Wednesday, May 30, 2012

Whose Birth-Day Is It, Anyway?

Yes, I am pregnant.
As you can imagine, birth is kind of looming large on the landscape of my thoughts these days.  Between witnessing a beautiful one (my neice's) last week, and my own "coming up" sometime in the next 3, it's kind of always there.  We went to Barnes & Noble for a family outing on Memorial Day and instead of raiding the young adult fiction (Brotherband Chronicles, Book 2, was calling my name... and there were all the rest of the 39 Clues I haven't read...), between readings of Eric Carle and Mo Willems (E's new favorite characters are "Gerald" and "Piggy"), I was devouring baby-books... books on what to buy where, books for calming squawkers, pregnancy books...

One question I've been wanting answering is, of course, when will he come?  And of course as I take all the little "how far are you from labor?" quizzes in the pregnancy journals, I'm hoping the answer is "pack your bags, mama!  It's gonna be SOON!"  Because, folks, I'm getting pretty sore.  Standing up takes lots of thought ("use your arms and legs, NOT your abs!") and maneuvering, and then there's that painful moment where the weight of my full uterus falls on my ligaments and I just have to take it like a man, er, woman... the whole "hours-to-fall-asleep-despite-exaustion" scenario that is getting SO OLD... the head-in-my-bladder sensation... the "if-I-itch-any-more-I-won't-have-belly-skin-left" realization... you get the point.  It's called "bearing children in pain" for a reason that FAR outstrips labor. (This sermon, "To be a Mother is a Call to Suffer," has stayed with me ever since I read it 11 years ago.)

First of all, though, I do take lots of joy in knowing that my Father knows my son's birthday (He knows all the birthdays of all the kids I'll ever have, which blows my mind).  Before a single day of life has come to be for William Christopher, they've all been written in His book (Psalm 139).  It's been surprisingly easy to calm my heart and wait patiently this time around, trusting that "good things come to those who patiently wait," and that the Lord whose voice makes the deer give birth is going to bring my baby forth in His timing.  Looking at how fast Eowyn is growing and changing, really, 3 more weeks is just not very long at all.  Bear with me, here, I know I risk stepping on some toes:  If we are honest, how much of our discomfort the last weeks of pregnancy is from impatience?  We Westerners sure love our schedules and our control of them. Instead of being content to wait and trust as women around the world always have (without a choice, lol), we take matters into our own hands and try and force the result we want.  It's a hard thing to wait without knowing.  (It was definitely the hardest part of my long labor with Eowyn!)  But faith isn't sight.  That's the whole point, right?  If we knew, we wouldn't have to trust.  [Please note that I know there are other factors that sometimes DO and should play into the artificial induction of labor-- mom's health, baby's health, even occasionally valid schedule considerations.]

I also firmly believe that the last few weeks of a pregnancy are vital to baby's health.  He's not JUST getting fatter in there-- his brain is growing.  Check out this poster from the March of Dimes on brain maturation the last 4 weeks of pregnancy.  "A baby's brain at 35 weeks weighs only 2/3 of what it will weigh at 39-40 weeks."  Wow.  It's one thing if a baby comes "early" on its own --it's quite another for us to artificially force it.  My working theory is that babies develop in the womb at just as varying paces as they do out of it-- some babies walk at 9 months, others at 15, for example.  So why wouldn't some "microwave babies" have ready-for-birth brains at 36 weeks, while other "crock-pot babies" need a full 41 weeks?  Still, I kind of want to know how our bodies know that "it's time."  Does the placenta just reach a time-release and start kicking baby out?  Does baby somehow let the cervix know "hey! my brain and lungs are ready! let me out!"?

Biologically, this topic is fascinating.  I've been Googling (and Google-scholaring) away trying to read up on what mechanisms play into setting labor into motion.  It's a natural process that has worked really rather well for the past couple thousand of years-- and how many sheep do you know that have to be induced?-- it's just been lately that we've all gotten fixated on "due dates" and counting weeks and making sure babies come at the time appointed a quite arbitrary best guess.  Obviously, there's a reason that babies come when they do-- what is it?  As far as I can tell, most doctors and scientists say "we don't fully know." (And obviously, sometimes the system, whatever it is, short-circuits out, and babies are born too soon.) One thing that's becoming clearer, though, is that the baby really plays a big role.  You might say they help pick their own birthday in quite a big way.

