What is the GBS test?

GBS or group B strep is a pathogen that approximately 1/3 of all women carry. It is not a sexually transmitted infection and it doesn't make women or their partners sick. However, newborns born to women with positive GBS vaginal/rectal cultures are prone to sepis (wide spread infection) or illness because of their immature immune systems. Only about 5% of babies born to a GBS+ woman would actually become sick, but the illness can be so rapid and the newborn could potentially die, therefore, we perform universal testing and treatment for all women. Testing occurs usually between 35-37 weeks gestation unless preterm labor or premature rupture of the amniotic sac occurs. In the latter case we would test and treat immediately. Otherwise, we routinely swab (with a q tip type swab) in the vagina and slightly into the rectum during the last month of pregnancy. We do the rectal swab because the majority of strep actually lives in the intestinal tract and that area is still a risk factor for transmission to the baby. If the culture is positive we give intravenous antibiotics at the onset of labor and continue to give them intermittantly every 4 hours until delivery to prevent infection in the newborn.
Some patients may be positive with one pregnancy and negative with another. The reason is because strep can colonize (grow) and once it has grown to a certain level it is picked up on culture and said to be capable of causing infection in the baby. Once we treat you, it may stay at low enough levels that it is not a problem in future pregnancies. However, we will often treat anyway (especially if you'd prefer) if you have been positive with other pregnancies and negative with the current one just in case the bacteria grows in the time from doing the test to the time of labor even though current guidelines do not say this is necessary. We also repeat the test if it is negative and you don't deliver within 4 weeks to see if it turns positive in that time.
For those of you going natural and concerned about the IV with being strep positive, we recommend treating it with antibiotics and then we can hep cap your IV between doses so you can still feel free to get up and move or walk. You can even soak in the bath once you are treated (and preferably if your water bag is intact).

What's the Difference Between Doctors and Midwives?

This is a question I get asked a lot by patients or potential patients seeking an obstetric provider. The answer consists of many things and some different philosophies in general. Of course, there are some midwives who practice differently, and some obstetricians who practice differently, so you can't put everyone into the same nutshell, but here are the main differences. Doctors have been to medical school and have done a residency in their specialty area which includes surgery and management of high risk medical conditions. Certified Nurse Midwives (CNM's) have received Bachelor's degrees in nursing and have most have gone to graduate schools for Master's degrees in nurse midwifery. We do clinical hours and deliveries over about 2 yrs of school which consists of clinic time managing pregnancy, primary care, and gynecologic care. We also deliver babies and assist c/sections in many hospitals. Some do deliveries in birth centers and a small portion about 4% in this country do home births. Direct Entry Midwives are midwives who have had some training usually about 1 yr and perform most deliveries at home or in birth centers. There are also lay midwives who learn the trade from experience and time with other lay midwives. They perform home births.

The general philosophy of midwives is that pregnancy and childbirth is a natural and normal process that requires care of the woman, but that less intervention usually leads to better outcomes-such as a lower c/section rate. We also focus on educating our patients about things to watch for and do during pregnancy to encourage a healthy mom and baby and vaginal birth. We offer more time during prenatal visits to educate our patients and to really take time to know them and care for them. Most of us, myself included want our patients to feel that their desires are being addressed and that we are giving our patients educated options to choose from to meet their desires for childbirth. I personally don't think there is just one way that is the best way. I think natural births are wonderful, but there are some women that do not desire this and just because you choose a midwife doesn't mean you can't use medication or an epidural if desired. We/I just want you to be comfortable and safe and feel like you had a great experience. We never put your safety on the back burner either. We do intervene when necessary and consult or manage your care with an obstetrician if things are varying from a normal safe path. That being said, most midwives have lower c/section rates, bigger babies, and less preterm delivery. Part of the latter is likely because of the education time we try to take with our patients.

Last but not least, midwives usually spend more time with you during your labor offering labor support or emotional support and advocating with the nurses and other care providers on your behalf to help you get the birth experience you want. So, if you are

considering a midwife, come on in, you won't be disappointed!

