Probiotics lower GBS colonization levels

Lily Nichols highlights this very important research brief:

In one well-designed randomized trial, 99 pregnant women who tested positive for GBS at 35-37 weeks were given either a probiotic supplement or placebo. The probiotic supplement contained 10 billion CFU (each) or two strains of probiotic bacteria that have been specifically studied for their beneficial effects on vaginal health: Lactobacillus rhamnosus, GR-1® and Lactobacillus reuteri RC-14®.

The probiotic supplement was taken for an average of 20 days. At the time of admission to the hospital for delivery, a repeat screen for GBS was completed. Among the women who received probiotics, 43% tested negative for GBS compared to only 18% in the placebo group. Those are pretty compelling statistics, though note that it did not reverse colonization in all cases.
The study authors propose that supplementation w/ these strains be started in the third trimester.


Questions to Ask your Care Provider

  • What is your philosophy on unmedicated births?

  • What do you think of women who want to give birth without any intervention?

  • What can you do/recommend to help me have as low intervention a birth a possible?

  • Do you practice in a group? Will I have a choice of practitioner? How many others do you share “call” with? What are the birth philosophies of the others on your team?

  • What percentage of your own patients births do you attend?

  • Will you be away for any period of time around my due date?

  • What are your routine procedures/interventions?

  • What percentage of your patients have unmedicated births? Epidural births? Cesarean births? Induced births? vacuum/forceps births? Episiotomy?

  • Are you willing to have a conversation with me about what I will need to support me in having a hypnosis-based birth?

  • Under what conditions do you recommend having an amniocentesis or ultrasound?

  • Do you tend to lean more towards “management of labor” or “mother directed birth”.

  • How much of my labor will you attend?

  • What is your view on doulas?

  • In the event that I need to give birth in an operating room, what will you do to support me in having my partner and doula in the operating and recovery room with me.

  • I may request that non-urgent medical providers be restricted. Do you support that?

  • What is your policy about fetal monitoring?

  • Under what circumstances is a fetal scalp electrode used?

  • What is your policy on my eating and drinking during labor?

  • Under what circumstances will you want to induce or augment my labor?

  • What percentage of your patients receive pitocin to stimulate labor?

  • What are your thoughts on artificial rupture of membranes?

  • If labor begins with spontaneous rupture of membranes, how long do you routinely wait before starting pitocin? What is the time limit in which you think my baby needs to be born?

  • When do you routinely suggest induction for reasons related to due dates?

  • I will want to give birth in my position of choice. Will you support that?

  • I will want to decline vaginal exams unless if I have a medical decision to make based on that information. Will you support that?

  • Will you support me in my decision about when to clamp the cord and when to cut the cord?

  • Will you support me in my desire to breastfeed my baby before any stitching is done.

  • How do you feel about me declining some of the newborn procedures?

  • Will you support me in delaying procedures?

  • What’s your opinion about circumcision?

  • How do you handle complications in labor such as “failure to progress.”

  • How do you handle breech birth? IF my baby were to be in a frank-breech position, would you support me in waiting until my labor starts and then having a cesarean?

  • Do you do VBACs?

  • If my baby needs to be born by cesarean, what is the policy about baby leaving the OR or staying with me and my partner in the OR?

​Hospital and Time of Delivery May Affect Mother’s HealthThe risk for complications in childbirth was highest during night shifts, weekends, holidays and in July.

Compared with daytime deliveries on weekdays, the risk for complications during night shifts was 21 percent higher, on weekends 9 percent higher and on holidays 29 percent higher.

The researchers also found an increased risk of 28 percent in teaching hospitals in July, when new residents begin their training. This difference was reduced to statistical insignificance by the following June.

Can your partner be your doula?

Partners know the birthing mom intimately.  Doulas know birth intimately.  Together we make a great team.  Not sure if you need a doula?

