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

What’s a Poor Midwife To Do?

This question came in to my blog in response to my archived post on the use of Castor Oil. Since it is a subject I seem to deal with daily, I’ve answered it where everyone can join in the discussion. Gloria

QUESTION

Hi Gloria! I am a student midwife, and in my state, women must be transferred to an OB if they have not given birth by 42 weeks. The local midwives (my preceptors) use castor oil as a last resort induction method. They don’t like doing it, from what they tell me, but they feel that, if after nothing else works (walking, sex, black and blue cohosh), it would be better to try castor oil and breaking the woman’s water, than to have a perfectly healthy woman transferred to the hospital.

What is your opinion on this? If you were faced with a similar situation (I should mention that midwifery licensing is strict in Florida, and midwives may lose their license if they do not follow the “rules”), what would you recommend? I do not plan on practicing here in Florida when I graduate from midwifery school, but I’d like to pass along some information to the midwives that I work with. Florida Student

RESPONSE

I am faced with a similar situation in my province. We have registered, government paid midwives who have to play nice with the doctors in order to have hospital privileges, a government salary, and publicly funded malpractise insurance. They have the same complaint “We hate to induce naturally but it’s better than what they are going to get in hospital. . . .” We also have the same mess here in B.C. as the rest of North America. Those membrane stripping, castor oil, acupuncture, herbal inductions don’t work because the woman isn’t ready to have the baby and, then, she gets on the prostaglandin/pitocin intervention-cascade train and the midwife feels so bad. . . but, hey, what could she do?

Canadian midwife with client

Canadian midwife with client

Every day, I thank my lucky stars that they used me as an example to the government of what a “renegade” midwife was. Midwives in my province could only become a professional body if they proved there was a “danger to the public” by NOT having a profession. I got to be the designated “danger” because I had proven for years that I would not lie down with the doctors and side with them against my clients. Obviously, the midwives organization would never have given me a license, even if I applied, so I didn’t have to bother applying. A few of my friends did and they were bankrupted and humiliated by the “professional” body. As soon as the government registrations were issued, we saw these inductions start. So many women in my community have been fooled by this cruel trick.

When the local midwives first obtained registration, there was a lot of righteous conversation about “evidence based” midwifery. The large multi centre trial about 41 week inductions conducted by Mary Hannah of Toronto (1) was pointed to by midwives to frighten women into being induced at 41 weeks. We had never seen this in our province prior to regulation. We had twenty years of experience as lay midwives with many post dates women and had not seen any problems but that experience was set aside in favour of the “evidence base”. Even though the midwifery empirical knowledge did not support Ms Hannah’s conclusions and even though the midwives were extremely conflicted and frustrated by the results of their labour inductions, they still obeyed the medical “evidence”. Then, the “evidence” was shown to be without merit. In 2002, Hall and Menticoglou published a paper in the British Journal of Obstetrics and Gynecology proving that Hannah’s study was wrong (2). Has that meant that midwives in my province are now encouraging women to relax up to and past 42 weeks gestation? Oh no, because now the doctors have kept on with their aggressive policies of inducing everyone at 41 weeks and, evidence- be- damned, they’ll make the midwives do the same thing. Science is trumped by community “standard of care” which basically means “we’ll all follow like sheep and hope the wolf doesn’t catch us”. Now, I don’t hear too much rhetoric about “evidence based practice” among local midwives. There is still a lot of lamenting about “how bad they feel” but the inductions continue unabated. Of course, the midwives don’t feel even 1/100th as bad as the woman who has had major abdominal surgery thanks to their aggressive policies.

I’ll post a link here to the B.C. Government Vital Statistics chart (click on Item 11) which shows that, prior to regulating midwives in 1998, there was an up and down pattern to cesarean rates and the rates remained below 25%. For the last reported year (2011) the rate was over 30%. This means that, since midwifery regulated on January 1, 1998 the cesarean rate has risen and the pattern has been a steadily upward climb. The cesarean rate is the score card of what is happening in obstetrics in any given jurisdiction. We’re obviously not doing so well here in B.C. When the registered midwives were soliciting the government for a professional designation, one of the cornerstones of their bid was that they would save the government money by preventing cesareans.

