GAS Infections (Group A Streptococcus) In Pregnancy

What is a GAS infection?
Group A Streptococcus is a bacterium which may be present in the throat, on the skin or within the anogenital tract (Anogenital tract name for the area including both the anus and genital tract which includes the external and internal sex organs in men and women). Although it can cause many infections some people carry Group A Streptococcus without any symptoms being observed.

GAS infections are spread through:
• close contact between individuals, through direct contact with mucus from the nose or throat of a person infected with the bacteria even if they have no symptoms of infection.
• contaminated objects

Group A Streptococcus (GAS Infections) have had peaks over recent years and there is currently an increase in cases, especially in children and young people. Children under the age of 4 are a big contributor in transmitting infections due to their close proximity to other children and adults.

Children often rely on adults for their hygiene, health & feeding needs, and therefore if you work with children, already have children in the home or have small children as part of your wider family network, then the infection risk increases.

Why am I at more Risk In Pregnancy?
Pregnancy reduces the body’s immune system and therefore it is much easier for you to acquire the infection.
Children are considered are a common source of infection transmission due to their higher rates of GAS infections in the throat.

Prevention:
* Hand washing. It is one of the most effective ways to protect against germs which cause infection and illness
* Covering your mouth and nose with a tissue when you cough or sneeze will prevent mucus droplets to become airborne and enable any germs to be disposed of.
* Avoid sharing bedding and eating utensils as viral and bacterial infections can be transmitted by direct contact as well as through mucus.

Good hand hygiene is the first step in avoiding GAS infections Knowing when to wash our hands and how to wash our hands is the key to protecting ourselves or reducing our risk of infection and illness!

Signs & Symptoms of illness associate with GAS infections
** Tonsillitis & Pharyngitis – sore throat, difficulty swallowing, red swollen tonsils.

** Impetigo – fluid filled blisters, itchy rash, breaks on the skin.

** Cellulitis – redness or swelling on areas on the skin which are warm to touch, pain in the affected area, pus/abscess in the affected area.

** Pneumonia – dry cough, wheezing, nausea/vomiting, aching muscles, chest pain.

When should I get help?

If you have an illness which is left untreated, such as those listed above, it can quickly develop into a severe infection called Sepsis. Sepsis requires early diagnosis and antibiotic treatment.
Signs of Sepsis include:
• High Temperature (38.0꙳C)
• Headache
• Chills and shivering
• Fast heartbeat (over 100 beats per minute)
• Severe Abdominal Pain
• Fast breathing, breathlessness
• Extreme sleepiness

Reducing Your Risk

In the Antenatal period
• Wash your hands with soap and water frequently as well as before/ after using the lavatory or changing pads
• Wash the vaginal area from front to back.
• Don’t share eating utensils, bedding or towels
• Avoid close contact with nose and mouth mucus, especially from children, example kissing – kiss on the forehead instead.

Following Birth
• Washing hands with soap and water before/ after using the lavatory and when changing sanitary towels.
• Contamination of the perineum can occur when a woman has a sore throat or upper respiratory infection as the organism may be transferred from the throat or nose via her hands to her perineum. Washing hands before/ after using the lavatory or changing sanitary towels.
• Keep wound areas clean

You MAY BE at an increased risk if you have:
1. A raised BMI (>30)
2. Impaired immunity
3. Anemia
4. Increased vaginal discharge
5. History of pelvic or GBS infections
6. Had any antenatal Invasive procedures such as amniocentesis
7. GAS in contacts or other close family members – especially children
8. You work in close contact with children
9. Minority ethnic groups
10. Diabetics
11. Your waters have broken for over 24 hours.
12. Vaginal trauma/ Caesarean section/ wound issues
13. Any retained placenta following delivery

This information is not for diagnostic purposes but rather to provide information for you to seek further advice and assessment especially if you feel may have any signs or symptoms of illness.
If you feel this is so please contact your GP or Midwife

Having spoken to many women about their birth choices, one of the issues they experience time and again is actually not knowing or understanding what happens when they need to have or choose to have a caesarean section! This isn’t from the point of the actual procedure, because almost all the women have some awareness that the baby is coming out of their tummy rather than their nether regions! No, this is from the perspective of when they have made the decision – what happens next?

