UK Midwifery Archives

These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.

Group B Strep and other bacterial infections

• Group B Streptococcus
• Toxic Bacteria - Group A Streptococcus
• Hospital-Acquired Infections
• Links to other sources of information

Group B Streptococcus

I am a midwife from the USA. I was hoping that some of the European midwives on this list could share their Strep B protocols with me so I could share it with other USA midwives. Your own protocal and your local standard of care protocals would be appreciated.

Morgaine
Midwife, USA

Like most UK independent midwives, we work without set protocols. Each woman's care is tailored to her individual circumstances, and also to her own wishes regarding care. We give her the information, she makes the decisions, we then give appropriate support.

In a case like strep B, so much depends on when the woman books in pregnancy, whether or not she is symptomatic for strep B, how she is choosing to treat the condition, and so on. One woman we looked after, who had a vaginal colonisation of strep B, but who was asymptomatic, chose not to use antibiotics, but went the homeopathic route. When she gave birth, the baby was born wrapped in the membranes, which I had to puncture when the head was delivering. The baby was fine, and the mother remained asymptomatic. The baby took care of the problem herself!

You'll have gathered that we manage conservatively, and largely follow the 'wait and see' principle. Of course we were monitoring both mother and baby carefully for any symptoms, and if either had become sick would have suggested antibiotic treatment (which the woman would probably have accepted). In the event, it wasn't needed.

Comments from consultant bacteriologist

The consultant bacteriologist I consulted during the pregnancy about the woman's situation made the following general comments, which I reproduce here as they may prove useful:

1. The fact that a high vaginal swab sample may test positive for strep B does not necessarily reflect vaginal infection, but is more likely to be relatively benign colonisation. This should be assumed unless there is positive evidence of disease, such as cellulitis, vulval inflammation, or Bartolin's abcess.
   
   
2. It is unlikely that a woman with a vaginal colonisation of strep B, even if levels are raised, would carry a blood-borne infection of the same organism.
   
   
3. This being the case, it is most unlikely that such a woman's baby would be born with congenital strep B infection.
   
   
4. There is no conclusive evidence to suggest one approach more beneficial than another in treating women and babies at higher risk of strep B infection at or after birth. There is not enough evidence to support giving I/V antibiotics to the woman during labour and the baby post-delivery. Oral amoxycillin given to the woman in labour, and one dose of oral (or I/M) antibiotic given to the baby post-delivery is probably as effective.
   
   
5. Most infection of mother and baby in the early postnatal period with strep B is relatively benign, and may be adequately treated with oral antibiotics when symptoms appear. The most reasonable approach is to manage these babies expectantly - waiting to see whether or not symptoms appear.
   
   
6. In the case of pre-labour rupture of membranes, there will be an increased risk of amnionitis and intra-uterine infection, increasing with the length of time between PROM and delivery. Although this situation also may be managed expectantly, and no one strategy has been shown to be superior to any other, it could be argued that it is advisable for the woman to be admitted to hospital in this case.

Melanie

Early-Onset Group B Streptococcal Disease --- United States, 1998--1999

Medscape article: www.medscape.com/27197.rhtml

Discusses a screening approach versus a risk-based approach. A 'screening approach' means prophylactic antibiotics if mother tests positive for GBS in pregnancy, while a 'risk-based' approach means giving them only if there are signs of risk, such as fever, prolonged rupture of the membranes, or preterm delivery).

The study is retrospective, so they look at cases of babies who had GBS and then discuss whether different management might have prevented it. This sort of study always seems to come out in favour of more intervention, probably because it has no means of quantifying overall outcomes or any disadvantages to intervention. The editor's comment does discuss antibiotic resistance; in 15- 20% of cases, erythromycin and clindamycin resistance was documented.

My friend was having her first baby in a US hospital. Because Strep B infections are so much more common there than in the UK, she was screened for infection during pregnancy and pronounced clear. I believe she had two further checks shortly before being induced (no pressing reason for the induction - she'd just reached or shortly passed EDD), and again all were clear. Her membranes were ruptured, monitors attached, pitocin, etc....

During the labour the baby went into severe distress and had to be delivered by emergency C/S. Baby was suffering from Strep B. Baby nearly died and spent a week in intensive care - as a 6 year old, still has scars on her arms from IVs. Subsequent tests on mother found that she STILL tested negative for Strep B, and only explanation was that baby picked it up during labour from infection in the hospital after membranes were ruptured. Her subsequent two children were born by planned c/s too; I get the impression she wasn't even aware there was an alternative.

