The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Midwife Informed Consent for Group B Strep Screening

This is from the informed consent I give my clients:
 

Information Regarding Group B Streptococcal Infections

The issue of Group B Strep is one of the most complex issues in normal pregnancy and birth.  My recommendation is that all women get this test.  If you agree to be tested, then you do not need to read the rest of this handout, but please do indicate your choice and sign on the last page.

Group B Strep (GBS) is one of the many bacteria that can be carried in the human digestive tract without causing any health problems. 20-40% of women carry this bacteria, and it usually does not cause a harmful overgrowth, which we would call an infection. Although GBS is more likely to be carried in the intestines, it can also be introduced into the vagina, and the baby may be exposed to GBS in the vagina or to GBS in stool or feces from the birth process.

Typically, a woman who has been carrying GBS in her body for some period of time will also have produced an effective antibody response that protects her from developing a GBS infection. These antibodies would be passed through the placenta to the baby during the last weeks of a normal term pregnancy, so that the baby is born with antibodies to GBS.  These antibodies protect the baby from infection even if the baby is exposed to GBS during the birth process.

Rarely, it may be the case that a woman's genetic system lacks the ability to manufacture antibodies to GBS.  In the case where a woman carries GBS but is unable to mount an effective immune response to it, it is likely that the woman will develop GBS infections herself, most commonly in the urinary tract or in the vagina. Urine testing done during pregnancy would detect a GBS infection in the urinary tract, and this kind of infection should be treated because any urinary tract infection can cause preterm labor.  The vagina is also tested for the presence of GBS, and different tests can provide information about whether there is any GBS at all, or whether there is a light, moderate or heavy colonization of GBS in the vagina. Vaginal GBS colonization is not treated because it cannot be eradicated from the body completely, and GBS in the vagina is not usually a problem during the pregnancy.

Women with the ability to develop antibodies to GBS still might not have mounted an effective immune response to it yet if the exposure was very recent.  Although GBS is not technically a sexually transmitted disease, sexual contact is one of the more obvious ways for it to be transmitted.  It is likely that women in a long-term monogamous relationship are at decreased risk for recent exposure to GBS, but there is no research about this.

Newborns have an immature immune system, and they are not always able to mount an effective immune response to GBS on their own. If a newborn is exposed to GBS during the birth process but has not been getting antibodies from the mother, then the newborn may develop a harmful overgrowth of the GBS bacteria, and this GBS infection could cause life-threatening illness in newborns. Babies who become ill from GBS infection often suffer serious brain damage or other neurological problems, and many of the babies who become seriously ill will die.

The medical approach to GBS has changed drastically over the years. For many years, GBS was not remarkable in the obstetric world, and it was largely ignored by midwives and obstetricians. Sometimes, a newborn's severe illness might be attributed to GBS, just as other bacteria could cause severe newborn illness. Around 1990, GBS became the leading cause of severe illness, brain damage and death among newborns.

The Cochrane Collaboration, an international group of doctors who review current literature in different fields, says this about GBS: "Reviewers' conclusions: Intrapartum antibiotic treatment of women colonized with group B streptococcus appears to reduce neonatal infection. Effective strategies to detect maternal colonization with group B streptococcus and better data on maternal risk factors for neonatal group B streptococcus infection in different populations are required."

For women who culture positive for GBS, there are alternative approaches that can eliminate the GBS bacteria from the vagina and reduce the colonization in the rectum.  (GBS can never be completely eliminated from the digestive tract because it cannot be sterilized.)  Women can take acidophilus supplements and a variety of other nutritional supplements to boost their immune system, increase their antibodies to GBS and decrease the GBS colonization in the gut.  Women can self administer hydrogen peroxide vaginal washes to eliminate GBS in the vagina.  There is some research that shows that a vaginal wash of chlorhexidine is also effective at lowering the transmission of GBS from mother to baby.

