Friday, June 29, 2012

Ask a Midwife: Why don't you risk out for postive GBS clients?

Why does being GBS + (Group B Strep) not qualify a woman to be risked out of home birth?  I know the pill antibiotics are not as effective as the IV antbx. A CNM can give IV antbx at home, but how likely is that? As I understand, the GBS+ status of the mother is only important for the baby's safety. What can you tell me about this? There was a case of a CPM in California who delivered a healthy baby that died a day or so later of GBS sepsis. Very, very tragic. -- Concerned Reader
 The most accurate information concerning GBS can be found here: The majority of OOH birthing centers and home birth practices do not risk out women who are GBS carriers. CNMs have prescriptive authority and therefore can order the IV prophylaxis that is recommended for the prevention of GBS.

2010 Guidelines for Prevention of Perinatal Group B Streptococcal (GBS)

Safer Midwifery added these thoughts to the discussion:
Again, the difference between CNMs and CPMs comes into play here, as does the importance of licensing, regulation, and defined risking out criteria/scope of practice.  Deb O'Connell, our resident midwife on the blog is a CNM, licensed, insured, and uses strict risking out criteria.  She has prescriptive authority.  If CPMs are unlicensed, unregulated, and have no defined scope of practice, they can treat clients with any unproven method they choose.  They don't have an obligation to transfer care or risk out.  I would venture to say that most home birth midwives are not CNMs and therefore do not have prescriptive authority.

Perhaps the difference in care is that the CPM (Certified Professional Midwife) in CA may not have had prescriptive authority, and resorted to her own unproven methods for treating GBS.  I have read stories of mothers whose GBS was treated by putting garlic in their vagina instead  properly being treated for a serious complication and the baby died hours after birth because of pneumonia from GBS.  See Wren's Story.  Garlic is not a substitute for antibiotics.

The problem then lies in the fact that the midwife made the decision to treat her client for GBS when she was unqualified to do so, instead of getting her client the help she needed.  Without the ability to treat GBS properly with prescriptive authority, the midwife should absolutely be risking out her client so she can receive the care she needs, and transferring her to the care of a physician.  Many, many midwives don't risk out at all and consider everything to be a variation of normal.

A CPM would need prescriptive authority in order to safely treat a client for GBS, strict risking out criteria would have to be clearly defined in order to practice safely, transfer of care would have to be seen as necessary to maintain a safe standard of care, and a solid, foundational education must precede all of these points.  Thank you for the excellent question!

 "Ask a midwife" is a write-in series here on the blog. If you have a question for our Certified Nurse Midwife, please share it with us here.


  1. Thank you for the answer! I had a friend who delivered her last two babies with a CNM at home and opted for oral antibiotics. From my research, oral antbx are not nearly as effective as IV antbx. I think the whole idea of an IV at a home birth is unthinkable to many women's views of what a home birth is supposed to be. I wonder how many CNM's with GBS+ clients actually do give IV antbx during home births. I have a suspicion it is a very, very low number.

  2. I was GBS+ for my second child. I desired a natural hospital birth, but was faced with needing an IV in the best interests of the baby. (dislike IVs) I insisted that the anesthesiologist be called so I could get a local first to numb the area in my hand, then just had the small bag of antibiotics strapped to my forearm. When it was empty, I did agree to keep the heplock, since the lidocaine still kept me unaware of the IV.

    So it's definitely possible to combine a "natural" birth with the need for IV antibiotics AND be in the hospital to boot.

    Baby (41 wks) was born bluish, Apgar of 5. Since mec was observed, a team was called in and he was taken care of immediately. I never considered homebirth, but if I had him at home, who knows what might have happened?

  3. An anonymous reader and apprentice midwife sent me this insightful response (I have to post it as two comments):

    Midwives will carefully and painstakingly explain that GBS is a type of bacteria that is present in 30% of all pregnant women and that it causes no harm to the pregnant women. Then they explain that sometimes newborns contract GBS during birth, and some of these babies get sick, and then a small amount of these babies die from GBS infection.

    Midwives will review the CDC recommendations with their clients – that IV antibiotics are administered to all women in labor who tested positive for GBS during their pregnancy. They might then add their own commentary about how most of the antibiotics administered are completely unnecessary because most of the babies born to GBS positive mothers will not become sick from GBS.

