GBS Swab Opinions - Alan? Schmickers? Others?

[Cricket]

Well, I went through this dilemma with my previous pregnancy, and decided to have the GBS swab done, thinking it would likely be negative, as all my previous ones had been... It was positive and a week of garlic clove treatment and a hydrogen peroxide rinse before the next test didn't change the result. I missed out on my homebirth because of the policy here that you MUST have IV antibiotics during labour if you are GBS positive. (Yes, I know I could refuse treatment, but I wasn't prepared to do that, and I didn't feel like I had enough information on the whole business to decide what was the best choice for me.)
So now, I'm trying to get my research done beforehand, so I have time to make a good decision.
What do you think about the swab and the antibiotic treatment for positive results? Worthwhile? A waste of time? From what I understand, a baby is at risk to contract GBS if they are premature or if you labour for a long time with waters broken. My babies have all been full term, and delivered within about 30 min of waters breaking.
I am wondering about skipping the test entirely this time around. Alan, as a midwife, and Schmickers, as a pediatric nurse, what are your opinions on this, if you don't mind sharing? Anyone else out there want to add your two cents? I do not want to put my baby at risk, but I'd much rather have a homebirth if I can. I think that antibiotics have their own impact on my health and the baby's health - all their healthy gut bacteria would be thrown off, I'd think. Plus, there's the whole range of bacteria that you're exposed to simply by being in the hospital.....
I don't know - give me some feedback here if you can! Thanks!

[Pandora]

Im not sure about Canada, but at a lot of hospitals here, once you have had any positive GBS test you get Abs every time after that.

[entreat]

I have absolutely no advice, but am really interested to hear what the options are. I havent got my results back yet. Could you PM what the garlic cloves treatment is?

[Cricket]

Pandora - that's not the policy here, although some obstetricians might do that themselves. (Which is silly - the bacteria is apparently transient, and has about a 6 week cycle, or something like that....?)

Entreat - have a look at this article: https://www.bellybelly.com.au/forums...ve-garlic.html In the article, they are talking about yeast, but it should work for GBS too, apparently. (Didn't for me, but I've heard it has for others.)

And here is the thread where Alan and Julie Doula and a few others helped me out (bless them!) with suggestions. https://www.bellybelly.com.au/forums...tive-help.html

I was allowed to swab a second time, after the first positive result. My midwife was a great lady. Some doctors might not give you that option.
Hope you get a negative result!

[Pandora]

Yes it is silly isn't it? I didn't have the GBS test at all last time so I don't have much mor advice. I'm sure Alan will

[Traveller]

Personally I am opposed to routine GBS swabbing in pregnancy as I believe the risks of abx in labour and the effects this has on a newborn's gut to outweigh the risks of sepsis in the newborn. Don't get me wrong, sepsis is extremely serious but it can be caused by a myriad of infections, and monitoring all babies (at home, by the parents) is a much better option IMO than mass treatments "just in case".

[BellyBelly]

I posted this on my FB yesterday:

Group B Streptococcus | What Does the Research Really Say?

Group B Streptococcus
What Does The Research Really Say?
In the US, most pregnant women have heard of Group B Streptococcus, but unfortunately know little true information about the condition and the real risks involved. The American College of Obstetricians and Gynecologists (ACOG) and the US Centers for Disease Control and Prevention (CDC) recommend that all pregnant women be screened between weeks 35 and 37 of their pregnancies to determine if they are carriers of GBS by taking a swab of the vaginal and rectal areas. About 30% of pregnant women are found to be colonized with GBS in one of both areas.

The recommended treatment by the CDC and ACOG is intravenous antibiotics during birthing because GBS can be passed from you to the baby during delivery and cause sepsis (a blood infection), pneumonia, and/or meningitis (an infection of the fluid and lining of the brain).

WHY WOULDN'T A MOTHER CHOOSE ANTIBIOTICS?


To answer this question, we need to look at what GBS truly is and why it might not be such a good idea to recommend that a third of all pregnant women expose themselves and their babies to antibiotics from birth.


