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You’ve reached the blog of Jodilyn Owen, Licensed Midwife and Certified Professional Midwife.

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You can learn all about midwifery care, professional topics, and options that come up during pregnancy and birth here.  Enjoy and be sure to send me your questions or comments or contact me if you’d like to talk further.

 

NRP 7th Edition Out of Hospital Chart

CLICK her for a PDF.  OK to reuse if you cite the source (at bottom of chart)!  Use your own judgment in the care of every newborn.  Adapt for that baby’s needs.  If you need help, call EMS and get it.  This is not a replacement for your NRP program nor does it qualify you to give NRP.  It is a TOOL for people who have taken the NRP course and received their card, primarily directed to students to help you gain an overview.  And finally, this reflects my preference for practice but your preceptor will have their own expectations.

NRP EM AM WB

GBS Prevention: The Short-Winded Version

Read the long-winded version

See the Infographics up-close

This post examines the role of preventative health care in the inhibition of Group B Streptococcus (GBS) infection.  It uses the term “mother” for simplicity’s sake although babies have all kinds of parents who identify in all kinds of ways and all are welcome here.

Let’s break down the long article:

Infections resulting from GBS  can be life-threatening to a newborn.  All pregnant moms are offered a test which detects this bacteria around 36 weeks of pregnancy.  If found, it can be treated through the use of IV antibiotics during labor, which significantly reduces the rate of infection and resulting meningitis and/or sepsis in newborns. While this article does not focus on the treatment of women who test positive, it does promote prevention, which improves the overall health of both mom and baby through the use of probiotics taken orally throughout the pregnancy.  These come in tiny capsules or a liquid packed with powerful lactobaccili (among other gut-friendly bacterium) that usually cost between five and twenty dollars per bottle or package).  It’s a small price to pay for so many amazing benefits.  As a midwife, I often pay for them for clients because of the massive health benefits of these supplements to every mom and baby, including avoiding a host of obstetric complications that would increase risks to mom and baby and often require transfers out of my care.  Great midwifery promotes the intrinsic health of mother and baby through programs like this which lend greatly to positive birth outcomes.

Let’s explore just some of the many benefits:

The Mother

Take a look at what the microbiota is if you aren’t already familiar with it.  The use of probiotics promotes this system that does a bit of everything good in the body including prevent the over-colonization of “bad” bacteria like GBS.  It also happens to prevent diabetes and keep your mood even.  It exists in the mouth, gut, and vagina of the mom and the placenta (and some studies found evidence in the fetal gut as well).

Over the course of pregnancy, the levels of good bacteria in the microbiota change.  By the time you give birth, you have an over-growth of lactobacilli which ensures that your baby will get exposure to this important “good” bacteria during vaginal birth.  When the system is supported right it will also prevent yeast infections, and keep the bacteria that cause UTIs and GBS in check.

The Baby

Impaired levels of probiotics have been correlated to preterm birth.   They are correlated because “bad” bacteria like GBS and candida (yeast) cause cellular damage to the cervix.  It loses its integrity and is not able to hold in the pregnancy as long as it should.  There are dramatic consequences for being born too early—the March of Dimes was founded because of babies born too early or too small.

When mothers take probiotics, they are found in the placenta and fetal gut and stay with the baby after birth to help regulate the baby’s microbiota.  That’s profound!!  You can help your baby synthesize vitamins and amino acids, regulate immune function, have smoother transitions between emotional states, and get a balanced healthy start just by taking probiotics during pregnancy.  After pregnancy, breast milk takes over the important function of populating the baby’s microbiota with everything it needs.