Emergency Caesarean

If you have laboured and at some point during your labour it is discussed with you to opt for a caesarean section, there are a lot of decisions and small changes that take place to get you ready to meet your baby. As this is often a bit of rush, mainly because of the need to deliver the baby, often women feel they haven’t had all the necessary information.

So, following this discussion (including any risks and benefits to you and baby), the midwife will offer to help you change into a hospital gown. This is so there is free access to your back to permit an anaesthetist to perform a procedure called a spinal anaesthetic. However, you will only need this if you haven’t already got a form of pain relief called an epidural. If you have this, then this is used and converted to a spinal administer the medication for the caesarean.

If you haven’t got an epidural, this is usually done in the theatre (this procedure is covered in another blog).
You will, in most cases, be asked to have a catheter inserted into your urethra (where you pee). This is to empty your bladder and keep it empty so that the bladder doesn’t fill. The reason this is important is because if your bladder is full it rises just above the bony part of your pelvis at the front (called the symphysis pubis) and it is possible that the sharp scalpel can cut the bladder if it is full. Some hospitals will empty the bladder using a catheter which is not left in place, and if you have a preference you can ask for either if it is important to you. In addition you will be read a list of risks for the procedure of the caesarean and asked to sign a consent form. You will also be fitted for a pair of compression stockings which will be put on for you, and given an ant-acid to remove any acid from the stomach.

In an emergency it feels very scary and fast paced to get to theatre. In some cases there may not be time to do any spinal and as such you may need to have a general anaesthetic (where you are put to sleep for the procedure). But this is avoided as much as possible and so you can meet your baby as soon as possible.
An elective Caesarean Section

If you have decided to choose to have your baby by caesarean section it is often referred to as an elective caesarean section. At around 37 weeks you will be given a date for your caesarean, usually by your obstetrician or via your midwife, which will also require another date (slightly earlier) for something called a pre-op. This ‘pre-op’ is to a pre-operative appointment in which you will be asked to attend to go through what happens on the day of your caesarean. At this appointment the staff will take bloods, go through your notes with you, discuss the consent form (which you will be asked to sign on the day of your caesarean section) and in some cases you will be given an antacid tablet for you to take on the morning of your caesarean before you arrive at the hospital. The staff will go through when you should last eat and drink the night before and give you any information in relation to your individual needs.

On the Day

You will be asked to come in and shown to your bed on the ward. This may or may not be where you will be after your caesarean. You will be given a gown and some compression stockings (unless the hospital use an electric device which effectively inflates and deflates acting similar to the stockings) and talked through the procedure of the spinal anaesthetic. You will meet the anaesthetist and the Obstetrician performing the caesarean section. They will repeat all the information to make sure you are happy and if not already signed, ask you to sign the consent form for the procedure (there are variances in different regions and this pertains to the UK – it may be different in other countries, in which case I would love to know what these are).

Your partner will be given a set of scrubs (a top and bottom usually worn in theatre). I would advise that partners don’t wear anything except underwear under these as it can get hot in the theatres with all the people and lights and is often the reason partners faint!

It is possible to have a playlist playing in theatre, so ask at your pre-op appointment or on the day if this is important to you.

When it is your time, you and your partner will be escorted to theatre. You will also need to take clothes for your baby and possibly a nappy. I would recommend not taking your best outfit or the outfit you want to show your baby off in as baby may pee on this or there may be a bit of fluid/blood that could get onto them. Your partner may be asked to sit outside the theatre until after the spinal has been put into your back and is working. You will be supported by your midwife, but if you would like your partner to hold your hand, just ask. I have been in many different hospitals whereby both of these are carried out (again variances in regions).

If you would like have skin to skin with your baby in the theatre, let the staff know at this point. In some areas they don’t do this, and often it is because of risk of something happening such as you as the mum not being able to move much to make sure the baby is able to breath through the nostrils, however, show your awareness and ask your partner to make sure the baby’s head is turned to the side and keep a watch. Sometimes women can feel sick and ask that the partner perform skin to skin (it is their baby too). Either way, get this crucial part of building baby’s immune system started and request this to happen – optimise your birth.

Back to having the spinal in ….., you will then be assisted to lay flat on your back and tilted slightly to the left side on the theatre bed. There will be lots of staff – a couple of nurses, your midwife, perhaps a student midwife, the anaesthetist, a health care assistant, and two doctors. So before everyone enters the room you can ask the midwife to catheterise you (which is usual in elective caesarean sections – although you can ask to have an in/out catheter performed). Once this is complete, you will have surgical fluid rubbed across your abdomen with a sponge to remove any bacteria and keep the procedure sterile. When dry a drape will be applied. And then the doctors will check that you can’t feel anything. Once this is confirmed they will begin.

