By Jessica English, LCCE, FACCE, AdvCD/PCD/BDT(DONA)
You've done your research and you know that laboring at home until strong, active labor could help you lower your risk of cesarean birth and other interventions. You've got your doula on board, you've prepped with a great birth class, and you're ready to rockstar your way through an upright, active birth. Then around 35-36 weeks of pregnancy, you get some unwanted news.
You're positive for GBS. Now what?
Group B Strep is a common type of bacteria that is found in the vagina and rectum. Depending on the study, between 10 and 30% of people test positive for Group B Strep in their pregnancy. There's some evidence that taking a probiotic during pregnancy might reduce your risk of being positive for Group B Strep. In the United States, GBS is treated with IV penicillin every four hours in labor, until the baby is born. (For the purposes of this article, we'll assume that you are not allergic to penicillin, since the protocol looks a little different if another antibiotic needs to be used.)
You can learn more about GBS, its risks and treatment from Evidence Based Birth — check out their one-page printable if you don't want all the detailed information — and the Centers for Disease Control and Prevention. (You might also be interested to learn that in the United Kingdom and many other countries, midwives and doctors don't routinely test for GBS in pregnancy and they only use antibiotics in labor if there are other risk factors; as is often the case, thoughtful experts can come to different conclusions about the best way to approach a problem.)
If you decide on the standard treatment for GBS in America (most of our students and clients do), that will mean IV antibiotics every four hours at the hospital, until your baby is born. The ideal protection comes if at least four hours have passed since your first dose. So what will that mean for your carefully laid plans to labor at home? What new interventions will be part of your birth?
Let's talk it through.
1. Timing to go to the hospital.
If we had a crystal ball to know exactly how long your labor would last, it would be great to get you to the hospital about five or six hours before your birth. That's enough time to get two doses of antibiotics, and not so long that you're likely to run into a lot of unnecessary interventions.
For a first baby, the GBS news probably doesn't change much if you're aiming to get to the hospital in "strong, active labor." Even if you arrive at 6 or 7 centimeters dilation, you'll likely have enough time to get in two doses of antibiotics. If you're having your second or later baby, especially if you've had a previous vaginal birth (meaning this isn't a VBAC), the timing gets a little trickier. For these "multips" who have given birth before, sometimes labor can turn a corner really quickly in active labor, and babies can be born faster than expected.
How strongly do you feel about having two doses? How important is it to you to labor at home? Having one dose in place for a few hours (less than four) does give some protection to your baby, although the best protection comes when at least four hours have passed since the first dose started. You can find more information at Evidence Based Birth as you weigh your feelings and the benefit/risk.
Keep in mind that most providers in our area will recommend that you come in immediately if your water breaks, especially if you are positive for Group B Strep, as GBS risk to the baby does go up the longer your water is broken. They'd like to start antibiotics right away. Even if you decide to go in, it's still an option to wait awhile to see if labor will begin on its own, even as you are receiving antibiotics.
If you don't have at least two doses of antibiotics before your little one arrives, in our experience the hospital staff will recommend you stay at least 48 hours after the birth, so they can watch the baby for any signs of early onset Group B Strep. How do you feel about the possibility of staying that long? Some people enjoy the hospital stay and others want to get home as quickly as possible. Your feelings on this front might play into your decision on how soon to go to the hospital.
2. Getting hooked up to an IV.
Sometimes our clients are hoping for a physiologic birth and they truly don't want to be attached to anything. If you decide on IV antibiotics to treat GBS, that of course means an IV. We have some tips to help make it the best-ever IV experience.
First, ask for a saline lock (sometimes also called a hep lock or saline well). This means that you'll be attached to the IV while the antibiotics are running (the first dose usually takes about 45 minutes and later doses about 30 minutes), but your nurse can cap off the IV line in between doses. We train our Birth Kalamazoo doulas to watch for the antibiotic bag to be empty, so clients can alert their nurse if they'd like to be unhooked from the IV pole ASAP after each dose.
Second, try for the IV in your forearm, not your hand. Most nurses in our area seem to look for a spot in the forearm first, which is so helpful. You need your hands a lot in birth, and it's normal that you'll be leaning forward on them. Whether you're connected to the IV pole or if the saline lock is in place, it can really get in the way in your hand throughout labor. The forearm seems to be the sweet spot if your veins are agreeable.
Next, if your veins are tricky, ask for the best IV starter on the floor. If your nurse seems hesitant or is struggling to get the IV in, or if you just know that medical professionals often struggle to find a good vein, you don't have to get poked five or six times. There's almost always someone on the floor who has "the touch" with starting IVs. Ask for that person! Don't be afraid to speak up, it's your body. In rare circumstances for someone with very small or hard to find veins, hospitals also have a special team that can come to your room if needed.
