Group B Strep: What Does it Mean for Me and my Baby?
Group B Streptococcus, otherwise known as GBS or Group B Strep, is a normally occurring bacteria that lives in the lower intestines of human beings - from babies to the elderly. It's a hot topic in the world of having babies, and there are no easy answers. I encourage educating yourself, weighing the risks and benefits of each option regarding testing, prevention and treatment, and deciding what is best for you and your baby.
Around 10-30% of pregnant women are colonized with the bacteria, depending on the population studied - but about 25% are reported to have vaginal GBS in the US. When there is a large amount of GBS in the colon and rectal areas, it can come forward to the vaginal and urinary tracts.
If detected vaginally in a non-pregnant woman, there is nothing wrong, and no need for treatment. The main concern is if a pregnant women has it in labor, and baby is exposed to the vaginal bacteria after the 'bag of water' breaks (during pregnancy, the baby is encased and protected in a double layered membranous sac of amniotic fluid, in lay terms referred to as the bag of water).
Although the vast majority of pregnant women with vaginal GBS have healthy babies, half are simply colonized - test positive for it but stay healthy, and about one in 200 babies in the US who are exposed to it during childbirth, can get infectious illness. GBS infection can become very severe or life threatening for about 1-2% of these babies, which is thankfully rare, but potentially devastating for those who are affected.
Every human life matters, and I take those 1 or 2 babies per a thousand very seriously, as would any parent of a very gravely ill newborn.
I’ve collected some information for you below. I hope that this bite-sized chunk will save you from endless searching on the internet. Take note, that if you are in any doubt, please consult me, your midwife or doctor.
After a positive GBS test, don’t let anyone pressure or scare you out of having a free-standing birth center or home birth, if that’s what you want. GBS can easily be managed in the out-of-hospital setting. And know you do have options and can speak up on how the issue is dealt with; even though there is a standard of care that is strictly upheld in the US, there are different standards in other Westernized countries like the UK, that might just make more sense for you.
Risks During Pregnancy
Serious complications in pregnant women are rare. Complications of GBS can lead to urinary tract infection in women, but often the positive test results are actually from vaginal discharge, even if a ‘clean catch’ culture was obtained. In my practice, I found that out early on, after sending women with persistent GBS on clean catch urine culture tests, to a wonderful local urologist; she found them all to be negative for GBS in the urine using a sterile straight catheter specimen, and said there was no urinary infection to treat.
In the United States, GBS is routinely managed in the United States according to the Center For Disease Control (CDC) guidelines. It is tested for between the 35th and 37th week of pregnancy, by taking a Q-tip like swab from the vagina and rectal area, and sending it to a lab. This is currently the best time for obtaining results closest to the onset of labor. It takes several days to get results, which are allegedly valid for 5 weeks. Current testing is not completely predictive, as tests can yield different results at different times because GBS can come and go intermittently. A mom can test negative in late pregnancy, but actually be positive for GBS if tested in labor. Likewise, but less commonly, a mom can test positive in late pregnancy, and test negative for GBS in labor. There is a new home GBS test in the UK called Strepelle that gives accurate results 3 days from receipt of the sample - but it is not without controversy. Unfortunately at this time, there are no reliable, widely available, cost effective, rapid test available during labor - which would at least address this issue.
In other countries like the United Kingdom, women are not routinely tested in pregnancy for group B strep, according to recommendations by The National Institute of Health and Care Excellence; this is because they determined that evidence of the effectiveness of routine GBS testing in all pregnant women remains uncertain. Per guidelines of the Royal College of Obstetricians and Gynecologists, pregnant women are treated with antibiotics in labor only if there are risk factors - such as signs of infection like fever in labor, a prolonged time between 'water breaking' and birth, or if a preterm baby is expected. Until 2002, in the United States, GBS in pregnancy was managed this way as well. The change in American obstetrical practice guidelines was based on analysis of some large studies around that time, even though there are limitations to the quality of those clinical trials, as is common with research; one major bias that concerns integrative, holistically minded practitioners, which most of the mainstream medical world discounts, is that this research is largely funded by for profit pharmaceutical companies who manufacture the antibiotics. Today, in the US, all women who test positive for GBS during the late third trimester screen are given IV antibiotics in labor. That is a lot of healthy women and babies exposed to antibiotics when the risk of serious infection in newborn babies is rare. Additionally, most cases of group B strep in term newborns occur after screened pregnant women tested negative.
