Group B Streptococcus (GBS)
Prevention of perinatal infections: Antimicrobial prophylaxis
Clinical and public health authorities in the USA, Canada,
and Australia have issued guidelines on intrapartum prophylaxis. The
1996 US consensus statement recommended one of two strategies--a screening-based
approach, in which vaginal-rectal swabs are collected at 35-37 weeks'
gestation for culture in selective broth medium and GBS carriers and
those delivering before 37 weeks with unknown GBS status are then offered
intrapartum antimicrobial prophylaxis; or a risk-based strategy in which
women of unknown GBS status receive intrapartum prophylaxis based on
threatened delivery at [greater than] 37 weeks' gestation, rupture of
the membrane 18 hours or more, or intrapartum fever (38C). Penicillin
was the agent of choice because its antimicrobial spectrum, narrower
than that of ampicillin, would reduce the likelihood of resistance developing
in other organisms.
A review of early-onset GBS during 1995 in four areas in North America
suggests that these strategies would reduce early-onset disease by 41%
(risk-based) or 78% (screening-based). As predicted, substantial decreases
in early-onset GBS disease have been reported in individual hospitals
where policies were implemented and in larger geographical areas. The
US Centers for Disease Control and Prevention's surveillance data indicate
that early-onset disease declined by 53% between 1993 and 1997 in areas
with continuous data. The incidence of late-onset disease remained stable.
This decline in early-onset disease in a multistate population in the
USA was accompanied by a significant increase in the proportion of hospitals
adopting prevention policies. Only 14% of hospitals had a written GBS
policy in 1994 compared with 46% in 1997.
Complex issues regarding management of babies whose mothers have received
prophylactic antibiotics remain. For example, the extended observation
(e.g., 48 hours or more) of these newborns has important economic consequences,
and more data are needed to clarify whether this is necessary. Also
guidelines for evaluating infants born to women who have received prophylaxis
consider less than two antibiotic doses or an interval of less than
4 hours from initiating antibiotics until delivery to be inadequate-i.e.,
in such situations additional evaluation of the baby is deemed necessary.
More research is needed to refine recommendations on what is adequate
maternal antibiotic prophylaxis and appropriate neonatal management.
GBS prevention significantly increases the use of intrapartum antimicrobial
agents. Although all GBS strains continue to be susceptible to penicillin,
erythromycin and clindamycin resistance have been reported in 7.4% and
3.4% of invasive GBS isolates, respectively, and in 16% and 15% of genitourinary
isolates. Alternatives such as a cephalosporin may be more appropriate
than these two drugs for prophylaxis in penicillin-allergic women. No
widespread increase in the incidence of neonatal sepsis due to organisms
other than GBS that are penicillin resistant has been identified in
the context of either intrapartum or postnatal prophylaxis programmes.
However, episodes of resistant infection after prophylactic antibiotic
use have been reported, and this issue merits further attention. Because
there is substantial variation in the incidence of neonatal sepsis between
hospitals and over time, long-term monitoring in large populations is
needed to characterise the adverse effects of antimicrobial prophylaxis.
- The Lancet, January 2, 1999
How your decision about GBS testing will affect your
labor and birth (excerpt)
If you choose not to have a GBS culture done during your
pregnancy, you have about an 18 percent chance of needing antibiotics
during labor, using the CDC/ACOG guidelines. Your baby's chance of developing
GBS disease depends on whether you have (or develop in labor) any clinical
risk factors.
If you don't have any clinical risk factors, your baby has about a one
in 750 chance of developing GBS disease, and antibiotic treatment is
not recommended.
If you do have one or more clinical risk factors, your baby, if untreated,
has about a 1 percent chance (one in 100) of developing GBS disease.
The Centers for Disease Control (CDC), American College of Obstetricians
and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP)
all recommend treatment with intravenous antibiotics in labor. This
can be done at home and you can continue plans for a homebirth.
If you choose to have a GBS culture done during your pregnancy, you
have about a 28 percent chance of needing antibiotics during labor,
using the CDC/ACOG guidelines. Your baby's chance of developing GBS
disease depends on the results of your culture and whether you have
(or develop in labor) any clinical risk factors.
