Hypothetical situation:
Your first pregnancy was normal. GBS screen was negative at 37 weeks. However, after you have an uncomplicated labor and birth, your baby develops early onset GBS infection. Your baby has a prolonged stay in the NICU with overwhelming sepsis, but eventually recovers fully and is discharged home.
You're pregnant again. You're 37 weeks along. You plan on having your baby in the same hospital as the first pregnancy. You are not in labor at the moment.
Do you:
1. Do the GBS swab?
Positive results - treat with antibiotics in labor.
Negative results - no treatment in labor.
Negative results - treat with antibiotics in labor despite the negative result.
or do you........
2. Decline the GBS swab and opt to have antibiotic coverage in labor?
Remember, your first pregnancy you were tested GBS negative, yet your baby ended up with an overwhelming GBS infection.
Just another personal choice/moral situation for you to ponder.
39 comments:
I have no doubt I would go for option #2
I would decline the test and treat with probiotics, garlic and hibcleanse during labor, saving the antibiotics for after birth if an infection developed.
I would probably go for option 2. Then again, I was GBS positive in my pregnancy, so I have an idea of what it entailed.
what are the risks of taking an antibiotic during labor?
So timely with the recent post from Birth Sense on GBS! I've been getting more curious about GBS and the evidence base around the US testing and treatment protocols (I've read a little but not much). I know enough to find GBS very scary - just not enough to know what we should actually be doing about it.
I think I'd take option 2. I was GBS positive with my twins (almost) two years ago. And even despite the antibiotics, worried about them becoming infected.
I tested negative this time with the new baby girl we just had 2 1/2 weeks ago. But again, I worried about her becoming infected knowing I was a carrier last time. If they would've offered me antibiotics, I just may have accepted to calm my fears!!
I would not treat with abx unless absolutely necessary. There's been some research in the past few years that indicates the abx may not be as effective as once believed anyway. I would certainly do the homeopathic treatments, and then reconsider my options and choices as necessary.
That said, there is no one right answer, and I wish more women realized this. Thank you AYC for always keeping us on our toes and thinking. :)
First, I'd want to know more about the first labour. How long were the membranes ruptured prior to the birth? How many VEs? Did mom develop a fever at all during labour?
@ Anonymous: Good question! The general risk of antibiotics is the development of "superbugs" - germs that can't be treated with antibiotics. Another risk is getting thrush, which will make early breastfeeding harder.
I would be very surprised if this case was a real situation. It's possible but so rare - 1/200 babies get sick out of GBS+ moms.
But if this was my situation, I'd probably not test and do hibiclens. When I was researching this recently for a friend, studies show hibiclens is just as effective as abx.
With my 6th pregnancy, I did not get swabbed and got antibiotics during labor. With babies 4 & 5 I did test positive for GBS so I just went straight for the antibiotics with my 6th. I would probably encourage women to look at reliable homeopathic methods suggested by a midwife instead. The likelihood of a baby being permanently harmed in the rare event they do get infected by GBS is fairly rare. However, my nephew's mom (sil) was not swabbed and he got very, very sick immediately after birth. He's "ok" now, but it was really awful. So, because it hits close to home for me, I was more likely to go straight for the antibiotics. Is this a real case that you witnessed, but can't discuss in detail b/c of HIPAA?
For me it would be option #2 though I can totally see an OB pushing option #1 because defensive medicine is all they know or at least all they care to practice.
I'd go with the ABO myself but what do I know? I haven't been pregnant for 16 years.....
Abx, definitely. Why play around with your baby's life?
Homeopathic medicine is a crock. No proven effectiveness beyond placebo effect....and since I don't think bacteria have a mind to bamboozle....
A friend of mine was in a similar conundrum, but not exactly the same
first baby tested positive for gbs, but only got first dose of PCN before baby was born r/t rapid labor. baby became septic and was hospitalized for two weeks after birth
so in her second pregnancy, she got tested and was gbs negative this time. She wasn't sure whether to take the abx or not, but because of how sick the first baby had been decided to take them. that baby was fine and didn't get infected
pesonally, i dont know what I'd do!
I would definitely do option 2. I know one shouldn't throw antibiotics around lightly, but especially with past history, I'd rather be safe than sorry.
Is it possible to take the antibiotics prior to labor? The reason I ask is that I am one of those women that birth too quickly for the antibiotics to get through my system. If I could take them ahead of time, say around 38 weeks, I would opt for that.
I was postive for my first, negative for my second, and postive for my third. Testing is almost stupid after you have a positive test because they will treat you with antibiotics with subsequent pregnancies even if you later test negative. Swabbing is almost just for them.