Angela

Don't assume that anything occurs more frequently in the US than it does in the UK. Do assume that American doctors just make a much bigger deal about it to justify their control over the whole process of pregnancy and birth and to justify all their interventions. And it justifies their presence there in the first place instead of a midwife.

Melody - US Midwife

Is GBS that much more common in the US than in the UK? It was my understanding, and I may well be wrong, that the reason for all the hubbub in North America has been litigation and a powerful consumer movement for universal testing and prophylactic IV antibiotics... Any info on the incidents on infection by region would be welcome.

Sky

Southern Norway: lots of Group B strep infections, not just in newborns. Some very virulent ("meat-eating bacteria" as the tabloids have named them). The virulence of strep and other bacteria undergoes cyclical changes and always has. When I was a child, strep throat was common. I hardly heard of them as a young adult. Now the streptococci are back. Nothing necessarily sinister or doomsday about that.

I don't have our hospital protocol here at home, sorry. From memory: ROM (rupture of membranes) preterm-- we take high vaginal swabs for cultures and follow FHT's, amniotic fluid appearance and odor, mother's temp and C-reactive protein daily. Await spontaneous labour unless signs of infection, in which case it is induced.

In very premature ROM (before week 32) mother is kept on strict bed rest until as close to week 32 as possible, and given steroids IM (intra-muscular injection) initially and then weekly boosters until week 34. We have had numerous babies born over two months after ROM and they do amazingly well.

In acute infections C-section may be used, while starting IV antibiotics. After birth, if baby's condition is normal, mother and baby are monitored daily for signs/symptoms of infection (CRP, temp, and HR and RR in baby) and treated as needed.

ROM at term is handled much the same way minus culture, if I remember correctly.

If mother has positive GBS culture in pregnancy, which is not routinely checked, nothing is done unless a previous child has been infected and needed treatment. We simply observe mother and baby post-partum and treat as needed.

Rachel
Midwife, Norway

I don't have a reference, but was under the impression that GBS can be missed unless a rectal swab is also taken? Does anyone know where this comes from?

Lynn

I am currently doing some research on GBS and the general understanding is that GBS bacteria naturally colonises the body, the primary reservoir being the gastrointestinal tract with approximately 30% of the population carrying the organism at any one time. So this would fit with fact that a rectovaginal swab should isolate the bacteria if present.

Diane

Toxic Bacteria - Group A Streptococcus

I want to respond to the statements about virulent strep infections. Having had a loved one die of Toxic Strep A after childbirth I have researched it better than most doctors, along with my husband.

Southern Norway: lots of Group B strep infections, not just in newborns. Some very virulent ('meat-eating bacteria' as the tabloids have named them). The virulence of strep and other bacteria undergoes cyclical changes and always has

The virulent strains that have made the news are various types of Strep A that have mutated to become what is termed "toxic". These strep bacteria figured out how to release a "toxin" each time the bacteria "divides" and multiplies. The toxins and cell membrane coating that these bacteria produce make them an extremely poor target for antibiotics. The more virulent strains are almost entirely resistant to antibiotics. When the toxins are released they travel quickly in the blood stream to destroy internal organs and kill. Toxic strep can kill in a matter of hours from the first sign of illness, unlike the Strep B bacteria that causes the majority of Uterine infections.

Now the flesh-eating bacteria have a different action, a little less deadly as their first target is to multiply within the tissue and destroy tissue rapidly. It is when Toxic Strep goes systemic that the organs are attacked, and even if the infection can be stopped the internal damage to organs can be so great as to cause death at a later date from internal damage, to the organs, liver, heart, kidneys....

Strep A has been broken down into different strains. Some known to be more virulent than others M-1 and M-2 Strep A are the most deadly strains and then there are strains T-1 to T-4 which are not so "toxic" and are more treatable.

My family member died of an M-1 toxic strep A. She was talking and laughing on her way to the hospital to be checked out 50 hours after birth; she had no fever. She died before nightfall.

My husband had a postpartum mother come into the ER. She had come into the ER earlier that day with nausea and not 'feeling well'. The doc on call sent her home with an anti-nausea medication. She called later than night and spoke to Lewis, he sent an ambulance out to her home as she had no ride to the hospital. She came to the ER laughing and talking; she died 65 minutes later.

Both had died of heart failure-due to the rapid damage to the heart tissue.