HPV AND CERVICAL CANCER

HPV or human papillomavirus has 100+ strains, a few of which are considered "high risk" meaning they can cause cervical cancer. HPV is sexually transmitted, and because it is a virus, it is not curable. However, like flu virus, there is a vaccine to protect young women (and men now) against the dangerous strains of HPV. Not all HPV infections will turn into cervical cancer. In many cases, your body will take care of the virus and you will not require treatment for abnormal pap tests or cancer. However, your body may not treat all of the strains, and some of them may mutate and cause changes in the cervical cells which may lead to cancer down the road. Most abnormal cervical tests take 5+ years before they would be considered as full blown cancer requiring hysterectomy, etc. However, there are some cases that move faster and therefore, it is important to follow up with regular screenings, colposcopy, or other treatment as recommended by your provider. Further, there are other types of cancer that are not caused by HPV and that is why all women must be screened, not just women with muliple partners.
Gardisil and Cervarix are vaccines that are available to prevent cervical cancer. The vaccines are recommended for women aged 14-27. It must be given in three separate doses and most insurance does cover this vaccine, so if you fall in this age group, check with your insurance and your provider and get vaccinated! Gardisil also prevents certain types of HPV that cause genital warts as well, so if this vaccine is right for you, you may be "killing two birds with one stone!"
So....don't skip out on those yearly exams or vaccines!

Preeclampsia or (Toxemia, the old fashioned term)

I just realized I've never posted on preeclampsia which is one of the number reasons why it is important to get prenatal care. The cause of preeclampsia is unknown, yet its damaging effects are well known. Preeclampsia is diagnosed by an elevation of blood pressure and protein in urine. Thus the reason for regular urine samples and blood pressure checks during your prenatal visits. There is no cure for preeclampsia besides delivery, and so the goal of treatment is to hopefully get you to term 37+ weeks gestation and then deliver. However, if it becomes severe and begins to involve other organs such as your liver, then delivery prior to term becomes mandatory. Signs and symptoms of preeclampsia are elevated blood pressure, protein in the urine, abnormal labs typically low platelets, and elevated liver tests, spots in vision and/or blurry vision, headaches unrelieved with medication, and swelling of extremities and face. It is important to note however, that swelling by itself is not diagnositic of preeclampsia as many patients believe. You must have the elevation of blood pressure and protein in urine to truly have preeclampsia. If you believe you may be having these symptoms it is important to see your provider as soon as possible or go to labor and delivery for evaluation. The worst case scenario if this is left untreated is seizures in the mother (eclampsia), stroke, or even death. In the fetus, there is risk of growth restriction, morbidity and mortality associated with preterm delivery, and death as well from vasospasm and constriction of blood flow to the placenta and therefore to the baby. So, moral of the story, be sure to keep your regular prenatal appointments, and pay attention to symptoms that could be worrisome. Hopefully, the majority of you out there will not experience this!

Glimpse of my Lake Powell vacation

For those of you who want to see the good times had at lake powell last week-here you go! And yes I know it doesn't have to do with midwifery, but since I don't have a separate personal blog, I figured my friends would like to see that I do dare to go on vacation even if it's only about every 3 years!

Vitamins

I am a huge believer in vitamins. Here are just a few thoughts on what I think are the most important vitamins to take on a daily basis. First-a multivitamin. These have all the basic vitamins and minerals you need to meet the majority of the daily recommendations. Second-calcium. The reason for the calcium is that most women will suffer some degree of osteopenia later in life which leads to osteoporosis. Most of us (men included even though they won't admit this) don't get enough milk or other dairy products to make up the amount of calcium and vitamin D that you need. Multivitamins have some calcium (usually about 400 mg/day) but not enough to prevent osteopenia. The recommendation is that we get 1200-1500 mg/day of calcium and that those supplements need to have Vitamin D. Researchers are finding we are very deficient in vitamin D and taking extra in these supplements will not lead to overdose (even though Vit D is fat soluble). Further many mood disorders such as depression can be helped somewhat with vitamin D supplements. If you are worried about your vitamin D levels, come in and we can draw blood to test this if you desire. The third daily supplement I recommend is fish oil. I think 2-3 capsules/day is recommended. These can promote normal cholesterol levels to prevent heart disease. It also helps the neurons or neurotransmitters in the brain so you can think and process information better and helps your nerves (I'm not sure the exact etiology of this off hand, but you can research this further if you desire).

