Want to share a GBS experience

[jengacnm]

Hello all,

With all the passion around GBS testing, I wanted to share something that certainly shifted my views.

Last month one of my clients had a one hour labor and precipitous birth in the caul. Her doula was there but I wasn't; I got there about 30 minutes later. She had declined GBS testing, as do many of my home birth clients. Immediate post birth was fine, the two day visit was fine.

On day eight, she called me three times. First, the baby had a temperature of 100.5. It was HOT out, so I had her take the baby down to diaper and skin to skin. The temp came down. Then she was crying unconsolably. Her other three kids had food sensitivities, and she'd had a heavy onion and garlic meal the previous night. More supportive info. Then the baby's temp was high again, this time 101. I talked with her pediatrician, who recommended going to the hospital. (Ordinarily our home birth babies are seen by day 8, but their office wasn't able to accomodate her until a few days later.) I thought to myself, when an experienced and confident mother calls me three times in one day, something's up.

The baby was diagnosed with GBS meningitis and spent three days in the hospital. This mom was lowest of low risk-the baby was born in the caul, for heaven's sake-but it still happened.

I used to counsel my clients in the direction of, babies that get sick with GBS are preemie, water broken for a long time, or somehow or another compromised. Now that I've seen a healthy full term home birth baby get sick with this, GBS is more real and less of a boogeyman.

Ultimately, not much in our plan would have changed. Her labor was way too fast for any kind of antibiotic, and it happened on day 8-if she had had her baby in the hospital she would have been home for six days.

So there it is. Hopefully I'm done seeing this in my career.

[Ironica]

Back the truck up!

Ok, I know I'm not a birth professional... but I do read too much. ;-) Your client's baby had late-onset GBS infection, which is NOT affected in any way by the existing testing and treatment protocols:

http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5447a2.htm

Yes, it's a real disease, it causes real problems... but the standard treatment most likely wouldn't have prevented this particular case.

[Snork]

My good friend who also happens to be my own midwife recently had a tragedy with GBS. The mother declined testing as do many, myself included. She had a spontaneous labour, quick delivery, normal birth in hospital and went home two hours later.

The next morning the midwife went to visit - baby was asleep in the bedroom so she chatted with the mother who mentioned baby had co-slept and fed for half the night, then hadnt fed since and was quite hot from co-sleeping, so she unwrapped him a bit. The midwife felt no red flags at this - its normal enough. She went to see the sleeping baby. It was pale, cold and almost dead. She called an ambulance - baby died on the way to hospital, aged 22 hours old. GBS was the coroners finding.

[Maggi315]

I do test all my clients at 36 weeks, mostly because if they transfer, they are given a hard time. however, I do treat positive with hiblicens washes. What else are homebirthers going to do? iv antibiotics are out of the question.

I have also heard that late-onset GBS is something independent of the mothers status?

[momto l&a]

And then theres the woman who is treated for GBS and her baby still gets GBS. So it seems treatment isn't all that effective either.

[sunnysideup]

Originally Posted by Maggi315

I have also heard that late-onset GBS is something independent of the mothers status?

No, the only way for a baby to get a GBS infection is from the mother.

I do think GBS testing is important. Even if the mother chooses not to have antibiotics during labor, you can watch closely for signs of infection.

[Tattiana]

These are the stories that make it such a difficult choice for mommas like me who have had a terrible time with abx, but tested positive again. I had done so many things before the test to ensure a "negative" status but it didn't work. But, even though DH and I had desperately hoped to not have to deal with abx this time, we weren't willing to not test or treat knowing people who have had very sick babies due to this. The argument that "it is rare" doesn't work on us because we have had some "rare" things happen to us and we know that even if the chances are 2-3%, SOMEONE has to be in that 2-3%, and we aren't willing to gamble with our child's health. I also have to ask myself how I would feel if this happened and I hadn't even tried the standard protocol.

I do appreciate you sharing this story. I recently asked a couple of questions pertaining to this in another forum and nobody really answered my questions. It just seemed like nobody wants to acknowledge that there could REALLY be a risk, and I felt like I got a lot of "non-answers" (this is rare, abx don't prevent strep, etc). Of course, the idea of hibicleanse sounds better than abx and I doubt that in the hospital setting I will be in that would be an option, but I am glad that your clients have that option.

