These emails from Lisa Porter on Straight Talk:
Am I at risk of infecting my baby? Also, So you're Group
B Strep positive? Now what? and GBS Myths and Common Questions GBS+ Parents Ask
Straight
Talk: Am I at risk of infecting my baby?
Hi all,
Cheryl asked me to post some information about GBS prevention to
help those of you who are debating where to birth and what to do for
prevention.
I am NOT a doctor, but I am a well-informed GBS mom. I attended
the GBS prevention conference in San Francisco that resulted in the
current guidelines, and I've talked to lots of GBS moms and dads.My
advice is intended to be used in conjunction with a birth
practitioner care. (I'm not a lawyer, either - but I have to say it!
;)
I am posting two messages.1) The stats on the REAL risks of GBS
and its treatment from the CDC.If you are considering home birth,
these are the numbers you'll need to learn before you decide what
your REAL risk of complications will be. As you will read, some women
are at great risk, others at very low risk.
2) The recommendations and tips I give to moms about prevention -
gleaned from lots of actual moms and the prevention strategies
they've used. I think Cheryl will be posting some of the information
to the FAQ or website to help future moms...let me know if there are
other major topics that I've missed.
If you have questions, please post general questions to the list
so that others can read the answers, too. If you have a specific
question about something unique to you, e-mail me directly. I'll
be glad to try to help.
1) STATS ON GBS:
This is an overview of the basic information (taken from the CDC
prevention guidelines - web site for reference):
-- It is useful to know whether a risk is large or small before
making choices about prevention strategies. All of the information
below assumes that the GBS test was done at 35+ weeks by swabbing the
lower vagina (not cervix) and rectum using a test specifically for
GBS. If you were tested earlier, it's safest to assume that you will
carry GBS at delivery. Don't assume that all will be fine if you
later test GBS negative - if you carry GBS during pregnancy, it is
likely that you will not be able to pass on immunity to GBS to baby
-- IMO it's safest to assume you're GBS+.
-- Women who are GBS+ are 29 times more likely to deliver an
infected child than GBS negative
women.http://www.cdc.gov/ncidod/dmbd/gbs/slide7.htm
Risk of infected baby if:
GBS+ WITH risk factors: 1/25
Women who are GBS+ and have risk factors (labor or delivery before
37 weeks, fever in labor >100.3F, rupture of membranes >12-18
hrs before delivery, previous GBS infected baby, GBS urinary tract
infection) have a 1/25 chance of having an infected child if they are
not given antibiotics in labor.
GBS+ WITHOUT risk factors: 1/200
Knowing that you carry GBS tells you that your risk is 1/25 or
1/200, depending on whether risk factors occur.
Bear in mind that 46% of the women who deliver GBS infected babies
had no risk factor(s). This means that 1/2 of the women who had sick
GBS babies had no warning or chance to begin antibiotics before
problems
developed.http://www.cdc.gov/ncidod/dmbd/gbs/slide24.htm
GBS negative WITH risk factors: 1/900In other words, there is a
1/900 chance that a woman who tests GBS negative who develops risk
factors actually carries GBS and might infect her baby.
GBS negative WITHOUT risk factors: 3/10,000A GBS negative woman
_without_ a risk factor has a 3/10,000 (.3/1,000) chance of having a
sick child. http://www.cdc.gov/ncidod/dmbd/gbs/slide25.htm
Risks of antibiotics:Risk of a minor reaction (like a rash):
1/10Risk of a serious complication (shock or death) 1/10,000
The risk of infecting baby is much greater than the risk of
antibiotics for GBS+ moms. No one wants to use antibiotics
unnecessarily, but they are worth consideration if you carry GBS.
-- Vaginal/rectal cultures are at least 90% accurate in predicting
who will be GBS+ at delivery if done at 35-37 weeks gestation. So, if
a woman is GBS+ at 35+ weeks, the odds are 90% or better that she
will be GBS+ at delivery. The reliability of the test is much lower
if the test is done too
early.http://www.cdc.gov/ncidod/dmbd/gbs/slide19.htm
Screening for GBS at 35-37 wks and OFFERING antibiotics in labor
to GBS+ moms can prevent more than 88% of the cases of GBS in the
first week of life - a huge number.