    Midwives will tell their clients that until 2002, the CDC offered women a choice – they could opt for prophylactic IV antibiotics OR IV antibiotics only when additional risk factors were present. The risk for developing septic GBS infection in newborns increases with low-birth weight babies, babies born at or before 37 weeks of gestation, or during labors when ROM has exceeded 18 hours. Midwives will leave out that the reason the CDC switched to the IV antibiotic prophylaxis recommendation only is because is more effective at preventing newborn sepsis than the risk-factor based strategy.

    These two options will be presented equally – sometimes along with this: “If you know that you will refuse antibiotics in labor regardless of your GBS status, ask yourself whether you want the GBS screening at all. Regardless of a woman’s GBS status, we will transfer care if risk factors develop or signs of infection become apparent during labor.”

    Midwives will present alternatives: argh, the garlic suppositories, courses of oral antibiotics during pregnancy (with MD collaboration), probiotics, Hibicleans douching during labor, or stating that they’ll seek out antibiotics per the 2002 (outdated) recommendations if any of those risk factors occur during labor.

  4. (Part II from Anonymous Apprentice Midwife)

    Midwives will provide this informed consent and ask parents to make a decision. Some parents will opt to be tested for GBS, others will refuse. A consent form documenting the parents’ decision will be signed. For the mothers who test GBS positive, they will be given another choice, would you like to go to the hospital for IV antibiotics or would you like to consider IV antibiotics only if other risk factors are present. These mothers are in their third trimester of pregnancy, are attached to their midwife and idea of home birth, and leery of what seems to be excessive intervention in hospital practices. They will think opting for IV antibiotics during labor if risk factors are present is a reasonable option.

    Some midwives will offer the Hibiclens douching during labor. And for the parents that choose this treatment (which does have some limited evidence to support it – and is not without its own set of risks), it will be used in a pretty half-assed manner – and the schedule of douching (every 4 hours) will go by the wayside once labor becomes active.

    Some women will go into labor at 37 +1, or have PROM at 37 +1 – (GBS colonization increases the risk of PROM) and there will be no discussion of how there are now increased risk factors. The woman will be treated like any other woman in labor. She will be allowed to wait until labor starts. There will be no discussion of her baby’s estimated birth weight or gestational age. There will be no discussion of increased GBS infection in babies born early. There will be no discussion of having to transfer at 18 hours post ROM for IV antibiotic treatment, as discussed (take note, but not explicitly consented to) during prenatal care.

    After the baby is born, there will be no increased duration of time for monitoring the baby for signs and symptoms of infection. There will be no extended immediate postpartum presence (which in a home birth practice would be staying at the home for 6-12 hours after the birth). There will be no additional visits to the family’s home during the first hours and days postpartum – only the standard home visit at 24-48 hours postpartum. Some midwives provide information regarding early signs of respiratory distress (nasal flaring, grunting, increased respiratory rate, difficulty feeding), and assign the task of assessing the baby to the postpartum parents, but most do not.

    The midwives will hedge their bets that *this* case of a GBS positive mother will not result in a baby with a life-threatening infection – because statistics are on their side. It’s not that midwives believe they are putting their patients at increased risk. They themselves don’t really believe the risk is real.

    And this brings up one of the major problems with “professional” midwifery: that they are not acting like a group of professionals. A professional organization should provide standard of care guidelines and evidence-based practice guidelines based on scientific evidence. Midwives should not be left to their own devices to scour the medical research and understand what is and isn’t an increased risk. And some of these complications are so rare, that midwives will rarely encounter them in their small practices. But the profession *will* encounter these complications – and any adverse outcome encountered by one midwife will reflect on the entire profession, and, not to minimize this point, cause harm to the people they serve: women and babies. THAT is why there are practice standards. Or should be.

    In a nutshell: homebirth midwives don’t risk out GBS + mothers because they have no professional practice standards.

    Well, I take that back, they do have practice standards, see above.

  5. I had IV antibiotics during all three of my hospital births (GBS positive all three times). I didn't find it bothersome at all; what is an IV when you're in LABOR?! I hardly noticed it :) And the nurses were great about taking it out for awhile when I wanted to walk around or get in the shower.

  6. Thank you anonymous midwife. That is literally EXACTLY what happened to us, and Wren died as a result.

  7. I remain flabbergasted at the lack of professional standards and the blatant disregard of risk.