GROUP B STREP: GUIDELINES FOR PREGNANCY
Streptococci can be present asymptomatically in the vagina. It can cause inflammation of the amniotic sac, the uterine lining or lead to a urinary tract infection in the mother if symptoms appear. Occasionally a newborn will have a local infection, septicemia or meningitis as a result of vaginal strep.
Approximately 20 percent of all women have streptococcus present in the vagina. As many as 75 percent of their babies contract strep, but only 3 to 4 percent per 1000 get sick as a result. Of these sick babies, 7 percent of them are under 1000 gm (around 2 lbs). Babies born before 37 weeks gestation are at much higher risk of infection than full term babies. There is an increased risk for the baby with premature rupture of membranes (PROM) or surgical delivery.
In clinical practice, vaginal strep is usually not checked for unless there are symptoms. As a precautionary measure, oral sex should be avoided whenever a strep infection is present in the throat of a partner (this is usually strep A). If recurrent prematurity has been a problem for the mother or a urinary tract infection (UTI) is present, a culture may be done to determine if strep is present. In a hospital setting, when premature rupture of membranes is being checked, a culture can be done at that time. There are five serotypes of Group B strep, with type III as the most associated with meningitis. However, all types may cause disease.
If the client has a past medical history with a positive result of Group B strep or a current indications or symptoms which arise during the current pregnancy, the midwife should screen at 34-36 weeks with vaginal/rectal culture.
MIDWIFE RECOMMENDED MANAGEMENT OPTIONS
If the result is positive, the midwife should discuss management options. Some options are listed below:
Bee Propolis can be taken daily, either in capsules or tincture, 3 to 4 times daily.
Herbal Remedies: Propolis Throat Spray, 1.05 fl. oz.
Herbal Remedies: Bee Propolis, Original Flavor, Made in New Zealand, 12 High Potency Lozenges
Herbal Remedies: Bee Propolis, Lemon Honey Flavor, Made in New Zealand, 12 High Potency Lozenges
Herbal Remedies: Bee Propolis Extract, NOW Foods, 500 mg, 100 Caps
Herbal Remedies: Propolis Extract Liquid, Comvita, Alcohol-Free, PFL 15, 0.8 fl. oz.
ECHINACEA ROOT DOUCHE
Echinacea Root (Augustofloria) can be taken either as a tea or tincture, 3 times daily. To make the tea, use 1 ounce of the root to 1 pint of boiling water and steep for 6 to 8 hours. Echinacea root is specific to staph and strep infections. It stimulates the body's defense mechanisms as well. A strong tea may also be diluted and used as a douche. When douching in pregnancy, extra care must be taken to avoid forcing water up into the uterus, causing infection and other problems.
Herbal Remedies: Echinacea Immune Support Tea, Yogi Tea, Certified Organic, 16 Tea Bags
Herbal Remedies: Echinacea Tincture, Orange Flavor, Alcohol-Free, 100% Organic, 1 fl. oz.
Herbal Remedies: Echinacea Root Complex, Nature's Way, 180 Caps
Herbal Remedies: 5-Echinacea Supplement, Vegetarian, Herbal Remedies USA, 1,000 mg, 60 Liquid VCaps
Herbal Remedies: Echinacea Extract, Standardized, Nature's Way, 340 mg, 60 Caps
Herbal Remedies: EchinaGuard Echinacea Supplement Tincture, Nature's Way, 1 fl. oz.
Herbal Remedies: Echinacea Products & Supplements
SAFE DOUCHING DURING PREGNANCY
Fill douche bag with cooled tea, attach cleaned vaginal tip.
Hang bag 10 inches or less from the floor.
Lay in the bathtub and gently insert the nozzle into the vagina no more than half way in.
Very gently release the hose clamp and allow tea to run in and out of the vagina, do NOT attempt to retain water in the vagina in pregnancy.
When finished, clean the equipment thoroughly.
Douching should never be attempted if there is any question that cervical dilation, placenta previa or prematurely ruptured membranes are present.
GBS ESSENTIAL OIL TREATMENT
Essential Oil Protocol to get rid of GBS (From thebirthsource.homestead.com/gbs.html
It is imperative that the oils are of highest quality.
Put the following in an Empty Double "0" gelatin or vegetable capsule:
5 drops Lemon Essential oil
3 drops Oregano Essential oil
5 drops Mountain (Winter) Savory Essential oil
Take one capsule 3 times daily.