If women are NOT screened and are only treated if risk factors
develop, the number is cases prevented is much lower (69%). http://www.cdc.gov/ncidod/dmbd/gbs/slide27.htm
A woman has the right to choose whether or not to be screened for
GBS as well as the right to choose whether or not to be treated if
she is GBS+, but she MUST consider all of the information to make an
informed choice.
Warning -- the following is my **opinion**:I think it's fair for
GBS+ moms to choose EITHER hospital or home birth, but each couple
must decide for themselves what level of risk is acceptable. If you
have had an uneventful pregnancy without preterm or a GBS urinary
tract infection, the risk of having problems from GBS is about 1/200
(if you are not treated with IV antibiotics in labor). If you develop
a risk factor, that number goes 1/25.
Since most GBS urinary tract infections do not cause any symptoms,
moms considering home birth should STRONGLY consider getting a GBS
URINE culture. If the culture is negative, home birth might be a
reasonable choice. If the urine culture is GBS+, the risk is much
higher (1/25). In my opinion, home birth without IV antibiotics is
not a responsible choice if you have GBS in the urine during
pregnancy or have any other risk factor(s). Don't flame me...this is
my *opinion*.
In case you wondered, ORAL antibiotics are NEVER recommended for
use instead of IV antibiotics in labor. This is because digestion
slows down (or stops) during labor, and the drugs cannot get to baby
to help baby. IV antibiotics are recommended b/c they get to baby
very fast (perhaps as little as 15-30 minutes). ORAL antibiotics in
labor are not an acceptable alternative to IV antibiotics.
ORAL antibiotics ARE useful if you have a urinary tract infection
(u.t.i) though. If your urine tests GBS+, you should be treated with
oral antibiotics IMMEDIATELY. Some doctors treat only high numbers of
GBS in the urine, but in my opinion, ALL GBS in the urine should be
immediately treated with oral antibiotics unless there is reason to
think that the urine sample was contaminated by GBS from the
perineum.It is especially important to still get IV antibiotics in
labor if you had a GBS urinary tract infection!
The information about prevention tips will be sent in a separate
message.
Lisa
So you're GBS+, Now What? Tips for a healthy labor and a healthy
baby
Remember, I'm not a doctor or a lawyer...ask your birth professional for more
information and educate yourself - read and decide for yourself if this information is
reasonable for your situation.
Tips for GBS+ moms:
(These are generally geared toward moms WITHOUT a history of GBS complications,
but they work for most GBS moms who had complications in past pregnancies, too.)
1) None of the GBS prevention protocols recommend inducing labor in term GBS+
moms to control labor and get "enough" antibiotics.
If you are term (37+ weeks) and haven't had any risk factors (fever in labor,
prolonged rupture of membranes, etc.) the antibiotics begin to be effective
against GBS very quickly.
Two doses of antibiotics (or more) before birth are recommended as a *guideline*
for doctors. If you get ANY antibiotics they can help, but doctors like to see
you get at least two doses before delivery. This DOESN'T mean that the recommendation
calls for induction to get that amount of antibiotics!
"Four hours" of antibiotics are recommended because the second dose is often
given 4 hours after the first dose. Get the antibiotics as soon as it's reasonable
to get to the hospital/birth center, but NO EXPERT recommends inducing labor
just to get two or more doses of antibiotics before birth.
If you're concerned about a fast labor, be reassured -- a natural, fast labor
means babies come into contact with the bacteria for a shorter amount of time.
2) Avoid "routine" internal fetal monitoring in labor.
The internal probe creates a small scrape on baby's head where the bacteria
can get into the bloodstream. Routine internal monitoring is not a good idea
for most GBS+ moms. If it's absolutely necessary, make sure you've had IV antibiotics
for a reasonable period of time before the internal monitor is used, and talk
with your provider about the risks and benefits of using the internal monitor.
