Download Note: prepare your bed in the early stages of labor. You will need 2

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Note: prepare your bed in the early stages of labor.
You will need 2 sets of sheets, one set that you do not mind getting blood
and fluid on, the other a regular sheet set for daily use after the birth; 2 extra
pillows covered with plastic and old cases.
The other 2 things you need are: large safety pins (from your birth kit) and
plastic sheeting. Clear plastic covering can be found at any hardware store
It is the same material used to cover surfaces for painting. It needs to be
large enough to cover the mattress and the sides of the mattress.
The sheets that you want to use after the birth go on first (put on both fitted
and top sheets)
Next put the plastic over the 1st set of sheets assuring that the entire bed
surface is covered. Try to get most of the creases/wrinkles out.
Put the 2nd set of sheets on (the set you don’t mind getting messy).
Secure everything by using the safety pins. To make sure everything
doesn’t move around too much, use the safety pins to pin all layers into the
mattress. Pin at the corners, and at the sides. Securing everything can take
10-12 pins!
These are wonderful during labor and postpartum to sooth and protect the perineum
Use the herbal package in your birth kit that you ordered from Cascade and prepare these
before the home visit (36-37 weeks)
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Mix 4 drops of the PeriClens concentrate in 2 cups of water
 Take 3-5 pads (sanitary napkins)
 Pour 1/3- ½ cup of herbal liquid on each pad (don’t discard the remaining liquid)
 Wrap each pad individually in plastic wrap
 Place the wrapped pads in a medium sized bowl so that they curve to the edges of the
bowl (this ensures that the pads are comfy on your bottom, don’t skip this step)
 When the pads are completely frozen, remove the bowl but leave the pads in the freezer
 Place the remaining herbal liquid in a plastic container with a lid and keep it in the fridge
or freezer. This will be used later for perineal washes after the birth with a peri-bottle
(also in your birth kit).
Heather LeMaster, LM, CPM
4135 54th Place, San Diego, CA 92105
Ph. 619-565-8831, Fax 619-814-0569
Preparing Your Birth Supplies
In addition to ordering your “Heather LeMaster’s Birth Kit” from Confident Beginnings Online Store,
please have the following items prepared, set aside and ready for use at your home visit.
Rubbing Alcohol; 2 Hydrogen Peroxide
1 Bottle of Arnica Homeopathic, 200ck (Boiron) for mom*
4oz. Olive or Almond Oil
2 Large bowls-Serving Size
Plastic to Cover Mattress
4 Kitchen Size Plastic Garbage Bags
One Roll “Viva” Paper Towels
Fitted Sheet for Labor Bed; Clean Sheets for Postpartum Bed
3 Extra Washcloths & 4 Towels
2 - One Gallon Zip-Lock Bags
Thermometer – Digital for Baby
Working flashlight with extra batteries
Mark 3 paper grocery bags (warm, mom and baby) and place the following in each:
Warm
6 Receiving Blankets
2 Cotton Hats
Soft Washcloths 2
Mom
Underwear
Nightgown
Socks
Sanitary Pads
Peri-Bottle
Baby
Disposable Diaper
1 Cotton Hat
SKIN TO SKIN
Prior to your home visit, have the following listed on your refrigerator: phone numbers of your
midwives, birth team members, childcare provider, closest relatives, pediatrician, physician backup
if available, and the phone numbers and driving directions of both your closest and preferred
hospital ER and L&D units. Include a copy of your medical insurance card front and back. Keep
your refrigerator well-stocked with nutritious foods in the last weeks of pregnancy and have
enough food available for everyone in you home during the labor.
*Please be sure that all brand new clothes, blankets etc. are washed before the birth, it makes them much
softer to your new baby’s skin and removes excess lint. The Arnica 200ck can be purchased at Kemp
Pharmacy 619-234-2166. They will mail it to your home.
SDCM/Birth Supplies 2012
Heather LeMaster LM, CPM
4135 54th Place
San Diego, CA 92105
Fetal Movement Record
1. A very good time to do fetal kick count monitoring is after a meal. Babies are receiving a boost of energy from
the foods that you eat and are more likely to be more active. Try to be consistent, i.e. after lunch or dinner every
night.
2. Lie down on your side or sit in a comfortable easy chair. Do not watch TV or carry on a conversation. This is a
time for you to connect with your baby and have some you time. Just pay attention and tune into the movements
of your baby.
3. The first time you feel your baby move, note the time and write it down on the chart below. Count every
movement or kick until your baby has moved ten times (this does not include hiccups). When you feel your tenth
movement, write down the time. Bring your graph with you to your prenatal visits.
Day-Wk 1
Start Time
End Time
Total Time
Day-Wk 2
Monday
Monday
Tuesday
Tuesday
Wednesday
Wednesday
Thursday
Thursday
Friday
Friday
Saturday
Saturday
Sunday
Sunday
Day-Wk 3
Start Time
End Time
Total Time
Day-Wk 4
Monday
Monday
Tuesday
Tuesday
Wednesday
Wednesday
Thursday
Thursday
Friday
Friday
Saturday
Saturday
Sunday
Sunday
Start Time
End Time
Total Time
Start Time
End Time
Total Time
Heather LeMaster, LM, CPM
4135 54th Place, San Diego, CA 92105
Tel.: 619/565-8831
Home Visit: Map & Directions
Name
Phone #
Address
Alt. #
EDD
Approximate distance (miles) from office
Do you own a dog? yes / no
Please provide written directions in the space provided. Please include any information that will
help us to arrive at your house or apartment in a timely manner.
Please draw a map in the space below
Special parking instructions
Heather LeMaster, LM, CPM
4135 54th Place, San Diego, CA 92105
Ph. (619)565-8831 Fax (619)814-0569
Mother ________________________________ Date of Birth ______________
Neonatal Prophylactic Eye Treatment Consent/Refusal
Erythromycin antibiotic eye ointment is recommended by the State of California
to be administered to all newborns after birth. This treatment is considered
effective in preventing bacterial eye infections or blindness that may occur if the
mother is infected with gonorrhea or chlamydia. The ointment may temporarily
cloud the baby’s vision. While frequent antibiotic use may increase individual
resistance to antibiotic effectiveness, there are no known long-term detrimental
effects to babies with this treatment.
We are prepared to administer Erythromycin to your baby’s eyes shortly after
birth, but it is your legal right to refuse this procedure. Please authorize or refuse
such treatment below with your initials. By signing below, you agree to take
responsibility for your decision and to hold harmless Heather LeMaster, LM, CPM
or her agent(s) for any complications that may result from that decision.
As undersigned below, we are the parent(s) of newborn,
___________________________, born on this date __________________, and
______ I/we authorize Heather LeMaster, LM, CPM or her agent to administer
Erythromycin antibiotic eye ointment to our baby.