 Here's HBS’s handy checklist to explore if your partner is prepared to be your doula:

  • Has your partner attended births of people they aren't related to as a primary emotional, physical, and informational support person?

  • Does your partner regularly participate in continuing education opportunities on topics related to supporting families through pregnancy, birth, and the postpartum period?

  • Is your partner someone you'd consider a primary resource for information during pregnancy? What about after your baby is born?

  • Does your partner have referrals on hand in case you need extra support? Can they point you toward a great childbirth class, prenatal chiropractor, lactation counselor, pelvic floor physical therapist, prenatal massage therapist, ...?

  • Is your partner a member of any doula/birth professional groups or associations so they can learn from others' experience as well as their own?

  • Is your partner well-versed in the language of birth? Do they have a thorough grasp of commonly used medical terminology, abbreviations, acronyms and other language specific to labor?

  • Does your partner have an in-depth understanding of the ways medications and technology can be used during labor? Do they understand the common side effects of medications and procedures that are sometimes used in birth? And if so, are they practiced at communicating that information with people who are deep in labor to help them make thoughtful and informed decisions if the need arises?

  • Does your partner have a wide working knowledge of coping skills and comfort measures to help people through labor? Do they have tips and tricks up their sleeve that they can offer at pivotal moments during labor, based on their experience and knowledge?

  • Does your partner have advanced knowledge and skills to help identify ways you might be better supported during labor? Can they identify labor patterns that might indicate that a specific change in position for labor progress could be helpful?

  • If labor needs to be induced for whatever reason, can your partner walk you through what to expect from the induction process and what questions you might want to ask your care provider? What if a scheduled cesarean is necessary?

  • If there is a challenging situation during birth, does your partner have the experience and knowledge to offer a solution that may not have been offered by your care providers yet if the need arises?

  • Is your partner totally comfortable in a hospital labor and delivery room? Do they have tricks for helping YOU feel more comfortable there?

  • Does your partner have experience "holding space" for laboring parents? Are they practiced at staying balanced within themselves even in the uncomfortable, challenging, or even frightening moments that can happen during birth, all the while supporting you fully?

  • Does your partner have experience speaking to and touching people during birth? Are they in tune and responsive to the needs of someone who is in labor?

  • Is your partner used to spending hours upon hours in a small space with little nourishment and/or sleep while still supporting someone through their labor?


    Thank you HB services for putting this checklist together!

The importance of Salt in Pregnancy

Ever wonder why so many pregnant women crave pickles and olives?

It’s probably the salt.

Salt gets a bad rap in conventional nutrition, but you need salt to survive.

When you’re pregnant, your body has more fluids on board (blood volume expands + amniotic fluid) and when you have more fluids, you need more salt to balance it out. 

Think about it for a minute. If you’ve ever received IV fluids at the hospital, did they give you plain water? NO! They give you salt water because all of your bodily fluids also contain salt, where it serves as an electrolyte (among many other functions).

Many women are (erroneously) told to restrict salt as a means to avoid fluid retention or high blood pressure, but neither of these suggestions are scientifically sound.

A Cochrane review—a highly respected source of evidence-based analyses—concluded that advice to lower salt intake in pregnancy should NOT be recommended. This advice holds true even for women who have high blood pressure or preeclampsia (some research suggests that more salt, NOT LESS, is ideal in these situations).

In fact, restricting salt can have serious consequences, such as growth restriction in baby and even fetal loss.

As one study explains:
“Salt is one of the integral components for normal growth of fetuses. Salt restriction during pregnancy is connected to intrauterine growth restriction or death, low birth weight, organ underdevelopment and dysfunction in adulthood.” (Journal of Biomedical Science, 2016)

And another: 
“Extra salt in the diet seems to be essential for the health of a pregnant woman, her fetus, placental development, and appropriate function.” (Journal of Reproductive Immunology, 2014)

I could go on and on about this, but I cover all the relevant research on this topic in Chapters 2 and 7 of my book, Real Food for Pregnancy.