[SublimeBirthGirl]

If only it were so simple. Accepting the antibiotics has risks, too.

[olive&pimiento]

Originally Posted by Maggi315

I do test all my clients at 36 weeks, mostly because if they transfer, they are given a hard time. however, I do treat positive with hiblicens washes. What else are homebirthers going to do? iv antibiotics are out of the question.

I have also heard that late-onset GBS is something independent of the mothers status?

The homebirth practice I study with tests all clients at 36 weeks and treats all positives with antibiotics in labor. Why are IV antibiotics out of the question for your practice? Is it due to client preference?

[bryonyvaughn]

Originally Posted by sunnysideup

No, the only way for a baby to get a GBS infection is from the mother....

If this is the case, how do you explain all the antibiotics given to mothers in the past decade drastically reducing the rate of early onset GBS infection in infants, but not budging the rate for late onset GBS in infants?

~BV

P.S. I'd be curious if the mother from the OP was GBS+ in her urine. Systemic GBS colonization could explain how the baby born in the caul getting GBS in utero.

[Defenestrator]

Originally Posted by sunnysideup

No, the only way for a baby to get a GBS infection is from the mother.

I do think GBS testing is important. Even if the mother chooses not to have antibiotics during labor, you can watch closely for signs of infection.

No, this is totally wrong. Late-onset GBS infection can come from anyone. It is transmitted to the baby after birth, not during birth.

GBS testing is not reliable and plenty of other organisms can cause perinatal infections. Wouldn't you want an attendant to watch for signs of infection in the case of a negative test?

I do offer GBS testing to my clients, but it is for the sole purpose of providing a negative GBS test to the hospital in the case of transport instead of an unknown (assumed to be positive) result. There has been quite a lot of research that has gotten buried which supports the old risk-based management of GBS which says watch for GBS and possibly give antibiotics if the mom has a previous baby sick with GBS, a fever, prolonged rupture of membranes, a preemie, or a GBS-caused UTI in that pregnancy. It has also been proven that giving prophylactic antibiotics has lowered the rate of GBS transmission but not lowered the overall death rate due to infection.

[jengacnm]

Well, well, Ironica, thank you....this is from the CDC website:

"How common is late-onset group B strep disease?

Approximately 3 babies out of every 10,000 births develop late-onset group B strep disease. Late-onset disease used to be less common than group B strep disease in the first week of life. Now that prevention efforts have reduced cases of early newborn disease, about half of all infant group B strep infection fall in the late-onset category."

And Maggi315, you were quite right...

"How do babies get late-onset group B strep disease?

Early studies suggest that only about half of late-onset group B strep disease among newborns comes from a mother who is a group B strep carrier. The source of infection for others with late-onset group B strep disease can be hard to figure out. CDC is involved in some research studies to try to better understand the causes of late-onset disease."

A flowery way of saying, "Duh, we dunno..."

mom to l&a, do you have a citation for your statement? I am interested in knowing exactly how much abx DON'T work.

SBG, she would never have gotten abx anyway, with her labor being as fast as is was. But had she had the knowledge, the choice, and a crystal ball, I think she may have accepted abx over a four day hospitalization for her baby.

I could be wrong, though. And given this information that early and late onset gbs are different creatures, it looks like we won't change anything for future pregnancies, either-and given her religious persuasion, another baby is quite likely.

I'm just grateful that she kept calling me that day and that I trusted her concern enough to suggest something I never want to suggest.

I'm also glad that I probably AM done with this sort of problem in my career. 3 in 10,000? Sheesh.

[Ironica]

Originally Posted by jengacnm

SBG, she would never have gotten abx anyway, with her labor being as fast as is was. But had she had the knowledge, the choice, and a crystal ball, I think she may have accepted abx over a four day hospitalization for her baby.

But that's the point of the info from the CDC website...