Cesarean Rates in British Columbia Before and After Midwifery Regulation

Cesarean Rates in British Columbia Before and After Midwifery Regulation

So, in answer to your questions: a)What is your opinion on this? I think it is disgusting that midwives are so cowardly and turn perfectly healthy pregnant women into wounded mothers. And (2) If you were faced with a similar situation (I should mention that midwifery licensing is strict in Florida, and midwives may lose their license if they do not follow the “rules”), what would you recommend? I will not be faced with a similar situation because I would not join an organization where I was made to go against my conscience, my common sense and my promise to my clients. If I was in such an organization and realized that I could not do my work with integrity, I would not be complaining about these ridiculous “protocols” I’d be changing them or resigning in protest.

(1) Hannah ME et al. Postterm pregnancy: putting the merits of a policy of induction of labor into perspective. Birth 1996;23(1):13-9.
(2) Menticoglou SM and Hall PF. Routine induction of labour at 41 weeks gestation:
nonsensus consensus. BJOG 2002;109:485-91.

related post: Castor Oil Inductions
This post was updated on Sept 5, 2014 to reflect B.C. Vital Statistics to 2011
Updated Dec 30, 2014 to include link to “Nonsensus Consensus”

The "Slow Birth" Movement

Somehow, we all got hooked into thinking that “quick was better” when it came to birth. When women tell their birth stories, it seems to be a point of pride to be able to say “I gave birth in 5 hours”, “I barely made it to the hospital”, “even with my first, it was so fast”. We hear these stories and may envy the women thinking that they performed in a fast, efficient manner and we view them as having a coveted talent.

I’ve been observing women giving birth for thirty years and I have given birth three times. From my experience, I don’t think that quick is necessarily a good thing when having a baby. Often fast births afford the woman no time to get her breath and regain her strength. Some women describe their fast births as feeling like they have been whipped around in a blender. In a rapid birth, the woman’s body sometimes displays the symptoms of transition after the birth of the baby (shaking, feeling hot/cold, vomiting). When a baby comes slower, there’s a building up of the intensity of the sensations so that the woman can adjust herself to the process that’s happening and, even though most women would like to shave a few hours off the whole thing, nevertheless, they know they can cope and that they will get to the finish line of birth. When the baby comes slower, the woman often dozes between her pushing sensations and seems to derive a great deal of energy from those short snatches of sleep even though they are interrupted often. The hormones of birth seem to allow the woman to operate in a different domain of sleep, energy and strength. I’m fond of telling women who are tired and discouraged at transition “You’re going to get a big burst of energy when you get the reflex to push” or “you’ll get an energy rush when you feel the baby’s head at your perineum”.

This trust in the process and knowledge that energy can ebb but then be regained in the birth process seems to be greatly lacking in today’s Western obstetrics. Slowing down or taking a long time to dilate is simply viewed as a problem and it’s a problem to be fixed by hurrying the woman’s body along. There’s no such thing as a resting phase, going in and out of the process, or simply a looooonnnnngggggg, slow birth process. This is not allowed and it’s viewed as pathological.
It hasn’t always been that way.

Waiting for the baby

Waiting for the baby

In his book “The Farmer and the Obstetrician”, Michel Odent does a comparison of big agri-business to modern hospital obstetrics. When we see the environmental disaster that large scale agri-corporations have produced and we know that the hospital obstetric system has produced a North America wide cesarean rate of 30% and rising, it’s clear there’s been a severe skewing of priorities and principles. We have to re-order our thinking about farming in order to survive: local organic farms, 100 mile diet, moratoriums on genetically modified crops, co-op gardens, raw diets—all these things have grown in the past few years as the few who knew they were important have held onto the knowledge (and the seeds) for the ones of us who were slow to catch on to the urgency.

Instead of talking about “fast food” that seemed so sensible a while back, we’re talking about slow food. Food that takes time, patience, work and integrity to grow, sow and cook. Some are even talking about “slow money” to fund “slow food”, the kind of financing that doesn’t look for a quick return and a scheme but rather looks to the quality of neighborhoods, children, the air we breathe and the long term future.

