Ampicillin for GBS patient with imminent delivery???

SmilingBluEyes · Feb 13, 2005

Hey fellow nurses! This is my first post here. I'm excited to be part of this community.
I'm wanting feedback about a case I had tonight. My patient was a primip, came in with SROM, and her VE was 5cms. Another nurse had admitted her, and I received her as a patient at 0315, just as she was getting her IV. I collected the chart and set out to take care of her. I saw no prenatals, so I got them out of the drawer, at which time I saw she was GBS +. I called the dr. to get orders for ampicillin. It was about 0335. About 5 minutes later, she called me and told me she wanted her epidural. I called anesthesia and then went to go get my ampicillin. Not 3 mins later, she called me again to say she had an urge to push. I hadn't had time to mix my ampicillin yet. I checked and she was complete, and +2 station. We cancelled the epidural and told the doctor to come in. I pushed with her for 1/2 hour and the doctor arrived. Since I knew delivery was immenent (she was pushing wonderfully) I didn't give the ampicillin. When the doctor arrived, at 0420, I told him this, and he was upset and told me to give it anyway. So, whatever... I did. She delivered at 0435.
I find this so wasteful. The research shows (so I thought) that you need AT LEAST 2 hours before delivery for the ampicillin to benefit the baby, and more likely, 4 hours.
Is this what you guys know to be true, too? What are you thoughts? What would you have done?
Thanks in advance for your thoughts!

I know this is not an answer, but you have me wondering why you don't have standing orders for all GBS positive patients first off. We never have to call for orders for GBS + cases, and these charts are flagged in our prenatal file with a bright fushia colored sheet saying " THIS PATIENT TESTED GBS POSITIVE" and the standing order for GBS protocol follows, as a physician order, signed by the doctor.

In the case where GBS status is unknown or the patient is "no-doc" the protocol is automatically put in place and patient treated. Having this protocol in place, you waste much less time. If I am busy starting IV and getting consents, I ask another nurse to mix and label(and if she has time, give) the ampicillin for me. This saves even more time. It would have helped in the case you present here. Now back to your question......

Yes, you are right; it probably did not have a very beneficial effect in the time table you present here. It takes a good hour or more for the medicine to circulate mom, and cross the placenta for it to completely benefit the fetus. But in any case, our doctors would have us do the same; pushing the AMP even at the 11th hour, in hopes some beneficial tx would be achieved. In the case where less then 2 doses are given ( 4 hour apart), we MUST keep the baby for no less than 48-72 hours for observation. ANY symptomology (temp changes, poor sugars out of range, etc.) and we proceed to r/o sepsis protocol without a moment's hesitation. ( blood counts are monitored, baby goes on antibiotics and is under close observation). Hopefully you are observing this baby for signs/symptoms of GBS infection anyway......

I hope this helps. You must not hesitate to treat as soon as you are aware a patient is GBS positive, even in the later stages of labor. You can't go wrong doing that. Yes, at the late hour, it may not have been too beneficial, but not to treat at all looks MUCH worse, particularly in a court case. If you have no comprehensive standing protocol for GBS prophylaxis, (including alternate tx for moms allergic to -cillins), then please ask the manager to work on that ASAP; you need it.

JaneyW · Feb 13, 2005

I know this is not an answer, but you have me wondering why you don't have standing orders for all GBS positive patients first off. We never have to call for orders for GBS + cases, and these charts are flagged in our prenatal file with a bright fushia colored sheet saying " THIS PATIENT TESTED GBS POSITIVE" and the standing order for GBS protocol follows, as a physician order, signed by the doctor.
In the case where GBS status is unknown or the patient is "no-doc" the protocol is automatically put in place and patient treated. Having this protocol in place, you waste much less time. If I am busy starting IV and getting consents, I ask another nurse to mix and label(and if she has time, give) the ampicillin for me. This saves even more time. It would have helped in the case you present here. Now back to your question......
Yes, you are right; it probably did not have a very beneficial effect in the time table you present here. It takes a good hour or more for the medicine to circulate mom, and cross the placenta for it to completely benefit the fetus. But in any case, our doctors would have us do the same; pushing the AMP even at the 11th hour, in hopes some beneficial tx would be achieved. In the case where less then 2 doses are given ( 4 hour apart), we MUST keep the baby for no less than 48-72 hours for observation. ANY symptomology (temp changes, poor sugars out of range, etc.) and we proceed to r/o sepsis protocol without a moment's hesitation. ( blood counts are monitored, baby goes on antibiotics and is under close observation). Hopefully you are observing this baby for signs/symptoms of GBS infection anyway......
I hope this helps. You must not hesitate to treat as soon as you are aware a patient is GBS positive, even in the later stages of labor. You can't go wrong doing that. Yes, at the late hour, it may not have been too beneficial, but not to treat at all looks MUCH worse, particularly in a court case. If you have no comprehensive standing protocol for GBS prophylaxis, (including alternate tx for moms allergic to -cillins), then please ask the manager to work on that ASAP; you need it.

I agree with this answer--this is what happens at my facility except that r/o sepsis is usually initiated on all babies without 2 doses of pcn during labor regardless of s/s.

However, isn't it better to get the ax in before srom or arom? Some of the nurses where I am act like it is useless after rom. The nursery nurses are especially vocal about this.

My other question would be that if your team was being so helpful in the admission/IV start--why hadn't they pulled the PNR and started the amp when they started the IV? That is what we do--even if we are passing the pt along. Thanks for bringing the subject up--it is something I've wondered about myself.