GBS is a bacterium that normally lives in the intestinal tracts of many healthy people. In truth, you should never be termed “GBS infected” but rather “GBS colonized”. Remember that the intestinal tract is composed of normal healthy bacteria, including GBS. It is usually a transient condition that will come and go through your pregnancy. You may swab positive at 36 weeks, only to be negative again at 38 weeks.

GBS can cause problems only when it is present in the genital area during birthing and delivery. When this happens, there is a very small risk that the bacteria will be passed on to the baby and become sick. Approximately 0.0225% of women found to be GBS+ at 35 to 37 weeks who aren’t treated with antibiotics will have a baby who becomes ill. That's 1 in 4444 babies who will become ill.

But here’s the most important point: in women who do receive antibiotics, 0.0225% of babies will go on to become ill from GBS. That's also 1 in 4444 babies who will become ill.


Antibiotics make absolutely no difference in the number of babies who will die from GBS.

In truth, there are many reasons you don’t want antibiotics for Group B Streptococcus, besides the fact that they don’t improve outcomes at all. These include:

• Increasing occurrence of antibiotic-resistant infections (“superbugs” - think MRSA)
• Use of antibiotics has increased risk of developing other infections (sepsis & E. Coli included)
• Colonization of GBS is a poor indicator of which babies will become ill
• Antibiotics fail to prevent infection in 30% of cases

The most-commonly used antibiotic for treating Group B Streptococcus during birthing is penicillin. Fewer bacteria currently show a resistance to penicillin than to other antibiotics used to treat GBS. Ampicillin and amoxicillin are virtually worthless for treating GBS due to overuse that has now made Group B Streptococcus resistant to them. It’s only a matter of time until penicillin is also ineffective against GBS. The superbug is on its way.

If you are allergic to penicillin, your options decrease. 29% of Group B Streptococcus strains are resistant to non-penicillin antibiotics. If you don’t know if you’re allergic or even if you’ve had it in the past, there’s a 1/10 chance of a mild reaction such as a rash, and a 1/10,000 chance of anaphylaxis, a life-threatening allergic reaction.

Two in 10,000 babies may be saved by antibiotics during birth, but this comes at the cost of giving 1/3 of all pregnant women antibiotics. The risks of developing a superbug are greater than the chances of saving your baby with antibiotics. This also doesn’t take into account how many other infections babies given antibiotics may develop other than Group B Streptococcus.


WHAT ARE THE RISK FACTORS FOR MOTHERS WITH GBS?



There are three significant factors that place your baby at increased risk of infection: fever during birthing, water breaking 18 hours or more before birthing (prolonged rupture of membranes, or PROM), and/or birthing or broken water before 37 weeks. Other factors that can contribute to a newborn's risk of contracting Group B Streptococcus infection include age, ethnicity, and medical criteria, such as the following: being born to a mother who is less than 20 years old, being African American, large amounts of GBS bacteria in the vaginal tract, and having a previous baby with GBS disease.


WHAT ARE THE SYMPTOMS OF GBS INFECTION IN A BABY?


There are two forms of Group B Streptococcus infection: early and late onset. In early-onset GBS disease, your baby will become ill within seven days of birth. In severe early-onset GBS infection, about 6 percent of babies will die from complications of the infection. Full-term babies are less likely to die; 2-8% suffer fatal complications. Premature babies have mortality rates of 25-30%. Late-onset GBS infection is more complicated and may not have anything to do with whether you had GBS during birthing. It occurs between seven days and three months of age.

Symptoms of early-onset Group B Streptococcus infection include any of the following: fever or abnormally low body temperature, jaundice (yellowing of the skin and whites of the eyes), poor feeding, vomiting, seizures, difficulty in breathing, swelling of the abdomen, and bloody stools. The most common symptom is difficulty breathing, which is also the most common complication in babies whose mothers choose drugs during birthing. Since these symptoms can occur in so many circumstances not related to GBS, a C-Reactive protein test can be given to a symptomatic baby to reveal the presence of an active infection.


ARE THERE ALTERNATIVES TO ANTIBIOTICS?


Even though Group B Streptococcus is a transient infection, without an active effort to eradicate the GBS colonization, it is likely that you will still be colonized after 37 weeks. We will see better outcomes by simply focusing on reducing colonization rather than treating it after the fact.

