Group B Strep

Group B strep (GBS) is a bacteria that is carried in the vagina and/or rectum of about 25% of pregnant women at any given time. It normally doesn't cause any problems or symptoms in the mother, but when she gives birth, she has a higher chance of passing the bacteria along to her newborn than an non-colonized mother. This can cause GBS infection in the newborn, which can be very serious or even fatal.

Here is more information about GBS infection, screening, and treatment from the CDC. Here is an article that presents an alternative view regarding treatment, from Mothering magazine.

With Littles
I was screened for GBS at my 36-week checkup, via a swab of my vagina and rectum.

I tested positive.

I was devastated. This was the first real curveball thrown at my med-free birth plans. (It wouldn't be the last.) It meant that I needed to get IV antibiotics during labor -- ideally, at least two doses, at least four hours apart, prior to the birth. I didn't like the idea of having to get to the hospital early to ensure I got the first dose of antibiotics in time. I didn't like being required to get an IV. I didn't like that Littles would get antibiotics before she even took her first breath.

I talked it over with Dr. K at my next appointment. She made me feel a little better by saying that I could get a saline lock (also called a hep lock), rather than a constant IV. This would allow me to be hooked up to the antibiotics when needed -- that is, for roughly 10-15 minutes every 4 hours -- and then disconnected, to give me freedom of movement until it was time for my next dose.

She also wasn't overly concerned about changing when I left for the hospital. Since I was a first-time mom, she was pretty confident that as long as I followed the standard 5-1-1 rule for leaving for the hospital (contractions every 5 minutes, lasting for at least one minute, for at least one hour), I'd end up getting there in time for my two doses regardless.

I asked her about alternative treatments, such as a chlorhexidine wash or even declining antibiotics completely. (Even with no antibiotics at all, fewer than 1% of babies born to GBS+ mothers actually develop GBS disease.) She had never heard of a chlorhexidine wash. She said that I could decline antibiotics, but added that if Littles developed any symptoms of possible GBS disease, she would be treated very aggressively. "Spinal taps on a newborn are no fun," she cautioned. I decided that it made sense to do the antibiotics, rather than risk any unnecessary discomfort for Littles.

As it turns out, I had to be induced, and so the GBS thing was not a big deal at all compared to everything that came along with the induction. Induction eliminated any concerns about getting to the hospital in time, and since I had a constant IV for Pitocin, I barely even noticed when they added the bag of antibiotics to the mix.

And, of course, Littles was fine. Hardly surprising. The antibiotics cut her risk of developing GBS infection from about 1 in 100 to about 1 in 4000.

In retrospect, even if I had gone into labor on my own, the whole GBS thing really wouldn't have affected it much at all. I really had no reason to be as upset as I was when I first found out.

With Noob
Some doctors treat a mother who has tested positive for GBS in past pregnancies as being GBS+ for any subsequent pregnancies as well. Early in my pregnancy with Noob, I asked my midwives if they did this, and they answered no. So my history with Littles made no difference: I'd be screened at 36 weeks again, and as long as I tested negative, there would be no need for antibiotics.

When I relayed this to my doula, she told me about a regimen of vitamins and herbs that her own homebirth midwife suggested to fight GBS prior to the screening. It consisted of probiotics, echinacea, vitamin C, and garlic, starting around 32 weeks. All of these things are naturally antibacterial, so they can potentially kill off GBS bacteria in a colonized mother. They also carry no known risks. I figured it was worth a try.

Some people consider this to be "cheating the test." I disagree. If this stuff does in fact kill off the GBS bacteria in advance of the test, presumably it will keep killing off any new GBS bacteria for as long as you continue taking it. For this reason, I opted not to take garlic: It's a blood thinner, so you need to discontinue use of it at 37 weeks, to avoid any bleeding issues during birth. I started on everything else, fully intending to continue taking until I gave birth.

