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About 40% of adults are carriers of Group B Streptococcum (GBS) in their genital
or intestinal tracts. Usually, GBS doesn't cause problems. In fact, in most healthy
adults it is considered a "normal" organism, and treatment with antibiotics
is not given. It does have significance for the pregnant woman, however. GBS,
which can be passed from mother to baby during childbirth, is the leading cause
of newborn sepsis--serious infection throughout the baby's body soon after birth.
A specific combination of factors seems to be at work in babies who develop
GBS disease. It is most likely to develop in babies whose mothers are carriers
of GBS and who have one or more clinical risk factors. In these babies, who are
at the highest possible risk for GBS disease, about five out of 100 will develop
it. Babies whose mothers are GBS carriers but have no clinical risk factors are
less likely to develop GBS disease: about one in 200 babies will get GBS disease.
Those whose mothers have clinical risk factors but test negative for GBS are even
less likely to develop GBS disease--about 1 in 1000--and those whose mothers have
neither risk factors nor a positive GBS culture have a very small chance of getting
GBS disease--about 1 in 3000.
Clinical Risk Factors for Developing GBS Disease:
Prenatal risk factors: Previous baby with GBS disease; urinary tract infection
with GBS at any time during this pregnancy
Labor-related risk factors: Onset of labor before 37 weeks, rupture of membranes
before 37 weeks; rupture of membranes more than 18 hours before birth; fever over
100.4 degrees during labor.
- "Group B Screening," Midwifery
Today Issue 52
====
Researchers conducted a review of infants who had early-onset group B streptococcal
(EOGBS) infections and were born in Southern California Kaiser Permanente Hospitals
from 1988 through 1996. To summarize:
*319 infants with EOGBS sepsis, bacteremia, or clinically suspected infection
were identified from a population of 277,912 live births (approximately 1 in every
870 births).
*Of the 172 term infants with culture-positive infection who had clinical signs
of infection, 95% exhibited them in the first 24 hours of life.
*All of the infants exposed to antibiotics during birth became ill within the
first 24 hours of life.
Researchers concluded that "exposure to antibiotics during labor did not
change the clinical spectrum of disease or the onset of clinical signs of infection
within 24 hours of birth for term infants with EOGBS infection."
- Pediatrics August 2000; 106: 244-250
from Dr. Joseph Mercola, www.mercola.com/2000/aug/13/group_b_strep.htm
====
At least nine types of GBS exist, but five of them cause 95 percent of the disease.
====
Incidence: Approximately 17,000 cases occur annually in the United States; approximately
7,500 occurred in newborns before recent prevention. The rate of neonatal infection
has decreased from 1.7 cases per 1,000 live births (1993) to 0.4 cases per 1,000
live births (1999).
Sequelae: Neurologic sequelae include sight or hearing loss and mental retardation.
Death occurs in 5% of infants and 16% of adults.
- www.cdc.gov/ncidod/dbmd/diseaseinfo/groupbstrep_t.htm
====
Can GBS disease among newborns be prevented?
Most GBS disease in newborns can be prevented by giving certain pregnant women
antibiotics through the vein during labor. Any pregnant woman who previously had
a baby with GBS disease or who has a urinary tract infection caused by GBS should
receive antibiotics during labor.
Pregnant women who carry GBS should be offered antibiotics at the time of labor
or membrane rupture. GBS carriers at highest risk are those with any of the following
conditions:
* fever during labor
* rupture of membranes (water breaking) 18 hours or more before delivery
* labor or rupture of membranes before 37 weeks
Because women who carry GBS but do not develop any of these three complications
have a relatively low risk of delivering an infant with GBS disease, the decision
to take antibiotics during labor should balance risks and benefits. Penicillin
is very effective at preventing GBS disease in the newborn and is generally safe.
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 4000 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.
If a prenatal culture for GBS was not done or the results are not available, physicians
may give antibiotics to women with one or more of the risk conditions listed above.
- Centers
for Disease Control
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WWW.MIDWIFERYTODAY.COM
A Web Site Update for E-News Readers
GROUP B STREP: Read articles in back issues of Midwifery Today magazine.