There are many probiotic, natural remedies that focus on restoring a healthy vaginal flora balance, reducing bacterial overgrowth, and directly reducing the bacterial concentration. These treatments can begin at 32 weeks rather than waiting for a positive culture. Another option is to NOT screen for beta strep during pregnancy, but to follow a strict protocol during birthing if you have the following risk factors: 1) fever over 38 degrees Celsius, 2) pre-term birthing < 37 weeks, 3) prolonged rupture of membranes > 18 hours, 4) multiple births, and 5) previously-infected baby. In these cases antibiotics may be indicated. Those infants who are symptomatic (fever, fast breathing, poor feeding, high pitched cry) can be evaluated for sepsis and given antibiotics for 48-72 hours. Alternately, you can request a C-reactive protein test to determine the presence of an active infection before giving antibiotics to the baby.
Return to Top of Group B Streptococcus
TREATMENT OPTIONS
Below are a series of treatment options for you to consider:

TREATMENT OPTION #1:
If you have a heavy colonization, use Tea tree oil vaginal suppositories 3-4 times daily for that time. This can be done on a small size tampon or a cotton ball, whichever is more comfortable. Colonization is measured on a range from 1-4 with 1 being minimal and 4 being heavy colonization.


TREATMENT OPTION #2:
Take 500mg Vitamin C, Propolis 4x daily, and insert a tampon soaked in 2% Tea Tree oil solution (2%Tea Tree essential oil, 98% Olive oil). Leave the tampon in for 4 hours each day for 6 days.

TREATMENT OPTION #3:
Take 3 caps of Congaplex by Standard Brands 3 times a day for a week, then re-culture. If still positive, take 1 cap per day until the end of pregnancy.

TREATMENT OPTION #4:
At 32 weeks, begin to take a supplement of 500 mg of Vitamin C and one cup of burdock root and Echinacea root infusion. To prepare the infusion, steep one-half ounce of each of the herbs in four cups of boiling water for two hours. Strain and take the above dose, storing the rest in the refrigerator for the next day.

TREATMENT OPTION #5
Drink 3 teaspoons of Colloidal Silver, which is silver suspended in water, per day between meals. Hold the liquid in your mouth a few minutes before swallowing. Colloidal Silver can be purchased in most health food stores. It is antibiotic in nature and safe in pregnancy.

TREATMENT OPTION #6:
Use of oral antibiotics: 3 a day starting at week 37 and then one a day until birthing begins. When birthing begins, take one every 4-6 hours until the baby is born. (It seems like a lot, but it lets you avoid the cascade of interventions that IV antibiotics brings at the hospital).

TREATMENT OPTION #7:
Treat with antibiotics by intramuscular injection (IM) before the birth. This method will cover you for 30 days after the injections (4 injections total to give the full dose).

TREATMENT OPTION #8:
Take 1/3 teaspoon of echinacea and astragalus tinctures twice daily. You can get dried astragalus in the herb department of health food stores. Cook two strips into a pot of rice or soup 2-3 times per week Remove the strips when done cooking and eat the rice or soup. Astragalus is an immune system tonic used in Chinese medicine.

TREATMENT OPTION #9:
Make a garlic elixir by blending 1/2 cup of honey, 1/4 cup of apple cider vinegar, and half a bulb of fresh garlic until liquified. Take 1/2 teaspoon up to twice daily. Season to taste with honey or vinegar.
Return to Top of Group B Streptococcus

PREVENTION TIPS

• Breastfeed immediately and frequently. The colostrum is the best antibiotic treatment your baby could ever get.
• Refuse vaginal exams
• DO NOT permit artificial rupture of membranes.

SAMPLE BIRTH PLAN LANGUAGE

After you have assessed your situation and decided upon your preferred course of treatment, you must add it either in the body of your birth plan or as an addendum. Here is some sample language you may wish to include:

I (will/will not) be screened for Group B Streptococcus.

If the result is negative, the only precautions will be to closely monitor birthing for the above risk factors and monitor the baby after childbirth for possible signs of infection.

