Transcript episode #31:PREGNANCY AND GBS (GROUP B STREP)
Click here to download a transcript.
00:00 Today, I'm talking about GBS, also known as group Beta strep. What the heck is this?
00:17 Welcome to the All About Pregnancy and Birth podcast, I'm your host, Dr. Nicole Calloway Rankins, a board certified ob gyn physician, certified integrative health coach and creator of The Birth Preparation Course, an online childbirth education class that will leave you feeling knowledgeable, prepared, competent, and empowered going into your birth. Quick note, this podcast is for educational purposes only and it's not a substitute for medical advice. See the full disclaimer at www.ncrcoaching.com/disclaimer.
00:46 Hello, hello, hello. Welcome to another episode of the podcast, episode number 31. Thank you so much for being here with me today. So today I am talking about GBS or group Beta strep and I'm going to cover what it is, how many women have it, why we even care about it, how it affects a pregnancy, how it affects a baby, how we test for it, how we treat it, all of the things. This affects all pregnant women, so you definitely want to listen in to this episode. Now before I get into the episode, I want to remind you that today is the day for my free live online class on how to make your birth plan the right way. If you're listening to this episode and it's before noon eastern standard time on July 30th, you still have time to register and join me.
01:38 Making your birth plan is about so much more than those templates and forms you find online. I can teach you how to make your birth plan in a way that's super clear. You know exactly what to include and your doctors and nurses will pay attention. I go way beyond a form and you will be empowered to have the birth that you want. You can go to www.ncrcoaching.com/register and even if you can't make it live, sign up anyway and I will send you a replay.
02:04 Okay, so let's talk about group B strep or GBS. GBS stands for Group B Streptococcus or group Beta streptococcus. And this is a bacteria that colonizes in the gastrointestinal tract and the genital track, in anywhere between 15 and 40% of pregnant women. And what the heck does colonize mean? Well, what that means is that all women, we all have bacteria that normally live in our GI tract. So that's our intestines or in and around our vagina. And for up to 40% of pregnant women, they may carry GBS as part of the normal bacteria that live in their bodies. Now, GBS colonization is asymptomatic and pregnant women, you don't know that you have it. It doesn't cause any problems. It doesn't cause any issues it's just with the rest of the bacteria that are there. But the reason that if mom has GBS colonize in her vagina and her gastrointestinal tract, then that is the primary determinant of whether or not a baby will get GBS infection within the first few days of life. It doesn't automatically happen. And I'll talk about the numbers and all that stuff a little bit later, but this is why we get concerned about GBS, why we measure GBS, look for it because of the effects that it can have on a baby. A GBS infection can actually can make babies pretty sick. So that's why we worry about it.
03:37 Okay, so the way that babies primarily get a GBS infection is when GBS goes up through the vagina and gets into the amniotic fluid after labor has started or after the water has broken. Sometimes it can occur with the bag of water still being intact and sometimes it can occur when baby comes through the vagina as it's being born. But typically we believe that it's the bacteria goes up the vagina and then into the amniotic fluid once the water is broken. Now in the mid 1980s there were several studies that showed that if you give mom IV Penicillin or Ampicillin, ampicillin is just a slightly different form of a penicillin type medicine, if you give penicillin or ampicillin to moms that carry GBS, then it protects their babies from developing that early onset GBS disease. So that's GBS within the first six or seven days of life. There's also a late onset GBS, but that's not what I'm talking about.
04:46 The most common type of GBS is early onset within that first week or so of life and if you give mom antibiotics through the IV, then it reduces the chances of baby getting it. So based on these studies back in the mid 1980s the Centers for Disease Control and Prevention, or the CDC, published some guidelines for prevention of Neonatal GBS disease and those guidelines have been updated over time. The most recent ones are from 2010, they've actually changed over time. They were different from what I first started practicing to what they are now. And ACOG, the American College of Obstetricians and Gynecologists, the governing body for ob gyn as well as the American College of Nurse Midwives, which is the big body for nurse midwives and the American Academy of Pediatrics for this body for pediatricians, all three of these organizations endorsed the guidelines that the CDC has put forth.
05:45 Now, the key tenant of these guidelines is what I talked about, that if you give moms the IV antibiotics, then it reduces the risk of a baby developing early onset GBS infection. However, the key or the changes that have come about through these guidelines is determining which moms should receive antibiotics. So determining which moms are at risk for having GBS or being a carrier or colonized the GBS. And there are two approaches to that. One is a risk based approach and that is kind of like what it sounds, where if you have certain risks than we thought that you may be at an increased risk for developing GBS. And actually when I first started practicing this was the approach that was used was a risk based approach. And I'll tell you a little bit more detail about what those risks are in a second. But then it has since changed at least in the US to a culture based approach, which is a little different.