He's not so obvious from the front.
This article from 1996 talks about research done in rhesus monkeys (similar in many ways to humans).  Researchers found that when the hormone androgen, which is made by fetal adrenal glands, was artificially increased in the placenta earlier than normal in pregnancy, it set "off a chemical chain reaction through the placenta to the mother's blood, resulting in premature labor and live delivery of healthy babies."  But what do adrenal glands have to do with being ready to be born?

This (quite technical/tedious) paper comparing sheep & human pregnancies & labors explains that in both sheep & humans, the fetus' hypothalamus-pituitary-adrenal system puts out increasing amounts of cortisol, which increases prostaglandins, in turn ripening the cervix, causing contractions, and changing the placental blood flow.  However, while in sheep the placenta provides the androgens needed for these changes to start, in humans, it comes from the baby's (and in part the mom's) adrenal glands.  Cortisol is a steroid hormone made by the adrenal glands that triggers lung development in the unborn baby, so he's ready to breathe air.

This rather technical Special Feature article from Molecular Endocrinology, and this abstract ("Molecular Insights into the molecular endocrinology of parturition") gives some clues that the baby's maturing lungs play a big role:
"augmented production of SP-A by the maturing fetal lung near term provides a hormonal stimulus for activation of a cascade of inflammatory signals within the maternal uterus that culminate in the enhanced myometrial contractility leading to parturition. This hormonal signal, which is transmitted to the uterus by fetal macrophages, reveals that the fetal lungs are sufficiently developed to withstand the critical transition from an aqueous to an aerobic environment."  Translation:  Baby's lungs send a hormonal message to Mom's uterus that they are ready to breathe air, and the uterus starts contracting.   
"Our findings, therefore, indicate that SP-A secreted into amniotic fluid by the maturing fetal lung serves as a hormone of parturition."  Translation:  this hormone signal travels through the amniotic fluid to reach Mom's uterus.

So, instead of sitting around hating the fact that I'm STILL pregnant and STILL not sleeping or walking normally or able to turn over or eat without awful heartburn, I'm envisioning my little boy getting cuter and fatter, yes, but also getting his lungs ready to breathe air, his brain ready to process and develop, and am confident that when these systems are a "go," his adrenal glands & lungs will signal my body and start the process to get him out.  Pretty cool, huh?

As I wait, this quote from Jim Elliott came to mind:  "Let not our longing slay the appetite of our living.”  May my excitement and longing to meet my baby boy not ruin these last precious weeks without him-- of time with just Eowyn, of time to enjoy my husband without the demands of a newborn, of time to grow closer to the One who ordains all my days!

Friday, May 25, 2012

Group B Strep- What's Up with That?

Around 35 weeks of pregnancy, most women begin hearing the initials "GBS."  Standard protocol in the West is to have a pelvic exam that includes a swab which is tested for the presence of "Group B Strep," a bacteria that many of us carry around in our bodies in various concentrations at different times.  If a woman is "GBS+," meaning that she has Group B Strep bacteria colonizing her birth canal, she'll be told she will have to have IV antibiotics (usually one in the penicillin family, most often ampicillin) every four hours during labor and delivery, to keep her baby from getting a Group B Strep infection.  (Moms allergic to penicillins will likely receive vancomycin, cefazolin or clindamycin, depending on their care provider & situation.  These aren't as effective as penicillin & have their own risks.)  If a mom comes into the hospital too late or progresses too quickly to get the antibiotics, the babies are usually given antibiotics and have several blood samples drawn to ensure they aren't infected. Signs of early-onset Group B Strep infections in newborns include: fever or abnormally low body temperature, jaundice (yellowing of the skin and whites of the eyes), poor feeding, vomiting, seizures, difficulty in breathing, swelling of the abdomen, and bloody stools.

