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Midwife Informed Consent for Group B Strep Carriers (Positive Screen)

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These are easy to read and understand and are beautifully presented.

by Ronnie Falcao, LM MS

This is from the informed consent I give my clients:

Informed Choice Regarding Homebirth for Group B Streptococcal Carriers

Overview of Group B Streptococcal Infections

Group B streptococcus (GBS) is a type of bacterium that can cause life-threatening illness in newborn babies, pregnant women, the elderly, and adults with other illnesses, such as diabetes or cancer. GBS is the most common cause of life-threatening infections in newborns.

How common is GBS disease? GBS is the most common cause of sepsis (blood infection) and meningitis (infection of the fluid and lining surrounding the brain) in newborns. GBS is a frequent cause of newborn pneumonia and is more common than other, better known, newborn problems such as rubella, congenital syphilis, and spina bifida. Approximately 8,000 babies in the United States get GBS disease each year; 5%-15% of these babies die. Babies that survive, particularly those who have meningitis, may have long-term problems, such as hearing or vision loss or learning disabilities. In pregnant women, GBS can cause urinary tract infections, uterine infections (amnionitis, endometritis), and stillbirth. Among men and among women who are not pregnant, the most common diseases caused by GBS are blood infections, skin or soft tissue infections, and pneumonia. Approximately 20% of men and nonpregnant women with GBS disease die of the disease.

Does everyone who has GBS get sick? Many people carry GBS in their bodies but do not become ill. These people are considered to be "colonized." Adults can be colonized in the bowel, genital tract, urinary tract, throat, or respiratory tract. Fifteen percent to 40% of pregnant women are colonized with GBS in the rectum or vagina. A fetus may become colonized with GBS on the skin if the mother is colonized with GBS in the rectum or vagina; colonization occurs before or during birth.
How does GBS disease affect newborns? Approximately 1%-2% of babies who are colonized with GBS develop signs and symptoms of GBS disease. Three-fourths of the cases of GBS disease among newborns occur in the first week of life ("early-onset disease"), and most of these cases are apparent a few hours after birth. Sepsis, pneumonia, and meningitis are the most common problems. Premature babies are more susceptible to GBS infection than full-term babies, but most (75%) babies who get GBS disease are full term. GBS disease may also develop in infants 1 week to several months after birth ("late-onset disease"). Meningitis is more common with late-onset GBS disease. Only about half of late-onset GBS disease among newborns comes from a mother who is colonized with GBS; the source of infection for others with late-onset GBS disease is unknown.

How is GBS disease diagnosed and treated? GBS disease is diagnosed when the bacterium is grown from usually sterile body fluids, such as blood or spinal fluid. Cultures take a few days to complete. GBS infections in both newborns and adults are usually treated with antibiotics (e.g., penicillin or ampicillin) given through a vein.

Can GBS disease among newborns be prevented? Most GBS disease in newborns can be prevented by giving certain pregnant women antibiotics through the vein during labor. Any pregnant woman who previously had a baby with GBS disease or who has a urinary tract infection caused by GBS should receive antibiotics during labor. Pregnant women colonized with GBS should be offered antibiotics at the time of labor or membrane rupture. Colonized women at highest risk are those with any of the following conditions:  fever during labor; rupture of membranes 18 hours or more before delivery; labor or rupture of membranes before 37 weeks ("preterm").

Because women who are colonized with GBS but do not develop any of the above complications have a relatively low risk of delivering an infant with GBS disease, the decision to take antibiotics during labor should balance risks and benefits. Penicillin is very effective at preventing GBS disease in the newborn and is generally safe. A colonized woman with none of the conditions above has the following risks:  a 1 in 200 chance of delivering a baby with GBS disease if no antibiotics are given  a 1 in 10 chance, or lower, of experiencing a mild allergic reaction to penicillin (such as rash) a 1 in 10,000 chance of developing a severe allergic reaction to penicillin, called anaphylactic shock or anaphylaxis.

Anaphylaxis requires emergency treatment and can be life threatening.

If a prenatal culture for GBS was not done or the results are not available, physicians may give antibiotics to women with one or more of the risk conditions listed above.  (Increasingly, antibiotics are being given for all risk factors, even if a GBS culture was negative.)

