Group B Strep: what you need to know

We are told that the concern about Strep B involves two groups at high risk of infection:
1. Premature infants under 37 weeks gestation
2. Any infant in utero with membranes released longer than 18 hours

Contractions are a possible indicator of infection, but this situation is a concern in weeks 0-36. After 36 weeks, Braxton Hicks are normal and a good sign of a healthy toned uterus getting ready to push a baby out.

A culture that shows Strep B in the vagina is not necessarily illness related. Just as we commonly have Strep A in our throats on a swab and have no sore throat symptoms (no strep throat), from one day to the next we can all culture positive for Strep B without any symptoms or danger to our unborn babies. This is why many practitioners refuse to test for it and simply wait to test until such time as the above two “at-risk infant scenarios” show up. One day a woman might test positive and the next be negative. To treat with antibiotics before labour would NOT be recommended. Why?
The woman’s body could build up a resistance to the antibiotics and so could her baby’s body. Then if either got a more serious infection after the birth, the antibiotics might be ineffective.

Taking antibiotics can also lead to thrush, vaginal yeast and severe colic in the months after birth. There is some indication that antibiotic use can lead to Vitamin K deficiencies in the baby.

I would advise pregnant women to do as many things as possible to minimize their risk of ANY infections and maximize their immune systems. Some safe suggestions:

1. Boost vitamin C in your diet—e.g., eat 2 grapefruit per day. Other good sources of Vitamin C are red peppers, oranges, kiwi fruit.

orange, grapefruit, kiwi

Boost Your Vitamin C

2. Drink a cup of echinacea tea or take 2 capsules of echinacea every day.

3. Get extra sleep before midnight. Slow down your schedule.

4. Take 1 tsp colloidal silver per day. Take it between meals. Hold the liquid in your mouth a few minutes before swallowing. Colloidal silver can be purchased in most health food stores. It is silver suspended in water. It is antibiotic in nature and safe in pregnancy if you limit the daily intake to 3 tsps or less. Do not take more because there is a danger of turning your skin permanently blue by overdosing.

5. Plan ahead for extra warmth after the birth for both the mother and baby. Hot water bottles, heating pads, hot packs, big towels dried in a hot dryer during the pushing phase all help keep the mamatoto extra toasty after birth and reduce stress. Have a friend or family member assigned to be in charge of the mother/baby warmth team. Colostrum is the best antibiotic treatment the baby could ever get.

6. Other good prevention tips: Keep vaginal exams to a minimum — 0 is best. Do not allow membrane stripping to start the birth (a.k.a. membrane sweeping). Do not permit artificial rupture of the membranes. Do not allow children of other families to visit the new baby for the first three weeks. Keep the older kids healthy so they are not sneezing and coughing on the new baby.

I often think we must have had a lot of women who were Strep B positive in the 1000 plus births I have attended. We do not test unless we have long rupture of membranes and/or a preemie. Once the baby is born, we keep all women warm and baby skin-to-skin with the cord intact and, of course, all our mothers breastfeed. I have never had a baby sick with Strep B in thirty years. Unfortunately, the use of high dose antibiotics on so many pregnant women has resulted in an increase in infant deaths due to E Coli. *Group B strep/antibiotics

Prevent the diagnosis of positive for GBS: If your care provider wants you to go for GBS testing to comply with their protocols, read this article by a Certified Nurse Midwife about the use of garlic in the vagina to knock out bacteria. Do this regimen prior to testing.
http://www.midwiferytoday.com/articles/garlic.asp

Be sure to check out Lisa Barrett’s blogpost (and the comments) about the Cochrane Review regarding GBS and Antibiotics at http://www.homebirth.net.au/2009/07/gbs-cochrane-report.html
*References:
(1.) E. M. Levine et al., “Intrapartum Antibiotic Prophylaxis Increases the Incidence of Gram Negative Neonatal Sepsis,” Infectious Disease Obstetric Gynecology 7, no. 4 (1999): 210-213.
(2.) C. V. Towers and G. G. Briggs, “Antepartum Use of Antibiotics and Early-Onset Neonatal Sepsis: The Next Four Years,” American Journal of Obstetric Gynecology 187, no. 2 (2002): 495-500.
(3.) C. V. Towers et al., “Potential Consequences of Widespread Antepartal Use of Ampicillin,” American Journal of Obstetric Gynecology 179, no. 4 (1998): 879-883.
(4.) R. S. McDuffie Jr. et al., “Adverse Perinatal Outcome and Resistant Enterobacteriaceae after Antibiotic Usage for Premature Rupture of Membranes and Group B Streptococcus Carriage,” Obstetric Gynecology 82, no. 4, pt. 1 (1993): 487-489.
(5.) T. B. Hyde ct al., “Trends in Incidence and Antimicrobial Resistance of Early-Onset Sepsis: Population-Based Surveillance in San Francisco and Atlanta,” Pediatrics 110, no. 4 (2002): 690-695.
(6.) M. L. Bland et al., “Antibiotic Resistance Patterns of Group B Streptococci in Late Third Trimester Rectovaginal Cultures,” American Journal of Obstetric Gynecology 184. no, 6 (2001): 1125-1126.
(7.) M. Dabrowska-Szponar and J. Galinski. “Drug Resistance of Group 9 Streptococci,” Pol Merkuriusz Lek 10, no. 60(2001): 442-444.
(8.) R. K. Edwards et al., “Intrapartum Antibiotic Prophylaxis 2: Positive Predictive Value Antenatal Group B Streptococci Cultures and Antibiotic Susceptibility of Clinical Isolates,” Obstetric Gynecology 100, no. 3 (2002): 540-544.
(9.) S. D. Manning et al., “Correlates of Antibiotic-Resistant Group B Streptococcus Isolated from Pregnant Women,” Obstetric Gynecology 101, no. 1 (2003): 74-79
(10.)Cochrane Database: Jan. 2013 “Maternal colonization with group B streptococcus (GBS) during pregnancy increases the risk of neonatal infection by vertical transmission. Administration of intrapartum antibiotic prophylaxis (IAP) during labor has been associated with a reduction in early onset GBS disease (EOGBSD). However, treating all colonized women during labor exposes a large number of women and infants to possible adverse effects without benefit.”
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007467.pub3/abstract

