|October 25, 2000|
Volume 2, Issue 43
|Midwifery Today E-News|
“Group B Streptococcus (GBS)”
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Quote of the Week:
"Birth takes some women to the extreme limit of sanity and they have to make their own way individually each and every time. To imply that women who literally suffer birth are in any way lacking in courage or self-control is to belittle their individuality and their birth accomplishment."
- Casey Makela, midwife
The Art of Midwifery
I always recommend that a new mother be checked for spinal subluxations after the delivery to make sure the spine and pelvis are aligned well. After the pregnancy has ended and the relaxin hormone decreases, the ligaments start to tighten up. This is a great time to help the spine return to a natural and more balanced state.
- Dr. C. Karl Krantz, "Chiropractic Care in Pregnancy," Midwifery Today Issue 52
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A Spanish study of calcium consumption concluded that women who don't consume enough calcium in their last trimester may have less of the mineral in their breastmilk. Women who took in less than 900 milligrams daily during the last part of pregnancy produced less calcium in their milk compared with those who consumed more than 1,100 milligrams daily in the last trimester.
- Fit Pregnancy, Fall 1999
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Group B Streptococcus (GBS)
Prevention of perinatal infections: Antimicrobial prophylaxis
Clinical and public health authorities in the USA, Canada, and Australia have issued guidelines on intrapartum prophylaxis. The 1996 US consensus statement recommended one of two strategies--a screening-based approach, in which vaginal-rectal swabs are collected at 35-37 weeks' gestation for culture in selective broth medium and GBS carriers and those delivering before 37 weeks with unknown GBS status are then offered intrapartum antimicrobial prophylaxis; or a risk-based strategy in which women of unknown GBS status receive intrapartum prophylaxis based on threatened delivery at [greater than] 37 weeks' gestation, rupture of the membrane 18 hours or more, or intrapartum fever (38C). Penicillin was the agent of choice because its antimicrobial spectrum, narrower than that of ampicillin, would reduce the likelihood of resistance developing in other organisms.
A review of early-onset GBS during 1995 in four areas in North America suggests that these strategies would reduce early-onset disease by 41% (risk-based) or 78% (screening-based). As predicted, substantial decreases in early-onset GBS disease have been reported in individual hospitals where policies were implemented and in larger geographical areas. The US Centers for Disease Control and Prevention's surveillance data indicate that early-onset disease declined by 53% between 1993 and 1997 in areas with continuous data. The incidence of late-onset disease remained stable. This decline in early-onset disease in a multistate population in the USA was accompanied by a significant increase in the proportion of hospitals adopting prevention policies. Only 14% of hospitals had a written GBS policy in 1994 compared with 46% in 1997.
Complex issues regarding management of babies whose mothers have received prophylactic antibiotics remain. For example, the extended observation (e.g., 48 hours or more) of these newborns has important economic consequences, and more data are needed to clarify whether this is necessary. Also guidelines for evaluating infants born to women who have received prophylaxis consider less than two antibiotic doses or an interval of less than 4 hours from initiating antibiotics until delivery to be inadequate-i.e., in such situations additional evaluation of the baby is deemed necessary. More research is needed to refine recommendations on what is adequate maternal antibiotic prophylaxis and appropriate neonatal management.
GBS prevention significantly increases the use of intrapartum antimicrobial agents. Although all GBS strains continue to be susceptible to penicillin, erythromycin and clindamycin resistance have been reported in 7.4% and 3.4% of invasive GBS isolates, respectively, and in 16% and 15% of genitourinary isolates. Alternatives such as a cephalosporin may be more appropriate than these two drugs for prophylaxis in penicillin-allergic women. No widespread increase in the incidence of neonatal sepsis due to organisms other than GBS that are penicillin resistant has been identified in the context of either intrapartum or postnatal prophylaxis programmes. However, episodes of resistant infection after prophylactic antibiotic use have been reported, and this issue merits further attention. Because there is substantial variation in the incidence of neonatal sepsis between hospitals and over time, long-term monitoring in large populations is needed to characterise the adverse effects of antimicrobial prophylaxis.
- The Lancet, January 2, 1999
How your decision about GBS testing will affect your labor and birth (excerpt)
If you choose not to have a GBS culture done during your
pregnancy, you have about an 18 percent chance of needing antibiotics
during labor, using the CDC/ACOG guidelines. Your baby's chance of developing
GBS disease depends on whether you have (or develop in labor) any clinical
If you choose to have a GBS culture done during your pregnancy, you have about a 28 percent chance of needing antibiotics during labor, using the CDC/ACOG guidelines. Your baby's chance of developing GBS disease depends on the results of your culture and whether you have (or develop in labor) any clinical risk factors.