The short answer is that salt is nothing to fear during pregnancy and, perhaps surprisingly, there are legitimate concerns about not getting ENOUGH salt. 

So, salt your foods to taste and don’t ignore those salt cravings; your body is sending those signals for a reason.

Lily Nichols

Fascinating Facts


(United States, 2016)

Live births: 3,945,875

Hospital births: 3,883,255 (98.4%)



Epidural or spinal anesthesia during labor 2,901,486 (73.5%) 

Induction of labor 967,811 (24.5%)

Augmentation of labor 826,783 (21.0%)

Steroids (glucocorticoids) for fetal lung maturation 93,931 (2.4%)

Antibiotics received by mother during labor 976,049 (24.7%)

Clinical chorioamnionitis during labor 60,505 (1.5%)



Vaginal, spontaneous 2,562,527 (65% of 3,945,875)

Vaginal, forceps 21,674 (0.5% of 3,945,875)

Vaginal, vacuum 100,602 (2.6% of 3,945,875)

Cesarean 1,258,581 (31.9% of 3,945,875)

Vaginal Birth After Cesarean 75,244 (12.4% of 601,788) 



Cephalic (Head-down) 3,719,121 (94.8% of 3,945,875)

Breech 152,519 (3.9% of 3,945,875)

Other Fetal Presentation 51,444 (1.3% of 3,945,875)

women’s diets have been restricted during labor without sufficient evidence to support the practice.

For years, women’s diets have been restricted during labor without sufficient evidence to support the practice. In this systematic review and meta-analysis, Ciardulli and colleagues did not find a single case of aspiration pneumonitis—the outcome on which the rationale for restricting diets during labor is based. A 2013 Cochrane review by Singata et al also found no harm in less-restrictive diets for low-risk women in labor. Ciardulli et al concluded that dietary restrictions for women at low risk for complications/surgery during labor are not justified based on current data.

See the research here.

Vaginal Seeding

Vaginal Seeding After Cesarean: Is It Safe and Recommended for Your Baby?

Dr. Aviva Romm

As a doctor, I appreciate the indispensable, lifesaving contributions of western medicine – such as cesarean sections and antibiotics. They’re examples that, for many women, help avoid the largely preventable tragedy of maternal mortality, which according to the World Health Organization, remains unacceptably high in developing countries where access to procedures like cesareans and appropriate pharmaceuticals are too often limited, or entirely unavailable. And now, I do have a “but…” to add here (did you see it coming?), because as lifesaving and indispensable as some medical procedures can be, that doesn’t mean they are not overused, and even when done appropriately, can have unintended consequences – sometimes wide-scale, long-term ones.

The Unintended Consequences Paradox

Antibiotic use and cesarean sections are prime examples of practices that while lifesaving when used appropriately, have both been widely overused in recent decades – and we’re facing the consequences now. Antibiotic resistance as a result of antibiotic overprescribing has become one of the largest global public health problems we face, while overuse of cesarean section, which is associated with increased maternal infection, hemorrhage, and even death, has led even obstetric societies in the US to seek strategies for reducing what currently sits at a 34% national cesarean section rate. For the record, the World Health Organization (WHO) recommends an average of no more than 15% of births by cesarean section, for best maternal and neonatal outcomes.

One of the problems with cesareans (despite the very obvious fact that they are major surgery carrying risk of infection and requiring weeks of recovery…) is that babies are delivered abdominally, bypassing the bacteria-rich environment of the maternal birth canal. Whew, you might be thinking, well that sounds gross anyway. Actually, though, missing this exit ramp means that baby also misses skin and oral inoculation with important organisms, such as Lactobacillus and Bifidobacterium species, that lead to healthy immune system development, colonization of the baby’s own gut and skin flora that prevents infection, and that allows baby to also tolerate ingestion of mother’s milk. In fact, these organisms are sometimes referred to as ‘milk bacteria.” So why does this matter?