With Eowyn, I was tested and was GBS- (I didn't have any Group B Strep bacteria colonizing me at the time), so it wasn't an issue.  This time around, I had the option to not have a GBS test done, as well as having an interest as a doula in the issue.  So... I set off researching.  First off, I wanted to know the risks of having GBS and not being treated.  Second, I wanted to know the risks of standard practice (IV antibiotics to all GBS moms).  Thirdly, I wondered if there were more selective, less invasive means of treating GBS (if it needed to be treated), both before birth, and after birth.  Lastly, I wondered what steps could be taken to help babies and moms treated in the standard way.  Here's what I've found out!

First off, I wanted to know the risks of having GBS and not being treated.  
About 10-30% of all women have GBS colonizations (and generally have no symptoms). I'll use 25% as a steady figure:  1 in 4 moms are GBS+. According to CDC estimates, without treatment only 1-2% born to moms with GBS will become infected (2% of 25% is 0.5%, or 1 out of 200 babies), and of those, 6% will die.  So death is a risk of about 3 in 10,000 babies born to GBS+ moms with no treatment.  Infections in newborns are never good things-- GBS infections affect the brain, spinal cord, or lungs.  The risk of a baby getting a GBS infection goes up if the mom has a long labor (18+ hours with water broken), a fever above 100.4 in labor, or goes into labor before 37 weeks.  For perspective, about 1 in 150 of all delivering moms in the US will have some form of placental abruption, and 1 in 300 will have a prolapsed umbilical cord.

Second, I wanted to know the risks of standard practice (IV antibiotics to all GBS moms).
my belly at 35 weeks
IV antibiotics are a pretty big gun to pull out, as they kill bacteria that we need.  Not only are there thousands of beneficial bacteria in our bodies, they are all over our bodies!  They help us digest our food all along the digestive tract, they act as our immune system's main line of defense, they are our main source of Vitamin K, they keep harmful yeast and bacteria in check on our skin, in our guts, in our ears & sinuses, in our urinary tracts, and in the female reproductive tract.  Wiping them ALL out is pretty drastic-- we've heard a lot about the dangers of overusing antibiotics lately.  From yeast infections to weight gain to chronic gastrointestinal problems to super bugs, killing off all the little guys in our bodies opens us up to a whole new can of, umm... bacterial worms. :)  New babies especially need to receive a healthy dose of bacterial flora as they journey into the world, so that they are able to digest food properly and begin to form their own defense mechanisms against pathogens.  They get this through their eyes, nose, mouth, and skin as they are born, and later through breast milk. If they are born to a mom whose bacterial eco-system has just been severely thrown off-balance by antibiotics, they aren't going to be able to get that colonization, and it will take weeks for her breast-milk to return to normal --provided she doesn't get a yeast infection in the meantime.  What about the baby who is born during IV antibiotics who is also formula-fed?  Has anyone ever tried to nurse with thrush (a yeast infection)?  NOT FUN.  Obviously, the risk of dying from an infection is more severe than the risk of starting off life with bacterial imbalances, but if the risk of dying of infection is so low in the first place, yet a fourth of all moms and their babies are being put on IV antibiotics, it bears considering.

Another, more dramatic risk of the antibiotics, is the risk of anaphylactic (allergic) reaction-- this can happen even if a mom's never reacted to a drug allergically before, at about a 1 in 10,000 rate.  These cases put both mom and baby at a very real risk of dying.  I'll quote again from an overview of the topic in Mothering magazine:
"We can compare this to CDC estimates that 0.5 percent of babies born to GBS-positive mothers with no treatment will develop a GBS infection, and that 6 percent of those who develop a GBS infection will die. Six percent of 0.5 percent means that three out of every 10,000 babies born to GBS-positive mothers given no antibiotics during labor will die from GBS infection. If the mother develops anaphylaxis during labor (one in 10,000 will), and it is untreated, it is likely that the infant, too, will die. So, by CDC estimates, we save the lives of two in 10,000 babies-0.02 percent-by administering antibiotics during labor to one third of all laboring women. We should also keep in mind that this figure does not take into account the infants that will die as a result of bacteria made antibiotic-resistant by the use of antibiotics during labor-infants who would not otherwise have become ill. When you take that into account, there may not be any lives saved by using antibiotics during labor."  (emphasis mine)
** The linked-to article is very helpful, and is a GREAT starting point to thinking through this issue!  Every GBS+ mom should read it and use it as a jumping-off point-- there are plenty of citations to journal articles and scientific studies that bear reading!**

