Question of the Month

Group Beta Strep

I am concerned about the Group B Strep test as mine is coming up in a couple of weeks. I am really against having antibiotics pumped into my system and my daughter before birth. Is there anything that I can do to prevent a positive test result, or the unnecessary administration of antibiotics?

Thank-you, Krista Phelps

A little about me: My husband and I have been married for almost 5 years and I am pregnant with my first child. Faith Anna Phelps is due the week of Mothers Day and I am doing everything in my power to insure she makes her debut naturally. I have always been interested in becoming a Doula but felt like I needed to experience the miracle of birth before I attempted to assist others. Christi Jones and Aimee Roberts referred me to Charis and I now plan to start the program next year after I have had the time to adjust to mother hood and being a stay at home mom/wife.

Thank you for your question, Krista. Christi Jones, RN, one of our Charis students, recently did some research on the topic that I think you and many others will find very helpful. ~Editor

Alternative Versus Traditional Approaches
Used to Diagnose and Treat Group Beta Streptococcus
submitted by Christi Jones, RN and Charis Student

According to the Centers of Disease Control, “Group B Streptococcus is the primary cause of neonatal morbidity related to infection” (“Prevention of Perinatal Group Beta Streptococcal Disease.”). It is an infection that has received a lot of attention over the last several years. Recently, the CDC put together several effective guidelines in using antibiotics to reduce the morbidity associated with GBS. However, the overuse of antibiotics is responsible for the rise in other potentially dangerous infections. Today, hospitals follow the protocol of testing for GBS by swabbing the rectal and vaginal area between the thirty-fifth and thirty-seventh week of pregnancy.  The current standard of practice used to treat mothers who test positive during that window of time is to give IV antibiotics during labor.  There are, however equally beneficial diagnostic procedures and treatments which are not currently offered to women delivering in the hospital. These alternative approaches challenge the more traditional stance and lessen the chances of exposing a newborn to a drug resistant bacterium by the unnecessary use of antibiotics.

Presently, there are two main medical approaches and a handful of alternative treatments used to diagnose, treat, and minimize the chances of the newborn contracting the infection from the mother during delivery. These approaches also come with the possibility of potential side effects for both mom and baby. The present debate in the medical field arises when deciding whether or not to treat the so called infection. Perhaps an exploration of the term infection would shed some light on the subject. The term infection is defined in the American Heritage Dictionary as: “an invasion by and multiplication of pathogenic microorganisms in a bodily part or tissue, which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms.” Group B streptococcus is a bacterium that normally lives in the intestines of typically healthy people. It becomes labeled as an infection by the CDC when it is found outside its normal dwelling and colonizes in the urethra or vagina of a pregnant woman. While evidence shows us that a handful of infants do benefit from antibiotics, the same research shows us that many babies were never in danger from their so called colonized mother. The question arises as to whether or not GBS can truly be categorized as an infection if there are no symptoms that progress to an overt disease in either the mother or newborn.

In 1996, the CDC recommended pregnant women to be placed in one of two categories for GBS. The first category arises from the risk based approach. This method suggests treating all mothers who present with one or more of the following risk factors: delivering before thirty-seven weeks gestation, a temperature during labor greater than or equal to 100.4 degrees Fahrenheit, or rupture of membranes for eighteen hours or more. The second approach is a culture-based screening, in which the pregnant woman’s vagina and rectal areas are swabbed and tested for GBS colonization between thirty-five and thirty-seven weeks gestation. Women who test positive in either category are then offered antibiotics during labor (“Prevention of Perinatal Group B. Streptococcal Disease.”). The dilemma with both of these approaches is the overuse of antibiotics during labor. With the rise in antibiotics use, infections such as E-coli have become the new threat to newborns. E-coli infections have a higher mortality rate than strep infections in newborns (Barclay, 280). In light of the rise of new infections and drug resistant infections, the CDC has updated the guidelines for treating GBS and recommends using an evidence-based approach. This update includes alternate antibiotics which are to be used in the event of an allergic reaction to penicillin and the use of even stronger antibiotics in case of drug resistance in the newborn.

