So, You’re Positive
And in this case, we’re not just talking about your overall outlook on life. Like so many mamas, you took the Group B Strep test in pregnancy and your results were positive for the presence of the bacteria. Maybe you immediately wondered what you “did wrong,” or if there was anything you could do to prevent it.
I know I did.
I’ve had three births – one where I tested GBS+ and received an intervention, one where I tested GBS+ and did not, and one where I did something differently and did not test GBS+. I learned a lot along the way.
Today I’m going to share my personal process in deciding whether to receive IV antibiotics, a chlorahexadine wash, or no intervention at each birth. Please keep in mind that – as I wrote in my post on the Vitamin K shot – “Best Boo-Boo Kisser South Of Puckett’s Gas Station” is about as official as things get for me professionally. I am not a doctor, this is not medical advice, and your decision is completely up to you. If you need some convincing on this, read my full disclaimer where I say it over and over again. Okay, let’s jump in!
What is Group B Strep?
Sometimes called GBS, Group B streptococcus is a common bacteria that is often found in the digestive tract and lower genital tract. It is considered a normal part of our microbiome and most people have no symptoms related to its presence. (source) However, newborns affected by it are at risk for developing Group B strep disease, a potentially serious illness.
There are two forms of Group B strep disease in babies: early-onset and late-onset. About 80% of cases are early-onset, which means the illness occurs within seven days of birth, usually within the first 24 hours of life. (source)
The remaining 20% happen between seven days and three months of age – this is referred to as late-onset. “Late-onset GBS infection is more complex and has not been convincingly tied to the GBS status of the mother.” (source) In other words, babies who develop late GBS may have acquired it from their environment.
What are the risks of GBS infection in newborns?
Most newborns who become infected with GBS will make a full recovery, but it can cause “life-threatening complications, such as:
- blood poisoning (septicaemia)
- infection of the lung (pneumonia)
- infection of the lining of the brain (meningitis)” (source)
In addition, some babies who are infected will experience problems such as “cerebral palsy, deafness, blindness and serious learning difficulties.” (source)
How likely is it that I will be GBS+?
GBS is present in the vagina and/or rectum of 10-30% of all pregnant women. (source)
Does every baby born to a GBS+ mother develop an infection?
NO. Even without intervention many GBS+ women will give birth to babies that do not experience any complications. (source) In one Canadian study, 19.5% of women tested at 36 weeks were positive for GBS. Left untreated, about 50% of those women passed GBS on to their babies, but 48-49% percent of the children who were colonized with GBS had no symptoms and 1-2% developed early-onset Group B strep disease. (source)
What factors increase the chances of actual infection?
The three most significant factors for early-onset GBS are:
- fever during labor
- the woman’s water breaks 18 hours or more before delivery (this is also known as prolonged rupture of membranes, or PROM)
- preterm birth (before 37 weeks) or broken water before 37 weeks gestation (source 1, source 2)
Other factors include low birth weight, the presence of GBS in your urine at any time during your pregnancy (this means that you may be heavily colonized), a history of giving birth to a child who experienced GBS infection, chorioamnionitis, allowing membranes to be stripped, and frequent vaginal exams during labor. (source) The last two factors are listed because membrane stripping and frequent vaginal exams may introduce GBS infection or encourage upward movement of vaginal fluid already containing GBS bacteria. (source)
Steps that may reduce the risk of early-onset GBS infection:
- “Refuse vaginal exams
- Avoid internal fetal monitoring
- Refuse membrane stripping or sweeping
- Avoid induction of labor or application of cervical ripeners
- Do not permit artificial rupture of membranes” (source)
- Birthing in water (more on this later)
What are the symptoms of GBS infection?
Symptoms may include any of the following:
- fever or abnormally low body temperature
- jaundice (yellowing of the skin and whites of the eyes)
- poor feeding
- vomiting, seizures
- difficulty breathing
- swelling of the abdomen
- bloody stools (source)
Of course, any of the above symptoms can also be a sign of a sick newborn who does not have a bacterial infection. Newborns with any of these symptoms should be immediately evaluated by a medical professional.” (source)
Can a mother develop GBS antibodies that protect her baby?
