I’ve been asked about this subject quite a lot recently so I thought I’d write a post about it. Before I begin, as always, remember I am a doula, not a health professional or medical expert. So, if this subject effects you, do talk to your midwife/doctor as well as reading other resources so you can make informed decisions about your birth.
I will therefore write this post based on what I’ve found out along the way as I’ve supported clients.
So…Group B Strep, GBS, Strep B…what is it and what ramifications does it have for your pregnancy and birth?
GBS is a bacteria that can colonise the human body. It is very common and usually causes no problems. Around a third of women are said to be carrying the bacteria in their vaginas. Most of the time, even when we are pregnant, here in the UK we are not aware of the presence of GBS because we are not routinely tested for it here.
The vast majority of term, healthy babies born to GBS+ mothers are fine. However, sometimes, this infection can cross to the new baby and cause a variety of problems. Here is what the NHS Choices website says:
Early-onset GBS infection
If a baby develops GBS infection less than seven days after birth, it’s known as early-onset GBS infection. Most babies who become infected develop symptoms within 12 hours of birth.
It’s estimated that about one in 2,000 babies born in the UK and Ireland develops early-onset GBS infection. This means that every year in the UK (with 680,000 births a year) around 340 babies will develop early-onset GBS infection.
What complications can it cause?
Most babies who become infected can be treated successfully and will make a full recovery.
However, even with the best medical care, one in 10 babies diagnosed with early-onset GBS infection will die. The infection can cause life-threatening complications, such as:
- blood poisoning (septicaemia),
- infection of the lung (pneumonia), or
- infection of the lining of the brain (meningitis).
Another one-in-five babies who survive the infection will be affected permanently. Early-onset GBS infection can cause problems such as cerebral palsy, deafness, blindness and serious learning difficulties.
Rarely, GBS can cause infection in the mother. For example, an infection in the womb or urinary tract, or more seriously, an infection that spreads through the blood, causing symptoms to develop throughout the whole body (sepsis).
So, whilst it’s a very rare occurance to have a baby become infected, and even rarer for that infection to be serious or God Forbid, fatal, the fear of this possibility for both parents and health professionals shouldn’t be under-estimated.
So, if infection is so rare, why are not all mothers routinely tested in the UK?
My understanding is that routine, universal testing has not been shown to improve outcomes. That means that even if you know you are infected, it won’t necessarily change the outcome for you, or your baby.
Why? Well, for a start, testing is not necessarily 100% accurate. Secondly, treatment for the condition during labour is not guaranteed to prevent your baby becoming infected. Thirdly, treatment during labour can restrict your birth choices (such as place of birth) and your ability to move and change position during labour. Fourthly, there are varying levels of risk factors for fetal infection, so if you are in a low risk group, the chance of your baby being infected are incredibly small. Lastly, the vast majority of newborn (“early onset”) infection if caught early can easily be treated.
As so many of us are GBS+, universal testing would probably mean a huge number of us on IV antibiotics during labour, with all the consequences that entails, not least a contribution to the number of women and babies developing resistance to antibiotics.
As I mention above, most of us will never know our GBS status and have perfectly normal healthy pregnancies and babies. However, for a variety of reasons, some women will find out in pregnancy that they are positive for GBS. They may also have known in a previous pregnancy that they were positive, in which case, any subsequent pregnancy will be treated as if she is positive this time, too.
For many reasons, some women choose to be tested, either by the NHS or privately. My experience with both kinds of testing is varied and I’d love to hear your views. My experience is that the NHS test appears to give quite a few false positive or false negative results. (I’ve seen it quoted that it can miss up to 50% of positive carriers) Whilst the private test seems to have a better repution in this respect, I do find the ‘customer service’ to be severely wanting. I have had more than one client receive a text telling them the result, with no explanation, no counselling through her options and no signposting to sources of information and support. This can be cripplingly upsetting for an emotionally vulnerable pregnant woman. Likewise, I have heard numerous stories of GP receptionists ringing women to tell them the results and informing them that they must therefore now go to hospital to have their babies. Again, very upsetting and frankly none of the receptionist’s business unless she also happens to be a doctor or midwife!
So, if you know you are GBS+ in this pregnancy, what are your choices?
