Group B Streptococcus (GBS) Protocol

July 14th, 2010 § 0 comments § permalink

I finally have my first-edition GBS protocol (see below). I imagine it might change slightly, though, as I gather more experience, and more research is done on this bacteria.

[Added later: This is a simple, but great article written by an Arkansas midwife on GBS. It shows the relatively low risk babies are at from this bacteria, and puts the risk in better perspective. Take a look.]

Group Beta-Streptococci

Definition:
Group Beta-Streptococci is a bacteria found in up to 40% of women. It originates in the intestinal tract, but because of the close proximity between the rectum and the vagina, if a mother has intestinal/rectal colonization she will most likely have vaginal colonization. Genital colonization can cause symptoms, but rarely results in maternal illness. It can carry significant risks for the baby, however, if he or she becomes colonized and develops an infection from the bacteria. Overall neonatal infection rate is 1-4/1000.

Early-onset GBS disease (within the first week of life) is the leading cause of neonatal mortality and morbidity including sepsis, meningitis, and pneumonia. The newborn may become infected in utero, or during passage through the birth canal. Vertical transmission from mother to baby primarily occurs after the onset of labor or after the membranes rupture.

Predisposing factors to colonization:
Age >20
Low parity
Colonization with Candida
Multiple sexual partners in the previous 12 months (although not all studies have found this a factor)
External genital erythema and scaling
Use of tampons
Purulent vaginal discharge
Vaginal pH >5

Increased risk for active neonatal infection in the following circumstances:

Preterm birth (<37 weeks), although less than 30% of all infected babies are preterm
Rupture of membranes (>18 hours)
Heavy maternal or neonatal colonization with GBS
Maternal fever over 100.4 F
Previous birth of a baby with active GBS infection
Internal fetal monitoring for over 12 hours
Maternal GBS urinary tract infection
Multiple birth (only one study found an increased risk independent of the prematurity factor)
Low maternal titers for anti-GBS capsular IgG antibodies

A baby can be colonized and infection in any of the following ways:
GBS ascends into the intrauterine space from the vagina in an asymptomatic mother
The fetus aspirates infected amniotic fluid (can lead to stillbirth, pneumonia, or sepsis)
The baby passes through a colonized genital tract during birth (usually leading to colonization of newborn skin/mucous membranes; most of these babies do not get sick)
On rare occasions, babies become ill with GBS without any evidence of colonization in their mothers.
Group B Strep, Continued

Plan:
An informed consent form giving a thorough description of the disease, the testing, the risks, and options for treatment will be given to each client. The client will read and decide what course of action to take. I will offer routine testing at 36 weeks, but will respect the client’s right to decline. The client may choose to:
Decline testing, and watch the baby closely after birth for signs/symptoms of GBS disease (see below)
Consent to testing and do nothing if GBS-
Consent to testing, and if GBS+ discuss treatment options (see below)

For clients testing GBS+ I shall inform the client of the risks, and the standard for care, which includes IV antibiotics during labor or upon rupture of membranes, if that occurs first. I will offer the following treatment options:
Do nothing prophylactically, carefully watch the baby for s/s of infection, and immediately transport to hospital for antibiotic treatment if signs of GBS disease develop.
Use natural treatments to suppress the bacteria and boost the mother’s and baby’s immune system from 36/37 weeks until the baby is born. I may recommend:
Naturally fermented foods (natural yogurt, keifer, miso, kombucha) to support naturally-occurring flora
Acidophilus 2x daily (lactobacillus- 2 billion per capsule)
Echinacea 2x daily (350 mg)
Garlic 2x daily (580 mg)
Insert a clove of peeled, unnicked garlic vaginally every other night (remove in the morning)
Vitamin C (2000 mg daily)
Vitamin E 2x daily (500 mg)
Grapefruit seed extract (33%) 10 drops 2-3x daily, along with HMF Probiotics 1-2 capsules 2x daily until birth
Tea tree oil suppositories- Soak cotton ball or small cotton tampon with 50/50 blend of tea tree oil/olive oil, every 4 to 6 waking hours for ten days (to be done near term)
Use Hibiclens vaginal washes during labor/upon rupture of membranes (if ROM occurs first).
If a client desires to have IV antibiotics during labor, I will refer her to a doctor or other health care provider able to provide antibiotics.

I will monitor the well-being of my client and her baby during labor and delivery and proceed with desired course of treatment for GBS.

I will fully inform the client of the s/s of GBS disease in the newborn, and shall instruct the client to call immediately if the baby develops s/s of GBS disease.
If baby develops signs of sepsis, I will transport immediately for testing and treatment as needed. Signs of sepsis include:
Temperature lability
Tachypnea (apneic periods)
Labored breathing
Poor color
Lethargy
Poor suck

References:
Holistic Midwifery Volume 1 by Anne Frye, pg. 573
Heart and Hands 3rd Edition by Elizabeth Davis, pg 30, 133-134 [4th edition, 40]
Varney’s Midwifery 4rd Edition by Helen Varney, pg 868-870
Understanding Diagnostic Tests in the Childbearing Year 7th Edition by
Anne Frye, pg. 743-756

Push, Push, Push!

July 12th, 2010 § 0 comments § permalink

I think I’m past transition. =)

Guess what comes next? Oh, I already told you…

Yes, right now it feels like I’m pushing myself to keep going, but in a good way. It’s an exciting feeling, this being close to graduation, but there is also a feeling of urgency to pack all the learning I can into these last weeks and months, into these last prenatals and births, into this last bit of time where I have a preceptor committed to training me. I feel an urgency to keep studying diligently, though my homework is pretty much done for the next workshop, because of the upcoming NARM. I so want to be well-prepared for that, and for practicing, of course!

Well, I’d better not push myself more than I need to—I should get to bed now.