 Who is at higher risk for GBS disease? Pregnant women with the following conditions are at higher risk of having a baby with GBS disease:
previous baby with GBS disease
urinary tract infection due to GBS
GBS colonization late in pregnancy
fever during labor
rupture of membranes 18 hours or more before delivery
labor or rupture of membranes before 37 weeks ("preterm")

 The above information is extracted from materials provided by the Centers for Disease Control and Prevention.  For more information, contact Childhood and Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases Centers for Disease Control and Prevention, MS C-09,1600 Clifton Rd NE, Atlanta, GA 30333

Much more information is available online from my Web pages:

Non-Standard Observations on Risks and Benefits

Risks from Antibiotic Treatment - - The risks of intrapartum penicillin include mild allergic reaction (about one case per 10 instances of penicillin administration), anaphylaxis (about one case per 10,000 doses) and fatal anaphylaxis (about one case per 100,000 doses).  In addition, as the administration of intrapartum penicillin becomes more common, GBS is becoming more resistant to penicillin; in about 4% of cases, the GBS is not affected by the penicillin as expected, so "preventive" treatment doesn't prevent the disease.  In this case, a baby showing mild signs of illness may not be properly evaluated because it is assumed that the GBS has already been adequately treated.  Lastly, the administration of intrapartum antibiotics increases the risk to the baby of all antibiotic-resistant bacteria - in particular, antibiotic-resistant E. coli infections, which is relatively common. The incidence of  E. coli infection of newborns has doubled in the last ten years, and most deaths from these infections are from ampicillin-resistant organisms, typically associated with intrapartum administration of ampicillin.

Little information is available about the effects of antibiotic treatment during labor and birth on the newborn's establishment of normal bacteria on the skin and in the digestive tract.  Typically, a baby is born sterile and relies on immediate, intimate contact with the mother to introduce the bacteria that will colonize the baby's skin and digestive tract.  Nature has provided a wonderful system whereby these first germs will "rule the kingdom".  These germs from the mother are the germs for which the baby has been receiving antibodies through the placenta and will continue to receive antibodies through the colostrum and breastmilk from the mother, and a healthy colonization from these germs will protect the baby from other, foreign germs.  Antibiotic treatment certainly disrupts this process and leaves the baby vulnerable to colonization from foreign germs to which it has no antibodies, many of which may be untreatable by antibiotics.

Another disadvantage of relying on antibiotics is that they need to be in the mother’s system for a few hours before they are effective.  This is problematic for second or subsequent babies who come quickly.  The alternative approaches such as hydrogen peroxide and chlorhexidine vaginal washes are effective on contact and so are much more practical for second or subsequent babies.


Unfortunately, there is no ideal, guaranteed approach to the issue of GBS.  Cultures don't yield consistent results; women without risk factors can still pass on GBS to their babies; women who receive antibiotics can still pass on GBS; antibiotics can cause severe, even fatal side effects; even the most aggressive treatments cannot reliably prevent death and disease in newborns; and antibiotic treatment may actually increase the severity of infection from antibiotic-resistant organisms.

Recent Research

Several recent studies have focused on the increase of newborn infections from resistant strains of bacteria following administration of antibiotics to the mother during labor.  "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."

It is important to understand the danger of establishment of any antibiotic-resistant strain.  Bacteria have a very interesting and very dangerous ability to share resistance across species of bacteria.  This means that any antibiotic-resistant bacteria that comes in contact with the staph and strep germs that are all around us in the environment may pass along the antibiotic-resistance to those germs, resulting in a raging, untreatable infection in a vulnerable newborn.

Standard of Care regarding Group B Streptococcal Carriers
Current recommendations from the CDC consensus protocols are:
Obtain cultures from all women (rectally and vaginally) at 35-37 weeks. If the woman's rectal or vaginal cultures are positive for GBS, she should be offered intrapartum antibiotic prophylaxis.
Treatment. Oral antibiotics are ineffective. The following regimens may be used:
Penicillin G 5 million units IV and then 2.5 million units every 4 hours until delivery. Penicillin G is the preferred antibiotic because of its narrow spectrum, thereby making it less likely to select for antibiotic-resistant bacteria.
Ampicillin 2 g IV followed by 1 g every 4 hours until delivery.
If the patient has a penicillin allergy, either clindamycin 900mg IV every 8 hours or erythromycin 500 mg IV every 6 hours may be given until delivery.
The Issue of Group B Streptococcal Infections in my Practice

I believe that parents have the right and obligation to decide the treatments that they and their baby receive around the time of birth.  I believe that women who have had positive Group B Streptococcal cultures have the right to choose or decline antibiotic prophylaxis during labor.  A woman may reasonably decline antibiotic prophylaxis because she has bad reactions to antibiotics which would interfere with her labor and might require other, more dangerous interventions; she wants to avoid the risks associated with antibiotics; she wants to avoid the risks to the baby of receiving antibiotics, particularly the risk of infections from antibiotic-resistant GBS or antibiotic-resistant E. coli.