A final risk of the routine IV treatment is non-GBS infections (often anti-biotic resistant), especially E. coli infections.  
A study published in 1998 on the effects of the use of ampicillin before delivery concluded that:
"The increased administration of antenatal ampicillin to pregnant women may be responsible for the increased incidence of early-onset neonatal sepsis with non–group B streptococcal organisms that are resistant to ampicillin. At this time penicillin G, rather than ampicillin, is therefore recommended for prophylaxis against group B streptococci. In addition, future studies are needed to determine whether alternate approaches, such as immunotherapy or vaginal washing, could be of benefit. "
E seems unimpressed with the idea of IV antibiotics for GBS
In English (:D), they found that there is an increase in infections from bacteria besides Group B strep (especially E. coli) which don't respond to normal antibiotic treatment.  Especially scary is that this risk is even more pronounced in preemies, and labor before 37 weeks is one of the #1 signs of GBS infection, and therefore moms of preemies are the women most likely to get IV antibiotics.  The researchers recommended the use of penicillin G instead, and research into another approach, such as localized use of antibiotics.  (Mind, this was 14 years ago... WHY are IV drugs STILL the treatment of choice for GBS??) Two more quotes from Mothering magazine highlight the risk of antibiotic-resistant infections:
"We should not take lightly the use of antibiotics for 200 women and their babies to prevent only a single blood infection-however serious that infection might be-especially in this age of increasing resistance to antibiotics. [Edit:  remember the figure that 1 out of 200 babies get a GBS infection if their moms are untreated.] Concerns have arisen in several areas regarding the use of antibiotics for so many laboring women. One dilemma is that colonization of the vaginal area by GBS is, at best, a poor method of predicting whether a newborn will develop a GBS infection. As mentioned, even without any intervention during labor, fewer than 1 percent of infants born to carriers of GBS develop infections."
"A study of 43 newborns with blood infections caused by GBS and other bacteria found that, when the mothers of the ill newborns had been given antibiotics during labor, 88 to 91 percent of the infants' infections were resistant to antibiotics. It is unlikely to be a coincidence that the drugs to which the bacteria showed resistance were the same antibiotics that had been administered during labor. For the newborns who had developed blood infections without exposure to antibiotics during labor and delivery, only 18 to 20 percent of their infections were resistant to antibiotics."

So, are there more selective, less invasive means of treating GBS (if it needed to be treated), either before birth, during labor and after birth?
YES!!  The more I've read about IV-antibiotics, the more they seem like using an AK-47 to shoot a fly:  waayyyyy overkill.

First line of defense:  help the body regulate its own bacteria before birth.  If a mom is re-tested before she goes into labor and is GBS-, this whole issue is removed from the table.  This occurs without any intervention in some moms, and it can be helped along by non-invasive natural means, the biggest of which are:  probiotics (in capsules and in fermented foods like saurkraut and yogurt), garlic, and echinacea.  My own midwife puts any GBS+ moms on doses of garlic & echinacea, and retests in 3 weeks.  Read here about using garlic & goldenseal.  A fuller listing of suggestions is here.  As far as probiotics go, L. rhamnosus GR-1 and L. reuteri RC-14 are really helpful in regulating vaginal flora, and S. cerevisiae boulardii, Lactobacillus rhamnosus GG, and Bacillus coagulans GBI-30 are good for regulating digestive flora, so probiotics containing those strains would probably be most helpful.  (See a great article on using probiotics to fight various ailments here.)

Second line of defense, during labor: avoid cervical exams (and stripping of membranes), dilute the bacteria by giving birth in the water, or use a chlorhexadine vaginal wash (once every 6 hours) during labor once water has broken.  Not only are these methods less invasive, they target the only area where the GBS is located, as opposed to flooding the entire body.  To use the wash, a mom is handed a periwash squirt bottle and irrigates herself... no needles, no invasion of privacy, it's simple and done.  This has the added benefit of reducing other, non GBS infections, such as E. coli, as well-- remember, IV antibiotics INCREASED the risk of those!
"In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine." (from “Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.” J Matern Fetal Med 2002 Feb;11(2):84-8.-- Read its abstract and other related articles here.)
Third line of defense, after birth: as has been stated before, if a mom goes into labor without knowing her GBS status, or as an untreated GBS carrier, her baby can be tested for GBS infection and treated immediately if infected.

