GROUP B STREP FAQs

FAQ's and Links
Induction / Membrane Stripping / Vaginal Checks / Pitocin / Cervical Gel / Fetal Monitoring / Amniotomy / Other Resources / Special Thanks

Birth practices differ substantially around the world, and home births and less invasive procedures during hospital births might limit the risk of GBS sepsis in the newborn. - Anne Schuchat MD, Group B Streptococci, Lancet 1999; 353: 51-56
Most doctors will tell you that the solution to being GBS+ is to receive IV antibitoics in labour. That way, the number of bacteria can be reduced prior to delivery preventing MOST Group B Strep infections in the newborn.
However, treating GBS+ moms with IV antibiotics in labour is not 100% effective. It IS the most effective, but of the cases that remain, some can be attributed to the fact that there are fail points in the testing (testing too soon, improperly handled, taken from wrong site, recolonization), to non maternal sources (as in ~50% late onset cases) and to early introduction of the bacteria to the baby by invasive obstetrical procedures. In 88% of the cases where the baby became ill despite IV antibiotics in labour, the baby was ALREADY ill with invasive GBS disease prior to labour.
Although this may be a rare occurance, eliminating UNNECESSARY invasive procedures in late pregnancy and early labour represents ONE MORE opportunity to easily prevent AVOIDABLE infection.

Induction

An increasing number of women are being told by their doctors that they need to be induced due to their Group B Strep status. Some of the reasons I have heard of for inducing a GBS mom include:
  • Short labour
  • Previous GBS infected baby
  • Maternal Physician anxiety
    • None of the current GBS recommendations suggest inducing. In fact, inducing just because of Group B Strep might increase your odds of having an infected baby.
  • It is not surprising that your doc suggested induction as overall our nation's induction rate is increasing. Docs are suggesting induction more and more because they are getting more comfortable with it...many times it offers no medical benefit...AND in your case it may present real risk. If induction were such a great idea, I feel certain it would be a part of the CDC guidelines...endorsed by the American College of OB/GYN's...BUT it isn't...because of the unnecessary risk it produces with no evidence of benefit. The problem with induction is that all of the means used (with the exception of pitocin) increase the risk of infection. - Tracy Webb, CBE
  • If you are term (38+ weeks) and haven't had any risk factors, the antibiotics can be effective in as little as 15-30 minutes.
    Four hours or more of IV antibiotics are recommended as a guideline for doctors. If you get ANY antibiotics they can help, but more is better in most cases. Get the antibiotics as soon as it's reasonable to get to the hospital/birth center.
    If you're concerned about a fast labor, be reassured -- a natural, fast labor is actually better -- babies whose moms had fast labors at term are LESS likely to be infected.
    If you have a risk factor BEFORE the IV antibiotics are started, it takes more time to fight the infection and baby MIGHT still get sick, even after treatment. This is why it's important to get IV antibiotics in early labor - before risk factors occur.
    - Lisa Porter, Group B Strep Information and Support
    • If your provider is suggesting induction because of Group B Strep, you should carefully consider each of these points and then raise the questions to your doctor. Some of these interventions are not a means of induction, but often occur as a result of induction and should also be considered.

    Stripping of Membranes

    Stripping the membranes seems to be very popular with some providers as a method of ripening the cervix. Apparently, the procedure increases the chances of labour occurring within 48 hours and decreases the likelihood of labour happening past a week. There is speculation that stripping the membranes lengthens the latent phase of labour. Membrane stripping or, sweeping/ringing the membranes/cervix is sometimes done without your knowledge or consent during an internal exam. Make your wishes known prior to every internal exam at term.
  • Stripping the membranes is where a health care provider will separate your bag of water from the cervix, it is not intended to break your water, however, it may. It may also cause infection, and may be painful for some. - Childbirth.org 1997, Stripping the Membranes
  • Research has been done showing that both labor contractions and manual or digital examinations by care providers can actually move infectious vaginal fluid through the mouth of the womb. - Dr. James MacGregor, Group B Strep: A Patient/Provider Approach for Optimizing Care
  • In addition to increasing the risk of infection, many providers question the relationship between stripping and the onset of labor. Stripping often increases the length of latent labor...creating a lot of cramping that may be mistaken for active labor and will prevent Mom from resting...BUT ultimately will not result in effacement or dilation. Because a single stripping may have no effect, it is not uncommon for a Mom to be stripped multiple times over the course of a week...nor is it uncommon for stripping to be the beginning of a series of interventions attempting to induce or augment labor. For the GBS+ Mom, there are two questions to consider. Will stripping stimulate labor? Maybe. Will it increase your risk of infection? Definitely. - Tracy Webb, CBE