If a GBS culture comes back negative, your baby has a very small chance
(one in 2,000) of developing GBS disease, and antibiotic treatment is
not recommended.
If the GBS culture comes back positive, your baby's chance of developing
GBS disease depends on whether you have (or develop in labor) any clinical
risk factors. Antibiotic treatment for all women with a positive culture
(regardless of clinical risk factors) prevents about 86 percent of GBS
disease. Antibiotic treatment for only those women with a positive culture
plus clinical risk factors prevents about 51 percent of GBS disease.
If you don't have any clinical risk factors, your baby, if untreated,
has about a 0.5 percent chance (one in 200) of developing GBS disease.
The CDC, ACOG and AAP all recommend offering treatment with IV antibiotics
in labor to women in this category.
If you do have a clinical risk factor, your baby, if untreated, has
about a 5 percent chance (one in twenty) of developing GBS disease.
The CDC, ACOG, and AAP all recommend giving treatment with IV antibiotics
in labor to women in this category.
- Lynn McDonald, CNM, "Group B Screening," Midwifery
Today Issue 52
E-News readers write:
The best thing I've ever found [on GBS] is the CDC Handbook
for Parents. It is a concise guide to the strep issue, including risks
of following the various protocols. It puts things into common, everyday
language and is helpful for caregivers as well as expectant parents.
It's available free online. Go to: http://www.cdc.gov/ncidod/index.htm
My favorite quote is the following: "A GBS carrier with none of
the conditions above has the following risks: 1 in 200 chance of delivering
a baby with GBS disease if antibiotics are not given; 1 in 4,000 chance
of delivering a baby with GBS disease if antibiotics are given; 1 in
10 chance, or lower, of experiencing a mild allergic reaction to penicillin
(such as rash); 1 in 10,000 chance of developing a severe allergic reaction--anaphylaxis--to
penicillin. Anaphylaxis requires emergency treatment and can be life-threatening."
Doesn't that put it nicely in perspective? I know folks who are telling
moms their babies have a thirty percent chance of getting sick or dying
with strep if mom is positive. That is a heck of a lot different from
CDC's estimate of one out of 200!
- Gail Hart
I had midwifery care throughout my pregnancy and had a positive
GBS at 36 weeks. My midwife assured me that only in the case of SROM
and long labor would this be a problem. My water broke and had light
meconium staining. After 12 hours I still had no labor. The baby had
great heart tones but after discussing the possibilities we decided
to transfer. I was against birth in a hospital and having to have interventions.
I had the standard GBS antibiotics IV after 19 hours SROM and also the
dreaded Pitocin. After 8 hours of contractions that were at odds with
my body and I was still only 3 cm I needed pain relief.
Three hours after the epidural, which was so strong I couldn't feel
my chest, I was complete. Sol was born after 30 min of blind pushing
because I couldn't feel a thing. There was no meconium to speak of.
After some time he had rapid breathing but was trying to nurse and happy
in my arms after a long labor full of drugs. I was told he needed to
be observed in the nursery and I hesitantly let him go. We spent the
next 5 days there, receiving routine antibiotics, for an infection he
may or may not have had.
Four months later I go over and over what I wish I would have done or
why I hadn't just stayed home. I long to have a powerful homebirth now
more than ever. I am a student midwife and I know that it is a hard
call for some of the more conservative midwives to hold off transfer
in cases such as mine but I truly believe that intervention only forced
my labor, not helped my labor. I would love to hear some other GBS stories
and outcomes from other midwives' practices.
- Jessica Rios
Davis CA
Reply to: chacharios@yahoo.com
Some midwives who are not licensed to give antibiotic IV
therapy will have the mom douche with Betadine (6 tsp. to 1 liter water).
- Merna Black LM, CPM
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Question of the Week
Are midwives' clients experiencing any medical problems from refusing
the vitamin K shot and eye prophylaxis (assuming, of course, they tested
negative for chlamydia and gonorrhea)?
- Anon.
Send your responses to:
Question of the Week Responses
Q: When should the infant's cord
be cut, before or after the infant is breathing well on its own? Why?
- D. Young
A: I was taught that the cord should be cut after breathing is
established because the cord may be the only source of oxygen the baby
is getting. However, if after the first minute more resuscitation measures
are needed, the cord should be cut and oxygen and bag and mask be initiated.
