A High Risk Pregnancy Group B Streptococcus Nursing Essay

For this assignment I have been asked to look at the care I have seen and been involved in giving to a woman with a high risk pregnancy. I intend to identify how my practice could be developed to meet the similar needs of women in the future. To do this I am going to use a reflective approach. I am going to look at the normal anatomy and physiology and analyse the patho-physiology in relation to high risk pregnancy and birth.

For most women, their midwife is their first point of contact so they have a crucial role to play in identifying any risks. Included in their extensive role is facilitating pregnancy and childbirth as a positive and fulfilling experience. This is most fundamental for those women whose childbearing experience has been categorised as high risk.

A pregnancy is classed as high risk if there are any factors that may adversely affect the fetal or maternal outcome. Risk factors must be identified as early as possible to increase the chances of an improved outcome (Queenan et al, 2007).

When a woman is booked for her maternity care, her medical and obstetric history is taken to ascertain whether she would be suitable for midwifery led care (low risk) or consultant or obstetric led care (high risk). A woman can change from either group during her pregnancy. For example, she may start her care as low risk but then something may happen or a condition may develop so she may therefore require consultant input into her care.

Factors which could mean a woman has a high risk pregnancy include epilepsy, diabetes, cardiac problems, multiple pregnancy, hypertension, obesity and previous obstetric complications, i.e. caesarean section, previous haemorrhage (whether that be ante partum, intrapartum or postpartum), recurrent miscarriages or previous intra-uterine death.

Using a reflective approach I am going to discuss a woman I recently cared for whilst working on Central Delivery Suite, whose pregnancy had been assessed as high risk. This was due to her having had a previous emergency caesarean section and a previous ventouse delivery.

In accordance with The Code (NMC, 2008) I have changed all names mentioned to respect their confidentiality.

Laura, aged 39 years old, 39 weeks pregnant, gravida three, para two. As just mentioned her obstetric history meant she would see an obstetric consultant during her pregnancy. As Laura was planning on having a vaginal birth after caesarean section (VBAC) this increased her risk. It was also apparent she had tested positive for group B streptococcus (GBS) in both her previous pregnancies. Laura had gone into spontaneous labour.

In view of the previous two pregnancies testing positive for GBS and her admission temperature reading was 38.1°C, it was decided she would receive antibiotics during labour.

As soon as we confirmed she was in established labour, the antibiotic Benzylpenicillin (Penicillin G) 3g was administered intravenously. Then at four-hourly intervals she was given 1.5g until delivery.

Postnatally, Laura’s observations were taken and baby observations were also taken six hourly and observed for a minimum of twelve hours in accordance with Local Trust Guidelines (2005).

Group B streptococcus (GBS) is a common type of streptococcus bacterium. Approximately a third of men and women are ‘carriers’ of GBS in their intestines and a quarter of women carry it in their vagina. Most people are unaware they are carriers as it can be difficult to detect and does not cause any symptoms. Carrying it is perfectly normal as it is one of many different bacteria’s that live within our bodies.

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I have a personal interest around GBS as this was something I tested positive for during my pregnancy and I did not really understand what it was or the complications of it. I was screened routinely as I was living in Spain at the time. However, due to the uncertainty of clinical evidence and cost effectiveness, pregnant women here in the UK are not routinely screened (NICE, 2003 & Woodgate et al, 2004).

Laura was only aware of her GBS, in her previous pregnancies, due to routine screening in Germany. She had not been screened here in the UK for GBS in this pregnancy.

Where risk factors exist, the administration of prophylactic antibiotics during labour and at least two hours before delivery has been shown to reduce the frequency of neonatal GBS infection (Local Trust Guidelines, 2009).

During my placement on the Neonatal Unit, I also cared for a baby that had to be admitted for antibiotics as its mother had tested positive for GBS during her pregnancy. She was unable to receive antibiotics as the the delivery was so fast and there was not enough time. Therefore the baby was admitted to the Neonatal Unit so he could receive antibiotics. Blood cultures from the baby were obtained and he was treated with penicillin until the culture results were available. This enhanced the importance of the woman receiving the prophylactic antibiotics during labour.

During the booking appointment, the woman will be asked for a mid-stream urine sample. This is primarily to test for asymptomatic bacturia. However, if included in the normal screening regime for the specific laboratory it is sent to, other things, like GBS, could be detected. There is no national guideline for them to do so, so this is clinician led which is relevant to different Trusts.

