IV ABX for GBS-- talk to me!

[WeasleyMum]

Gotta love the acronyms, right? OK I'm 38 weeks pregnant, and am too tired to research any more. So help! Here's my story:

I tested + for Group B Strep at 8 weeks, from a urine sample. (Which kind of annoyed me, because I didn't know they were checking pee for that, and I had sort of thought about declining the swab test later on.)

I am seeing an OB practice and delivering in a hospital, both of which are pretty natural-birth-friendly*. So I was a little surprised at the adamance with which my OB was insisting on intravenous antibiotics during labor. He was good enough to say that of course it was my choice and that they wouldn't do anything I didn't want (which seems like a given but after some of the stuff I've read here on MDC...), BUT made sure to let me know that refusing the abx would be going against medical advice-- have to sign a disclaimer and all that. He also reassured me that they don't do a continuous IV, but put in a hep-lock and just top off the abx every 6 hours or so, leaving me free to "move, walk around and do my own thing" is how I believe he phrased it.

While having a hep-lock in my hand during labor would be annoying, it's hardly a big deal. I'm much more concerned with the effect of the ABX (or not) on the baby. From what I've read, the antibiotics do dramatically decrease the chance that the baby will be infected with the Group B, and given that Group B can be deadly to newborns, is not something to dismiss offhand. But it also apparently increases the chance that the baby will develop some other serious infection within the first 6 months of life. I'm not even sure if OBs know about that, since an infection at 4 months would be a pediatric issue... they probably just see the obvious positive results of fewer immediately-post-birth Group B cases and wonder why anybody would refuse the abx.

I know what the odds are (sans abx) of a GBS-infected baby (like 1 in 200) and what percentage of those babies actually die (~6%) but I can't shake the mindset that something will happen to my baby... too many miscarriages have broken the logical part of my brain and I no longer believe that I can have a simple, healthy pregnancy/ birth/ baby. I feel like I have to choose between two evils-- the immediate risk of GBS if I decline the abx, and the later risk of an E coli infection or sepsis or something. Part of me thinks that it would honestly be better to avoid the immediate risk, and hope that exclusive BF will help mitigate the later risk. Part of me wonders whether that other part just doesn't want to have to fight her doctors and sign AMA papers.

So spam me with your advice/ experiences. Am I making a big deal over nothing? Or am I making too little out of a big deal?


*Actually not natural-friendly so much as consumer-oriented. In this small city of 40,000 or so, we have a medical school, two hospitals, and a LOT of doctors. I think there's a healthy level of competition amongst them, so the general attitude seems to be, "whatever you want!" I took the hospital tour last week and it was really funny-- "We have Jaccuzis! We have birth balls! We have squat bars! We have epidurals! We have NO epidurals! Keep your baby 24/7-- or send it off to the nursery! It's ALL YOUR CHOICE!" Seriously, the nurse doing the tour must have used the phrases "your choice", "your decision", and "what you want" a dozen times in half an hour.

[XanaduMama]

Either way, honestly, I don't think it's a huge deal. The chances of either GBS infection in a newborn, or serious consequences for the abx, are way low, so you're not going to make a huge mistake or anything, no matter what you decide.

I got abx for my first (hospital birth), but regretted it afterward bc I blame that for the yeast struggles we had all of ds's first year. If I'd known more/better then, I would have given him probiotics early on--so that's one option.

The heplock wasn't a big deal at all, though I must also say that being GBS+ was a huge disappointment for me, because it meant I "had" to go in as soon as my waters broke (which they did, 18 hours before any cxs started), and I think ultimately contributed to my ending up on pit (which fortunately had a quick and happy ending). So that's one consideration.

The 2nd time (home birth), I did the hibiclens wash to make sure I was negative before I tested, which I was.

One thing to think about with a hospital birth and refusing the abx, is that they're likely to be super-paranoid about any signs of infection in your baby and may well end up sending him to the NICU or doing LPs or who knows what at the slightest sign of elevated temps etc. Just something to consider.

[PTmorgan]

I was GBS positive the first time - declined the abx, but ended up hours later with an emergency c-section which obviously includes abx. This time I was negative.

I would recommend you read about the chlorhexidine/Hibiclens wash. This will cut your risk of the baby getting GBS as well as the other bacteria according to the studies. Here are a few links:

http://www.gentlebirth.org/archives/gbs.html#Lavage

http://www.mothering.com/articles/pr...n/group-b.html

Good luck with your decision!

[mommyminer]

Where I work, if you are GBS+ & don't receive your abx (it has always been b/c mom has birthed too fast.... never actually had anyone refuse abx... most people come in way too early b/c they're worried about getting in 2 doses abx), then baby has blood tests (cbc, etc).

