Third Trimester

 
Feeling Good Near the End

 

The following are some ideas about how to de-stress and/or support your body:

 

  • 2-3 L water, daily

  • Nutritious meals

  • Moderate exercise, especially if calming such as yoga or walking

  • Swimming (hydrostatic pressure minimizes swelling, decreases stress)

  • Epsom salts baths: 2 cups in tub, daily

  • Lavender essential oil: 3 drops in bath

  • Full body massage

  • Foot massage

  • Stopping work

 

Baby health

 

  • Fetal movements:

 

You are very aware of your baby's movements. If you feel that your baby isnt moving well, sit quietly with your hands on your belly and see how long it takes to get 6 movements. If you don’t get 6 movements in two hours, you should page your midwife urgently.

 

 

 

Group B strep (GBS)

 

What Do I Need to Know?  

 

The purpose of this information is to explain:

 

  • Group B Streptococcus (GBS)

  • How to find out if you have GBS

  • Factors that increase the chance your baby will have GBS disease

  • What choices you have to lower the chance that your baby will become sick due to GBS in their first seven days of life (known as early-onset GBS disease)

 

This handout does not tell you about:

  • How GBS causes sickness in newborn babies

  • GBS disease that happens after the first seven days of your baby’s life (known as late-onset GBS disease)

 

This information can help you make choices about your care. It does not replace the advice you receive from your midwife about your own situation. 

 

What is GBS?
 
  • GBS is short for Group B Streptococcus, one of many kinds of bacteria that normally live in our bodies.

  • Most people who have GBS have no symptoms and it is not usually harmful to the majority of people.

  • It is unknown why some people carry GBS and others do not.

  • 10% to 35% of people who are pregnant will have GBS in their vagina and/or rectum at any time.

  • GBS is a type of bacteria that lives in our bodies at different times. If we test different people to see if the bacteria is there over a certain time period, we might find it is always there, never there, or sometimes there.

 

What could GBS mean for my baby?
 
  • GBS may cause sickness in babies within the first seven days of life (called early-onset disease) or after 7 days (called late-onset disease). This information focuses on the prevention of early-onset GBS disease.

  • The most common way for babies to get GBS bacteria is from the pregnant person during labour.

  • The majority of babies born to pregnant people with GBS are not affected by the bacteria. However, a very small number of these babies will develop a GBS infection.

  • GBS can cause bacteria to enter the blood (bacteremia), lung infection (pneumonia), inflammation in the brain and spine (meningitis), respiratory infections and death.

  • One study showed that 30%-50% of infants with early-onset GBS disease had long-term problems (this means 50% to 70% of infants with early-onset GBS disease had no long-term problems).

  • Some babies with early-onset GBS disease may have long-term effects such as mild to severe delays in mental function (cognitive delays), paralysis of all four limbs (quadriplegia) or deafness. 

 

What increases my baby's risk of getting early-onset GBS disease? 

 

Your baby is more at risk of getting sick with early-onset GBS disease when one or more the following happens: 

 

  • you are GBS positive during labour

  • your baby is born before 37 weeks (also called preterm)

  • your baby weighs less than 2500 g (low birth weight)

  • your water breaks more than 18 hours before the baby is born

  • you get a fever during labour (≥ 38°C)

  • you had a previous baby with GBS disease

  • you have GBS in your urine during pregnancy

 

How can I find out if I carry GBS? 
 
  • At 35 to 37 weeks of pregnancy, you will be offered a test for GBS.

  • Because GBS can come and go in human bodies, you are offered this test near the end of your pregnancy. This way the test can most likely show whether or not you have GBS in your body when you have your baby.

  • You can do the test yourself or your midwife can do it for you. It is just as accurate for you to do your own test as for the midwife to do it. If you choose to do the test yourself, your midwife will explain how to do it.

  • The test for GBS involves passing a cotton swab, like Q-Tips, inside your vagina and rectum. Your midwife will send the swab to a lab for testing.

  • If your test shows you carry GBS, you are considered GBS positive. If you test shows you do not carry GBS, you are considered GBS negative.

  • No test is 100% accurate. The test may say you are negative when you are positive or say you are positive when you are actually negative for GBS. This test correctly identifies when someone has GBS 87% of the time.

  • If you do not receive this test or choose not to take the test, you will be considered GBS “unknown.”

 

What is the most effective way to prevent early-onset GBS disease in my baby? 

 

  • If your baby is considered at risk of developing early-onset GBS disease, you will be offered IV (in the vein) antibiotics during the active stage of your labour.

  • You will receive antibiotics through an IV every four to eight hours (depending on the type of antibiotics you get) until your baby is born.

  • Your midwife can offer most antibiotics at either a home, birth centre, or hospital birth.

 

What are the risks of getting antibiotics?

 

  • Antibiotics can cause rare but serious health problems for you and your baby.

  • Relatively common side-effects of antibiotics include: yeast infections for you and your baby and minor allergic reactions to penicillin, such as rash.

  • Other less common side-effects of antibiotics may include: serious allergic reactions to penicillin, the growing number of GBS bacteria that are resistant to antibiotics, other bacteria-related illnesses in babies, and possibly an increased chance your baby will develop asthma or allergies.

 

What are my choices?

 

The two most common ways of screening for and treating GBS are: 

 

1) Everyone takes the test and takes antibiotics if they are GBS positive. 

  • This option is currently used by most care providers in Canada.

  • With this choice, you will be offered antibiotics during labour if you tested positive for GBS between 35 to 37 weeks of pregnancy.

  • With this choice, about 31% of people receive antibiotics in labour.

  • This choice reduces early-onset disease in babies by 65% to 86% when compared to babies born to people who do not receive antibiotics.