Lastly, I wondered what steps could be taken to help babies and moms treated in the standard way.
Probiotics!!  Both mom & baby will desperately need to rebuild their bacterial ecology.  One study found huge reduction in "colic" in infants who received the probiotic L. reuteri.  It would make sense to proactively give antibiotic-exposed infants such probiotics (the specific brand in the study was BioGaia, and it's readily available online at Amazon or at drugstores such as Walgreens), and to have moms taking therapeutic doses of the above mentioned probiotics.

One final note I'll make is that there is no real need for an expectant mom to have to have a full pelvic exam to be tested for GBS.  Many midwives simply hand their patients a swab and send them to the restroom to privately culture themselves.  I must say I greatly prefer this method. :)  As a dear friend put it yesterday, "they're called PRIVATE parts for a reason-- I'd like to keep it that way!"

[Personally, I feel the proactive measures of taking probiotics-- both in fermented foods and capsules (I'm taking first Renew Life Ultimate Flora Extra Care Probiotic- containing 10 probiotic strains including L. rhamnosus, L. acidophilus and several Bifidobacteria strains, then Nature's Way Primadophilus Reuteri, which contains L. reuteri, L. acidophilus & L. rhamnosus)-- as well as planning a water birth are the way to go.  If I'd had the option, I would have cultured myself and been tested that way... next time!  If I were GBS+ I'd first try the preventative measures of probiotics & garlic, etc, and if those weren't enough, I'd do the chlorhexadine wash.  :)]

Wednesday, May 23, 2012

37 Weeks!

37 Weeks
Last week I got a wonderful distraction from the end-of-pregnancy-waiting-game in the form of the birth of my niece, Adelaide Mae.  In answer to all of your prayers, the Lord allowed me to make it to North Carolina (barely) in time to witness the miracle!!  (I even got to cut the cord!)  We spent a few days enjoying baby Addie and trying to help out.  I'm glad I got a bit of a third-trimester energy boost!

As far as my own pregnancy goes, I'm progressing along.  37 cm, 159 lbs, baby's heart rate is strong, my bp & heart rate are dandy.  I'm back to my old ways of being ridiculously hungry, and I feel like Liam is taking up ALL the room in my abdomen. I regularly feel identifiable bones pushing FAR out.  He continues to drop-- we'll see how long he sticks around.  Restless legs continues to be my primary torment, though calcium supplements help, as well as peppermint oil on my feet, hot baths & massages from Ryan.  I absolutely hate the sleeplessness.

We are treasuring our days with Eowyn... hard to imagine that our "baby" will be our oldest child in a few weeks!

Ok... I can't sit still any more.

Holding my Blimp

Wednesday, May 16, 2012

35 Weeks & Counting...

Eowyn, Dad (i.e. GB), me, and Anna at Clemon's graduation
As you can see, William is growing along.  I am not gaining any weight, but am continuing to pop right out (35.5 cm on Monday) and to be in great health.  My belly itches like crazy as my stretch marks stretch, and I'm down to a very few trusty shirts, and even those aren't quite long enough.  I joked that it was a good thing Dad & Anna graduated when then did, or else I'd have had to show up in Ryan's old t-shirt! Several unpleasant episodes of nausea, vomiting, and general digestive unrest, and my favorite old symptom from Eowyn's pregnancy:  restless legs, but otherwise I've got good energy and am breathing easier as he is dropping lower and lower (get outta my diaphragm, boy!).  **Tips for restless legs:  hot bath just before bed, cat-cow stretches, and peppermint essential oil rubbed on the soles of my feet.  The three of those combined USUALLY mean I can fall asleep!  If they fail me (usually when I'm super-over-tired, then a nice head rub and back massage from Ryan finishes it off).