UPDATE: Cochrane Library, June 10, 2014
Intrapartum antibiotics for known maternal Group B streptococcal colonization
Women, men and children of all ages can be colonized with Group B streptococcus (GBS) bacteria without having any symptoms. Group B streptococcus are particularly found in the gastrointestinal tract, vagina and urethra. This is the situation in both developed and developing countries. About one in 2000 newborn babies have GBS bacterial infections, usually evident as respiratory disease, general sepsis, or meningitis within the first week. The baby contracts the infection from the mother during labor. Giving the mother an antibiotic directly into a vein during labor causes bacterial counts to fall rapidly, which suggests possible benefits but pregnant women need to be screened. Many countries have guidelines on screening for GBS in pregnancy and treatment with antibiotics. Some risk factors for an affected baby are preterm and low birthweight; prolonged labor; prolonged rupture of the membranes (more than 12 hours); severe changes in fetal heart rate during the first stage of labor; and gestational diabetes. Very few of the women in labor who are GBS positive give birth to babies who are infected with GBS and antibiotics can have harmful effects such as severe maternal allergic reactions, increase in drug-resistant organisms and exposure of newborn infants to resistant bacteria, and postnatal maternal and neonatal yeast infections.

This review finds that giving antibiotics is not supported by conclusive evidence. The review identified four trials involving 852 GBS positive women. Three trials, which were more than 20 years old, compared ampicillin or penicillin to no treatment and found no clear differences in newborn deaths although the occurrence of early GBS infection in the newborn was reduced with antibiotics. The antibiotics ampicillin and penicillin were no different from each other in one trial with 352 GBS positive women. All cases of perinatal GBS infections are unlikely to be prevented even if an effective vaccine is developed.
Source: http://summaries.cochrane.org/CD007467/intrapartum-antibiotics-for-known-maternal-group-b-streptococcal-colonization

UPDATE April 2016: From the (30th Anniversary Special) copy of Midwifery Today Magazine. Quote: “Unlike the US, the UK does not recommend universal screening because, while GBS disease is the most common cause of infection in full-term newborns, it is statistically still quite rare.(Wickham discusses these numbers in depth.) The Royal College of Obstetricians and Gynecologists (RCOG) firmly states that it will not support routine screening for GBS “until it is clear that antenatal screening for GBS carriage does more good than harm and that the benefits are cost effective” –two factors that have yet to be affirmed in any research done to date.” End Quote

This was part of a book review in Midwifery Today Magazine, Spring 2016 for “Group B Strep Explained” by Sarah Wickham, Midwife, 2014, paperback, pub’d by AIMS

Low Amniotic Fluid Scam

This article from Medscape illustrates the folly of diagnosing oligohydramnios through ultrasound. True low amniotic fluid at full term is an extremely rare condition which can be diagnosed properly only by doing palpation of the pregnant belly. Thousands of women have been unnecessarily launched down the cascade of obstetrical interventions by being frightened by this erroneous diagnosis at 41 weeks gestation. It’s time to ditch the “Biophysicial Profile” as an indicator of pathology. It is not based on science and continues to cost women their births and good health. Gloria Lemay

Quote: “The AFI was introduced in 1987 as a technique to assess the amount of amniotic fluid in the amniotic sac.[3] Although the AFI is widely accepted as the standard to diagnose oligohydramnios in the United States,[1] many studies have found it to be an inaccurate method for assessing the actual amount of amniotic fluid, especially in the lower or higher ranges.[3,4,6-9]”. end of quote. Source, page 3 of the Medscape article http://www.medscape.com/viewarticle/551032_3

Oligohydramnios at Term
(From Journal of Midwifery & Women’s Health
Oligohydramnios at Term: A Case Report

Maria L. Lanni, CNM, MS; Elizabeth A. Loveless, CNM, MS

Posted: 02/07/2007; J Midwifery Womens Health. 2007;52(1):73-76. © 2007 Elsevier Science, Inc. )

(excerpt)
In Conway’s[13] retrospective, case-controlled study, women who were induced for oligohydramnios had an increased rate of cesarean section when compared women with oligohydramnios who were in spontaneous labor. The authors postulated that this increase was caused by the induction process itself.[13] One may conclude that a woman who is at term with isolated oligohydramnios with reassuring fetal surveillance and the absence of maternal morbidity and evidence of FGR is not associated with adverse perinatal outcome. (End of except)

Conclusion (of Medscape article)

Adverse perinatal outcomes associated with oligohydramnios are: umbilical cord compression; uteroplacental insufficiency, which is related to fetal growth restriction, pre-eclampsia, and other maternal morbidities; and increased incidence of meconium stained amniotic fluid.[3,4,14] The adverse outcomes associated with oligohydramnios have led to recommendations of delivery following the diagnosis of oligohydramnios in pregnancies at or past 37 weeks.[2] However, Sherer[18] identifies a number of the original studies linking oligohydramnios with adverse perinatal outcomes that included fetuses with structural anomalies, small-for-gestational-age and FGR fetuses, postmaturity syndrome, and fetuses of mothers with various comorbidities, all of which may have affected AFI and led to the adverse outcomes. Thus, low AFI may be an epiphenomenon. The true number of adverse outcomes solely caused by isolated oligohydramnios is difficult to know.

The question of the best management for AFI remains. Individualized care, with consideration of the many maternal and fetal factors, including time of day, cervical readiness, and emotional readiness for labor, should be considered. While research has shown that expectant management with maternal hydration has comparable maternal and neonatal outcomes in women with isolated idiopathic oligohydramnios at term, clinicians may be reluctant to abandon the approach of active management. It is reasonable to begin with active maternal hydration prior to routine fetal surveillance of term pregnancies or for borderline AFIs. More research needs to be done on the effect of acute hydration prior to fetal surveillance. It may be beneficial for providers to encourage adequate hydration to our patients prior to assessment of AFI to decrease potentially unnecessary interventions.

http://www.medscape.com/viewarticle/551032

Related post: http://wisewomanwayofbirth.com/60/

Cord Around the Neck

From Susan:

“My first was born by c-section due to brow presentation. I was induced at 41 weeks 4 days. Long labor.