YES. In this landmark study that the CDC draws many of its GBS recommendations from, researchers concluded that “Sufficient amounts of GBS capsular polysaccharide type-specific serum IgG in mothers have been shown to protect against invasive disease in their infants.” In plain English, this means that women who have developed an immunity to GBS bacteria pass immunity on to their children.
On the other hand, low antibody levels in the mother put baby at an increased risk for early-onset GBS. Why is that? Some people believe that the women who were found to have low antibody levels either had compromised immune function, a genetic inability to make GBS antibodies, or a recent exposure to GBS that they had not yet built an immunity to, and therefore could not pass on. (source)
Are GBS tests accurate?
Results can vary slightly depending on specimen collection and culturing techniques. In addition, most GBS tests are performed between 36-37 weeks gestation so that the results are known before labor begins. Unfortunately, a woman who tests positive at 36 weeks may be negative during labor, and vice versa.
In this study, women were screened for GBS using a culture test once at 35/36 weeks gestation and once during labor. “Of the women who screened negative for GBS at 35-36 weeks, 91% were still GBS-negative when the gold standard test was done during labor. The other 9% became GBS positive. These 9% were ‘missed’ GBS cases, meaning that these women had GBS, but most (41 out of 42) did not receive antibiotics.
Of the women who screened positive for GBS at 35-36 weeks, 84% were still GBS positive when the gold standard test was done during labor. However, 16% of the GBS-positive women became GBS-negative by the time they went into labor. These 16% received unnecessary antibiotics.” (Source: Evidence-Based Birth)
Another study found that 61% of early-onset GBS cases occurred in babies whose mom’s tested negative for GBS. (source 1, source 2) It’s not clear why this is, but it may be because, as mentioned above:
- the mom’s infection was recent (after the test done at 35-36 weeks) and mom hadn’t fully developed immunity
- the mom was immune-compromised
- the mom had a genetic inability to make GBS antibodies
Another possibility is that the baby acquired GBS from a non-maternal source. Hospital-acquired GBS cases are documented. (source)
What are the recommended treatment options?
Because some moms want to avoid IV antibiotics, rinsing the birth canal with a chlorahexadine/Hibiclens antiseptic to kill bacteria is sometimes recommended as an alternative.
We used to think that babies are 100% bacteria free in the womb, and that their first encounter with GBS would be in the birth canal. Given that scenario, the antiseptic wash makes sense.
HOWEVER, three things ought to be considered when weighing the risks/benefits of this method:
1. New research indicates that babies are not sterile. Dr. Madan, who serves as assistant professor of pediatrics at the Geisel School of Medicine at Dartmouth, has examined the stool of newborn babies whom had not yet eaten their first meal. He found a variety of bacteria in the stool collected from both full-term and premature babies. (source1, source2) Based on his research, some experts now believe that a baby could already be colonized (which is the term used if they remain healthy) or infected with GBS before they descend into the birth canal.
2. It may not work well (if at all). “Even though women who used vaginal chlorhexadine reduced their infants’ risk of being colonized with GBS by 28%, there was no difference in rates of early GBS infection between women who used the chlorhexadine and those who did not.” (source) In other words, there were fewer “colonizations” – introduction of GBS in which the baby remained healthy – and the same amount of illnesses that resulted. We’ll discuss why this might be in the next section on antibiotics.
3. The microbiome needs to be considered. Passing through the birth canal is a once-in-a-lifetime opportunity for a child to inherit our microbiome. It’s difficult to overstate how important this may prove to be for lifelong health.
