Journal: Case Study 2 completed

I have had a busy week, with births, postnatal work, and the deadline for the second Case Study, which accounts for 20% of the total mark in the course.  I had some concern when I checked the word count of my draft, and found that I had written about 6,000 words.  The word limit was 3,000.  So I did some radical editing, and posted the finished document on Thursday morning, then went out and enjoyed a game of tennis with my friends.

The Case Study question was about Group B Streptococcus (GBS) colonisation, and treatments.  I chose to focus on the use of prophylactic antibiotics in labour. 

In my 20 years of primary care midwifery practice, attending women who are planning homebirth, I have experienced a couple of examples of GBS infection that, without timely consultation and referral and antibiotic treatment, would have likely led to severe infant and maternal morbidity or mortality.  A case that I would like to record here is that of Katy, a primigravida, aged 28.  Katy had been well through her pregnancy, and at Term experienced spontaneous rupture of membranes, with a gush of clear amniotic fluid at 06:00 hours.  

Katy felt well, and was active through the day.  Her labour became established, and within 12 hours, she asked me to attend.  When I arrived at the home, Katy was in good labour, and appeared to be progressing quickly.  Initial observations were within normal limits.

Over a period of 1-2 hours, I observed Katy’s condition deteriorating slightly, in that she could not keep herself warm.  Katy then went under the shower.  Her temperature was not elevated, but the fetal heart rate was high >170.  Although Katy’s membranes had ruptured spontaneously, and she had had quick progress in labour, and no vaginal examinations, I suspected infection.  I arranged immediate transfer of care to the local hospital, where Katy gave birth spontaneously soon after arrival.  Blood and swabs were taken from mother and baby, confirming GBS infection, and both were treated with antibiotics, and did not experience further morbidity. 


Here are a few excerpts from my assignment. I have not included all the references, as I do not try to present an academic paper in this blog.

Antibiotic regimes in labour, and strategies in neonatal care to prevent GBS colonisation of the fetus and newborn have been implemented since the 1970s, leading to a dramatic decrease in case-fatality ratio from as high as 50% to 4-6% currently.    

In the absence of screening for GBS, specific risk factors for GBS infection in labour and birth are:

• previous infant with GBS sepsis
• GBS bacteriuria in this pregnancy
• Onset of labour <37 weeks
• Membranes ruptured >18 hours
• Fever > 38.0C 

 Any one or more of these risk factors indicate the need for antibiotic treatment in labour.

In settings implementing universal screening, it has been estimated that “2000 women will need to be screened and 500 treated to prevent one neonate developing EOGBS.  Assuming intrapartum antibiotic prophylaxis is 80 % effective in preventing EOGBS disease, 20,000 women would need to be screened for GBS to prevent one neonatal death from EOGBS.” (3Centres 2006, p1).  If a woman makes an informed decision to decline the recommended antibiotic prophylaxis, I am confident that ongoing observation of mother and fetus in labour would indicate the onset of sepsis, and the need to revisit the decision.

My usual practice is not to screen; to be vigilant about risk factors; to avoid internal examinations; and to advise treatment if there are any signs of developing infection.
 
Thankyou for your comments