My second was a successful VBAC. I was induced with him also at 41 weeks, 5 days with a Pitocin drip. Contractions didn’t start right away and, after about 3 hours, the doctor broke my water. Things started so slow, but the doctor was very patient and we waited. Finally the contractions were getting a bit heavy and I decided on an epidural. I was given a small amount and was still able to feel the contractions but the peaks had been tapered off. I then dilated quite quickly from 8 to 10 (45 minutes) and had that intense need to push. So I pushed for about 30 minutes and our son was born. But when he came out his cord was wrapped twice real tight around his neck. He was not breathing. His one minute Apgar was 3. He was given oxygen and, within 5 minutes, his Apgar score was up to 8.”

Gloria responds:

Susan, you said- ‘But when he came out his cord was wrapped twice real tight around his neck. He was not breathing, Apgar was 3. Given oxygen and within 5 minutes his Apgar was up to 8.’ Susan, you are making a very common mistake. Attributing your baby’s low 1 minute Apgar to the cord around the neck is not correct. Your baby had a low Apgar at birth because you had an epidural and the pitocin drip was turned up too high. We know this because the second stage was so short. The cord around the neck is the reason the doctors give you so you won’t ask questions about why he was blasted out so quickly.

This kind of pitocin induction is sometimes associated with delayed speech and/or learning difficulties. It depresses the baby’s oxygen levels through the pushing stage. The reason the baby’s Apgar score came up nicely after 5 minutes is because you grew an essentially healthy baby and it was difficult for modern obstetrics to kill him.

So many women are told the baby didn’t breathe or wasn’t pink because of the umbilical cord being around the neck. It is a lie. We don’t see this at unmedicated home births and I have attended births where the cord was tight and up to five times around the neck.

The two most important things with a VBAC are:

1. don’t do anything to increase the strength of the contractions and
2. don’t anaesthetize the woman.

Your former doctor put you and your baby in danger by not following those two protocols. Your uterus was put in unnecessary danger of rupturing by both the Pitocin drip and artificially rupturing the membranes.  In hindsight, the cord was around the neck and, thus, probably out of danger but artificially rupturing the membranes is associated with causing the umbilical cord to prolapse–an obstetric emergency.
Susan replies:

“Gloria, it sounds like you just completely described what happened to me and my son–who does have learning difficulties and developmental delays.”

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

This photo shows a baby born at home in the U.K. who had the cord twice around the neck and was in a breech presentation.  Note his good colour.

Nuchal cord

Added January 2015: I just saw this video of a woman giving birth unassisted. The birthing woman calmly unwraps one loop of cord once the baby is out. Found on www.midwifethinking.com

Here’s a video of a hospital birth. Doctor is busy in the Operating Room. Woman births her baby and unwraps the multi-wrapped cord around the neck.

LIES THAT MEDICAL PROFESSIONALS TELL CHILDBEARING WOMEN

Don't let them induce you

Quiz:  Guess what’s being sold when a medical professional tells you any of the following.  Some of these lies have more than one application in the childbearing year.

1.“THIS IS A HORMONE JUST LIKE YOUR BODY MAKES.”

2.“THIS IS OXYGEN”.  “THIS IS MOSTLY OXYGEN AND IS GOOD FOR YOUR BABY”.

3.“WE’LL GIVE YOUR BABY A SUGAR PACIFIER FOR THE PAIN AND HE WON’T REMEMBER IT.”

4.“THIS IS ONLY SOUND WAVES AND IT HAS BEEN USED FOR THE PAST 40 YEARS WITHOUT HARM”

5.“I WOULD RECOMMEND THIS FOR MY OWN WIFE.”

6.“THIS WILL HELP LOOSEN THE MEMBRANES FROM YOUR CERVIX AND HOPEFULLY YOUR BABY WILL COME BY HIS/HER DUE DATE SO WE DON’T HAVE TO INDUCE.  IT MIGHT BE A BIT UNCOMFORTABLE, THAT’S ALL.”

7.“THIS WILL RIPEN YOUR CERVIX.  IT’S THE SAME HORMONE AS YOU GET DURING SEX.”

8.“YOUR SEX LIFE WILL BE JUST AS GOOD AFTERWARDS AND YOU WON’T HAVE TO WORRY ABOUT AN UNWANTED PREGNANCY.”

9.“NATURAL CHILDBIRTH IS OVER-RATED.”

10.“NOT EVERY WOMAN CAN DO THIS SO YOU SHOULDN’T FEEL BAD.  BE HAPPY THAT WE HAVE GOOD SUBSTITUTES NOWADAYS.”

11.“WE STOPPED PUTTING THAT PRESERVATIVE IN THEM YEARS AGO.”

Feel free to add more lies and to leave your best guesses.  Gloria

Artificial Rupture of the Membranes (a.k.a. A.R.O.M., A.R.M., Amniotomy)

A $12 MILLION DOLLAR COURT CASE ARISES FROM A COMMON INTERVENTION
========

FACTS OF THE CASE

This medical malpractice action seeks damages for brain injuries sustained
by infant Christopher Andres Peraza as a result of the events surrounding
his birth at Arden Hill Hospital (Orange Medical Center) on May 24, 2003,
particularly, the artificial rupture of the mother’s membranes (A.R.O.M.)
by Dr. DiCostanzo to accelerate the baby’s delivery. Defendant-Respondent
Dr. DiCostanzo is the private obstetrician involved in the pregnancy care,
labor, and delivery.