Babies, Birth, and Their Microbiome

Studies have demonstrated that babies born by cesarean have a greater lifetime risk of obesity, Type 1 diabetes, asthma and celiac disease, and it is thought that other diseases, including juvenile arthritis, inflammatory bowel disease, immune deficiencies, and perhaps additional conditions, are associated with this early perturbation of natural colonization of the infant with the maternal microbiome at the time of birth, early antibiotic exposure, or (yikes!) both. In other words, we’ve starting to uncover that vaginal birth possesses health advantages that cesareans miss out on.

Further, cesarean sections are accompanied by routine antibiotic administration to mom at the onset of the surgery to prevent infection – women undergoing cesarean section have a 5 to 20 times greater chance of getting an infection from birth compared with women who give birth vaginally. As research has been emerging on the importance of the human microbiome on our health, so too, has research emerged on the potentially deleterious impacts of early antibiotic exposure and cesarean section – which go hand-in-hand – on the long-term health of our children, including increased risk of obesity, alterations in the intestinal microbiome, increased risk of allergies, and more.

“But, Dr. Aviva, what if I don’t (didn’t) have a choice but to birth by cesarean?”

Yeah, I hear you. It’s frustrating to hear this information and hard not to blame ourselves, because we live in a culture that blames the mom – as if we don’t do that enough to ourselves! The fact is, though, that sometimes cesareans are necessary. If you did birth by cesarean, out of necessity or not, learning about its effect on your baby’s health isn’t about judging the type of birth you had, mom judging, or mom shaming. It’s about exploring possible solutions and letting go of judgment and guilt to focus on what really matters: how we can support our children’s health and that of future generations, while also nurturing our own.

I know this probably sounds scary and, to be honest, slightly depressing, but I actually have some great news to share: researchers and microbiologists, such as Dr. Maria “Gloria” Dominguez-Bello, PhD, whom I had the pleasure of interviewing for my podcast, are exploring solutions to help increase the health outcomes for mothers and babies through a technique they named Vaginal Seeding, which can be used following a cesarean. I touched on the practice here in my article Protecting Baby’s Microbiome, and you can listen to the podcast on Natural MD Radio instead, here.

While research into the practice of vaginal seeding is new and in the early stages, it does hold great promise for the future health of our children. Curious about vaginal seeding and whether it is safe and recommended for you and your baby? Whether you’re expecting yourself, or are a natural health practitioner wanting to help make recommendations on vaginal seeding for your clients, read on for what you need to know.

Curious about vaginal seeding and whether it is safe and recommended for you and your baby? Whether you’re expecting yourself or are a health practitioner, read on for what you need to know.

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What is Vaginal Seeding?

Vaginal seeding, in very simple terms, means swabbing baby with vaginal fluids following a cesarean birth. These fluids are collected prior to birth: a sterile gauze is folded and inserted into the vagina and left to soak up beneficial vaginal microbiota for one hour.

Right at birth, the newborn is swabbed with the gauze, starting on the lips and the face and moving to the rest of the body for about fifteen seconds, before proceeding to standard newborn examination.

In a landmark but very small pilot study conducted by Dominguez-Bello et al, the microbiome of infants in whom vaginal seeding was done post C-section resembled that of vaginally delivered infants.

The procedure is quite simple, but there are important guidelines to follow to avoid potential health risks, which I’m covering below, and importantly, this is not yet recommended as a ‘self-help’ practice at this time. Further, while the pilot study on vaginal seeding did show partial restoration of the baby’s microbiome, we don’t yet know whether the partial restitution of these naturally occurring organisms will have a long-term impact on babies’ health – long-term studies are needed to determine this.

Are There Risks Associated With Vaginal Seeding?

The concept of vaginal seeding is gaining speed in the press, and many moms wonder: is the practice right for me, and more importantly, is it safe for my baby?