I usually take this little cocktail at night all at once because this is the only time I remember, but it is probably better to take at least 1 or 2 capsules of the calcium in the morning and a fish oil in the morning and the other capsules and vitamin at night. I'm sure as long as long as you are getting the amounts in your system though, it is better than not at all.

I also recommend an extra folic acid pill if you are trying to conceive. They are finding more neural tube defects and perhaps if we get people taking closer to 1 gm of folic acid prior to conception this rate might be lower. Folic acid is water soluble so don't worry about overdosing on this if you are taking it with a multivitamin.

There are other herbs, etc available too that I take at times including garlic, and echinacea. These are not FDA approved but I think in small amounts can have some reasonable benefits. Well, happy vitamin taking!

To ultrasound or not, that is the ?

Our office offers ultrasound every visit. We have found this to be a very satisfying thing for patients to see their baby and have a better idea of their baby's growth, amniotic fluid, position, and even facial pictures via our 4D scan. I do have patients question the safety of this now and then though, so I thought I'd address this. Doing ultrasounds every visit (if desired) is not necessary, and doesn't necessarily mean your care is better than another office that doesn't do them. Years ago, some research suggested that too frequent of ultrasounds may result in growth restriction in the fetus or left handedness (oh no!) in the fetus. It also suggested that there is an increase in cesarean section in those with frequent ultrasounds. Further evidence later refuted that and said this could not be proven (besides the increase in cesarean section during labor from continuous monitoring-which is another story). So, because ultrasound has been around for so long and there is no good research to prove it is doing harm, we offer them regularly. However, you do not have to have them every visit. I still have the good old tape measure for your belly and doppler to check fetal heart beat if you would rather do this method. I do believe ultrasound is nice to have at least one per trimester for the following reasons. First trimester-to accurately assess your due date by your baby's size. Second trimester-to make sure your baby is anatomically normal with no lethal defects. Third trimester-to check fetal position to verify your baby is head down for delivery and to assess amniotic fluid levels. All the other in between ultrasounds unless specified for other follow up reasons, are basically for some growth assessment and for fun. Ultrasounds are also good for some situations too such as the overweight patient who a normal fundal height measurement is not as accurate. This is especially true for them because obese patients are more at risk for a fetal death so I think more regular ultrasounds to check for growth and blood flow in the cord is not a bad idea.

Now for the reason why continuous fetal monitoring in labor is an increased risk for c/section. Babies in labor typically have some decelerations in the heartbeat from umbilical cord compression or from head compression coming down the birth canal. Sometimes, we (providers and nurses included) interpret these decelerations to be more harmful than they might actually be, and we jump to do c/sections in the hopes of saving your baby or preventing cerebral palsy. Oddly enough, despite all these c/sections and continuous ultrasonic monitoring in labor, the cerebral palsy rates have not declined and the c/section rates have only increased. Thus, it may be better to have intermittent monitoring. Of course, this is only possible if you are not on pitocin and an epidural as these may increase your risk of having more or worse decelerations in the fetal heart rate necessitating a c/section. C/sections are not all bad of course. There are definite reasons to have a c/section such as a prolonged deceleration, or other more serious types of decelerations (that are not all caused by pitocin use:). Anyway, just more blah blah blah for you on ultrasound usage and the pros/cons. Hopefully, I'm not boring everyone to death.

Home Birth??