This case is unusual, in that the plaintiff alleges that this invasive
obstetrical procedure (A.R.O.M.) was performed without her consent and
despite her outright refusal of consent. This is not an “informed consent”
case. The claim is not that the plaintiff was given insufficient
information about the risks, potential complications, or alternatives,
needed to make an informed decision. Rather, plaintiffs contend that
regardless of whatever information that was (or wasn’t) supplied, she
never consented to this invasive procedure – the rupture of her membranes
– at all. The procedure was performed against her wishes, disregarding her
refusal of permission. As such, the quality or quantity of the information she was given, is

irrelevant.Amni-hook instrument

The plaintiff (mother) Elsa Peraza, defendant obstetrician Dr. DiCostanzo,
and all three Labor and Delivery Nurses, as well as the plaintiff’s mother
(the infant’s maternal grandmother) and sister, have all been deposed to
completion. Not one witness testified that the mother consented to the
A.R.O.M

A. The Mother’s Refusal of Consent:

The mother, Elsa Peraza, testified that she wanted a natural labor that
would progress at its own speed. Accordingly, she refused to have her
labor accelerated with chemical stimulants, and refused to have her labor
sped up by artificially rupturing her membranes (“A.R.O.M.”). [R. 39-40,
574, 579, 586]

From the time the mother first arrived at the hospital at about 7:50 p.m.,
until her emergency cesarean section at 1:42 p.m. the next day, three
Labor & Delivery Nurses (Donna Daley, RN, Loretta Colgan, RN, and Cindy
Shannon, RN) cared for Mrs. Peraza, over the course of two nursing shifts.
All three nurses uniformly testified that from the time Mrs. Peraza
arrived until Dr. DiCostanzo artificially ruptured the mother’s membranes
some eighteen hours later, the mother refused consent for A.R.O.M.
(Although the parties disagree as to whether or not the mother relented
and eventually consented to induction or “augmentation” of her labor with
drugs, this appeal is limited to the performance of the artificial rupture
of membranes (A.R.O.M.) to speed up the labor.) The fact that all three
nurses whose care spanned the entire time from admission to A.R.O.M.
uniformly testified to the mother’s refusal of consent to the A.R.O.M., is
important, because it disproves the inference of “acquiescence by conduct”
that underlies the lower court’s Decision and Order [R. 9].

Mrs. Peraza testified that her obstetrician, defendant Dr. Lynne
DiCostanzo, pushed to have this delivery expedited for her own (the
doctor’s) convenience, and the mother reluctantly went to the hospital
because Dr. DiCostanzo was so insistent and bullied her into it:

A. So, I want to be everything okay. [Dr. DiCostanzo said] I will
induce your labor. And I say, no, I don’t want it. I want to wait
for the end, because I want to feeling normal; you know, my
normal contraction and everything. I want everything normal.

And she explained to me how she’s going to induce my labor.

And I say, I don’t want it. But she insist. She insist to me. And
she push it to me, like it — she say, no, this is better day.

I think her daughter or somebody, her son or her daughter born
in May. And she say, oh, so, is going to be like my daughter –
May 24th, or something like that. And I say — I don’t say anything
now; I’m think about by myself – so, I don’t care if her daughter
born on that day. So, only, I’m worrying about how I’m feeling
that day.

And she say, I waiting for you 6 o’clock in the Arden Hill
Hospital.

I say, but I’m not ready. You know, I’m not ready with my baby
things and stuff.

Q. Did you tell her you didn’t want to go to the hospital that night?

A. Yeah, I told her. [Peraza EBT, pages 99-100, R. 566-567]

A. And she insist to me to have it – induced labor the same day.
I mean, go to the hospital the same day to induce my labor.
[Peraza EBT, page 104, R, 571]

When she arrived at the hospital, Elsa Peraza reiterated her refusal of
artificial means to speed up her labor, explicitly telling the admitting
nurse (Nurse Daley) that she refused consent to the use of drugs or
rupture of membranes to bring accelerate her labor and delivery. She went
to the hospital, as directed, with the intention of having childbirth on
nature’s schedule, without drug or surgical interventions. Questioned by
Dr. DiCostanzo’s attorney, Mrs. Peraza testified:

Q. And as you’re talking to me now, you told her you didn’t
want to go in for an induction?

A. Yes. I told her, I don’t want it. I say, I don’t want it today.

Q. Why?

A. Too early, you know. I know is three weeks early.

Q. Did you tell her you didn’t want it that particular day, or that
you didn’t want it at all?

A. All. I don’t want it at all. … [Plaintiff’s EBT, page 107, R. 574]

Labor and Delivery Nurse Donna Daley admitted Mrs. Peraza to the maternity
unit at about 7:50 p.m., and wrote in the chart that the patient refused
induction of labor and refused the artificial rupture of membranes. The
Intake Note clearly documents that the mother “States does not want
A.R.O.M. or induction.” [R. 16, 431]

At her deposition, Nurse Daley testified that the mother never withdrew
that refusal [R. 28]:

Q. From the time that Elsa first told you she didn’t want an artificial
rupture of membranes until the time you went off shift about 7:00
the following morning, did she ever say to you, I have changed my
mind, I consent to artificial rupture of membranes?

A. No. [Daley EBT, p. 34, R. 18]

Nurse Lauretta Colgan took over Elsa Peraza’s care for the night shift.
During Nurse Colgan’s shift, Dr. DiCostanzo visited the mother in the
hospital at about 10:00 p.m., and had a discussion with Mrs. Peraza in
Nurse Colgan’s presence. Neither Dr. DiCostanzo, Nurse Colgan, nor Mrs.
Peraza testified to the exact words that were exchanged, nor the quantity
or quality of information that was supplied, but the defense contends that
this was an “informed consent” discussion. In any event, even after this
discussion, the mother did not verbalize any retraction of her prior
refusal of an artificial rupture of membranes (A.R.O.M.).

Dr. DiCostanzo did not testify at deposition that the mother consented to
an A.R.O.M., nor supply an affidavit or affirmation or any other
supplemental materials contradicting Elsa Peraza’s explicit and unyielding
refusal of consent for the A.R.O.M.