06:52 I'll tell you a little bit more about that too where we check by culture to see if women have GBS. And that change came about in 2010. Now in the US, we use the culture based CDC approach and again as I said, ACOG, the American College of Nurse Midwives, the American Academy of Pediatrics, all of those organizations endorsed that culture based approach. However, that is not the approach that's used everywhere. I believe in the UK they still use a risk based approach and in some places either approach is considered acceptable.
07:31 So what are the different approaches and a bit more detail. Okay, so the risk based approach, what that does is that we look at four risk factors that a woman may have for certain characteristics that kind of indirectly give us a clue that the baby is at increased risk of developing that early onset GBS disease, that mom is colonized and baby's at an increased risk. And what those specific risk factors are is if mom has a fever during labor greater than 100.4 degrees, delivery before 37 weeks, so a preterm delivery, if the water is broken for greater than 18 hours, if mom had a previous baby that was affected by early onset GBS or even late onset GBS or if mom had GBS in her urine during pregnancy. So those risk factors, fever, preterm, water being broken greater than 18 hours previous GBS, GBS in urine, those were the risk factors that we used in order to determine if a mom was at increased risk. And if you had any of those risk factors, then you received penicillin or ampicillin while you were in labor. We still actually use those risk factors if the culture based method that I'm going to talk about wasn't done for some reason during pregnancy. So we still keep those factors in mind.
09:07 Now, the culture based approach, and this is what we do here in the US, the CDC recommends that all pregnant women are screened between 35 and 37 weeks using a rectovaginal screening, a swab. And I'll talk about how that works and that testing in just a minute. All women should be tested between 35 and 37 weeks for GBS. We don't use that risk factor based approach. We test all women between 35 and 37 weeks for GBS and the reason that we check during that time point is because many women may have transient or intermittent colonization. So if you have it early in pregnancy, it may not predict if you have it later in pregnancy. If you don't have it early in pregnancy, you may have it later in pregnancy. So when you do the culture closer to the end at a round about 35 weeks, that gives us a nice window.
10:11 So that's why we do the cultures near term and we also do it between 35 and 37 weeks and not say like 38 or 39 weeks is because the results will be available before most women go in to labor. And we also know that those results are pretty valid for about five weeks. So five weeks is a good time frame to know that their results are valid. If it's been more than five weeks at a test was done. For example, if you had preterm labor or something to those lines, if it's been more than five weeks since the gbs was done, it should really be repeated again.
10:50 Now cultures are also done with every single pregnancy. So even if you had GBS swabs last pregnancy and it was negative or positive, either one, whatever, we're still going to repeat it with every single pregnancy. And the reason that's the case is because anywhere from 50 to 60% of women who are colonized in one pregnancy, will not be colonized during the next pregnancy. You know, the bacteria that we have in and on our bodies changes. So we check every single time in pregnancy. Now there are a few women who we do not check for GBS. So we do not check for women who have GBS in their urine during the current pregnancy. So if you're currently pregnant and you have had GBS in a urine culture, all pregnant women get a urine culture towards the beginning of pregnancy, like as part of the initial evaluation. So if you had GBS bacteria show up basically at level in that culture, then we don't test you later on. If you for some reason has some symptoms of a urinary tract infection and you had a urine culture done and you had GBS in your urine, that GBS bacteria was shown, then we don't test you again at 35 to 37 weeks.
12:11 And the reason that is the case is because even if you have GBS in your urine and even if it's treated and a repeat culture has shown that the GBS has gone away, GBS in the urine is a marker for what we call heavy colonization. So that means that you have lots of GBS in your body or I should say in your genital track, gastrointestinal track. And even if we treat it in the urine and we show that it goes away, treating it in the urine doesn't eliminate it in the vagina or in the rectal area. So if you had GBS in your urine at any point during pregnancy, then you should be treated during labor. We do not repeat the culture between 35 to 37 weeks.
13:02 The other instance where we do not repeat the culture and not do the culture I should say is women who have previously given birth to a baby that had GBS disease that contracted GBS disease. Once that happens once, then we don't, you know, take a risk and test again, you're just going to automatically get treated for any future pregnancies.