If a GBS culture comes back negative, your baby has a very small chance (one in 2,000) of developing GBS disease, and antibiotic treatment is not recommended.
If the GBS culture comes back positive, your baby's chance of developing GBS disease depends on whether you have (or develop in labor) any clinical risk factors. Antibiotic treatment for all women with a positive culture (regardless of clinical risk factors) prevents about 86 percent of GBS disease. Antibiotic treatment for only those women with a positive culture plus clinical risk factors prevents about 51 percent of GBS disease.
If you don't have any clinical risk factors, your baby, if untreated, has about a 0.5 percent chance (one in 200) of developing GBS disease. The CDC, ACOG and AAP all recommend offering treatment with IV antibiotics in labor to women in this category.
If you do have a clinical risk factor, your baby, if untreated, has about a 5 percent chance (one in twenty) of developing GBS disease. The CDC, ACOG, and AAP all recommend giving treatment with IV antibiotics in labor to women in this category.
- Lynn McDonald, CNM, "Group B Screening," Midwifery Today Issue 52
E-News readers write:
The best thing I've ever found [on GBS] is the CDC Handbook for Parents. It is a concise guide to the strep issue, including risks of following the various protocols. It puts things into common, everyday language and is helpful for caregivers as well as expectant parents. It's available free online. Go to:
My favorite quote is the following: "A GBS carrier with none of the conditions above has the following risks: 1 in 200 chance of delivering a baby with GBS disease if antibiotics are not given; 1 in 4,000 chance of delivering a baby with GBS disease if antibiotics are given; 1 in 10 chance, or lower, of experiencing a mild allergic reaction to penicillin (such as rash); 1 in 10,000 chance of developing a severe allergic reaction--anaphylaxis--to penicillin. Anaphylaxis requires emergency treatment and can be life-threatening."
Doesn't that put it nicely in perspective? I know folks who are telling moms their babies have a thirty percent chance of getting sick or dying with strep if mom is positive. That is a heck of a lot different from CDC's estimate of one out of 200!
- Gail Hart
I had midwifery care throughout my pregnancy and had a positive GBS at 36 weeks. My midwife assured me that only in the case of SROM and long labor would this be a problem. My water broke and had light meconium staining. After 12 hours I still had no labor. The baby had great heart tones but after discussing the possibilities we decided to transfer. I was against birth in a hospital and having to have interventions. I had the standard GBS antibiotics IV after 19 hours SROM and also the dreaded Pitocin. After 8 hours of contractions that were at odds with my body and I was still only 3 cm I needed pain relief.
Three hours after the epidural, which was so strong I couldn't feel my chest, I was complete. Sol was born after 30 min of blind pushing because I couldn't feel a thing. There was no meconium to speak of. After some time he had rapid breathing but was trying to nurse and happy in my arms after a long labor full of drugs. I was told he needed to be observed in the nursery and I hesitantly let him go. We spent the next 5 days there, receiving routine antibiotics, for an infection he may or may not have had.
Four months later I go over and over what I wish I would have done or why I hadn't just stayed home. I long to have a powerful homebirth now more than ever. I am a student midwife and I know that it is a hard call for some of the more conservative midwives to hold off transfer in cases such as mine but I truly believe that intervention only forced my labor, not helped my labor. I would love to hear some other GBS stories and outcomes from other midwives' practices.
- Jessica Rios
Some midwives who are not licensed to give antibiotic IV therapy will have the mom douche with Betadine (6 tsp. to 1 liter water).
- Merna Black LM, CPM
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Question of the Week Responses
Q: When should the infant's cord be cut, before or after the infant is breathing well on its own? Why?
- D. Young
A: I was taught that the cord should be cut after breathing is established because the cord may be the only source of oxygen the baby is getting. However, if after the first minute more resuscitation measures are needed, the cord should be cut and oxygen and bag and mask be initiated.
But a few years later there was a horrible shoulder dystocia in the hospital where I was trained. The perinatologists were involved and after a 13 minute dystocia the head was pushed back in and a cesarean was performed. The mother and baby both did well. The perinatologists later sent a memo stating they believe one reason the babe survived such a long dystocia was because they had not cut the cord early and babe was still getting oxygen from the cord.