Toxic bacteria are still very rare but it is a good idea for us to understand them so as to accurately describe them to our clients should they read of them or be concerned about them.

The development of Toxic strep has been blamed on the overuse of antibiotics - the bacteria have created the mutant toxins to survive. The medical community has tried to play down the significance/real dangers of this happening but there has been 'some' response to try to limit unnecessary antibiotic use.

The reason that Strep B has become more actively treated in the US is not due to Strep B developing the toxic strains. If anyone can verify for me the development of a Toxic Strep B I very much want to know.

I do not think that bacterial deaths from Strep B have become more common at births; they remain steady. This aggressive treatment is an attempt to take action on something that we have little control of, the rare occurrence of a baby becoming systemic with Step B, which otherwise would not affect the child. No-one knows why one baby will become that 'one' out of many exposed vaginally to Strep B who becomes systemically affected and who also fails to have the proper antibody response to fight it off. Perhaps it is related to something allopathic medicine has yet to find much of an answer for, like auto-immunity. It is a very rare baby exposed who becomes systemically affected.

Routine antibiotic treatment has not been shown effective in bringing down the damage (mortality/morbidity) of Strep B. But of course we know that this is not the determining factor in the US when instituting a standard or care. This is why I am asking about the routine treatment of Strep B in Europe. It was my understanding that testing and antibiotic use was not routine intervention. Where as in the US there is pressure on homebirth midwives to treat positive cultures with antibiotics in labor at home.

Morgaine
Midwife, USA

Hospital-Acquired Infections

My friend was having her first baby in a US hospital. Because Strep B infections are so much more common there than in the UK, she was screened for infection during pregnancy and pronounced clear. I believe she had two further checks shortly before being induced (no pressing reason for the induction - she'd just reached or shortly passed EDD), and again all were clear. Her membranes were ruptured, monitors attached, pitocin, etc....

During the labour the baby went into severe distress and had to be delivered by emergency C/S. Baby was suffering from Strep B. Baby nearly died and spent a week in intensive care - as a 6 year old, still has scars on her arms from IVs. Subsequent tests on mother found that she STILL tested negative for Strep B, and only explanation was that baby picked it up during labour from infection in the hospital after membranes were ruptured. Of course, this being the US, her subsequent two children were born by planned c/s too; I get the impression she wasn't even aware there was an alternative.

Another friend whose baby was born in the UK last year was induced at 8-10 days past dates. She was planning a home birth but a consultant put the frighteners on her over post-dates risks, and told her her cervix was so ripe, induction would be really easy. After 24 hours of hard induced labour she was still only dilated to 2 or 3 cm and the baby went into distress, so emergency c/s was performed. Baby taken to SCBU for observation, released after a day or so, during which time mum had to fight to stop staff giving formula.

Mum is a nurse, and was convinced a day or so later that baby was not quite right. Hospital staff dismissed her fears. Mum took baby home, only to have to rush back as baby developed roaring temperature and turned blue. Turns out baby had septicaemia, and had to spend several days in intensive care, also on IV antibiotics. Fortunately he recovered well. Mum is convinced that the most likely place for her baby to have contracted his infection was SCBU, where of course he was subjected to numerous blood tests etc. in the name of 'observation'.

The first person I knew who had a home birth was a microbiologist who decided, after contracting a nasty postnatal infection following her first hospital birth, that the risk of hospital birth was just too great if there were no complicating factors. She went on to have a 9 1/2 lb baby girl at home; the baby was a full face presentation. Mum wishes that an epidural had been available, but is still glad that she did not go into hospital; her career has left her adamant that she is not going into hospital in future unless she is dying!

Of course, half the time when you mention home birth, people start on the 'But what if something goes wrong.... ' routine. I am tempted to ask the same when those people tell me they're planning a hospital birth!

Angela Horn
Home Birth Reference Site
www.homebirth.org.uk

Links to other sources of information:

US Midwife Archives pages on GBS
(www.gentlebirth.org/archives/gbs.html)

US Center for Disease Control page on GBS: www.cdc.gov/ncidod/dbmd/gbs/
and www.cdc.gov/ncidod/dbmd/diseaseinfo/groupbstrep_g.htm

Women's Health Website (by UK obstetrician Danny Tucker): www.womens-health.co.uk/gbs.htm

UK Group B Strep Support Group: www.gbss.org.uk/

AH updated 4 July 2002

Radical Midwives' Homepage - www.midwifery.org.uk

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