13:26 So how are these GBS swabs done? They are little q-tips, like long q-tips, they're not terribly huge or anything like that, think ear q-tips, cotton swabs, same sorta size and they should be done before any type of digital exam to check the cervix. And I say that because a lot of providers, we'll use that 35 to 37 week time point to check the cervix. I personally never did it because I didn't find it terribly helpful, you know they check to see if you're dilated, you're probably not going to be dilated if you're haven't had a lot of contractions. It is a bit helpful to determine the position of the baby and whether or not the head is down. But for me personally, I could do that fairly good by feeling.
14:13 Some providers do check your cervix at 35 to 37 weeks when they do the GBS, but the GBS swabs should be done before the cervix gets checked. No lubricants should be used and again, it's a small swab. The swab needs to go into places, it needs to go in the lower vagina. So just inside the vagina like maybe an inch or so. And it also needs to go around in the rectum to get the sample from the GI tract and it needs to go through the anal sphincter. So that's the part that helps you stop poop as its coming out. So it's going to feel a little bit uncomfortable with the swab going through out. I'll tell you, it feels a little like oh, like okay. But it's quick. It doesn't last long. So the swab needs to go again in your vagina and your rectum.
15:07 You don't need a speculum. Actually it's recommended not to have a speculum and you also don't need to swab other places like the cervix. You don't need to swab around the urethra, which is the opening to the bladder. You really just need to do just the lower vagina and the rectum. You can use one or two swabs. If you use one swab, you start in the vagina and then go to the rectum. You don't go the other way. And if you use two swabs and you just do one in the vagina and one in the rectum. Now the specimens can be obtained by your provider, but you can also do the specimens yourself. Studies show that self sampling is just as accurate as long as you are taught how to do the swabs, the right way. So if you would feel more comfortable doing the GBS swab yourself, then ask your provider if you can do it. Studies show that again, the results are just as accurate.
16:07 Now you will have to do it in the office because the test swabs have to be transported fairly quickly so you can't take it home and bring it back. You will have to do it in the office, but if you feel like you would be more comfortable doing the GBS swab yourself, you should be able to do it again, it's not that hard. You're just sticking it in your vagina a little bit, stick it in your rectal area a little bit and get the sample. Now the results take about 48 hours to return. Like everything else, they're not 100% accurate, but they are pretty accurate. About 4% of women will have a false negative, but again it takes about 48 hours for the results to come back. They actually look and see old fashioned are the bacteria growing when you played it out.
16:54 If you remember science and chemistry or biology, I guess looking at bacteria grow, so it takes a little bit of time to determine for sure that the bacteria are not growing. Now, one thing that's really important that's communicated at the time of the test results is whether or not you have a penicillin allergy. Because remember I mentioned earlier that GBS is treated by either penicillin or ampicillin. Those are the two medicines that we know work the best to treat it. However, if you have a penicillin allergy then obviously you can't take those medicines and we have to come up with something else. Now there is a medicine that we know works well to treat GBS that is not penicillin, it's something called clindamycin. However, 20% of the strains of GBS bacteria that are out there are actually resistant to clindamycin and clindamycin won't treat them.
17:53 Okay, so we have to be sure that the type of GBS that you have if you have it, is actually sensitive to clindamycin. So they need to do something called susceptibility testing if you have a penicillin allergy. So let me say that one more time. So if you have a penicillin allergy when at the time the test is done, be sure that your doctor knows that and has noted it on the sample form for when they, you know, send the sample in because they need to make sure that if you do have GBS that the type of GBS that you have, will be susceptible to clindamycin. And the reason this is important is because if it's not susceptible to Clindamycin, then we have to use a really big gun antibiotic, Vancomycin and we try to reserve use of Vancomycin for really, really special circumstances cause it's a powerful antibiotic.
18:49 Now, there are rapid GBS tests available that can give results in less than two hours. So that's another option. However, they are expensive. You cannot do susceptibility testing with those and they are not as accurate as the culture methods. So the CDC doesn't recommend using them routinely. Some hospitals may use the rapid GBS. If you come in in labor and we don't know your GBS results, but not a lot of hospitals do that. So the really preferred method is the culture based method. That's what's recommended here in the US. Now when you think about some of the risk factors, if you're wondering like, Oh, do I have it, do I maybe have GBS? Like I said, it's fairly common. Anywhere from 15 to 40% of pregnant women will have it and we don't have a huge amount of data. We do have at least one study that looked at risk factors for GBS and this was in young actually non pregnant women and women who had multiple sex partners, women who engaged in male to female oral sex. If women had frequent or recent sex, if they used tampons, if they did not wash their hands frequently or if they were young, less than 20 years old.