I'd never do #2. even with the first experience you described, I'd only go for Antibiotics if I was tested positive. The overly lightly use of ABs in general is dangerous.
If I was seriously worried about GBS yes or no, I'd rather pay another swab out of my pocket a few days or a week before the expected date of birth. If it was positive, then I'd take ABs if it was best for the child, if it was negative, I wouldn't.
Oh, also, if in the theoretical case as described I'd have been negative for GBS but the baby positive, I'd possibly had switched hospitals for the next birth anyway, in case the infection was somehow caused by the staff (you never know). Although a good NICU is worth a lot, so if they were brilliant - I might return. ;-)
The problem is that you can never really find one right answer for a question like this. There's not just right and wrong, but statistics and likelihoods and personal belief regarding the use of ABs etc.
Personal choice would be option #3 - no test, no abx. Baby is observed after birth anyway, and there are plenty of cues ahead of time to know if GBS is a problem. Treating with abx for no proven reason just adds to the problem of super bugs. Testing positive (or negative) at 37 weeks doesn't mean the test would be the same in labor.
Never have had a culture or abx in labor "just in case" and still won't.
Is it possible to take the antibiotics prior to labor?
No because it may lower the colonization but no guarantee it will get rid of it and stay gone for birth. Oral doesn't help either, you just expose you and your baby to the overuse of antibiotics. Hibiclens can be used as a vaginal wash and has been proven as effective as antibiotics. This can be done at the onset of labor and every 4 hours or so til birth without the risks of antibiotics. I used this with my home birth knowing I was GBS positive and baby was fine. You also have to take into consideration the interventions that are done that can spread the bacteria, ROM and internal monitors increase exposure.
Also, just because one tests positive at 37 weeks is no guarantee she will still be so at 40 - the same goes for testing negative for GBS. 37 weeks is just too early to get a clear understanding of a mom's colonization status. Hibiclens is an excellent choice because it doesn't carry the risk of adding to the "superbug" problem.
Having been diagnosed with GBS during my first pregnancy I wanted to just forgo the testing during pregnancy #2 but due to having a different doctor for baby #2 he wanted to do the test and I wasn't shocked when it came back positive. If #3 ever happens for me I'd opt for antibiotics in labor w/o testing if it's an option for me.
Probably #2. Given her positive history, I would have the antibiotics. What if her baby didn't get better? What if it died? It's okay to say "I'd still decline the antibiotics" given that we know the baby's okay, but even though it's rare, it can still pose devastating consequences.
When I was 8 years old, my younger brother was born with GBS. I remember bits and pieces from it, mostly not being able to see him for awhile, him being transported to Akron Children's and seeing pictures of a PICC line in his head. Take the antibiotics already.
I have seen 2 deaths of a baby with GBS. It happens very quickly - the downward spiral and in both cases it was within 24 hrs of birth.
Having said that, unless I have ruptured membranes, I would probably opt out of tx with abx. I agree with Aron that there is no guarantee that the testing result will be what you are at time of delivery. I would also want as few VE's as possible -IMHO there are WAY too many done in the course of labor, and I would make a decision at the time.
If it is such a big concern, why don't they test every woman who comes to the hospital during delivery and if she tests positive, give the baby antibiotics?
I was very happy, especially for my baby's sake, that I tested negative, because she was born 20 minutes after arriving at the hospital- there wasn't even time for them to weigh me much less start and IV. That was one of the only questions that I remember them asking me after she was born- do you know your GBS status? Of course, even though I did test negative, it didn't mean that I wasn't positive at the time!
What about vaginal douches as an option???
The problem with douches is that they disrupt your body's normal (healthy) bacterial flora, hindering its ability to protect against harmful bacteria. Douches also can push harmful bacteria further up into the vagina, or if she's dilated at all even into the uterus (BAD). A better choice is to use hibiclens, check status in labor (if there's time), limit VEs, avoid amniotomy and use abx during labor if positive or immediately following if unknown.
I am 25 weeks along and was just treated for a GBS caused bladder infection (worst UTI I have ever had!) Would this be an extra reason to have antibiotics during labor?
sara: you would be delivered before a culture came back POS or NEG for GBS which is 2 days.
I agree with Aron (once again)
Frandsen: this is between you and your MD, however, GBS can be treated and later appear again...but unless you are preterm or prolonged ROM or fever you would be in same catagory as any GBS+ mom.