Well, I think the first thing to remember is just that – you have CHOICES. No-one is able to tell you that you are GBS+ and therefore you MUST…
Most woman will be encouraged to have a hospital birth. This is because the recommended treatment is IV antibiotics. Hospital policy seems to differ from place to place, so it may well be useful to find out what your hospital advises. Some give one dose only, at least 4 hours before the birth. Others seem to want to put up another bag of antibiotics every 4 hours during labour. It takes around 20mins for the dose to go through, during which time your mobility is restricted somewhat by the cannula in your arm and the drip pole you are attached to.
IV antibiotics in labour have been shown in research to decrease the likelihood of a baby being infected. A recent Cochrane review concluded however, that many studies are particularly biased, more research is needed in this area and that prophylactic (Just In Case) antibiotics in labour did not decrease the chances of babies dying. Furthermore, there are serious albeit rare) risks to antibiotics being given, including allergic reaction either in the mother or child or thrush colonisation in mother and/or baby after birth, which can be extremely painful when breastfeeding and result in the cessation of nursing, with all the subsequent risks of not breastfeeding for baby and mum. There is also some research to suggest that early exposure to antibiotics as a fetus or newborn can contribute to the risk or allergies or asthma developing later.
In theory, IM antibiotics (an injection) during labour would be a possible alternative. This makes homebirth possible for mothers who feel they want to be treated. A couple of my clients have opted for this, but it was only possible because this choice was made available to them in my city. I am unaware of it being offered elsewhere and the evidence for it’s effectiveness is not there – but only because we need more research!
Some mothers opt for doing nothing and becoming familiar with what to look out for in their babies during the first few days.
(Early Onset infection will happen before one week of age (usually before – around 90% of infected babies will show symptoms by 48 hours) – if infection happens after this, it is unlikely that it has come from the mother but from some other source).
So here are some of the signs to look for in a baby who may be infected, there may be others, like low blood pressure that most parents couldn’t check for themselves.
(Early Onset): grunting, poor feeding, lethargy, irritability, and/or abnormally high or low temperature, heart rates or breathing rates.
So how do parents choose?
Well, many women will want to take their personal risk factors into account when deciding where and how to give birth if they know they are GBS+
Here are the risk factors, if you tick some of these boxes, whether you choose to reassess, or to stick with the original plan, but you do need to know that each of these factors increases the likelihood of fetal infection (risk increases as you go down the list)
If you are in preterm labour. That means before 37 weeks
If your waters have broken before 37 weeks
Where your waters have broken before labour starts and this situation has been going on for more than 24 hours
If you have a temperature, either in labour or before labour starts with ruptured membranes (waters broken)
If you know you are GBS+
If you have been tested and found to have GBS in your urine at any point in your pregnancy. If you do have it in your urine, this is a more serious infection and you should be offered treatment then with oral antibiotics.
If you have had a baby before who developed a GBS infection.
So many of us want straight answers, but unfortunately, in this situation, I don’t think there are any! If this subject applies to you and I were your doula, I would suggest you read some of the resources below (and some of these links in this article go to research abstracts), look at your particular risk factors, listen to your care-givers (ie doctors/midwives) and then listen to your gut instinct. This is one area where we really do need more research as it appears to me that at the moment we are possibly basing routine treatment on studies that may be flawed.
AIMS (Association for Improvements In Maternity Services)
Royal College of obstetricians and gynecologists
I’d love to hear your experiences and thoughts – do feel free to comment below, especially if you think I’ve forgotten something or got something wrong!
I’m 40 weeks pregnant and was found to have a GBS urine infection about a month ago. I’m currently awaiting the results of a private swab test to see if I am still carrying GBS. If I am I have opted to go into hospital in early labour for IV antibiotics and will then return home to continue my home birth plans. The usual antibiotic given is penicillin, which is as you stated given at 4 hourly intervals. Another option (and what I will be having) is clindomycin, which is a more expensive antibiotic and therefore not usually given except in the case of penecillin allergy. The benefit of clindomycin is that it is given at 8 hourly intervals, meaning that it is unlikely I will need another dose.
