What is Group B Strep (GBS) and why does it matter in birth?
Understanding GBS, its detection, and its treatment is really important to understanding how physiologic birth and birth that has been medicalized affects you and your baby.  Here’s a great discussion at Evidence-Based Birth.

GBS is a normal part of your gut bacteria

GBS is one of a multitude of bacteria that live in your intestines, rectum and vagina.  It normally causes no problems at all and, given all that we do not know about the gut biome, probably has an important job.  We do not know what percentage of the entire population carries GBS, but we have tested pregnant women and found that approximately 30% carry GBS.  It is probable that many people, men and women, carry GBS at any given time.  GBS blood and tissue infections can happen in adults.  This page is meant to address GBS as it relates to birth and newborns.

So if it’s normal, why is it a problem?

Simply, the concern is that an unmanageable, rapid GBS infection can take hold in the newborn baby and cause significant morbidity or mortality.  Just like E. coli or C. dificile, GBS is a bacteria that causes problems if it is in the wrong place at the wrong time.  Infection of the newborn by GBS is called early-onset GBS disease (when it happens 7 days after birth).  Early onset is most common and generally occurs within the first 24 hours of birth.  It is related to transmission from mother to baby during labor or at birth.  Late onset disease is not related to birth and is likely caused by transmission from other infected people, such as another adult with GBS infection, nursery staff, or other babies in the nursery.

Early onset GBS disease is the focus of this page because it is related to birth, location of birth, and birth practices.

Isn’t GBS just another bacteria like the others?

In the past, many babies died from many sorts of infections, usually caused by poor hygiene and sanitation or by the widespread misunderstanding germ theory.  For example, many babies have been born in locations where the livestock live in the same house, where chamber pots were emptied into the streets, or where local custom says to place dried cow dung on the umbilical stump.  Many babies also died from bacteria or viruses transmitted from the mother during pregnancy or birth.  Almost certainly GBS caused some of these newborn infections but was never identified as the culprit.

It makes sense to follow guidelines that reduce the transmission of any kind of bacteria to the newborn and increase the immunologic support of the newborn, no matter what bacteria we talking about.  Thus, clean hands and closed sewage systems help protect babies.  But so do gentle birthing practices such as the avoidance of AROM to induce or augment labor, internal fetal scalp monitors, and routine suctioning of the newborn’s mouth;  the reduction in cesarean sections and epidurals; the increase in vaginal deliveries; and the increase in immediate and exclusive breastfeeding.

Don’t antibiotics help prevent GBS disease?

Thankfully, the 19th century brought the knowledge of germ theory and of the need for public sanitation.  However, babies still died from infection and the effort was made to identify the cause of newborn infections.  Around 1950, GBS was isolated from a sick baby for the first time and it was postulated that GBS was the primary cause of newborn infections.  The 19th century also brought the discovery of antibiotics (i.e. penicillin).  Around 1975, doctors began experimenting with the use of antibiotics in newborns and in mothers during labor as a way to prevent newborn infections.  Since there were no standard protocols yet, individual doctors and hospitals developed their own and had varying results.

Once GBS was identified as the main culprit in newborn infections around 1980, standard antibiotic protocols were developed and implemented to a high degree in most institutions.  For several decades, the GBS infections in babies dwindled.  In 2001, there were 1,700 cases of early onset GBS in newborns (http://www.cdc.gov/groupbstrep/downloads/GBS_Patient_Info.pdf, accessed 04/27/2013).  However, we are now seeing a plateau in the numbers of early onset GBS cases, antibiotic resistant GBS, a rise in infections with bacteria other than GBS, and increasing antibiotic resistance  in multiple bacteria.

Is GBS more damaging than other germs?  How dangerous is it?

An infection by GBS generally takes hold in the first 24 hours, advances rapidly, and most commonly shows up as sepsis,  pneumonia, or meningitis.  GBS infection in the newborn can also happen after a week or more.  Other germs that infect babies, such as E. coli and C. dificile, cause these symptoms as well as necrotizing enterocolitis (infection and death of intestinal tissue) and sepsis (overwhelming blood infection).