______ I/we refuse Erythromycin antibiotic eye treatment for our baby.
_________________________
__________________________
Mother’s signature
Partner’s signature
_________________________
__________________________
Date
Witness’s signature
2/10/14
Heather LeMaster LM, CPM
Consent/Refusal
Eye Prophylaxis
Heather LeMaster, LM, CPM
4135 54th Place, San Diego, CA 92105
(619) 565-8831
Mother ________________________________
Date of Birth ______________
Vitamin K Informed Consent/Refusal Form
With the intent to reduce Vitamin K Deficiency Bleeding (VKDB) in infants, the American Academy of
Pediatrics recommends an intramuscular injection of .5 – 1.0 milligrams of Vitamin K (phytonadione) into
the thigh of every newborn within one hour of birth. VKDB was formerly known as Hemorrhagic Disease
of the Newborn. All newborns normally have prolonged clotting times, but the abnormal condition of
VKDB occurs in 0.01% - 1.5% of those who have not received a Vitamin K injection. VKDB is near
confirmed when a bleeding infant has a prolonged prothrombin time (PT) together with a normal
fibrinogen level and platelet count. Rapid correction of the PT and/or cessation of bleeding after Vitamin
K administration confirm the diagnosis of VKDB. In national surveys researching millions of babies
conducted from 1980 forward, almost all of the babies who had VKDB were breastfed. Most breastfed
babies have an adequate Vitamin K supply and do not have bleeding episodes when they are NOT
treated with Vitamin K. Most formulas have Vitamin K added.
An early warning sign of VKDB is visible bleeding evidenced by skin bruising or blood seepage from any
body opening which can quickly lead to internal hemorrhage. In approximately 30-60% of cases,
concealed internal bleeding is from fragile capillaries in the brain and can result in severely delayed
development or death. If such bruising or bleeding occurs in an infant, it is imperative that a health
professional be notified immediately. Medical intervention and Vitamin K administration are needed swiftly
before seizures begin; internal bleeding may sometimes occur without visible outward signs.
If a baby is circumcised, he must be observed carefully afterwards for hemorrhage. It is normal for a baby
girl to have an occasional spot of vaginal bleeding caused by hormones transferred from the mother. A
few drops of blood from the umbilicus are also normal, but it should not continue.
Vitamin K Deficiency Bleeding can occur as early as within 24 hours of birth. A Vitamin K injection may
be particularly warranted if the birth has been unusually traumatic or if certain maternal drugs have been
used during the pregnancy (these may include anticonvulsants, cephalosporin antibiotics, tuberculostatic
agents and Vitamin K antagonists). A reported link between intramuscular Vitamin K and childhood
cancer prompted a number of studies that have yielded inconsistent results. The possibility of a small risk
may exist, but we currently have inadequate information. An alternative to the Vitamin K injection is to
administer Vitamin K orally. This is standard practice in Europe, but is not recognized as an effective
alternative by the U.S. medical community. For further information, check with your midwife.
I/we, _________________________________ and _________________________________ are the
parents of ___________________________________, born at home on _______________. We have
read this form and understand the medical recommendations to administer a Vitamin K injection to this
baby.
_____ I/we give permission for this newborn to receive a Vitamin K injection. We release Heather
LeMaster LM, CPM and agents from any and all liability that may be result from administration of Vitamin
K to this infant.
_____ I/we give permission for this newborn to receive an Initial Dose of Oral Vitamin K. We release
Heather LeMaster LM, CPM and other agents from any and all liability that may be result from
administration of Vitamin K to this infant.
_____ I/we understand the risks and refuse a Vitamin K injection for our baby. We release Heather
LeMaster, LM, CPM and other agents from any and all liability that may result from our decision to refuse
a Vitamin K injection.
_________________________ _________________________
Mother’s Signature
Partner’s Signature
____________
Date
_________________________ _________________________
Witness’s signature
License Midwife Signature
_____________
Date
Heather LeMaster, LM, CPM
2/10/14
Vitamin K Informed Consent
When to Call Your Midwife
It’s time to call your midwife when you experience:
1. Membranes rupture.
2. Contractions start and then:
a. Grow in intensity.
b. Get closer together.
c. Not affected by warm shower or bath.
d. Stronger when walking.
e. Contractions felt in lower back.
3. Call as soon as you suspect anything!
Ruptured Membranes
1. Cleanliness!
2. Nothing in the vagina.
3. No vaginal exams until active labor is established unless otherwise indicated
4. Take temperature 4 times daily.
Early Labor Management
1. Call birth attendant
2. Eat if hungry.
3. Rest if tired.
4. Walk to stimulate labor.
5. Drink 8 oz. every hour.
6. Urinate at least 1 time every hour.
7. Relax, relax, relax.
8. Keep it cool.
9. Be cheerful and patient.
Danger Signs in Pregnancy
1. Vaginal bleeding of any kind.
2. Sudden puffiness of face and hands.
3. Severe headaches late in pregnancy.
4. Dimness or blurring vision, visual disturbances (seeing spots or stars).
5. Severe pain in your abdomen.
6. Temperature over 100 degrees F.
7. Burning or pain when you urinate.
8. Lack of fetal movement for more than 8 hours after the 26th week.
9. Vomiting lasting more than 24 hours.
10. Pain or pressure in your belly or back that gets stronger over several hours.
11. Liquid leaking from your vagina.
Preterm Labor Signs and Symptoms
Premature labor, also known as preterm labor, is a very serious complication of
pregnancy. This is defined as labor that begins prior to 37 weeks gestation.
Unfortunately, many women do not understand the signs of premature labor. Early
detection can help prevent premature birth and possibly enable you to carry your
pregnancy to term or to give your baby a better chance of survival.
Causes of Preterm Labor
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Maternal factors:
o preeclampsia (also known as toxemia or high blood pressure of
pregnancy)
o chronic medical illness (such as heart or kidney disease)
o infection (such as group B streptococcus, urinary tract infections, vaginal
infections, infections of the fetal/placental tissues)
o drug abuse (such as cocaine)
o abnormal structure of the uterus
o cervical incompetence (inability of the cervix to stay closed during
pregnancy)
o previous preterm birth
Factors involving the pregnancy:
o abnormal or decreased function of the placenta
o placenta previa (low lying position of the placenta)
o placental abruption (early detachment from the uterus)
o premature rupture of membranes (amniotic sac)
o hydramnios (too much amniotic fluid)
Factors involving the fetus:
o when fetal behavior indicates the intrauterine environment is not healthy
o multiple gestation (twins, triplets, or more)
o erythroblastosis fetalis (Rh/blood group incompatibility)
Signs of Premature Labor
Call your practitioner if you have any of the following:
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Contractions or cramps, more than 5 in one hour
Bright red blood from your vagina
Swelling or puffiness of the face or hands, a sign of preeclampsia
Pain during urination, possible urinary tract, bladder or kidney infection
Sharp or prolonged pain in your stomach (preeclampsia signs)
Acute or continuous vomiting (preeclampsia signs)
Sudden gush of clear, watery fluid from your vagina
Low, dull backache
Intense pelvic pressure
Prevention of Preterm Labor
While not all cases of preterm labor can be prevented there are a lot of women who will
have contractions that can be prevented by simple measures.
