October 10, 2007
Volume 9, Issue 21
Midwifery Today E-News
“Infections in Pregnancy”
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In This Week’s Issue:


Quote of the Week

"Doctors prescribe medicine of which they know little, to cure diseases of which they know less, in human beings of which they know nothing."

Voltaire


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The Art of Midwifery

Natural remedies generally are more successful than antibiotics in eradicating [an] infection without harmful side effects, but if the normal microflora are not restored, rate of recurrence is high. The use of probiotic therapy has enormous potential in preventing and treating infections in pregnancy. Treating with probiotics is not a new idea, but the focus in most trials has been on re-inoculation of the intestinal tract alone, and generally the same strains of lactobacillus used for that purpose have not been successful when used to prevent or treat urogenital infection. Recent studies, however, have shown that specific strains taken orally and implanted vaginally have resulted in remarkably successful re-colonization of normal microbiota in the female urogenital tract, with a whopping 79% decrease in UTI and with no toxic side effects. Lactobacillus rhamnosus GR-1, L. Fermentum RC-14, and L. Fermentum B-54 significantly alter both gut flora and vaginal flora. The natural bacteria remained in the vagina for several months after insertion, protecting against many pathogens. In fact, supernatants from the strains GR-1 and RC-14 can inactivate viruses within minutes.

Genevieve Lewis
Excerpted from "Probiotics: A Better Way to Prevent Infections during Pregnancy"
Midwifery Today Issue 79

Midwifery Today Issue 79


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Toxoplasmosis

Toxoplasmosis is a disease caused by a single-celled parasite known as Toxoplasma gondii. Since no law requires reporting it, we don't know exactly how many people are infected. Estimates are that 400–4000 new cases develop each year; 750 people a year die from it.

Most people who are infected with the Toxoplasma parasite, an estimated 23% of the population, will show no signs of it. Only those with compromised immune systems develop serious health problems. The other group that may suffer noticeable problems is babies.

How Is It Spread?

Toxoplasma is spread orally by cat feces; raw or partially cooked meat—mostly pork, lamb and deer; drinking water contaminated with Toxoplasma; or a contaminated organ donation or blood transfusion, in rare cases.

What Are the Symptoms?

Occasionally infection with Toxoplasma may cause flu-like symptoms such as fever, swollen glands or muscle aches. Symptoms in individuals with weakened immune systems can lead to blindness or organ damage. Babies whose mothers are infected just prior to or during pregnancy generally show no signs at birth, but later on may develop mental retardation, blindness or epilepsy.

How Can Toxoplasmosis Be Avoided?

Midwives and other birth professionals can ask the women they serve about whether they have cats, the ages of the cats and whether they are indoor or outdoor. They can advise them about the risks of Toxoplasmosis and recommend testing, if necessary. If a woman receives positive results from a test prior to becoming pregnant, then she was previously infected and has antibodies and need not worry about passing it on. If negative, she will need to take precautions, all of which are good practices in any event.

Wear gloves for gardening or any activity that involves handling dirt. Wash hands well with soap and water after outdoor activities. Do not eat or handle food until after washing.

Try to avoid preparing or handling raw meat. If you must do so, wash your hands and everything the meat comes into contact with thoroughly with soap and hot water. Cook all meat thoroughly—to an internal temperature of 160 degrees. Invest in a cooking thermometer, if possible, or make sure that the meat is completely cooked.

If you have a cat that normally goes outdoors, train it (ideally before the pregnancy) off the litter box, or ask your partner to clean the litter box during this time. If you must clean the litter box, do so frequently, making sure to use gloves and wash your hands thoroughly with hot, soapy water afterwards. If the cat is normally an indoor cat, keep it in the house, do not feed raw meat or allow access to rodents or birds. Do not adopt any strays or new kittens at this time. Since cats are only infectious for a few weeks after they become infected, an older cat is safer to have around.

The risk of getting toxoplasmosis during pregnancy is small, but the results when it does occur can be huge. Pregnant women and women who are planning to become pregnant should have all the necessary information to make things go as smoothly as possible.

Cheryl K. Smith
Excerpted from "Toxoplasmosis and Your Baby"
The Birthkit Issue 51


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Research to Remember

Urinary tract infections during pregnancy are a risk for both women and their babies. A retrospective analysis of records from a two year period in Chicago, eliminated cases in which another type of infection was involved, showed preterm low birth weight to be the most common adverse perinatal outcome. Other risks were for low birthweight, prematurity, premature labor, hypertension/preeclampsia, maternal anemia and amnionitis. According to the authors "urinary tract infection was associated with perinatal death only among subjects 20 to 29 years of age."

Am J Public Health 84(3): 405–10, 1994


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Annual incidence of early onset Group B Strep disease (i.e., in infants aged 0–6 days) was 33% lower from 2003–2005 than from 2000–2001. Although incidence among white infants decreased steadily during the years 2003–2005, incidence increased 70% among black infants during that same period.