The CDC says:

      • 30% of pregnant women test GBS positive when tested at 35-37 weeks gestation,
      • 1 in 700 chance of having a baby that develops GBS disease if you are GBS positive AND do not receive antibiotics,
      • 1-2 in 100 chance of having a baby that develops GBS disease if you are GBS positive AND do not receive antibiotics AND you have any one of the risk factors listed below,
      • The risk factors that increase the risk of your baby getting GBS disease are: a previous baby with GBS disease, a UTI caused by GBS during pregnancy, preterm birth (before 37 weeks), prolonged rupture of membranes during birth, and a maternal fever during labor or birth.

How do we protect our babies against GBS?

Current protocols recommend testing and treatment.  This means the mother is tested for GBS at 35-37 weeks gestation at her provider’s office.  The results take 48 hours.  If she is positive for GBS, it is recommended that she receive prophylactic antibiotics during labor.  The antibiotic of choice is penicillin.  Mom must have at least 4 hours of IV antibiotics before the birth in order for the baby to receive enough antibiotics in its system to be effective against GBS.  Ideally, she receives two doses (at least 8 hours).

Your midwife tests her clients for GBS and carries antibiotics and IV supplies for this purpose.  If you are GBS positive and wish to have antibiotics during labor, the only special arrangement needed is to make sure she is there at least 4 hours before birth, ideally 8 hours before birth.

Is that all we really know about early onset GBS?

GBS has only been studied in the context of hospital birth, often large-scale and in research institutions, as this is where the money and structure to perform the needed studies lie.  Additionally, most births in the US have taken place in hospitals.  Thus, all we “know” about GBS comes from hospital-based viewpoints and procedures.  This matters immensely because it is at the hospital that the majority of women and babies are subjected to procedures that increase the likelihood of bacterial transmission and the reduction of immunologic protection of the newborn.  One must take into account the history of birth in the US to fully appreciate the problems associated with “known” GBS infection rates:

      •  Twilight sleep and highly medicated mothers have been the standard for almost 100 years.  This means the rates of forceps, vacuum extraction, manual rotation of the baby within the canal, manual dilation of the cervix, and multiple vaginal exams (sometimes 1 per hour) skyrocketed.  These all disturb the normal process and push bacteria up the birth canal toward the baby.
      • Interventions such as internal fetal monitoring (IFM) introduce vaginal bacteria directly into the baby’s bloodstream.  A corkscrew-shaped, needle-like metal probe is inserted into the scalp…after it passes through the vaginal fluids which carry bacteria.  IFM is mainly used because it takes less time and effort for the staff to monitor the baby and because previous interventions have necessitated its use.
    • Artificial rupture of membranes (AROM), also known as breaking the bag on purpose, has been egregiously overused.  It is still common for doctors to “start labor” with AROM when the mother is
    • Immediate newborn resuscitation efforts, such as immediate cord clamping, suctioning, intubation, oxygen, and examination, have disturbed the normal transitional efforts of the baby AND introduced bacteria.  These interventions cause excessive ventilation efforts by the baby before he is able to clear fluids, they scratch or irritate the baby’s skin and/or mucous membranes (allowing for bacterial transmission directly into the blood stream), and they remove the baby from the mother’s protective bacteria.
    • Immediate breastfeeding, which provides protective bacteria and colostrum that feeds beneficial gut bacteria, is still not promoted by most hospitals.  In fact, breastfeeding rates are still miserable and many babies are given formula or glucose water instead of pumped breastmilk.  Of note, the lowest rates of breastfeeding in this country (mid 1960s) coincides with the interest in GBS infection of the newborn.
    • Immediate placement of the baby on mother is not standard.  This protects the baby from exposure to the bacteria carried by other people and things that may touch the baby.  In the past, babies were commonly held in the nursery for several days before the mother could even hold her baby.