Care Recommendations, Alternatives and Issues
The current standard of practice in the USA is based on the guidelines published by The Center For Disease Control and Prevention (CDC), which dictates that antibiotics are to be given during labor, to all women who tested positive for GBS in current pregnancy. This is hospital routine, and is based on the interpretation of the available research, indicating that IV antibiotics in labor significantly lowers the chance of infection in babies from 1 in 200 to 1 in 4000. But antibiotics can have serious side-effects. Many healthy moms in my practice don't want routine IV antibiotics, even though they can be given both in the home and freestanding birth center settings. It feels too medical for them; they are worried about it interfering with their ability to have a beautiful natural birth, have valid concerns about the consequences of the antibiotics and feel their risks do not outweigh potential benefits. Some pregnant moms do want the standard treatment, as they are more concerned with GBS than a few doses of intravenous antibiotics, and do not feel the IV in labor will hinder them or their birth dreams.
If you do want the IV antibiotics, know you can still move around during the infusion, and be in the tub or shower if the access site is covered properly. I was gifted with a home IV pole on wheels, by a family in my practice. We had previously hung the IV on whatever we found in the house - like a door hook or hanger on a curtain rod (once antlers on a wall-mounted moose head did the trick); or when she needed to walk, someone would personally hold it up, and follow her around with it. You also don't need to be attached to an IV the entire labor and birth, but can have a saline lock, also known as a hep-lock. This is an IV catheter that's inserted into your vein, used only for the 15-30 minutes it takes for the medication to infuse; it is then disconnected from the access portal, so you are not attached to the IV tubing, pole and solution bag in between doses for the majority of your labor.
One reported side-effect of IV antibiotics in women is a harmless rash. Another potential annoying but treatable consequence is a vaginal yeast infection, which can lead to thrush in baby's mouth and on your nipples, and make breastfeeding painful for you until it resolves. A far more serious but fortunately very rare side-effect is Anaphylaxis, an allergic reaction which can be life-threatening, but most often managed effectively with medication. What concerns us most is the effect antibiotics can have on us and our little ones.
Microbiome disruption is the disturbance of the intestinal tract balance of normal flora in babies (and mothers). More research is needed, but a recent Harvard magazine article tells us that this can cause life-long complications in infants. It also ups the antibiotic resistance in adults and infants, another life-long consequence and can lead to other serious infections for them both. The award-winning chilling documentary MICROBIRTH, delves deeply into the microbiome - the trillions of bacteria that live on and in us that could be critical for human health.
Chlorhexidine gluconate vaginal wash is commonly used in Europe for pregnant women who have been diagnosed with Group B Strep. Some studies have shown that the treatment of GBS using Chlorhexidine is safe, cheap, and as effective as antibiotics, without negative side-effects. Other studies suggest Chlorhexidine reduces GBS colonization, but not GBS infection in newborns. It is known in the US as Hibiclens, and is available over the counter without a prescription. It needs to be diluted and there are several effective protocols in pregnancy or during labor. It is not natural. It's a potent antiseptic and does disrupt the vaginal flora, which can hopefully be restored with vaginal probiotics; but it doesn't travel through the body and cross over to the baby like the IV antibiotics do. While it prevents the baby from exposure to GBS, it also does not allow exposure to the healthy vaginal bacteria during birth. But many moms in my practice prefer this to IV antibiotics in labor. I have tested its efficacy in my practice. After its use, I get back a culture swab negative for GBS, and have had no cases of newborn infection. Chlorhexidine for GBS is increasing in the US, mostly in out-of -hospital settings.