[mrsfrazier]

I tested GBS positive and decided to do the iv antibiotics. It was very uncomfortable, as I had to be in bed the whole time the bag emptied into my arm (although they only have to do it every 4-6 hrs). I wanted to labor in the birth tub and they kept making me move around to try to keep the iv area out of the water wihch was frustrating. Between the intermittent fetal montioring and iv it was awful. I also had discomfort from the abx going it, it was very itchy and cold as the bags had been in the frig--they had to wrap my arm in blankets to warm it up.

I wonder how much influence they had on ds getting 3 serious infections his first 6 months.

I am planning a homebirth this time, and hope i end up GBS neg--my husband died in November and I cannot imagine not erring on the side of caution as far as this baby-the last piece I have of him-is concerned. Given your miscarriages I think you may feel similarly to me in that respect and it is def worth your peace of mind.

An interesting point: my neighbor is an OBGYN, and she said she has seen several babies now with other serious infections similar to GBS now that they r killing off GBS-so you just never can know exactly what will happen.

[CEG]

The CDC has lots of great info about GBS on their website.

I did a lot of research on this a few months ago for school but my memory is getting a little foggy, so double check anything you doubt. The risk of early-onset (<7 days) GBS infection has been greatly reduced with the introduction of intrapartum antibiotics- from 1/200 to 1/10000. The risk of late-onset (>7 days) has been unchanged. A baby of a GBS colonized mother is just as likely as a baby of an uncolonized mother to get a late-onset GBS infection.
The likelihood of E Coli infection in a pre-term infant is higher in those treated for GBS in labor. The rate of E Coli infection in term infants has not changed.
The exception to this data is early-onset GBS infection in African American neonates, it has risen slightly in the last 5 years for no known reason.
There is increased resistance to the penicillin alternatives (clindamycin and erythromycin in particular). So if you are not allergic to penicillin it is best to receive Penicillin G over any other antibiotics.

Doing a hibiclens wash before testing is a very bad idea in my opinion, as you can then test negative without knowing what your status really is. GBS negative status can then provide false reassurance if your baby becomes ill and treatment may be delayed. If you were GBS positive or GBS unknown and developed risk factors or your baby became sick then aggresive treatment/testing could be started. If you are going to use an alternative method of being GBS negative it should be something that you continue up until the time you deliver to ensure that you are actually negative. Infections in newborns become serious very quickly.

If you do have the antibiotics in labor there is no reason you have to stay in bed. The pump can be moved to you or the antibiotics can be run without a pump. You don't have to lay in bed. There is no reason to remain hooked up to the fluid between doses of antibiotic.

There are also some other issues to consider. The increased risk of thrush/yeast is something to be aware of. Also, there is some really interesting data on the effects of antibiotics on gut colonization of the baby and future risk for allergies, eczema, asthma, Crohn's disease and some other immune system issues. Breastfeeding is generally a great mediator for all of these problems but research has found delayed or different colonization in babies whose mothers were treated with antibiotics in labor.

[AugustLia23]

If it were me(I did not test with either pregnancy, so may or may not have been +) I would not use the abx unless I showed signs of infection. If s/s of infection began appearing, I would treat accordingly. Certain babies are more at risk, but these babies are more at risk anyways, premature babies or premature rupture of membranes of membranes, etc. Another good thing to refuse, vaginal exams, this will also help keep infection away.

However, as far as I have ever heard, gbs in the urine means a high colonization in the body. What that means for you, I don't know.

Not a big believer in testing for GBS over here, just another thing to get moms all nervous about. I wonder how the testing of all women across the board has affected compliance rates in the hospital. I almost feel like it's just a way to have even more control of the birthing process. Okay, okay, I'm done ranting.

[XanaduMama]

Originally Posted by CEG

Doing a hibiclens wash before testing is a very bad idea in my opinion, as you can then test negative without knowing what your status really is. GBS negative status can then provide false reassurance if your baby becomes ill and treatment may be delayed.

The hibiclens wash doesn't give a false negative or just fool the test. It *makes you negative*, by killing off the GBS bugs, as effectively as abx do. Of course you can become positive after you wash and test, but that's true any time you test negative, whether you've done anything to become negative or not.

[SallyN]

I was GBS+ for my first birth. For this recent pregnancy, I did a garlic treatment (vaginal suppository) nightly for a week prior to the swab, and then once a week until birth.

For the first birth, I did get abx via IV. Aside from the pros/cons that have been described above, the one thing I have to add is... DO NOT get the IV in the top of your hand. This can SERIOUSLY limit your ability to utilize different positions to manage your pain naturally. Instead, have it put in on the top of your forearm. The IV I had on the top of my hand hurt so badly (constantly) that I couldn't put any weight on that entire arm. I also had pitocin, and ironically I think I could have handled the pain of the pitocin contractions if it hadn't been for the pain of the IV.

[CEG]

Originally Posted by XanaduMama

The hibiclens wash doesn't give a false negative or just fool the test. It *makes you negative*, by killing off the GBS bugs, as effectively as abx do. Of course you can become positive after you wash and test, but that's true any time you test negative, whether you've done anything to become negative or not.