Since the last reader inquired about home birth, I've been giving this idea some thought. This is not something that I've done before but I'm starting to consider the idea of doing a few maybe. I would have to talk to my malpractice insurance company and my back up obstetrician and see if these are things that they would cover. One of the problems is if I have a patient at home and at the hospital in labor at the same time. I think the situation would depend on the time and the risk involved in any particular pregnancy. I still believe it is safer in most situations I'm delivering in, to be in the hospital. That being said, most low risk pregnancies that deliver at home (approximately 90%) are free of complications. However, that 10% or so still makes me a little nervous. To date, I have had no intrapartum fetal deaths, still births, major maternal complications, etc. and I'd really like to keep that record. Of course I've had hemorrhages and other more minor complications, but they've all been fairly treatable because I've had help for the baby and medications, etc. right there in the hospital with extra staff available to assist. That being said, I do believe in a women's right to choose her birth experience and that she has intuition about her own abilities and situation, and if home birth is something she is adamant about, maybe I should look into this? I'm just wondering how many patients or readers out there in the Weber County area would genuinely be interested in home birth if I offered this to certain patients who met a certain criteria?...ie very low risk! Please send me your thoughts, I'd be interested:)

Post partum blues/Depression

I thought I should touch base on this topic, especially with all the child abuse I am hearing about lately on the news. Postpartum blues is a normal change in women after delivery that comes about due to the sudden drop in hormones at delivery. It generally causes you to be teary and emotional at things that wouldn't normally cause this reaction. The blues usually lasts only 2-3 weeks. If you are feeling this way longer than 3 weeks, or are having negative thoughts towards yourself, or your baby, you may be heading for depression. Unfortunatley, depression robs about 20% of mothers of valuable moments and bonding with their newborn. This type of depression can you leave feeling apathetic, tired, and in some dysfunctional and irrational. Although these can be devastating to your growing family, there is treatment. We frequently use medication and/or counseling in the treatment of depression. It is also important for you to share your struggles with your partner or other family or friends that can help. Sometimes the best thing for you is to have some time for yourself. Make sure you are getting out of the house, getting rest, and getting a little exercise if appropriate to do so. It is also important to note, that if you feel that you cannot handle a crying infant leave them in their crib where they are safe and have someone come help you! Babies cry and although this is frustrating, it is generally not harmful for them. If you have concerns about the crying or other medical problems, call your pediatrician.
I am always happy to talk to you and you can call our office or my cell phone for any concerns. Just know, you are not alone. Many women struggle with this and there is help... just don't be afraid to seek it!

Breech Baby

Usually babies are head down by 32 weeks and hopefully 36 weeks. But if they remain breech or head up, then we have to decide what the best option for delivery is. If you have a normal uterine anatomy and your baby does not have any anomilies and your placenta is in a place that makes it safe to attempt to turn your baby, then we can schedule you for a time in labor and delivery and I will assist my OB backup physician in attempting to manually turn your baby. This is call an external version. We/he places our hands on your abdomen and try to somersault your baby into the right position. There is about a 3% risk of doing harm which would necessitate an emergency c/section. If all goes well, we monitor your baby for about 30-60 mins after and then send you home. We usually do these around 36-37 weeks when your baby is small enough to hopefully have success at turning, but old enough that survival outside the womb would be fine if you have to be delivered immediately. Your other options are to wait and see if the baby turns on its own, or you can try leaning down in the decline position on your elbows and knees a couple times a day for 5-10 mins and see if that helps your baby spontaneously move. If your baby doesn't turn and remains breech at the time of labor, you will likely need a c/section. If you think you are a good candidate to deliver a breech baby and you wish to try this, we send you to Dr. Silver at the University of Utah. I think he is one of the only OB's in Utah that will still attempt breech deliveries, as these are fairly dangerous. Otherwise we schedule you for a c/section. I have also had some patients go to acupuncturists and do acupuncture and they have had success. These acupuncturists claim to have an 80% success rate-which is pretty dang good if you think about it! Of course you check with your provider to make sure this is appropriate. If your uterus has a septal defect, or your baby has some other defect, or your amniotic fluid is low, it is best to leave things alone and have the c/section. You risk more damage to yourself or the baby to try to intervene, and let's face it, we want you to have a live healthy baby even if this means a longer recovery for you!

