Lachlan Horn - a few hours old.
Born at home despite mum's positive GBS test
Women who have tested positive for Group B Streptococcus (GBS) in pregnancy are often told that their only option is to have a hospital birth, with intravenous antibiotics given to them during labour. There are, of course, other options; you may feel, after researching the subject, that intravenous antibiotics are not necessary, or that you would want to have them in certain situations, but not all. You may also be able to arrange to have intravenous antibiotics administered at a home birth. There are many women who have had home births despite being carriers of Group B Strep; the aim of this article is to help you make your own choice.
Group B Streptococcus (usually abbreviated to GBS; also known as 'haemolytic Strep' or 'Beta Strep') is a bacteria which many women carry in the vagina with no symptoms at all, while for others it can cause infections in the uterus or the urinary tract. It is thought that 10-30% of women in the UK carry GBS in the vagina.
As women in the UK are not normally screened for GBS routinely in pregnancy, the vast majority of women who carry GBS during pregnancy and birth will never know about it, their labours will not be managed any differently, and they and their babies will be none the worse off.
A proportion of babies pick up GBS from the birth canal during labour, and again, for the vast majority of these, it will not cause any problems at all. However, a small minority of babies go on to develop Group B Strep Disease, more technically termed Early Neonatal Group B Streptococcal Septicaemia (ENGBSS), which is where the GBS infection causes blood poisoning. This can lead to meningitis and disability or death.
GBS disease is very rare - in the UK, if the mother is known to carry GBS when she is in labour, there is a 35-50% chance that her baby will pick up GBS, but only 0.2-0.5% of these babies will become ill as a result. Putting these figures together, if a woman who is carrying GBS in labour has a 50% chance that her baby will pick up the bacteria, the chance of the baby developing GBS disease is between 1 in 400 and 1 in 1,000.
The source for these statistics is a good introduction to GBS from the Women's Health website (www.womens-health.co.uk), which is owned by a UK obstetrician, Danny Tucker. Note that rates for GBS disease in newborns are higher in the USA than in the UK, which is why you may read of higher infection rates in other articles online.
These figures are for the average risk faced by all women carrying GBS in labour. They do not tell the whole story, because some women are at far higher risk of having a baby affected by GBS disease than others. Babies who fall into certain groups have a higher risk of developing the disease:
If a woman who falls into the high-risk categories for GBS, as described above, is given intravenous antibiotics ('IV antibiotics') when she is in labour, the chance of her baby contracting GBS disease is reduced by 60%, and the chance of the baby dying from GBS disease is reduced by 95%. Taking antibiotics before labour - whether oral or intravenous - does not seem to make much difference, which is why the emphasis is on IV antibiotics in labour. Note that having IV antibiotics does not mean that you will be on a drip thoughout your labour. Midwife Denise Ellis writes: "In most hospitals IV antibiotics are administered via a venflon and given as a bolus dose (administered directly into the vein via a venflon - which takes minutes) and means there is no drip."
Again, see the Women's Health website (www.womens-health.co.uk) for sources, and see the UK Group B Strep Support group for more details.
The availability of IV antibiotics in labour is a modern miracle which has undoubtedly saved the lives of many babies. But, like many other obstetric life-savers, this intervention carries risks as well as potential benefits. The balance of risks and benefits will be different for each family, and as with any offer of medical treatment, it is up to you as an individual to decide whether to accept it.
The risks of intravenous antibiotics in labour are discussed in detail in an article by midwife Sara Wickham in the AIMS Journal, Winter 2003, but they are also noted briefly in the Royal College of Obstetricians and Gynaecologists (RCOG) clinical guidelines on Group B Strep [3]. Rather than discuss them at length here, I suggest you read these two papers - see References for how to obtain them.
In brief, the risks of antibiotics for GBS prophylaxis are:
The RCOG paper on GBS states:
"Antenatal screening and treatment have not yet demonstrated an effect on all cause neonatal mortality, and may carry disadvantages for the mother and baby. These include potentially fatal anaphylaxis, the medicalisation of labour and the neonatal period, and infection with resistant organisms." (Page 1, Section 2)
Although it seems that most UK hospitals recommend that women have IV antibiotics during labour if they test positive for GBS antenatally, in fact the RCOG recommendation is just that antibiotics be 'considered' in this situation, and that the risks are balanced against any possible benefit of IV antibiotics in labour.
Some hospitals have policies that women who have tested positive for GBS should not be 'allowed' to have a waterbirth. I have not found any evidence which supports this approach when the mother is simply GBS positive, without any other risk factors. The rationale is sometimes that the unit likes to use continuous electronic fetal monitoring where the mother has tested positive for GBS, but again, this does not seem to be supported by the evidence if there are no other risk factors. If you are planning to use a birth pool at home, that is your decision, of course, and it may be easier to arrange than a waterbirth in hospital.
