Group B strep & pit concentration

kstec, LPN · Oct 1, 2007

When I was pregnant with my second son I had Group B strep and because of the 1 in 100 babies who die when they get this, my doctor induced me 11 days early. They first started the Pen G K and then right before the next dose of abx was due they gave me the cytotec. His goal was to get atleast two doses of abx in me before the baby went through the birth canal. It worked and my baby is fine. I guess from my understanding is they don't want to rush delivery but control it in order to administer abx prior to delivery. I don't know what other protocols are but that is what they did with me. I would assume if delivery is rushed than baby goes through the birth canal and is infected and that is where the trouble begins.

Jolie, BSN · Oct 1, 2007

How long had mom been ruptured? How far had her labor progressed at that time?The minute the membranes are ruptured, the baby's protection from strep ascending the birth canal is lost. The longer the baby is exposed to the bacteria prior to delivery, the more likely infection becomes, but conversely, it is desirable for mom to receive IV antibiotics prior to delivering the baby.

I assume that the pit was started to mimimize the length of time the baby would be exposed to strep. But even with pit, most labors will still last several hours, which allows for a few doses of IV antibiotics to be given prior to delivery. The dosage of pitocin is not influenced by the length of time membranes have been ruptured, or how quickly delivery is desired. Pit is used safely when it is titrated according to maternal and fetal tolerance, not according to a timetable. If it is necessary to deliver an infant quickly, then a C/S is indicated, not a massive dose of pit.

If the baby delivers quickly, prior to mom receiving IV antibiotics, then a protocol is followed regarding evaluating baby for possible infection and treating the infant with IV antibiotics.

PattonD · Oct 1, 2007

The membranes had been ruptured for approx 1 hr. with a dialation of 1.

I guess what I am trying to find out is should pit be started slow, fast, or not at all?

With what Jolie said I think C/S would be the safest option for the baby ....but maybe not for the mom...

Man, ya'lls profession is crazy confusing. Seems like every patient is or has the potential to be like an ER/ICU situation. On top of that its like seperating siamese twins and hoping both survive. Wifey says that most laypeople see having a baby as a joyus occasion but she sees it as a very risky and extremely dangerous process.

Wow what drasticly different view points patients & family have from reality!

Jolie, BSN · Oct 1, 2007

The membranes had been ruptured for approx 1 hr. with a dialation of 1.
I guess what I am trying to find out is should pit be started slow, fast, or not at all?
With what Jolie said I think C/S would be the safest option for the baby ....but maybe not for the mom...
Man, ya'lls profession is crazy confusing. Seems like every patient is or has the potential to be like an ER/ICU situation. On top of that its like seperating siamese twins and hoping both survive. Wifey says that most laypeople see having a baby as a joyus occasion but she sees it as a very risky and extremely dangerous process.
Wow what drasticly different view points patients & family have from reality!

With the limited information provided, I believe the patient's care was appropriate. With a dilation of 1cm, it is likely that the patient would have labored for a prolonged period of time (12-24 hours) before delivering her baby. The use of pitocin to augment her labor seems appropriate to increase the likelihood that she would deliver in 12 hours or less to minimize the risk of baby's exposure to strep, while still providing adequate time for mother to receive IV antibiotics prior to delivery.

Your question about starting "pit slow, fast, or not at all" puzzles me. Pit is not given "faster" to bring about a faster delivery. Pit dosing is based on mother's and baby's tolerance of the drug, not how fast mom dilates. You would not increase the rate of pit infusion to speed up dilation.

C-section is not necessarily the best option for a baby exposed to strep. If membranes have not been ruptured for a prolonged period of time, mom is not exhibiting any s/s of infection, and baby appears to be tolerating labor, it is safer to allow labor to continue. C-sections carry risk for the baby that many people overlook. Babies born by C-section are at risk for breathing problems, so unless there is a compelling reason for a C-section (such as prolonged rupture of membranes, maternal temp, abnormal CBC, fetal tachycardia, or non-reassuring fetal heart rate pattern), it is probably better from the baby's standpoint to allow a lady partsl delivery.

I'm sorry that your wife views labor and delivery as very risky and extremely dangerous. It is vital that L&D nurses be prepared for emergencies, but also crucial to recognize that birth is a natural experience that most women are able to facilitate without complications.

NurseNora, BSN, RN · Oct 1, 2007

The membranes had been ruptured for approx 1 hr. with a dialation of 1.
Man, ya'lls profession is crazy confusing. Seems like every patient is or has the potential to be like an ER/ICU situation. On top of that its like seperating siamese twins and hoping both survive. Wifey says that most laypeople see having a baby as a joyus occasion but she sees it as a very risky and extremely dangerous process.
QUOTE]
Yes, every patient does have the potential to become an ER/ICU type situation. You take a similiar risk every time you get into your car to drive to work. Life is so filled with uncertainties that we just ignore most of them rather than paralize ourselves with worry. The large majority of the time, car trips are uneventful and birth is a beautiful and joyous occasion.