Vaginal Infections

I thought I'd post about something different than pregnancy stuff, although vaginal infections can occur during pregnancy. There are different types of vaginal infections with different symptoms and complications. I would say this is one of the primary things we see in the clinic on a typical day. To start with, let's talk about yeast infections. Most women will experience a yeast infection at least once in their lifetime, and likely more than that. Yeast is a natural pathogen that we all have a small amount of in our vaginas. However, it can multiply and grow when other good bacteria are killed off such as when you take antibiotics. It also thrives on sugar, so people with diabetes or who ingest too much sugar may be more prone to yeast infections. It is also present in people who are HIV positive-that is another story though. Symptoms of yeast are typically intense itching and burning. Sometimes women will notice a white, curdly discharge as well. Yeast is usually easily treated with medications some vaginal, some oral-dependent on your preference. You can also naturally treat this with eating yogurt that contains live acidophilus cultures or acidophilus tablets that can used vaginally or taken orally. And then avoid excessive sugar consumption!
The next vaginal infection we see, and probably the most common is bacterial vaginosis. This is usually caused by the bacteria "gardnerella." The most common symptom is foul odor-typically a fishy odor. There is usually runny clear to gray discharge. The odor is also ususally worse after intercourse. This one is somewhat worrisome during pregnancy as it can potentially cause the water to break early and increase infection risk from that to you and the baby. This in turn will lead to preterm delivery. This may not happen to all, but it does to some and therefore, I believe it is worth treating during pregnancy especially. This is easily treated with oral pills or vaginal gels. There are also some natural remedies available to such as garlic, but I'd prefer you come talk to me about those so I can tell you how to do it correctly:) I actually think some of the more natural treatments are better especially for recurrent bacterial vaginosis.
The other vaginal infections are usually sexually transmitted. Chlamydia is the most common and unfortunately, many women do not have symptoms. Therefore, unless you come in and ask to be screened, this can be missed for some time. Gonorrhea is another one, and you may have green discharge, or some burning, or you may have no symptoms at all. It is less common than chlamydia, but we do see it and it is very important for both of these infections to be treated. Which, luckily, those two are 100% curable. However, if it isn't detected for months or years, it can lead to infertility and chronic pelvic pain. So moral of this story is, don't be embarrassed, come in and be screened for everything and avoid problems down the road. We have seen it all before, and won't be surprised!
I forgot to mention warts and herpes...also sexually transmitted infections. Herpes causes blister like lesions on the outer and sometimes inner vagina. They are very painful. It is almost always pain that brings people with these lesions in to be checked. Unfortunately, there is no cure for herpes. You will have outbreaks throughout your life. We can somewhat control and suppress these outbreaks, but you will always have the virus and can spread the disease even when you don't have lesions. We can also treat some of the pain, but the disease remains.
Genital warts are also another nuisance. These are more common than herpes, but like herpes they are not really curable. We can apply an acid to them in the office or give you a prescription for a cream to help lessen or rid of you the present lesion (s), but the virus remains. You may still have outbreaks. The good thing is, these are not painful and do not usually cause a problem with vaginal delivery down the road (which herpes can). There is a vaccine however, that can prevent most strains of genital warts if you get the vaccine months prior to the exposure. The vaccine as some of you know is gardisil, and it also protects against some types of HPV that can cause cancer. Check with your provider if you think this may be something you are interested in.
Well, I think this mostly sums up vaginal infections.