The transient nature of GBS makes it difficult to diagnose as an infection. For example, a woman can have a positive culture early in pregnancy and then test negative at thirty-six weeks. Studies have shown that four to seven percent of women who had negative cultures late in the second trimester will have positive cultures at delivery, but about thirty-three percent of women who have positive cultures during the second trimester end up to having negative cultures at delivery (“What is Group B Strep”). This is why testing is not recommended until thirty-six weeks.

If a woman does test positive during the thirty-fifth through thirty-seventh week, there is also a need to determine if the GBS bacteria is an inactive or inert positive result. Susan Oshel, director of midwifery studies for Charis Childbirth Education, gives her personalized treatment plan to determine the need to treat GBS during labor. Three pills of Echinacea with goldenseal, taken three times a day, for a total of three days before being tested or retested will provide a more definitive diagnosis of GBS (interview 2008). This theory, supported by many other practicing midwives, is based on the herbs capability of killing off the inert bacteria (Novelli 2003). If the woman is in fact heavily colonized she will have another positive strep test and would then be advised to treat the GBS during labor with antibiotics. This approach helps to minimize the overuse of unnecessary antibiotics.

When treating GBS with antibiotics there are a few options which are not approved by the CDC, that have shown favorable results in case studies. One approach is administering oral ampicillin versus the traditional intravenous route. The oral route is less cumbersome, which is especially important to a mother desiring to give birth naturally and wishes to move around freely during labor. Oshel practiced midwifery in Southwest, Virginia. A couple doctors her clients consulted after being diagnosed with group B Strep administered oral antibiotics and stated that "they would cover the risk of infection to the baby if they were given during the last week before labor". (Oshel interview).

Midwives have traditionally used Garlic to treat many different vaginal infections. GBS is not an exception. Medical researchers at the Maxwell Finland Laboratory for Infectious Diseases in the Boston Medical Center have supported this approach (Benitz, Gould, and Druzin 10).The protocol for using garlic to treat GBS is to insert a freshly peeled half clove of garlic into the vagina the evening before the woman goes to sleep and remove and replace the following morning. This process should be repeated for a couple days and then followed up with another swab of the vagina to test for colonization (Cohain).

Perhaps one of the easiest approaches to preventing a vaginal bacteria invasion in the first place, is to keep a well balanced diet. An acidic vagina is more resistant to bad bacteria. An alkaline diet high in complex carbohydrates such as; vegetables, fruits, and whole grains, increase the level of bifidobacteria growth. This growth allows the normal healthy bacteria to grow in the intestine. Since GBS normally exists in the intestine of healthy people, it can be kept in control with a healthy diet. On the other hand, a diet high in simple sugars presents a perfect breeding ground for the unhealthy bacteria to flourish (Gasta).

Water Birth is another alternative approach. The theory is that water dissipates the infectious organisms (Hart 2002). Gail Hart, a midwife and well known speaker, found in her research that water birth infection rates are lower than air births. The Journal of Maternal Fetal Medicine backs up this claim in a research study done in 2005, showing the rate of neonatal infection was not increased with water births (Theoni, et al, 357).

Another alternative approach to IV antibiotics that is not currently offered to women testing positive is vaginal rinsing with Chlorhexidine. This treatment proves to be as effective as ampicillin in preventing vertical transmission of GBS. The rinse is preformed every four hours once labor begins. One of the benefits in using Chlorohexidine as apposed to ampicillin is that it also treats E coli (Facchineti F, et al 2002). Chlorohexidine was originally used as a broad-spectrum antiseptic and has been used in the dental field to treat or prevent strep infections for many years. It has been around since the 1950’s and at one time was used to bathe all infants after delivery to reduce staphylococcus infections without any adverse effects of dermatitis (Stray-Pedersen, et al. 245). Research has shown that vaginal douching with chlorhexidine during labor can significantly reduce both maternal and early neonatal infectious morbidity (Stray-Pedersen B, et al. 245).

Another way to minimize the overuse of antibiotics is to perform a rapid strep test during labor. According to the New England Journal of Medicine, the length of time required to obtain results was reported to be as little as thirty to forty-five minutes. This time is much less compared to the thirty-six hours it takes to get the results from the standard culture. “Approximately eighteen percent of all pregnant women who are considered at risk, according to the risk based approach, recommended by the CDC, are treated with antibiotics. Of these, as few as twenty percent are actually carriers of GBS” (Bergeron, et al 209-10). These results support the need for higher accuracy in identifying treatment for women whose babies truly need the antibiotics. The rapid strep test should in theory decrease the amount of unnecessary antibiotics given to the eighty percent of women who are not carriers.