As GBS is asymptomatic, women do not know they carry it unless they have been screened for it. When GBS is carried it can live within the body, with no affects and causing no harm. If a woman tests positive for GBS from a swab or a urine sample, this means she is colonised with GBS, at the time the sawb or urine is taken. It doesn’t neccessarily mean that either her or her baby will become ill. It can however be especially harmful for the woman if it gets into the blood and causes septecemia or it could cause menigitis in the baby.

An infants immune system derives from maternal immunity, so if the mother is a carrier, she could pass her carrier status on to her baby which would not neccessarily be a bad thing.

Within Clinical Green Top Guideline number 36, written by The Royal College of Obstetricians and Gynaecologists (RCOG, 2006) the woman who should be offered intrapartum antibiotic prophylaxis will have the following risk factors:

â- previous baby affected by GBS

â- GBS bacteriuria detected during the current pregnancy

â- preterm labour (less than 37 completed weeks of pregnancy)

â- prolonged rupture of the membranes (more than 18 hours before delivery)

â- fever in labour (a temperature of more than 37.8°C)

Women must also be reminded of the risks with taking antibiotics and be given all the information so they can make an informed choice. The antibiotics a woman receives will also depend if she has any allergies to medication. The recommended antibiotic for those allergic to penicillin is clindamycin, 900mg administered intravenously, from onset of labour and every 8 hours until delivery.

According to GBS Support (2007), some hospitals routinely swab healthy babies. These babies may be started on antibiotics until the blood/urine cultures come back from the swabs that grew GBS. However, the medical advisory panel for GBS Support do not recommend this. If GBS grows from surface swabs, this is just an indication that GBS is colonised, which does not require treatment as the baby is not actually infected. The majority of infants who develop the GBS infection will show clinical signs before results of swabs are available.

In any high risk situation it is vital that maternal and fetal well being is monitored.

As Laura was high risk she was placed on continuous cardiotocograph (CTG) monitoring.

This gave us a recording and trace of the fetal heart rate so we could indentify any deviation from the norm, in comparison with the baseline for that baby.

Screening is also a form of technology. It is a process which has been developed, which wasn’t done previously due to lack of knowledge and technology. In line with the National Institure for Clinical Excellence (2003) pregnant women should be offered evidence based information and support to enable them to make informed decisions regarding their care. This means women should be at least told about the screening available for GBS. Even though its not provided routinely by the National Health Service, women have the option to pay for private testing.

Although screening for GBS is not routine, if there were any symptoms of a urinary tract infection, for example, then a swab would be obtained and GBS would be screened for at this time. However, it seems women are not told this. During my placement time, both on community and on Central Delivery Suite, when woman have consented for swabs to be taken or a urine sample to be sent off for analysis, I have not heard anyone mention it would also be screened for GBS. I believe this practice needs to be changed. Women should know and they have the right to know everything the swab or urine is going to be screened for.

There are two techniques used within the laboratory investigation systems to screen for GBS. The basic screening process is performed by taking a high vaginal or low vaginal swab which takes a sample of vaginal fluid and epithilial cells which is then streaked across an agar plate and then incubated at 37°C. After 24-48 hours the plate is examined for GBS.

The second technique takes a low vaginal swab and also a rectal swab. These are both put into an enriched culture medium (ECM) which enhances the detection of GBS. This is incubated for 24 hours and then the culture medium is streaked over an agar plate and left for a further 24 hours before being examined for GBS. These results take 48-72 hours as they have to wait for the bacteria to ‘grow’.

A sensitivity test could also be performed, which would determine which antibiotics the bacteria is repsonsive to, ie. Penicillin, Clindamycin or Arythromycin.

There are arguments for and against introducing routine screening for GBS in the UK. Plumb, Holwell and Clayton (2007) argue that in the UK, GBS prevention is inadequate. They believe the NHS should offer testing for GBS in late pregnancy, thus giving women the opportunity to establish whether their baby is at higher risk of developing the GBS infection.

My current trust guideline (2005) states there is not enough evidence for it at this time. However, this guidance is six years old now so could probably do with being revised and updated. Even the 2007 RCOG guideline is now fours years out of date.

GBS awareness campaigners, Group B Strep Support, are pushing for routine testing to be introduced in the UK (Prince, 2011). According to GBSS, Western countries that routinely test have a lower incidence of infection in new born babies, where as cases in the UK are on the rise. Even since the introduction of the Royal College of Obstetrics and Gynaecologist’s guidline for preventing GBS infection in newborns, in 2003, there has not been a decrease in either the number or the incidence of GBS infections in babies.