    • Vaginal Checks
    Has your provider ever asked you, "Do you want me to check you?" Isn't it thrilling to know, when you are at 37 weeks that you're 2cm dilated and 50% effaced? - another milestone! It won't be long now! Did you know that cervical dilation is NOT an indicator of WHEN you'll go into labour?
    Did you ever answer, "no" when you doctor asked you if you wanted to be checked? Chances are, he was only offering, not recommending.
  • Having a vaginal exam can cause your membranes to rupture prematurely (making an induction necessary in the eyes of most care providers, which is also more likely to end in a cesarean), you run the risk of getting an infection which can harm both you and the baby… - Childbirth.Org, 1997, Vaginal Exams Late in Pregnancy
  • Maternal infection with GBS most commonly presents as chorioamnionitis, endomyometritis, cystitis, or pyelonephritis. Invasion of the amniotic fluid is the most likely cause of both premature labor and overt infection of the newborn. Risk factors for amnionitis include colonization with GBS, rupture of membranes > 6 hours, duration of internal monitoring > 12 hours, and more than 6 vaginal exams.Russell W. Steele, MD, A Revised Strategy for the Prevention of Group B Streptococcal Infection in Pregnant Women and Their Newborns
  • The role of GBS colonization in maternal infections was recently investigated. Factors that independently increased the risk for clinical amnionitis included GBS colonization, duration of membrane rupture (i.e., >6 hours), duration of internal monitoring (i.e., >12 hours), and number of vaginal examinations (i.e., more than six) CDC MMWR: Prevention of Perinatal Grou B Streptococcal Disease: A Public Health Perspective, May 31, 1996 / Vol 45 / No. RR-7
  • Research has been done showing that both labor contractions and manual or digital examinations by care providers can actually move infectious vaginal fluid through the mouth of the womb. - Dr. James MacGregor, Group B Strep: A Patient/Provider Approach for Optimizing Care
  • Remember, often providers will strip the membranes during a regular vag exam without providing informed consent. If you do not want to be stripped because of the risk of infection, you should tell your provider this before any vag exam. If you have ever had a "rough" vag exam that was painful--you probably had your membranes stripped and didn't even know it.) - Tracy Webb
  • The more you put something in the vagina, the more chance of pushing the bacteria up to baby. Research indicates that more than 6 internal exams/cervical checks is possibly linked with more serious infection, so the fewer exams the better. Also, douching is a bad idea if you're pregnant, and especially if you're GBS+. Some homeopaths recommend douches to get rid of the bacteria -- this is a BAD IDEA! GBS usually lives at the entrance of the vagina -- douching forces it closer to the cervix - and baby. -Lisa Porter

    • Pitocin
    So, does the use of pitocin increase your risk of GBS infection? No, not directly. And certainly, if there is a medical need to induce, pitocin seems to be the safest method in terms of GBS prevention. But, consider this… pitocin use very often goes hand in hand with internal monitoring, vaginal exams and epidurals. THOSE interventions can increase your chances of invasive GBS infection.
  • With pitocin you will also receive continuous electronic fetal monitoring. This is because fetal distress is more common with pitocin use and needs to be detected if it occurs. We have also witness that pitocin can be the beginning domino in the domino effect. The IV, the infusion pump, and the continuous monitoring will confine most mothers to bed, decreasing her ability to deal with the contractions naturally. With the more painful contractions a mother is more likely to need pain medication, such as an epidural anesthesia. -
    • Childbirth.org, 1996-1998, Pitocin FAQ
  • Pitocin is a prime example...you wrote "OK this one has nothing to do with GBS..." BUT IT DOES when you consider than most providers will not administer pitocin without an internal monitor and frequent vag exams. Pitocin CAN be administered without other interventions...particularly if a slow dosing regimen is used. You don't have to have an AROM, an internal monitor, etc...BUT you need to discuss your desire NOT to have all the other "bells and whistles" that increase your risk of infection with your provider in advance. - Tracy Webb, CBE
    		•

    Cervical gel
    When you are facing induction, is there a method that might be preferable over another?
    I guess, if you think about trying to keep the bacteria away from the baby, vaginal exams, stripping membranes and application of cervical gels could theoretically introduce bacteria to the cervix, amniotic membranes, etc. Here's something to consider….
  • OBJECTIVES: Our purpose was to determine the effect of induction of labor on neonatal infection if mothers are group B streptococci positive and have prelabor rupture of membranes at term.
    STUDY DESIGN: In the TermPROM study 5041 women were randomized to induction with intravenous oxytocin, induction with vaginal prostaglandin E2 gel, or expectant management with induction, if needed. Of these, 4834 women had vaginal or introital swabs for group B streptococci taken at entry. We used logistic regression to test for effects of treatment within group B streptococci subgroups.
    RESULTS Group B streptococci were predictive of neonatal infection for the induction with vaginal prostaglandin E2 gel and expectant groups but not for the induction with oxytocin group. For women positive for group B streptococci the rates of neonatal infection were 2.5% for the induction with oxytocin group and >8% for all other groups.
    CONCLUSIONS: Induction of labor with intravenous oxytocin may be preferable for group B streptococci–positive women with prelabor rupture of membranes at term. (    Am J Obstet Gynecol 1997;177:780-5.)

