Re: GBS testing for repeat cesarean
From: Barbara Nicol MD (blnicol@ix.netcom.com)
Fri Mar 17 12:17:38 2006
Good point. We keep the loading dose of the penicillin on the unit in
the Pyxis, which means that we can hang it at IV start, and we draw the
admission labs at the IV start. We also have Keflex available. I do
run into problems similar to yours, however, with bad PCN allergy as the
other antibiotics do take a while to get, and wouldn't delay a CS for
that reason.
(My favorite stupid-hospital-bureaucracy reason for delay: "We can't
order the antibiotics/send the labs/check her blood sugar because the
patient doesn't have an account number yet, because admitting is still
working on it". (Isn't that supposed to be one of the signs of the
youngest day or end times or something? - you can't take care of the
patient because she doesn't have a number?) The RNs are just as
frustrated by this as we are. Does this happen to you?)
Anyway, I do see your point about the logistics - and yet the
antibiotics do cross fairly fast and the umbilical cord is a pretty good
intravenous access to the fetus. How much additional time will it take
the pediatrician to get antibiotics on board if the baby isn't looking
good?
I feel like a Talmudic scholar carefully parsing the exact meaning of
the CDC guidelines - but my reading of them is that we're stuck with
trying to give prophylaxis if we can. I'd resist, however, the
suggestion that we should risk other complications by waiting to do the
CS until antibiotics are given or for a certain time after antibiotics
are given - babies can die of E. Coli sepsis too and uterine rupture
too.
Wish ACOG would settle the matter for us - seems like just the sort of
thing a committee could clarify.
- Barb
At Fri, 17 Mar 2006, ainsron wrote:
>
>I don't know about your hospital, but in mine it usually takes 45-60 minutes
>to get the antibiotics from the pharmacy. For a non-scheduled urgent c/s,
>it takes about the same time, to get preop labs, IV started, consents, etc.
>Tell me what benefit to the baby it would have to give the PCN a few minutes
>prior to incision? That makes about as much sense as having a GBS positive
>patient come in with ruptured membranes, 9cm and giving the PCN as the head
>is crowning. In either event, the pediatrician will do serial CBCs and
>watch the baby like a hawk.
>
>Ronald E. Ainsworth, MD, FACOG
>
>-----Original Message-----
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Barbara
>Nicol MD
>Sent: Friday, March 17, 2006 10:06 AM
>To: Multiple recipients of list OB-GYN-L
>Subject: Re: GBS testing for repeat cesarean
>
>Yeah, but it still might make a difference to the outcome for the baby,
>right? The goal is to prevent GBS sepsis, not to prevent pediatric
>intervention. ROM is a known risk factor - why not give the prophylaxis
>while setting up for the CS?
>
>The relevant paragraph from the full version of the CDC guidelines,
>quoted below, is probably helpful. As I read it, it pretty much tells
>us to use chemoprophylaxis for labor or ROM, and the last remaining
>question is whether to wait 4 hours after initiating antibiotics or not.
>As I say, in our institution, we do not wait, feeling that the risk of
>infection from other bacteria in the case of ROM, or the risk of uterine
>rupture with continued labor in a patient who is not a VBAC candidate,
>outweigh the benefit of waiting a full 4 hours.
>
>- Barb (CDC quote follows)
>
>Planned Cesarean Delivery
>Because GBS can cross intact amniotic membranes, a cesarean delivery
>does not prevent mother-to-child transmission of GBS. Moreover, because
>cesarean delivery itself is associated with health risks for mother and
>newborn, GBS colonization of the mother is not an indication for
>cesarean delivery, and cesarean delivery should not be used as an
>alternative to intrapartum antibiotic prophylaxis for GBS prevention.
>
>However, although a risk does exist for transmission of GBS from a
>colonized mother to her infant during a planned cesarean delivery
>performed before onset of labor in a woman with intact amniotic
>membranes, it is extremely low, based on a retrospective study at a
>single hospital (99) and a review of CDC active, population-based
>surveillance data from the 1990s. Thus, in this specific circumstance,
>in which the risk for disease is extremely low, the individual risks to
>a mother and her infant from receiving intrapartum antibiotic
>prophylaxis may balance or outweigh the benefits. Intrapartum
>antibiotic prophylaxis to prevent perinatal GBS disease is, therefore,
>not recommended as a routine practice for women undergoing planned
>cesarean deliveries in the absence of labor or amniotic membrane
>rupture, regardless of the GBS colonization status of the mother.
>Patients expected to undergo planned cesarean deliveries should
>nonetheless still undergo routine vaginal and rectal screening for GBS
>at 35--37 weeks because onset of labor or rupture of membranes may occur
>before the planned cesarean delivery. In rare situations in which
>patients or providers opt for intrapartum prophylaxis before planned
>cesarean deliveries, administration of antibiotics at the time of
>incision rather than at least 4 hours before delivery may be reasonable
>(100).
>
>- Barb
>
>At Fri, 17 Mar 2006, ainsron wrote:
>>
>>Because I'm usually not going to wait four or more hours for the cesarean
>>section and if you don't have them onboard for that long, it doesn't make
>>any difference to how the pediatrician is going to handle the newborn.
>>
>>Ronald E. Ainsworth, MD, FACOG
>
>--
>Barbara Nicol MD
>St. Luke's Health Care Center
>San Francisco CA USA
>
--
Barbara Nicol MD
St. Luke's Health Care Center
San Francisco CA USA