“Scientists are only just beginning to understand the microbiome – the unique colony of microbial organisms that populates every human – and they’re looking into the role it plays, not just in birth, but in every aspect of our mental and physical health. So cutting edge is this field that some refer to the microbiome as a ‘newly discovered organ’, and believe that further understanding of it may throw light on some major areas of humanity: disease, personality, life expectancy, and more.
As a baby is born vaginally, the colonisation of the microbiome begins. In fact, studies of the birth canal have shown that in the time before labour starts, the make up of vaginal bacteria changes, for example to include extra Lactobacillus, a bacteria that aids in the digestion of milk. Studies comparing the microbiomes of vaginally born babies with those born via caesarean have shown differences in their gut bacteria as much as seven years after delivery.
There is much we don’t yet understand about why or how much these differences may matter. But scientists are beginning to explore connections between the microbiome of caesarean born babies, and the rising cases of health problems such as obesity, asthma, eczema, and type 1 diabetes.” (source)
You can find a more technical discussion on microbiomes and birth here, or you can watch the fun video below.
Is an antiseptic rinse better than nothing if antibiotics are not an option/not wanted? Perhaps the best way to answer that question is to discuss the risk and benefits of antibiotics.
IV Antibiotics for GBS+ Mothers
The Centers for Disease Control (CDC) and American Congress of Obstetricians and Gynecologists (ACOG) both recommend that all women who test positive for Group B Strep receive IV antibiotics during labor. However, critics say that in at least some cases, there is no clear benefit to that approach. Here’s why:
A Cochrane analysis found that antibiotics do not affect GBS death rates
According to a Cochrane Review, the death rate from GBS remains the same whether or not antibiotics are administered. There was a reduction of babies who became ill, but mortality rates were not affected when IV antibiotics were administered.
Furthermore, the Cochrane Review concluded that very few women who are GBS+ give birth to babies who become infected with Group B strep disease, and “antibiotics can have harmful effects such as severe maternal allergic reactions, increase in drug‐resistant organisms and exposure of newborn infants to resistant bacteria, and postnatal maternal and neonatal yeast infections. This review finds that giving antibiotics is not supported by conclusive evidence.”
Antibiotics may make babies more vulnerable to superbugs
Why is it that both the chlorahexadine wash and IV antibiotics seem to reduce the rate of GBS colonization (and in some studies illness) but not deaths? One theory is that while these methods do kill most GBS bacteria, a certain number may have mutated in a way that makes them resistant to antibiotics. When these strains are left behind, they band together to form a superbug – an infection that is resistant to one or more antibiotics. Essentially, the idea is that you take a relatively harmless colony – something like a small town with cooks, bakers, schoolteachers, etc. – and through antibiotic administration eliminate everyone but the soldiers. Obviously, a band of soldiers is more likely to win a battle than a band of bakers. (As a note: Most antibiotic resistant bacteria are not necessarily soldiers – aka more dangerous than other types when they start out. However, they can become dangerous simply because they are difficult to stop.)
What evidence is there to support the theory that babies who succumb to GBS infections may be encountering antibiotic resistant GBS bacteria?
In a study of 43 newborns diagnosed with blood infections from GBS or other bacteria, 88-91% of those whose mothers were given antibiotics during labor were suffering from an infection that was resistant to antibiotics. Specifically, the bacteria was resistant to the same antibiotic that was administered during labor. (source 1, source 2) In the same study, only 18-20% of infants whose mothers had not received antibiotics during labor had infections that were resistant to antibiotics.
Is routine administration of antibiotics during labor creating a GBS superbug?
Possibly. In the past, GBS was easily treated with common antibiotics such as penicillin, but now strains are showing up that can resist “last resort” options such as vancomycin. (source1, source 2) It is unclear why this is, but some believe that the widespread use of antibiotics among laboring women could be part of the reason.
Can antibiotics the increase risk of other blood infections?