Additionally do the following:
Soak an ORGANIC tampon in...
15 drops Lemon Essential oil
9 drops Oregano Essential oil
15 drops Mountain (Winter)Savory Essential oil
1 tsp carrier (V-6) oil (See Recipe below)
Leave soaked tampon in overnight. Insist on being retested. Do this daily for the last six weeks of pregnancy.
Herbal Remedies: Organic Tampon Without Applicator, Natracare, Regular Absorbency, 20 Count
V-6 VEGETABLE CARRIER OIL FOR ESSENTIAL OILS:
V-6 Mixing Oil combines food-grade vegetable oils for mixing with essential oils to create blends, formulas and massage oils. Grape seed oil, wheat germ oil and vitamin E are nurturing to the skin as natural antioxidants. V-6 is also excellent for cooking and making salad dressings.
Blend 15-30 drops of an essential oil to 1 oz. mixing oil. V-6 is good for mixing massage oils, creating your own blends and formulas, for cooking and making salad dressings, etc. The ingredients of V-6 Mixing Oil are:
Sesame Seed Oil.
Grape Seed Oil.
Wheat Germ Oil.
Sunflower Seed Oil.
vitamin E Oil.
CONGAPLEX CAPSULES FOR GBS
Another GBS Remedy (From the archives at http://www.gentlebirth.org/archives/gbs.html:
3 capsules of Congaplex by Standard Brands 3 times a day for a week, then reculture. If negative, no more Congaplex. If positive, 1 cap a day until the end of pregnancy.
Congaplex Ingredients: Bovine thymus Cytosol extract, carrot root, ribonucleic acid, bovine bone, nutritional yeast, defatted wheat, bovine adrenal, dried alfalfa juice, oat flour, alfalfa flour, bovine kidney, veal bone PMG extract, mushroom, dried buckwheat juice, buckwheat, peanut, soy bean lecithin, mixed tocopherols and carrot oil.
Do not take if you have food allergies to any of these ingredients. Congaplex is available from Amazon.com.
Take 500 mg Vitamin C every 4 waking hours.
1 Acidophilus (4 billion micro-organisms or higher) capsule every 4 waking hours.
Take Congaplex, Vitamin C and Acidophilus daily for the last six weeks.
Herbal Remedies: Meta C Vitamin C Supplement, 500 mg, 100 Caps
Herbal Remedies: The Right C, Vitamin C Supplement, Nature's Way, 500 mg, 120 VCaps
Herbal Remedies: Acidophilus & Bifidus, 8 Billion, NOW Foods, 60 Caps
Herbal Remedies: Primadophilus Optima, 35 Billion CFU, Nature's Way, 60 VCaps
TEA TREE OIL
Insert an small ORGANIC tampon or a cotton ball, whichever is more comfortable, soaked in a combination of 10 drops of Tea Tree Essential Oil and Olive Oil. Leave the tampon in for 4 hours each day for 6 days.
Herbal Remedies: Tea Tree Essential Oil, 100% Pure, NOW Foods, 1 fl. oz.
EHB FOR GBS
EHB by NF Formulas taken 6 caps daily over a 10 day period. Take (E.H.B. by NF Formulas, Inc.), and Tea tree oil vaginal suppositories 3 to 4 times daily for a 10 day period. This mom was re-tested at two weeks after positive culture (3 to 4 days after last EHB taken), two weeks after that (2-1/2 weeks after first positive culture), and on one occasion was tested again 2-1/2 weeks later (5 weeks after positive culture) because of a prolonged ROM with no labor.
Then insist on retesting to see if the GBS has gone away. Midwives have seen heavy colonization completely cleared with these treatments, although there is no scientific study to support it.
Herbal Remedies: Tea Tree Oil Vaginal Suppositories, 6 Count
Another midwife had a case of a mom's GBS culture at 36 weeks yielded a result of 2+ colonization, which was the same at 38 weeks. She had her take 500mg Vitamin C every 4 waking hours, 1 EHB (NF Formulas) capsule every 4 waking hours, Propolis 4x daily, and she inserted a tampon soaked in 2% Tea Tree oil solution (2% Tea Tree essential oil, 98% Olive oil). She left the tampon in for 4 hours each day for 6 days. Culture at 39 weeks was negative for GBS. She had a long labor, a high leak for 72 hours, then a rapid active phase and 2nd stage, healthy baby, normal placenta, and normal recovery. The midwife has become a believer in Tea Tree oil for a variety of infections, though in this case she believes it acted synergistically with the other natural therapies the mother used. She has used it as a spray on throat infections, as well as for vaginal yeast, trichomoniasis, and gardnerella, all with great success. Not much is seen about Tea Tree oil in midwifery literature, but it may well be worth a try for other GBS+ moms who are averse to standard antibiotic therapy.