One of the first things that your practitioner will tell you to do if you are having
contractions is staying very well hydrated.
We definitely see the preterm labor rates go up in the summer months. What happens
with dehydration is that the blood volume decreases, therefore increasing the
concentration of oxytocin (hormone that causes uterine contractions) to rise. Hydrating
yourself will increase the blood volume.
Others things that you can do would be to pay attention to signs and symptoms of
infections (bladder, yeast, etc.) because they can also cause infections. Keeping all of
your appointments with your practitioner and calling whenever you have questions or
symptoms. A lot of women are afraid of "crying wolf," but it is much better to be
incorrect than to be in preterm labor and not being treated.
Management of Preterm Labor
There are a lot of variables to managing preterm labor, both in medical options and in
terms of what is going on with you and/or your baby. Here are some of the things that
you may deal with when in preterm labor.
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Hydration (Oral or IV)
Herbs (To stop and reverse preterm labor symptoms)
Bedrest (Home or Hospital), usually left side lying
Medications to stop labor (Magnesium sulfate, brethine, terbutaline, etc.)
Medication to help prevent infection (More likely if your membranes have
ruptured or if the contractions are caused by infection)
Evaluation of your baby (Biophysical profile, non-stress or stress tests, amniotic
fluid volume index (AFI), ultrasound, etc.[/link])
Medications to help your baby's lung develop more quickly (Usually if preterm
birth in inevitable)
Preparation for preterm birth
The best key is always prevention and early detection. Make sure to ask your practitioner
to discuss the signs and symptoms of preterm labor to you and your partner.
Resources:
http://www.healthsystem.virginia.edu/uvahealth/peds_hrpregnant/ptl.cfm
http://pregnancy.about.com/od/pretermlabor/a/pretermlabor.htm
Group B Streptococcus Infection
What is Group B Streptococcus?
Group B beta-hemolytic streptococcus (GBS) is a type of bacteria that can cause serious illness in newborns and is
sometimes fatal. The bacteria are considered normal colonizers of the gastrointestinal tract (gut) and are also found
in the vagina in about 10-30% of the population. Typically women who are GBS positive have no symptoms of the
infection and are not sick.
How does someone get GBS?
Anyone can be colonized with GBS. It is not a sexually transmitted disease. Most women never have symptoms or
know that they are colonized.
Why worry about GBS?
GBS in pregnancy can cause infection in both mothers and babies. Approximately 2-4% of pregnant women acquire
a urinary tract infection from GBS. Women may also become ill during labor (chorioamnionitis) or in the
postpartum period (endometritis). Without antibiotic treatment, approximately 3% of babies born to women
colonized with GBS will become sick from the bacteria. Babies can contact GBS from the amniotic fluid and the
birth canal during labor. GBS can cause sepsis (blood infection), meningitis (infection of the fluid and lining around
the brain) and pneumonia in the newborn. Approximately one of every 20 babies with GBS infection will die.
Babies who do survive, particularly those with meningitis, may have long-term problems such as hearing loss,
learning disabilities and other neurological injuries. Most cases of GBS disease in newborns occur in the first week
of life and symptoms are usually seen in the first hours after birth.
Symptoms of GBS infection in a baby include:
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difficulty breathing
fever or abnormally low body temperature
jaundice
poor feeding
vomiting
seizures
swelling of the abdomen
bloody stools
GBS prevention efforts in the United States
The first guidelines for preventing newborn GBS infection were issued in the United States in 1996. If you had a
baby before 1996 you probably never discussed GBS with your care-provider. In 1993, before prevention efforts
were underway, there were approximately 7,500 cases of newborn GBS infections and 310 deaths out of about
4,000,000 live births. This means that in the United States we had a rate of 1.7 cases of GBS infection per 1,000 live
births. The first GBS guidelines recommended two approaches for the prevention of newborn GBS infection.
Universal Screening
The first approach involves swabbing the vagina and rectum of all pregnant women between 35 and 37 weeks of
pregnancy and sending it to a laboratory to see if GBS is present. Women identified as being colonized with GBS
are treated with prophylactic intravenous (IV) antibiotics during labor.
Risk-Based Screening
The second approach for GBS prevention recommended in the 1996 guidelines is based on labor risk factors to
identify which women should be treated with IV antibiotics. The three labor risk factors are labor prior to 37 weeks
of pregnancy, fever of 100.3 or higher, or prolonged rupture of membranes (18 hours or longer). This
prevention method requires women to be treated with IV antibiotics if they have one of these risk factors in labor.
Studies showed that the rate of GBS infection decreased after the 1996 GBS prevention guidelines were issued. In
2000-2001 the rate of GBS infection had dropped to 0.49 cases per 1,000 live births. In 2002 the Centers for Disease
Control issued revised guidelines for the prevention of newborn GBS infection. The current guidelines recommend
universal screening as the preferred approach to the prevention of newborn GBS infection. The risk-based screening
approach is recommended only if universal screening has not been done.
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Updated 2/10/2014
Both universal screening and risk-based screening have been shown to be effective in reducing newborn GBS
infection, but until 2002 it was not clear which approach was better at preventing newborn GBS infection. A study
published in the New England Journal of Medicine (NEJM) in 2002 showed that universal screening prevented more
newborn GBS infections compared to risk-based screening. The current GBS prevention guidelines were heavily
influenced by the publication of that study.
The results from the NEJM study show that universal screening reduced the rate of newborn GBS infection by 50%
compared to risk-based screening. However, the rate of newborn GBS infection was very low in both groups,
0.33 cases per 1,000 live births if universal screening was used and 0.66 cases per 1,000 live births if risk based
screening was done. Another interesting factor is that in the risk-based screening group only 61% of the women with
risk-factors actually received IV antibiotics in labor. This means that some of the cases of infection may have been
prevented if the proper protocol for risk based screening had been followed.
Evidence-Based Evaluation of GBS Protocols
The Cochrane Collaboration is a non-profit organization comprised of over 28,000 contributors from more than 100
countries who work together to provide systematic reviews of health care interventions tested in biomedical
randomized controlled trials and observational studies. The results are published as Cochrane Reviews and are
widely considered to be the “gold standard” for reliable evaluation of evidence-based medical practices. In 2009,
the standard protocols for GBS testing and treatment received this evaluation by the Cochrane Collaboration,
provided as a plain language summary for the public:
Women, men and children of all ages can be colonized with Group B streptococcus (GBS) bacteria
without having any symptoms; bacteria are particularly found in the gastrointestinal tract, vagina and
urethra. This is the situation in both developed and developing countries. About one in 2000 newborn
babies have Group B streptococcus bacterial infections, usually evident as respiratory disease, general
sepsis, or meningitis within the first week. The baby contracts the infection from the mother during labor.