What Matters

  • Take probiotics throughout pregnancy to help keep your body hostile to “bad” bacteria and to strengthen the integrity of your tissue (muscles and skin included), especially uterine tissue like the cervix (and to boost your immune system, keep your mood even, etc., etc., and etc.!)
  • If you are planning a VBAC this winds up mattering a lot. Infections like candida and GBS can wear down the tissue that you are relying on to keep the scarred area strong and healthy.  Take a full dose of 4 probiotic capsules per day for your entire pregnancy.  I have supported an extremely high percentage of VBACing moms in my practice and this statement is NOT a judgment about your scar.  It is part of a recipe that will contribute to your overall success.  Check out this article for more ideas from the VBAC playbook or contact me to discuss further.
  • Have a vaginal, antibiotic free birth for maximum exposure to lactobacilli
  • Ask your provider ahead of time about swabbing your vaginal tract during labor prior to any antibiotics if you need them for any reason (including a planned or unplanned cesarean birth)
  • Regardless of how you deliver your baby, spend time skin to skin with her or him. Allow them to touch your breasts and arm pits with their hands.  You have lactobacilli on your skin that they will benefit from
  • Breastmilk feeds babies and promotes the growth of healthy bacteria in baby’s own microbiota, boosting their immune system and setting them up for good health
  • Babies born to a mom who had to take antibiotics or who were born by cesarean or who drink formula exclusively or as a supplement can all be given oral probiotics. They are available with a dropper or can be mixed into breast milk or formula and given through a bottle or made into a paste (just break open a capsule and add one drop of water at a time, mixing with your finger) and applied to mom’s nipples which is both soothing and healthy for the breast

Some disclaimers and information of note

  • The recommendations in this article are not designed to cheat a test but to actually improve the health of the mother, the integrity of the cervix, and the health of the placenta, fetus and newborn
  • Taking probiotics is not a guarantee of avoiding GBS or other complications related to imbalanced or missing gut flora. Talk with your provider about nutritional measures you can take to support your over-all health.  No amount of probiotics or exercise can undo the effects of a diet high in sugar and processed foods
  • Do get tested between 35 and 37 weeks for GBS. If you still test positive after a sustained period of time taking probiotics, eating a diet low in processed sugars and carbs, and rich in food that looks like it was alive, the colonization is highly likely to be one that needs antibiotic treatment. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease. If a pregnant woman who tests positive for group B strep bacteria does not get antibiotics at the time of labor, her baby has a 1 in 200 chance of developing group B strep disease.
  • If GBS is found in your Urine during pregnancy, antibiotics can eliminate or greatly reduce the high colonization. Take probiotics at the same time as you take antibiotics and for the rest of your pregnancy.  The CDC recommends that anyone with GBS in their urine at any point during their pregnancy receive antibiotics during labor
  • Please discuss this information with your provider and work together to find a solution that is right for you. If your provider does not have time to discuss this or other preventative measures with you, there are plenty that will and I highly recommend you shop for the one who will serve you best

Capture

You can see the source for these infographics and get an up-close view by clicking here

Share your thoughts on preventative health care during pregnancy and your comments and questions below!

Additional Resources

Microbiota/Microbiome and Pregnancy/Birth/Breastfeeding

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943946/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464665/

https://www.amazon.com/Your-Babys-Microbiome-Critical-Breastfeeding/dp/1603586954

https://www.amazon.com/Microbiome-Effect-Affects-Future-Health/dp/178066270X/ref=sr_1_2?s=books&ie=UTF8&qid=1490123008&sr=1-2

Preterm Birth

http://www.marchofdimes.org/complications/premature-babies.aspx

Group B Strep Disease

https://www.groupbstrepinternational.org/

GBS Infographics

Read the Short-winded blog post

Read the full article

Read The Notes

microbiome changes of pregnancy

PMC full text:Front Microbiol. 2016; 7: 1031. Published online 2016 Jul 14. doi:  10.3389/ fmicb.2016.01031

microbiome changes at birth and feeding

PMC full text:Front Microbiol. 2016; 7: 1031. Published online 2016 Jul 14. doi:  10.3389/ fmicb.2016.01031

The Notes

Read the Complete Article

Read the shorter Blog Post

See The Infographics

The Notes.