With regards to the private test for GBS that you can have done, it is not the same test that the NHS use. The NHS one as you say is only 50% reliable – essentially useless in my opinion! With the private one when done within 5 weeks of delivery a negative result is 96% predictive of not carrying GBS at delivery and a positive result is 87% predictive of carrying GBS at delivery. This is why I chose (albeit at the last minute!) to pay for the private test and will base my final decision on the result. With regards to how you get the result, I’m not sure why getting a text message is a bad thing? This is an option on the form you send with the swabs and means that you get the results as soon as they are available! For me this is really important as I’ve done the test late in the game (as I said, my edd is today!). I don’t see why you’d be expecting a lab to offer any kind of counselling on the results. I also don’t think there will be much to the results – either I will be carrying it still or I won’t. Perhaps when I get the paper results through they will have more detail on which swab was positive (if it is) or the number of cells cultured – but at the end of the day if I am carrying it I am carrying it and will base my decision on that. It is a very, very difficult issue to make a decision about and we have agonised for weeks over what to do. There is a lot of information available though and thoroughly educating yourself and as you said, listening to your instincts are the most important things.
Thanks for your lovely informative reply and for sharing your experience – I’m sure it will be huge help to others!
With reference to the text message results service, what I mean is that some women may not have research all the implications of being positive before they send off the test. This means that they potentially receive unwelcome news when in the supermarket or elsewhere away from a support person. I just feel that results should come together with some text about what it means and some signposts to support groups and information.
I’ve had clients that just blindly paid for the test because they wanted homebirths and they just wanted to check for themselves because they had heard scary stories about GBS. So when they got a + result by text, their immediate emotional response was “my baby is in danger and I can’t have a homebirth” and collapsed into an emotional wreck! All tests should come with information before taking the test so that women can make an informed choice as to whether they want to take it, and if they do, what they are going to do with the information gained.
I hope that clarifies! Obviously you were so sensible and got fully informed before paying for the test!
I had a client about a year ago who was GBS+ve (also VBAC) and we had a wonderful home waterbirth – we had a fully discussed and informed plan of care written up between myself and her and her partner and it worked beautifully – with research thoughtfulness and forward planning you can achieve the birth you want even with a GBS +ve result xxxx
Absolutely you can Amanda! 🙂
Hannah Ashford says
Great Blog piece 🙂
I am almost 20 weeks and have already got one lucky little 100% survivor from a GBS infection.
I did not know I was carrying it the first time, this time it has already been picked up in my urine at 17 weeks.
I am so torn as my last birth had so much intervention that I am worried about going into hospital, I would like to have a home birth but I am terrified of having another GBS+ baby.
The ordeal we went through last time of seeing her have so many tests including a highly painful lumbar puncture was traumatic.
I am really torn, I think if I was just a carrier I would be fine but the fact my baby was GBS+ I have been told I am 10x more likely to have another GBS baby…
Hannah, that must have been so traumatic for you to go through.
If it is what you want then I’m sure you could have a home birth. As I said above I am having a home birth but still being treated with antibiotics in labour. I’m sure I could have pushed to have antibiotics given at home but being late in the game for me I didn’t have the emotional energy (or time really) to do so. AIMS would be a great place to start if you wanted help going down that route though. Bear in mind that clindomycin is a longer acting antibiotic also which broadens your options.
For me, having antibiotics in labour makes it even more important to me to birth at home because whilst the antibiotics will drastically reduce the chances of the baby being infected with GBS, the chances of picking up other infections (think e.coli, mrsa etc) in hospital and after being exposed to antibiotics is much higher.
I could offer you all sorts of bits and pieces of my opinions but they are such personal things and what fits me won’t necessarily fit another person, so what I would suggest is doing a lot of reading (which will probably make you feel a little numb in the brain after a while, it did me!) and take it from there. We did a lot of verifying sources of information on websites (a lot is very biased one way or the other) and a lot of working the maths out for ourselves and verifying figures and statistics independently of where they were being presented to us. It’s been really difficult but ultimately we are the sort of people that don’t like to take anyone’s word for it, we have to find out for ourselves and make our own decisions.
I hope you manage to reach a decision you are comfortable with – I know it isn’t easy!
Thanks for your reply Claire – your suggestions are so supportive and useful!
Hannah, it must, indeed have been horrific for you last time. As far as I’ve read, if you’ve had a previous baby infected, then it does increase your risk factor this time by 10%. Remember that 10% sounds very scary, but you could look at it as only increasing a tiny, tiny number by 10%, which still makes it a tiny number. However, your emotions surrounding your memories from last time, and your personal perception of risk will come into your decision-making too – which is why no-one can or should tell you what to do.