So far, as pointed out by the American College of Obstetricians and Gynecologists (ACOG), there’s been a single pilot study in which only four infants underwent seeding, with no long-term follow up. What’s more, the pilot study in question involved only women who were not carriers of group B streptococci, had no signs of bacterial vaginosis (BV), and had a vaginal pH of less than 4.5. In other words, we don’t have solid data yet on the possible risks associated with vaginal seeding in the general public.

The question is, then: could the potential benefits of vaginal seeding still outweigh the possible risks despite the early stage of research?

The main concern with vaginal seeding is the spreading of undiagnosed infections in the mother (Group B Strep, chlamydia, gonorrhea, human papilloma virus, group A streptococci, and herpes simplex virus, among others), which could result in (serious!) neonatal infection otherwise avoided through cesarean.

In my opinion, concurred by Dr. Dominguez-Bello, the practice of vaginal seeding – with proper testing beforehand for infections in mom and supervision by a qualified birth practitioner such as a CNM, OB, or Family Physician – is likely quite safe and simply exposes baby to what she or he would have been exposed to any had the birth occurred vaginally. That being said, I agree with Dr. Dominguez-Bello and other physicians, midwives, and scientists who recommend waiting until more evidence is available before commonly practicing vaginal seeding, and all agree that pregnant women should be tested for GBS, HIV, Hepatitis B & C, and VDRL, and should be negative for genital HSV before proceeding with it. Several large studies are underway now.

Is Vaginal Seeding Ready for Primetime?

While vaginal seeding might not be ready for primetime just yet, it does reflect a really interesting and promising shift in our collective mindset regarding birth and the importance of the microbiome on children’s health. Mothers are waking up to the fact that their children’s health is suffering, and that it’s time we do something about it. Widespread allergies, food intolerances, eczema, asthma, autoimmune diseases, obesity, diabetes… I’ve certainly seen the rise in health concerns in children in the last decades, both as a midwife, a herbalist, as a doctor, and as a mom and grandma.

So, until more research is completed and vaginal seeding becomes standard practice, what can we do to support a healthy microbiome right from the start? Here are some of my recommendations below.

What Else Can We Do to Support Baby’s Health and Microbiome After Birth?

Avoid unnecessary cesareans
One of the best ways to support your baby’s microbiome right from the start is to avoid unnecessary cesarean. This includes allowing for more time for labor to progress in the active phase, along with working with a midwife and doula (read more about why here) and of course, educating yourself about birth (start here, and here). Listen to my Natural MD Radio podcast episode with Neel Shah, MD, to learn more about unnecessary cesareans and how you can avoid one.

Consider vaginal seeding if appropriate, safe, and accessible
Work with your health care provider to arrange for vaginal seeding post-cesarean after thorough testing for possible hidden infections.

Practice attachment parenting
Starting at birth with skin-to-skin contact, continuing with breastfeeding ideally through the first year of life with no solids until at least 6 months or baby’s shows social readiness for food (reaches out for foods you’re eating and wants to put things in her/his mouth), and extending lots of cuddles with skin-to-skin and co-sleeping, encourages transfer of beneficial bacteria to baby and gets us closer to what nature intended.

Use a probiotic
While not all practitioners agree on the value of using probiotics in infants, preliminary research suggests that giving probiotics to babies born via cesarean could lead to health benefits later in life. While researchers haven’t yet confirmed whether boosting a healthy baby’s gut with beneficial bacteria could lead to lower incidence of disease, the hope is that supporting diversity of bacteria may help fight conditions like allergies and autoimmune diseases. Probiotics are a perfect example of a process that offers little risk and many possible health benefits, so I encourage moms to both take them during pregnancy and breastfeeding, and give them directly to baby.

Get dirty
As your child is able to sit up and play, encourage your child to “get dirty” in clean, natural outdoor spaces – while we have come to culturally equate ‘dirt’ with ‘unclean’ we’ve also missed out on important exposures to soil microbiota that also inoculate us and prime a health immune system. Playing outdoors, having pets, and being exposed to natural environments have all been associated with reduced rates of allergies, asthma, and eczema.

