Log onto Squarespace
Archives
« Babies in Bloom GBS Redux | Main | What a New Mama Needs »
Sunday
Jun052011

This is Informed Consent?

Recently, I was asked to view a blog post on the Babies in Bloom site, written by Amber Plyler of Heath Springs, South Carolina. She is a doula, a midwifery student and an admitted “birth junkie.” Amber’s post, now pulled, was entitled “GBS+” and began this way:

“There are many various tests that pregnant women in America are recommended, encouraged, and sometimes coerced into doing. Testing for GBS (Group B Strep) is one of those tests.”

Right out of the gate, this lays out Amber’s prejudice against GBS testing. She goes on to malign routine testing, saying it is a:

“highly inaccurate way to judge if a woman will be GBS+ in labor seeing as GBS results can change depending on the day and you may not be + during labor even if you tested + at 32 weeks.”

While her information is incredibly inaccurate (testing is done between 35-37 weeks, not 32) and she has zero place as a doula to give a recipe for Hibiclens use (incorrectly and dangerously, I might add), the biggest irk I have about this piece and others like it are the promotional aspects that are designed to sway a woman’s thinking towards her own. I certainly share my thoughts and opinions (loudly and freely), but when I’m counseling a woman, I am as middle-of-the-road as I can be, offering each option as clearly as possible so she is able to have all the information with which to make her own decision. This piece by Amber was being touted as an educational piece, something for women to look at as an “option.” Her bias was showing.

If you decide to stand your ground, you’ll most likely be told that you’ll be given IV antibiotics during labor in the hospital –‘just in case’.”

Note the inflammatory language?

Here is my comment to her post:

First of all, it is so far out of a doula's scope of practice to recommend, offer, teach, suggest a treatment for Hibiclens, I'd personally like to see this post removed. If you are a Certified Doula with anyone, you are surely extremely outside the bounds of that contract. 

Secondly, you must live in some crazy world if they are testing at 32 weeks. IF the women are being tested at 32 weeks, their OBs, CNMs and midwives are asking for a buttload of lawsuits and are seriously putting women and babies at risk... if not just the risk of GBS infection, but at risk of not having all the information they need to make an educated decision. 

Thirdly, the Hibiclens wash does not Not NOT go IN the vagina. AT ALL. Suggesting that any douche go IN the vagina, especially in labor and ESPECIALLY with ruptured membranes is asking for an infection/possible embolism. GET YOUR INSTRUCTIONS RIGHT. 

Do you see why doulas aren't equipped to give this information? You think you've got it all wrapped up after talking to a local midwife, but maybe talking to many midwives, some nurses and even listening to a doctor or three would help you have balanced information with which to share with your client. 

As providers, we are so not supposed to shove our agenda down the client's throat. We are supposed to offer options and let the women choose what works for them. One of my major irks about (too many) non-nurse midwives is they 'sell' the treatment they are good at or are allowed to do. All too often, it has zero to do with what is truly safer for the baby, but is all about the midwife. 

I've recommended the Hibiclens wash as well, but after learning even more and talking to parents who've had GBS-infected babies (and learning about two homebirthed babies that died from GBS), I'm much more inclined to recommend the antibiotics. Antibiotics are sucky, I agree, but sick, NICU-kept and dead babies are even worse. 

However, women should be given TRUE Informed Consent. ALL the information; not just the information that's the crunchiest or easiest to employ.”

I hope my message is heard.

Reader Comments (66)

I'm with you that the blog post is both biased and full of inaccuracies.

I think that articles such as these can be extremely dangerous to those who read them and take them to be fact.

I'm glad you wrote the writer to educate her.

HOWEVER, I think it's a little harsh to call the writer out by name. In all honesty, it feels a bit dirty to me. Was it not enough to simply communicate directly with her? I don't quite grasp what there is to gain here.

June 5, 2011 | Unregistered CommenterEmily

You know what bothers me the most about the whole GBS debate? the thought that it's preferable to wait for the baby to show symptoms before treatment. Clearly, any one who thinks that is preferable to wait for a baby to get sick (with a 1:200 risk) is not thinking this through. Think about it......rather than take the antibiotics yourself (and reducing the risk of your baby getting sick to 1:4000), you would rather risk your newborn having to be seperated from you, in a NICU, subjected to spinal taps and IV's, and a very real risk of death or permanent damage.
Personally, I'd rather deal with thrush or a yeast infection than have my newborn in a NICU being poked and prodded and very, very sick.

Another screaming pet peeve of mine is all the advice given on how to dupe the test. I've heard everything from garlic cloves (the mother of the baby in California who died used garlic cloves, if I'm not mistaken) to Clorox douches. Yes. Bleach. In the vagina. To avoid taking antibiotics. Holy shit.

Also, in our area, if G-d forbid a baby or mama transports to the hospital with a positive or unkown GBS status without prophylactic treatment is going to have thier baby in NICU for observation and prophylactics pending culture. What I hear from other, more "authentic" (haha) midwives is the parents can refuse. Sure, they can refuse. And have the hospital social worker, neonatologists, and possibly CPS down their throats for endangering their newborn. Is it really worth having to fight "The Evil Medical Establishment" so soon after birth, when you should be cuddling your newborn and celebrating his life?

And about MWs selling their own agenda according to their skill level, I see it all. the. time. MWs who can't suture convincing others it's not necessary and seaweed is a perfectly acceptable alternative (WTF?). MWs who can't start an IV convincing others antibiotics are not needed. Midwives who can't draw blood saying routine testing is over-rated. AND! Trying to pass off their lack of basic skills as more "authentic" midwifery.

(Don't get me started on THAT whole debate! Who's the more authentic midwife? FU! And your Trust Birth crew! )

June 5, 2011 | Unregistered CommenterColleen, LM

Because she has other things on her site that need to be examined and removed as well.

I'm tired of being told to not name the people I see doing things, Emily. If people are going to write something, they should bloody well have to stand behind them. I do. And I'm called out all the time! It's part of the Net as far as I'm concerned.