20:07 All of those things are risk factors to be a carrier of GBS outside of pregnancy. I'm not aware of any studies looking at risk factors for carrying GBS within pregnancy. Now some of them want to try and decrease their risk of carrying GBS or having GBS are testing positive for GBS I should say because of the antibiotics and the effect on the microbiome and I'll talk about that in just a minute. You may see some studies or things out there talking about how to reduce your risk of testing positive for GBS and one of the things that pops up quite frequently is oddly enough, is putting garlic in the vagina to eliminate GBS before our GBS tests. Yes, just raw garlic in the vagina in various ways to do that.
21:01 There is no evidence whatsoever, no data to support that putting garlic in your vagina is going to eliminate the GPS before a GBS test is done. Yes, garlic does have some anti-microbial properties and we know that garlic is good for your health in general, but there's nothing that demonstrates that it's going to reduce your chances of having GBS. And we also don't know if it's going to cause any problems. Is that garlic going to increase the risk of your water breaking? Is it going to change the bacteria in your vagina? We don't know that. So I suggest not putting garlic in your vagina to try and eliminate GBS before GBS tests.
21:42 Now there is some evidence that maybe probiotics may help. Probiotics are good bacteria that you take by mouth. You just take them by mouth in order to help promote the growth of good bacteria in your GI tract. And there may be some evidence that probiotics help, but there's not a ton of data out there to provide any solid or sound recommendations. So if you come back with a positive GBS test, you are colonized with GBS. And again, remember that doesn't have any effect on you personally, nor does it matter when you're not pregnant, but you should be aware of it and your results and your doctor should tell you, hey, you're GBS positive because again, it's important to get treated with antibiotics and you also need to call your doctor midwife when labor starts or when your water breaks.
22:37 In general, I recommend that you try and stay home as long as possible when you're in labor so that when you come to the hospital that you're in good, strong, active labor. So I do recommend that you stay home as long as possible. And I also recommend that if your water breaks, if the fluid is clear, you can stay home until your contractions come on. However, I do tweak that in the case of women who are GBS positive. So if you're GBS positive and your water breaks, then I do say you should head on into the hospital to go ahead and get the IV penicillin or ampicillin started just because there's a certain timeframe that we want the antibiotics to be in your system and I'll talk about that in a second. So when you go into labor, if you're GBS positive, just make note of that when you call your provider and let them know and everybody does it a little bit differently. I'm not saying you have to head to the hospital like the second something happens and I think you can still stay at home once you're started. You don't have to come right away as soon as your contractions start, but you do want to let your provider know sooner rather than later that things are starting to pick up because in general we do want you to come in and so you can get those antibiotics started.
24:00 Now, as I've mentioned a few times, GBS is treated with IV antibiotics, either penicillin or ampicillin and we do IV antibiotics because that's going to be the route that gets the medicine to the placenta and the baby and the amniotic fluid the fastest and the treatment is very effective. It has decreased the incidents of early GBS disease by greater than 80% so it is very, very effective and as I mentioned, it's going to be penicillin, ampicillin. Clindamycin, if you are allergic to penicillin and we've done that appropriate susceptibility testing. If not, then it's that big gun antibiotic vancomyicin and ideally you want to be treated at least four hours before delivery.
24:51 Studies show that if you've had a dose of antibiotics for at least four hours before delivery, then that helps provide that protection. Now we don't delay anything, any treatment or necessary procedures or anything. Nobody is going to say like, oh, close your legs and hold the baby in or anything ridiculous like that just because it hasn't been four hours. That's the ideal time, but sometimes that doesn't always happen. One thing we will not do, we will not electively offer to break your water. If you're GBS positive and you haven't had a least four hours from when you got the antibiotics, that is one thing we definitely will not do, but if your water breaks on its own and you haven't had four hours or if you deliver, it's only been two hours since you got the antibiotics, that kind of is what it is now.
25:35 Since delivery is not predictable, we give the antibiotics right away so when you come in you're going to start getting the antibiotics so that you don't have to stay hooked up to the IV. I know this is something that women worry about who want to do an unmedicated birth is that you're going to be hooked up to this IV, but you do not have to stay hooked up to it. The medicine goes in over 15 to 30 minutes. If it's the Vancomycin though, it does take longer. It takes about an hour for that to go in. You do have to stay hooked up to the IV during that time, but once the medicine is finished going in, you can get unhooked from the IV and move around, get in the tub, you know, cover the IV site, all of that is just fine.
