|September 12, 2001|
Volume 3, Issue 37
|Midwifery Today E-News|
“Group B Streptococcus”
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Quote of the Week:
"Perhaps the most powerful intervention is the healing power of love and intimacy and the emotional and spiritual transformation that often results."
- Dean Ornish
The Art of Midwifery
To guarantee the vertex anterior birth position of the baby, the mother must run or at least walk a good distance (5 km) regularly. Humans are meant to be mobile, and in so doing, the baby's heaviest part is pulled by gravity toward the earth. Also the symmetrical, rhythmical movements of running and walking literally rock the baby into the most beneficial position for birthing.
- Simonne Kalau, traditional birth attendant
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A strong antibody response was evoked in 100 women who received an experimental vaccine made up of Group B streptococcus (GBS) capsular polysaccharides conjugated with tetanus toxoid. The National Institutes of Health, which supported the research, called it an important step on the way to a maternal vaccine to prevent neonatal GBS infection. Researchers explain that transplacentally acquired anti-GBS antibodies protect against perinatal infection. Efforts to induce maternal immunity have been thwarted by the variable immunogenicity of purified capsular polysaccharides of GBS. To enhance immunogenicity, the researchers developed a polysaccharide-tetanus toxoid conjugate vaccine. Antibody responses in the women were measured in a three-way comparison between the conjugate vaccine, a simple polysaccharide capsule vaccine, and a placebo. Eight weeks after vaccination, the conjugate vaccine stimulated a greater than fourfold rise in antibody concentration in 90% of recipients, whereas the unconjugated vaccine stimulated this increase in 50% of the women immunized. Antibodies evoked by the conjugate vaccine were able to neutralize GBS in vitro.
- J Clin Invest 1996;98:2308-2314 reported at www.geocities.com/HotSprings/3017/
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Group B Streptococcus
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
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.
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.
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GROUP B STREP: Read articles in back issues of Midwifery Today magazine.
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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.
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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.
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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?
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.
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
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.
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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 firstname.lastname@example.org
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
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?
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!
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