Giving the mother an antibiotic directly into a vein during labor causes bacterial counts to fall rapidly,
which suggests possible benefits but pregnant women need to be screened. Many countries have
guidelines on screening for GBS in pregnancy and treatment with antibiotics. Some risk factors for an
affected baby are preterm and low birthweight; prolonged labor; prolonged rupture of the membranes
(more than 12 hours); severe changes in fetal heart rate during the first stage of labor; and gestational
diabetes. Very few of the women in labor who are GBS positive give birth to babies who are infected with
GBS and antibiotics can have harmful effects such as severe maternal allergic reactions, increase in drugresistant organisms and exposure of newborn infants to resistant bacteria, and postnatal maternal and
neonatal yeast infections.
This review finds that giving antibiotics is not supported by conclusive evidence. The review identified
four trials involving 852 GBS positive women. Three trials, which were around 20 years old, compared
ampicillin or penicillin to no treatment and found no clear differences in newborn deaths although the
occurrence of early GBS infection in the newborn was reduced with antibiotics. The antibiotics ampicillin
and penicillin were no different from each other in one trial with 352 GBS positive women. All cases of
perinatal GBS infections are unlikely to be prevented even if an effective vaccine is developed.
Read more from the Cochrane Review here: http://www2.cochrane.org/reviews/en/ab007467.html
GBS & The Midwives Model of Care
It is very important to us that you ask questions about GBS and have a thorough understanding of the options
available to you prior to making a decision about screening. We have included links to outside resources that we
think are helpful, and we encourage you to seek out other sources of information. You must weigh for yourself the
risk and benefits of each approach. In the Medical Model you would just be screened for GBS, and there would not
be any discussion about other options. We understand that part of the reason that you chose home birth and
midwifery care is because you want to have information presented to you so you can make an individualized,
informed decision about your care. This is, in fact a hallmark of the Midwives Model of Care.
As part of our home birth practice, we routinely limit the number of internal vaginal exams we do during labor
(especially if the water bag is broken). We also do not routinely rupture the bag of waters, waiting for it to break
naturally. This usually means that the water bag breaks late in labor and that sometimes the baby is born in the
amniotic sac (the “caul”). Both of these practices are believed to minimize the exposure of the baby to GBS in the
vagina.
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Testing options
As midwives we offer the choice of universal screening for GBS between 35 and 37 weeks of pregnancy or riskbased screening in labor.
Can IV antibiotics be given at home?
Currently, we do offer prophylactic IV antibiotic therapy at home. If maternal GBS screening is positive, we offer
the standard of care, which is a loading dose of 2 grams of antibiotics via IV and 1 gram of antibiotics every 4-6
hours (as indicated per antibiotic type) until birth.
What if I don’t want to be screened for GBS?
You have the right to decline universal screening for GBS. When universal screening is declined we use the risk
based screening approach in labor. In the event that labor risk factors are present (labor prior to 37 weeks, fever
>100.3, or prolonged rupture of membranes >18 hours) we may recommend transfer of care to the hospital for
IV antibiotic therapy. A negative GBS screen does not completely eliminate the risk of GBS infection in mother or
baby. Recent studies have shown cases of GBS infection in newborns whose mothers screened negative between 35
and 37 weeks of pregnancy. We still recommend using risk-based screening in labor even with a negative screen
prior to labor.
Alternative treatment options
Promoting good bacterial health
A fundamental element of minimizing colonization of any harmful bacteria in the body is maintenance of a healthy
intestinal tract. This usually includes supplementing your diet with probiotics, which are extremely helpful in
maintaining the beneficial balance of good bacteria in the gut.
Resources for a nutrition-based approach to GBS colonization:
Vaginal Ecology- An owner's guide to care and maintenance By Sheri Winston
Handout on Vaginal Health By Gail Hart
Garlic to Treat GBS Protocol By Judy Slome Cohen
Yin Care
Yin Care is an herbal wash comprised of many Chinese herbs. It is China’s most widely used topical/intra vaginal
wash for gynecological as well as general bacterial, fungal and viral skin complaints. The formula is comprised of
both the water-extracted and essential oil materials of many herbs which can be quite effective in small
concentrations (5-10%). It can be effectively applied as a wash, rub, sitz bath or compress.
To properly use the Yin Care, apply intra vaginal rinse using a Yin Care applicator, which will help measure the
10% dilution, 3 times daily for 3 days, then once on fourth day. Repeat for 3 rounds in this pattern. Recheck GBS
after this regimen.
Procaine penicillin G
No universal recommendations exist for the management of the newborn if maternal intrapartum chemoprophylaxis
was not given despite an indication. However, a single intramuscular dose of aqueous penicillin G (50,000 units per
kg within one hour of birth) to newborns whose mothers received less than three hours of antibiotics but did not
develop intrapartum risk factors appeared observationally to decrease neonatal sepsis without increasing late-onset
(four to 30 days of age) disease, GBS meningitis, or mortality. Parkland Hospital in Dallas, Texas and others
observed that the rate of GBS infection in newborns treated with penicllin G was extremely low. A summary on this
topic written by physicians at the Mt. Sinai School of Medicine was published by the Journal of Pediatrics in 1997
and is available from your midwives. This treatment option remains an acceptable protocol in the Newborn
Intensive Care Unit of Stanford University Hospital in Palo Alto, California,
http://newborns.stanford.edu/GBSscreen.html
Hibiclens Vaginal Wash as an Alternative to Antibiotics in Labor
Some research has demonstrated the effectiveness of using a chlorhexidine (Hibiclens) vaginal wash to prevent
newborn GBS infection. Hibiclens is an over-the-counter, medical grade antiseptic and antimicrobial soap.
If this is your treatment method of choice, please ask your Midwife for the Hibiclens Handout.
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Updated 2/10/2014
Client Consent/Refusal for Testing
My signature anywhere below indicates that I have read the above four-page document regarding GBS and have
researched the topic myself to understand fully the risks of GBS disease to my baby and me as well as the risks and
benefits of intrapartum antibiotic therapy.
RISK FACTORS IN THIS PREGNANCY: ______________________________________________________
_____ I have no known risk factors, and I refuse prenatal GBS cultures.
_____ Due to the above risk factors, or by personal choice in absence of risk factors, I consent to prenatal GBS
cultures at an additional cost.
_____ Despite having the above risk factors, I refuse prenatal GBS cultures.
_______________________________
_____________________________ Date______________
Midwife’s Signature , CPM, LM
Client Signature
THE FOLLOWING ARE TREATMENTS THAT MAY BE OFFERED DURING LABOR:
Client Consent/Refusal for Treatment
RISK FACTORS IN THIS PREGNANCY OR LABOR:
_____
I refuse any and all treatment for GBS including: Hibiclens protocol, Yin Care, Procaine penicillin G
protocol, and IV antibiotics.
_____
I consent to intrapartum intravenous antibiotic therapy due to the above risk factors or by personal
choice. I permit my Midwife or her agents to administer said treatment, releasing the midwives from
responsibility for any complications that may result for me or my baby from this decision.