If any of the risk factors (fever over 38 degrees Celsius, pre-term birthing < 37 weeks, prolonged rupture of membranes > 18 hours) occur, mother will consent to alternative treatment options other than those listed above in the best interest of the health of the baby.
If the result is positive the treatment of choice is (list treatment option #):_______

Mother’s Signature Date Care Provider‘s Signature Date


REFERENCES

F. Smaill, "Intrapartum Antibiotics for Group B Streptococcal Colonization," Cochrane Database Syst Rev 2 (2000): CD000115: Pregnancy, Birth & Baby At BellyBelly. The Best Pregnancy, Birth & Baby Articles Online!. nih.govl.

S. D. Manning et al., "Correlates of Antibiotic-Resistant Group B Streptococcus Isolated from Pregnant Women," Obstetric Gynecology 101, no. 1 (2003): 74-79

R. K. Edwards et al., "Intrapartum Antibiotic Prophylaxis 2: Positive Predictive Value Antenatal Group B Streptococci Cultures and Antibiotic Susceptibility of Clinical Isolates," Obstetric Gynecology 100, no. 3 (2002): 540-544.

M. Dabrowska-Szponar and J. Galinski. "Drug Resistance of Group 9 Streptococci," Pol Merkuriusz Lek 10, no. 60(2001): 442-444.

M. L. Bland et al., "Antibiotic Resistance Patterns of Group B Streptococci in Late Third Trimester Rectovaginal Cultures," American Journal of Obstetric Gynecology 184. no, 6 (2001): 1125-1126.

T. B. Hyde ct al., "Trends in Incidence and Antimicrobial Resistance of Early-Onset Sepsis: Population-Based Surveillance in San Francisco and Atlanta," Pediatrics 110, no. 4 (2002): 690-695.

R. S. McDuffie Jr. et al., "Adverse Perinatal Outcome and Resistant Enterobacteriaceae after Antibiotic Usage for Premature Rupture of Membranes and Group B Streptococcus Carriage," Obstetric Gynecology 82, no. 4, pt. 1 (1993): 487-489.

C. V. Towers and G. G. Briggs, "Antepartum Use of Antibiotics and Early-Onset Neonatal Sepsis: The Next Four Years," American Journal of Obstetric Gynecology 187, no. 2 (2002): 495-500.

S. J. Schrag et al., "A Popular/on Based Comparison of Strategies Co Prevent Early-Onset Group B Streptococcal Disease in Neonates," New England Journal of Medicine 347 (2002): 233-239.

[Cricket]

Thanks so much Kelly! I might print that off and bring it to my midwife next time to see what she thinks. I'm hoping to come to a decision that we can all be happy with.

[Alan]

Hi Cricket
As I am sure that you know the main problem with the GBS swab is that it only indicates if you have GBS at the time of the swab. This in itself can cause a major dilemma. If your swab is negative then there is no guarantee that you will not be colonized by GBS at the time of your birth. Om the other hand if you test positive you could be negative at the time of birth and expose your baby to the antibiotics that they will give you in labour.

There is a test that has been developed in USA that gives a very quick result and it can be performed when you are in early labour. Unfortunately I have not had the time to have a good look at this test yet so I am unable to give you much information on it. I should imagine that if you did a search on line you may be able to find a little more about it. If you can’t let me know and I will see what I can do.

Another treatment to add to the list that Kelly provided is a Chlorhexidine douche.
Here are a couple of research articles.

J Matern Fetal Med 2002 Feb;11(2):84-8
Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.
Facchinetti F, Piccinini F, Mordini B, Volpe A. )Department of Gynecology, Obstetrics and Pediatric Sciences, University of
Modena and Reggio Emilia, Modena, Italy.)