Colleen: Gads, we are sooooo sisters! Love you, dear friend.

June 5, 2011 | Registered CommenterNavelgazing Midwife

Barb - I'd really appreciate it if you didn't use my mistake as gratification and use this as a show-off of what you shouldn't do. I read your comments and took them to heart and realized you were correct and I hadn't thought the piece out in it's entirety.

I posted here - Please consider reading and reconsider using me as a platform for what not to do http://blossomingbabies.blogspot.com/2011/06/simple-clarification.html

Also - please understand I don't really use my blog as a doula - per se - I use it for all of my own personal thoughts and feelings in relation to birth and my journey into midwifery. I do not - as a doula - tell people what method to use for what. I support their decision - that they make - and come to on their own. My journey is a long one, I have much learning to do, and am in the very beginning of that journey. I appreciate being told when something is wrong, but don't feel it is necessary to make a spectacle of someone's wrongdoing.

June 5, 2011 | Unregistered CommenterAmber Plyler

But, it's perfect, Amber! I love that you pulled the piece (as I said), but it still deserves to be examined and your mistake is a lot of women's benefit. You are teaching, long before you ever knew you would. I don't look at you with disgust *at all*... but in the same light as I do myself when I was a younger student. I know it's hard to be picked out and used as an example (welcome to my world), but if you're able to look at the greater picture, I know you'll be able to look back and chuckle about this.

The best part of all of this is you SEE where the issues came in! Too many... FAR too many... would just dig their heels in and refuse to acknowledge the discrepancies in what they were writing about. I'm really proud of you, Amber.

June 5, 2011 | Registered CommenterNavelgazing Midwife

Barbara and Colleen, you may be the last hope of the natural birth movement. Thank you for being rational. I'm not (sticky) pregnant yet, but I'm so tired of seeing my friends put at risk by inaccurate, willfully ignorant information designed to serve the illustrious goal of perfect birth regardless of their personal outcome. I may not always agree with you, but times like these, you need to be congratulated. Call the dishonest and irresponsible out. It is the only way to work toward having only accurate information available.

June 5, 2011 | Unregistered CommenterWhatPaleBlueDot

I think the author NEEDS to be called out by name. It is these kinds of "informational" posts on a doula's website that normal people go to looking for information. The doula is looked at as a resource for childbirth "education". It is incredibly dangerous for babies that this misinformation is out there. Thank you NGM for a wonderful post.

June 5, 2011 | Unregistered CommenterAmanda

It's not about letting things go- especially dangerous advice.

I'm just talking about the difference between a teacher giving a student a (well-deserved) failing grade and giving information towards improvement, vs. failing a student, taping a giant "F" to her forehead and marching her around the playground during recess.

I love your blog and admire your fearlessness in combatting the misinformation that's out there- please don't think otherwise.

June 5, 2011 | Unregistered CommenterEmily

Yes, Barb, I will always be thankful when I make mistakes and they are pointed out by more knowledgeable individuals! If I was perfect, and never made any mistakes, there would be no reason for any training - I could just be a know-it-all, and call myself a midwife at that!


I do want to clarify a few things because I'm being made to sound as if these were my own ideas!

The instructions for the vaginal flushes with Hibiclens are not my own as you implied - I didn't come up with that out of my head - it is from several midwifery (not doula, but true midwifery) websites and resources. Gentle Birth is a collection of articles written by various midwives, including studies to back those articles up. This is where I was directed (by another midwife) to the HIibiclens protocol for flushes during labor.

Also - many providers do not follow protocol to test at 35-37 weeks, I, and many clients of mine, have been tested at 32 weeks routinely! It's common practice locally. So to say that I'm wrong in that isn't true. I never said all women were tested at 32 weeks, I simply said that was true in my own experience and in the experience of most of my clients. My ultimate point was that GBS status can change in a days time, so testing much before labor is - IMO - pointless.

And thirdly - I am not handing this information out as a doula. As it clearly states on my blog, the blog isn't a "doula business blog", it is simply my own personal blog documenting my learning experiences, birth experiences, and journey into midwifery - whatever that all entails. You implied I was giving this info out as a doula, and I simply am not. To give medical information would be beyond my scope of practice. It is well within my scope of practice to give evidence based information to a client - showing both sides of a story with proof to back each up - and allowing her to make her own decision. However, where I did go wrong, was not showing all the evidence regarding other methods (ex: antibiotics) for GBS+ women.


I just wanted to point these few things out because you are making it something that it isn't - and I want to be clear that while I am wrong for not pointing out both sides of a coin, I did not employ wrong information intentionally (especially regarding the Hibiclens flushes). I didn't simply sit down and decide to tell all GBS+ women to pour Hibiclens in their vaginas, I sought out tried and true studies and articles from other midwives and used my judgment on what to include in the article.

June 5, 2011 | Unregistered CommenterAmber Plyler

I really enjoy your posts, NGM. I think you are the perfect mix between the natural and technological, which is how I strive to practice as a student nurse midwife. Thank you for your sanity and clear-mindedness! At present, I only practice as an L&D nurse on a high-risk unit, but I should be clear that the Full Term Nursery and NICU would likely do a sepsis workup or prophylactically treat any baby whose mother has a known or UNKNOWN GBS status at term and was not treated w/ abx. I agree with you that abx suck, but what sucks worse is growing a baby for 9 months only to avoid abx for a treatable illness, which may result in the death of your baby. We as pregnant women avoid so much during pregnancy that is known to be harmful to our growing fetuses (alcohol, fried foods, soda, fish, certain other foods, etc. the list goes on)...why would we also choose to abstain from lifesaving abx. that could potentially save the life of our baby? Yes, death by sepsis is fairly rare in the industrialized world, but not too rare that we don't see it happen *all too often*. Let's get smarter about our choices and stop feeding ignorance.

