The Big Group B Strep (GBS) Post
Lots of women who choose allopathic care (or even some types of midwifery care in some states) are confronted with a “simple” test that could potentially change the course of their pregnancy and birth experience depending on the results.
This simple test is the GBS or group B strep test.
Women are typically tested for GBS in the last 6 weeks of their pregnancies and the way doctors and midwives test for GBS colonization in women is to do a vaginal and rectal swab and send the swab off to a lab (or do an in-office culture).
The test results actually show a GBS “colonization” in the vagina and/or anus (colonization does not necessarily mean infection.. GBS is present in every human being, but when it overtakes the beneficial bacteria and monopolizes other parts of the body like the urinary tract and the uterus, it can be more harmful - aka an infection).
The worry is that during a vaginal birth, the GBS will pass to the baby and make the baby very sick, potentially fatally. There are two categories of GBS disease in newborns: early onset GBS disease (symptoms presenting in the first 7 days of life but *usually* showing in the first 24 hours) or late onset GBS disease (symptoms (usually less severe) showing between 7 days and 3 months old).
The symptoms of GBS disease in newborns are the same as sepsis symptoms: fever, trouble breathing, unusual drowsiness, coughing, unusual congestion, seizures.
The CDC shows a rate of 0.22/1000 babies born will develop GBS disease (from 2016 statistics) in any given year (this equates to a .022% chance of any baby getting the disease).
The most common path of action currently in the United States is to test EVERY woman regardless of risk factors for GBS colonization toward the end of her pregnancy, and then to treat EVERY woman who shows a GBS+ result or who is high risk (high risk = women who go into labor prematurely or who have an extended time (>18hrs) with their membranes “ruptured”/waters open, or who develop fever in labor).
This is known colloquially as the “test all/treat all" protocol.
Rates of GBS disease have not fluctuated much since the establishment of the “test all/treat all” protocol in the United States. The rate dropped before this protocol was implemented, and has stayed steady since, fluctuating up or down by only a few cases per TEN thousand births each year.
The sticky part is that GBS positive (GBS+) mothers give birth without antibiotics sometimes (when women make an informed choice to refuse the offered antibiotic treatment) and very often these women’s babies do NOT get an infection.
Other times, GBS+ mothers give birth to babies *with* the use of antibiotics during labor, and the babies are found to be infected with GBS anyway at birth. (At least a third of the babies who get early onset GBS disease correctly received antibiotics in labor.)
Still other times, GBS NEGATIVE women will give birth (without antibiotics, since they tested negative), and then their babies will get sick with GBS disease after birth, even though the women tested negative during their pregnancy.
Some women who test positive for GBS colonization one week via the rectal/vaginal swab will test negative for it two weeks later without changing anything in their behavior or diet. And vice versa.
This is part of the reason that the current testing/treatment protocol is perhaps flawed.
The two types of tests for GBS status, prenatal GBS cultures and the rapid test (Polymerase Chain Reaction, PCR) are only about 80% to 85% accurate and the false negative rate is high (meaning that many women who actually ARE colonized with GBS will have test results stating that they do NOT have colonization.) The newer 'enriched broth' culture is over 90% accurate, with less false-negatives, but this test takes more time.
Roughly 30% of babies born to women with GBS colonization will become colonized themselves, and of those 30%, only about one percent of colonized babies will develop GBS disease.
Modern robust research shows that more likely than being infected during birth, these babies who are showing symptoms of GBS infection immediately after birth were infected IN THE WOMB, prior to birth even beginning.
Another troubling aspect of this whole ordeal is that GBS+ babies are often born with antibiotic resistant strains of GBS, which means the current protocol of treating every woman who is positive for GBS colonization with antibiotics (along with all the other ways antibiotics are overprescribed and used incorrectly or inappropriately in this country) may be doing more harm than good.