“While many studies have found that giving antibiotics during labor to women who test positive for GBS decreases the rate of GBS infection among newborns, research is beginning to show that this benefit is being outweighed by increases in other forms of infection. One study, which looked at the rates of blood infection among newborns over a period of six years, found that the use of antibiotics during labor reduced the instance of GBS infection in newborns but increased the incidence of other forms of blood infection.23 The overall effect was that the incidence of newborn blood infection remained unchanged.” (source)
A study published in 2002 found that when GBS cases decreased by 3/4 due to the use of antibiotics, cases of e. coli doubled. “The shift is worrisome,” wrote The New York Times, “because E. coli bacteria can be more deadly than streptococcus germs.” It is thought that when certain antibiotics wipe out good and bad bacteria in the gut, pathogens like e. coli may use the opportunity to take over before the good bacteria can re-establish itself.
This is not a universal perspective, though. The CDC does not think there is a link between antibiotic use and e. coli. You can read their report here.
Do antibiotics raise the risk of yeast infections/thrush?
Very possibly. Antibiotics during labor or anytime thereafter kill good and bad bacteria but leave candida albicans intact. (source) With its competition eliminated, candida may thrive and cause yeast infections/thrush. According to this study, women and babies who received antibiotics during labor were more likely to suffer from candida related infections.
Do IV antibiotics increase a child’s risk of asthma and allergies?
Several studies do suggest that early exposure to antibiotics may be a risk factor for allergies and asthma. This study found that one-year-olds were more likely to suffer from wheezing and allergies, while this review of several studies also found a possible link to eczema.
What other side effects might there be?
“Although rare, severe allergic reactions in mothers have been reported. The risk is estimated to be 1 in 10,000 for a severe reaction, and 1 in 100,000 for a fatal reaction. (Weiss and Adkinson 1988).” (source)
Other side effects due to the way antibiotics alter the microbiome may be significant, but they have not yet been thoroughly studied.
Are any new approaches for antibiotic use being explored?
According to Gentle Birth, “some OBs and pediatricians have a new approach; for cases of prolonged rupture of membranes, they’re only giving antibiotics if the mom runs a fever. Otherwise, they just do a simple blood test on the baby (can be done from cord blood or a heelstick if they miss the cord blood opportunity) to check for C-reactive protein. This is an indicator of an acute infection. If it’s negative, everyone can be reassured that baby’s fine, even though mom didn’t get antibiotics; if it’s positive (for whatever reason!), then baby will be appropriately treated for an acute infection. This has great potential for focusing the treatment where it is most needed and not exposing all the others to unnecessary side effects and increased risks from resistant bacteria.”
Another option may be to test women for antibodies to GBS (GBS capsular polysaccharide type-specific serum IgG) when testing them for the presence of GBS. Since we know that they pass on those antibodies, it might be worthwhile to have that info when making a decision on whether to administer antibiotics.
How does water birth affect Group B Strep?
In 4,432 waterbirths studied, only one resulted in a case of early onset newborn GBS, “suggesting that low-risk women who give birth in water may have a far lower rate of newborn GBS than women who have a dry birth. The last reported rate of newborn GBS for dry births was 1 in 1450. Several theories for this phenomenon are suggested in this article:
(1) inoculating the baby with mother’s intestinal flora at birth protects against GBS infection;
(2) water washes off the GBS bacteria acquired during the descent through the vagina;
(3) the water dilutes the GBS bacteria and mixes it with a multitude of other intestinal bacteria that compete with GBS;
(4) early onset GBS is elicited by complications and interventions at birth, which occur less often at water-births;
(5) kangaroo care at birth promotes healthy newborns;
(6) GBS and antibiotic-resistant GBS are more prevalent in hospital environments, where waterbirths are not an option;
(7) a higher rate of underreporting of adverse events at waterbirths compared to dry births; and/or
(8) a massively successful international campaign has covered up the reporting of all deaths and disease from GBS after waterbirths.” (source)
What about late onset GBS?