_____
_____
I refuse intrapartum intravenous antibiotic therapy, despite the above risk factors, and I release the
midwives from responsibility for any complications that may result for me or my baby from this
decision.
I choose to follow the Yin Care protocol.
_____
I choose to follow the Hibiclens protocol and have received the Hibiclens Handout.
_____
I choose to have the Procaine penicillin G protocol administered to my baby.
__________________________________________
Client Signature
______________
Date
__________________________________________
Partner Signature
______________
Date
__________________________________________
Midwife Signature
______________
Date
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Updated 2/10/2014
Gestational Diabetes Mellitus (GDM)
What is GDM?
In approximately 3-10% of pregnancies the mother may develop Gestational Diabetes Mellitus,
or GDM. This is a condition in which blood sugar is abnormally elevated during pregnancy and
generally develops because the pancreas cannot meet the extra requirements for insulin. Signs
and symptoms of GDM are mild and mimic other signs of pregnancy: increased hunger, thirst,
and urination. Women with GDM are at increased risk for infections, elevated blood pressure,
and problems that accompany the delivery of a large baby, such as tissue trauma and/or
shoulders dystocia.
Infants born from diabetic mothers may need to have their blood sugar levels monitored for the
first few days. These babies are more likely to develop low blood sugars as their bodies are now
withdrawing from their mother’s continuous high glucose supply and are also more susceptible
to jaundice. Problems for the baby are generally related to the degree of severity of GDM in the
mother.
Risk Factors for GDM
•
•
•
•
•
•
•
Maternal age of 26 and older
Obesity, determined by a body mass index more than 27
Ethnicity: women from Hispanic, African, Native American, South or East Asian, or
Pacific Islands ancestry
Previous history of abnormal glucose tolerance testing
Past poor pregnancy outcome (stillbirth, spontaneous miscarriage, birth defects) or
family history
Family history of GDM or Type 2 diabetes
Previous history of large newborn (more than 9 lbs)
Other signs that may point to GDM include:
•
•
•
•
Excess amniotic fluid
A large fetus
Accelerated weight gain
2 or more unexplained sugar spikes in the urine, or repeated urinary tract infections.
Urine testing alone is not an adequate screening test for glucose intolerance during
pregnancy because the kidneys have a lower renal threshold for glucose. A high sugar
diet is often responsible for high urine glucose.
Testing for GDM
GDM Screening Tests
In addition to your prenatal panel the Hemoglobin A1C test is now standard; this test is done in
the beginning of pregnancy and again around the last half of pregnancy. The Hemoglobin A1C
results correlate with your average blood glucose levels over the prior two to three months. This
is a weighted average which will reflect how your blood sugar levels are over time. This is a
good tool to determine whether or not a GTT will be necessary. An HgA1C level ranging from
4.8-5.6% is considered normal, a result ranging from 5.7-6.4% is considered increased risk for
diabetes, any result greater than 6.4% is considered positive for diabetes.
All pregnant women should be screened for GDM, whether by patient history, clinical risk
factors, or a 50-g 1-hour loading test to determine blood glucose levels. The screening test is
usually done between 24-28 weeks of gestation. This test does not determine if a woman had
GDM. It does help the midwife determine if further testing for GDM is required. The Glucose
Screening Test (GST) involves going to your midwife's office, drinking a very sugary drink (50g
glucose), and then getting blood drawn at the 1-hour mark.
An alternative is the 2-Hour Postprandial which involves going to your midwife's office for a
blood draw after an overnight fast, then eating a meal within 15-20 minutes and returning to the
office 2 hours after beginning the meal. This method of screening is not as accurate as the GST.
The Diagnostic Test: Glucose Tolerance Test (GTT)
A diagnostic test is done if the blood sugar levels on the screening test are elevated. Again the
mother goes to the midwife's office (for 2-3 hours), only this time she must fast throughout the
night prior to her arrival. An initial blood draw is taken upon arrival. Then a 100g glucose
solution is consumed followed hourly by blood tests. From this extensive testing a diagnosis of
GDM can be determined. This test is also available for women who were diagnosed with GDM
in a previous pregnancy.
What if you have GDM?
The next step will involve information and instruction on diabetic care such as exercise and
monitoring of blood sugars. Very few women will require insulin. Generally, blood sugars
returns to normal levels shortly after birth. If a client is found to have GDM the midwife will
provide counseling on nutrition and lifestyle changes. Each case will be handled individually.
Women who have had GDM have a 20-50% increased chance of having diabetes in the next 5-10
years. This is something very important to consider as this may affect your and your baby's
health in the near future.
Occasionally GDM occurs regardless of risk factors or tests results. This is one of the reasons the
midwife will continue to monitor for sugar in the urine, and assess baby's growth at each prenatal
appointment.
Pros and Cons of Testing
Advantages
Women who develop GDM are at a greater risk for developing Type 2 diabetes later in life.
Being diagnosed with GDM may encourage these women to develop a healthy lifestyle early on.
This may be an effective way to prevent or postpone the onset of Type 2 diabetes later in life.
Disadvantages
Some health authorities question the benefits of diagnosing GDM. There is considerable
controversy that exists in the literature about the efficacy and ethics of screening and treatment.
The concern is that the diagnosis of GDM comes with an increased likelihood of medical
interventions (e.g. induction, caesarean sections), yet there is little information regarding the
effectiveness of treatment versus no treatment. Proper diet, exercise, and monitoring of blood
sugar may reduce the risk for large babies. However, studies have not proven that these
treatments have significant benefits for the outcomes for mothers and babies.
Information and Recommendations
•
•
•
•
•
•
•
•
No eating, drinking (water is okay), or gum chewing, or physical activity is allowed at
the lab.
Unfortunately the GST has a high false-positive rate (i.e. you're incorrectly diagnosed as
having GDM). The GTT or diagnostic test will clarify the results.
The glucola drinks are very sweet and may cause feelings of nausea, and/or dizziness.
Prior to testing, try to avoid high sugar foods such as fruit juice, soda, ice tea, cereal,
white bread, pasta etc. Protein food sources (eggs, beans, meat, nuts) are preferable and
will give a more accurate reading.
Women with results greater than 10.3mmol/L on the screening test can be diagnosed
with GDM without further testing.
Results for the GTT are:
Fasting: Less than 95 mg/dl
1 hour: Less than 180 mg/dl
2 hour: Less than 155 mg/dl
3 hour: Less than 140 mg/dl
Bring some reading material to help pass the time.
Most women gain on average 20 pounds by 20 weeks gestation. Ranges may differ
whether a woman is overweight or underweight.
Informed Consent or Informed Refusal for Gestational Diabetes Mellitus (GDM) Testing
I, ________________________________________ have read the GDM information sheet, and I
understand the information. I have had the opportunity to discuss and research this topic, and the
opportunity to ask questions with my midwife. At this time I:
CONSENT _____
DO NOT CONSENT _____ to have the glucose screening test.