For those of us who know there’s something terribly wrong with the state of obstetrics in North America, we must call for a return to SLOW BIRTHING. Birth which understands that some women will wait for several days after releasing their membranes and have no pathology. Slow birth means returning to a time when induction of birth was reserved for very seriously ill women and undertaken with great trepidation. Midwifery would be patient beyond all known limits . . . practitioners only steering the birth process in the most rare cases. We would return to a time when practitioners used to say such expressions as:

“Every birth is different, every woman is different and every baby is different.”
“Don’t let the sun set twice on a woman who is in active labor (past 4 centimeters dilation).”
“Don’t practice “meddlesome midwifery”.”
“A good obstetrician does not pick unripe fruit.”
“A good practitioner has two good hands and knows how to sit on them.”

These are all things I heard when I first started attending births 30 years ago and, now, I never hear them. We must get back to those times when the cesarean rate was below 15% or we will perish. As a society, we cannot withstand the damage that is being done to large numbers of women, babies and their extended families. The idea that we can “turn hospital beds” in order to make maximum use of the dollar cost of that bed is insane when it comes to giving birth.
The notion that a woman can be induced with all the pursuant cascade of interventions simply for the convenience of scheduling staff or room availability is a crime. We must wake up and recognize that giving birth to a baby is one of the most powerful transformative events in a woman’s life. This process is so important to the family and the rest of society that all efforts must be made to have it flow normally. Our priority must be the well being of the newborn baby and the conditions that are favorable to a long, satisfying breastfeeding experience. What we are doing right now with inductions, surgeries and the mass use of narcotics in childbirth is as harmful to the planet as fish farms and DDT. The small band of people who have kept the notion of SLOW BIRTH alive so that society at large can get back to what we know is the holistic way to treat new mothers and babies must be listened to and appropriate action taken. Childbirth is not a frill, it’s not an expendable experience, it’s a fundamental lynch pin in forming the family and, without it, we are doomed to being a sick society.

Helping your client avoid a Gestational Diabetes diagnosis

There is controversy in obstetrics about the diagnosis of gestational diabetes and the testing that is done to ascertain which women are at greatest risk. Dr. Michel Odent has written an article GESTATIONAL DIABETES: A DIAGNOSIS STILL LOOKING FOR A DISEASE? which can be viewed online at http://www.gentlebirth.org/archives/gdmodent.html

Pregnant woman testing blood sugar levels

Pregnant woman testing blood sugar levels

.

Until all the controversy is resolved and a more scientific test can be offered, we are stuck with the glucose tolerance test at 28 weeks gestational age. The mother can look at the list of who is at greatest risk and decide to decline the test if her risk is low.

Women at risk:
– maternal age over 25
– – obese woman prior to pregnancy
– – previous birth of baby weighing over 10# at birth
– – previous unexplained stillbirth at term
– – family history of diabetes (esp. close relatives who became diabetic at a young age
i.e. juvenile onset diabetes)
–previous history of recurrent miscarriages
–extremes of heaviness or thinness
–history of alcohol abuse
–history of anorexia or bulimia

This risk factor screening will only pick up 50% of women who are GD. Therefore, we would be wise to treat everybody “as if” they are GD because the diet and lifestyle changes are good for everyone (preventive health care).

If your client has any of the above factors, urge her to follow a GD diet and exercise program as early as possible and then, if she does take the 28 week test, she will usually sail through it with flying colors.

This doesn’t mean that she can start eating junk food though. I tell my clients that ice cream and chocolate are toxic to unborn babies–there is way too much fat, salt, sugar and caffeine in these products for a baby in utero to cope with.

Whole, organic foods, fresh water, and love are the ingredients to grow a healthy baby.

How can we best serve the health interests of mother and baby?

If you meet your client prior to the 28 week test, you can let her know that she can improve her chances of passing the test by eating healthy, unrefined food for the week preceding the test and exercising every day (a 20 minute brisk walk that elevates her heart rate). You can explain to her that some healthy women who just ate badly (lots of sweet desserts and junk food) prior to the 28 week test have tested positive for risk of GD and then had to undergo the more unpleasant fasting 3 hour blood tests.