Currently “No strategies exist to prevent late-onset disease, although more than half of reported cases of neonatal GBS disease now occur during the late-onset period. In addition, concern continues among health officials that widespread intrapartum antimicrobial use might delay, rather than prevent, GBS disease onset, resulting in increased rates of late-onset disease. No evidence exists to suggest an increase; however, careful monitoring of disease trends remains a priority.” (source)
Are there any natural treatments for Group B Strep?
Though they have not been studied formally, many midwives have found at-home remedies helpful in avoiding Group B Strep, eliminating it after a positive result, or both. Here are some of their suggestions. Please note that when taking this approach it is usually recommended that moms be tested between 32-36 weeks so they have time to be re-tested. When you are retested, you can evaluate how these approaches are working for you and modify things if needed.
Strategies for avoiding or eliminating Group B Strep
- Fermented Foods – Consume foods rich in beneficial bacteria such as yogurt, kefir, and sauerkraut throughout pregnancy.
- Probiotics – Probiotics support the growth of healthy flora in the gut, which affects the flora that we see in the birth canal. I personally use this one– here’s why and here’s a link to my review of it, but my midwife recommends this one specifically for reducing GBS colonization.
- Raw Garlic Daily – I’d take about 2-4 cloves per day in addition to whatever is cooked with. Simply mince and allow to sit for 10 minutes to activate the anti-microbial compound allicin, then add to a salad, salsa, etc, or swallow it in one go with a glass of water. Personally, I wouldn’t use the capsule form because highly-concentrated doses may have a blood thinning effect. (source) I don’t say this to scare anyone. Even water can be toxic in high enough doses, so this isn’t an indictment of garlic. Just a reminder that whole food forms are often very gentle while still being incredibly beneficial.
- Echinacea and Astragalus Tincture – “Take 1/3 teaspoon of echinacea and astragalus tinctures twice daily. You can get dried astragalus in the herb department of health food stores. Cook two strips into a pot of rice or soup 2-3 times per week. Remove the strips when done cooking and eat the rice or soup. Astragalus is an immune system tonic used in Chinese medicine.” (source)
- Burdock Root and Echinacea Infusion – Emily of Holistic Squid shares how to prepare it here.
- Apple Cider Vinegar Bath – “This method is quite possibly the most effective. Three times a week, take a bath with 1/4 cup of apple cider vinegar added to the bath. The smell might be less than desirable, but it works. The theory is that the bacteria cannot live in the acidic environment of the vinegar and therefore dies.” (source)
- Apple Cider Vinegar Tonic – Other midwives recommend 2 teaspoons of raw apple cider vinegar in water daily during the last trimester to prevent colonization. Raw apple cider vinegar is great for overall digestion and can often help with heartburn as well.
- Daily Vitamin C – I prefer whole food-based versions that contain co-factors for optimal absorption. Unfortunately, about 99% of all vitamin C products on the market today are synthetically made ascorbic acid or something similar, and some studies show that these synthetic versions can actually weaken the mitochondria and possibly cause kidney stones. (source) Unfortunately, it’s not so easy to tell what’s what just by reading labels:
“Almost all of the vitamin C in supplements is made in a laboratory, despite labeling that implies otherwise. For example, the label might say, “ascorbic acid from sago palm.” Dextrose, a form of sugar that contains no vitamin C at all, is extracted from sago palm and used as the base molecular material for a complex laboratory process that synthesizes vitamin C. Or the label might say “vitamin C derived from the finest natural sources.” True, but the vitamin C was synthesized. It might also say “with rose hips and acerola,” which are then used as the base material for the tablet or capsule. But a tablet of rose hips or acerola can contain only about forty milligrams of truly natural vitamin C; the rest is synthesized.” Ron Schmid, ND ~ Dietary Supplements: What The Industry Does Not Want You To Know
When looking for a quality Vitamin C supplement I suggest looking for something in which the Vitamin C is derived from 100% whole food sources, like rose hip tea or elderberry syrup. Acerola powder is also generally a very good option, but there is not much research on its use with pregnant/nursing women so talk to your trusted healthcare provider before using it. (I did find a website that said they didn’t see any reason to think their acerola supplement would cause a problem for pregnant women, but their particular product is a blend of acerola powder plus synthetic ascorbic acid so I personally wouldn’t use it)
- Garlic Suppository – You can find “how to” instructions from Emily of Holistic Squid here. However, something to keep in mind is that the effect of garlic suppositories is relatively temporary, so if you use this method before taking a GBS test and then do not continue using it, there is a possibility that if GBS was present (but suppressed) that it will grow back.