Amber, like you, I am also a doula, nurse and midwifery student and while it's probably embarrassing to have your post called out by NGM, please know that she does this with client safety in mind. She has seen far more than you and I have and when we have our decades of experience like NGM, then perhaps we will also be called to dispute wrong or potentially dangerous info given. It is a cautious line we walk as doulas....and it's so important not to give clinical advice as a doula. When I'm wearing my nurse hat and working with a doula at the hospital I almost always see them practicing somewhat outside of their scope. I agree that if a doula is hell bent on providing clinical advice, she should take the time to study nursing or midwifery like we are doing. Being a 12-hour trained doula isn't going to cut it in a court of law when you are giving advice about GBS treatment or ay other clinical matter. I wish more doulas saw this and acted with appropriate caution.

June 5, 2011 | Unregistered CommenterMaria

Amber, I read the post before it was deleted. You were giving out advice and your sources were not cited. You did not give ANY information out about what the medical community recommends as treatment for GBS. The blog WAS a doula advertising blog. You have just changed it in the last few days. You were directing people there on many online forums as an advertisement of your services and beliefs. I wish I had a screenshot. You were wrong and now to sheepishly sit back and say that you were just quoting other websites, is not taking ownership of your mistakes. Everyone is allowed a mistake but when those mistakes start costing babies their lives, is when you really need to take a good, hard look at yourself and reevaluate.

June 5, 2011 | Unregistered CommenterAmanda

I do have screen shots.

Back-pedalling is terribly unattractive.

June 5, 2011 | Registered CommenterNavelgazing Midwife

You are 100% Amanda (and NGM) since you mentioned back pedaling.

All of my doula information is on my blog - my services offered, ect.. But a disclaimer is given (and I wasn't under the impression I NEEDED one until this was brought to light) stating that I, as a doula, am not allowed to give medical advice and this blog is not intended to do so. When I started the blog, it wasn't intended at all to be a "doula blog" thought i was perceived that way. It was just all about life in the birth profession - learning and growing - changing from myself, to a doula, to a midwife and learning along the way. Part of learning is making mistakes and I know that. However, I wasn't thinking of those that my misinterpret my own thoughts as medical advice - and I can now see how that might happen! And I see that by the NGM pointing out my flaws on that post, and therefor changed it. However, it isn't to back-pedal I can assure you both as I stand firm in what I say and accept when I am wrong - that should be clear! I put up that statement for future reference however. Hopefully that can be understood.

June 5, 2011 | Unregistered CommenterAmber Plyler

And Amanda - I am not sheepishly sitting back and saying I took that info from other places to cover up my own mistakes!

I did indeed take that Hibiclens protocol from several midwifery sites and can happily provide references to that.

The GBS testing information I took from my own experience - I've been tested twice at 32 weeks - as have many, many of my clients in our area.

That is not blaming - it is fact. I really did piece together that article from multiple sources. I'm not using that as an excuse for my own mistakes, I can assure you. I own my mistakes.

June 5, 2011 | Unregistered CommenterAmber Plyler

This doula is a midwifery student? What kind of program? Displaying this kind of ignorance on so many levels would get her a performance review if she's in a CNM/MSN program, which I bet she's not.

June 5, 2011 | Unregistered CommenterJane Doe

i am sending you a big HUG for this post NGM ! thank you for standing up :)

June 5, 2011 | Unregistered Commenterliz p

Thank you, Barb :)

June 5, 2011 | Unregistered CommenterBrandy

THANK YOU for is post. and THANK YOU for trying to set the record straight about Hibiclens and ABX. The denial of ABX for GBS+ kills, and it saddens me to see so many people deny this.

Amber- you couldn't have read and researched and come to the conclusion that Hibiclens douches are a good idea. Especially in place of ABX, which has been thoroughly studied, used for years, and found to WORK. Not ONE study says H douches shield be used! A few studies have tried Hibiclens wipes (not douches, which are a very bad idea infection and embolism wise) but in developing nations where it is seen as a worth a try, hoping it's better than absolutely nothing.

Should we look to the worst, most deprived conditions in the world for our health care? I should think not. We have access to ABx, and they work, what's the problem?

Again, THANKS for this Navevlgazing MW. Calling people out that give bad info is very important.

June 5, 2011 | Unregistered Commenterstaceyjw

You didn't provide references Amber. You stated it as opinion with a bold arrogance and obvious anti-medical establishment agenda. To now say that you would provide references is putting the blame on others for your wrongdoing. You can NOT speak from the experience of your own 2 births plus the maybe dozen clients you have doula'd for as evidence that the standard is to test at 32 weeks. Surely you realize that sample size is incredibly inaccurate. Advertising your blog on natural parenting sites such as MDC, DS, and the like, will allow traffic to your blog from all over the world. There are still many posts on your blog that are horribly inaccurate, as NGM pointed out. The blog should be removed and the link to it should not be advertised. You are spreading misinformation and NCB agenda, which includes your distaste for the medical community.

June 5, 2011 | Unregistered CommenterAmanda

I was one of the commenters in Amber's original post on her site. When shown CDC guidelines, given other comments from obviously more learned folks, and offered that she really must re-educate herself about this topic (and several others) before touting advice to anyone, her reply was even more concerning. She simply dismissed that she may not have all the information, and because she has seen things done her way "many times," she clearly knew better than others. She is also tromping around the MDC forums as an expert, doula, midwifery student (set to take NARM in 2/12, then 8/12, with no known preceptor?). It is truly frightening to me that Amber is advising expectant moms in any way, because she clearly has major educational gaps. My sincere hope with this international light NGM has shown on this issue, is that Amber takes several years to humble and educate herself in a thorough, intense, difficult doula re-training program and learn her boundaries. Midwifery? hmmmm.....

