
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Intro:
I’ve only attended about 70 births as a birth doula, which means I’ve helped about 17 women face the decision of accepting or declining antibiotics for being GBS positive. For some, it’s an easy decision. It’s preventative, so why not? For others, the consideration of baby’s gut flora comes into play and these parents want to learn about how to make a safe decision all around. One couple of parents who were my clients are professionals in the health and exercise industry. They looked at the risks and ultimately decided, unless her water was released for a prolonged amount of time, or there were signs of infection, they would forgo the antibiotics. Thankfully her birth was a beautiful challenge met with bravery and she successfully delivered her big boy less than a few hours after her water released. Unfortunately, her care provider was rushed during the delivery and pulled a lot on the baby’s neck. When the baby came out, he didn’t seem to take to breathing well. He grunted a lot and it was the first time ever I could not get a baby to latch. I was so confused about the baby’s lack of interest in feeding, but blamed myself and decided to investigate outside of the parent’s vulnerable eyes. The baby was admitted to the NICU for GBS induced phenomena within an hour or so of his birth. No, I thought. There’s no way! He was not exposed to the birth canal for long enough to develop an infection that quickly! I called a chiropractor, a midwife, and a lactation consultant. I explained what I saw and put all of their wisdom together. I learned that the majority of the remaining fluid in a baby’s lungs is pushed out as they take their first few breaths. I learned that a vagus nerve injury is very possible when there is aggressive neck pulling. I learned that the vagus nerve is directly related to proper breathing. That week the baby spent in the NICU simply to finish his round of antibiotics was the most frustrating thing. But I can’t even begin to describe how frustrating it was for his parents. Not only were they met with the challenge of maintaining their beliefs on avoiding formula, getting skin to skin time, etc… they were also being told it was their fault for not taking antibiotics in labor. This was the beginning of my obsession with GBS protocol. I could not let this scapegoat diagnosis turn these wonderful, smart, protective parents into doubt and fear. We all learned something very important and that baby IS an overcomer just like his parents. Discussion: Welcome to my latest obsession in maternity care! My name is Karen Brann and I am a certified birth doula, a certified childbirth educator, and a certified lactation educator/counselor. I don’t really know how I ended up with all those titles after my name other than the fact that I completely fell into this passionate pursuit. The seemingly endless pursuit of returning birth a postpartum care to an evidence based, calm, and safe place. I’ve learned a lot about the difference between the midwifery model of care and that of the OBGYNs. I realize that these are two different worlds. You could almost sum up that difference with all things expectant management vs all things controlled management. The last thing I dug up and pulled apart was third stage management, and let’s just say, yanking on a cord and ripping off blood vessels attached to a uterine wall is NOT a proven method to lessen postpartum hemorrhage. It’s not, and that’s obvious. Anyways, back to the rabbit hole at hand; GBS positive moms and maternity care protocol. I’m about to go way deeper than you ever thought possible on the topic of what happens in labor when you test positive from a vaginal and anal swab for Group Beta Strep Bacteria. This is NOT about testing positive in your urine. I am not going to pick apart the protocol or use of antibiotics for women who test positive for GBS in their urine as those risks are completely different. This IS about the one million + women per year in America who are being given prophylactic antibiotics in labor. I believe many of them unnecessarily treated. The prevention method is there to lower the risk of babies who develop GBS disease. Either early-onset (less than 7 days old) or late-onset (greater than 7 days old). 