Group B strep & pit concentration

[PattonD]

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.

[CEG]

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.

A agree it's a tough balance, GBS is so scary- esp from a NICU perspective. Of course anything that prevents unnecessary AROM is probably not a bad thing;)

[SmilingBluEyes]

You said it well Lizzy and Patton. Your bullet statements in your post above are correct.

We are really, really over-medicalizing birth in the USA and this is just more evidence.

Where we are, we prefer a lady with pos GBS get at least 2 doses of AMP prior to delivery of her baby. IF she comes in ruptured, she gets AMP immediately and if she gets only one dose the baby is watched no less than 48 hours in our hospital. If GBS is unknown, we treat as if positive.

Pitocin is so controversial and often poorly understood by those using it. I have found in just my experience, much more than about 10 mu/min really does not speed ANYthing up anyhow and much increases the chance for hyperstimulation and the problems that go with it. I go "low and slow" for this reason, particularly in ladies with ruptured membranes. More and more evidence supports doing this in the literature and I am always having to discuss this with some of the OBs who think faster and more are better.

AHHH the fun of being an OB nurse today.

[SmilingBluEyes]

Thanks for the information, CEG. We have been reading the same things. Where I am, the babies are not treated immediately, but rather, observed first. But moms are ALWAYS given ABX. And yes, most of our OBs still insist on suctioning at perineums and amnioinfusion with thick mec, despite more current literature disproving the efficacies of such interventions. It's very frustrating to me.

[Selke]

In addition to the above guidelines others quoted, consider that many providers order PCN (or ampicilin) not be started until "active labor", not at 1 cm. Getting in at least one dose before birth is considered OK, two is optimal. The antibiotic crosses the placenta pretty quickly (sorry, don't have sources at hand for more specifics), within a matter of minutes, so the baby gets it even if mom is pushing. Scalp electrodes are contraindicated if at all possible, as a potential route of entry of the microbe into baby, but I haven't heard of a reluctance to AROM due to GBS.

The U.S. guidelines for treatment of GBS aren't necessarily followed elsewhere in the world. In the UK they don't even give antibiotics for GBS any more and wonder why we still do it -- this was talked about on a listserv. I believe they observe babies and treat symptomatically. Maybe someone here has more information on this?

[CEG]

In addition to the above guidelines others quoted, consider that many providers order PCN (or ampicilin) not be started until "active labor", not at 1 cm. Getting in at least one dose before birth is considered OK, two is optimal. The antibiotic crosses the placenta pretty quickly (sorry, don't have sources at hand for more specifics), within a matter of minutes, so the baby gets it even if mom is pushing. Scalp electrodes are contraindicated if at all possible, as a potential route of entry of the microbe into baby, but I haven't heard of a reluctance to AROM due to GBS.

The U.S. guidelines for treatment of GBS aren't necessarily followed elsewhere in the world. In the UK they don't even give antibiotics for GBS any more and wonder why we still do it -- this was talked about on a listserv. I believe they observe babies and treat symptomatically. Maybe someone here has more information on this?

Yes I have heard this too. They also test for gestational diabetes based on risk factor. I am sure some of it is a profit/spending question from a private vs. public health system perspective, but it would be interesting to compare outcomes. From what I understand they are similar.

[Labor of Love]

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.

Thanks for the great reply!

I have been reading that they are working on a GBS rapid screen that may be done at the bedside at some point. Like you said, since GBS could be positive one day and negative the next a rapid screen would be more benificial to Mom and Babe. Why introduce abx when not needed and would be nice to get them in when they are!! (Ah in a perfect world)

[nurseryRN14]

I was diagnosed with group B strep about 2 months in my pregnancy because I thought I had an infection. I was spotting and could smell an odor that I didn't have before. My doctor treated me with an abt, but a month after I felt the abt didnot work, so they increased the dose and that time I felt ok. My MD didnt want to treat it a second time because they usually dont at all. During my labor as soon as I came in, I let the nurse know I was group b positive and I still didn't get but one abt. My son ended up in NICU, because they thought he could be septic. He stayed for three days , then ended up going to the ER a day later because he wasn't breathing right. He has had a horrible start. The did blood cultures which were neg and his bili level was up. He also had fluid around his lung. They said that he wasnot septic from being exposed to gbs. He is still sick, crying all day long. I'm having a hell of a time.