Nurse Colgan testified to her impression of that conversation – that
although the mother understood the need to deliver the baby, she still did
not want induction or A.R.O.M. Nurse Colgan could not remember the
conversation verbatim, but she recalled the substance:

Q Can you give it to me in substance, if you can’t give it to me
word for word?

A. I would say that she understood the need for the
induction. Did she want it, no. Did she understand the need
for it, yes. [Colgan EBT, p. 33-34, R. 891-892]

Nurse Colgan further testified that the patient refused all chemical
stimulation to accelerate of her labor, and refused A.R.O.M.:

Q Where did you get this information that she did not want A.R.O.M.?

A It says [in the hospital chart], ‘states does not’. Elsa [said that].

Q She said it to you?

A Right.

Q You said before that she didn’t want any chemicals?

A Right . . . She didn’t want induction of labor. Whether you
want to call it prostaglandin or whatever, a chemical stimulation
or, you know. Yes, Elsa said that to me. [Nurse Colgan’s EBT, P.
21-22. R. 19, 880-881]

* * * * *

Q From the time Elsa first told you she didn’t want an artificial
rupture of membranes, to the time you went off shift about 7:00
the following morning, did she ever state to you that she changed
mind, that she does want chemical stimulation or that she does
want artificial rupture of membranes?

A Stated, no. [Colgan EBT, p. 22, R. 881]

However, despite the complete absence of verbalization, Nurse Colgan
testified that she “absolutely” believed that Mrs. Peraza acquiesced to
the Cervidil induction by her conduct. [R. 881] Mrs. Peraza stayed in the
hospital overnight, and changed from street clothes to a hospital gown. A
change of clothes is necessary to insert the Cervidil vaginal suppository
(to accelerate the labor) [Colgan EBT, p. 32-33, R. 891-892], but there is
no testimony from anyone that Mrs. Peraza changed her clothes for that
purpose, rather than simply to avoid going to bed in street clothes. The
defense contends that the change of clothes implies the mother consented
to induction, and the Order Appealed From adopted the defense’s
conclusion, holding that “Ms. Colgan’s testimony raises a triable issue of
fact as to whether plaintiff acquiesced by conduct to her treatment after
her initial admission to the hospital.” [R. 9].

Although Nurse Colgan surmised that the change of clothes evidenced
unspoken consent to induction, she did not testify that it evidenced
consent to the A.R.O.M. that followed some fifteen hours later. To be
absolutely sure there was no misunderstanding, Nurse Colgan was asked
again:

Q. But she never said I want it [Cervidil] and she never retracted
her prior statement – –

A. Not verbally.

Q. – – that she didn’t?

A. Not verbally. [Colgan EBT, p. 33, R. 892]

* * * * *

Q. From the time Elsa first told you she didn’t want an artificial
rupture of membranes, to the time you went off shift at 7:00 the
following morning, did she ever say to you I have changed my
mind, I consent to an artificial rupture of membranes?

A. No. [Colgan EBT, p. 34, R. 893]

Nurse Colgan was asked about the routine end-of-shift “report” she gave to
the succeeding nursing shift, and she re-confirmed the mother’s refusal of
consent to A.R.O.M. a third time:

Q, If I told you that yesterday, Nurse Shannon gave testimony in
this case and said that you told her Elsa Peraza did not want an
artificial rupture of membranes [at the end of your nursing shift,
when you gave your “report, “], would you have any reason to
disagree with that?

A. No. [Colgan EBT, p. 37, R. 896]

Labor Nurse Cindy Shannon took over at 7:00 o’clock the next morning when
Lauretta Colgan’ shift ended and she went home.

Nurse Shannon testified that when she came on duty, she was informed by
Lauretta Colgan of the patient’s refusal of consent to A.R.O.M., and there
was “no question” that the patient refused artificial rupture of
membranes. [Shannon EBT, p. 31, R. 956] Nurse Shannon testified:

Q Were you aware of this note [stating that patient refused
induction and A.R.O.M.] when you took on the patient [at the
beginning of your shift]?

A Yes, I was.

Q How did you become aware of it?

A Loretta [Colgan, the prior shift nurse, told me when she
went off shift]. [Shannon EBT, p. 30, R. 18, 955.]

Therefore, according to all three nurses that throughout the night shift
and continuing into the following morning, the mother never retracted her
refusal of consent for A.R.O.M.. Even assuming that the mother reluctantly
acquiesced to induction (which is in dispute), there is nothing at all
suggesting she acquiesced to A.R.O.M. Every witness testified Mrs. Peraza
was steadfast in her refusal of consent to A.R.O.M.

This is of great importance, because it directly refutes the inference the
defense drew from Nurse Colgan’s testimony, that the mother acquiesced by
conduct. Nurse Colgan herself testified to the mother’s unwavering refusal
of consent to the A.R.O.M. right to the time she ended her shift Dr.
DiCostanzo never testified that the mother consented to an A.R.O.M.,
either. No one did.

B. Dr. DiCostanzo Proceeded Without Consent:

When Mrs. Peraza was admitted, her obstetrician, Dr. DiCostanzo, had not
yet arrived at the hospital. Notwithstanding the mother’s
clearly-documented refusal of induction and A.R.O.M., Dr. DiCostanzo
issued a telephone order that a chemical labor-inducing/accelerating drug
(Cervidil) be ready for administration as soon as she arrived at the
hospital. Dr. DiCostanzo inserted the Cervidil vaginal suppository
immediately on her arrival. [Nurse Colgan’s EBT, R. 269, 887-889] Doing so
was in direct violation of the mother’s explicit, documented refusal.