80% of cases are early-onset. For late-onset of GBS, there is evidence that suggests it can be acquired through community sources and through the hospital itself (“nosocomial transmission”). GBS disease has been deemed the leading bacterial infection associated with illness and death among newborns in the United States since its emergence in the 1970s. The estimated fatality rate for newborns with GBS disease is about 6%. Unfortunately, my research has revealed that 50% of the babies who developed sepsis did have a GBS positive mother who RECIEVED antibiotics in labor. Also, I have read that there is a found correlation with sepsis and E.coli in these babies. In other words, clean eating may be a helpful way to lower risks. Preterm labor and prolonged rupture of membranes (more than 12 hours) are the greatest link to early-onset GBS disease; those variables increase the likelihood of early-onset neonatal GBS by 8 times more than those without those factors who simply tested positive for GBS from a vaginal and rectal swab. Even if you test negative for GBS during pregnancy, studies show a .0004% chance of neonatal GBS disease. Furthermore, it’s only a .0032% chance of baby developing GBS disease when testing positive even if we combine the rectal and vaginal results. For high risk factors, (prolonged water release and premature labor) it’s a .0076% chance. The emergence of this bacteria has been connected to a change in milk processing at dairy farms. The gastrointestinal tract is the most likely human reservoir for GBS. Culturing specimens from both the rectum and vagina increases the likelihood of a positive test from 5% to 27%. Having a heavy surface colonization increases risk factors; however, there is no communication between provider and patient about how much of the bacteria is being found. I theorize this has something to do with the fact that the levels of GBS bacteria can go up and down with changes in diet. I also theorize this is why it’s more likely to test positively only rectally (41%-50% more likely) and not vaginally. Studies show that if the bacteria is only found rectally, it’s a lesser risk for baby; however, those results are not discussed between providers and patients even though statistically speaking that’s a possibility of up to twice the necessary antibiotic use in labor. These possible unnecessary treatments should be considered for the 10 babies a year who die from the antibiotics themselves due to allergic reactions. Why so many? GBS is a very common bacteria to test positively for. We never know, without doing a test on the spot, if a women is still considered positive at the time of delivery. However, it’s very common to test positive during her pregnancy. It’s a positive test for about a 1 in every 4 women in America. The amount of positive tests, are the amount of women who will be told to take antibiotics in labor. That is because a meeting of experts from the CDC, ACOG, and the AAP in 1995 (that’s over 20 years ago) decided the standards. From that day on, the standard remains that all women who test positive from one swab at 35-36 weeks will be given antibiotics in labor regardless of any and all low risk factors. AND if they don’t know the results of the test, its presumed positive and antibiotics are given then too. I decided to read all of the studies that contributed to that decision, yes, all of them. Probably the most frustrating thing I learned was that they did not follow through on implementing a test given in labor because it was decided it wasn’t worth the cost. There would have to be a working lab open 24hours a day and 7 days a week. Even though that would statistically save 23% from any need to take antibiotics in labor. Furthermore, they did a lot of trials on intrapartum testing, and they found that 8.9% of women who were positive during labor, were tested negative during pregnancy! Hello! Aren’t we missing something here?! To make matters worse, the other reason for not having a rapid result test in labor is the common belief in the labor and delivery room that women can’t be trusted to make their own informed decisions. The concern with the intrapartum test is, “the complexity of communicating risk information regarding GBS to women during pregnancy.” –CDC In reality, simply the fact that some women chose not to take the antibiotics during trials was mentioned as a concern. Sickening, I know. I suppose then the discussion of how to lower the GBS colonization with diet changes would also be too much responsibility for patients to understand as well? If you read my introduction, you know that I also theorize another problem. Could early-onset GBS disease be, in part, a scapegoat for other birth-related influences? Since GBS disease is characterized as pneumonia, and pneumonia is by definition retained fluid in the lungs, lets look at what else can cause this. If a vagus nerve injury could cause poor breathing thus fluid retention, what other connections could we be missing? If pneumonia is described as fluid in the lungs, it makes sense that 25% of cases of neonatal GBS disease occurs in premature infants. Was that GBS disease? Or was that a baby who didn’t get the chance to live in utero during the time that hormonal changes push out some of the fluid in their lungs? This connection also provides an explanation for the fact that low-birth weight babies are also at a higher risk. In addition to this potential scapegoat, I can also see a possible issue with diagnosis in that greater risks