It makes you negative at that particular moment. This is the same reason that GBS is not treated prenatally with antibiotics. A hibiclens would eliminate GBS only in the areas it happens to come in contact with (i.e. lower in the vagina). GBS does not originate in the vagina so eliminating it with a douche does not eliminate the colonization, particularly in someone who has GBS in their urine so we know is heavily colonized. Antibiotics do a better job of elimininating the colonizations systemically but even then we know it can come back if we treat in advance of labor. Also, if you figure you are eliminating GBS earlier than 35-37 weeks in order to test negative, the chances of recolonizing are higher than if you tested positive and treated prenatally at 38-40 weeks with either the douche or anitbiotics when you had the test results.

Testing at 35-37 weeks was the best balance between the amount of time it takes to recolonize and the amount of time it takes to get the test results back. Obviously we know it is theoretically possible to test negative and be positive at delivery and vice versa but 35-37 weeks is the best compromise. We do know that there has been a significant decrease in the number of GBS infections and deaths since the instituion of universal screening and prophylaxis so the timing is effective. Rapid tests exist but are expensive and not very accurate.

I'm not saying that continuing to use hibiclens wash for the rest of pregnancy and during labor would not reduce the risk of transmission, I'm sure that it would. I am saying the using it one time before the test and not again is not a sound way to avoid transmission of GBS if it is there, just as we know taking antibiotics before the test and not again isn't effective.

Testing negative is not the point anyway, lowering the risk of infection in the baby is.

I'm not madly pro-antibiotics or testing or anything, just stating the facts as supported by evidence. The OP should decide for herself what to do based on risks/benefits.

There is not a lot of evidence to support douching to prevent GBS, most seem to find a reduction in neonatal colonization but not a reduction in infections. I couldn't find any studies about prenatal treatment. Here is a cochrane review on labor treatment with vaginal douching:

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Vaginal chlorhexidine during labour to prevent early-onset neonatal group B streptococcal infection.Stade B, Shah V, Ohlsson A.
Pediatrics, St. Michael's Hospital, 30 Bond Street, 15th Floor Cardinal Carter Wing, Toronto, Ontario, Canada, M5B1W8. [e-mail]

BACKGROUND: Early-onset group B beta-hemolytic streptococcus (GBS) infection accounts for approximately 30% of neonatal infections, has a high mortality rate and is acquired through vertical transmission from colonized mothers. Several trials have demonstrated the efficacy of intrapartum chemoprophylaxis (IPC) for preventing early-onset disease (EOD). Vaginal disinfection with chlorhexidine during labour has been proposed as another strategy for preventing GBS EOD in the preterm and term neonate. Chlorhexidine has been found to have no impact on antibiotic resistance, is inexpensive, and applicable to poorly equipped delivery sites. OBJECTIVES: To determine the effectiveness of vaginal disinfection with chlorhexidine during labour for preventing early-onset GBS infection in preterm and term neonates. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth trials register (October 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2003), MEDLINE (1966 to October 2003), EMBASE (1980 to March 2003), CINAHL (1982 to March 2003) and LILACS (1982 to September 2003). SELECTION CRITERIA: Randomized and quasi-randomized trials comparing vaginal disinfection with chlorhexidine to placebo, or no treatment. DATA COLLECTION AND ANALYSIS: We extracted information from the results sections of the included studies. We reported relative risk (RR) and risk difference (RD) with 95% confidence intervals (CI) for dichotomous outcomes. We calculated the number needed to treat (NNT) with 95% CIs when a statistically significant RD was found. We used a chi square test (chi2) and the I2 analysis to test for heterogeneity, and applied a fixed or random effects model accordingly. MAIN RESULTS: Five studies, including approximately 2190 term and preterm infants, met the inclusion criteria and reported on at least one of the outcomes of interest for this systematic review. When all studies were combined there was a statistically significant (p = 0.005) reduction in colonisation (RR 0.72, 95% CI 0.56 to 0.91); RD -0.16 (95% CI -0.26 to -0.05); NNT 6 (95% CI 4 to 20). There was no statistically significant between-study heterogeneity. There was no statistically significant between-study heterogeneity both for RR (chi(2) = 3.21 [p = 0.2], I(2) = 37.8%) and for RD (chi(2) = 1.66 [p = 0.44], I(2) = 0%). There was no statistically significant reduction in EOD including GBS infection, GBS pneumonia, GBS meningitis or mortality. REVIEWERS' CONCLUSIONS: Vaginal chlorhexidine resulted in a statistically significant reduction in GBS colonisation of neonates, but was not associated with reductions in other outcomes. The review currently does not support the use of vaginal disinfection with chlorhexidine in labour for preventing EOD. Results should be interpreted with caution as the methodological quality of the studies was poor.