June 5, 2011 | Unregistered CommenterOne "anonymous"

I can't speak entirely to what the doula wrote since I didn't see the original, but I didn't see that the opening quoted line as prejudiced. She was quoted as saying, "recommended, encouraged, and sometimes coerced into doing," and that is true. GBS is among the recommended tests, I didn't see it quoted that she referred to GBS as a "coerced" test, but I will say that it is in some settings absolutely coercion. If they don't test, they don't get to birth there. And if that is their protocol, they own it, that's fine--women know it, and they can choose accordingly. I'm not judging whether any practitioner or institution should coerce a GBS culture, but it's a statement of fact that some do. As well as some recommend or encourage, and she included all those words. I just felt that opening really was setting up this entire post as inflammatory against someone who--whether or not she posted other inaccurate information, has already apologized and removed it. I feel badly that she's being taken to task with this part:

"If you decide to stand your ground, you’ll most likely be told that you’ll be given IV antibiotics during labor in the hospital –‘just in case’.
Note the inflammatory language?'

Well...honestly, the inflammatory language that my eyes see, Barb (based only on what I see here since her piece is gone), is actually yours. She is accurate in that particular quoted statement as well. If the woman "stands her ground" (?context? I presume on refusing GBS testing), she will indeed be told that she'll be given IV abx in labor just in case. It's true. And women need to know that. It actually can be helpful, because some women would be negative, and NOT testing can lead their caregivers to make recommendations or decisions based on presuming positive. I found her statement factual, but then the adding of "note the inflammatory language" can make some readers think they should be seeing something in there that just isn't there (at least in this context).

But semantics aside, chlorhexidine is absolutely a viable potential option. It's not really unbiased informed consent if one truly recommends antibiotics...or doing nothing...or chlorhex. I don't think there's anything wrong with recommendations, because that is partly what they pay us for, and we are SUPPOSED to know more than they do about certain facts. But then we need to own and be clear that we are recommending something because we believe it is better vs verbally saying we are middle-of-the road, not influencing them by saying that we are giving all sides to the story so that they can make their own informed decision. If it's something we aren't middle-of-the road on, we need to take that stand and own it. Just SAYING that we are out loud may make some people think they are truly making their own decision when there's really the undercurrent of "you can do what you want, but you should do it this way."

I try to give unbiased facts to clients, and I do want them to know as many sides to the decision as is currently available. My handout on GBS is very lengthy, and when women ask what they should do, I tell them I cannot make that decision. When they say that they heard that GBS can come/go, so "what's the big deal," I say that GBS has killed babies. Dead is a big deal. AND...they also need to know that antibiotics have made people very sick and have killed people, too. Those risks are low, but they exist. Some people are told, "GBS in babies is a completely preventable disease, just take the antibiotics!" And that is not true. The incidences of GBS-sick babies were significantly lowered with IV antibiotics, but they were not eradicated. And insufficient study was put into the RISKS of antibiotics to the baby and mother at the time poilcy was made, and now research shows us that we have a whole new problem of babies getting sick 1-2 months postbirth because they were dosed as fetuses.

Parents need to know that IV antibiotics should be a very serious decision for both the mother and the baby. It does set the baby up for potential of late-onset GBS or e.coli infections as well as a host of other issues. It prevents or inhibits the laying down of healthy gut bacteria--which can be a problem that follows them for life--and their skin will resist any healthy bacteria left from the mom's vagina (if any really is). THAT is also a very big deal. In my clinic, I work with babies who have severe digestive issues or apparent malabsorption who were dosed with IV antibiotics as fetuses, and I have to wonder how that start to their lives affected them. Unfortunately, there is no study that I know of that is following these babies long-term who received IV antibiotics as fetuses to report what sorts of ongoing problems they may have that affect their quality of life. While I think most parents would prefer a living, gut-sick, immunocompromised child over a dead one, they do need to know both sides so that they can make a truly informed decision.

Chlorhexidine, while not a perfect solution, has been found to reduce GBS colonization, and it so far from studies, appears to not interrupt lactobacillus which is a huge deal for baby's later health. Chlorhexidine is also a good option for women who have a very short labor since they need antibiotics twice four hours prior to birth. So for people who think long-term health and who want both the risks and benefits, IV anbiotics should be a very serious decision to weigh. Either way, there are risks of illness or death, and for informed consent to be perfectly honest, women need to hear that as well. I am not suggesting that chlorhex is the perfect answer. That is not up to me. But neither are the IV antiobiotics given to so many women. This is not crunchy information. We have an international health crisis directly as a result of the rampant overuse of antibiotics, and science is too late in paying attention to it--but they ARE finally paying attention, slowly..

As for administration of chlorhexidine in labor...I have never heard that it does not go in the vagina. Everything I have ever read including the original studies refer to it as either a douche or a flushing. The vagina is the very organ we are trying to "clean," so if not in the vagina, then WHERE? Of course, high-pressure douching is not recommended for any woman at any time, but mild douching/flushing/washes/lavage (whatever people want to call it) is exactly what IS supposed to happen (or so I thought)--unless you have some newer information I have not seen. I see bold insistence that it does not go IN the vagina, but there is no mention of where you believe it SHOULD go. Your own previous post on chlorhex for GBS did cite the various studies referring to it as a douche or a wash, and your own recommendations to clients were for it to be a "shallow douche." http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2010/6/16/chlorhexidinehibiclens-vaginal-wash-info.html

As concerned as you are, Barb, with people taking that doula's possible inaccuracies as fact, I'm concerned that some homebirth women (or even hospital birth women who THINK they are taking the decision seriously and caring for it at home and refusing antibiotics at the hospital) will read this and not know that if they choose the chlorhexidine option, they do indeed need to wash their vaginas...and the entire vagina is IN, so I agree with you that people need to get their instructions right. if they do not put the wash IN, then how else do they get it IN the vagina?

June 5, 2011 | Unregistered CommenterVickii

I didn't see the post on the other site before it was deleted. I have, however, seen the Hibiclens Discussion post in this blog, and even though you (NGM) stated that douching is not part of Hibiclens in this post you stated differently in your previous post:

'So, I am offering you the option of IV antibiotics, either with my giving them or your going into the hospital to receive them (and birthing there) OR the chlorhexidine wash (which includes a shallow douche as well as a wash).' (quoted from your letter in Hibiclens Discusion).