have been documented for vaginal exams, internal monitoring, and membrane rupture for more than 12 hours. All of these things promote bacteria, especially vaginally exams which we know are the leading cause of corioamniostitis (the infection they talk about when they say your water has been released for too long). Lastly, the fact that women in labor who simply have an elevated temperature are being presumptuously diagnosed with an infection is jumping right over the fact that 70% of women have epidurals and we know epidurals cause fevers. It’s all one complicated mess of variables. GBS is the easiest thing to point the finger at for all of these variables. In case you’re wondering, what else raises and lowers the risk of neonatal GBS disease, let’s talk about some more information. The chance is about 25% for all pregnant women that they will test positively in pregnancy. As discussed earlier, much greater for premature births and prolonged water release. It is also more likely for women who are less than 20 years old. It is more likely for women of black race. It is less likely if for Hispanic women. It’s more likely if you’ve tested positive in the past, and more likely if a previous delivery has resulted in early-onset GBS disease. It’s also more likely for babies born via belly (c-sections). It’s less likely for the fourth or subsequent babies. In case you’re wondering, can we treat women with antibiotics during pregnancy instead of in labor? Sorry, no. 70% of women who were colonized and treated in their third trimester of pregnancy were still positive at delivery. Conclusion (AKA SKIP TO HERE IF YOU'RE TOO BUSY) : So let’s sum up some of this surprising information. Over one million women per year in America are being treated with antibiotic in labor for testing positively for GBS during their pregnancy. With the biggest risk factors included (premature birth and prolonged water release for more than 12 hours), the chance of a baby developing early-onset neonatal disease is .0076%. It’s possible that at minimum 41% of these cases of moms being treated, could be avoided if providers communicated the fact that they only tested positively rectally, which lessens risk for baby. It’s possible that 23% of these cases of moms being treated could also be avoided if there was a rapid results test. Frighteningly, there are cases missed because there isn’t a rapid results test. Even more frighteningly, there isn’t one because of the cost and also because women aren’t considered responsible enough to make their own informed decisions when they know all the risks. Probably the most shocking thing, is that 50% of the cases of sepsis for neonatal early-onset GBS disease happened even when the mother was treated with antibiotics in labor. Frustratingly, the characteristic of pneumonia being a description of early-onset GBS is very possibly a reason for a scapegoat diagnosis. So what will we do with all of these facts? My goal in uncovering this information is not to convince women to decline antibiotics in labor. It is however, to give them all the facts so they can make their own informed decisions. Also, I’d like to encourage the patient population to demand a rapid results test. I am not a doctor, I’m not a medical professional of any kind. I’m not even a medical student writing a paper for a class. I’m a birth doula and a childbirth educator. I’m an advocate for women. I spent my own time and my own recourses to research and uncover this information simply because my job means that much to me. If you’d like to check some of my claims, feel free to check out these sources listed below. You will not find clear cut statistics like I stated. There was some calculating involved by looking at the numbers stated in the various studies. Do your own research and make your own decisions. If there’s one thing that I shouldn’t have to prove it’s that women deserve to be treated like capable parents, and parents deserve to make informed decisions for their bodies, their births, and their babies. http://www.cdc.gov/mmwr/preview/mmwrhtml/00043277.htm THE JOURNAL OF INFECTIOUS DISEASES • VOL. 148, NO.5. NOVEMBER 1983 © 1983by The University of Chicago. All rights reserved. 0022-1899/83/4805-0004$00.81 Selective Intrapartum Chemoprophylaxis of Neonatal Group B Streptococcal Early-Onset Disease. II. Predictive Value of Prenatal Cultures Kenneth M. Boyer, Cecile A. Gadzala, Peggy D. Kelly, Laurence I. Burd, and Samuel P. Gotoff THE JOURNAL OF INFECTIOUS DISEASES • VOL. 145, NO.6. JUNE 1982 © 1982 by The University of Chicago. All rights reserved. 0022-1899/82/4506-0002$00.75 Anorectal and Vaginal Carriage of Group B Streptococci During Pregnancy Hugh C. Dillon, Jr., Elizabeth Gray, Mary Ann Pass, and Barry M. Gray |
Karen Brann
Birth Doula, Childbirth Educator, Lactation Educator/Counselor Archives
July 2019
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