Thereafter, when the labor still did not progress fast enough to suit Dr.
DiCostanzo, a second labor-accelerating drug, Pitocin, was added. [R. 287]

Later, when the two chemical stimulants still did not speed things up as
fast as desired by Dr. DiCostanzo, she undertook a third, fateful
procedure to expedite the delivery: Dr. DiCostanzo performed an elective
artificial rupture of membranes (an A.R.O.M.). This invasive procedure
consists of inserting a blade or hook, up and into the birth canal and
piercing the amniotic membrane that contains the baby, the umbilical cord,
and the amniotic fluid. [DiCostanzo EBT, p. 159, R.830]

Elsa Peraza’s flat-out refusal of this A.R.O.M. procedure is clearly
documented in the Nurses’ Admitting Note [R. 16, 431] and was testified to
by all three labor nurses, who agreed that the mother’s refusal of the
A.R.O.M. was never withdrawn or modified. Dr. DiCostanzo simply pressed
on, disregarding her patient’s documented refusal of consent.

Labor Nurse Shannon was an eyewitness to the A.R.O.M. and the delivery.
Nurse Shannon testified that Dr. DiCostanzo ruptured the patient’s
membranes artificially although she specifically told the doctor that the
patient refused consent just before the membranes were ruptured:

Q Was there any conversation between Dr. DiCostanzo and Elsa Peraza that
you observed or overheard at about the time the membranes were ruptured up
to the time of the rupture itself?

A I made Dr. DiCostanzo aware that she didn’t want ruptured
membranes.

Q That the patient didn’t want it?

A That the patient didn’t. And the conversation I can’t recall her
discussing it with Elsa.

* * *

Q Did she go ahead and rupture the membranes anyway?

A. Yes, she did.

Q In your presence?

A Yes, she did. [Nurse Shannon’s EBT, p. 43-44, R. 20-21, 968-969]

(4) Nurse Shannon testified:

Q. Is cord prolapse something which was recognized in the labor and
delivery service as being a real obstetrical emergency?

A. Absolutely.

Q. Why?

A. Because the head would come down and press on to the cord and
cut off the oxygen supply to the baby….. [Shannon EBT, page 53, R.21,
978]

Holding amni hook to insert up vagina

C. The A.R.O.M. Caused a Catastrophic Cord Prolapse:

Immediately after the membranes were artificially ruptured, a loop of the
baby’s
umbilical cord popped out of the birth canal. This condition, known as a
“prolapsed cord” or “cord prolapse,” is an obstetrical catastrophe
requiring an emergency cesarean section.

Cord prolapse is an obstetrical emergency because the baby’s head is still
undelivered, and the head pinches off the umbilical cord (from which the
unborn baby gets its oxygen from the mother) in the confined, tight space
within the birth canal. Before the membranes are ruptured, the intact
membranes hold the cord back, preventing prolapse. A frank cord prolapse,
as herein, can only happen after the membranes are ruptured. [21-22, 32,
1030]

Because the prolapsed cord is pinched shut in the birth canal, the baby
cannot get oxygen and asphyxiates within the womb. That is exactly what
happened here. [R.22, 31, 978, 1939]

Despite an emergency cesarean section and emergency resuscitation 32
minutes after the A.R.O.M. produced the cord prolapse, the baby was born
with severely depressed Apgar scores of 1 one minute after birth, 1 five
minutes after birth, and only 5 at 10 minutes after birth. (10 would be a
perfect Apgar score). [R. 22, 328, 1002]

The newborn was rushed to Westchester County Medical Center, where he
remained in the Neonatal I.C.U. for several weeks. Now, at approximately
age 2-1/2 years, he shows the severe brain injury from these terrible
events. [R. 22, 121-123]

Defendant Dr. DiCostanzo reluctantly admitted that prolapsed cord “very
likely” caused the precipitous drop in the fetal heart rate. She
testified:

Q. Is it your testimony that you are not sure if this dramatic drop in the
heart rate eight minutes after the prolapse is related to the prolapse? Is
that your testimony?

A. My testimony is that I don’t think anyone can say that it ‘absolutely’
is caused by the prolapse.

Q. Is it very, very likely that it was caused by the prolapse?

A. Very likely. [DiCostanzo deposition, page 172, R. 22, 844]

Thus, even though the defendant tried to evade the question by couching
her
testimony in absolute terms, when pushed, she was forced to concede that
this was “very likely.” Since the law only requires that expert testimony
be given with reasonable certainty, and not absolute certainty, causal
connection is established through the defendant’s own testimony.

Plaintiffs’ expert, board-certified obstetrician Dr. Jeffrey Soffer,
confirmed the causal connection:

It is also my opinion within a reasonable degree of obstetrical certainty,
that there is absolutely no question that the A.R.O.M. in this case
directly caused the cord prolapse, which caused a deprivation of oxygen to
the infant, and the infant’s resultant brain damage. [R. 31]

In what may have been evidentiary overkill, plaintiffs also submitted an
excerpt from the Gabbe, Niebyl, and Simpson’s authoritative textbook,
Obstetrics – Normal and Problem Pregnancies, (2002), “Intrapartum
Complications,” which instructs that:

Cord Prolapse: Cord prolapse refers to passage of the umbilical cord into
the vagina ahead of the presenting part following rupture of the fetal
membranes. … Prevention of iatrogenic cord prolapse can be achieved
by performing amniotomy [rupturing the membranes] with fundal
pressure and only when the vertex [the top of the baby’s head] is well
applied to the cervix. [Emphasis ours] [R. 1038-1039]

This published statement, made without hedging or qualifications, tells us
both that iatrogenic cord prolapse is preventable (“prevention can be
achieved”) through proper technique, and that the cord prolapse herein
could not possibly have happened but for Dr. DiCostanzo’s unconsented-to
A.R.O.M. (“Cord prolapse [happens] following rupture of the fetal
membranes.”) [R. 1039]

========

Mark won $1,500 per month, every month, for the rest of the child’s life.

“In addition, when Christopher turns age 18, the structure will
additionally pay a “college fund” of $50,000.00 per year ($200,000.00
total) to fund his higher education. In addition, the structure will pay
our further lump sum cash payments of
$ 60,000 on 05/24/2028
$ 80,000 on 05/24/2033
$100,000 on 05/24/2038
$150,000 on 05/24/2043

In all, it is anticipated that over a lifetime of 75 years, this structure
will pay Christopher Andres the total sum of $12,680,842.56.”