I think it's great for bloggers, professionals, etc to have feedback but I don't agree with the entire post to her. If her information was incorrect, correct her in an appropriate way but speaking to someone in such a way isn't right.

As far as informed consent, if any woman looks to one resource (doctor, midwife, website, book, etc) for information on what to do if.... then that should be her responsibility not everyone else's. Is it any better for an OB to require antibiotics or refuse treatment at all, it happens all the time, and women need to start taking responsibility for any misinformation out there, and find what is best for them.

Also, I am a GBS carrier. Despite this I chose, with careful discussion with a few different midwives, to ensure my immune system was well taken care of, going into labor we monitored for any sign of infection, and decided if my water was broken for an extended time I would go to the hospital for abx. Antibiotics at home in my area is not an option, and I would not give up a home birth. I also did the Hibiclens wash.

June 5, 2011 | Unregistered CommenterJKruger

I need to take some classes in blog writing because these comments are *totally* missing the point of the piece! I am NOT writing to contraindicate the Hibiclens (although I am revising my previous stance, but am not throwing out the Hibiclens with the baby), but writing about the way "counseling" is done on-line and with the care provider. I seriously missed my mark!

The original instructions, quoted from a homebirth midwife were blah blah "warm water, mixed in a peri-bottle gently squirted into the vagina every six hours in labor. There is loads of data to support its effectiveness equal to the IV antibiotics protocol in the USA but this research is totally ignored here due to the widespread use of IV in labor in the United States. After all, it can't possibly be any good if it is from Europe!"

Maybe more of the original post needed to be heard to catch the tone? Perhaps we're hearing different tones now? I wouldn't leave out that distinct possibility.

Re: the "douching," the instructions I gave on my paperwork... I'll accept that I did say "douche," but further explain to *not* push the water *into* the vagina, but to allow the water to wash the introitus and labia. Perhaps *those* instructions were the wrong ones! If that's the case, I withdraw all encouragement to use Hibiclens if there is water/soapy water pushed into the vagina.

But, once again, this was not the purpose of this post. Bad on me for missing the point so enormously.

And, Vickii, re: advising clients, that IS a midwife's responsibility. It is *not* a doula's and the OP is a doula and midwifery student, not a midwife.

June 5, 2011 | Registered CommenterNavelgazing Midwife

Staceyjw, please do not be so harsh on others when you yourself do not have the facts. I do not know the doula blogger in question, and I am not covering her or anyone else, but people are jumping all over her about her "inaccuracies" when some of you are then retorting with your own inaccuracies. Chlorhexidine (hibiclens) as indeed been studied AS A DOUCHE. The protocol is written up as a DOUCHE. Women do need to be told to not be forceful, of course, but it is for a vaginal rinse/douche/lavage/whatever you want to call it. It HAS been studied. It is NOT standard of medical care in the United States. Douching is NOT evil. It can be a helpful way to clean or rebalance an imbalanced vagina, and of course, good technique is to be emphasized, but it's not like it's an embolism waiting to happen, for crying out loud.

And nobody here is discussing the risks of antibiotic overuse AS WELL as of GBS. Current standards for GBS testing and for IV antibiotic treatment are NOT a panacea cure-all miracle. I'm totally comfortable with someone aligning with the current medical standard for themselves, but if we're going to rank on someone getting facts straight, we should have our own facts straight first.

June 5, 2011 | Unregistered CommenterVickii

JKruger...I'm confused. Can you not have a hb as a GBS + mom? What if you have a nurse-midwife administering abx the same way it's done at a birthing center? Does this assume you are only willing to birth with a CPM at home or nothing at all? Genuinely curious here.

June 5, 2011 | Unregistered CommenterA reader

Hopefully everyone is reading the comments, though it doesn't appear that way judging by a few of those commenting

As I've stated repeatedly, I appreciate the correction from the NGM regarding showing both sides of a situation being important. If I am presenting a piece as anyone (doesn't have to be as a doula, or a student midwife, or a midwife, or a nurse), it is always best to show both sides even if the piece is intended to just serve one purpose.

Regarding giving such information out as a doula - I am not doing that. Never would I go up to a GBS+ client and tell her to not get IV ABX, but to squirt this up her vagina. Never. While the blog originally may have appeared to be a "doula blog" (and it did seem that way I agree!) I never meant it to be like that. I wanted it to just be a blog about pregnancy and birth in general, and my worries, fears, and concerns. A blog about my learning journey from a person, to a mother, to a doula, and finally to a midwife. I've changed the wording and taken out all of my business information so that it no longer appears that way to avoid any further confusion, as that is not my intention for the blog itself.

I've stated numerous times where the information came from, and will be checking over the credibility of those sources and researching a little more. I'll be working on the wording of my writing as well so as to avoid confusion.


Hopefully that clears some more things up for those who may not have caught all that in the comments the first time.

Specifically in question:

Amanda (and the NGM) what other posts do you feel are wrong and giving misinformation on my blog exactly? I have several "fun" posts, and my birth stories, along with some midwifery education and cesarean information - but for what I know - all of that is accurate and the other posts are opinion.


"anonymous" - I'm not sure who you are, but you must know me personally or we've talked VIA email or such or you wouldn't know this much about my personal journey to midwifery. The reason I gave other links to the CDC protocol is because I most definitely, along with many others, do not take the CDC's word as gospel and do not follow it. The CDC has a set vaccination schedule, yet I don't follow it. My children are not vaccinated despite what the CDC says. And in regards to MDC, I post there several times a week, but certainly not as an expert. I do not see myself as an expert in birth most certainly! I'm learning! And you are quite right - I'm hoping to sit for the NARM in August 2012. Though now, it may be later because I was told SC is changing the requirements to say that your apprenticeship must be done with a CPM and I'm currently working under both a CNM and an OB on occasion as well. And in regards to giving information to expectant moms - check the internet - in real life - anywhere! Almost anyone dishes out "medical information" or opinions to expectant mom's. Do you think everyone should just shut up and not talk about anything? I agree I needed to research more, and admitted that. How is that so wrong and horrible? I'm fully aware of more research needs to be done, and fully aware I need to show both sides of a coin, but to say I shouldn't be talking to anyone in relation to these things is a tad over the top, no? And your hopes I take several years to humble myself - I have several years to go yet! Tons of humbling, tons of learning, tons of mistake making I'm quite sure!