  • The recommendations in this article are not designed to cheat a test but to actually improve the health of the mother, the integrity of the cervix, and the health of the placenta, fetus and newborn
  • Taking probiotics is not a guarantee of avoiding GBS or other complications related to imbalanced or missing gut flora. Talk with your provider about nutritional measures you can take to support your over-all health.  No amount of probiotics or exercise can undo the effects of a diet high in sugar and processed foods
  • Do get tested between 35 and 37 weeks for GBS. If you still test positive after a sustained period of time taking probiotics, eating a diet low in processed sugars and carbs, and rich in food that looks like it was alive, the colonization is highly likely to be one that needs antibiotic treatment. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease. If a pregnant woman who tests positive for group B strep bacteria does not get antibiotics at the time of labor, her baby has a 1 in 200 chance of developing group B strep disease.
  • If GBS is found in your Urine during pregnancy, antibiotics can get the high colonization in check. Take probiotics at the same time as you take antibiotics and for the rest of your pregnancy.  The CDC recommends that anyone with GBS in their urine at any point during their pregnancy receive antibiotics during labor
  • Please discuss this information with your provider and work together to find a solution that is right for you. If your provider does not have time to discuss this or other preventative measures with you, there are plenty that will and I highly recommend you shop for the one who will serve you best

Got Questions?

GBS Prevention: The Real Deal (an article)

The stakes are high. With all of the science supporting the idea that we can impact outcomes through simple and inexpensive measures, we cannot disregard the first and best options we have to address a disease. And especially where that prevention, aimed at reducing illness for the baby will also dramatically improve the health of the mother.

This is a long article y’all and way past the normal blog length acceptable in the blogosphere….however, you’ll find all of the background information, standards of care, reasoning for examining a new model and solutions for dramatically improving the health of mother and baby long after the relatively brief moment of pregnancy and birth have passed. This model is the real deal.  It provides preventative, protective, and health sustaining treatment for all instead of treating a disease process when symptoms become present in some.  I hope you enjoy the ideas and look forward to your thoughts and input.

If you are already worried I am going to recommend against treating GBS+ moms you can take a quick look at these important notes.

Looking for an upclose of those infographics?

Looking for a short-winded version of this article?

The Issue

Over colonization of the bacteria Group B Streptococcus (GBS) can cause a life threatening infection in newborns.  Most expecting families hear about this at the 36 week visit when they are asked to consent to a test for this bacteria.  If found, antibiotics are delivered through an IV during labor which greatly reduces the baby’s chance of exposure.  Many midwives share the fact that this bacterium is transient and can come and go so the test may be unreliable.  They may offer alternative treatments and discuss the low odds of babies who are exposed actually getting sick in an effort to consider antibiotic over-exposure.  Some providers might scare the living daylights out of their patients with images of weak, mewing infants suffering from high fevers and a very difficult disease to treat in an effort to ensure treatment is given.  Neither is wrong.  On one end the use of antibiotics reduces bacterial diversity in both mother and baby and can cause resistance to antibiotics later in life.  On the other end is the prospect of a disease where the only option once infection sets in is antibiotics and sometimes they are not enough to save the life of a sick newborn.  The cost to a newborn who experiences GBS disease is extraordinary.  The cost to a family who has a seriously ill baby or who lose a baby is immeasurable.  This disease starts with the presence of normal bacteria, progresses to an overgrowth of those bacteria, which progresses to exposure and then transfer and then a normal or a sick newborn.  Every baby at the start of pregnancy is looking a road that might lead to a GBS infection.  So one must ask, is there an answer that might keep babies safely at the start of that road with no progression on the continuum?  This article seeks to look at one answer that gives each baby a high chance of avoiding the long walk towards infection.

The Platform

I would like to reframe how we view testing and treatment of GBS and look at front-line prevention as first-line treatment.  This is to say that medical providers are trained to diagnose and treat, but as the keeper of your and your baby’s body (or your client’s or patient’s for providers), prevention is actual medicine.  The stakes are high.  With all of the science supporting the idea that we can impact outcomes through simple and inexpensive measures, we cannot disregard the first and best options we have to address a disease process.  And especially where that prevention, aimed at reducing illness for the baby will also dramatically improve the health of the mother. Our checklist for GBS management and testing in pregnancy should be:

  1. Recommend quality probiotics high in lactobacilli at first encounter, 1 cap 3-4 times daily
  2. Swab as normal between 35-37 weeks
  3. If antibiotics are given in labor advise to start probiotics as soon as possible.