Another treatment in late pregnancy that has been used especially among out-of-hospital midwives is a vaginal antibiotic. Research is sparse, but suggests possible effectiveness. There is currently only one medication that apparently works, if the strain of GBS is not resistant to it, called Clindamycin; its IV use in labor is an alternative within the CDC guidelines, if mom is allergic to the drug of choice. When testing for GBS, it’s sensitivity to the various antibiotics can also be tested. There is a small study, done by a colleague of mine, on its effectiveness to reduce GBS infection in newborns of moms who had tested positive for GBS in pregnancy. My relatively large homebirth practice was included in her research, as for years, I had been offering this option to pregnant women who tested positive for the bacteria. The option includes a Hibiclens daily wash protocol, other recommendations for prevention of recurrence and weekly GBS follow-up testing. The study demonstrated that this treatment was effective in the vast majority of women without any known complications; but it is only one small retrospective study, not a large, gold-standard, randomized clinical trial. I am still impressed by the negative follow up testing in my practice, and that no baby in my care, after this treatment had GBS infection or other problems. It is also not natural. It is an antibiotic medication, but with more of a local vaginal affect. Moms who have follow up cultures negative for GBS, feel better about declining the IV antibiotics in labor, especially if there are no risk factors. But it also disrupts the healthy balance of bacteria in the vagina, can similarly cause yeast and thrush, and contribute to the issue of disease causing bacteria developing resistance to the antibiotic.
Both of these treatments are easily accessible and thus convenient for home births, as well as birth center and hospital births. You can be empowered and learn to administer them yourself, once you have the supplies. It is important to know that Hibiclens or vaginal Clindamycin are NOT standard of care in the US, and they are not recognized to date by the medical world as a valid treatment to prevent GBS infection in babies. Women who chose either option are educated on the symptoms to watch for, advised to inform their pediatrician, and have the baby evaluated in 1-2 days. I also tell women who opt for either Hibiclens or vaginal Clindamycin, that they would be considered untreated for GBS and given antibiotics if transferred to the hospital - unless they refuse. Although you have the option to decline IV antibiotics in the hospital, disturbingly, it can get nasty if they are not supportive, involve social services or you are reported to the child protection agency and investigated for child abuse and negligence. Do discuss your plans with your provider and setting in advance, to avoid problems.
Although I prefer natural remedies when they are effective, unfortunately in my 22 years of midwifery practice, I have yet to find one that works once GBS is detected; and I have had numerous moms who have used just about all of them, then have a positive GBS test on follow-up. There is forever a place in my heart, for a naturopathic mom who declined antibiotics and Hibiclens, and her severely ill newborn with GBS infection - the outcome was tragic. She tested positive for GBS repeatedly despite using the best of the best of protocols of natural remedies. What baffled all of us was there were no risk factors; it was a relatively short beautiful healthy birth with no interventions, water broke on its own during pushing. Yes, countless babies of moms treated naturally did not get sick even though follow up cultures were still positive for GBS. But the one case was enough for me. There is currently insufficient evidence of the effectiveness of any natural treatment remedy for preventing GBS infection in newborns. Holistic care includes all modalities, and sometimes there is a role for medication. When a pregnant mom tests positive for GBS, I discuss the issue, give her literature to read, present her with the pros and cons of all the options, from doing nothing to the alternative modalities, to IV antibiotics in labor, and honor her informed decision. Some want to use the UK’s risk factor protocol and decline GBS testing during pregnancy, and I respect their informed choice.
It must be said, however, that no treatment is 100%. Cases are still reported in the medical literature where babies were infected with GBS after any treatment - including IV antibiotics, even though IV antibiotics have significantly reduced the incidence and severity of GBS illness in babies according to the research to date. I therefore recommend to keep a close eye on your newborn if you carry GBS, regardless of treatment. If any symptoms present themselves, consult your pediatrician immediately.
Symptoms To Look Out For (Scary But Rare)
Early onset GBS occurs within the first week of life, most commonly within hours after birth. Signs and symptoms include: Lethargy; irritability; poor feeding; very slow or fast heart rate; abnormally high or low temperature; difficulty breathing such as flaring of the nostrils or grunting noises; too fast or slow breathing rate; blueness of the skin of baby's trunk, and/or pale or grey appearance.