At the time, I didn't know that I'd be switching to homebirth. I made the switch at 36 weeks, so I never did the GBS screening with my hospital-based midwives. Instead, I did the screening with C at 37 weeks. She handled it differently from the OBs I had with Littles:

• C left it entirely up to me as to whether I even wanted to do the screening. She gave me a paper with all sorts of information about GBS screening and treatment to ensure I could give truly informed consent. I opted to do it. In my eyes, there was no downside to screening: Even if I tested positive, as long as I birthed with C, I was free to choose my preferred course of treatment, including no treatment at all. And there was a potential downside to not screening: If I ended up having to transfer to the hospital for any reason and my GBS status was unknown, I'd be treated as positive regardless.
  
• C had me swab myself. It's really easy to do, no need for years of medical school to learn how, honest. And as far as I'm concerned, it's good to minimize how often I take off my clothes unnecessarily :)
  
• C instructed me to only swab my vagina, not my vagina and rectum. Rectums have more bacteria in general, so it's hardly a surprise that women who have both swabbed will be more likely to test positive than women who have only their vaginas swabbed. In case there was any doubt, this is backed up by studies, such as this one and this one. But those studies only looked at the number of women who tested positive from a vaginal swab vs. vaginal + rectal swab, not the actual incidence of GBS infection in their babies. And, well, last I checked, the baby doesn't come out your rectum. The reason generally given for doing the rectal swab is that a woman with GBS colonization in her rectum is more likely to develop GBS colonization in her vagina as well, but if that's the case, wouldn't a vaginal swab pick that up, at least the vast majority of the time?
  
• If I tested positive, C was not able to give IV antibiotics during labor. For better or worse. She offered a couple of alternative options, such as a chlorhexidine wash (which has been shown to be effective, e.g. in this study and this study), various herbal treatments, or no treatment at all, simply observation of the newborn in the early postpartum period. If I really wanted IV antibiotics, I would've had to go to the hospital myself.

C knew I was anxious about the results, so she called me as soon as they came in, even though it was just a day before my next appointment and she could've easily waited till then to let me know.

I was negative.

Of course, I have no way of knowing whether it was the vitamins/herbs that made the difference, or if it was skipping the rectal swab, or if I just wasn't carrying the bacteria this time around. (It does come and go.) Whatever the reason, it was a huge relief for me.

I continued taking everything until I gave birth.

With Q
Since I was with C from the start, I asked her for her preferred GBS-fighting regimen. Hers was similar to what my doula had suggested with Noob:

• Vitamin C (at least 500 mg/day)
• Echinacea (without goldenseal, following the dosage on the container)
• Optionally, garlic oil capsules (following the dosage on the container, stopping at 37 weeks).

Again, I opted out of the garlic, but took the other two, starting at 35 weeks. Again, I tested negative at 37 weeks.

Birth plans

Birth plans get such a bad rap. A common joke around L&D wards is: "When a woman comes in with an extensive birth plan, might as well start prepping the OR for her c-section." And many expectant mothers will scoff, "My 'birth plan' is to show up and have a baby."

Maybe it's the ridiculous name. Any woman who has been through birth will tell you that it cannot be "planned." The awesome (and totally terrifying) thing about birth is that you have to give yourself over completely to your body and your baby. "Plans" be damned.

But a (good) birth plan is not a minute-by-minute account of how you want your labor to go. It's more of a list of philosophies and preferences that you want to guide your labor. The value of a birth plan is not really the plan itself, but the research and discussion -- with your partner, your provider, and any other parties that might be present (e.g. your doula or family members) -- that goes into it.

In many cases, the problem with a birth plan isn't the birth plan itself, but the communication (or lack thereof) around this. It's like writing a plan for a party that includes a catered meal, but not talking to the caterers about what kind of meal you want -- and then being upset when they serve a five-course sit-down dinner, when you were envisioning a hamburger/hot dog buffet. You might conclude, "Party plans are stupid. Nothing ever goes according to plan." But the meal mix-up really wasn't the fault of the party plan...