If I have the screening test and the results are positive I understand that I will be advised of the
need to follow through with additional testing.
Client Signature: _________________________________ Date: ____________________
Midwife Signature: ________________________________ Date: ____________________
Whole-Food Supplements: The Prenatal Vitamin Option
by Gerri L. Ryan, CPM, LM
Much has been written concerning the nutritional needs of pregnant women and whether the
average diet supplies the necessary vitamins, minerals and nutrients to grow a healthy baby. This
subject is quite polarized—some studies stating that adequate nutritional intake does not require
supplementation and some indicating that specific supplementation may be needed for various
risk factors. While this article does not attempt to resolve this question, it does propose an
alternative to traditional prenatal vitamins—whole-food supplementation.
Adequate Nutrition
Ideally, nutrients should be obtained from whole, organic foods eaten fresh from the garden with
little or no cooking. Whole foods contain micronutrients that allow for optimal absorption of
proteins, vitamins, minerals and calories needed for maintaining healthy bodies and growing
healthy babies. The ideal diet would contain whole grains, legumes, fruits and vegetables along
with adequate high quality proteins and essential fatty acids.
The reality is that few families can or do eat in the manner noted above. Our diets are full of
foods that sit on the shelf (ours or the store’s) for weeks prior to consumption. Even if the
processed foods we consume contain added vitamins and minerals, are they in such a form that
the body can absorb and utilize them beneficially?
Specific risk factors increase the need of supplementation for many expectant women. Women in
these categories often include:
•
Working women
•
City dwellers
•
Teenage women (under 18)
•
Women having babies less than one year apart
•
Women bearing more than one baby (multiples)
•
Underweight women
•
Overweight women
•
Breastfeeding women
•
Women with previous or current eating disorders
•
Women using over-the-counter medications and herbs
•
Women with certain socio-economic risk factors
o
Low income
o
Cigarette use
o
Substance abuse
o
Alcohol consumption
Other factors that may affect sufficiency of nutritional intake include stress and a busy lifestyle.
The importance of high quality food cannot be emphasized enough. Supplementation cannot
make up for a diet high in refined and processed foods. However, supplementation can be used to
augment specific nutritional deficiencies.
Supplementation Options
For those women who can benefit from supplementation, what is the best form of
supplementation? Standard, off-the-shelf prenatal vitamins contain sufficient folic acid and
usually the Recommended Dietary Allowance (RDA) of other vitamins and minerals. But keep in
mind that RDA is the minimum amount necessary to prevent malnutrition, not the optimal
amount to ensure good nutrition for mom and baby. Most prenatal vitamins do not contain
sufficient amounts of vitamins, essential fatty acids, bioflavonoids, minerals and antioxidants for
optimal health.
Many formulas contain vitamin A acetate instead of beta-carotene, raising the concern of birth
defects from oversupplementation. Vitamin A acetate is a fat-soluble substance that can build up
in the tissue to toxic levels. Conversely, beta-carotene converts into vitamin A in our bodies at
safe levels. When we have enough vitamin A, the body simply turns off the conversion and
therefore will not accumulate to dangerous levels.
If whole food is the best way to obtain adequate nutrition, it stands to reason that whole-food
supplements would be the best choice. Whole-food supplements are “grown” or “cultured” in
food nutrients, thereby picking up the bio-active (live) nature of whole food. These bio-active
nutrients are vitamins and minerals cultured in fermented organic soy, fruits and vegetables. This
allows the body to recognize the supplements as food and makes them easily digested and
palatable to pregnant women. The active nutrients enhance the bioavailability and potency of the
supplements consumed.
The digestive process actually begins in the mouth. As we chew food, it mixes with saliva, which
begins to break down starches. Proteins need the stomach acids to begin breaking them down, and
as the food begins its journey into the small intestines, minerals are freed up and can begin to pass
through the gut and into the blood. Other minerals attach themselves to amino acids, which are
absorbed by the cells lining the gut and then carried into the blood stream to the liver, where they
will be sent on their way for use by cells throughout the body. Simple inorganic mineral salts
used in many vitamins, such as oxides, carbonates, sulfates and phosphates are just not available
for use by the cells. Make sure the vitamins use chelated minerals or are part of a whole-food
supplement that the body will recognize as food. For a more complete discussion of how the body
absorbs minerals see Comparative Guide to Nutritional Supplements noted in the references.
Some prenatal supplements provide “extras” such as organic Class I herbs that are completely
safe during pregnancy and enhance the uptake of various vitamins and minerals. A good balance
of vitamins and minerals that are easily digested can be found in Nature’s Variety, Standard
Process, New Chapter and other whole-food supplements. Most of my clients report no stomach
upset and less constipation and indigestion after switching to Perfect Prenatal. I appreciate that
these contain fruits, herbs and grains as well as 10 strains of beneficial probiotics that promote
digestion. Probiotics are beneficial strains of bacteria that live in the gut and aid the digestive
process. They are also known to reduce diarrhea and overcolinization of negative bacteria such as
candida (yeast). For women with yeast issues, I usually recommend a separate, stronger probiotic
that can be used seven to 10 days.
Gerri L. Ryan, CPM, LM, is the mother of four grown children. She practices as a midwife
in San Diego and is a DONA approved doula trainer.
Sources:
Barker, D.J.P. 1998. Mothers, Babies and Health in Later Life. Churchill Livingstone, New York.
Coad, J., and M. Dunstall. 2001. Anatomy and Physiology for Midwives. London: Mosby.
Frye, A. 1998. Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth
Practice. Portland, OR: Labrys Press.
MacWilliam, Lyle. 2003. Comparative Guide to Nutritional Supplements. Vernon, BC, Canada:
Northern Dimensions Publishing.
Nichols, F., and E. Swelling. 1997. Maternal-Newborn Nursing: Theory and Practice.
Philadelphia, PA: W.B. Saunders Co.
Varney, H. 1997. Varney’s Midwifery, 3rd Ed., Sudbury, MA: Jones & Bartlett Publishers.
Lewis, Gerald R.J. 2002. Dietary Supplements—Fad, Fable or Fact? Mt. Roskill, Auckland, New
Zealand: Lewis Publications.
Pregnancy Tea
Drinking two to three cups per day of the following herbal mixture will add substantially to
the mother’s health throughout pregnancy and lessen pain and bleeding during birth. These
herbs are primarily nutritive in nature, providing much-needed vitamins and minerals in a
form that the body can easily assimilate. The teas should be taken postpartum as well, to
help tone the uterus and build a healthy milk supply.
Red Raspberry leaf is best known for strengthening the uterine muscles so they work more
efficiently during labor. High in easily assimilated calcium and magnesium, they help to
relieve leg cramps. Also high in iron, the leaves and berries help prevent anemia. Raspberry
leaf is an acid neutralizer so it soothes an upset stomach and will help alleviate mild
morning sickness. Taken after birth, it slows bleeding, helps the uterus regain tone, and
increases breast milk. Helps tone the uterus. High in A,B, E vitamins.