What should I do?
As you can see, there is no “one-size-fits-all” method that is right for everyone. I suggest that you discuss your personal circumstances, along with the risks and benefits of each approach, with your healthcare provider. And of course, make sure to ask lots of questions.
What I did with my three children
As I mentioned at the beginning of this post, I’ve had three births – one where I tested GBS+ and did the wash, one where I tested GBS+ and did not, and one where I did something differently and did not test GBS+.
With my firstborn, Katie, my GBS results were delayed due to a mixup with my midwife. I was positive, but did not know it until very late in my pregnancy. I wanted to avoid IV antibiotics if possible but didn’t have very much time to research. In the end, I opted for my midwife’s recommendation, which was to rinse my birth canal with chlorahexadine. I did not know anything about how this might affect my daughter’s microbiome at the time.
When I became pregnant with baby #2, Micah, I tested positive for GBS again. However, after reading more on the microbiome and talking things over with my midwife, I decided to decline IV antibiotics and the chlorahexadine wash. For me, it was a research-based decision in which I weighed my personal risks and benefits. For example, I considered the fact that one of the most vulnerable populations are pre-term babies. My son was born at 41+ weeks gestation. I ate a 100% traditional diet with lots of fermented foods, got plenty of Vitamin D from the sun, and worked to boost immune function through some of the natural supplements listed above. I also educated myself on the symptoms of early-onset GBS.
I started using this probiotic before I became pregnant with Levi (baby #3), and was surprised to learn when we finally tested that I was negative for GBS. Per the guidelines set by the CDC, ACOG and healthcare providers, no antibiotics or antiseptic washes were considered.
None of my children developed GBS disease. All were born in water, which as I mentioned earlier reduces the likelihood of developing GBS disease. Of course, this is just what I chose to do. You may choose something entirely different, and that’s ok.
Looking For More Info On Birth Choices?
Happy Healthy Child: A Holistic Approach is a DVD childbirth education course that shares insights from over 30 world-renowned OB/GYNs, midwives, pediatricians, scientists, psychologists, childbirth educators, sleep experts and lactation specialists that can help improve the birth experience and overall outcome mama’s and their babies.
If you read through this site much you’l find many of the same names mentioned – these are the people I turned to when I was researching things like routine ultrasounds, co-sleeping, natural birth and more. People like:
- Dr. Bob Sears, who received his pediatric training at Harvard Medical School’s Children’s Hospital in Boston and The Hospital for Sick Children in Toronto — the largest children’s hospital in the world. Dr. Sears is the author of over 30 books on childcare and a fellow of the American Academy of Pediatrics (AAP) and the Royal College of Pediatricians.
- Ina May Gaskin, who has been called “the mother of authentic midwifery
- Dr. James McKenna, head of the University of Notre Dame’s Mother-Baby Behavioral Sleep Laboratory. This post and this post are based on his work.
- and Dr. Sarah Buckley, who was the first to make me dig deeper into routine ultrasounds
Topics covered include:
- Optimal nutrition for you and your developing fetus (I did not agree with all the recommendations in this section. Beautiful Babies is a better resource for dietary recommendations in my opinion.)
- The best ways to prepare for your labor and birth
- Building your birth team
- Overcoming the intensity of labor
- Common interventions and how to avoid the unnecessary ones
- Taking care of your new baby (bonding, breastfeeding, infant sleep, etc.)