The Mother

There are hundreds of articles available that help explain and define the microbiome, but in short each of us has a unique microbial population that includes bacteria, archaea, fungi, and viruses.  This whole system is referred to as the microbiota and is located in the mouth, gut, vagina, and placenta.  It is responsible to:

  • Digest and absorb nutrients
  • Synthesize vitamins and amino acids
  • Prevent pathogenic colonization (this is important to our discussion of GBS)
  • Regulate immune function
  • Modulate hormone release in the gastro-intestinal tract which for example helps prevent diabetes
  • Regulates mood and behavior through production of serotonin

(Kristensen et al. Genome Med. 2016; 8:52)

From this short list, one can easily see the massive importance of working right from the start of pregnancy (or long before, ideally) on balancing the microbiota in order to achieve optimal health in the mother.  Additionally, the changes in a healthy microbiota that occur from the first to the third trimester are dramatic and much needed for the health of mother and baby.  While the baby is often the focus of GBS discussions, the mother is a worthy and whole person, deserving of high regard for all that she is and does.  She is far too often viewed merely as a vessel we must sustain until she delivers the human baby who is the real focus of pregnancy and birth.  I have seen first-hand over and over again that when we take excellent physical and emotional care of the mother, the baby thrives.    Even in high risk pregnancies, carrying a baby does not supersede a woman’s autonomy over her own body, her needs, or her desire to be heard, felt, and understood.   It’s an archaic rite of passage that we feel compelled to remind her that, “it’s not about her anymore.”  It is deeply, deeply about her.  It is deeply, deeply about baby.  It is deeply, deeply about how they are together, and how they are separate.  The mother provides the building blocks of the placenta through her well-being.  The baby relies on that placenta for his or her well-being.  The baby experiences the hormones of the mother’s emotional states and learns from the patterns of stress and recovery she teaches during pregnancy.   A mother’s mental health has long term effects on both her and baby.  The question is, how can we promote the optimal physical and mental health of both?  How can we prevent disease for both?

Addressing gut-flora health will absolutely improve the fundamental health of the mother and therefore the health of the placenta and the baby.  During the third trimester levels of lactobacilli naturally rise and even over-grow to ensure exposure for the baby while protecting against bacterial and viral infections in the vaginal tract.  This entire system is its own natural pharmacy when supported correctly.

The Baby

Several studies suggest that impaired levels of probiotics in the vagina correlate with preterm birth.  This is because of the cellular damage that an abundance of harmful bacteria can cause to the strength and integrity of the cervix.  This includes yeast infections and GBS infections as well as STI’s.  Babies born too early or too small are at risk for a number of poor outcomes, including being three times as likely to die within the first year of life than a baby born at term.  You can read more about the effects of preterm birth here.

In her talk entitled “No Guts, No Glory: The Microbiome in Diabetes,” Meghan Jardine, M.S., M.B.A., R.D., L.D., D.D.E. notes that the critical shapers of gut biology are:

  • Natural delivery
  • Breast milk fed babies have probiotics
  • Formula fed babies have reduced/missing probiotics
  • By the time the child is 3 years old the gut composition is established
  • Over time, our environment continues to change our microbiota

A well designed 2012 study showed that taking probiotics during pregnancy affected the placenta and fetal gut and even the regulation of the infant’s microbiota. (Rautava S, Collado MC, Salminen S, Isolauri E. Neonatology. 2012; 102(3):178-84.)  Exposure also seems to correlate with reduced allergic diseases like eczema.

Mode of Birth and Feeding

Exposure to probiotics taken orally by the mother can be seen in the placenta and meconium of the fetus during pregnancy.  That said, the two most important factors found to shape the infant gut microbiota are mode of birth (vaginal vs cesarean) and feeding (breastmilk vs formula).