But a few years later there was a horrible shoulder dystocia in the hospital
where I was trained. The perinatologists were involved and after a 13
minute dystocia the head was pushed back in and a cesarean was performed.
The mother and baby both did well. The perinatologists later sent a memo
stating they believe one reason the babe survived such a long dystocia
was because they had not cut the cord early and babe was still getting
oxygen from the cord.
- M.S.
A: Cutting the cord is the last thing I worry about! Obviously,
making sure the baby is OK is the first priority. The second priority
is blood loss to the mom. When all else is well and good, I finally get
around to cutting the cord. But there is an exception to every rule. If
twins share a placenta, or if it is unknown whether they share a placenta,
I would at least clamp the cord of the first twin immediately to avoid
twin-to-twin transfusion. If all is not going well, once the cord is flaccid
it's of no further use to the baby, so I would cut it to better deal with
the baby--i.e. take it to a warmer spot, put it on a firmer surface, transport
to hospital, etc. But while the cord is still attached it can be used
to help resuscitation efforts. One of the steps of neonatal (and some
adult, for that matter) resuscitation is to give a fluid bolus. What quicker,
easier way than to give baby all its own blood back by simply holding
the baby below the placenta and let it all drain in! (Caution: in a healthy
baby giving all that blood can cause polycythemia and jaundice just as
holding the baby up above the placenta can cause anemia. If there is delayed
cord cutting, they normally fare better if the two are kept level.)
- T.W.
A: If the cord is not cut until it has ceased pulsating, the baby
can receive up to 20% more circulating blood volume which is obviously
of benefit to the newborn, especially if it is preterm. Studies have shown
it has beneficial outcomes for the preterm, especially if the baby is
laid on the abdomen and not higher than the placental position in the
uterus. Laying the baby higher than the uterus until the cord has been
clamped may result in blood flowing from the baby back to the placental
site, draining much needed fetal circulating volume and producing backflow
to the uterus.
Studies have also shown that not immediately clamping the cord enables
the physiological compaction and compression of the placenta to be completed
and if it is clamped too early, it produces counter-pressures that impede
the physiological processes.
Although all women are at risk of placental-fetal transfusion, if the
third stage is not "managed" effectively, those that are rhesus
negative are more at risk if the cord is not clamped quickly (this depends
on the time lapse involved and the baby's position--higher or lower than
the placental position. If the baby is higher, there is less risk of placental-fetal
transmission than if the baby is lower.) If there are large amounts of
fetal blood cells in the maternal circulation from the placenta, then
it may cause haemolysis of fetal blood cells in future pregnancies. (Sweet
1998)
Not cutting the "lifeline" too soon obviously has its benefits
for the baby who is slow to start respirations. Until the cord has ceased
pulsating it is still receiving much-needed oxygen via the umbilical cord.
Unfortunately, many professionals are reluctant to allow this as there
is a rush to give oxygen via facial mask on the resuscitaire rather than
bring the oxygen to the baby if needed, still allowing it to receive the
vital blood from the cord. Obviously if the baby is in real need of help
after the birth, then relying upon the physiological processes are not
enough, and the cord should be cut and clamped as soon as possible.
If the birth has been normal and the baby is not compromised in any way,
cutting the cord after it has ceased pulsating is a gentler way and more
physiologically natural way of welcoming the baby into the world.
- Helen H.
UK
A: I do not cut the cord until the placenta has been expelled.
It has proved to prevent any trouble from occurring!
- T.S.
A: In the Lotus Birth practice, the cord is never cut. Baby, mother
and placenta are "enthroned" in bed with the placenta coated
in ground rosemary. The placenta and cord dry up, and the baby kicks or
pushes away the cord, disconnecting it from him/herself between the 3rd
and 5th day. I learned of this in the wonderful "Sacred Birthing"
seminar presented by Sandy Karll and David Lewis. They had series of photos
of a few Lotus Births. Sandy and David spoke of the protective functions
of the placenta. They had an adult-sized mock-up of an umbilical cord
made of stuffed cotton; it's proportionally quite large.
- Anon.