June 5, 2011 | Unregistered CommenterAmber Plyler

I do know what a midwife's, doula's and physician's responsibilities are--and I do know that not all members of each profession are competent. I was referring to midwives advising in response to you saying you are giving unbiased information but yet favor antibiotics (we could always argue...can any of us give truly unbiased info, I don't know if we truly can). I do not know the doula blogger in question or what she wrote in context. I was only responding to what was written here.

I don't understand the ardent fears about douching. The research has NOT studied washing the vulva and introitus, so if someone recommends that, they are not following the research that has shown this protocol to reduce GBS (and other bacterial) colonization and GBS-sick babies. The protocols resulting from the research specifically state DOUCHING or VAGINAL rinsing or lavage. Washing the introitus is NOT the same as washing the vagina. It's just really important that readers know the difference, what's been studied and as much about risk v benefits that we currently have available.

And while I still think women should know the standard of medical care and be offered it in hospital or at home as well as have the right to refuse it and practice alternatives, they should also know that there is speculation as to whether or not the research stating that IV antibiotics during labor really does reduce neonatal GBS infection. A Cochrane database review disputes whether this is actually validated evidence or not. I am not wise enough, rich enough or powerful enough to be the one to research or refute or validate IV these studies, but the information is out there for all to review.

June 5, 2011 | Unregistered CommenterVickii

Amber, just because you don't agree with the CDC does not mean it doesn't set protocols for commonly accepted standards of care that EVERYONE working with pregnant mothers ought to know about. As a midwife you will have to interface with obstetricians and nurse midwives in a professional manner. Sticking your head in the sand about something you don't like or agree with will not earn you any professional respect or support when you need it for your clients.

Curious....just how are you planning to become a Licensed Midwife without an Apprentice License first?

June 5, 2011 | Unregistered Commenteranother "anonymous"

Amber, you completely missed the point. Giving out such advice when you are not even a certified doula, along with the fact that you barely started the CPM program online, just proves that you have no earthly idea what you are talking about. That kind of arrogance is what kills babies. Would you like to share the non-accredited, online program in which you are studying?

http://midwifetobe.com/

This is the kind of joke program that makes "birth junkies" think they can catch babies safely and without intervention. You are spewing all kinds of misinformation to online groups and when called on it you continue to sheepishly retort that you were just copying what other midwives have said.

June 5, 2011 | Unregistered CommenterAmanda

I think a few of you need to further read into the available research on the GBS topic including the updated CDC protocols, because it's obvious some of you do not actually have all the information.

Although I don't have enough information to know whether I would have agreed or disagreed completely with the doula's blog post, I have to commend her on her humility and professionalism here. Already she has some excellent traits as a midwife. The way she was publicly mocked and berated by several (most of whom actually posted inaccurate information themselves while berating her allegedly inaccurate information) was both disheartening and embarrassing to watch. I'm not sure I would have exhibited the grace she did under such attack. Believe it or not, it IS possible to point out errors--and possibly even teach some good--in a way that is not so destructive.

June 5, 2011 | Unregistered CommenterVickii

Thanks so much for your comments Amber, as exhibited in this post, not just you, but many people, including me, have much to learn about GBS. You have brought up different issues and it is important to question standards of care. Many docs do perform early screening as do, mostly in southern CA area, home birth midwives. Some believe that they can rebalance the vaginal flora, some are testing in case a mother delivers early or even in certain cases to prevent mothers from delivering early. The test is only valid for 4-6 weeks according to various sources, so an early test means to retest.

I lurk here now and then and am incredibly upset that this blog would be taken as informational as well, meaning the one that I'm posting upon.

And as far as antibiotics being the end all to the answers for GBS. GBS is a deadly disease especially for preterm babies (who are born before the mom is tested for her GBS status). It can be a deadly disease for babies born to mothers who tested positive or negative as well. However, per http://www.ncbi.nlm.nih.gov/pubmed/19588432, antibiotics have not proven to be effective in reducing the number of babies that die from GBS. And not only that there are a growing number of babies that are now facing strains of GBS that are antibiotic resistant. Sure that may only be 3-4%. And yes, antibiotic therapy has reduced the number of babies with early onset GBS disease, but how many more babies get sick from e coli or other bugs and then their immune system is void of good flora to fight?

Questioning this system needs to happen, and yes, it is not our responsibility to give the answers to women, but it is our responsibility to bring evidence based information to the surface (and in some ways even questions like in this blog) so that women can decide for themselves what they see as a risk. They may have just a little less of a risk of dying driving to get the GBS test then their baby dying of GBS, but to bring that up would be ludicrous.

And, from the new CDC protocols, when a woman's GBS status is unknown, no longer will they use antibiotics prophylactically. It is now policy to...........observe the baby for signs of GBS. Imagine that. And they'd be doing that if she was positive or negative or had antibiotics anyways.

Also the problem with the current methodology is that we are treating the symptoms of a body that is out of balance rather than rebalancing the body. That is of course, not the point of this blog.

Finally just wanted to address the fact that I'm sorry that this discussion has been directed at a specific person posting...and by name. I believe it could have been done with more integrity had it been addressed off-line and Amber had remained nameless.

June 5, 2011 | Unregistered CommenterNicole

Unfortunately, I don't live in the US, and where I do live it is not an option to have a midwife give antibiotics at all. Even within the hospital they only monitor the mother, and administer medications if the OB approves it.