A: Cutting the cord is the last thing I worry about! Obviously, making sure the baby is OK is the first priority. The second priority is blood loss to the mom. When all else is well and good, I finally get around to cutting the cord. But there is an exception to every rule. If twins share a placenta, or if it is unknown whether they share a placenta, I would at least clamp the cord of the first twin immediately to avoid twin-to-twin transfusion. If all is not going well, once the cord is flaccid it's of no further use to the baby, so I would cut it to better deal with the baby--i.e. take it to a warmer spot, put it on a firmer surface, transport to hospital, etc. But while the cord is still attached it can be used to help resuscitation efforts. One of the steps of neonatal (and some adult, for that matter) resuscitation is to give a fluid bolus. What quicker, easier way than to give baby all its own blood back by simply holding the baby below the placenta and let it all drain in! (Caution: in a healthy baby giving all that blood can cause polycythemia and jaundice just as holding the baby up above the placenta can cause anemia. If there is delayed cord cutting, they normally fare better if the two are kept level.)
A: If the cord is not cut until it has ceased pulsating, the baby can receive up to 20% more circulating blood volume which is obviously of benefit to the newborn, especially if it is preterm. Studies have shown it has beneficial outcomes for the preterm, especially if the baby is laid on the abdomen and not higher than the placental position in the uterus. Laying the baby higher than the uterus until the cord has been clamped may result in blood flowing from the baby back to the placental site, draining much needed fetal circulating volume and producing backflow to the uterus.
Studies have also shown that not immediately clamping the cord enables the physiological compaction and compression of the placenta to be completed and if it is clamped too early, it produces counter-pressures that impede the physiological processes.
Although all women are at risk of placental-fetal transfusion, if the third stage is not "managed" effectively, those that are rhesus negative are more at risk if the cord is not clamped quickly (this depends on the time lapse involved and the baby's position--higher or lower than the placental position. If the baby is higher, there is less risk of placental-fetal transmission than if the baby is lower.) If there are large amounts of fetal blood cells in the maternal circulation from the placenta, then it may cause haemolysis of fetal blood cells in future pregnancies. (Sweet 1998)
Not cutting the "lifeline" too soon obviously has its benefits for the baby who is slow to start respirations. Until the cord has ceased pulsating it is still receiving much-needed oxygen via the umbilical cord. Unfortunately, many professionals are reluctant to allow this as there is a rush to give oxygen via facial mask on the resuscitaire rather than bring the oxygen to the baby if needed, still allowing it to receive the vital blood from the cord. Obviously if the baby is in real need of help after the birth, then relying upon the physiological processes are not enough, and the cord should be cut and clamped as soon as possible.
If the birth has been normal and the baby is not compromised in any way, cutting the cord after it has ceased pulsating is a gentler way and more physiologically natural way of welcoming the baby into the world.
- Helen H.
A: I do not cut the cord until the placenta has been expelled. It has proved to prevent any trouble from occurring!
A: In the Lotus Birth practice, the cord is never cut. Baby, mother and placenta are "enthroned" in bed with the placenta coated in ground rosemary. The placenta and cord dry up, and the baby kicks or pushes away the cord, disconnecting it from him/herself between the 3rd and 5th day. I learned of this in the wonderful "Sacred Birthing" seminar presented by Sandy Karll and David Lewis. They had series of photos of a few Lotus Births. Sandy and David spoke of the protective functions of the placenta. They had an adult-sized mock-up of an umbilical cord made of stuffed cotton; it's proportionally quite large.
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Coming E-News Themes
1.DOULAS: If a birthing woman has good midwifery care, why might she also benefit from having a doula attend her birth? (Issue 2:44, Nov. 1)
2. INTACT MEMBRANES: What are the fetal benefits to labor with intact membranes? Do you have any documentation to share with E-News readers?
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Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!
More on birth rituals:
Excerpts from "Pregnancy, Childbirth, and the Navajo Culture" by Summer Elliott
During pregnancy, Navajo women are encouraged not to drink milk or eat salt, attend funerals or look at dead bodies of humans or animals, be around sick people for long or go to crowded places, lie around too much, tie knots, lift heavy things, look at the eclipse of the moon or sun, weave rugs or make pottery, kill living things, or make plans for the baby or prepare layette sets until after birth (Wilson, 1992). Most animals, especially dead ones or those considered "evil" or dangerous in any way should be avoided. The pregnant woman should avoid strange or violent activity or it will affect the baby. She should avoid excessive fat and sugar. If a woman ties knots or puts bowls together while she is pregnant, she will have a hard time having the baby. If the pregnant woman stands in a doorway while pregnant or someone else stands in the doorway when a pregnant woman is present, the baby will have difficulty coming out. Any activity that seems to bind something up, to nail something shut to secure it, or to plug an opening is seen as improper activity for a pregnant women or her husband and perhaps other members of the family, at least while she is present.
Traditional Navajo beliefs concerning labor and birth include thinking positively about the delivery, having medicine people sing baby chants and sing "unraveling" songs if necessary, drinking corn meal mush, wearing juniper seed beads, burning cedar, holding onto a sash belt while pushing, drinking herbal tea to relax, loosening the hair, having someone apply gentle fundal pressure during pushing, squatting to push, and drinking herbal tea to strengthen contractions if necessary (Wilson, 1992).