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Coming E-News Themes
1.DOULAS: If a birthing woman has good midwifery care, why might she
also benefit from having a doula attend her birth? (Issue 2:44, Nov. 1)
2. INTACT MEMBRANES: What are the fetal benefits to labor with intact
membranes? Do you have any documentation to share with E-News readers?
Send your responses to:
Know a strong woman? Helping empower one? If you haven't already done
so, please forward this issue of Midwifery Today E-News to one or two
of your friends or business associates. Thanks so much!
Switchboard
More on birth rituals:
Excerpts from "Pregnancy, Childbirth, and the Navajo Culture"
by Summer Elliott
During pregnancy, Navajo women are encouraged not to drink milk or eat
salt, attend funerals or look at dead bodies of humans or animals, be
around sick people for long or go to crowded places, lie around too much,
tie knots, lift heavy things, look at the eclipse of the moon or sun,
weave rugs or make pottery, kill living things, or make plans for the
baby or prepare layette sets until after birth (Wilson, 1992). Most animals,
especially dead ones or those considered "evil" or dangerous
in any way should be avoided. The pregnant woman should avoid strange
or violent activity or it will affect the baby. She should avoid excessive
fat and sugar. If a woman ties knots or puts bowls together while she
is pregnant, she will have a hard time having the baby. If the pregnant
woman stands in a doorway while pregnant or someone else stands in the
doorway when a pregnant woman is present, the baby will have difficulty
coming out. Any activity that seems to bind something up, to nail something
shut to secure it, or to plug an opening is seen as improper activity
for a pregnant women or her husband and perhaps other members of the family,
at least while she is present.
Traditional Navajo beliefs concerning labor and birth include thinking
positively about the delivery, having medicine people sing baby chants
and sing "unraveling" songs if necessary, drinking corn meal
mush, wearing juniper seed beads, burning cedar, holding onto a sash belt
while pushing, drinking herbal tea to relax, loosening the hair, having
someone apply gentle fundal pressure during pushing, squatting to push,
and drinking herbal tea to strengthen contractions if necessary (Wilson,
1992).
After the birth of the baby, Navajo families are encouraged to bury the
placenta, drink juniper/ash tea for cleansing, drink blue cornmeal mush,
breastfeed the baby, smear the baby's first stool on mom's face, and wrap
the sash belt around the mother¹s waist for four days after delivery.
Mom is encouraged not to drink cold liquids or be in a cold draft, smell
afterbirth blood for too long, show signs of displeasure if baby soils
during diaper change, burn placenta or afterbirth blood fluids, or have
intercourse for three months after delivery (Wilson, 1992). I have seen
a few more of these beliefs being preserved. Most Navajo families still
do take home the placenta to bury under a tree. The cafeteria occasionally
serves blue cornmeal mush. Moms are also encouraged to breastfeed their
babies.
- Anon.
In India, it seems that most of the ancient rituals are not regularly
practiced anymore. They have been replaced by crude hospital protocols
that include beating a complaining labouring woman. Originally their culture
promoted a very strong respect of mothers.
However, the following two ceremonies described in the Hari Bhakti Vilas
written some 500 years ago are still followed. I recommend it to all the
families when I assist with the birth of their children.
When a mother is soon to give birth, she is taken to a room in the southwest
of the house. In India, they follow Vastu which is the ancient Vedic equivalent
of feng-shui. According to Vastu the room in the southwest should be reserved
for tranquility. Before entering this room, there are extensive religious
ceremonies, with offering in fire, welcoming the soon-to-arrive child
and thanking the Lord for the blessing.
When the child is born, before the cutting of the cord, the husband first
orders that no one cuts the cord and that the baby not be given milk.
He then quickly showers, and returns. By that time, the baby is breathing
nicely and the cord has stopped pulsating. At that time he prays to Lord
Visnu for intelligence, strength, and beauty for the child and applies
a minuscule portion of ground rice and barley mixed with ghee (clarified
butter) on the newborn's tongue. The rice and barley are to be ground
by hand by either a pregnant woman or a virgin girl--both considered very
auspicious. The father, or someone he asks, then cuts the cord. The mother
will be considered "contaminated" or unfit to cook or attend
most religious functions for at least a month. This works out pretty well
as it allows the mother to recuperate without feelings of guilt for not
participating in the communal housework.