Home birth here is neither illegal nor supported, midwives who do offer home births (even CNM's that studied in the US or other developed countries) do so under the table and risk being shunned by the medical community/government. They are especially not allowed to carry or prescribe medications (except what you could get yourself at a drug store).

It really is a sad state here for anyone wanting more natural options.

June 5, 2011 | Unregistered CommenterJKruger

I can't help but wonder...

Who directed the author of this blog to the post by Amber? Was it Amanda? I work on a website online and there has been some discussion between Amber and Amanda there for some time. Neither one of these two ladies has much in common.

I can't help but think that perhaps this other woman brought attention to Amber's blog post in the hopes of something being written about it... I find it incredibly odd that this woman posted a link to this blog entry on the website I work at the very day this info is posted to this blog. One might would think she might have had a hand in trying to stir things up 'eh?

To provide information is one thing. A post sharing these same thoughts could quite easily have been made and names omitted. To contact a person you do not agree with and share information is one thing. To publicly use their name and then post your opinion is another (and let's face up to the fact that the use of hibiclens in the matter being discussed here is just opinion is it not? Is it not a fact that it has been suggested to further study the use of hibiclens during labor and delivery? I swear I read that lately.)

As far as the hibiclens, I have been advised to use it as a wash by 4 different midwives. (Three of which were not "just" lay midwives either but women who are licensed!)

I'd say it is a safe bet that not all midwives agree on the "proper" use of hibiclens.

I sure hope that the woman on the website I work on didn't just use this blog and it's author in an attempt to discredit a doula she never seems to agree with...

June 5, 2011 | Unregistered Commenter~happy2Bamommy~

nevermind that the information is ridiculously inaccuarate- so is her grammar! Lord have mercy:

“There are many various tests that pregnant women in America are recommended, encouraged, and sometimes coerced into doing"

Good god gurl, stop the madness and get a grammar book as well.

June 5, 2011 | Unregistered Commenterguesty mcguesterson

I have witnessed OB professionals of all backgrounds (CNMs, LMs, RNs, Peds, OB, Neonatology, MFM, CB educators, and Doulas) of misleading parents on GBS facts either due to their own lack of keeping updated on the latest evidence or to promote their own agendas. There is no excuse for anyone student or professional promoting inaccurate information on a deadly disease.

Here are facts on GBS from the CDC that have been endorsed by the AAP, ACNM, and ACOG.

In the U.S., group B strep is the leading cause of meningitis and sepsis in a newborn’s first week of life. Incidence of GBS newborn sepsis in 1990 prior to routine screening was 2:1,000 births in 2008 after routine screening it was reduced ton<.05:1,000 births. Approximately 25% of ALL pregnant women carry group B strep in the rectum or vagina. Group B strep bacteria may come and go in people’s bodies without symptoms. The 2010 CDC’s guidelines recommend that a pregnant woman be tested for group B strep when she is 35 to 37 weeks pregnant. Women in preterm labor should receive IV antibiotics. Women with threat of preterm labor should be tested, with a positive result treat when active labor but preterm with a negative culture no antibiotics needed if active labor begins. Retest at 35-37 weeks if undelivered. A pregnant woman who tests positive for group B strep and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease, compared to a 1 in 200 chance if she does not get antibiotics during labor. There are about 7,600 Group B strep cases annually in newborns, and death occurs in about 1 in 20. The antibiotics used to prevent early-onset group B strep disease in newborns only help during labor — they can’t be taken before labor, because the bacteria can grow back quickly. Intrapartum antibiotic prophylaxis is recommended for:
Women who delivered a previous infant with GBS disease
Women with GBS bacteriuria in the current pregnancy
Women with a GBS-positive screening result in the current pregnancy
Women with unknown GBS status who deliver at 37 weeks or > AND have intrapartum temperature of 100.4°F or greater, OR have rupture of membranes for 18 hours or longer should also be treated. Adequate treatment of intrapartum antibiotics is EITHER penicillin or ampicillin 4 hours prior to birth. Antibiotics should be continued every 4hours until birth. If allergic to penicillin a sensitivity for alternate antibiotics should be done with the culture. Infants without signs of sepsis that are 37 weeks or > who are born to GBS positive mothers who did not receive adequate antibiotics AND are afebrile AND membranes ruptured < 18 hours can be observed without septic workup. Anaphylaxis associated with GBS prophylaxis occurs but is sufficiently rare that any morbidity associated with anaphylaxis is greatly offset by reductions in the incidence of maternal and neonatal invasive GBS disease.  Estimates of the rate of anaphylaxis caused by penicillin range from 4/10,000 to 4/100,000 recipients, as many as 10% of the adult population have less severe allergic reactions to penicillin. GBS isolates with confirmed resistance to penicillin or ampicillin have not been observed to date.  There is evidence of increasing prevalence of resistance to clindamycin, and erythromycin The reported increases in antibiotic-resistant early-onset infections in a few studies are not of sufficient magnitude to outweigh the benefits of intrapartum antibiotic prophylaxis to prevent perinatal GBS.

Here is where my personal opinion starts. I have witnessed healthy term infants of uncomplicated birth die from GBS sepsis prior to the initiation of routine screening. GBS is a very heartbreaking disease to witness. Once symptoms appear it kills quickly even with treatment. There are some limited studies on the beneficial use of hibiclens and garlic to reduce GBS transmission at birth. In order to be clinically relevant larger studies need to be done. Who would fund these studies? Hibiclens is a very potent antiseptic and says clearly on the label not to be used on mucus membranes. Isn't destruction of healthy vaginal flora one of the reasons antibiotics are avoided? Hibiclens has been known to cause severe burns on mucus membranes. Mucus membranes easily absorb drugs systemically and the ingredients of Hibiclens are toxic when ingested. Why would such natural remedy minded people want to use such a potent antiseptic? We recently went to a workshop with Ina May and the Farm midwives. We had a very interesting AND non confrontational discussion among a variety of maternity providers. What we recommend at our birth center is very similar to what the Farm midwives recommend: CDC guidelines for screening and treatment along with the use of probiotics developed specifically for vaginal flora to reduce the incidence of GBS positives. For moms who get IV antibiotics high dose probiotics and infant probiotics immediately after birth to reduce yeast and restore good flora. I will be happy to share our policy and what we learned from the farm midwives with anyone interested.