The overgrowth of lactobacilli in the vagina provides essential exposure for the baby to lactobacilli during vaginal births.  Babies do not get this exposure during a cesarean birth.  Many hospitals are swabbing mom’s vaginal area prior to cesarean birth in order to be able to transfer lactobacilli from the mom to the baby.  (Dominguez-Bello MG, et al. JC Nat Med. 2016 Mar; 22(3):250-3.) Be sure to swab well before the administration of any antibiotics given prior to surgery.  Exposing baby to the skin of the mother under her breasts and armpits during skin to skin time and breastfeeding over the first months of life help increase exposure. Additionally, babies born by cesarean who are breastfed should receive oral probiotics for the first four months of life.

The most abundant organisms in breast-fed infant guts are not the same as those found in formula-fed babies (Balmer SE, Wharton BA. Arch Dis Child. 1989 Dec; 64(12):1672-7.)  Breastmilk has elements which promote and nourish healthy bacteria in the baby’s gut.  Breastmilk feeds both the baby and the bacteria.  Babies who are formula fed should receive probiotics orally to help promote the growth of a healthy microbiota.

Prevention

As noted in the beginning of this article, prevention of GBS over-colonization should be seen as the first and best method to stop the long walk to full blown GBS disease.  In addition to preventing GBS exposure for babies, we can help maintain healthy microbiota and all of the benefits for mother, placenta, and baby that are the natural outcomes of that system.  In our day-to-day healthcare regimens, we should all be taking probiotics.  Every provider should be recommending probiotics along with a high quality prenatal vitamin at the first visit.  In an early release of data comparing midwifery care to OB care there was a very large difference in the number of patients who tested GBS positive between the two groups.  The numbers are still being teased out but one theory is the normalcy of midwives recommending probiotics to all patients.  (will update when final numbers are published)

The Solution

  • Take a daily form of probiotics (take 1-4 capsules per day) containing anywhere from 10-25 billion units of mixed flora but with high amounts of bacilli noted (available in grocery stores, Super Supplements or the Vitamin Shoppe).
  • Reduce the amount of sugar and refined carbohydrates you eat. GBS is a bacteria that tends to like sugary environments, and seems to colonize where there are not sufficient lactobacilli to keep it at bay.
  • Help keep your vaginal tract acidic and hostile to bacteria by taking probiotics and Azo Cranberry capsules (take one in the morning and one at night). Do not drink cranberry juice as the added sugar causes more harm than the cranberries help.

The Notes

  • The recommendations in this article are not designed to cheat a test but to actually improve the health of the mother, the integrity of the cervix, and the health of the placenta, fetus and newborn
  • Taking probiotics is not a guarantee of avoiding GBS or other complications related to imbalanced or missing gut flora. Talk with your provider about nutritional measures you can take to support your over-all health.  No amount of probiotics or exercise can undo the effects of a diet high in sugar and processed foods
  • Do get tested between 35 and 37 weeks for GBS. If you still test positive after a sustained period of time taking probiotics, eating a diet low in processed sugars and carbs, and rich in food that looks like it was alive, the colonization is highly likely to be one that needs antibiotic treatment. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease. If a pregnant woman who tests positive for group B strep bacteria does not get antibiotics at the time of labor, her baby has a 1 in 200 chance of developing group B strep disease.
  • If GBS is found in your Urine during pregnancy, antibiotics can get the high colonization in check. Take probiotics at the same time as you take antibiotics and for the rest of your pregnancy.  The CDC recommends that anyone with GBS in their urine at any point during their pregnancy receive antibiotics during labor
  • Please discuss this information with your provider and work together to find a solution that is right for you. If your provider does not have time to discuss this or other preventative measures with you, there are plenty that will and I highly recommend you shop for the one who will serve you best

Additional Resources

Microbiota/Microbiome and Pregnancy/Birth/Breastfeeding

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943946/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464665/

https://www.amazon.com/Your-Babys-Microbiome-Critical-Breastfeeding/dp/1603586954

https://www.amazon.com/Microbiome-Effect-Affects-Future-Health/dp/178066270X/ref=sr_1_2?s=books&ie=UTF8&qid=1490123008&sr=1-2

Preterm Birth

http://www.marchofdimes.org/complications/premature-babies.aspx

Group B Strep Disease

https://www.groupbstrepinternational.org/