Home birth is still an option after a positive GBS result. If you are booking with independent midwives then they will probably be very familiar with the condition. If you are planning a home birth on the NHS then you may have to be prepared to state your case clearly and firmly; remember that it is your decision. You may find that it helps to have relevant research and articles available to discuss with your midwives.
GBS became an issue for me when I was expecting my fourth baby, and discovered that a swab, taken by my GP a few months before I became pregnant, was positive for GBS.
Here is a copy of the letter I sent my midwife team. The team agreed to support the plan of action I proposed, but in the event my repeat test at 36 weeks did not find any GBS infection. For details of the most reliable test for GBS, please see the UK Group B Strep Support group website.
Dear X,
I've just been to see my GP and we checked through my notes to see what the situation was regarding Group B Streptococcus.... a swab in September 2003 found moderate presence of GBS, but nothing else ...
I've been reviewing the RCOG's latest clinical guidelines for GBS (see below, copy enclosed in case you don't have one to hand) and have looked at the section on GBS in 'A Guide To Effective Care in Pregnancy and Childbirth' by Enkin, Keirse et al.
It looks to me as if an incidental finding of GBS colonization before the current pregnancy is not of huge significance at the moment, and that I would need to have another swab taken at 35-37 weeks to see if there is likely to be any colonization when I actually go into labour. The RCOG do not, for instance, recommend that antibiotics are given in labour to a woman who has just had GBS colonization detected in a previous pregnancy (see section 9.3), and I suppose that this is most similar to my situation.
Where a woman has GBS colonization in late pregnancy but has no other risk factors such as prolonged ROM in labour, preterm labour, fever in labour, GBS in urine, etc., the RCOG recommendations are just that intrapartum antibiotics should be 'considered' (section 9.2) but they are not strongly advised or recommended explicitly.
In the absence of any of these other risk factors, and if a woman does not take intrapartum antibiotics, the chances of the baby having GBS disease to any extent, even mildly, is about 1 in 500, and the risk of it dying is less than 1 in 10,000, if my maths is correct. It does not seem to be clear that taking antibiotics in labour in such a situation makes any appreciable difference to cases of severe neonatal infection.
I would not want to take antibiotics in labour without very good reason. Quite apart from making the whole process more complicated (and making me feel ill, as antibiotics usually do), it seems that it could increase some other risks to my baby. There is quite a bit of research which has found that, where women have taken antibiotics in labour because of GBS colonization, their babies have been more likely to suffer later from antibiotic-resistant bacterial infections, especially E. coli. The theory is that antibiotic-resistant E. coli has more room to flourish when GBS is depleted by antibiotics. The RCOG guideline mentions some such risks and gives refs (see page 1, section 2), but if you would like more detailed references I'd be happy to get them for you.
In the light of all this, I think that I would like to manage the situation expectantly, ie not plan to take intrapartum antibiotics unless there are other risk factors present, and to continue to plan a home birth. Would you be able to support me in this? Or is there anything else that you think I need to know about, in order to make an informed decision?
I would like to have a swab taken in late pregnancy so that I know if I am likely to have GBS colonization during labour, as obviously this could make a difference to my decisions. I do understand as well that women can test negative for GBS at different stages of pregnancy, but that babies can still be affected. However, all the research I've looked at suggests that a swab at 35-37 weeks offers the best chance of predicting whether the bacteria is likely to be present in labour.
If I did test positive for GBS at 35-37 weeks then we would of course review the situation, but I think I would be inclined to continue with expectant management unless the situation changed, eg I had PROM in labour, or baby decided to turn up at 36 weeks.
I thought it would be best to write to you as soon as I knew about the GBS result, so that you had time to think about it before we met again. I wanted to try to deal with this issue now, rather than find myself getting anxious about it.
Very best wishes...
I gave birth to my fourth lovely boy, Lachlan, at home, in a birth pool, on 7 September 2004. GBS did not cause either of us any problems. It was my easiest labour and birth, but I doubt that would have been the case if I had laboured in hospital on an intravenous drip.
My personal view is that it is worth knowing that you have GBS if you do go into premature labour, or your waters are broken for a long time while you are in labour, because it does mean that your baby is at higher risk of problems. That doesn't mean that you automatically 'have' to have intravenous antibiotics in labour if you start labouring at 36 weeks, or if your waters are broken for 18 hours while you are labouring, but it is something that you can take into account when deciding if you want to risk hospital birth and/or antibiotics.
For instance, if I were to go into labour at 35 weeks, I would go into hospital and would probably accept IV antibiotics. If my waters broke but there was no sign of labour within a day or so, I would want to pay close attention to my baby's condition, and to my own temperature, for signs of infection. But if I went into labour at term (ie after 37 weeks) and my waters were intact and/or things were moving along rapidly after they broke, and I didn't develop a temperature, and the midwife was happy with the sound of my baby's heart, then I would certainly not consider hospital birth or antibiotics.