If you meet your client after she has been diagnosed as GDM (gestational diabetic mother), I would encourage you to attend with your client at the diabetic clinic where a nurse will give her counseling and nutrition advice. Usually, the woman will be asked to maintain a food diary and daily ‘exercise after meals’ regimen. She will be shown how to test her own blood and may be asked to count the number of times her baby kicks in a 12 hour period.

The philosophy behind the diet is that the GDM needs to control her blood sugar levels at an even rate (also known as staying in the Zone–not getting stuffed or starved) and can do so by “grazing” on small amounts of wholesome food, eaten often.

What foods should your clients avoid?
*sugar (white or brown)
*honey, molasses, syrup, jams, jellies, marmalade
*chocolate, candy
*puddings, Jell-O, fruit yogurts
*desserts—cakes, pies, pastries, iced cookies, etc.
*soft drinks, tonic water
*sweetened condensed milk
*sweet sauces—oyster sauce, teriyaki, plum, sweet & sour, ketchup

Caffeine has been shown to make the body more resistant to the effects of insulin so tea, coffee and all soda pop should be avoided.

Fruit sugar should only be consumed in small portions. ½ a banana, 10 grapes, a small apple are the serving sizes. Milk products are also high in sugar and should be used in moderation according to the advice of a diabetic nutritionist.

    Update: June 16, 2015

Nice compilation of articles about Gestational Diabetes by an Australian doula http://www.themoderndoula.com.au/g-is-for-gestational-diabetes/

A Proven Method for Lowering the Cesarean Rate

Another article in my local newspaper last week bemoaned the fact that the cesarean rate keeps rising and physicians are concerned not only about the high rate of surgery but also the future complications that increase after cesarean surgery.  It’s a well-documented fact that a cesarean can adversely affect a woman’s health for the rest of her life and can lead to catastrophic complications in future births.  That’s one reason why, 40 years ago, doctors did everything in their power to prevent that first cesarean from being done.

What if there was a tried method of reducing the cesarean rate within hospitals?  What if it involved some truly innovative thinking?  What if it had a proven track record and had resulted in a significant drop in the rate of surgeries for first-time mothers?  What if it saved money, recovery time for the patient, and better health for the babies?  Would you think that method would be adopted all over North America right away?  Yes, that would be a reasonable assumption.  Unfortunately, this project was undertaken at B.C. Women’s Hospital, it was a success, and it was dropped once the project was complete with a resulting re-increase of the cesarean rate.  No reason for discontinuing the project has ever been given but i will speculate at the end of this post.

A cesarean is major abdominal surgery

A cesarean is major abdominal surgery


The results were published: Grzybowski S, Harris S, Buchinski B, Pope S, Swenerton J, Peter E, et al. First Births Project manual: a continuous quality improvement project. Vol 1. Vancouver: British Columbia’s Women’s Hospital and Health Centre; 1998.

It was the first phase of a Continuous Quality Improvement project with the aim of “Lowering the Caesarean Section Rate“. Start date was January of 1996. The target objective was to lower the caesarean section rate by 25% for nulliparous women, while maintaining maternal and infant outcomes, within 6 months of implementing solutions. 

Staff from all departments of the hospital were brought together in a brainstorming session to share hypotheses on what was causing the high rate of cesareans.  Many of the ideas thrown out were not under the control of the hospital but, in the end, four practices were identified as possibly contributing to the high rate of surgical births.

1. Women were being admitted to hospital too early (before reaching 4 cms dilation, active labour).

2. fetal surveillance by electronic fetal monitoring (continuous electronic fetal monitoring has been proven to increase the cesarean rate with no improvement to the health of the baby)

3. too early use of epidurals (women who get an epidural before 8 cms dilation are at increased risk of surgery)

4. inappropriate induction (inducing birth before 41 weeks gestational age with no medical indication).