26:14 You may also ask about whether there are other options other than IV treatment and we don't know of any. We don't know of medicines that can be given in the muscle. We don't know that oral medication works. Really the studies and data that we have, it's best treated with IV antibiotics. There is one a subset of women who will not get antibiotics even if they are GBS positive and that is women who are undergoing a scheduled c-section and they haven't had any labor and their water hasn't broken. If you know that you're having a schedule cesarean birth, then you do not need antibiotics even if you're GBS positive because we know in that circumstance the risk of transmission is very low. We still test everyone for it because occasionally women who are having a scheduled cesarean birth, their water breaks before the time of their scheduled c-section or they go into labor before then, so we still want to know the information, or they changed their mind at the last minute and decide they want to do a TOLAC, or trial of labor after cesarean, or VBAC or vaginal birth after cesarean. And so we do want to test all pregnant women. However, if you know that you're undergoing a scheduled c-section, even if you have GBS, then you don't need the antibiotics.
27:30 Now, one of the big questions or things that there is a concern about is how the IV antibiotics will affect the microbiome, and the microbiome is the collection of bacteria that live on our skin inside of our body, particularly in our gastrointestinal tract. We actually have 10 times as many bacteria in and on us as we do human cells. I think that's just a fun, fascinating fact. We're all like walking around little ecosystems. And there's increasing evidence that microbiome has lots of effects on many areas of health and in episode 15 of the podcast, I had Dr. Sarina Pasricha on and she talked about the gut microbiome and pregnancy, so you definitely want to go back and listen to that episode for sure. And one of the things she talked about in regards to how to have a healthy gut microbiome is avoiding antibiotics if you can. Now she did say if you need to take them, then obviously yes, for sure take your antibiotics, but if you can avoid them then avoid them. Now this would be a case where if you are colonized or a carrier of GBS and you should take the antibiotics, that's the right thing to do for the health and safety of your baby based on the research that we have. However, we do know that antibiotics will affect the microbiome. Antibiotics kill bacteria, good or bad. Now, there's not a ton of research out there, but from the research that we do have, we found that women who receive IV antibiotics during labor, it will reduce the beneficial bacteria or increase the non-beneficial bacteria on your baby, the gut microbiome particularly, at least temporarily.
29:20 Okay, so when you get IV antibiotics during labor, it will change the gut microbiome by reducing the good bacteria and increasing the non-beneficial ones at least temporarily. And when studies have looked at how that changes over time, they're kind of mixed as to whether the microbiome recovers about half, say the microbiome recovers fairly quickly. Another half say that even up to several months, I think the longest was a year, it wasn't quite the same as babies who weren't exposed to IV antibiotics. We really need more research for any long term effects. We don't have a lot of research regarding the long term effects on the gut microbiome of moms receiving antibiotics in labor. However, there is some good news, the negative effects on the gut microbiome can be lessened by breastfeeding. So if you breastfeed then that will certainly help decrease those negative effects on the gut microbiome.
30:24 Also, one of the things Dr. Pasricha Talked about in that episode, that's episode number 15 of the podcast and of course we'll link to that in the show notes, one of the things that she talked about is that one over time you can change your microbiome and she talked about some specific things you can do to change that and she also talked about things in that episode that you can do for your children to help them have a healthy gut microbiome. So you can implement the things that she talked about if you're concerned. Again that's episode number 15 and we will link to that in the show notes.
30:59 Now real quick, I want to end with why do we get concerned about GBS? What exactly happens for babies who are affected with early onset GBS? Now early onset GBS disease, and that's again GBS within those first few days of life, six or seven days of life, it's not very common. It's about 0.24 cases per 1,000 live births in 2016. So there are about 4 million births in the United States each year, so 0.24 cases per 1,000 live births with 4 million live births in the US translates into about 1,000 cases per year at least in 2016 of GBS and that's down from 1.8 cases per 1000 deliveries in 1990. And that huge decrease is because of using the antibiotics like we talked about. So it's not very common, but because so many women give birth, again, it's going to be about 1,000 cases per year. There is an ongoing racial and ethnic disparity. Black babies are at a greater risk of infection than white babies. For black babies, the risk is 0.51 per 1000 live births, whereas 0.17 per 1,000 live births.