    • Fetal Monitoring
    So how can fetal monitoring cause a GBS infection? Well, an internal monitor attached to baby's scalp offers a direct path of entry to baby's blood for any bacteria. Also, it requires that your waters be broken, which is a risk for infection in itself. There are clear benefits in some cases, but it's wise to consider the added risk of infection when an internal monitor is offered.
  • Maternal infection with GBS most commonly presents as chorioamnionitis, endomyometritis, cystitis, or pyelonephritis. Invasion of the amniotic fluid is the most likely cause of both premature labor and overt infection of the newborn. Risk factors for amnionitis include colonization with GBS, rupture of membranes > 6 hours, duration of internal monitoring > 12 hours, and more than 6 vaginal exams.Russell W. Steele, MD, A Revised Strategy for the Prevention of Group B Streptococcal Infection in Pregnant Women and Their Newborns
  • The role of GBS colonization in maternal infections was recently investigated. Factors that independently increased the risk for clinical amnionitis included GBS colonization, duration of membrane rupture (i.e., >6 hours), duration of internal monitoring (i.e., >12 hours), and number of vaginal examinations (i.e., more than six) CDC MMWR: Prevention of Perinatal Grou B Streptococcal Disease: A Public Health Perspective, May 31, 1996 / Vol 45 / No. RR-7
  • The internal probe actually creates a small scrape on baby's head where the bacteria can get into the bloodstream. Internal monitoring is NOT a great idea for most GBS+ moms. If it's absolutely necessary, make sure you've had IV antibiotics for a reasonable period of time before the internal monitor is used.-Lisa Porter

    • Amniotomy
    "When did your waters break?" "My doctor broke it…" seems to be a common theme in many birth stories now. It seems harmless enough, and it's very common. So, why does it bear consideration if you are GBS positive?
    The amniotic sac is the final barrier between GBS and your baby. Once that is gone, most doctors will put you "on the clock". After so many hours past rupture of membranes, your risk of infection increases significantly, and therefore your risk of emergency c-section.
    Once the waters have broken, many doctors will want to use internal monitoring, as it is more convenient and more reliable. It also carries a higher risk of infection.
  • AROM's are often provided to either start or speed labor...stats indicate they only save you an hour or two on the total length of labor...not much benefit for the increased risk of infection. You were worried that walking might increase your baby's risk of infection (it won't)...but imagine what AROM will do by creating a warm, moist path from the wet chux pad you sit on in the hospital bed right up into the aminotic sac. - Tracy Webb, CBE
  • The membranes are a barrier between baby and the bacteria, and rupturing them too early puts you on a schedule for delivery and increases the chance of prolonged rupture (a risk factor). Rupturing membranes AFTER the IV antibiotics are started LATE in labor does not seem to be as problematic. Lisa Porter

    • Other Resources
    For more information on interventions and the link with infections, please check the following:
  • The Thinking Woman's Guide to a Better Birth, Goer, Henci, Berkley Publishing Group: NY, NY, 1999.
  • Ask the Birth Guru, Henci Goer at Ivillage's ParentsPlace
  • Get Group B Strep support from the Group B Strep messageboard at Ivillage's ParentsPlace
  • GBS, and several other bacteria, may cause preterm premature rupture through a variety of mechanisms, including secretion of proteases that degrade collagen and weaken fetal membranes.-Anne Schuchat MD, Centers of Disease Control and Prevention, Lancet 1999; 353: 51-56
  • Since its emergence in the 1970’s, group B streptococcal (GBS) disease has been the leading bacterial infection associated with illness and death among newborns in the United States....stillbirths and premature delivery also have been attributed to GBS.- CDC MMWR May 31, 1996/Vol. 45/No. RR-7
  • Group B Strep can definitely invade the placental membranes.- Dr. Sharon Hillier, University of Pittsburgh School of Medicine
  • Occult streptococcal infection is an important cause of fetal asphyxia, and stillbirths frequently occur with unruptured membranes (Naeye & Peters, 1978; Peevy & Chalhub, 1983). -Pathology of the Human Placenta, Third Edition Kurt Benirschke and Peter Kauffman

    • Special Thanks
    Many thanks for all the contributions and insights for this page. Special thanks to:
  • Tracy Webb, Child Birth Educator
  • Lisa Porter, former Group B Strep Association member and GBS mom
  • Marti Perhach, mom to angel Julia Rose
  • Cheryl Sandburg and her Group B Strep Website and mailing list members
    		•

    PLEASE NOTE: I am not a medical professional and this is not presented to be medical advice. Please discuss these issues with your doctor to decide upon the best course of action for you and your baby. If you have information in addition to, or in conflict with this information, please forward it to cl-cathiemac@ivillage.com