Most UK hospitals do not offer the option of having intravenous antibiotics at a home birth, because of concerns about the mother having a severe allergic reaction. However, there are certainly some midwife teams which are prepared to administer antibiotics at home - eg see Judith G's birth story. If you think that this is the right choice for you, it may be worth writing to the Supervisor of Midwives at your hospital to request that you be given intravenous antibiotics at home.
Another option is to go to hospital in early labour and have a dose of intravenous antibiotics there, and then return home to continue with your labour. It may take some arranging, but it can be done - see Kate Simpson's birth story. However, be aware that once in hospital, there may be great pressure on you to remain there, and you may not feel like moving. See 'Accidental Hospital Birth' for cases where this has happened. Therefore, if you are considering doing this, you may want to make a birthplan focussed on a hospital birth as well as one for a homebirth. You could also research the hospital's policies regarding babies born to GBS positive mothers, and consider whether you are happy with them - it may be difficult to assert yourself, or research the issues, once you are in hospital.
Because it is not usual to screen for GBS in the UK, and around 30% of women are thought to carry the bacteria vaginally, it is likely that just under a third of the homebirth stories on this website are actually from GBS-positive mothers. However, very few of them will ever have been diagnosed as GBS carriers, so nobody is any the wiser!
Here are some birth stories where the mothers have, at some stage, had a positive GBS result. Note that this is not always mentioned in the birth story itself.
0. The war on group B strep, by Sara Wickham - AIMS Journal, Winter 2003/2004, Volume 15 No 4 1. Prevention of Early Onset Neonatal Group B Streptococcal Disease, RCOG
Guideline No 36, November 2003 -
Royal College of Obstetricians and Gynaecologists (RCOG) clinical guidelines on Group B Strep 2. J Reprod Med. 1999 Apr;44(4):381-4.
Anaphylaxis in labor secondary to prophylaxis against group B Streptococcus.
A case report. 3. BMJ 2002;325:308-311 ( 10 August ) Women's Health website article on GBS (www.womens-health.co.uk) UK Group B Strep Support group (www.gbss.org.uk)
Prevention of Early Onset Neonatal Group B Streptococcal Disease, RCOG
Guideline No 36, November 2003 -
Royal College of Obstetricians and Gynaecologists (RCOG) clinical guidelines on Group B Strep (www.rcog.org.uk/index.asp?PageID=520 ) UK Midwifery Archive page on GBS Treating Group B Strep: Are Antibiotics Necessary?
GBS on the US Midwife Archives at Gentlebirth.org The Jesse Cause - links to GBS sites (www.thejessecause.org/pages/gbs_links.html) .
The Birth Source - Group B Strep Protocol
MoonDragon Birthing Services - GBS Guidelines Birthsong Childbirth Education - GBS ********************************** Home Birth Reference Site www.homebirth.org.uk
Dunn AB, Blomquist J, Khouzami V.
CONCLUSION: Prophylaxis against group B streptococcal sepsis is of proven
benefit, but the possible harm to the mother and fetus from treatment with
penicillin must be recognized.
PMID: 10319312 [PubMed - indexed for MEDLINE]
Risk factors for early onset neonatal group B streptococcal sepsis:
case-control study
Sam Oddie, specialist registrar, Nicholas D Embleton, specialist registrar,
on behalf of the Northern Neonatal Network.
Links
(www.radmid.demon.co.uk/strep.htm)
By Christa Novelli
Mothering Magazine, Issue 121, Nov/Dec 2003
Well-explained, thorough article with discussion of risks and benefits of antibiotics and other options.
www.mothering.com/articles/pregnancy_birth/birth_preparation/group-b.html
www.gentlebirth.org/archives/gbs.html
William E. Benitz, MD*, Jeffrey B. Gould, MD, and Maurice L. Druzin, MD
From PEDIATRICS Vol. 103 No. 6 June 1999, p. e77
Detailed, academic paper discussing how much difference each risk factor makes, eg the significance of having a heavy GBS colonization compared to a minor one, preterm baby, bacteria in urine, etc..
(http://pediatrics.aappublications.org/cgi/content/full/103/6/e77)
Note that this is a US
site set up by parents of a baby who became severely ill through GBS and, as
such, articles on the site are very much in favour of preventative
antibiotics etc.. However, the links page is, obviously, full of links to
other sites with a range of information and views.
Complementary and nutritional therapies for GBS./
thebirthsource.homestead.com/gbs.html
More on non-antibiotic approaches.
http://www.moondragon.org/mdbsguidelines/strepb.html
Lots of info collated here on the US conventional approach to GBS; explains the rationale for antibiotics well.
http://onyx-ii.com/birthsong/page.cfm?gbs
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