32:29 Now the way that early onset GBS disease manifests itself in the baby is primarily through three ways. One is sepsis and sepsis is infection of the bloodstream essentially, and early onset GBS will manifest between 80 and 85% of the time as sepsis. Another 10% of babies will have pneumonia and another 7% will have meningitis, which is infection around the meningis, which is the covering of the brain. Most babies will have symptoms very quickly within the first 24 hours or so and the way that early onset GBS is treated, one of the mainstays of treatment of course is antibiotics and it's going to be 10 to 21 days of antibiotics. Babies are also going to receive supportive care and that supportive care may include a variety of things. If baby has a bad pneumonia, pneumonia is infection of the lungs, then they may need to be on a ventilator. They may have anemia from sepsis, they may need to get blood transfusions for that.
33:36 Sometimes when babies get very sick, they develop seizures, so the supportive care involves all of that. But again, as I said, it's not very common that it happens as far as how many babies will die from early GBS infection. Those babies that get early GBS infection then 2 to 3% of full term babies with early GBS infection will die. That is higher for preterm babies. It can be as high as 20% or so for preterm babies depending on where you are in the pregnancy. And unfortunately that risk of mortality remains even after discharge from the hospital. So among babies who are affected with early onset GBS, if they survived the hospital discharge, which most will, the risk of mortality, studies have shown, will remain elevated through the first decade of life and in one study the risk of mortality was approximately three fold higher in GBS infected children compared with uninfected children.
34:49 So that's a serious risk and then babies can also have potential on going problems. They're at risk for longterm issues. In addition to that increase death risk, they're also at risk for developing cerebral palsy, for having intellectual disability, for developing seizures, hearing loss, visual impairment. They have a higher likelihood of requiring hospitalization during the first five years of life compared to babies who weren't infected. So this is why we take this very seriously because some of the consequences can be very serious. Death is a possibility and longterm problems are a possibility, but they're not likely to happen. The vast majority of who are carriers of GBS, you'll get antibiotics and everything will be fine and even if you don't get antibiotics and your baby does get GBS, most babies will be asymptomatic with it. They won't have any problems. So it's not very common that babies who are exposed to GBS will get very sick from GBS.
36:01 But if they do get GBS, then we know that those longterm potential problems are there and we want to avoid that if possible. I hope all of that makes sense. Okay, so to recap, GBS colonization effects up to 40% of pregnant women. In the US we use a culture based approach where all women receive that rectovaginal swab between 35 and 37 weeks of pregnancy per their provider or you can do it yourself. If you had GBS in your urine or if you had a prior baby who was infected with GBS, then you will automatically receive antibiotics while you're in labor. It is treated with antibiotics through your IV because that's the most effective method during labor and it's going to be penicillin, ampicillin, or clindamycin if you're penicillin allergic, or Vancomycin. And we know that treatment may affect your baby's microbiome, but breastfeeding can help with that.
37:02 And in episode 15 of the podcast, Dr. Pasricha talked about some things that you can do for your kids to help them develop a healthy microbiome so you can check that episode out. All right, so that is it for this episode. Come join us in the All About Pregnancy and Birth Community on Facebook where we can continue the discussion. We'll link to the group in the show notes. I'm curious if you know anybody that has a baby that was affected by GBS or if you yourself had a baby that was affected by GBS for sure. Come check us out and let us know in the group, in the group. You can also connect with other pregnant mamas. I have a doula who manages the group, so you definitely want to be a part of it. That's the All About Pregnancy and Birth Community on Facebook.
37:47 Also be sure to subscribe to the podcast in iTunes or wherever you listen to podcasts and please I'd appreciate you leaving an honest review in iTunes. I love reading the reviews. I give shout outs to folks on episodes and it also helps other women on the shows. So I would appreciate it so much if you left a review for me in iTunes and don't forget about the live online class on how to make your birth plan. If you're catching this before noon on July 30th, noon eastern standard time, there's still time for you to register. Go to www.ncrcoaching.com/register. Now next week on the podcast we have a birth story. Kristen had a lovely vaginal delivery in the hospital and I am excited to share her story. So come on back next week. And until then, I wish you a and happy pregnancy and birth.
38:40 Today's episode is brought to you by Women's Wellness Coaching by Dr. Nicole Calloway Rankins. Head to www.ncrcoaching.com to check out my free one hour mini course on how to make your birth plan, as well as my comprehensive online childbirth education class, The Birth Preparation Course, with over eight hours of content and a private course community. The Birth Preparation Course will leave you knowledgeable, prepared, confident, and empowered going into your birth. Head to www.ncrcoaching.com to learn more.