Giving antibiotics in labor so frequently has resulted in a large rise in antibiotic exposure to millions of women and babies and all the potential negatives that go along with that exposure, with little evidence that this has been an effective strategy. Over a million pregnant women are exposed every year to antibiotics, in an attempt to prevent a disease which is rare, easily identifiable, and treatable.
Babies and mothers who are given antibiotics during labor often suffer other negative effects afterward because their entire microbiome of both positive and negative bacteria were completely wiped out, making way for all the antibiotic resistant bacteria as well as any other nasty bugs lurking at the hospital or birth place to flourish inside the body and cause sickness or dis-ease.
Antibiotic exposure during birth is linked to higher risk of: thrush, yeast/candida and potentially dangerous systemic fungal infections, reduction in probiotic bacteria, risk of Crohn's disease, suppressed immune system, asthma and allergic dermatitis, respiratory infections and pneumonia in the first six months, and other severe infections in the first two months of life for these babies!
A Cochrane review in 2009 could not find enough evidence to support the use of automatic antibiotics for women who were GBS+, stating that the studies which showed effectiveness in reducing early onset GBS were “poorly designed” and “had a high risk of bias,” and noting that there has been no improvement in mortality with the “test all/treat all” policy.
What HAS been shown to be effective at preventing GBS disease in babies is a different policy of identifying and treating every woman at *high risk* in labor (high risk = preterm labor, women with a previous baby who developed GBS disease, women with GBS+ urine cultures in labor, or with fevers in labor) instead of testing every woman in pregnancy.
This protocol picks up women who would have had false negative results in pregnancy and who mistakenly wouldn’t be treated with antibiotics in labor. The New England Journal of Medicine published a collection of data from ten US states, showing that 61% of GBS disease cases occurred in babies from women who were screened, but tested negative. And in general in the whole of the United States, 40% to 75% of babies who develop early onset GBS disease are born to mothers with risk factors in labor, but under the “test all/treat all” policy they are skipped for antibiotics in labor “because they tested negative for GBS.”
The rate of early onset GBS disease in England is 0.3/1000 and 0.4/1000 in Ireland, even though they don’t use the “test all/treat all” protocol and instead follow the policy outlined in the previous two paragraphs.
The reason this other protocol actually makes more sense (to me, at least) is because it’s treating an actual problem that is likely to exist. Finding every woman in labor who has risk factors for a baby that may come out sick, and offering to treat all of those women with antibiotics, could help prevent more babies from becoming sick than if we are perhaps NOT giving these women who are actually showing signs of dis-ease anything “because they tested negative for GBS.”
Keep in mind that there is always the option to not be treated with antibiotics, even if you are showing risk factors listed here. You could give birth to a perfectly healthy baby, it’s just that the likelihood of doing so decreases when you show these risk factors.
Risk factors in labor are a clue that these babies are going to be the most susceptible to infection, but they're also an indication that infection may have already occurred before birth.
The in-labor risk factors for GBS disease in the baby are: preterm birth, maternal infection (fever due to chorioamnionitis (infection of the membranes and amniotic fluid), placentitis (infection of the placenta), uterine infection, UTI, and waters open for >18 hours.
Yet these are not causes of infection in labor – these are symptoms of an infection which has already occurred.
This is a chicken/egg conversation, yes, but I would imagine that infections occur in the mother’s body BEFORE her body initiates preterm labor (side note: because of this, maybe we should re-evaluate the use of medications to delay preterm birth until after the lungs are mature because preterm labor is more likely a sign of infection already established in the baby, and that the baby wants out and wants help once they’re out… ) and there was probably an infection in her uterus BEFORE her waters opened before labor. Fever in labor is a SIGN of infection (or the body’s response to an epidural/pitocin, but that is a conversation for another day).