Finally, consider asking for the IV fluid to run slowly. You'll be hydrating with water throughout your birth, and IVs have some downsides, including negative effects on breastfeeding when a baby's weight can be artificially inflated. (Learn more about that issue from Nancy Mohrbacher, IBCLC.) You can ask your nurses to run the fluids that come in with the antibiotics at a slow drip, so that you minimize the total amount of fluid you'll receive during the times you're hooked up.
Can you say no fluid all together? Sure, but that has a potential downside. Nurses have often told my clients that without the fluid, the antibiotic would burn going in. I did have one client still decide to decline all fluids (receive the penicillin only), and she did not find that it burned. I haven't seen research on this to say whether it's a medical myth or reality that it would burn without the fluid, but a slow drip of fluid with the penicillin doesn't seem to have any negative impact compared to the usual rate of fluids. You can always ask your nurse for more information if you're unsure.
3. Keep on movin'.
Sometimes our students and doula clients worry that their vision of an upright, active birth will be dashed by having an IV for at least part of their labor. Not so! That IV pole is on wheels, so you're just going to drag it with you wherever you go while the antibiotics are running. (Or better yet, your partner or doula will drag it next to you as you move, so you have total freedom.) Hands and knees? Sitting on the ball? Laboring in the tub or on the toilet? No problem, the IV pole can come right along. (In the tub, some nurses do ask that you try to keep the arm with the IV out of the water as much as possible. Others don't seem to mind if it's submerged.)
Although it can feel a little limiting to have that extra equipment to haul around, in the end it is a short time during your birth that you'll be attached, and there are no insurmountable limitations that we've seen.
4. Consider a probiotic after the birth.
Receiving IV antibiotics in labor reduces the risk that your baby will be affected by Group B Strep, but it also negatively impacts both your and your baby's gut health and microbiome. There may be some benefit in taking a probiotic after the baby is born.
This is something you can prepare for ahead of time if you know you are GBS positive. We don't like the newly postpartum parents running around in the days after their little one arrives — rest, nurse, recover. But it would be easy to grab some probiotics close to your due date. You can ask at the health food store for a probiotic they would recommend after an antibiotic. Those probiotics often have more strains of beneficial bacteria, but they're also often very expensive. If the store's top recommendation isn't in your budget, ask for their second and third top suggestions. Any probiotic (some beneficial strains) is probably better than no probiotic at all.
We know that skin-to-skin and breastfeeding can help to populate a more normal microbiome over time for babies born by cesarean, and this is probably also helpful for babies exposed to IV antibiotics. So keep your little one close in the days and weeks after the birth, especially as you restore your own microbiome. A postpartum doula can help you have the time to exclusively focus on this kind of connection. Definitely seek out breastfeeding support to get all of you off to a good start, too. Your birth doula, postpartum doula, La Leche League and a lactation consultant are all great resources. The probiotics might also help reduce the chance that you or your baby will experience thrush while breastfeeding, which is a side effect related to antibiotics. Reach out for help right away if you notice itchy, red, shiny or burning nipples, a deep stabbing pain during or after nursing, or a white coating covering your baby mouth. (Get more info on thrush from KellyMom.com.)
We don't have all the research we would hope for on how probiotics might help at this stage, but given that there are no known harms, I'd put it in the "can't hurt, might help" category. Think of it as an ounce of prevention for you and your baby in those tender weeks postpartum.
The moral of the story? All is not lost. You can still have a great birth with GBS.
So reading all of this, what do you think? Are you feeling better? Do you still have questions? Share them below, and also leave us a comment if you have another tip to share on how you were able to manage Group B Strep during your birth. We'd love to hear from you! And if you are local to Kalamazoo, don't hesitate to reach out if our doulas can help you in your birth, or if you're interested in our natural birth class. We have tons of tips and information on topics like this one, it's our job to help you have a better birth. Even if you don't live in Southwest Michigan, reach out to find the amazing doulas and childbirth educators in your area, too.
Jessica English is the owner and founder of Birth Kalamazoo. She is an advanced certified birth doula, certified postpartum doula, and certified childbirth educator. Jessica has advanced training in using the rebozo during birth, preventing and treating birth trauma, Spinning Babies, VBAC and cesarean prevention, pregnancy and birth after infertility, and cultural humility. In her sister business, Heart Soul Birth Pros, Jessica trains new doulas for DONA International and new childbirth educators for Lamaze International. She's also a frequent speaker at national conferences and is hired often by hospitals and nursing organizations to train nurses in hands-on labor support skills. As a doula, she loves helping women find strength that they didn't even know they had. Jessica is comforted herself by having lots of information, and the Type A mamas are her people.