Remedy for an Intact Belly, Tincture of Time

130,000 unnecessary cesareans are done per year in the U.S. because doctors have been trained to fear a resting phase in active birth.

This is the news report about Dr. Caughey’s study:

While ACOG already recommends waiting at least two hours with adequate contractions in the setting of no progress in active labor, it is routine practice in many clinical settings to proceed with a cesarean for “lack of progress” before those ACOG criteria have been met, according to Aaron Caughey, MD, PhD, an associate professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, and senior author on the paper.

“One third of all first-time cesareans are performed due to active-phase arrest during labor, which contributes to approximately 400,000 surgical births per year,” said Caughey, who is affiliated with the UCSF National Center of Excellence in Women’s Health. “In our study, we found that just by being patient, one third of those women could have avoided the more dangerous and costly surgical approach.”

The cesarean delivery rate reached an all-time high in 2006 of 31.1 percent of all deliveries, according to the UCSF study. Arrest in the active phase of labor has been previously shown to raise the risk of cesarean delivery between four- and six-fold.

“Cesarean delivery is associated with significantly increased risk of maternal hemorrhage, requiring a blood transfusion, and postpartum infection,” Caughey said. “After a cesarean, women also have a higher risk in future pregnancies of experiencing abnormal placental location, surgical complications, and uterine rupture.”

The ten-year study identified all women who experienced what is known as active-phase arrest during their delivery at UCSF from 1991 to 2001. The study only included women with live, singleton deliveries who were delivered full-term.

The researchers examined maternal outcomes such as maternal infection, endomyometritis, postpartum hemorrhage and the need for blood transfusions. It also examined the infant’s Apgar score, rates of infection and frequency of admission to the neonatal intensive care unit, among other health indicators.

The study found an increased risk of maternal health complications in the group that underwent cesarean deliveries, including postpartum hemorrhage, severe postpartum hemorrhage and infections such as chorioamnionitis and endomyometritis, but found no significant difference in the health outcomes of the infants.

It concluded that efforts to continue with a normal delivery can reduce the maternal risks associated with cesarean delivery, without a significant difference in the health risk to the infant.

“Given the extensive data on the risk of cesarean deliveries, both during the procedure and for later births, prevention of the first cesarean delivery should be given high priority,” Caughey said.

Source: University of California – San Francisco

Just a Spoonful of Sugar Helps the Amputation Go Down

This was sent to me by a nurse friend.  It’s off an online email list for nurses.
Gloria Lemay, Vancouver BC
 

<  

Another set of sucrose questions:
 

1)     What is the strength of the sucrose you are using for pain tx
during circs?   25%
 

2)      Do you solely apply the sucrose to a pacifier or do you
administer a prescribed amount?  sucking and sweet are synergistic, so
we do use a pacifier
 

3)     For those using pacifiers, how do you deal with breastfeeding
moms who are adamantly against them?  we tell them it is only during the
procedure and then we throw it away
 

4)     Do any of you use breast milk in lieu of sucrose? Haven’t,  but could
 

5)   Where do you get your sucrose?  Toot Sweet 1 mL twist off single use
vials from Hawaii Medical www.hawaiimedical.com
 

Thanks in advance for your answers! I appreciate each one of you! Feel
free to contact me off-list.
 

Another nurse answers:
I would imagine you can use a gloved finger for the baby to suck instead
of a pacifier.>>

Is it any wonder that we have such low rates of successful breastfeeding in the United States?  Right at the beginning of life we are inflicting pain, comforting with white sugar, and putting latex/rubber into the mouths of these little baby boys.  Nurses who want to end the insanity can join Nurses for the Rights of the Child and get support for being a conscientious objector.

And, finally, here’s what one baby thinks about the idea of amputating his foreskin:Alternamoms baby with finger 

WORSHIPPING AT THE FALSE SHRINE OF WESTERN MEDICINE

WORSHIPPING AT THE FALSE SHRINE OF WESTERN MEDICINE

The data has been there for some time. Electronic fetal monitoring (EFM) does not save infant lives.  The only thing EFM has been proven to do is to raise the number of cesarean operations that are done.  This month, one manufacturer in particular has been named by the FDA as producing a piece of junk that should be recycled for parts ASAP.   See:  FDA Warns of Potential Inaccurate Readings by Philips Avalon Fetal Monitor  Instead of insisting that these malfunctioning devices be trashed immediately to save women and babies from inaccurate readings, Philips Electronics (and the FDA) merely suggests double-checking strange readings against another machine or (if one can be found in the hospital) simply listening with a fetoscope.  Now, my rhetorical questions are:  If the machine is giving false readings of distress in babies who are well, isn’t it conceivable that the machine is giving reassuring readings on babies who are in trouble?  And, what is the point of having faulty equipment around a hospital?

I can recall a birth I attended in a hospital where the decision was made that the mother needed an augmentation of the birth process about midnight.  She was hooked up to a pitocin intravenous drip but not much happened through the night and, when the day shift came on, one of the nurses said “Oh, that infusion pump doesn’t work, it should have been sent down to maintenance.”  This is how you lose all faith in institutions.  Having equipment that you can’t count on has to be draining for the staff as well as having the potential to completely destroy the birth experience for the family. 

Another birth that I attended more than 20 years ago is a classic example of the false worship of obstetrical electronics.  My client entered hospital nearly fully dilated.  Just as we got into her hospital room, the membranes released and the fluid was meconium stained.  The nurse requested a 10 minute monitoring strip to check on the well-being of the baby.  This seemed reasonable and the parents okayed the belts being put around the mother’s abdomen.  The belts were very uncomfortable for the mother and so her husband and I anxiously watched the clock to see

No Science to support the use of these machines  which use ultrasound

No Science to support the use of these machines which use ultrasound

when the 10 minutes would be up and we could remove them.At the 10 minute mark, I went to get the nurse.  She was talking on the phone and motioned to me that she’d be right there.  Another 10 minutes passed and the father took the belts off his wife.  Just then, the nurse walked in and she was furious that he had done that.  She said that she needed to do more monitoring because the baby did not look good at the beginning of the strip.  The father said “The reason the tracing was poor then is that you were moving the electrode around looking for the baby’s heart, but once you found it, the heart rate has been in the normal range.”  The nurse’s response was “Sir, I think I know a little bit more about these machines than you do and I think this baby is showing signs of distress.”  The father said “No, I happen to design and build this type of equipment and I wouldn’t use this piece of junk to even test another piece of equipment.”  It turned out that he was some kind of engineering genius at our local university.  I’ve never forgotten that interaction.  Of course, when the doctor arrived, she got into a big huff about how uncooperative the family was being, too, but the mother birthed her baby fairly quickly so all ended well despite technology.
 