Nettle is a blood building and cleansing herb that is high in iron and calcium and an
excellent source of folic acid. Nettle strengthens the kidneys and adrenals, while it relieves
fluid retention. Because nettle also supports the vascular system, it can prevent varicose
veins and hemorrhoids. Postpartum, it increases breast milk.
Dandelion root increases digestion and promotes bile to relieve constipation. It is one of
the best herbs for cleansing and strengthening the liver, our main detoxifying organ. The
liver breaks down hormones no longer needed by the body after birth, and any drugs that
may have been given at birth. Drink dandelion leaf tea if a diuretic is needed to relieve fluid
retention. Because of its high potassium content, it does not deplete the body of this
important mineral, as other diuretics are known to do.
Alfalfa, with its deep root system, contains many essential nutrients including trace
minerals, chlorophyll and vitamin K, a nutrient necessary for blood clotting. Many midwives
advise drinking mild tasting alfalfa tea or taking alfalfa tablets during the last trimester of
pregnancy to decrease postpartum bleeding or chance of hemorrhaging. Alfalfa also
increases breast milk, as alfalfa hay is fed daily to milking goats and other dairy animals.
Rose hips contain the entire vitamin C complex. Good for vascular problems
(hemorrhoids, varicose veins) and to boost the immune system. Recommended for Rh(-)
and for fighting off infections.
Spearmint is soothing to the stomach, aids in digestion, and lends a pleasant taste. (Note:
mint can antidote some homeopathic remedies)
Red Clover is a blood purifying herb that can be added from time to time. Especially good
during acute illness and for high blood pressure.
Directions: one part raspberry leaf to one part nettles. Add some or all of the optional
herbs if desired. Two small handfuls of herbs to one quart water. Use glass or other nonmetal container with a lid. Cover the herbs with almost-boiling water and cap tightly. Steep
this mixture four to eight hours. Pour through a strainer, discarding the herbs. Tea will stay
fresh for up to four days in the refrigerator. Play with herbs to find a taste you like!
Labor & Birth Pool Clean Up
Below you will find basic instructions for
setting up and taking down your labor & birth
pool.
HOT WATER TANK: It is important that your hot water tank is turned up in early labor.
You want to be certain that you will have LOTS of hot water for your pool, showers and
clean up. It is recommended that you turn your hot water tank up to 140 degrees.
TIP: Debris settles at the bottom of most water tanks so it is advisable to flush out the
tank completely, then fill and raise the temperature to 140 degrees. If waiting until ‘labor
day’ to do the below steps - you need to allow at least one hour for pool to be ready for
use. Your pool comes pre-sanitized, and has been inspected by the Midwife. Please do
a practice dry-run prior to ‘labor day’ to ensure there are no
issues with set-up or equipment.
LOCATION FOR POOL:
Choose a place where you have:
1. Privacy
2. Can walk around all sides-or at least ¾ of the way
around to better reach mom
3. A lead free water hose will reach from water source to the tub and to
location of draining (bath tub, or outside through window or door)
4. Where floor boards can support additional weight
5. Where there will be room to get mom out and down on floor if needed
INFLATING AND CLEANING POOL:
1. If new, slide pool from its box and allow to come to room temperature
(12hrs) before inflating to prevent damage to pool.
2. Inflate bottom of pool to firm. You can place plastic on the floor, then an
old blanket or comforter under pool for extra cushioning.
3. Inflate sides to very firm (should not sink when leaned on-test prior to
birth) – but do not over inflate!
4. Wash pool if you wish. You can use warm soapy water or antibacterial
soap. Rinse well. You can also rinse pool with a bleach solution -1 tsp.
chlorine bleach in 1 gallon of cold water. Rinse, drain and let air dry.
5. Repeat step 4 if pool became soiled prior to use.
FILLING POOL:
1. A plastic liner on floor under pool will protect surface from water. Liner
should extend 2 feet beyond the pool.
2. Be sure to place a large flat sheet or a comforter underneath the tub, but
on top of the plastic which will prevent slips and will help absorb water.
Attaching water hose to water source.
3. Remove aerator from kitchen faucet or shower head from shower pipe.
Attach hose adaptor. Attach “Y” (opt.)
4. Attach hose firmly to “Y” or to adapter.
5. Fill pool to ½ full with 98 -100 degree water. Adjust to mom’s desired
temperature and depth after she is in pool.
6. Have towels and bathrobe available for mom and old towels for the floor.
DRAINING POOL:
1. Remove debris from pool with net as best you can.
*DO NOT PUT BIRTH WATER DOWN SEWER DRAINS OR INTO DITCHES*
WITH ELECTRIC/BATTERY WATER PUMP METHOD:
2. Attach lead free hose to pump and place submersible pump in bottom of
pool.
3. Place draining end of hose where you wish water to go: bath tub, shower,
garden, grass. Be sure that birth water goes to a place that people will not
come into contact with it.
4. Plug electric pump in – turn battery pump on.
WITH HOSE SIPHON METHOD:
2. Coil a good portion of hose into the water in the pool. Be certain that all air
leaves the hose.
3. Block one end of the hose with your hand to prevent air from entering and
carefully lift from pool.
4. Extend to drain area: bath tub, shower stall, garden, grass. Be sure that
birth water goes to a place that people will not come into contact with it.
5. Remove hand from end of hose and water should freely flow from the
pool. Draining end should be lower than water level in pool to create
siphon.
OR- If draining into tub, push water through hose from tub faucet to push out air then
drop to floor of tub to drain.
CLEANING POOL: If you have rented your tub from your midwife,
then her and her team will take care of sanitizing the tub. You are
responsible for returning the tub clean and in good condition.
DEFLATING POOL: Your air pump can usually be used to help deflate the pool. Attach
the hose to the “air outlet” and turn on. This will suck the air out of your pool.
Things to consider when choosing a Pediatrician
1.
2.
3.
4.
5.
6.
7.
8.
9.
Location of office.
Cost of office visits.
Doctor’s education, certified by American Academy of Pediatrics?
Is the Pediatrician on staff at the hospital you will deliver in?
If member of a group, will you see the same doctor or a different one each time?
What emergency and weekend services are available?
How large is the practice? How long does it take to get a regular appointment?
Get a fee schedule- how much will a newborn exam cost?
How does the Pediatrician feel about:
A) Breastfeeding on the delivery table vs. glucose?
B) Erythromycin in the eyes?
C) PKU test- will s/he let you wait and bring your baby to the office in a few days?
D) Circumcision?
10. What is the Pediatrician’s opinion of breastfeeding (in support, not mere tolerance of)?
11. How does s/he feel about supplementary bottles?
12. Does s/he advocate introducing solids to bottle and breastfed babies at the same time?
13. When does s/he recommend solids and what kind first?
14. How does the Pediatrician feel about mother’s working?
15. How does s/he handle family concerns (willing to talk on the phone to parent)?
16. Talk with the Pediatrician about timetables and schedules- what is his/her feeling about
demand feeding?