Diet, Exercise, Weight Gain

So, I get asked all the time "How much weight should I gain with pregnancy?" The answer is slightly different depending on your starting weight, so here goes. If you are a normal weight and BMI (body mass index) when you become pregnant, you should gain about 25-35 lbs. If you are overweight or obese meaning a BMI greater than 26, you should gain no more than 20 lbs. If you are underweight BMI less than about 21 you should gain about 28-40 lbs. Weight gain is something I believe is so important in growing a healthy baby. If you are not gaining enough weight, you risk a small for gestational age baby or a growth restricted baby. You also increase your risk of preterm birth (which although you may not care to be pregnant anymore, this is extremely dangerous for the baby). On the flip side of this, if you gain too much weight during pregnancy you risk a baby that is large for gestational age and the baby may have difficulty regulating blood sugars. Further a large baby (usually 9 + lbs is considered large) is at greater risk of birth trauma from shoulder dystocia (meaning we get the head delivered and the shoulders get stuck). This can result in Erb's palsy which causes the affected arm to be permanently numb (some are can be temporary) and can also result in death if we are unable to get the baby delivered rapidly. It also increases your risk of more severe vaginal and/or rectal lacerations :(

Okay, so now you know the risks, what can you do to prevent them? Try to eat healthy diet full of fresh vegetables, fruits, proteins, and complex carbohydrates. Try to avoid excess sugar, soda pop, and juices. Typically if you can include a small amount of protein with each meal, you will keep your blood sugars more stable and will not have rapid drops in sugar levels which make you crave more of the unhealthy sugars that contribute to some of the above problems. Protein is found in meats, fish, beans, nuts, peanut butter, tofu, yogurt, and cheese. I find if I tell patients that are feeling episodes of dizziness to include a small amount of protein with each meal, they tend to do better.

The other thing is exercise. Although I'm not a believer that you should be out running marathons or anything too strenuous, a little bit of exercise will help you maintain a normal weight gain with pregnancy and can help you be in shape for delivery. I would recommend walking, swimming, light aerobics, light weight lifting (no greater than about 10 lbs), yoga or pilates. Exercise also increases your brains natural endorphins such as serotonin and norepinephrine making you less depressed and moody.

Well, all of that being said, genetics do play a role in the size of your baby and some other conditions that you may not have total control of. So don't beat yourself up if you have a baby less than 6 lbs or over 9 lbs, you may not have been able to help it. I'm only suggesting ways to try and have the healthiest pregnancy and birth experience for you and your baby....

Good luck!

Preterm Labor

Hi everybody. Sorry I haven't posted for awhile. I just get busy with work, kids, etc. I've thought of some other topics though that might be worth writing about, so I'll hopefully get posting more regular again. I decided to start with I would do this one on preterm labor.

Many women will experience some signs of preterm labor during pregnancy, and I thought it would help to write some signs to help you decide between what is "false" labor from what is real. If you are having occasional contractions such as a few per day, this is usually nothing to worry about. However, if you feel that you are starting to have a pattern to the contractions such as 3 or more contractions per hour for more than hour you should be checked. Other signs of preterm labor include cramping (feeling like menstrual like cramps), pressure in the vagina or rectum, increase in vaginal discharge, leaking amniotic fluid, or backache, then you should be evaluated by your practitioner.

Typically, when patients present with signs of preterm labor, we run a test call a fetal fibronectin which we obtain from a vaginal swab. If this test is negative, there is a 99% chance you will not deliver for at least 2 weeks. Thus, this test is very indicative. However, if it is positive, you won't necessarily deliver early, but we will be more aggressive in our treatment to prevent preterm birth. Treatment is usually aimed at stopping contractions and thus slowing cervical dilation, and at buying more time for fetal maturity. We stop contractions with medications, and bed rest, as well as hydration. We also give you injections (steroids) to aid in fetal lung maturity in the event that your baby is born early. If you have had a history of preterm labor or preterm birth (preterm being less than 37 weeks gestation) we also may start you on progestone shots at about 17 weeks until 36 weeks. Although this doesn't always prevent preterm birth, there is some good evidence that it may delay it and allow more time for fetal maturity.

So, bottom line, make sure you tell me or your practitioner if you are noticing signs of preterm birth or if you have a history of preterm birth....hopefully we can have a better outcome than before!