3) Discuss ways to avoid excessive digital exams in labor with your provider.
The more you put something (hands, monitors, etc.) in the vagina, the more you
push the bacteria toward baby. It appears that GBS lives near the entrance of
the vagina in most cases. Don't push it toward the cervix by getting unnecessary
cervical checks. Research indicates that having more than 6 internal exams/cervical
checks might be linked with more serious infection. In general, the fewer cervical
checks, the better.
4) Don't agree to let the provider rupture membranes to induce labor.
The membranes are a barrier between baby and the bacteria, and rupturing them
allows access to baby, puts you on a schedule for delivery and increases the
chance of prolonged rupture (a risk factor). Rupturing membranes AFTER the IV
antibiotics are started LATE in labor does not seem to be as problematic.
5) Talk to your OB/midwife about her prevention strategy.
If you're using an OB or CNM, she should plan to start IV penicillin (it's recommended
over ampicillin) or clindamycin/erythromycin (if allergic to penicillin) when
you're admitted and continue it until delivery.
You can ask for a heparin or saline "locked" IV if your goal is an unmedicated
birth. The antibiotics can be given in just a few minutes every four hours,
and the rest of the time you can move around as you choose.
Remember, the antibiotics are given to you to protect baby. IVs in labor aren't
fun, but the reasons for IV antibiotics in labor are compelling.
If you're birthing at home or at a birthing center, ask if they are able to
give IV antibiotics. Find out what they'll do if you develop risk factors. Be
sure to read the information about risks of infection to make an informed choice
about preventing GBS in your chosen birth place.
6) Antibiotics BEFORE labor are not recommended EXCEPT for treatment of GBS
in the urine.
Taking oral antibiotics BEFORE labor to get rid of vaginal/rectal GBS colonization
(as opposed to urinary tract infection) will not reduce the risk to baby - and
will use antibiotics unnecessarily.
IV antibiotics in labor are the only proven way to protect baby from GBS infection:
they work when baby is at the highest risk of encountering the bacteria - during
labor and delivery.
7) Consider a URINE screen for GBS during late pregnancy.
GBS in the urine indicates a higher risk of infection in baby since it correlates
with high levels of GBS in the vagina. GBS urinary tract infections (u.t.i.s)
are often asymptomatic (without symptoms), so you might not know it's there.
Testing the urine for GBS is the only way to know if GBS is present.
GBS in the urine has been linked to preterm labor/delivery and premature rupture
of membranes. It is very important to get rid of GBS in the urine immediately.
It does not matter how MANY GBS are found -- GBS in the urine requires oral
antibiotics when it's diagnosed.
If you have preterm labor, ask for a urine culture and vaginal/rectal culture to
be sure GBS isn't a problem. A urine culture for GBS is a reasonable idea if
you've had preterm labor in any pregnancy. Insist on oral antibiotics immediately
if there is any GBS in the urine. Be sure to also get IV antibiotics in labor,
even if the labor stops and the u.t.i. is cleared.
8) A c-section DOES NOT automatically reduce the likelihood of infecting baby
and increases his risk of other infections.
Chances of GBS infection are a slightly lower for baby after a c-section, but
25% of babies who are born via c-section still have GBS on their skin, so c/s
doesn't keep baby 100% safe from GBS. Also, mom is more likely to have serious
complications from GBS c-section: GBS causes 50,000 maternal post-cesarean infections
each year in the US. Just being a GBS carrier is not enough reason to have a
c-section.
9) Talk with the pediatrician.
Advise him that you are GBS+ and talk about what this means for baby. Baby should
be watched for a day or two to be sure all is well, but you should still be
able to nurse, change diapers, room in, etc., if baby is well.
A good site for information about the symptoms a sick baby exhibits is: Here
10) Learn all you can. Informed parents are the best defense against GBS.