“Preterm labor, and prelabor rupture of membranes (waters opening before labor has started) are strongly tied to infection and inflammation in pregnancy. The preterm labor or miscarriage starts because the infection is already present. The bacteria cause inflammation and the cervix suffers a prostaglandin response and dilates. The bacteria weaken the membranes causing prelabor rupture of membranes. The bacteria invade the membranes, amniotic fluid, uterine wall, or urethra, resulting in labor and/or maternal fever as signs of the infection.” - Gail Hart, “Research Updates for Midwives”
Preterm babies are more likely to be sick when they are born because they have weaker immune systems but also because they were likely infected before they were born, and that is WHY they were born. They most likely did not “pick up GBS” as they came through the birth canal.
In a study printed in Obstetrics and Gynecology (March 2012), researchers evaluated the record of all babies over an 8 year period born at a large hospital. Out of 43,384 babies born there, 94 of them had early onset GBS sepsis within the first 72 hours of birth and all but one of these 94 sick babies were diagnosed with GBS disease within the first hour of life.
Whether a baby shows early onset GBS disease after a term birth or a preterm birth, the baby is usually born already infected.
The following are risk factors for a baby developing (or being born with) GBS disease:
Preterm birth – the risk is more than 4 times higher if the baby is under 37 weeks. It is 21 times higher if the baby is under 28 weeks!
Prolonged rupture of membranes (PROM) >18 hours
Fever >99.5 degrees
Chorioamnionitis
Internal fetal monitoring >12 hours (please avoid internal fetal monitoring at all costs! I need to write another blog post on just this topic on another day..)
More than six internal vaginal exams during labor
So to explain some of the options in this scenario, I will start with saying that true pathological GBS *infection* likely shows up in a urine culture, more so than just the vaginal/rectal swab, because when GBS has colonized the urinary tract, this means that GBS is more likely to be in the uterus with the baby already.
A woman can be GBS+ from her vaginal/rectal swab but negative in her urine test. She could then decide, based on the results of the urine culture, whether or not she wanted antibiotics during her birth.
If a mother is GBS+ from her swab, it is still completely within her rights to refuse antibiotic treatment during birth and then take a watchful waiting approach after the birth, watching for signs of GBS infection in the baby and then treating the baby only if he or she shows signs of infection (lethargy, trouble breathing, fever, etc.).
A woman should also be able to choose to receive oral antibiotics instead of IV antibiotics if she has risk factors OR to wait until the baby is born and treat both parties uniquely at that point if necessary.
Also, trying to treat the colonization in the vagina/bowel before birth, and then retesting in order to try for a negative test in order to have more “validity” in your refusal of antibiotics is another option (though, not necessary because refusing with a positive result is completely valid of course!).
Though, I will say that waiting until so late in pregnancy to test and start trying to fix the problem of GBS colonization is not very ideal.
Here are the CDCs OFFICIAL recommendations for treating women with antibiotics in labor as it relates to GBS status:
Treat with antibiotics if any or some of these qualifications are met:
Delivery at <37 weeks gestation
Amniotic membrane rupture >18 hours
Intrapartum temperature >100.4°F (>38.0°C)
signs or symptoms of chorio-amnionitis (infection of the membranes and amniotic fluid)
“signs and symptoms such as fever (which might be low-grade), uterine tenderness, fetal tachycardia [heart rate too high], maternal tachycardia, and foul smelling or purulent [puss-filled] amniotic fluid. Maternal fever alone in labor may be used as a sign of chorioamnionitis and indication for antibiotic treatment”
CDC protocols for treatment options with regards to GBS status:
If mother had an indication for GBS prophylaxis [antibiotic use] but received no or inadequate prophylaxis, if the infant is well-appearing and ≥37 weeks and the duration of membrane rupture before delivery was <18 hours, then the infant should be observed for ≥48 hours, and no routine diagnostic testing is recommended”
If the infant is well-appearing and either <37 weeks and 0 days gestational age or the duration of membrane rupture before delivery was ≥18 hours, then the infant should undergo a limited evaluation [limited blood work, meaning a CBC with differential] and observation for ≥48 hours.
If ≥37 weeks gestation, observation may occur at home after 24 hours if other discharge criteria have been met, access to medical care is readily available, and a person who is able to comply fully with instructions for home observation will be present.