I’d like to see some press coverage of this revelation from the FDA.  The public doesn’t get to see most things that are published in the medical journals or online at PubMed.  These machines are dangerous toys that can harm children.  We have the right to demand a recall and to demand that the company fully disclose on its website.  Right now, the Philips corporate website says:  Quote
 

Reliable monitoring throughout the obstetrical care continuum
Philips Healthcare has a long and proud history in obstetrical care technologies — offering fetal and maternal monitors, obstetrical information systems, and monitors and measurements used during routine and high-risk deliveries.

end quote.

 

If that isn’t blatant false advertising, I don’t know what is.

 

  For further dismaying reading on the hoax of electronic fetal monitoring, here is a published legal paper by Margaret Lent from ten years ago which concludes with this line, “In short, there are no excuses left to defend the continued use of EFM. “

 The Medical and Legal Risks of the Electronic Fetal Monitor
Journal article by Margaret Lent; Stanford Law Review, Vol. 51, 1999

 The medical and legal risks of the electronic fetal monitor.

 by Margaret Lent

 

Electronic fetal heart monitoring (EFM) is the most widely used method of monitoring the fetal heartbeat for possible signs of distress during delivery. Soon after its development in the 1960s, EFM replaced intermittent auscultation as the standard of care in the obstetrical community. However, Margaret Lent argues that the widespread use of EFM is both medically and legally unsound Lent points to a series of clinical trials that demonstrate that EFM does not reduce fetal mortality, morbidity, or cerebral palsy rates. These studies suggest that EFM has a very high false positive rate, and that EFM usage correlates strongly with a rise in cesarean section rates. Similarly, EFM provides no protection in the courtroom. Though obstetricians believe that they should use EFM because its status as the standard of care will protect them from liability, Lent argues that it may in fact expose them to liability given its failings. Instead, she argues that
auscultation is equally, if not more, safe and effective, and is more likely to protect physicians from liability. Lent concludes that obstetricians have an obligation to their patients and to themselves to adopt auscultation as the new standard of care.

 

 

The medical profession depends on the latest medical technologies to provide top quality care and to extend that care to a greater pool of patients. This dependence is all well and good where the method, drag, or device is tested in clinical trials that establish its efficacy and safety. But what happens when new technology diffuses rapidly into mainstream medicine well before it has been adequately tested?

 

The story of electronic fetal heart monitoring (EFM) reveals the problems posed to physicians and patients by the hasty acceptance of relatively unproven devices and techniques. When EFM was introduced in the 1960s, enthusiastic advocates promised that by enabling the continuous, electronic monitoring of the fetal heart rate during labor and delivery, EFM would enable physicians to detect dangerous heart rate patterns and to intervene more promptly than with intermittent auscultation, the long-employed technique of periodically monitoring fetal heart rate with an obstetrical stethoscope. Thus, announced EFM proponents, the device would reduce rates of neonatal illness and death. Based on these promises, EFM became the predominant form of fetal heart monitoring by the mid- to late 1970s.(1) However, experts now conclude that these promises remain unfulfilled and that EFM is, at best, a “disappointing story.”(2) In the twenty-five years of its almost
ubiquitous use, no randomized controlled trial has demonstrated that electronic monitoring does a better  job of saving babies or improving infant health than intermittent auscultation.(3)

 

 

Moreover, studies indicate that the inaccuracy of the technique prompts unnecessary interventions and contributes to the nation’s excessively high rate of cesarean delivery, a major surgical procedure which places mother and infant at greater risk of injury and death than noncesarean delivery.(4) Despite the increased risks, the device remains employed in nearly all American delivery rooms. Continued high use of EFM is often attributed to physician concerns about medical malpractice liability and professional inertia. As one EFM critic has observed: “[Doctors] talk about [abandoning EFM] at conferences and at [medical] rounds and listen intently and all of that, but it’s not measurable in terms of changes in behavior. Everybody’s waiting for the next person to get brave.”(5)
 A quarter century of failure in clinical trials and striking new evidence documenting EFM’s imprecision indicate that now is the ideal time for the obstetrical profession to “get brave.” To ensure the safety of their patients and to preserve national confidence in the profession, obstetricians must abandon EFM and adopt safer, more effective monitoring methods such as intermittent auscultation. Close analysis of the legal and medical consequences of the use of EFM reveals that obstetricians have little to fear in discontinuing use of the technique. Not only is EFM an inferior diagnostic tool in the delivery room, but it fails to offer the courtroom protection obstetricians suppose. Moreover, a physician’s decision to return to safer, effective methods such as auscultation should not expose her to liability. In short, there are no excuses left to defend the continued use of EFM.

* * * * * * * * * * * * * * * * * ** * * * *

 
Added September 2015

    Study showing no value proven for doing so called “non stress tests” before baby is born.
    A U T H O R S ’ C O N C L U S I O N S
    Implications for practice
    We found no good evidence to support the use of traditional cardiotocography
    (CTG), or computerised CTG, in pregnancy for
    improving fetal outcomes. The data are not of high quality and
    lacked power to detect possible important differences in either
    benefit or harm. We recognise that many aspects of maternity care
    may have changed since the trials reviewed here were carried out,
    so new studies are needed to assess the effects of traditional and
    computerised antenatal CTG before they are used in clinical practice.
    http://apps.who.int/rhl/reviews/CD007863.pdf