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Issue 39: www.midwiferytoday.com/products/MT39.htm
Issue 42: www.midwiferytoday.com/products/MT42.htm
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Midwifery Today's Online Forum
In my community, there doesn't seem to be any opportunities for apprenticeship,
and I am looking to schools in the US where I can hopefully participate in this
ancient process. As well, someone responded to a posting I had made in the Midwife
Chat (about midwives' perceptions of apprentices) questioning whether anyone is
still taking on apprentices, which has opened up a whole new level of worry for
me personally and for the future of midwifery. I've already read tons about apprenticing,
but I never tire of your stories.
- Julia
Canada
To share your thoughts and experience, go to Midwifery
Today's Forums.
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First Annual Conference
Renew your license, friendships, energy
October 6th and 7th, 2001 in Fort Lauderdale, Florida
DoubleTree Suites, Fort Lauderdale, within walking distance of the famous beach.
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Conference costs include buffet breakfast and lunch each day.
For registration brochure, contact Sharon Hamilton LM 954-581-8126 or mgtepstein@juno.com
Question of the Week
Q: I am the midwife of a woman who had twins 16
months ago in a home delivery with no problems. She had some varicose veins while
carrying the twins. She had a 12-month-old baby when the twins were born and is
currently 34 weeks pregnant with another. That is four babies in less than three
years.
In the last 12 months she has developed significant varicose veins that start
in her feet and go up her leg to the perineum and into the labia internally. The
veins are larger than a large thumb. What is the danger of a varicose vein bursting
while in labor? If one does burst, what are possible procedures to follow to stop
bleeding?
During this pregnancy she has been faithfully using horse chestnut, butcher's
broom, hesperidan, bioflavonoids, vitamins, a good diet, and super food supplement,
but she has done nothing topically and is not much of an exerciser. Also, are
there upper body-only aerobic programs? One will be needed after this pregnancy.
- Debi
Send your responses to:
Question of the Week Responses
Q: What are midwives doing when women test positive
for group beta strep in pregnancy? What protocols are midwives implementing at
the birth and postpartum?
- Anon.
====
A: When a woman tests positive for beta strep the midwife should provide
proper and full informed consent to the mother so that timely treatment can ensue
when necessary. Midwives must study and be aware of current treatment modalities
and understand the risk categories. Beta strep is a true pathology and may implicate
the necessity for medical intervention.
Despite the fact that I believe that much of the medical community is overzealous
in treating women who test positive, the repercussions of not treating can be
disastrous to a midwife's practice and result in a malpractice lawsuit. The woman
should make the decision regarding treatment but only after being fully informed
and the midwife should document her consent or refusal on a well-drafted informed
consent form AND in subjective notes in the chart. If the midwife finds the woman
to fit within a high-risk category, she should report her findings to the woman's
physician and refer her to a medical provider. If the woman tests positive at
any time during the pregnancy, the midwife should, at the very least, report her
finding to the pediatrician after the delivery. These actions describe a midwife's
professional obligation to the mother, to herself and to the midwifery community.
- Suzanne Suarez
====
A: We test all moms between 35 and 37 weeks. If a woman is positive for
GBS we give her IV antibiotics in labor. We give penicillin, ampicillin or another
medication if she is allergic to penicillins. She is considered adequately covered
if she receives 2 doses. The problem is the pediatricians who keep changing their
way of handling the baby after birth. Right now they are keeping moms and babies
for 48 hours if mom was positive.
- Mary
====
A: In our practice we follow ACOG guidelines (risk-based strategy): Risk
factors are treated in labor with penicillin G; that is, if the urine culture
is GBS+ in pregnancy the woman is treated in labor. If she goes into labor <37
weeks, has fever, rupture of membranes equal to or >18 hours, she is treated.
The newborn provider is notified of all of the above.
If she is tested (testing is an option for all women in our practice and a routine
for some of the women we deliver who receive care through Planned Parenthood;
the American Academy of Pediatrics recommends testing vs risk-based strategy)
at 35-37 weeks and is positive, she is given penicillin G prophylaxis or Clindamycin
if there is a history of penicillin allergy.
- Midwifery Practice Stony Brook Medical Center
Stony Brook, NY
====
A: I am an independent midwife in the Netherlands. In our country, women
are not routinely tested for GBS because it appears that 80% of the women have
it but only a few babies get ill from it. So we only know that women test positive
when they had had an incident in the past and mostly it's when their baby got
ill within 12 hours or less postpartum. In most cases the babies are prematurely
born or the membranes are more than 24 hours ruptured.