You are the only parents of your baby, and it's your job to start protecting
him NOW. If protecting him means standing up for what's best for you and baby,
so be it. Believe me -- you won't care if you've ticked off the provider if
your baby gets sick when it could have been prevented!
GrpBStrep@hotmail.com
Debunk Group B Strep Myths
Here are the most commonly held MYTHS about GBS. None is true:
MYTH # 1: Adults "catch" GBS from a toilet seat
or sexual practices or by having poor hygiene.
THE TRUTH: Lots of normal, healthy people (perhaps
as many as 1/3 of the population!) carry GBS in the gut where it's a NORMAL
bacteria. Some of us carry it in the vagina as well, where it is also normal.
Usually it's only a concern during pregnancy -- then only for a small number
of women who cannot pass on antibodies to the bacteria.
MYTH # 2: Being GBS+ means you're infected or have
a disease.
THE TRUTH: If GBS is found in a routine vaginal/rectal
culture, you are COLONIZED.
Being colonized means that the bacteria live in your body but cause no problems
or infection. Humans are colonized with many bacteria; this is normal. You are
only infected if GBS gets into blood, urine, tissues, etc., where it shouldn't
be. This is rare; healthy adults usually don't get infected by GBS.
The exception to this rule is urinary tract infections, which happen to as many
as 10% of pregnant women. GBS is a frequent cause of urinary tract infections
in pregnant women and GBS u.t.i.s should be treated with oral antibiotics immediately,
as well as with IV antibiotics in labor.
MYTH # 3: You should only treat GBS in the urine
if there are symptoms of infection.
THE TRUTH: According to the CDC recommendations,
any GBS found in the urine should be treated. The number of bacteria doesn't
matter, nor does it matter if you have any symptoms of infection.
If the lab can identify any GBS in the urine, insist on oral antibiotics and
get retested to be sure it's gone. This might reduce the risk of the bacteria
crossing the placenta or causing preterm labor. If the provider thinks the specimen
was contaminated, repeat the test immediately to find out.
MYTH # 4: A large percentage of babies of GBS+
moms get sick.
THE TRUTH: Only 1 in 200 babies of GBS+ moms (who
aren't treated in labor) will get sick .
Unfortunately, we can't predict whose baby is the "one," so GBS+ women should
consider IV antibiotics in labor to minimize the risk of infection. To keep
this risk low, ask your birth provider to help you avoid interventions in labor
(induction, internal monitors, etc.) that increase the risk of infection.
MYTH # 5: Inducing labor to get "enough" antibiotics
will eliminate baby's risk of infection.
THE TRUTH: No medical organization recommends induction
of labor to get the recommended amount of IV antibiotics.
Birth providers agree that induction should only be done when the risks of inducing
are outweighed by the risks (if any) of waiting. Most babies are not in danger
from GBS in the womb. The 1/200 who become ill are usually exposed to the bacteria
during labor or after rupture of membranes.
In addition, IV antibiotics work fast - in possibly as few as 15 - 30 minutes.
Women with FAST labors seem to have a lower chance of infecting baby because
baby is in the birth canal less time. There is no recommendation to induce just
because you are GBS+.
MYTH # 6: GBS moms who had a previous infected
baby need a "high risk" doctor next time.
THE TRUTH: Yes, there is a risk of having an infected baby again (though
the risk is very small if you're educated about GBS), but high risk OBs are
potentially more likely to use interventions which might **increase** your risk
of infection instead of reducing the risks.
It's generally very easy to prevent serious GBS infections if certain guidelines
are followed (like treating GBS u.t.i's promptly, minimizing interventions,
and getting IV antibiotics in labor.)
MYTH #7: A c-section will prevent transmission
of GBS to baby.
THE TRUTH: There are several reasons that GBS+
moms don't need a c-section to try to prevent GBS.
a) Some babies still get early-onset GBS even after a c/section.
b) Mom's risk of postpartum infection from GBS is greater after c-section --
GBS causes 50,000 post-cesarean infections in moms every year in the US.
c) Baby is still exposed to GBS when the membranes are opened, AND they're possibly
exposed to other problematic gut bacteria like e-coli when a c-section is done.