As a mother in this situation, I would have intrapartum antibioitics. Invasive group b strep disease in a previous infant is considered a risk factor for repeat infection and treatment is usually recommended. The thinking is that if mom had a previous child with invasive strep disease, the strain she carries may be more infective than some and be higher risk for infecting another infant. The problem with early onset GBS disease such as mom's previous baby had, is that frequently symptoms are only mild/non-existent until baby is very ill. I have seen a healthy baby get so sick he needed ECMO from GBS sepsis, and I would want to avoid that at all cost. Although I am a big fan of limiting antibiotic use, reducing the chance of a repeat experience with invasive GBS is to me a good reason to use antibioitics.
Everyone notice how there really is no clear right or wrong answer to this dilemma? It comes down to making an informed, well-educated choice.
I will add this - in my experience, most providers will recommend treatment with antibiotics in labor for all future pregnancies when there was a history of a prior child with neonatal GBS sepsis.
My personal experience with GBS - unknown maternal postpartum infection with first baby. GBS testing not done prenatally with first two children (it wasn't done routinely then). GBS positive culture hx when not pregnant, but GBS culture negative with 3rd baby. No treatment in labor.
None of my children had GBS infection in the neonatal period.
Option #2. I had a GBS+ UTI about 8 years.
GBS sepsis can have such a rapid onset and cause signficant morbidity let alone death.
The plural of anecdote is not data but.....an online aquaintance had a baby about 2 weeks after I did in 2006. He was a perfectly healthy newborn. She had been ruptured for more than 24 hours but no fever. Her son ended up with a massive GBS infection at 24 hours old. He is now blind, has CP, uncontrolled epilepsy (100+ seizures/day) and will never talk, walk or feed himself.
My last baby had viral meningitis at 4 days old but we didn't know that until after we did a full septic workup.
He won't remember the spinal tap or urinary catheter or 3 days on a monitored unit but I will never forget.
I could never put another child of mine through that because I chose not to have a couple doses of IV ampicillin.
I completely understand the statistics but in the end, we, the mothers are the ones that have to live with the decisions. Maybe I will feel differently if one of my children ends up with a abx resistant infection but for now, it is choice #2.
Are there any data on a connection between intrapartum/neonatal use of ABs and development of allergies/reflux? Or is resistance the only risk associated with such AB use?
I wonder why no one seems to go with option 1. I can understand if you're for or against prophylactic abx but why wouldn't you do the culture....? At the very worst, you'd be armed with more information. I don't comprehend not doing a swab on the off chance that you'd again get a false negative.
Were it me, and bear in mind I'm nullipara and just starting my maternity course, I'd rather have a test with results which may not be completely reliable and have *something* on which to base a decision.
undergrad: problem is you can test negative and positive throughout your pregnancy. Even though you test negative at 37 wks, you might still be positive at time of delivery...or vice versa. Not really dependable really.
I was tested for GBS before I ever became pregnant and therefore I knew I was already a carrier. With my last pregnancy, they waited until at least 35 weeks - (maybe it was longer) - but I wasn't quite far enough along yet and they were counting down to the date (too bad the chart had my due date off by four days and should have gone by the date the early u/s gave).
I'd choose 'other', do a rapid test at the start of labor, if your hospital doesn't have them apparently a layman can order one, if I tested positive at the beginning of labor then id do abx. I never got testing early since gbs can come and go. A positive at 37 wks doesn't mean you'll have it at 40 wks, a negative at 37 also doesn't mean you'll be negative at time of labor. There are real risks and negatives associated with abx, and just because I had hit the 'unlucky jackpot' the 1st time has no statistical barring on it happening again..so yeah, treat IF I was colonized at time of labor.
I agree, DrJen. It is technically recommended by the CDC to treat a mother empirically for GBS if the mother has had a previous child with documented invasive GBS disease. It is easy to be the mom and refuse abx for whatever reason, but as an OB healthcare provder, I would document extremely carefully because you are putting yourself in a possible situation of litigation if you do NOT recommend antibiotics and a second child has GBS invasive disease. That being said, all you have to do is NOT test (because per the CDC criteria a previously affected infant with invasive GBS dz is enough to get abx with all subsequent deliveries/children - so test results do NOT matter - negative tests can always be false negativess anyway), but a patient can always refuse them (patient autonomy, of course!). But you have to be careful to know those recommendations and be able to let patients know what they are. Only can a fully informed patient make that decision. I personally would take the antibiotics because the few infants I have seen with GBS sepsis were the saddest and most horrible cases I have seen in my career. Also, research has greatly shown that intrpartum antibiotics reduce the rate of early-onset GBS disease, but NOT late-onset GBS disease, which is an important differentiation.
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