 

2) Everyone takes the test and takes antibiotics only if they are GBS positive and if there is another risk factor. 

  • With this choice, you will be offered antibiotics during labour if:

    • you tested positive for GBS at 35 to 37 weeks and

    • you go into labour early, develop a fever during labour, or your water breaks before labour.

  • With this choice, about 3.4% of people receive antibiotics during labour.

  • This choice reduces early-onset GBS disease in babies by 51% to 75% when compared to babies born to people who do not receive antibiotics.

  • Some people will choose not to swab and be GBS "unknown"
    If you are GBS "unknown"

    • you will be offered antibiotics if one or more of the following happens:

      • your baby is born before 37 weeks

      • you develop a fever during labour

      • your water breaks more than 18 hours before the baby is born

      • you had a previous baby with GBS disease

      • you have GBS in your urine during pregnancy

 

This information is developed to keep you informed about GBS screening and management.

It is your choice: whether you want to test for GBS at all and what options to take if you test positive.

Please speak with your midwife for more information about GBS.

This information was prepared by the Association of Ontario Midwives.

 

 

 

Vitamin K and Erythromycin
Eye Prophylaxis

 

There are two medications that are offered to the baby shortly after the birth, one is vitamin k and the other is erythromycin eye prophylaxis.

 

Vitamin K:

 

Vitamin k is a factor used in blood clotting. We form vitamin k from the bacteria in our gut, however, baby's guts are sterile and it takes up to three weeks for them to colonize the gut with bacteria and to begin making their own vitamin k. Only small amounts of vitamin k are able to cross the placenta or to come through breast milk.  During these few weeks the baby is vulnerable to abnormal bleeding because they do not have this clotting factor. The bleeding can be life threatening as it can be internal and even into the brain. Vitamin k deficiency bleeding is rare, so it is likely that some other risk factor is present that makes a baby vulnerable. We know that babies born to people who take anti-epileptic medication, and babies with liver problems are at increased risk, but this does not account for all cases, so we offer all parents the option of giving their babies a synthetic version of vitamin k by injection into the thigh within a couple of hours of the birth.

 

If we do nothing, the risk of vitamin k deficiency bleeding (VKDB) is 0.25% to 1.7% in the first week and 4.2 to 7.2 cases per 100,000 from 7 days to 12 weeks(1)  If we give the injection of vitamin K, VKDB is practically eliminated except in cases of malabsorption.

 

If you opt to not give the injection and your baby develops vitamin k deficiency bleeding, the treatment is to give vitamin k.  Signs of vitamin k deficiency bleeding include bleeding from the belly button and bruising easily. More severe bleeding or bleeding into the brain will have more severe symptoms; however, there may not be early warning signs.

 

If you opt to have vitamin k, the major risks are bleeding at the site of the injection similar to when you have blood taken. Pressure with sterile gauze stops this bleeding quickly. There is also a small risk of infection at the injection site. We clean the site with alcohol first to minimize this risk. The medication is a synthetic version of the vitamin K our bodies produce naturally.

 

An alternative to the intramuscular injection is to give the IM dose orally.  This is not as effective and there is evidence that the effect is of a shorter duration.  Even giving repeat oral doses at 2 and 4 weeks of age do not have the same efficacy as the intramuscular route.(1,2)  The community standard is to offer the injection.

 

 

Erythromycin Eye Prophalaxis

 

Erythromycin eye prophylaxis is an ointment put into the baby's eyes to prevent infection caused by chlamydia and gonorrhea from the pregnant person.(3)  It is possible for the pregnant person to have an asymptomatic infection (meaning you can be infected but not aware). This is why we offer routine screening for chlamydia and gonhorrea in early pregnancy during the booking visit.  If there is transmission to the baby during the birth, it can cause blindness. The erythromycin is an antibiotic (broad spectrum) meant to prevent this infection. The Canadian Pediatric Society’s most recent position statement on eye prophylaxis questions the value of this approach as a treatment because it is not effective and also because chlamydia can cause pneumonia in newborns and eye prophylaxis will not prevent this.(5) The CPS recommendation is that all pregnant clients be screening for STIs in pregnancy for their own as well as their baby’s wellbeing.

 

The administration of the eye ointment does not seem to cause babies any distress or side effects, however, it will blur the vision. For that reason, we defer the administration of this medication for a couple of hours. The reason for this is that babies have a quiet alert state after they are first born which is an optimal bonding time. Their eyes are open and they are looking around. This is also a crucial time to initiate nursing. This state lasts about 2 hours, so we usually defer the giving of medications to the baby to the end of this time. At this point the baby is often ready to go to sleep and the blurred vision becomes less of an issue.

 

After the birth, prior to giving medications we ask if you have any questions and whether you consent to us giving the medications or not.

 

References:

1. Canadian Pediatric Society Position Statement: Routine administration of vitamin K to newborns, Paediatr Child Health 1997;2(6):429-31. Reaffirmed: Feb 1, 2016

2. AMERICAN ACADEMY OF PEDIATRICS: Policy Statement: Controversies Concerning Vitamin K and the Newborn. Pediatrics. 2003 112(1pt1):191-192. Reaffirmed May 2009

3. Canadian Task Force of the Periodic Health Examination. Prophylaxis for gonococcal and chlamydial opthalmia neonatorum. CMAJ 1992;147(10):1449-53.

4. Health Promotion and Protection Act, 1990). Communicable Diseases – General, R.R.O. 1990, Reg. 557.

5. Canadian Pediatric Society Position Statement: Preventing Opthalmia Neonatorum, Paediatr Child Health 2015;20(2):93-96.

 
 
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