Once properly diagnosed with GBS, there are many ways to prevent the spread of infection to the unborn child. One way is to limit or refuse the practice of digital exams to determine dilation, which is especially important after the bag of water has been ruptured. A woman with GBS should also avoid stripping of membranes, which only increases the potential of moving the infection higher in the vaginal canal.

Group Beta Strep can cause sepsis, pneumonia, and meningitis, or it can cause no apparent problem whatsoever in the newborn. This is why there are still so many differences in opinion involving the diagnostic procedure. Just as every pregnancy and labor are individual cases and should demand individualized care, so should the treatment be in a women testing positive for GBS. Instead of placing all mothers into one protocol of treatment, it is my hope that by utilizing the information provided in this research paper, mothers will be able to make a more informed decision on how to treat or not treat their case of GBS.

Works Cited
Barclay, Laurie “New Strategies for Neonatal Group B Strep” 25 July 2002. New England Journal of Medicine: 280-281.

Benitz, Gould, and Druzin “Preventing Early-Onset Group B Streptococcal Sepsis: Strategy Development Using Decision Analysis.” 6 June 1999. Pediatrics. 23 March 2002.  <http://www.thermo.com/eThermo/CMA/PDFs/Product/productPDF_12061.pdf>

Bergeron MG, et al. “Rapid Detection of Group B Streptococci in Pregnant Women at Delivery.” New England Journal of Medicine. 20 July 2000: 209-210.

Cohain, Judy, CNM. “How to Treat a Vaginal Infection with a Clove of Garlic.” Midwifery Today. April 2007. <http://www.midwiferytoday.com/articles/garlic/asp>

Enkin Keirse, et al. A Guide to Effective Care in Pregnancy and Childbirth. Third Edition. Oxford: Oxford University 2000.

Facchinetti F, et al. “Chlorhexidine Vaginal Flushings Versus Systemic Ampicillin in the Prevention of Vertical Transmission of Neonatal Group B Streptococcus, At Term.” Journal of Maternal Fetal Medicine. Feb. 2002; 11(2): 84-8.

Gasta, Katie. “Internal Ecosystem Health." Midwifery Today. 42 (1997). 27 Feb 2008 <http://www.midwiferytoday.com./enews.enews0805.asp#main>

Gilbert, Ruth. “Prenatal Screening for Group B Streptococcal Infection: Gaps in the Evidence.” International Journal of Epidemiology. 33 (2004): 2-8.

Goer, Henci. The Thinking Woman’s Guide to a Better Birth. New York: The Berkley Publishing Group, 1999: 53-55.

Heart, Gail. Midwifery Updates. Summer Conference 2002. “GBS Prevention Strategies: New Possibilities.” Alternate Treatments to Reduce Strep.
<http://www.firstbreath.org/id7.html>

Novelli, Christa. “Treating Group B Strep: Are Antibiotics Necessary.” Mothering Magazine. Issue 121, Nov/Dec 2003. <http://www.mothering.com/articles/pregnancy_birth/birth_preparation/group-b.html>

“Prevention of Perinatal Group B. Streptococcal Disease.” CDC Morbidity and Mortality Weekly Report. 16 Aug. 2002: 1-22.

Oshel, Susan. Personal Interview. 18 Feb. 2008.

Stray-Pedersen, et al. “Vaginal Disinfection with Chlorhexidine During Childbirth.” International Journal of Antimicrobial Agents. Aug 1999: 245-51.

The American Heritage Dictionary of the English Language. “Infection” Fourth Edition. Houghton Mifflin Company(2000).
<http://education.yahoo.com/reference/dictionary/entry/infection;_ylt=AkO77IhfIM0LfWU2WLso3_.sgMMF>

Thoeni A, et al. “Review of 1600 Water Births. Does Water Birth
Increase the Risk of Neonatal Infection?” Journal of Maternal Fetal Neonatal Medicine. 17 May 2005: 357-61.

“What is Group B Strep” 4 Feb 2008.  <http://www.home4birth.com/pregnancy/gbs.html>
 

© Christi Jones ~ used with permission


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