Whilst there hasn’t been much research into it’s effectiveness, there always is the possibility of asking your caregivers to explore the possibility of having anbiotics by injection so you can stay at home for the birth. It has been done in my area, without any adverse outcomes to my knowledge. In light of the fact that the recent Cochrane review case doubt on the effectiveness of current policy for IV antibiotics, it means that at the moment, parents are in a bit of a unknown place when deciding what to do.
There are such differing policies between hospitals that it can also make it harder for parents to work out who might be providing the most up to date, research-based information. US midwives seem to use douches in pregnancy to treat GBS, but I’ve not heard of that happening here (although happy to be corrected!).
At the end of the day, it is only your heart that can tell you which way to go, once you done as much research as you feel able to. Contemplating risks to a baby are a different kettle of fish to thinking about personal risk (well I think so – I make my kids wear their cycle helmets, but sometimes whnn they aren’t looking, I pop to the shop not wearing mine 🙂
I send you my heartfelt good wishes on your decision-making journey and to anyone else reading this in a similar position. I often say to my clients that if they talk to one Dr and they still feel uncomfortable that they get a 2nd opinion…and get a 3rd, 4th and so on until they are happy, or at least at ease with the information and guidance they are receiving.
By the way, if they’ve found it in your urine this time, have they given you oral antibiotics?
Lots of love,
Kath Harbisher says
Hannah, did your baby actually develop symptoms of GBS infection or were these tests done ‘just in case’? I’m being nosey I’m afraid and so sorry to hear you such such a difficult time of it.
Generally speaking, and at the risk of shot down in flames, I do think that parents need to be aware that antibiotics do not guarantee that their child will not be affected. I find that IV antibiotics are often presented to parents as a prevention of GBS but they are not, they are are just a reduction of risk.
This Cochrane review suggests that IV antibiotics may make no difference to preventing a child developing early-onset GBS.
So, my own feeling is that this has to entirely a personal decision because there is no robust evidence. If parents decide to have antibiotics, they should be supported in that. But equally, if they choose not to have them, then they should not be treated as if they are risking the life of their child as I have heard many stories of such.
Julie Beavers says
I absolutely agree that antibiotics in labour againsts group B strep infection in babies should be presented as preventative measure to reduce the risk rather than any guarantee.
Given that the underlying rate of group B strep infection is estimated to be about 1 in every 1000 babies born (with current preventative strategies it’s actually about half this), then the trials used for the Cochrane review including only 852 would be hard-pressed to prove anything very much!
Having said that, iv antibiotics in labour have reduced the incidence massively in other countries – in the US, Italy and Spain to name but three, there have been very significant reductions. See Figure 1 in the latest US GBS guidelines at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5910a1.htm?s_cid=rr5910a1_e to see a graph over time, plus http://www.ncbi.nlm.nih.gov/pubmed/12357426?dopt=Abstract for Italian data and http://www.ncbi.nlm.nih.gov/pubmed/12681128?dopt=Abstract for Spanish data, all covering much larger samples. However, large scale randomised controlled trials have simply not been done on this and therefore such ‘gold standard’ data isn’t available for the Cochrane review and, given the current economic climate, it seems massively unlikely to happen now. It’s a shame, but there you go. The Cochrane reviewers point out that “Ideally the effectiveness of IAP to reduce neonatal GBS infections should be studied in adequately sized double-blind controlled trials. The opportunity to conduct such trials has likely been lost, as practice guidelines (albeit without good evidence) have been introduced in many jurisdictions.”
I believe pregnant women should be given all the relevant facts, offered the chance to have a good quality test for group b strep (not the standard NHS one which isn’t the method our Health Protection Agency recommends) and, if they have that and are positive, offered antibiotics in labour. I think at that point Mum should be able to make a choice based on her and her baby’s circumstances – some will want the antibiotics (and for some women where there are other things happening which mean the baby has a higher chance of Strep b infection) and some won’t – they should be supported in their decision.
If Mum and her health professionals know group b strep is around late in pregnancy, then they can take this into account during labour, delivery and the early hours after baby is born so they can take preventative (risk reduction rather than prevention guarantee!) measures sooner rather than later.