What does gentle birth have to do with GBS infection?

While infection of the newborn cannot be prevented 100% of the time, it can be minimized by respecting the natural processes of birth, promoting excellent health in the mother during pregnancy, and targeting medical interventions to those few situations that require it.  It is known that fewer interventions, such as vaginal exams and IFM, and immediate breastfeeding reduce the likelihood of infection in the newborn.  Gentle birth practices support this.

      • AROM should never be used to start or increase labor, especially if there are no or few contractions.  If the mother is not having regular contractions and dilating already, there is no way to know if she is actually in labor!  By performing AROM too early, it increases the likelihood of a long labor, induction with Pitocin/Cytotec/Cervidil, multiple vaginal exams, IFM, and c-section.
    • Vaginal exams should be minimized, as they push bacteria farther up the vagina.  In my practice, most births occur with
    • Newborn resuscitation can be minimized through reduction in interventions and drugs during labor, as well as delayed cord clamping.  The interventions and drugs cause or exacerbate fetal distress most of the time!   Delayed clamping (see page) prevents the need for aggressive measures such as suctioning, intubation, and supportive respiration.
    • Babies should be placed directly on the mother’s abdomen or chest and left there!  All assessments of babies who are doing well can be done from this vantage point.  If babies are not doing well, they should be assessed and assisted next to the mother.  During the time between the birth of the baby and the birth of the placenta, mother and baby should be talked to and interrupted as little as possible.  This facilitates bonding and breastfeeding.
    • Breastfeeding is essential to the immunologic protection of the baby because of its antibody content and pro-bacteria proteins.  Gentle birthing promotes breastfeeding because it increases mom and baby’s abilities to latch and nurse effectively.  Drugs received by the mother during labor and birth depress the baby’s neurological responses.  Interventions to the newborn over stimulate the baby and depress his breastfeeding reflexes. Suctioning and intubation (resuscitative measures used frequently) depress his sucking reflex.

What do we not know yet about GBS?  What should we be studying?

Given that widespread antibiotic use is wreaking havoc on our medical system today and the costs associated with childbirth are skyrocketing, we need to target our treatment of GBS more effectively.  There are many areas in which we are lacking information.  This is partly due to the fact that the main force in obstetrics/medicine thus far has been on medications and antibiotics to treat GBS and the inability to reduce interventions.  Here are areas in which we need more study in order to better identify who is at risk for GBS infection:

      • GBS’s function in our gut biome
      • Maternal GBS antibodies
      • Which types of GBS are the most prevalent/most infective/most destructive
      • Breastfeeding initiation rates, reduction in exclusive breastfeeding, and hospital practices and how these affect GBS infection rates
      • Rates of GBS in homebirth, birth center and gentle birth settings
      • Maternal bacterial balance/imbalance
      • Maternal diet and environmental exposure and GBS colonization
      • Effect of obstetric interventions on GBS infection
      • Effect of newborn interventions on GBS infection

BLAH, BLAH, BLAH….so what are my options and what do I do about GBS?

As a homebirther, you have more options available to you and a supportive provider.  Talk to your midwife and ask her questions!

First, you can choose to test for GBS via the vaginal swab or you can decline it.  It is usually done about 37 weeks in my practice, as I have such a low rate of preterm birth.  Plus, hospitals prefer a test that is less than 4 weeks old.
If you test negative, there’s nothing else to do.

If you test positive, you can choose 1) to receive the standard prophylactic antibiotics during labor, 2) to decline the antibiotics during labor, or 3) to see if the risk factors develop during your labor (preterm birth, long period between rupture of membranes and birth, or fever) and then choose to receive antibiotics.  Rest assured that your midwife will give you a timely and accurate assessment of infection risks as labor progresses.

It is important to know that all area hospitals (to the best of my knowledge) require a 48 hour assessment period for newborns who have an unknown GBS status.  If you and/or the baby were to be transported, a GBS test would be in the baby’s best interest.