In some ways, the issue of GBS for homebirth clients may seem more complicated because the research is based on hospital births and so is harder to apply to homebirth situations. On the other hand, midwives on the discussion lists say the issue is very simple . . . they do not see GBS in babies born at home.  Part of the reason for this is that many of the risk factors for GBS infection in the newborn would either risk mothers out of homebirth or cause transport to the hospital during labor for antibiotics: history of previous baby born with GBS infection; babies born before 37 weeks gestation; development of a fever during labor; premature or prolonged rupture or membranes. It also seems likely that many homebirth practices would further reduce the risk of GBS infection: reduced numbers of vaginal exams and strong encouragement for breastfeeding are the most obvious homebirth practices that protect the mother and baby.  Recent research shows that waterbirth reduces the colonization of newborns with GBS.
The whole issue of GBS is so complicated that a roomful of midwives could discuss the issue for hours and not get any closer to a set of protocols approved by all. The medical approach is a shotgun approach - wholesale administration of antibiotics that can actually sicken babies who would otherwise be healthy; this approach will also inevitably become less and less effective as increased antibiotic use increases antibiotic resistance among GBS strains.
Given my understanding of the known research and the folklore among midwives, I do not consider a positive GBS culture to be a serious risk factor unless a woman has other health problems that would indicate a problematic immune response to GBS. There are followup tests we can do to get a better idea of the seriousness of a positive GBS culture in your individual case.

I encourage my clients to choose to be cultured and to use the knowledge to customize late pregnancy and labor/birth practices that will further reduce the likelihood that your baby could become sick from GBS disease.

It is also important to have a GBS culture done in case your care is transferred to a hospital-based provider.  In many hospitals, women who have not been tested for GBS are treated as if they’re positive, so they are pressured to receive IV antibiotics or their baby is kept in the nursery for observation.  For this reason, I encourage all my clients to have this test done.

I do consider GBS in the urine to be a serious risk factor, and we could discuss the option of having another midwife come to administer antibiotics during labor.  Or we could pursue other alternative protocols.
 

Informed Choice Regarding Group B Streptococcal Infections

I understand that there is no "perfect" answer for Group B Strep-- no perfect screening program, no perfect protocols which will identify and prevent all strep infected babies; that no method of screening and/or prophylactic treatment is 100% effective in preventing GBS. All that we can do is reduce the incidence, acknowledging that antibiotic treatment introduces other risks.

I understand that the new 2002 guidelines from The Centers for Disease Control and Prevention (CDC) are:
"Vaginal and rectal GBS screening cultures should be performed at 35-37 weeks' gestation on all pregnant women except for those who had GBS bacteriuria [GBS in the urine] during the current pregnancy or gave birth to a previous infant with invasive GBS disease; these patients should receive prophylaxis, regardless of the result of any vaginal culture. The risk factor approach is no longer recommended unless a vaginal/rectal culture has not been performed." And " Patients should receive intrapartum prophylaxis if they meet any of the following criteria: (1) a history of a previous infant with invasive GBS disease, (2) the occurrence of GBS bacteriuria during the current pregnancy, or (3) a positive GBS screening culture during the current pregnancy.   Patients with an unknown GBS status (culture not done or not ready) should receive intrapartum prophylaxis if delivery is < 37 weeks' gestation, if rupture of membranes is >/= 18 hours, or if the intrapartum temperature is >/= 100.4º F (38º C)" [from Medscape's article, " An Update on Perinatal Group B Streptococcal Disease" at: http://www.medscape.com/viewarticle/444215
I have also read and understood the handouts from the ACOG as well as Ronnie Falcao's "Information Regarding Group B Streptococcal Infections".  I have had my questions answered to my satisfaction and can make an informed choice regarding GBS testing.  I accept full responsibility for my decision.

Statement of Choice
________ I have chosen to be cultured for Group B Streptococcal Infection and, if positive, will consider my options after getting the test results.
________ I have chosen to be cultured for Group B Streptococcal Infection and, if positive, will transfer care to a hospital-based provider for the administration of antibiotics during labor, even though this approach has not been proven to be more effective than pursuing alternative forms of treatment more compatible with a homebirth.
________ I have chosen to be cultured for Group B Streptococcal Infection and, if positive, will pursue alternative forms of treatment compatible with homebirth, even though this approach has not been proven to be more effective than transferring care to a hospital-based provider for the administration of antibiotics during labor.
________ I have chosen NOT to be cultured for Group B Streptococcal Infection and ask my midwife to inform me if she feels that I have any risk factors for GBS.

 ____________________
   Mother/Client’s Signature                                            Date