1) She may have tested NEGATIVE (therefore no abx), and the baby may have gotten the GBS infection from another source;

2) Even if she'd tested positive and had antibiotics, it would NOT necessarily have prevented late-onset GBS. The only way it might have is if the antibiotics successfully decolonized the mother, *and* the mother was the one who passed the infection to the baby.

As for the second story posted... hm. I know that the practice I'm seeing right now (hospital-based CNM practice), the SOP for those who decline testing is to keep them for 48 hours post-birth. I haven't yet decided whether to decline the test or to do what I can to try to get a negative, but if I decide to decline, I guess it's not such a bad idea to hang around for the 48 hours. :-/

[bryonyvaughn]

http://www.cdc.gov/groupbstrep/general/gen_public_faq.htm

.

[bryonyvaughn]

Originally Posted by jengacnm

...mom to l&a, do you have a citation for your statement? I am interested in knowing exactly how much abx DON'T work...

From about 1/2 way down the CDC FAQ page:

However, a pregnant woman who is a group B strep carrier (tested positive) at full-term delivery who gets antibiotics can feel confident knowing that she has only a 1 in 4000 chance of delivering a baby with group B strep disease. If a pregnant woman who is a group B strep carrier does not get antibiotics at the time of delivery, her baby has a 1 in 200 chance of developing group B strep disease. This means that those infants whose mothers are group B strep carriers and do not get antibiotics have over 20 times the risk of developing disease than those who do receive treatment.

~BV

[SublimeBirthGirl]

I wouuld personally not sit in a hospital for 48 hours for this reason. I didn't get tested at all with my 2nd, so I watched her closely. Actually, I'm totally paranoid about newborns anyway so I pretty much hold them/watch them constantly for about 3 months. Even sleeping they're not alone. So I think I'd probably be as likely to catch a sick baby as the hospital (honestly, I think I'd be more likely).

[nimblemama]

Originally Posted by SublimeBirthGirl

I wouuld personally not sit in a hospital for 48 hours for this reason. I didn't get tested at all with my 2nd, so I watched her closely. Actually, I'm totally paranoid about newborns anyway so I pretty much hold them/watch them constantly for about 3 months. Even sleeping they're not alone. So I think I'd probably be as likely to catch a sick baby as the hospital (honestly, I think I'd be more likely).

I am so that way too. I tested GBS+ with my second and sat in the hospital for 48 hours so that the hospital could "watch him". Hmmm, they came in maybe every 4+ hours, unless I let them know, they wouldn't have known if he had become sick for quite awhile (which he did not of course).

[Tattiana]

Originally Posted by SublimeBirthGirl

If only it were so simple. Accepting the antibiotics has risks, too.

This I totally agree with. The thing is that there are risks on both sides and we have to decide with ALL the facts which risks we are willing to take. I agonized over my choice to use abx, but DH and I prefer to take our risks with that than with a sick baby. Not that there are any guarantees either way, I realize that.

[Ironica]

Originally Posted by nimblemama

I am so that way too. I tested GBS+ with my second and sat in the hospital for 48 hours so that the hospital could "watch him". Hmmm, they came in maybe every 4+ hours, unless I let them know, they wouldn't have known if he had become sick for quite awhile (which he did not of course).

But compare that with the baby who got sick in the middle of the night, and wasn't diagnosed until the morning, related above. Every ~4 hours (which was standard for temp readings and my BP when we were in the PP ward after my son was born) would identify a spiking temperature well before baby got as sick as above. Plus, you're already AT THE HOSPITAL... no ambulance required.

It's a pretty rare thing anyway, very true. And, *if* you get treatment right away (and baby was healthy to begin with), it's unlikely to cause permanent damage. But... ick.

I'll have to review the hospital policies on visitors and stuff... see if my son would be allowed to stay in the room with us (last time, we sprung for a private room so DH could room in too; I know siblings are allowed to visit, but I don't know if they'd let him sleep there with us).

[SublimeBirthGirl]

If I had a baby get sick in the middle of the night I'd catch it way faster than 4 hours. For at least the first 3 months, even if my baby has a 5-hour stretch of sleep, I'm up every 1-2 hours, putting my hand on them, listening to them breathe. My babies slept right next to me. I have NO doubt I'd have noticed a fever extremely quickly.