Teams of nurses were assigned to do an audit of hospital records to see if these hypothetical practices were, in fact, as widespread as some of the staff thought.  The audit confirmed that these 4 areas were ones that needed attention.  Task forces were created in each area to use the best evidence and existing guidelines, as well as solutions from other hospitals to improve care at BC Women’s Hospital. Guidelines and other strategies in all four target areas were implemented in the spring of 1997.
 

WHAT HAPPENED?
 
According to published results from the hospital:
After six periods, BC Women’s had admitted and delivered 1369 nulliparous women (first time mothers) with singleton, cephalic, term presentations. The Cesarean section
rate was reduced by 21% compared to the 12 periods prior to implementation. The number of epidurals initiated at 3 3 cms was 64% lower, continuous fetal monitoring was used 14% less, the induction rate had dropped 22% and admission at less than 3 cms cervical dilation had dropped 21%. All changes were statistically significant. Newborn outcomes were unchanged post implementation.”

WHAT’S HAPPENING TODAY (2009)?

It’s back to business as usual at this hospital.  Women are induced, monitored, epidural’ed, and admitted early.  The cesarean rate is 30% and the head of obstetrics is concerned but has no action plan.  Why on earth would this be?  I assert that it is because it is an “up at dawn” battle with the physicians to change their ways.  The gossip that I hear from nurses is that the doctors did everything they could to undermine this project.  For example, a doctor would examine his patient and state “She’s 8 cms dilated, get the anaesthetist.”  Then, later, when the woman had her epidural, someone else would examine the same woman and find her to be only 6 cms.  The doctor would smile and shrug his shoulders, “whoops”.  The same thing happened around the issue of monitoring, induction and admitting. . . trickery to subvert the project and return to their old ways of doing things.

It’s a low tech, novel, innovative approach that had excellent results.  I’d love to see it copied everywhere in North America but it’s a bit like dieting. . . everyone knows how to lose weight (eat less, exercise more) but only a few get into action.  We DO know how to lower the cesarean rate, committed action is needed.

UPDATE: July 2017

A hospital in the USA brings their cesarean rate way down: http://www.stltoday.com/lifestyles/health-med-fit/health/st-mary-s-hospital-has-second-lowest-c-section-rate/article_38258dbb-a906-5e38-9c61-e321c16d6369.html

Marjorie Tew author of “Safer Childbirth?”

One of my heroes in the childbirth movement is Prof Marjorie Tew of Glasgow, Scotland. I’d love to meet her and give her a hug. She came to be a supporter of homebirth even though she gave birth in hospital herself and even though she was highly sceptical when her evidence showed homebirth to be safer than hospital. This is the kind of science that I love—when the scientist holds the opposite belief but can still trust her/his method enough to change beliefs. This book review of her 3rd Ed. of “Safer Childbirth” will give you an idea of what she has done for women.Book

Safer childbirth: a critical history of maternity care. Third edition.
Gavin Young
GP in rural Cumbria and member of the UK government’s Expert Maternity Group, which produced the report “Changing Childbirth”

Marjorie Tew. (442 pages, £15.95.) Free Association Books Ltd, 1998. ISBN 1-85343-426-4.

This book is exciting and makes humbling reading for doctors. Its relevance extends beyond maternity care. Marjorie Tew tells a tale of the abuse of professional power, the use of misinformation and the blindness and bigotry of those who should have known better. Even the very best, like Dugald Baird in Aberdeen, could lose their scientific footing in the headlong rush for doctors to take over and hospitalize childbirth: “if it is accepted that confinement in hospital is safer for certain types of patient, where the risks are high, it must also be safer for cases where the risks are less”.

The shift to hospital birth has been one of the great sociological changes in the industrialized world in the past 50 years. Yet this change took place with almost no evidence to support it. It ought to be a source of shame to those who promoted the shift through the 1950s, 60s and 70s that controlled trials were not considered necessary. Only a few brave voices cried in the wilderness, Archie Cochrane notably and Marjorie Tew.