- Yasomati
India
Editor's note: continue to send birth customs from your country and
culture and we will include them as a mini-column in E-News.
More on autism [Issue 2:41]:
The November issue of Discover magazine, p. 24, includes a small article
relating to autism. Basically, scientists have done studies on mice and
found that oxytocin plays a role in social memory (how a person remembers
someone they've met, for example). What the experiments showed is that
mice with low levels of oxytocin had no social memory ability. The article
also says, "Interestingly, people with autism who fail to form strong
social bonds have low levels of oxytocin." (R.S. Tuma)
Could the use of Pitocin trigger something in the brain that signals it
to make less oxytocin naturally (the equivelent to "Hey, we're all
full down here, don't worry about sending down more" messages in
the brain)? And if so, perhaps labor is the crucial "moment"
developmentally for that chemical trigger to be stimulated or squelched.
- Amanda Battles, doula
Asheville, NC
I was very surprised to hear that the second stage of a labor might have
taken so long! [Issues 2:41 and 42] As you know there would be lots of
complications and dangers for fetus and mother during second stage (full
dilation until bulging the fetus's head) if it took longer than as usual
(10-30 minutes in multipara and 20-60 minutes in nullipara) such as: uterine
exhaustion, fetal hypoxia, risk of fetal death, legacy prolapse and varying
degrees of urinary and faecal incontinence. Also, nowadays there are many
technical methods to understand the situation and position of a fetus
in his mother's womb. So we are able to make decisions before everything
goes wrong. All these can prevent any bad outcome.
Since all the complications aren't predictable, I'd like to know how midwives
dare to let it be and why they don't refer the pregnant mother for c-section.
- Dianat-Sheida, OB
More on sterile field [Issue 2:42]:
I suppose that midwives working in hospital environments have to be more
careful about protecting a birthing woman from pathogens, but I find that
I'm very relaxed about sterility in my out-of-hospital birth practice.
Anything that goes into a woman's vagina after rupture of membranes needs
to be sterile, of course, though I do vaginal exams in the pool in late
labor and that isn't exactly sterile. I've never had a problem with infection,
though. Catching a baby simply isn't a sterile procedure and I don't worry
at all about creating a sterile field for the birth. Although I sterilize
my cord clamps and scissors, I suspect that "clean" is probably
adequate. Suturing is done with sterile gloves and instruments because,
again, it is actually invasive. Mostly, I think that sterility during
birth is probably over-done to the detriment of the woman's ability to
control and enjoy her birth experience!
- Gretchen, CNM
I allow women to use the toilet as needed (as opposed to a bedpan where
waste is more likely to be in prolonged contact with the vagina and perineum).
The hospital birth packs (that contain the instruments needed for birth)
contain as well "sterile" drapes etc. I sometimes use the drape
for under a woman's behind (the drape has a plastic pouch if membranes
are intact and I fear for a flood, for this allows for quicker clean-up
and minimal interruption of the maternal-baby diad). Otherwise I just
wash my hands and keep mom's poop away from baby.
Over 5 years and close to 500 births I have not had a woman with a breakdown
of a laceration or fetal morbidity.
- Zora
I don't think sterile fields have a place; the baby needs to be colonised
with the mother's flora for protection and with bowels often opening at
delivery how do we guarantee sterility?
- Anon.
I'm curious if anyone knows the presidential candidates' positions on
homebirth, homeschooling, and vaccinations.
- Amy Jones
Reply to: thebirthsource@hotmail.com
Greetings from Fortaleza, Brazil! As you may know, in Brazil, a country
where midwifery does not exist as an established profession, the cesarian
section rate in most private hospitals is as high as 90%, whilst poor
women give birth in degrading conditions in the world's most crowded hospitals.
What you may not know is that in the same country, a number of initiatives
have been created since the 1980s that attempt to recover human values
in childbirth, a movement known as the "humanization of childbirth."
On November 2, 3 and 4 midwives and others interested in maternity care
from all over the world will gather at the International Conference on
the Humanization of Childbirth to promote humanized childbirth.
Contact the Conference Secretariat at +55 85 246 4302/246 0232, by fax
at: +55 85 246 2697, email: childbirth@eventuall.com.br,
WWW at
www.humanization.org
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