The table below shows the how the GBS infection in babies has increased throughout England, Wales and Northern Ireland.

Year report published

Number

All cases

(babies 0-90 days old

Incidence per 1000 live births

Number

Eary onset (babies 0-6 days old) Incidence per 1000 live births

Number

Late onset (babies 7-90 days old) Incidence per 1000 live births

Number

2003/3004

311

0.48

207

0.32

104

0.16

0.48

2006/2007

409

0.61

248

0.37

161

0.24

0.61

2007/2008

421

0.61

258

0.37

163

0.24

0.61

2008/2009

470

0.66

279

0.39

191

0.27

0.66

Table 1 Number and rate (per 1000 live births) of group B streptococcal bacteraemia reports in infants 0‐90 days old in England, Wales and Northern Ireland: 2003-2009.

(data published by the Health Protection Agency taken from www.gbss.org.uk/filepool/GBS_Infections_on_the_Increase.doc)

The overall number of GBS infections within adults is also reported to have increased by more than 72% from 2001 to 2008:

Table 2 Number of GBS infections in both males and females

within England, Wales and Northern Ireland: 2001-2008.

(data published by the Health Protection Agency

taken from www.gbss.org.uk/filepool/GBS_Infections_on_the_Increase.doc)

A better indication of the rise in GBS infections would be taken from women only, who are 35-37 weeks pregnant. I believe this would give more of an insight as these figures are very

Although the evidence states the increase in rates, I could not find any reasons for the increases. Some factors I believe may contribute to the rise include the lack of personal hygiene, modern living or even due to lifestyle. For example, many years ago clothing and underwear used to be boiled when washing but now people may be washing their clothes on a 40°C wash and this may not be enough to kill all the bacteria.

It may not be due to any of these factors, it may just be we have a better awareness of GBS now then what we did years ago. With the constant improvement of technoolgy, we will also be finding out new things.

Bacteraemia, sepsis, pneumonia or meningitis can all be caused by the early onset GBS disease. The early onset GBS diseases usually occur within 12 hours and not more than 6 days after delivery. For late onset GBS diseases which occur between 7 days and 3 months. Late onset GBS diseases are less common than the early onset diseases (RGOG, 2007).

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Although the internet is not a form of technology we use within midwifery, it is certainly a form of technology we definitely need to be aware of. Within the last ten years or so, the internet has become increasingly popular. This means the general public can find about anything, more importantly medical information they may not have been able to access before. Therefore, we need to be aware of those women that we care for, that may have either some basic knowledge or an in-depth knowledge of a medical issue, for instance GBS. The NHS even has a website called NHS Choices (www.nhs.uk) which people can access to check symptoms and research illnesses and also pregnancy. I think this is mainly a good thing, although women may read so much into something they find online and it may make them more anxious or worried. It should not replace the direct contact with their midwife.

If I was to come across any of the risk factors mentioned above I would now know that they should be offered antibiotics during labour.

I believe my Trust need to update their guidelines, as a matter of urgency and update them to correspond with the more recent research that has been done.

The Royal College of Obstetrics and Gynaecologists (RCOG, 2003) carried out an audit of obstetric units, within the UK, in 2007. They found that most of the unit protocols in use are not consistant with the guideline the RCOG produced in 2003. This is also out of date and should be reviewed and updated.

My local trust guideline being out-dated shows how important it is for midwives to take responsibilty for their own learning by keeping up to date with current research. This is the only way we can practice using the best available evidence.

As this has shown, the trust guideline not being based on the most recent evidence means they are not providing guidance on how to practice using the best available evidence.

The Nursing and Midwifery Council (NMC, 2008), also state we should be delivering care based on the best available evidence. By reading the research I have found to write this assignment I am adhering to The Code by giving women evidence based advice. I may not be able to radically change my operational practice but I will definitely be more aware of what to look for and how to manage the situation. I will also ensure I am aware of those women who may have a more in-depth knowledge about GBS and understand their anxieties.

This assignment inferences the fact we are practising to guidelines based on 2003/2005 figures where 2010 figures would be more relevant.

From writing this assignment I have identified the risks of GBS, who the risks effect and to what degree it could effect them. I feel I would be able to recognise the signs and be aware of the treatment and management. The main techonology used is for the screening of GBS within the laboratory investigation systems.