It's been a super-busy past week, with Ryan out of town, making the slide shows for my dad & sis, organizing and cleaning the house for two sets of guests, lots of family outings related to the graduation, and trying to get all our Mothers' Day cards & gifts finished & mailed.  I've been staying up past midnight for the past week and it's catching up to me!  We took a double-date trip with some Louisville friends (Kane & Lyssa H.) to the Biltmore Estate yesterday, while my dear mamita kept Eowyn all day.  It was a blast-- the audio-guide tour (ultra-spiffy headsets... which we all synchronized because we're cool like that) through the house, mansion, palace, let's be honest-- the vineyard & wine-tasting, and dinner at the Bistro.  We haven't been back since our honeymoon almost 5 years ago and it was lots of good memories, both recalled and made.  I did have to duck out mid-day and go nap for 2 hours in the car, while they went through the gardens & conservatory, but it was a small price to pay.  Ryan and I are hoping to return in the next few weeks for a little baby-moon! 

I've started Dr. Christopher's Birth Prep Formula; herbal capsules taken in increasing doses the last 6 weeks of pregnancy.  I can tell they are helping tone my uterus (more contractions!) and will hopefully live up to their hype of shortening labor!  I've seen them help friends of mine, and my midwife recommended them.  It made it seem a bit more real to be taking them!  I also had my physician-overseen visit, as SC requires in the final 6 weeks of pregnancy.  I was declared fit for an out-of-hospital birth and got 4 prescriptions to get filled for the birth (3 in case of emergency, and the Vitamin K for the baby)... also making this very real.  I just dropped them off today! 

My baby projects are mostly done; his crib quilt (matches Eowyn's!), the shelves all hung in the kids' room, a new flannel sailboat bassinet sheet, his "L'il Bro'" onesie and a faux-tie onesie...and something new I'm trying this time around- cloth postpartum pads.  (Some I ordered from Talulah Bean, others I made. ) All I need to do once he's here is get his quilt & towel monogrammed!  His bag is packed for the birthing center, and mine is almost there.  First, though, we are waiting on Baby "Lily" as my sister Nicole is due, well... in the next week-ish.  Barring any calls, we'll be heading up to be with her at the end of this week-- please pray with me that I'll get to be there to help ease her entry into the world!  We're hoping she bucks the late-first-baby trend so I can be there. :)

In the meantime, I've been researching Group B strep testing, and probiotics!  Posts forthcoming! :)

Eowyn is very excited about her brother coming, and is so sweet about kissing, hugging, blowing zerberts on, and itching/rubbing my belly.  She's gotten really "into" puzzles lately-- her great-grandparents brought her a horse puzzle she found a bit challenging at first, and now does about a dozen times daily.  I love how independently she's playing these days!  Last week she melted my heart twice:  once, with an out-of-the-blue "You a good mommy, Mommy.", and again with her unprompted effort to load the dishwasher after her breakfast.  Her explanation:  "I want be your helper, Mommy."  Yes, yes!! Please!

Saturday, May 12, 2012

Two Grads at Once!

It's been a crazy-full week looking forward to the double family-Clemson-graduation of my dad and my youngest sister.  Dad got his PhD in Mechanical Engineering and Anna got her Bachelor of Arts in Biology with a Music Minor.  As you can imagine, we've got lots of family in town (meaning I had to whip the guest rooms into somewhat decent shape) and had a full day of graduation and party yesterday.  Mom did the lion's share of the work- hosting a dinner Thursday and then the party Friday- my job was to do the slideshows.  Here they are for your enjoyment!  I so enjoyed looking at the skads of old pictures and realizing afresh just how much the Lord has blessed us.  We've had so many good times!

Dad's Slideshow

Dad's Graduation from Mama Szrama on Vimeo.  Song credits are "Sovereign Grace" by Judy Rogers (off her Pilgrim's Praise album-- which goes through Bunyan's Pilgrim's Progress) and "How Full is the Love of God" off our friend Benjamin Brainard's new album Behold the Savior (it's EXCELLENT!! I plan to do a full posting on what makes this album so good- look it up on iTunes).  
Anna's Slideshow
Anna's Graduation Slideshow from Mama Szrama on Vimeo.  Song credits:  "Great is Thy Faithfulness" by Fernando Ortega (on Shadow of Your Wings: Hymns & Sacred Songs) and "Class Reunion (That Used To Be Us)"" by Lonestar