Notice that they didn’t say anything about treating all infants born of mothers who are GBS+ (or whose GBS status is unknown) with antibiotics!!
Now that we’ve talked about what GBS is and possible treatment paths, let’s chat about how to avoid the whole ordeal in the first place.
How do you avoid testing positive for GBS?
Well, you can either not take the test in the first place OR you can try to ensure that you are taking measures all throughout your pregnancy in order to not allow the GBS strain to over-colonize your body.
An entire pregnancy’s length of time is needed sometimes to establish good flora in the vagina. Healthy diet is essential to this, because GBS proliferation begins in the gut and sort of “trickles down” into the vagina and bowel from there. Treating the gut throughout pregnancy is definitely more ideal than waiting until the end of pregnancy and trying to mask or band-aid the problem.
Taking measures to lessen your anaerobic bacterial pervasiveness in your gut/digestive system can help.
eat probiotic foods
avoid taking antibiotics during pregnancy (or before)
take high quality probiotic supplements
avoid eating foods that may contain high antibiotic levels (most conventional milk and dairy products would fall into this category, as well as conventional meat/poultry products. Animals grown conventionally are given high doses of antibiotics in order to combat sickness/dis-ease because they are in such close proximity to other animals and their waste products)
decrease stress levels majorly (anaerobic bacteria thrive on the hormones the body releases when it is stressed, plus the fact that high stress weakens the immune system in general)
drink clean pure water that does not contain chlorine or fluoride as these kill both bad and good bacteria in the gut
avoid artificial hormones including synthetic hormones found in conventionally grown animal products/dairy and in plastics/receipt paper (this hormone is known as BPA) because these upset the microbiome of your gut and also your general body/hormonal health
avoid chemical exposure during pregnancy as they can deplete the immune system and make way for anaerobic bacteria like GBS to take over. This is an issue for people who work in careers like hair stylists, dry cleaners, lawn care workers, painters, or people who work in the fuel or chemical industries
make sure to wear protection when engaging in unprotected sex with multiple partners in pregnancy, because sexually transmitted infections also leave the body in an immune deficient state
don’t use douches or tampons or anything unnatural that goes into the vagina
If you do “all of the things” and still end up testing positive for GBS in pregnancy, and you want to try to clear the GBS from your vagina/rectum in order to retest to get a negative result or lessen the likelihood of transmission to the baby, you can do some or all of these suggestions:
Make your vagina a more acidic environment. Alkalinity allows GBS to flourish there, so rinsing with hydrogen peroxide rinses (never douching, with anything! Just rinsing the external bits, including your anus) can help.
Insert probiotic capsules vaginally
Put plain yogurt (no sugar) with active lactobacillus on and inside of your vagina
Insert a peeled clove of garlic into your vagina at night and remove it when you wake in the morning
Rinse your external vagina with a dilution of a standard 4% Hibiclens-type wash at one part Hibiclens to twenty parts water right before your GBS swab is scheduled. (Repeated use of chlorhexidine may allow the absorption of the chemical into the maternal bloodstream)
Take 350 mg of echinacea daily
Take 1000 mg vitamin C daily with 200 mg bioflavonoids
Take 15 drops grapefruit seed extract daily
And, if you test positive for GBS in pregnancy, especially via urine culture, and you want to try to ensure your baby does not become colonized with GBS during birth but you don’t want to take antibiotics, here are some things to make sure of:
Avoid internal/cervical/vaginal exams in labor and in pregnancy. When we are pregnant, we have a mucus plug that seals our cervix and uterus/baby off from germs. This plug has strong antibacterial qualities against GBS. Avoid disturbing this natural protection by avoiding internal exams during your birth and in your pregnancy as well. These exams disturb the mucus barrier, allowing bacteria to access your membranes, uterus, and by proxy your baby.
In one study, when more than four vaginal exams were done in labor, the odds of infection of the membranes and amniotic fluid tripled compared to women who had four or fewer exams. This infection is strongly correlated with baby becoming sick with GBS after birth.