ANOTHER RECOMMENDATION FOR GBS
1. Boost Vitamin C in your diet, such as eating 2 grapefruit per day. Other good sources of Vitamin C: red peppers, oranges, kiwi fruit.
2. Drink a cup of Echinacea tea or take 2 capsules of echinacea every day
3. Get extra sleep before midnight. Slow down your schedule. Take it easy and eat well. Follow a nutritious Pregnancy Diet.
4. Take 3 teaspoons of Colloidal Silver per day. Take it between meals. Hold the liquid in your mouth a few minutes before swallowing. Colloidal Silver can be purchased in most health food stores. It is silver suspended in water. It is antibiotic in nature and safe in pregnancy.
Herbal Remedies: Colloidal Silver Liquid, SilvaSolution, Super-Strength Pro 50, 8 fl. oz.
Herbal Remedies: Colloidal Silver Liquid, SilvaSolution, 10 ppm, 16 fl. oz.
5. Plan ahead for extra warmth after the birth for both you and baby. Hot water bottles, heating pads, hot packs, big towels dried in a hot dryer during the pushing phase - will all help you and baby keep extra toasty after birth and reduce stress. Have a friend or family member assigned to be in charge of the "Mother/baby warmth team".
6. The colostrum from your breasts is the best antibiotic treatment your baby could ever get. The colostrum is very important for your baby. Breastfeeding your baby is the best thing you can do to keep your baby healthy since you pass on your immunities to your baby through the breastmilk.
7. Other good prevention tips: Keep vaginal exams to a minimum. No exams are best. Do not permit artificial rupture of the membranes. After the membranes have broke, keep vaginal exams to a minimum, again none is best if possible. If not possible, use extreme care and sterile technique if an exam is absolutely necessary. Any exam has the possibility of introducing GBS into the cervix of the mother if she has a positive GBS test result. Do not allow children of other families to visit the new baby for the first 3 weeks. Keep your older kids healthy so they are not sneezing and coughing on new baby.
A NOTE ABOUT GBS TESTING AND DIAGNOSIS PROTOCOLS
Many of us midwives think that we must have had a lot of women who were Strep B positive in the many numbers of births that we have all done over the years. Most of us pay special attention to nutrition and preventive care for our moms during their pregnancies, their births, and postpartum after the babies are born. Many of us do not test for GBS unless there is a real need to do so, such as a mom with a past history of GBS, a mom having long rupture of membranes and/or a preemie. Once the baby is born, we keep our moms and babies warm with skin-to-skin contact, with careful cord care and, of course, all our mothers breastfeed (this is a biggie with me and other midwives). I have never had a baby sick with Strep B since I began midwifing back in 1979.
In a hospital, if strep is present, the baby is cultured immediately after birth. If strep is found, antibiotics are begun. In a well nourished mother the baby will be more resistant to infection. Remember, problems only manifest in a small number of cases. At home, Echinacea tincture can be given prophylactically if desired. The infant dose is 1 drop tincture every 3 hours. Symptoms of neonatal infection often begin with respiratory distress which gradually worsens. Evaluate other signs of infection, e.g., alertness, nursing, etc., and if the midwife suspects trouble, the client's health care provider should be consulted by the client.
The midwife should have the client consult with her health care provider if the culture remains positive, in spite of treatment and if:
1. Labor is premature (less than 37 weeks).
2. A prolonged rupture of membranes, greater than 12 to 19 hours.
3. Maternal fever before or during labor.
4. There are signs or symptoms of maternal or fetal infection.
MoonDragon's Client Forms: GBS Information & Consent Form
MORE THOUGHTS ON GBS
Group B Strep is a normal bacteria that is present in 20-30 percent of women's vaginas. It becomes important in childbirth for you if you develop signs of an infection, which can be pretty nasty (after you have delivered). The infection can be found in the womb lining (endometritis) or a wound if you have a cesarean section.