For clients who have positive test results, I can work with them to reduce colonization levels through alternative methods and to provide education as desired in order for you to make informed choices.  It is your choice whether to transfer care to a hospital-based practitioner or choose other options:

[Note that it can be difficult to find a doctor who will co-operate in any non-standard antibiotic treatment plan for GBS.]
You may arrange to have another healthcare professional come to your home to administer IV antibiotics during labor.  (I can offer a referral for a midwife in Burlingame who sometimes does this.)
You may obtain a prophylactic injection of penicillin in your last month of pregnancy from your physician or your baby's pediatrician or a prescription for oral antibiotics.
You may obtain a prescription from your baby's pediatrician for a postpartum injection of penicillin for your baby.
You may choose to pursue only alternative approaches to reducing colonization and preventing and treating infection.  However, you must be fully aware that these methods are not proven to be as effective as antibiotics during labor.

Statement of Choice for Group B Streptococcal Carriers

Please have both parents initial these first three statements, and then check off your all choices for treatment options.
I understand that a rectovaginal culture shows that my body carries Group B Strep, and that there is a risk that my baby may be exposed to this bacteria during the birth process, and that this may cause an infection which could cause brain damage and death.
   ________    ________ (Both parents – please initial here)
I understand that the standard of care in the medical community is to administer IV antibiotics during labor in order to prevent infection in the baby; I also understand that this approach is not 100% effective and carries risks of its own, e.g. "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."  (Towers et al., 1998).
  ________    ________   (Both parents – please initial here)
I understand that there are no studies comparing homebirth without antibiotic prophylaxis to hospital birth with antibiotic prophylaxis.  In particular, there are no studies that weigh the overall increased risk of infection in the hospital against the increased risk of declining antibiotic prophylaxis at a homebirth.   ________    ________    (Both parents – please initial here)
Please check all the choices that apply:
________ I have chosen to labor and birth in the hospital, where prophylactic antibiotics can be administered during labor, at least four hours prior to the birth.

________ I have chosen NOT to labor and birth in the hospital, where prophylactic antibiotics can be administered during labor.  I have chosen an alternative approach for Group B Streptococcal Carriers.  [Please select the individual forms of treatment you choose.]

________ I have chosen to give birth in my home, where the risk of infection from antibiotic-resistant infections and other "super bugs" is less than in the hospital.
________ I have chosen to take herbal formulas to strengthen my immune system.  It is my understanding that this will help reduce the level of colonization that the baby may be exposed to, and it will help increase the level of antibodies that will be passed to the baby through the placenta and protect the baby. (Wood, 1981; Baker, 1976)
________ I have chosen to take homeopathic formulas to strengthen my immune system
________ I have chosen to take nutritional formulas to strengthen my immune system
________ I have chosen to give birth in water, which will dilute any vaginal bacteria and further reduce the risk that the baby will become infected with Group B Strep.  (Zanetti-Dällenbach, 2007)
________ I have chosen vaginal lavage with chlorhexidine at the onset of labor and at 6 hour intervals.  (Stray-Pedersen et al., 1999)

If the amniotic membranes rupture early in labor, I understand that the risk of infection to the baby starts to increase after 18 hours, although this may be reduced by avoiding cervical exams or other procedures which introduce bacteria into the cervix.
________ I have chosen to go to the hospital for prophylactic antibiotics when membranes have been ruptured for 12 hours, if it seems that the baby will not be born within 6 hours.
________ I have chosen NOT to go to the hospital for prophylactic antibiotics, even if amniotic membranes are ruptured for greater than 18 hours.
Other Details:
I understand that my midwife, Ronnie Falcao, LM, will strongly encourage me to go to the hospital for prophylactic antibiotics if I have a fever during labor, i.e. temperature over 100.4 degrees Fahrenheit, regardless of membrane status.   ________    ________

___________________________________________________                    ________________________
                               Mother/Client’s Signature                                                                                          Date

___________________________________________________                    ________________________
                                      Father’s Signature                                                                                              Date

This Web page is referenced from another page containing related information about Group B Strep (GBS)


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