My current doula wrote an excellent post on birth plans that talks about this in general: http://bellyupbaby.blogspot.com/2011/04/birth-planning.html.

I'll talk about what I've done specifically.

With Littles
My husband and I had never heard of birth plans until we took our Bradley classes. As part of our class series, we had to write our own birth plan. This is what we came up with:

1. I am hoping to have a drug-free childbirth. Please don’t offer any pain medication. My husband will let you know if I need it.

2. I am GBS positive. I wish to have a hep lock for my antibiotics, not a constant IV. [This was added after I tested positive for GBS at 36 weeks.]

3. I wish to be allowed to drink freely and eat light snacks during labor.

4. I would like to be allowed to move around freely during labor. To this end, I prefer to avoid any IVs, with the exception of my antibiotics.

5. Please monitor the baby intermittently if possible. If constant monitoring is necessary, I prefer external monitoring to internal monitoring.

6. I would like to be allowed to give birth in any position that feels comfortable.

7. I would like to avoid having an episiotomy. If an episiotomy is necessary, I would prefer a pressure episiotomy with no local anesthetic.

8. I do not want time limits placed on labor and delivery (e.g. only two hours of pushing).

9. Above all, I want a healthy baby. If any of my preferences above conflict with this goal at any time, please discuss with me, my husband, and my doula prior to performing any procedures.

That's it. Hardly a minute-by-minute "plan" of my labor.

At my next OB appointment (around 30 weeks, I think), I went over this plan with Dr. K. I never showed her the written document. I just asked her questions, such as, "Will I be able to eat and drink during labor?" Thankfully, just about all of her answers lined up with my preferences, and so I went into labor pretty confident that my preferences would be honored, without having to make a big to-do about my "birth plan." In fact, I don't think I even brought a printed copy to the hospital with me. No need.

I'll eventually get around to telling Littles' full birth story, but in short, most of this "plan" went out the window, because I had to be induced at 42 weeks. Still, Dr. K did a fantastic job of continuing to honor the spirit of my preferences, even if she couldn't honor the letter of them due to the induction. For example, I had talked with her about wanting the option to labor in the shower. A few hours into my induction, she breezed into the room and asked if I had gotten in the shower yet. Um, no: I was hooked up to a constant Pitocin IV, constant fetal monitoring, etc. She said to the nurses, "Take her off all that stuff and let her get in the shower." And they did. I wasn't able to stay in there for very long, but it was just the break I needed to keep going. I don't think Dr. K would've given me that break if we hadn't had extensive discussions prior to the birth about my desire to go epidural-free.

With Noob
Prenatal care preferences, from when we were planning hospital birth:

· I want minimal cervical checks prior to starting labor. In fact, I’d prefer not to have my cervix checked at all. If you do need to check my cervix, you can note my dilation/effacement statistics in my chart, but please do not tell me what they are. The only exception is if we start discussing induction for any reason.

· I do not want any sizing estimates performed via ultrasound. My daughter was 9 lbs 7 oz, so I’m fully expecting this baby to be big as well, but I’m also confident in my ability to deliver a large baby. I feel strongly that sizing estimates will only serve to shake this confidence. If you do need to do a sizing ultrasound, please do not tell me the estimated size unless it dramatically changes our course of action.

· I want to avoid induction. My daughter was born (via induction) at nearly 42 weeks. I’m mentally prepared to go to 42 weeks again. Unless there is a strong medical reason (e.g. pre-eclampsia), please do not even mention induction until at least my 41 week appointment.

I started talking about all of these preferences very early on. I think I asked J about whether she'd wait till 42 weeks to induce at my 10-week prenatal appointment :) These were serious dealbreakers for me, and so it was good to confirm that I was on the same page with my midwives right from the start!

Birth preferences:

I understand that birthing a baby can be unpredictable. Ultimately, I want my health/safety and that of the baby’s to take precedence. In all non-emergency situations, please discuss all proposed procedures with my husband and me, so that we can direct the decision making with informed consent.