Much more importantly for your baby is the disease called Early Neonatal Group B Streptococcal Septicemia (ENGBSS). This is occurs after the baby passes through an infected birth canal and the infection spreads to his blood stream. 30 percent of affected neonates develop meningitis and half of these sustain permanent neurological injury. It carries a 20-30 percent mortality rate. Neonatal carriage occurs in 35-50 percent of labors where a swab during labor was positive and in 25 percent where there was a positive maternal swab at some point in the antenatal period. Only 1-2 percent of neonates colonized develop ENGBSS. In the UK, ENGBSS occurs in 0.3/1000 neonates. In the US it is 3/1000. There are some well identified risk factors for an infant developing ENGBSS. In addition to a positive maternal swab, the following factors lead to a much increased chance of sepsis (about 50/1000 as compared to 0.3/1000), and would prompt treatment:
- Prolonged rupture of membranes (greater than 12 hrs).
- Pre-term labor (less than 37 weeks).
- Rupture of membranes before 37 weeks.
- Maternal temperature during labor.
- GBS found in the urine (heavier carriage).
- Previous infant with ENGBSS.
Treatment of GBS colonized mothers with the above risk factors during labor will lead to a 62 percent reduction in neonatal sepsis rate and 94 percent reduction in neonatal mortality due to this disease. Treatment of colonized mothers without these risk factors during labor does not significantly reduce the rate of ENGBSS. There is no perfect answer. In most cases, a mom who has GBS will also have GBS antibodies that are passed to the baby through the placenta. [ref: Williams Obstetrics] Nature is not stupid. In rare cases of either very high colonization or unhealthy mom or baby, the baby could be overwhelmed and then require antibiotic treatment. However, the treatment carries risks of its own - 10 percent of moms have a mild allergic reaction to the antibiotics - 1 in 10,000 experience anaphylactic shock, which is life-threatening to both the mom and baby. In addition, 4 percent of strains of GBS are now antibiotic-resistant. Again, nature is not stupid. If you carry a resistant strain of GBS, the antibiotics will kill off all the innocuous, normal bacteria that would keep the antibiotic-resistant GBS in check, so that the only thing left is the resistant strain, which tends to be more virulent than the regular strain. This is a horrible situation for a newborn with an immature immune system. In addition, of course, receiving antibiotics in labor is one of the dominoes in the cascade of interventions and increases overall risk due to the compounded risks of the cascade. There is no perfect answer. Alternative approaches to reducing colonization may be the most sensible solution.
Group B strep is not so virulent. It is normal vaginal flora in pregnancy (20 percent) of all women have it. It only causes a problem in 1 of 400 babies exposed to it. There are to my knowledge no studies associating it with miscarriage. Why is everybody so bent out of shape about this organism? The real problem is what is there about that 1 baby in 400 that is so abnormal that allows this benign bug to harm him/her.
SOURCES OF GBS INFECTION
Any caregiver can also introduce GBS. I have watched health care providers (physicians) and midwives when they do vaginal exams. They lube up and then do this little wipe of the vulva with their fingers (almost like foreplay) to lube up the woman. During that wipe they can easily pick up GBS and insert it with their fingers. And it is not unusual for anyone who has delivered in hospital to have GBS.
As everyone knows, most health care providers (physicians) do vaginal exams on the first visit of a pregnancy (for pelvimetry and STD checks). Many midwives do not do this and many believe that with that first vaginal the caregiver can introduce GBS to the cervix and all too often do. If a caregiver is going to do a vaginal in early pregnancy (and even in late pregnancy) then the vulva should be wiped first with a microbial swab. Far better to avoid GBS then have to treat it.
NEGATIVE EFFECTS OF ANTIBIOTIC THERAPY
About 4 percent of GBS isolates demonstrate penicillin tolerance (from Merck Manual).
Neonatal sepsis and death caused by resistant Escherichia coli: possible consequences of extended maternal ampicillin administration. (Terrone DA, Rinehart BK, Einstein MH, Britt LB, Martin JN Jr, Perry KG Am J Obstet Gynecol 1999 Jun;180 (6 Pt 1): 1345-8) "A relationship exists between neonatal death caused by ampicillin-resistant Escherichia coli and prolonged antepartum exposure to ampicillin."