Being GBS+ is not reason for a c-section by itself.
--------
GBS+ and NOT Pregnant?
If you need information about GBS in non-pregnant adults or the elderly, contact
the CDC in Atlanta at 404-639-2215.
Note: Some non-pregnant women are told that GBS caused their vaginal complaints when
GBS is found in a vaginal culture. In general, GBS is not known to cause symptoms
of vaginal discomfort, discharge or itching in healthy adults. Because up to
one third of healthy adults carries GBS, it's likely to be found if vaginal
cultures are performed while looking for a "cause." If you're having symptoms,
though, it's likely that something else is to blame. Ask your medical provider
to look into all possible causes.
Common Questions GBS+ Parents Ask
Where did I get GBS?
GBS is a normal bacteria for humans. You don't acquire it by "doing" anything
-- it's just one of many bacteria that humans carry. GBS is NOT a sexually transmitted
disease.
What does my GBS+ culture mean for baby?
In most cases, having a GBS+ culture means only that you are warned of the potential
for infection. Being GBS+ doesn't mean that you are sick or that baby is "doomed"
to get sick. It means that you carry the bacteria and might pass it to baby
during labor and delivery. Knowing that you're a carrier of this normal bacteria
means that you can educate yourself and make plans for prevention.
I'm scared -- why do I have to wait for labor to treat GBS?
The reason for waiting to treat in labor is that labor and delivery is when
baby comes into contact with the bacteria. Since GBS is a normal bacteria that
lives in the gut, treating before labor won't eliminate the risk to baby --
it often comes right back after treatment. You need to treat when baby comes
into contact with the bacteria. The only reason to treat before labor and delivery
is when GBS is found in the urine or if labor is premature.
What signs might my baby show if he is infected?
Most babies born to GBS+ moms are healthy and normal -- only about 1 in 200
babies of GBS+ moms becomes infected if mom isn't treated in labor. If baby
gets sick, baby might get pneumonia or blood infection (sepsis) or spinal fluid
infection (meningitis). Other infections also occur, but these are rare.
Babies who are fighting infection may show signs like problems breathing (including
"grunting" or having poor "color"), problems maintaining his temperature (too
cold or too hot), extreme sleepiness (for example, can't be roused even to eat),
problems eating/failure to eat, poor circulation, etc. If you or the doctor
notice any of these signs, baby should be checked out for infection.
What is the treatment for baby if he is infected? Will he recover?
If the infection is caught early and baby is term, most babies will completely
recover with intravenous ("IV") antibiotic treatment. In "mild" infections,
this means 1-3 days of IV antibiotics. In more serious infections treatment
may continue for a week or more. In the most serious infections or if baby is
very premature, treatment may take three weeks or longer.
Remember, very few babies born to GBS+ moms get sick. Of the ones who get sick,
about 1 in 6 babies will have serious complications if oxygen is decreased for
a period of time, if baby is preterm, or if the infection is rampant. About
1 in 6 seriously ill babies will die.
Does being GBS+ mean my baby will have birth defects? Is my baby already
sick?
Just being GBS+ won't cause your baby to be deformed in the womb. In fact, most
of the time, baby is not exposed to the bacteria until labor and delivery, which
is why treatment is reserved for labor in most cases.
A very small number of babies shows signs of having been exposed to the bacteria
prior to labor. This might be related to mom having high levels of GBS in her
vagina and/or having GBS in the urine. If mom has GBS in the urine and it's
not treated with oral antibiotics AND again in labor with IV antibiotics, baby's
risk of GBS infection is increased. There are no symptoms of GBS in the vagina
or the urine, so the only way to know if it's there is to be cultured.
GBS doesn't have to be scary: In the huge majority of cases, baby is healthy
and normal. If mom is given IV antibiotics in labor, very few babies become
infected.
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