Because it's been proven (read the latest "Effective Care in Pregnancy
and Childbirth") that testing the orifices of the baby directly postpartum
doesn't say anything and giving antibiotics within four hours of birth won't help,
in our region we let the women who previously tested positive test again in the
36th week of pregnancy. If GBS is tested positive they are given antibiotics and
after the strep is then tested negative they can eventually give birth at home.
After birth the baby will be closely observed for signs of illness (because
the strep can return within some weeks) and when these signs appear, the child
is immediately sent to the hospital where it is treated. When a woman previously
proved positive while giving birth prematurely, we send her earlier (30th week)
to an obstetrician to be tested and eventually treated.
We agreed to do this with some of the obstetricians we work with. Unfortunately
some are sticking to some old fashioned protocol and won't listen at all to the
latest discoveries on this subject.
I realise that these protocols are not possible all over the world because in
our region we have very good postpartum nurses at home who know exactly what to
observe so we can leave mother and child in good faith in her hands. We also have
frequent meetings with most of the obstetricians we work with and we try to come
together in regard to these questions by discussing the latest articles on several
subjects and regarding a home delivery for the women still can be an option. When
there must be a hospital delivery we can tell our clients why there is a greater
risk and what the hospital can offer more than their own home. That gives a good
basis for respect for what we as midwives and obstetricians can achieve together.
- Anon.
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This conference is FREE to all CAPPA members. Exhibitor and advertising opportunities
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Question(s) of the Quarter for Midwifery Today
Issue 60
What are strengths and weaknesses of your path to becoming a midwife? How does
the current controversy over the various pathways to becoming a midwife affect
your practice or your hopes for a practice? Do you have any specific thoughts
about midwifery education?
Please submit your response by September 30, 2001 to editorial@midwiferytoday.com
Selected responses will be published in our print magazine in the December issue.
Please include your full name, occupation and city/state/country.
Switchboard
International Connections
I enjoy your thoughts via E-News as I work amongst the local people of Quetta,
Baluchistan, Pakistan. Yesterday I delivered a G9 P8 Pashto-speaking lady who
had the biggest cystocele--like a medium-sized rough-skinned orange that only
really started bulging at the time. She commenced pushing at 8 cm. When I got
her up to admit/check her, it was rapidly joined by a rectocele like a tangerine
that was hard against the firmer cystocle. (The lady chanted/ squealed the next
hour and no one on the staff could understand her. It was a "different"
delivery!) I supported both the cystocele and the rectocele as much as I could,
with both hands, taking the stress and straining until delivery of the head through
them. I believed I was doing right (am sure this is what I was taught) but the
lady doctor arrived in the midst of the delivery and said it wasn't necessary--they
were there anyway and it was useless to support them. What are your thoughts?
- Robyn Aulmann, RM
Quetta, Pakistan
====
As a midwife in Scotland I am exploring the possibilities of 'employing' volunteers
in the maternity wards. Does anyone have experience of this to suggest what sort
of functions volunteers can perform?
- Liz
====
INTERNATIONAL MIDWIVES, please direct your questions, comments, and needs to
"International Connections." We're here to help you!
~*~*~*~*
On Sunday, September 16 on Dateline NBC there will be a segment on Cytotec induction
with comments by me and by ACOG. For the exact time it is shown, consult your
local TV guide. I have not seen it so can't recommend it except to say that getting
this before the public is good news.
Please spread the word to those interested.
- Marsden Wagner, MD
====
At 20 weeks I started experiencing numbness on the outside of my left thigh.
I had this same problem in my first pregnancy, but this time it started sooner
and was much more severe. By 30 weeks the numbness was constant and when I stood
or walked for too long it would develop shooting pains. I am now five weeks postpartum
and the numbness has only improved about 40% (the last time it went away immediately).
A doctor told me it was the only case he has seen like it, but he's calling it
meralgia paresthetica (compression of the lateral femoral cutaneous nerve). He
"thinks" it will fix itself within a month but seemed pretty uncertain.
Does someone have some experience with this and/or advice? I've been seeing a
chiropractor, but it hasn't helped at all yet.
- Samantha Gates
====
I think getting actual statistics about how often previas move is tricky because
it requires ultrasound and large study populations. However, I've heard recently
that use of homeopathic "cinnamonum" (yes, homeopathic cinnamon) can
be great for moving them. It's worth a try!
- Anon.
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