Take care of you, too!
A healthy mama is at the core of supporting the health of your baby’s microbiome, so remember to also restore your own microbiome after a cesarean (or if you’ve had antibiotics in labor for GBS or any other reason) with probiotic rich foods such as fermented vegetables and yogurt, and give yourself time to recover, allowing for self-care and rest.

You’re a powerhouse mom for reading this article! Have questions? I’d love to hear your thoughts in the comments below.

Probiotics and their impact on gestational and postpartum mental health

Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety

July 23, 2018 by Kim Stewart

Growing evidence about the microbiome and gut brain axis suggests that taking specific strains of probiotics may be an important aspect of mental health, and more specifically postpartum depression, which affects 10-15% of women. In this study, published by EBioMedicine, a LANCET publication, researchers studied the effects of probiotics supplementation during pregnancy and 6 months after delivery, if breastfeeding. This study, the first of its kind to study women during and after pregnancy, evaluated the effect of supplementation of the specific strain probiotic Lactobacillus rhamnosus HN001 on postpartum depression. Full text available to registered users at the end of this study summary.


CLICK THE IMAGE to see the slides and listen to Dr. Rebecca Slykerman’s summary of the research.

Methods for probiotic and postpartum depression study

A randomized, double-blind, placebo-controlled trial of the effect of HN001 on postnatal mood was conducted in 423 women in Auckland and Wellington, New Zealand. Women were recruited at 14-to-16-week gestation. Women were randomized to receive either placebo or HN001 at a dose of 6 × 109 colony-forming units (cfu) daily from enrolment until 6 months postpartum if breastfeeding. Modified versions of the Edinburgh Postnatal Depression Scale and State Trait Anxiety Inventory were used to assess symptoms of depression and anxiety postpartum.

Study Results

423 women were recruited between December 2012 and November 2014. 212 women were randomized to HN001 and 211 to placebo. 380 women (89.8%) completed the questionnaire on psychological outcomes.

  1. Mothers in the probiotic treatment group reported significantly fewer symptoms of depression and anxiety,
  2. Mothers who had been taking the probiotic had as much as half the risk of developing clinically significant anxiety than women taking the placebo.
  3. This is the first study to show that women taking probiotics during and after pregnancy significantly reduced symptoms of anxiety and depression.


Another interesting finding was that infant colic was associated with higher depression and anxiety scores.

There has been a suggestion in the literature that probiotic supplementation may benefit maternal mood by reducing infant colic,” the researchers wrote … “While infants in our study are likely to have been exposed to a small amount of probiotic in-directly, either in utero or via breastmilk, they were not administered the probiotic directly; furthermore, we found that prevalence of infant colic did not differ between the probiotic and placebo groups and hence there was little difference in the effect size when adjusted for infant colic. Multivariable analysis showed that probiotic supplementation and absence of infant colic were independently associated with lower postnatal depression and anxiety scores.

The lead researcher, Dr. Rebecca Slykerman, from the Department of Pediatrics, Child and Youth Health, University of Auckland, New Zealand, noted that this study evaluated the effects of one strain of probiotics, thus the results are not conclusive for strains other than the Lactobacillus rhamnosus HN001. Slykerman also warns that this study needs to be replicated to confirm its results for postnatal depression (PND). Nonetheless, she and her colleagues are confident in stating:

This study provides evidence that probiotic supplementation with L. rhamnosus HN001 in pregnancy and postpartum reduces the prevalence of symptoms of PND and anxiety postpartum. Not all probiotic strains have the same effect on health and it is possible that the results found using HN001 are not generalizable to other probiotic strains, or at lower doses than those used in this study.”

Source: Slykerman R.F. et al. Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety: A Randomised Double-blind Placebo-controlled Trial. EBioMedicine, Volume 24, 159 – 165.