CEG · Oct 1, 2007

Wifey wants me to ask.....
Ruptured Mom tested positive for group B strep and pit was started as the doctor was being called. Antibotics are supposed to take 4 hrs. to work??? So the question is: Is it beneficial to get the baby out faster to avoid being exposed to the virus any longer or should the baby stay put to let the antibotics work their magic?
What are the protocals on this in your hospitals?
Anyway there was some confusion on the pit dosage until the Dr. cleared it up......but was he right ...hmmm.

The antibiotics don't take 4 hours to work, they cover for four hours. So the idea is to get a dose of antibiotics in and then repeat every four hours. I think the maximum effect is achieved after about an hour, depending on the drug used, I guess. We use 1 hour as a general guide.

As for Group B Strep, around 40% of the population carries the Group B Strep becteria. The rate of infection in untreated mothers is 1 in 200. It is closer to 1 in 1000 in treated mothers. There is early-onset and late-onset which have different etiologies but are lumped together statistically. Even a woman with no risk factors can have an infected baby and one with every risk factor can have a baby who is not infected. Babies delivered by c-section can also contract Group B Strep. C-section in the absence of a true indication is more risky for both mom and baby.

GBS is also transient meaning that even a woman who is positive for GBS at 36 weeks may be negative at delivery and vice versa. GBS status is not considered indication for induction unless there is a history of precipitous labor (which in and of itself reduces risk of infection). So although this woman may have tested positive at her office visit she may have been negative when she delivered. The test takes a long time and cannot be performed in labor and delivery.

GBS treatment guidelines are outlined by the CDC and can be found on their website. Pregnancy and childbirth are a normal physiological event and rarely an emergency.

Also, higher doses of pitocin can lead to uterine hyperstimulation and fetal distress as well as dysfunctional labor. Manufacturer's instructors state to use the smallest dose possible. Larger doses will actually tend to slow labor progress.

LizzyL&DRN · Oct 1, 2007

In my hospital in this situation, Pitocin would have been started at 2 mu and titrated to facilitate active labor. The baby however would have been treated with our "GBS protocol." This is due to the fact the baby has been exposed to GBS because of SROM before antibiotics were given. The baby would have a CBC, CRP and blood culture done. The baby would also get one IM dose of Ampicillin and Gentamycin and would be observed for s/s of sepsis.

If we get the first dose of antibiotics in mom 4 hours prior to ROM, then we don't treat the baby. But, if we infuse the first dose of antibiotics, we don't want mom's water to break for at least 4 hours so we are conservative on the Pitocin because we don't want to have to treat the baby if it can be avoided. Seems a little confusing but it's what our hospital does. I think the CDC's recommendations is antibiotics in mom 4 hours prior to delivery, means you don't treat the baby.

PattonD · Oct 1, 2007

Wow, now I understand some things better ....

1. antibotics cover for 4 hours having max effect after 1 hour approx.

2. Pit rates don't speed up the birth process

3. Pit rates are set for mom's and babies tolerences with the smallest effective dose being best.

4. GBS is fairly common esp. in untreated mothers

5. A large majority of the time birth is a beautiful and joyous thing

6. It is rare that birth is an emergency

7. Most women don't have complications

8. I probably didn't provide enough details for an accurate answer to my question.

I probably over exzagerated how my wife feels about birth being dangerous. I think she probably enjoys happy endings too while keeping caution in mind.

PattonD · Oct 1, 2007

Thank you Lizzy that was the answer I was looking for. I appreciate the other responses too as I learned a lot from them but they didn't exactly hit the bullseye.

CEG · Oct 1, 2007

Here is a link to the CDC's guidance: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5111a1.htm

Just skimming, the only mention of ROM is that GBS can cross the membrane, so intact vs ruptured is not really a concern.

According to this guidance, only symptomatic babies of mothers who received antibiotics

LizzyL&DRN · Oct 2, 2007

Here is a link to the CDC's guidance: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5111a1.htm
Just skimming, the only mention of ROM is that GBS can cross the membrane, so intact vs ruptured is not really a concern.
According to this guidance, only symptomatic babies of mothers who received antibiotics
To be honest I think we over treat with our "GBS Protocol." Our policy on this was written by the chief of the NICU. His rationale is that GBS in an infant's blood can multiply exponentially in a very short time and cause devastating results including death. It drives our OB docs nuts. They hate it when we won't let them break mom's water because it hasn't been 4 hours. They always quote the CDC's recommendations and tell us it isn't necessary. But it's our policy and the docs understand our not wanting to draw the baby's blood and give them the antibiotics if we can avoid it.