Mrs Tew was teaching statistics to medical students and whilst using the results of the 1970 Birth Surveys found that the conclusions reached by government (through its specialist advisers) were not supported by the evidence. Despite her unbiased stance and clear presentation of the evidence, British medical journals disgracefully refused to publish her paper until the Journal of the Royal College of General Practitioners finally did so in 1985.1

Tew presents a sad litany of errors which doctors inflicted on childbearing women including: enforced recumbency in labour, induction rates at over 50% and X-rays. “It has been frequently asked if there is any danger to the life of the child by the passage of X-rays through it; it can be said at once that there is none if the examination is carried out by a competent radiologist” (Radiologist, 1937). I would personally add electronic fetal monitoring to this list. It is not Tew but a paediatrician who wrote in 1987 “the recent history of perinatal medicine abounds with instances in which belated controlled trials eventually revealed that the apparent benefits of some widely acclaimed treatment had merely disguised the real extent of its tragic consequences”. Most of this stemmed from a belief that biomedicine would solve all the problems of childbirth, ignoring social and psychological factors. Tew has a lovely example from the Rhondda of 1936, where Ovaltine not obstetricians may have reduced maternal mortality.

We should be grateful for Marjorie Tew for her courage and determination in the face of sometimes vicious opposition. She is in the end I believe too critical of the benefits of specialist care. There may be more balanced views, but Tew’s account is lively and impassioned. Readers ought to buy a copy and pass it on to an obstetric colleague, but don’t expect any thanks.

Reference

1 Tew M. Place of birth and perinatal mortality. J R Coll Gen Pract 1985; 35: 390–394

    Added October 2013

Tew, M. Place of birth and perinatal mortality. J R Coll Gen Pract 1985; 35(277): 390-94
Using the raw perinatal mortality rates (PMRs) from a 1970 British national survey, the hospital PMR was 27.8 per 1000 births versus 5.4 per 1000 for homebirths/general practitioner units (GPUs). This was not because hospitals handled more high-risk births. When PMRs were standardized based on age, parity, hypertension/toxemia, prenatal risk prediction score, method of delivery, and birth weight, adjusted hospital PMRs for each category ranged from 22.7 per 1000 to 27.8 per 1000 while homebirth/GPU rates ranged from 5.4 per 1000 to 10.5 per 1000.
The 1970 survey assigned a prenatal risk score to predict the likelihood of problems during labor. When PMRs for hospital versus home/GPU for the same level of risk (very low, low, moderate, high, very high) are compared, the hospital PMR was lower only at the very highest risk level. All differences, except in the “very high risk” category, were significant. The PMR for high-risk births in home/GPUs (15.5/1000) was slightly lower than that for low-risk births in the hospital (17.9/1000). Moreover, the PMRs in home/GPUs for very low, low, and moderate risk births were all similar, but hospital PMRs increased twofold between categories, which suggests that hospital labor management actually intensified risks.
The percentage of infants born with breathing difficulties (9.3% versus 3.3%), the death rate associated with breathing difficulties (0.94% versus 0.19%), and the transfer rate to neonatal intensive care units for infants with breathing problems who survived six hours (62.0% versus 26.2%) were all higher in the hospital (all p<0.001), further evidence that hospital interventions do not avert poor outcomes. Although no national study has been undertaken since, smaller studies confirm that increasing use of hospital confinement is not the reason for the overall drop in PMR since 1970. In fact, those years when the proportional increase in hospital births was greatest were the years when the PMR declined least and vice versa. (End of quote) Preterm labour study by M. Tew (link to abstract) http://www.midwiferyjournal.com/article/S0266-6138%2805%2980228-1/abstract

Quote from the book, Safer Childbirth by Marjorie Tew:

“The degree of pain in childbirth perceived by a woman depends not only on the physical stimulus, but also on her emotional state and her cultural expectations.
Her perceived pain is less when she feels relaxed, unafraid and reassured by the continuous, comforting support of her birth attendant.
Not all doctors or midwives can inspire peaceful confidence and this is rarely the atmosphere in a large obstetric hospital where the obstetric practices themselves have the effect of intensifying physical pain.”

“Safer Childbirth” by Marjorie Tew, p. 172

http://wisewomanwayofbirth.com/quote-for-thought/