17. What about responding to baby’s cries? Does s/he believe you can “spoil” an infant, or
that the cries signal a true need?
18. What are his/her feelings about letting the baby cry itself to sleep?
19. It is good if the Pediatricians philosophy of child development and care is openly
appreciative of the individuality of each child.
20. Does s/he hold vastly different opinion about what size family should be?
21. Is religion important?
22. Do you have preference of sex or age of the doctor?
23. Is a Pediatric nurse practitioner employed?
24. Does the Pediatrician feel good, bad or indifferent about the use of homeopathy?
25. What is his/her stand on immunizations?
26. Are you looking for a doctor who treats the whole person, or one who treats symptoms
only?
27. During the interview watch for signs that s/he has a since of humor and really likes
children.
28. After the interview take time to consider:
A) Did you feel comfortable?
B) Did you feel that the Pediatrician will issue verdicts or offer guidelines?
C) Was s/he honest or did s/he tailor answers to fit what you wanted to hear?
D) Were you treated as a peer and partner in child care?
E) Did s/he think the interview was a waste of time?
INTERVIEW PEDIATRICATIANS UNTIL YOU FIND ONE YOU LIKE AND FEEL YOU
CAN WORK WITH. SOME CHARGE FOR THIS INTERVIEW AND OTHERS DO NOT.
PEDIATRICAN REFERRAL LIST
Melinda L. Au, D.O.
285 N El Camino Real #C-202
Encinitas, 92024
(760) 436-5000
Steven Balch, M.D.
North Coast Pediatrics
285 North EL Camino Real
Encinitas, 92024
(760) 436-4511
Carol Barish, M.D.
2850 6th Street
San Diego
(619) 295-3911
Robert Barr, M.D.
15706 Pomerado Rd. S #104
Poway
(858) 673-9270
Ronald Becker, M.D.
41011 CA, Oaks, Suite 101
Murrieta, 92592
(909) 302-1435
Paul Brennan, M.D.
Family Practice
1330 Camino Del Mar
Del Mar, 92014
(858) 792-8721
Rochelle A. Broome, M.D.
3650 Clairemont Dr. Suite 8
San Diego (Sharp)
(858) 490-3000
Janna Cataldo, M.D.
Clairemont Pediatrics
10737 Camino Ruiz, Ste. 200
San Diego, 92126
(858) 578-4330
Leo Craychee, M.D.
Scripps-Rancho Bernardo
(858) 487-1800
Tom Cumming, M.D.
Pacific Beach
(619) 483-6830
Dalforno M.D.
3230 Waring Ct.,
Oceanside
(760) 433-8862
El Camino Pediatrics
Dockweiler, M.D.
Judith Rubin, M.D.
Frumin, M. D.
Suzanne Mills, M.D.
477 N. EL Camino Real
Encinitas
(760) 753-7143
Peter Hein, M.D.
Assoc. in Family Medicine
4320 Genessee Ave., #202
San Diego, 92117
(858) 565-6394
Holly Salzman, M.D.
Family Health Pavilion
499 North El Camino Real
Encinitas, 92024
(760) 436-5000
P. Hitchcock, M.D.
4150 Regents Park Rd, Suite 215
La Jolla, CA 92037
(858) 457-0030
Michelle Sanford, M.D.
Scripps Clinic
12395 El Camino Real
San Diego, 92024
(760) 794-0160
Duke Kim, M.D.
Mission Pediatric
27800 Medical Rd., Ste 116
Mission Viejo, 92691
(714) 364-6040
Wesley Kim, M.D.
Saddleback Pediatrics
27800 Medical Center Rd., #159
Mission Viejo, 92691
(714) 364-1380
Krack M.D.
3230 Waring Ct.,
Oceanside
(760) 433-8862
Sandra McColl, M.D.
2950 Sixth Street
San Diego, 92103
(619) 296-3366
MaryAnne Morelli, M.D.
(619) 583-7611
Tami Nakahara, M.D.
550 Washington St. Ste. 300
San Diego, CA 92103
Neglia, M.D.
7690 El Camino Real
Carlsbad, CA
(760) 436-4511
Rancho Santa Fe
(760) 755-9776
James Ochi, M.D.
Children’s ENT Specialist
Escondido
(760) 737-0197
Allyson Pizzo, M.D.
La Jolla Pediatrics
(858) 457-0030
Tamara Pratt, M.D.
San Marcos
(760-761-1125)
Gina Rosenfield, M.D.
1582 W. San Marcos Blvd. #203
San Marcos, 92069
(760) 744-6710
(760) 745-7313
Williams Sears & Robert, M.D.
655 Camino De Las Mares, #117
San Clemente, 92627
(949) 493-KIDS (5437)
Marty Stein, M.D.
6515 La Jolla Blvd. La Jolla
(858) 454-6162
Christine Strohmeyer, M.D.
Mission Park Clinic
Oceanside, CA
(760) 967-4900
Daniele Vecchio, M.D.
1349 Camino Del Mar
Del Mar
(858) 481-1151
Christine Wood, M.D.
Encinitas
(760) 753-7143
*Teresa O’Dea M.D. F.A.A.P
9850 Genesse Ave Ste. 340
La Jolla, CA 92037
(858)457-2043
(858)457-2092 Fax
*Accepts Tri-Care Insurance
Please Note: This is in no way
an extensive list of baby care
providers. I highly recommend
that you interview more than one
care provider, and ask questions
regarding their philosophy about
breastfeeding, immunizations,
anti-biotics, etc., to see if their
philosophy is compatible with
yours. If not, are they willing to
work with you and respect your
decisions? How willing are they
to answer your questions? The
above are doctors who have been
recommended by mothers who
are consumer oriented.
Pediatrician Referral list of those who will work with Non
Vaccinated children
Christine Wood, M.D. and Dr. Dockweiler
El Camino Pediatrics
447 N El Camino Real Suite B105
Encinitas, CA
(760) 753-7143
Dr Conrad Frey
505 North Mollison Ave #103
El Cajon Ca 92021
Dr. Donald Adema
Adema Family Medicine
10201 Mission Gorge Road Suite C
Santee, CA 92071
(619) 596-5445
Dr. Tami Nakahara
550 Washington Street
San Diego Ca 92103
619-297-5437
Dr Rubenstein
12395 El Camino Real Suite 219
858-193-1011
Dr Christal de Freitas,
Carmel Valley Pediatrics
12395 El Camino Real Suite 315
San Diego Ca 92103
858-794-5437
Sears Family Pediatrics
26933 Camino De Estrella, Suite A
Capistrano Beach, Ca 92624
949-493-5437 www.askdrsears.com
Dr. Watson, DO
(Ped’s, Nutritionist, Cranial Sacral)
Del Mar