OBJECTIVE: To investigate the efficacy of intrapartum vaginal flushings with chlorhexidine compared with ampicillin in preventing group B streptococcus transmission to neonates.
METHODS: This was a randomised controlled study, including singleton pregnancies delivering vaginally. Rupture of membranes, when present, must not have occurred more than 6 h previously. Women with any gestational complication, with a newborn previously affected by group B streptococcus sepsis or whose cervical dilatation was greater than 5 cm were excluded. A total of 244 group B streptococcus-colonized mothers at term (screened at 36-38 weeks) were randomised to receive either 140 ml chlorhexidine 0.2% by vaginal flushings every 6 h or ampicillin 2 g intravenously every 6 h until delivery. Neonatal swabs were taken at birth, at three different sites (nose, ear and gastric juice).
RESULTS: A total of 108 women were treated with ampicillin and 109 with chlorhexidine. Their ages and gestational weeks at delivery were similar in the two groups. Nulliparous women were equally distributed between the two groups (ampicillin, 87%; chlorhexidine, 89%). Clinical data such as birth weight (ampicillin, 3,365 +/- 390 g; chlorhexidine, 3,440 +/- 452 g), Apgar scores at 1 min (ampicillin, 8.4 +/- 0.9; chlorhexidine, 8.2 +/- 1.4) and at 5 min (ampicillin, 9.7 +/- 0.6; chlorhexidine, 9.6 +/- 1.1) were similar for the two groups, as was the rate of neonatal group B streptococcus colonization (chlorhexidine, 15.6%; ampicillin, 12%). Escherichia coli, on the other hand, was significantly more prevalent in the ampicillin (7.4%) than in the chlorhexidine group (1.8%, p < 0.05). Six neonates were transferred to the neonatal intensive care unit, including two cases of early-onset sepsis (one in each group).
CONCLUSIONS: In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine. PMID: 11995801
Int J Antimicrob Agents 1999 Aug;12(3):245-
Vaginal disinfection with chlorhexidine during childbirth.
Stray-Pedersen B, Bergan T, Hafstad A, Normann E, Grogaard J, Vangdal M. Department of Gynecology and Obstetrics, Aker Hospital, University of Oslo, Norway.

The purpose of this study was to determine whether chlorhexidine vaginal douching, applied by a squeeze bottle intra partum, reduced mother-to-child transmission of vaginal microorganisms including Streptococcus agalactiae (streptococcus serogroup B = GBS) and hence infectious morbidity in both mother and child. A prospective controlled study was conducted on pairs of mothers and their offspring. During the first 4 months (reference phase), the vaginal flora of women in labour was recorded and the newborns monitored. During the next 5 months (intervention phase), a trial of randomized, blinded placebo controlled douching with either 0.2% chlorhexidine or sterile saline was performed on 1130 women in vaginal labour. During childbirth, bacteria were isolated from 78% of the women. Vertical transmission of microbes occurred in 43% of the reference deliveries. In the double blind study, vaginal douching with chlorhexidine significantly reduced the vertical transmission rate from 35% (saline) to 18% (chlorhexidine), (P < 0.000 1, 95% confidence interval 0.12-0.22). The lower rate of bacteria isolated from the latter group was accompanied by a significantly reduced early infectious morbidity in the neonates (P < 0.05, 95% confidence interval 0.00-0.06). This finding was particularly pronounced in Str. agalactiae infections (P < 0.0 1). In the early postpartum period, fever in the mothers was significantly lower in the patients offered vaginal disinfection, a reduction from 7.2% in those douched using saline compared with 3.3% in those disinfected using chlorhexidine (P < 0.05, 95% confidence interval 0.01-0.06). A parallel lower occurrence of urinary tract infections was also observed, 6.2% in the saline group as compared with 3.4% in the chlorhexidine group (P < 0.01, 95% confidence p interval 0.00-0.05). This prospective controlled trial demonstrated that vaginal douching with 0.2% chlorhexidine during labour can significantly reduce both maternal and early neonatal infectious morbidity. The squeeze bottle procedure was simple, quick, and well tolerated. The beneficial effect may be ascribed both to mechanical cleansing by liquid flow and to the disinfective action of chlorhexidine.

[Cricket]

Thanks so much for helping me out again Alan. It is greatly appreciated! I will bring this information to my midwife as well, and see what we can decide. My current midwife is a little bit more of a "fill out the forms" and "dot the I's and cross the T's" kind of person. She's very kind and friendly, but I'm not sure how well she likes to deviate from "standard" care. She hasn't been practicing that long. The woman who delivered my two previous babies has shattered her ankle and has been off work for about 6 months now. She's talking about retiring now I hear.
Anyways, I'll see what I can do.
Thanks again!