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    Jul 26
    2006

    GBS-positive and induction

    Archived User
    I just read the chapter on labor induction in your book "The Thinking Woman's Guide to a Better Birth." A question that I have is regarding the delivery of my first baby. I had premature rupture of the membranes, and then my labor wouldn't start...contractions were very weak. I was GBS-positive, so as soon as my water broke, we headed to the hospital for antibiotic therapy per our doctor's recommendation. 10 hours later, still no labor. The doctor said I had to get labor going due to the risk of infection to the baby. I realize that usually they wait 24 hours before insisting on this, but due to my GBS-positive status, that timeline was bumped up significantly. With God's grace and help, we were still able to deliver without pain relievers while I was on pitocin. Certainly not what I had envisioned happening. But I must admit, I was a hairline away from an epidural if my cervix hadn't dilated to 10 cm by the time that it had. And all my fears of a C-section began to surface as the snowball effect seemed to emerge from all the medical intervention taking place.

    So....how long could I have safely waited before resorting to the pitocin? I am currently 30 weeks pregnant, and I am concerned about the same scenario again. We are with the same doctor, same hospital. By: PintyLane
    Archived User
    The Centers for Disease Control's recommendations for GBS diagnosis and treatment say nothing about inducing labor for ruptured membranes in GBS-positive women with full-term pregnancies and recommend against it in women with preterm babies. The key thing is to begin antibiotic treatment within 4 hrs of the birth. By the way, the baby needs no evaluation or antibiotic therapy provided that the baby shows no signs of infection, is at least 35 wks old, and the mother had antibiotics within 4 hrs of birth.

    -- Henci By: Henci Goer
    Archived User
    So it seems you are saying that women who are GBS-positive and have PROM, but yet labor is not starting, are not placing there babies under greater risk for infection by waiting for labor to start as long as they are receiving the antibiotic therapy. In other words, there is no need to induce labor earlier. By: PintyLane
    Archived User
    It's not that I'm saying it but that the CDC is NOT, at least to my knowledge, saying women should be induced under these circumstances. This is a subtle, but important, distinction. I am not a clinician, and I don't give medical advice. I report what the research has to say and raise issues for consideration with the goal of helping women make informed decisions.

    -- Henci By: Henci Goer
    Archived User
    My husband and I are seriously contemplating the idea of switching to a midwife for a home birth. Do midwives test for GBS? Do they treat it if it is positive? Should I be concerned about a GBS positive test? One midwife I have spoke with as well as a friend that has had 2 home births said midwives typically treat with more natural/herbal means. Is this proven effective?
    By: PintyLane
    Archived User
    Your questions could better be answered by a midwife. I have asked my supervisor, Amy Romano, a certified nurse-midwife, to respond.

    On a more general note, while care by a midwife is more likely to be individualized, flexible, collaborative, and supportive of normal birth, this is not always the case. I notice that you have my book. I have suggested questions to ask when interviewing care providers in the chapter on that topic and questions for midwives who attend home births in the chapter on deciding on place of birth. You can also go to Choosing a Caregiver on the Childbirth Connection website.

    -- Henci By: Henci Goer
    Archived User
    Sorry for the delay in weighing in on this issue...

    I would support your decision for a home birth. I work in a freestanding birth center and we offer screening to all women at 35-37 weeks per the CDC recommendations. We do have people make an informed decision to decline antibiotics and we are OK with that, however if another risk factor develops (fever during labor, prolonged rupture of membranes, etc.) we insist on antibiotics and/or transfer to the hospital because the baby is at higher risk and not a great candidate for early discharge. As for the PROM situation, we start antibiotics at 18 hours regardless of whether the woman is in labor or not. We require active labor by 24 hours, otherwise our protocols call for hospital induction. We often try castor oil, homeopathic remedies, breast stimulation, etc. to kick start labor. And we definitely avoid vaginal exams in this instance. I will admit that this protocol is not based on any particular evidence and Henci is right that the CDC doesn't comment on the PROM situation.

    I have had a home birth (and am pregnant with my second and planning another home birth.) My home birth midwife last time offered screening at 35-37 weeks but many of her clients (including myself) declined testing. There are risk factors you can rely on to pick up many (but statistically speaking, not as many as routine screening) cases where the baby may be at risk and antibiotics may be advised- maternal fever, preterm labor, history of a prior baby with GBS disease, 24+ hrs of ruptured membranes. The CDC guidelines are based on a large study that showed that screening at 35-37 weeks is better than this approach, but it doesn't mean that the risk-based approach is ineffective. With my home birth midwives, regardless of GBS status, it is always the family's decision to choose to use antibiotics or to avoid them (or to use alternatives - none of which have been studied to my knowledge.)

    I have major concerns about the liberal use of antibiotics in labor and in the newborn period. There is a lot of research coming out about the role of the newborn gut flora (beneficial bacteria in the intenstines) in establishing a healthy immune system. When you disrupt the gut flora with antibiotics (or by introducing pathologic bacteria in a hospital setting) the baby is at higher risk for allergies and asthma. I encourage women who choose antibiotics for GBS to treat themselves and their infants with probiotic supplements after the birth. Probiotic capsules can be opened and the powder mixed with breastmilk and placed on the baby's tongue. There is plenty of research supporting the use of probiotics in preterm infants in the NICU - I'm not sure if there has been research on this issue in healthy term infants. Breastmilk itself is also a great source of probiotics (lactobacillus and bifidobateria) but I think women/babies exposed to antibiotics need supplemental doses.

    With all of that said, antibiotics save lives when they are necessary! Unfortunately, we don't have the magic bullet to predict which newborns are going to develop GBS disease and would benefit from antibiotics - the only approaches we have now result in a HUGE number of women and babies being exposed to antibiotics when they never would have gone on to have a newborn GBS infection. GBS disease in the newborn is very rare and some studies have found that high colonization (lots of GBS in the vagina) and/or low immunity (not a lot of antibodies) are the most predictive of which babies will be affected. I think that future methods of screening women to determine who needs preventative antibiotics will focus on these factors, not simply the presence/absence of GBS in the vagina.

    I wish you lots of strength and joy as you approach the birth of your baby. Let me know if you have more questions about this important issue.

    Best,
    Amy Romano, MSN, CNM
    Editor, Lamaze Institute for Normal Birth By: Amy Romano

    All Times America/New_York

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