Late onset GBS occurs in 1/3 of babies with GBS infectious illness but is uncommon - effecting about 0.3 per 1000 babies, mostly who are premature. It can happen anywhere between the first week and 3 months postpartum; but it is rare after one month of life. Unfortunately there is no known prevention and like early onset GBS infection, can occur even when mom tested negative in pregnancy. An otherwise healthy baby can become critically ill within hours. Symptoms of late onset GBS are the same as early onset infection, but can also include: having a high-pitched, inconsolable cry, whimpering or moaning sounds; blank staring or trance-like expression; appearing floppy and listless; having an involuntary stiff body or jerking movements; not moving an arm or leg; excess sleeping and difficulty arousing; tense or bulging fontanelle (soft spot on baby's head); turning away from bright light; blotchy, tender skin; projectile vomiting; pus and red skin at base of umbilical cord or at any puncture site (from internal monitor).
Lets Talk Prevention!
Supplements during pregnancy can’t completely prevent GBS, but I highly advise taking them regardless, as I have had tremendous success with lowering the vaginal GBS rates in pregnant women who take the specific daily probiotic I recommend. Many of my colleagues report similar success with these probiotics. There is finally a small but growing amount of actual research - studies documenting the effectiveness of certain strains of probiotics to reduce the incidence of GBS. Probiotics are also safe and have many other health benefits. The other whole prenatal vitamins and minerals I recommend supplement a healthy diet with nutrients that enhance health and immunity.
You can lower the risk of infection also by minimizing exposure. You can try to lower the amount of GBS in your vagina, with natural remedies, such as in Dr Aviva Romm's protocol - even though there is no guarantee. If you have GBS in a healthy pregnancy and labor, you certainly can decline or limit vaginal exams, invasive procedures like internal fetal monitoring and having your bag of water broken artificially. If your bag of water has definitely broken before or early in labor, you can use natural remedies to gently stimulate labor and lessen the time it takes to birth. Some studies suggest that water birth can possibly help prevent GBS infection, because of less interventions and invasive procedures, as well as the bacteria being diluted or washed away, so baby is exposed to less of it.
Research is on the horizon regarding a vaccine for both early and late onset GBS infectious illness - which sparks an entirely different debate, as well as more accurate and available rapid testing in labor. There is much to be done to decrease risk and rates of preterm birth. But, my hope is for more research demonstrating prevention with probiotics in pregnancy, holistic modalities to improve immunity against infection, and the benefits of out-of-hospital midwifery care in terms of reducing newborn GBS infections. My dream is that there is widespread cessation of routine medical interventions in normal childbirth - one of the main pillars of authentic midwifery care. If there were more midwife-led birthing centers, out-of-hospital and home birthing for the low risk healthy population, according to evidence based NICES recommendations, this would decrease the rates of invasive procedures and hospital exposure to pathogens - especially resistant ones, that all increase risk of infection. And hopefully this would result in a major reduction of serious GBS illness in babies.
Can I Still Give Birth in a Birthing Center or Have a Home Birth?
Of course! And you might be better off doing so specifically in terms of GBS, by having a provider who honors your choices, possibly lessening infection risk by having a water birth, avoiding routine invasive procedures, as well as exposure to bacteria and infectious illnesses that are common in hospitals. Again, testing positive for GBS in pregnancy does not risk you out of either. Even the the usual protocol in the US to administer antibiotics by means of an IV, can be done at home or birth center with licensed midwives, which is good news!
If you are a carrier of GBS and experiencing a healthy pregnancy, I hope that you now feel confident that a home or birth center birth is still possible and actually a wonderful idea. I hope you have a better perspective about the issue, and feel more educated and empowered to make an informed decision about how you want to deal with it. Know you have alternative options to consider and most importantly do what you can in terms of prevention. Definitely take top quality prenatal supplements and probiotics!
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