Antibiotic use in pregnancy and drug-resistant infant sepsis. (Mercer BM, Carr TL, Beazley DD, Crouse DT, Sibai BM Am J Obstet Gynecol 1999 Oct;181(4):816-21) "Maternal antibiotic treatment is associated with neonatal sepsis by organisms resistant to ampicillin and to maternally administered antibiotics."
Potential consequences of widespread antepartal use of ampicillin. (Towers CV, Carr MH, Padilla G, Asrat T Am J Obstet Gynecol 1998 Oct;179(4):879-83) "The increased administration of antenatal ampicillin to pregnant women may be responsible for the increased incidence of early-onset neonatal sepsis with non-group B streptococcal organisms that are resistant to ampicillin. At this time penicillin G, rather than ampicillin, is therefore recommended for prophylaxis against group B streptococci. In addition, future studies are needed to determine whether alternate approaches, such as immunotherapy or vaginal washing, could be of benefit."
Intrapartum antibiotic prophylaxis increases the incidence of gram-negative neonatal sepsis. (Levine EM, Ghai V, Barton JJ, Strom CM Infect Dis Obstet Gynecol 1999;7(4):210-3) "Published guidelines have encouraged physicians to increase the use of intrapartum chemoprophylaxis to reduce vertical transmission of GBS. This study confirms the efficacy of this approach. Unfortunately, this reduction comes at the cost of increasing the incidence of ampicillin-resistant gram-negative neonatal sepsis with a resultant increased mortality. These data provide compelling evidence that the policy of providing ampicillin chemoprophylaxis in selected patients needs to be reconsidered."
Failure of intrapartum antibiotics to prevent culture-proved neonatal group B streptococcal sepsis. (Ascher DP, Becker JA, Yoder BA, Weisse M, Waecker NJ, Heroman WM, Davis C, Fajardo JE, Fischer GW J Perinatol 1993 May-Jun;13(3):212-6) "Intrapartum antibiotics may fail to prevent GBS sepsis in a number of infants born to mothers colonized with GBS or to those with acute chorioamnionitis."
Intrapartum Administration of Ampicillin Prophylaxis in GBS Mothers May Raise Risk of Neonatal E. coli Infection (Ob.Gyn.News April 15, 1998).
Severe E. coli Tied to Intrapartum Ampicillin (from Pediatric News via Medscape).
Neonatal early-onset Escherichia coli disease. The effect of intrapartum ampicillin. (Joseph TA, Pyati SP, Jacobs N Arch Pediatr Adolesc Med 1998 Jan;152(1):35-40).
The increased administration of antenatal ampicillin to pregnant women may be responsible for the increased incidence of early-onset neonatal sepsis with non-group B streptococcal organisms that are resistant to ampicillin. (The March 1, 1999 Ob.Gyn.News) Reports a presentation at the Society for Maternal-Fetal Medicine which found ampicillin resistance in 45 percent of septic neonates who had been exposed to antibiotics in the prepartum or intrapartum period. Their retrospective study included 8593 births at 6 hospitals between 7-97 and 2-98, and looked at the 96 neonates who were clinically ill with a positive blood or cerebrospinal fluid culture. 70 percent of these had been exposed to either prepartum or intrapartum antibiotic tx. Sepsis was 19.3 times more common in preterm babies (57 vs 3.1/1000). Ampicillin resistance was found in 50.1 percent of preterm babies, vs 20.6 percent of term babies. Intrapartum exposure was more likely to result in resistance than prepartum exposure (56.7 vs 16.7 percent) Most common organisms for early onset sepsis were GBS and e coli; for late onset, staph, e coli and candida. There were 11 early onset GBS cases (1.4/1000), which the presenter commented was about the same incidence as is usually reported. (So does that mean that even though 70 percent had antibiotics, the rate of GBS was no different than if nobody got them, or does it mean that the 1.4/100 is what is expected when antibiotics are given?) They did find less GBS in those who had intrapartum antibiotics vs those who had prepartum antibiotics (10 percent vs 32 percent). It still leaves me wondering if this experiment (lots of antibiotics to a wide range of moms in the name of prevention, vs tx) is really working out when you look at the big picture, or will this too fall by the wayside as more is known?
MoonDragon's MDBS Birthing Guidelines: Group B Strep (GBS): Labor & Delivery
MoonDragon's MDBS Birthing Guidelines: Variations of Pregnancy
MoonDragon's MDBS Birthing Guidelines Index
MoonDragon's Client Forms Index
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