After the birth of the baby, Navajo families are encouraged to bury the placenta, drink juniper/ash tea for cleansing, drink blue cornmeal mush, breastfeed the baby, smear the baby's first stool on mom's face, and wrap the sash belt around the mother¹s waist for four days after delivery. Mom is encouraged not to drink cold liquids or be in a cold draft, smell afterbirth blood for too long, show signs of displeasure if baby soils during diaper change, burn placenta or afterbirth blood fluids, or have intercourse for three months after delivery (Wilson, 1992). I have seen a few more of these beliefs being preserved. Most Navajo families still do take home the placenta to bury under a tree. The cafeteria occasionally serves blue cornmeal mush. Moms are also encouraged to breastfeed their babies.
In India, it seems that most of the ancient rituals are not regularly
practiced anymore. They have been replaced by crude hospital protocols
that include beating a complaining labouring woman. Originally their culture
promoted a very strong respect of mothers.
Editor's note: continue to send birth customs from your country and culture and we will include them as a mini-column in E-News.
More on autism [Issue 2:41]:
The November issue of Discover magazine, p. 24, includes a small article
relating to autism. Basically, scientists have done studies on mice and
found that oxytocin plays a role in social memory (how a person remembers
someone they've met, for example). What the experiments showed is that
mice with low levels of oxytocin had no social memory ability. The article
also says, "Interestingly, people with autism who fail to form strong
social bonds have low levels of oxytocin." (R.S. Tuma)
- Amanda Battles, doula
I was very surprised to hear that the second stage of a labor might have
taken so long! [Issues 2:41 and 42] As you know there would be lots of
complications and dangers for fetus and mother during second stage (full
dilation until bulging the fetus's head) if it took longer than as usual
(10-30 minutes in multipara and 20-60 minutes in nullipara) such as: uterine
exhaustion, fetal hypoxia, risk of fetal death, legacy prolapse and varying
degrees of urinary and faecal incontinence. Also, nowadays there are many
technical methods to understand the situation and position of a fetus
in his mother's womb. So we are able to make decisions before everything
goes wrong. All these can prevent any bad outcome.
- Dianat-Sheida, OB
More on sterile field [Issue 2:42]:
I suppose that midwives working in hospital environments have to be more careful about protecting a birthing woman from pathogens, but I find that I'm very relaxed about sterility in my out-of-hospital birth practice. Anything that goes into a woman's vagina after rupture of membranes needs to be sterile, of course, though I do vaginal exams in the pool in late labor and that isn't exactly sterile. I've never had a problem with infection, though. Catching a baby simply isn't a sterile procedure and I don't worry at all about creating a sterile field for the birth. Although I sterilize my cord clamps and scissors, I suspect that "clean" is probably adequate. Suturing is done with sterile gloves and instruments because, again, it is actually invasive. Mostly, I think that sterility during birth is probably over-done to the detriment of the woman's ability to control and enjoy her birth experience!
- Gretchen, CNM
I allow women to use the toilet as needed (as opposed to a bedpan where waste is more likely to be in prolonged contact with the vagina and perineum). The hospital birth packs (that contain the instruments needed for birth) contain as well "sterile" drapes etc. I sometimes use the drape for under a woman's behind (the drape has a plastic pouch if membranes are intact and I fear for a flood, for this allows for quicker clean-up and minimal interruption of the maternal-baby diad). Otherwise I just wash my hands and keep mom's poop away from baby.
Over 5 years and close to 500 births I have not had a woman with a breakdown of a laceration or fetal morbidity.
I don't think sterile fields have a place; the baby needs to be colonised with the mother's flora for protection and with bowels often opening at delivery how do we guarantee sterility?
I'm curious if anyone knows the presidential candidates' positions on homebirth, homeschooling, and vaccinations.
- Amy Jones
Greetings from Fortaleza, Brazil! As you may know, in Brazil, a country where midwifery does not exist as an established profession, the cesarian section rate in most private hospitals is as high as 90%, whilst poor women give birth in degrading conditions in the world's most crowded hospitals. What you may not know is that in the same country, a number of initiatives have been created since the 1980s that attempt to recover human values in childbirth, a movement known as the "humanization of childbirth." On November 2, 3 and 4 midwives and others interested in maternity care from all over the world will gather at the International Conference on the Humanization of Childbirth to promote humanized childbirth.
Contact the Conference Secretariat at +55 85 246 4302/246 0232, by fax at: +55 85 246 2697, e-mail: email@example.com, WWW at
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