Lesley... thank you!!! I suppose I could have gone to grab the info, too, but was busy watching the push and pull, listening as women said, sometimes, the same thing, but arguing as if they were diametrically opposed. Very interesting dynamic in this loud discussion. (Is it a discussion? Does anyone hear the other side?)

Vickii, you are very diplomatic, wise and a brilliant midwife. Your explanations are clear and I appreciate that. Thanks for not smacking me upside the head. I'll hang on tight when we see each other in person, though. ;)

No more being mean, though, ladies. Keep it civil or the comments go into the CyberTrash.

June 5, 2011 | Registered CommenterNavelgazing Midwife

It is not my style to smack people upside the head...the hearing and the talking abruptly cease when that happens. Then nobody gets heard, and nobody gets anywhere.

Though....I am born & bred Chicago, and you can't take the Chicago outta the girl, so there does come that point with some people sometimes...

June 5, 2011 | Unregistered CommenterVickii

*applauds* Thank you Lesley for bringing facts to the table.

June 5, 2011 | Unregistered CommenterMegan

I am currently working on a new piece regarding GBS - have been all day. Hopefully, it explains my views better and clears up some of the confusion.

June 5, 2011 | Unregistered CommenterAmber Plyler

Lesley - I'd love for you to post the information you gathered from the farm midwives - I'd love to look into that more!

June 5, 2011 | Unregistered CommenterAmber Plyler

I graduated from MTB after starting out with AAMI. I'm not a "birth junkie" by any stretch of the imagination. I am well-educated, professional, and skilled midwife that didn't want to go $$ into debt in order to graduate from a program. I apprenticed with amazing midwives (LMs and CPMs) and now serve clients.

MTB is?

June 6, 2011 | Registered CommenterNavelgazing Midwife

Personally I have heard the hibeclense douche before from other midwives and birth professionals, websites and pregnant mamas. Although I have never recommended it to one of my clients this is a popular alternative treatment that circulates the natural birth world. While I am all for informed consent and being unbaised when discussing certain procedures/protocols I can't help but feel like this you arer coming off as a bossy know it all. It seems like this information would have been much more effective if sent privately and not posted all over the internet in an attempt to ridicule the original poster. I don't like this at all nor do I respect your approach.

June 6, 2011 | Unregistered CommenterVanessa

I recently had a GBS+ woman receive 4 doses of ABX in labor while with us and transferred to the hospital where she received 6 more doses. 10 total. Her baby was born fine but given IV ABX for 2 days while the sepsis work-up was being done. Negative and they went home. I was saddened to see how many doses she received and that the hospital still treated the baby. Her question was, so what was the point of getting any in labor to begin with. I was stumped. I mean, I know the purpose, but this overkill (literally) is dumbfounding.

June 6, 2011 | Unregistered CommenterLillian

Amanda mentioned MTB above when she said -

"Would you like to share the non-accredited, online program in which you are studying?

http://midwifetobe.com/

This is the kind of joke program that makes "birth junkies" think they can catch babies safely and without intervention."

Midwife To Be is a program given by a Licensed Midwife from South Carolina. It is accepted widely as an educational program to educate midwife from all over the US. It is predominately a distance program, as are many CPM training programs. It is not MEAC accredited (again, quite a few schools are not), and if one attends MTB, they must go through the NARM PEP Process as part of their certification process. It meets and exceeds all national and state educational requirements. The reason it is not MEAC accredited it to keep the cost of tuition down (no accreditation fees). This is acceptable according to both SC DHEC and NARM standards. The MTB program is accepted by NARM and by the South Carolina Department of Health.

June 6, 2011 | Unregistered CommenterAmber Plyler

midwifetobe

http://midwifetobe.com/

June 6, 2011 | Unregistered CommenterAmanda

I'm not pregnant and was thankfully GBS- in my last pregnancy, but as I'm seriously allergic to all the cillins and sulfa drugs, I try to keep antibiotic options in mind. I really respect the importance of preventing GBS transmission, but from my research 2 years ago with my last pregnancy, it seemed that if you can't take penicillin or sulfa drugs, you're SOL.

What's the recommended treatment for someone with serious antibiotic allergies?

June 6, 2011 | Unregistered CommenterAshley

Midwife to Be program. Another commenter linked to it earlier.

June 6, 2011 | Unregistered CommenterCatie

MTB is http://midwifetobe.com/

"You will have to piece your training together as other midwives before you have done.

Some may go on to take CPM with NARMS. I will help you with records I have if you go the PEP route. If you want my course to be submitted for your state for approval let me know. Life itself will also teach you. Be a good listener. Have good character traits. Learn to communicate effectively. Your own spouse, births, kids, breastfeeding experiences, etc. will teach you much."

June 6, 2011 | Unregistered CommenterAtinaH

I have re-done the blog post.


It includes all of the original information, but cites sources. It also gives the "other side of the coin" so that readers - whoever they may be - do not see me as biased. I tried my hardest not to allow my bias to show, and I'm thankful that was pointed out to me. To write in a bias fashion is not very professional on a public blog such as this. People must be able to make their own decisions without seeing any prejudices I hold.


http://blossomingbabies.blogspot.com/2011/06/group-b-streptoccocus.html

June 6, 2011 | Unregistered CommenterAmber Plyler

PostPost a New Comment

Enter your information below to add a new comment.

My response is on my own website »
Author Email (optional):
Author URL (optional):
Post:
 
Some HTML allowed: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <code> <em> <i> <strike> <strong>