Labor:

· I intend to have as natural a labor as possible, including freedom of movement, intermittent monitoring, and a hep lock instead of a constant IV. I am hoping to birth without pain medication, but will let you know if I need it.

· I will be practicing self-hypnosis (Hypnobabies). Maintaining my positive frame of mind regarding birth is very important to this process. Please avoid using words such as “pain,” “hard work,” or other words with negative connotations in reference to birth.

· I’m a former Ironman triathlete and approach labor just as I approach an endurance athletic event. I know that keeping my energy levels up and staying hydrated is important in both! Please offer me clear liquids, such as juice and popsicles.

· I don’t mind cervical checks, but please keep them to a minimum.

· I have rented a birthing tub and would like the option to use it. I would also like a birthing ball.

· I hope to birth without the use of Pitocin. If it is required, I request that it be administered following the low-dose protocol, and increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each increase.

· If continuous EFM is required, I prefer external EFM to internal EFM.

· My husband and my doula will be present throughout labor. My two-year-old daughter may be present as well, along with one person (other than my husband or doula) to support her. Please turn away other visitors.

Birth:

· I want to “labor down” as much as possible and wait until I feel a strong urge to push.

· I hope to follow my body’s urges to push. Please do not count or otherwise direct my pushing.

· I would like to push in any position that feels comfortable. I welcome advice on positions that might be productive.

· Please allow any visitors present to take pictures and/or videotape the birth.

· We do not know the baby’s sex. Please allow us to see for ourselves, rather than calling it out.

· I would like to have the baby brought to my chest immediately for skin-to-skin contact. Please delay routine procedures (weighing, eye ointment, etc.) for as long as possible.

· My husband will cut the cord. We plan to donate the cord blood.

· I wish to nurse immediately after the birth and would appreciate assistance with this.

Emergencies:

· If the baby and I need to be separated for any reason after delivery, I want my husband to go with the baby and my doula to stay with me.

Again, most of this was discussed with my midwife ahead of time, to ensure I wasn't asking for anything that wasn't possible. For example, the reason I specified that I wanted access to clear liquids was that my midwife told me that hospital policy didn't allow for eating/drinking freely (which is really my preference). The hospital did have birthing balls and allowed mothers to rent birth tubs, hence why I included a reminder that I wanted access to both of those.

Of course, we ended up switching to homebirth. I didn't even bother showing this plan to C, because everything on it was either her norm (such as not calling out the sex of the baby) or not possible in homebirth (such as a constant IV or Pitocin).

With Q
I have even less of a need for a birth plan this time around, since again, most of my preferences are C's norms (assuming a non-emergency situation), and she also knows first-hand how I act and what I need during labor! There's also no need to write anything down; it's not like I'll need to inform some nurse I've never met before of my preferences.

We did do a brief "birth plan" during our home visit, including things like:

• Who will be present? (Me, my husband, midwives, doula, birth photographer. Also, probably both older kids, along with someone to care for them.)
• Water birth or no? (C assumed correctly that I'd like to try it again, although I don't have my heart set on it)
• Who will catch the baby? (Me! I gave first dibs to my husband, but he has no interest :)
• Who will announce the sex? (My husband)
• Who will cut the cord? (My husband and Littles)

Besides those things? My "birth plan" is to show up (well, really, for C to show up) and have a baby :)

In conclusion
If you're writing your own birth plan, feel free to steal from mine, either in pieces or in their entirety. There are also lots of online birth plan generators, such as this one or this one.

Just be sure that you research every point that's on your birth plan, and understand why you are asking for it. Don't copy my birth plan with Littles that talks about a pressure episiotomy if you don't know what that is and why you might prefer it. Remember, the value of a birth plan is not in the plan itself but in the research and discussion that goes into it. If you don't research a particular point, then you can't discuss it at an intelligent level -- and that doesn't help anyone.