Every cervical exam inevitably carries bacteria laden cells/fluids/etc from the lower vagina into the cervix, penetrates the germicidal mucus plug, and contacts the amniotic sac, intrauterine wall, or baby's head. Every exam – no matter how carefully done or how perfect the technique – brings bacteria from the vagina to the uterus. Don’t let anyone be responsible for introducing GBS bacteria directly to your baby.
Women who have their membranes swept in pregnancy to try to induce labor are at a higher risk of experiencing ruptured membranes before labor begins. This is strong evidence that the membrane sweeping causes bacteria to invade the membranes which may potentially elevate risk of membrane infection and GBS disease in the baby. Intact membranes protect the baby from infection. Anything which weakens the membranes raises the risk of both preterm birth and infection. Under-nutrition (lack of vitamin c), abnormal vaginal flora (lack of lactobacilli), sweeping the membranes, and cervical exams are all potential – and usually avoidable – risks.
Avoid letting your midwife or doctor/nurse break your waters artificially in order to prolong protection for the baby. Intact membranes reduce the risk of infection.
Avoid the use of an internal fetal monitor during labor. The use of an internal monitor more than doubles the risk of infection of the membranes/amniotic fluids.
One study of babies with GBS disease after birth showed that the odds of having a sick baby were seven times higher if an internal monitor was used for more than 12 hours of labor.
Avoid (for every reason, not just GBS) the separation of you and your baby after birth, physically as well as by using blankets, clothing, or hats on the baby, especially if those clothing items are provided by the hospital or birth center or midwife. Babies can become colonized with GBS from other sources besides their mothers. They are generally immune to the bacteria carried by their mother and close household members (even to GBS), actually, but they are wide open to strains from other people. Every person who handles the baby in the first days and any outside source of blanket, baby hat, or clothing is a potential source of bacterial infection.
In one study, 49% of GBS positive babies didn't get it from their mothers. They didn’t have the same strain of GBS as their mothers, they had the same strains carried by the other babies of that labor & delivery unit. This means that employees/staff at the hospitals were spreading the same strains around from baby to baby by touching, handling, breathing on, coughing around, swaddling, and clothing, etc.. the babies of that unit.
Consider giving birth in water. The GBS colonization rate of babies born in water is lower, and the rate of GBS disease is less than the rate of babies born on land. During water birth the baby is thoroughly cleaned as they are born. Eyes, ears, nose, mouth, the folds of the skin – the regions most likely to harbor vaginal secretions - are in full contact with the water. This actually clears GBS off the baby and leaves it in the water.
Throughout their pregnancies, friends, family, and strangers reach out to me with questions or concerns like GBS.
I hope that by explaining all of the options that their healthcare provider may not have talked with them about, folks can come up with their own plan of action for their own unique selves.
Like I said in the beginning, GBS+ diagnoses mean “automatic” IV antibiotics during birth in most modern obstetrical and even some midwifery practices, and women don’t know they have other options (ie not testing at all and/or refusing antibiotics or choosing a different path altogether) because they aren’t presented with them.
It’s really hard as a birthing woman, especially a first time mom, to know EVERYTHING about EVERY issue that may come up during pregnancy. I’m not claiming to know everything either, but being able to point women toward info and resources that will help them make truly informed decisions about their healthcare is vitally important and I am holding the vision that this will become standard practice at some point in our lifetimes. :)
Thanks for reading along and please let me know if you have any questions about GBS after reading this!
Did you know that I offer virtual sessions for pregnant & postpartum women, as well as women hoping to conceive? Click here to check out the info and book your session :)
Thank you to my sources:
Anne Frye’s “Diagnostic Tests for the Childbearing Year”
Anne Frye’s “Holistic Midwifery”
Gail Hart’s “Research Updates for Midwives”
Maryn Green’s podcast episode “Dispelling 10 Myths About Group B Strep”