MMWR 56(28): 701–70, July 2007


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Question of the Week

Q: I have had two homebirths and two hospital births; I will be having my third homebirth in January. With my last three children my body starts pushing when I am dilated to 8 cm. I can't seem to get my brain to function at this point to prevent any pushing at all until I fully dilate. My other problem is that with that pushing at 8 cm, I always have a cervical lip, which has to be massaged back in order for the head to get past the cervix. This is very painful, and probably needed to be done with my first child, but instead I was made to push for two hours. Any recommendations for me and my midwife?

— Peggy


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.



Question of the Week Responses

Q: A nulliparous client of mine who is now 36 weeks and has been planning a homebirth has just remembered that she was told after a miscarriage and D&C, and also at the first ultrasound of this pregnancy, that she has a bicornuate uterus (having two "horns," or heart-shaped). Other than that, the pregnancy has been uneventful. I told her to do another ultrasound and find out if there is also a septum and where the placenta is. The doctor told her that he can't see anything now because the pregnancy is too advanced, but the placenta is anterior. My question is: Should she see an ultrasound expert who can tell more?

I know that there is more of a chance of retained placenta and need for lysis and also more postpartum hemorrhage (PPH) with a bicornuate uterus. I had one patient in the past who even had a successful version at 38 weeks, but had to have a lysis after waiting one hour and the placenta was increta in the cornua and there was a big PPH during the lysis. Then she had another totally uneventful second birth where the ultrasound showed that the placenta was not near the cornua and there were no problems with separation.

Do you think this woman should be risked out of a homebirth if the birth is six minutes from the hospital?

— Ilana Shemesh

Editor's Note: We received no answers to the question, but got the following update from Ilana Shemesh:

The labor was very long (her contractions began the night before), and she dilated slowly but steadily. At 7:30 am, she was fully dilated, but then her contractions became irregular and weak. She tried to rest but couldn't so she did nipple stimulation and lots of position changes. I broke the water to try to stimulate contractions, which helped a bit. She never really felt pushing contractions, but after two hours fully dilated she began to squat and push with the contractions although she didn't feel such an urge. The head was asynclitic as well, which didn't help. The squatting led to little progress, so she tried side, and then jacknife (McRoberts), which seemed to help the most. Then suddenly the head gave a little turn and she made excellent progress the last 10 minutes. She birthed over an intact perineum at 11:06 am. The placenta took half an hour, no unusual bleeding either, and her uterus contracted nicely after. She was up and around after two hours, after a nice nursing with the baby. The ambulance was called at the very end around crowning in case of any placental problems due to the bicornuate uterus, and they stayed for a while after the placenta to see that the uterus was contracted. All in all it was a fine birth, despite the bicornuate uterus, and I'm not sure the long labor had anything to do with it. We are all happy we did it at home and all was well.

— Ilana Shemesh


Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


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Think about It

The Centers for Disease Control (CDC) recently began a program called "One Test. Two Lives," which provides HIV screening recommendations for obstetricians and midwives, as well as educational material for patients, and other tips regarding universal HIV testing for pregnant women. According to the CDC Web site, mothers of 40% of babies born with HIV were not known before delivery to have the virus.

The CDC is focusing on maternity care providers, because of research that shows that pregnant women are more accepting of recommendations from a health care provider. The intent is to provide HIV testing as early as possible in pregnancy, but also up to delivery, so that antiretrovirals can be administered to mothers and babies, preventing transmission of the virus.

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Feedback

I read the comment about the terminology surrounding male and female circumcision versus genital mutilation (E-News 9:18). I would remind the woman who commented that men's health is generally not so adversely affected by male circumcision. In fact, in some studies, it supports sexual health. While I am not a proponent of cutting anyone's genitalia from birth, for any reason, female genital mutilation is done for a very different reason: to adversely affect a woman's sexuality and genital organs for means of control by another person. In addition, female genital mutilation causes a multitude of health problems that go beyond sexual practice, specifically with regard to basic human functions such as urination, menstruation and childbirth. Male circumcision does not take such a heavy toll on a boy's or a man's health; comparing them as equal procedures is dangerous and misleading.

Rebecca Williams Jackson

I totally agree with Cynthia B. Flynn on her attitude to society's gender discrimination regarding circumcision, but anytime I have tried to explain my feelings, they have been dismissed as ridiculous! The way I see it, all cultures that practice either of these traditions do so for reasons that originated long ago—reasons that no longer apply today. I believe that female circumcision is a far greater injury to a person than male circumcision, but I don't think that means we should condone male circumcision. It appears that speaking up against male circumcision is considered "politically incorrect."

Juli Townsend, RN, RM


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