SmilingBluEyes · Feb 13, 2005

I agree with this answer--this is what happens at my facility except that r/o sepsis is usually initiated on all babies without 2 doses of pcn during labor regardless of s/s.
However, isn't it better to get the ax in before srom or arom? Some of the nurses where I am act like it is useless after rom. The nursery nurses are especially vocal about this.
My other question would be that if your team was being so helpful in the admission/IV start--why hadn't they pulled the PNR and started the amp when they started the IV? That is what we do--even if we are passing the pt along. Thanks for bringing the subject up--it is something I've wondered about myself.

Yes, the efficacy of prophylaxis post-ROM can be hotly debated. It is "better" to get in ASAP, and yes, preferably before AROM/SROM. If a planned AROM, we give ABX FIRST, before the doctor starts the induction. And, Where I work, we err on side of caution. This means, we give AMP as soon as the patient is admitted for labor, whether ruptured or not, and we continue to give IV Amp q4 hours until delivered, period.

Further, it is widely believed what subjects a post ROM mom and her baby to infection (GBS and otherwise) is the practice of doing too-frequent cervical checks, MORE THAN ANYTHING. I have read more than once, statistically, you have about 6, yes SIX, lady partsl exams total , before you significantly raise the chances of infection in a woman whose membranes are ruptured. This means you need to be conservative checking people, and only check when maternal/fetal conditions warrant it, not being gratuitous with checks OR the use of internal monitors.

I have not seen any of of our babies developing GBS infection whose moms have been treated per protocol, and yes, that would be post as well as pre-rupture. The best thing you can do to prevent infection in an unborn baby is to limit cervical/lady partsl checks and use of internal monitors. Hope this helps.

Jolie, BSN · Feb 13, 2005

Another thought that occurs to me is that even though delivery seemed imminent, it may not have played out that way. We've all seen cases where the pushing stage lasted far longer than we would have initially expected. Had that happened, it may have been possible for the Amp to have circulated thru mom's bloodstream and cross the placenta to baby before delivery.

I arrived at the hospital with my last baby with SROM at 6cm, +2 station, and regular contractions, and delivered 2 days later. Got a lot of Amp during that time!

SmilingBluEyes · Feb 13, 2005

Another thought that occurs to me is that even though delivery seemed imminent, it may not have played out that way. We've all seen cases where the pushing stage lasted far longer than we would have initially expected. Had that happened, it may have been possible for the Amp to have circulated thru mom's bloodstream and cross the placenta to baby before delivery.
I arrived at the hospital with my last baby with SROM at 6cm, +2 station, and regular contractions, and delivered 2 days later. Got a lot of Amp during that time!

VERY true. That is why we treat no matter what.

ShannonC · Feb 14, 2005

Great responses, thanks everyone!

Yes, I was less than thrilled that my coworker who started the patient before I got her hadn't pulled the prenatals. It was a situation in which we were suddenly busy... in fact, I was home in my bed, on call, and got called in at 2:45. IF she would have pulled the prenatals, we'd have known she was GBS positive and could have started the amp right away. SHe wouldn't have gotten the second dose, as it turns out, but still. NOt pulling the prenatals is a big no-no in my book. Just reinforces the thought that the MINUTE you start to think you can be blase about this business... WHAM! You're wrong!

Thanks, again, guys!

SmilingBluEyes · Feb 14, 2005

It sure sounds to me as if you are VERY conscientious. We all learn some things the "hard way". That you ask about this, tells me you care and are a great nurse. Best wishes.

Mermaid4 · Feb 14, 2005

Stuff happens. People labor quickly than expected. They have for thousands of years. SO, the baby should have a cbc and everyone else should get over it...Some is better than none, and Iv is better than nothing. Plus, technically, now a days, you are supposed to give two doses of ampicillin (although Penicillin is the drug of choice unless they have an allergy). Some docs also give unasyn but if you end up having to give that make SURE the patient doesn't have an allergy to amoxicillin or ampicillin ( I did and had an anaphylactic reaction). We also have protocols but the doc has to give the official order before it is given. And ampicillin can run right in....

ShannonC · Feb 15, 2005

It sure sounds to me as if you are VERY conscientious. We all learn some things the "hard way". That you ask about this, tells me you care and are a great nurse. Best wishes.

Wow! Thank you so much. What a nice thing to say...

SmilingBluEyes · Feb 15, 2005

I meant it. Never be afraid to ask. I promise not to flame you...we all had to learn. I have a lot to learn, still, only being in the "business" 7 years myself......

This is the beauty of such forums. Lots to learn. Lots of experience to draw on. Take care. You are doing well.

ShannonC · Feb 17, 2005

I meant it. Never be afraid to ask. I promise not to flame you...we all had to learn. I have a lot to learn, still, only being in the "business" 7 years myself......
This is the beauty of such forums. Lots to learn. Lots of experience to draw on. Take care. You are doing well.

I think when we support each other, we all benefit. I really learned something from this, and in the future, it's going to benefit my patients as well as myself... I'll always push Amp no matter how soon that baby is coming out!

On a related note... Do you guys ever fudge and give the 2nd dose early (say at a 3 hours interval) when it seems like baby is going to come before the 4 hours are up? I've occasionally given a 2nd dose at like, 3 1/4 hours. Anyone else?

Incidentally, I've been a L&D nurse for 7 years, too! But, with 2 years off in the middle to have my twins : )

Thanks again!