Friday, April 25, 2008

OB appointment #7: 33 weeks 1 day

I have been looking forward to this appointment for days. Dr. Wonderful is very nurturing and I think having Brad gone for a week left me with a bit of deficit in the nurturing / warm fuzzy department. Brad does what he can, but he is only one person and I am needy these days. To be honest, I think Brad enjoys the reassurance too.

Perhaps my expectations were a bit too high because now I am feeling a little disappointed. I got a hug at the beginning and some verbal warm fuzzies, but then he went right to, "What are you going to do about the beta strep test?"

For those that don't know, it is routine in this country (at least in the last 10 years or so) to test pregnant women for beta strep AKA Group B streptococcus or GBS. It rarely causes any symptoms in adults, but can make a baby sick if infected during delivery. In rare cases it can cause serious, long term consequences and even death. If the mother is positive or "colonized" she will be given a intravenous antibiotics during labor. According to the CDC this has decreased the number of cases from 0.7 cases per 1000 live births in the U.S. in 1997 (before routine screening) to 0.37 cases per 1000 live births in the U.S. in 2006 (See note 1) (Interestingly, this is up from 0.32 / 1000 in 2004 - a little antibiotic resistance?)

It seems simple enough . . . just take the test and treat it if I am "colonized". One problem is that the treatment may not be compatible with a home birth. Since my midwife is also a nurse, it may be possible to have an IV. There may also be other options for treatment that aren't as well studied since most people give birth in a hospital and get an IV anyway, why not just add some penicillin to it?

But the issue is even more cloudy. Consider the following:
  • Tests are typically done by swabbing the lower 1/3 of the vagina and the perineum (and sometimes the rectum). The idea is that if a person is colonized either in the vagina or in the rectum (more common) then the person should be treated. I asked my doctor how a rectal colonization could be a problem during labor / delivery and he said that it is swabbed with the theory that a colonization of the rectum could spread to the vagina during the weeks between the test and delivery. Why not test everyone a little later in the pregnancy then? Because some will delivery earlier. Why not make a guess with each individual? My opinion is that it protects the doctor and makes studies easier if there is a "standard of care"
  • The studies I have seen look at the number of babies infected, but don't talk about who gets a little sick and who gets very sick or dies (or how many).
  • Many studies found that preterm infants were the most at risk. What are the risks at full term?
  • Studies have found that the following people are at greater risk: blacks, women under 20, health care workers and obese women. I am none of these. What are my risks?
  • From the land of lies, damn lies and statistics: Prior to routine screening a woman would have about seven hundredths of a percent chance of having a baby get infected. After routine screening (assuming treatment if needed), a woman would have a bit less than four hundredths of a percent chance. Yes, it decreases my chances by about 1/2, but the chances are pretty darn small in the first place.
  • Some studies found rates of infection lower in non-hospital birth. (One anecdotal story of a woman who tested negative for GBS before and after delivery, but the child got infected with GBS and had lasting complications)
Currently my thought is to either not test at all or try to time the test as close to expected delivery as possible (there is only a one to two day turn around time for test results) and only do a vaginal swab. If I test, I will have a plan on how to treat it. Some internet research found that it may be possible to use oral doses or watch the baby closely for infection and give an IM shot if needed (normally the baby will show signs of infection within a couple of hours.). There is also the risk of late onset GBS infection (after three weeks) but whether that infection is picked up from the mother or another sources is even more mysterious.

I don't make this decision lightly. It is hard to go against expected norms - even when the risk is low. I don't like going against my OB's recommendations. I consider myself more than up to the task, but as crazy as this sounds, I find I want to please him. This made the discussion very stressful and has led me to start thinking that it is time to move away from seeing my OB. I don't need to hear about worst case scenarios and how birth is fraught with risks. (See note 2)

I adore my OB, but he is a product of his medical enculturation. He has to believe in his understanding of birth and medical practices just as my midwife believes in her views. Although I believe "the truth" is somewhere in between, I have opted to follow a more natural approach to birth and I believe my mental space is an important factor in that. I need to trust that my body knows how to birth a baby and that a home birth is as safe (or safer) than a hospital birth. At the same time, I know things can go wrong and I hope to have my OB "in the wings", if you will just in case.

To that end, I will make an appointment with my OB for four weeks out when I will be (if all continues to go well) 37 weeks along. At that point, I will discuss it being my last planned prenatal visit with him and ask how he wants to handle the birth. That is, would he like to know when I go into labor, would he like updates or would he prefer contact only if it looks like a transfer to the hospital in imminent. I'm going to miss him being part of this pregnancy, but I think it will be for the best.

1) From this CDC web page
2) This is one of the reasons I am not keen on a hospital birth - the staff are trained to watch for trouble and if you want to feel afraid, just be around people who are fearful - even Stephen King recommends watching scary movies with people to heighten that sense of fear. If a woman is afraid, her labor will stop until she finds a safer environment. Or in the case of a hospital birth, she will get pitocin to artificially keep labor going.


Geohde said...

Good luck with it all Kami, it's always hard with these low-probability but high stakes decisions.


AwkwardMoments said...

thank you for this information- good luck to you on deciding

Summer said...

Seems like this is one of those cases where you just have to make the decision that is right for your situation. You certainly have done a lot of research on it. I think you will eventually come to a decision that is best for you.

jen @ negative lane said...

Just thought I'd mention that my OB only does a vaginal swab. Good luck on whatever you choose.mmzpk

Irish Girl said...

Good luck making these decisions. As always, we must trust our instincts. I know you'll consider all your options and make the choice that is best for you.

Bee Cee said...

This was an interesting read. I have tested positive for Strep B and it does worry should I ever ever get pregnant.

MrsSpock said...

I know Ina May Gaskin is not a huge fan of medicating everyone with penicillin. She has a nice discussion of what she thinks is appropriate in "Ina May's Guide to Childbirth".

We didn't do my beta strep until week 37ish. My OB only does a vaginal swab. Luckily, I was negative, so I haven't been faced with the decision. I think in the end I would have assented to it, though I know the local homebirthers don't- and will use probiotics and herbs to try to get rid of it.