The caesarean should feel sensations of pushing and pulling but no pain. In a few moments your baby will emerge. Usually once the baby is born, the time is recorded and the baby is placed either into a sterile drape over a cot or handed to the midwife. The baby is then taken to a specific area to be dried, have the cord shortened using cord clamps – and if your partner would like to cut the cord this can be done here which is similar to cutting the cord in a non-operative delivery. Then the nappy is put on. If you have opted to have vitamin K by injection, this may well be given here. Although I used to wait until in recovery when the baby was feeding (feeding stimulates endorphins which are natural pain relief hormones for baby, so it is kinder to give the injection at this time). Then the baby will be left unwrapped and given to you under the drape for skin to skin, or your partner to go under the scrubs for skin to skin.

At this time the doctors will deliver your placenta and stitch up the areas. When finished you will be transferred to another bed and moved to the recovery room to continue observations and so you can feed your baby.
Once the recovery nurse is happy that your observations (blood pressure, temperature, heart rate, respiratory rate) are all stable, you will be transferred to the ward. Your baby can remain in skin to skin even at this point. This is important because skin to skin helps to regulate the baby’s temperature, heart rate and breathing and kick starts their immune system from the microscopic bacteria on your skin. Baby’s who are born vaginally have this kick start from bacteria in the vagina.

Over the next few hours you may notice that your baby seems a bit mucusy because the fluid in the lungs hasn’t been squeezed out like a baby that has been born vaginally, and it is important to reassure you that this is normal and happens in almost all baby’s born by caesarean section.

Please be aware there will be regional/geographical differences in this

If you would like to discuss your birth options, create a bespoke birth plan, or book onto my birth preparation package contact me using my email [email protected] or visit my facebook page @naturalpregnancyandbirth

A recent Facebook post suggested women were choosing to ‘free birth’ because they feel midwives and doctors are ignoring their needs. This was a very upsetting and concerning article as I strive to give care that is tailored to the needs of the women I care for and work alongside. However, it very quickly hit home that the reason behind such actions being taken by women was due to the medical interventions imposed by health professionals not respecting women and their choices over their own bodies!

I was then contacted by a lady looking for a vaginal birth after caesarean section (VBAC). Her opening line stated ‘I am allowed to try a normal birth’. My heart sank. This single sentence destroys all that I have entered my profession for. Following this I received another request by a lady who stated ‘They want to induce me at 40 weeks exactly because I am over 40’. I asked the lady what it was SHE WANTED. Her reply was simply, ‘I don’t want to be induced’. I asked if she had been given any information about the risks and benefits around induction, to which she said no. I then asked if she had been informed of any other options such as sweeping the membranes, or complementary therapies. Again, she answered ‘no’. Time and time again I am contact by women who feel the reasoning behind the doctors wanting to initiate labour is questioned, examples I hear often are:

*   I am considered large for dates, so they want to induce me at 38 weeks. I have had ultra sound scans with estimated weights but I    have read that these can be wrong.

*   I saw in my notes the doctor had written ‘induction discussed’, but he just said he would sort a date at 39+2 weeks. I have no idea what it is or if I wanted, he seemed in a rush.

*   My baby was conceived through IVF so I know when my baby is due; however, they are going with the scan date. In other parts of the UK induction is not offered until 40 weeks. This is my first baby and they want to induce at 39, but I feel very strongly I want to wait because although my circumstances MAKE me higher risk, but I don’t have any of the other underlying issues to increase what I feel is a minimal risk to let me choose?

As a midwife, it is within my professional code of conduct to ensure I advocate the wishes of women, especially when women feel they cannot. I cannot help but feel that we are failing women through:
• not giving them choices in their care; and
• informing them of the risks with balanced information of any benefits
Only then can we ensure women have true informed choice and as such are able to reach THEIR OWN informed DECISION – NOT being coerced into a medical procedure because a healthcare professional feels it is their expertise in which women’s choice does not matter.

WOMEN’s AUTONOMY must be RESPECTED.

As such Complementary Therapies have a huge role to play in maternity care, both to nurture the midwife to mother relationship and offer enhanced care which supports women-centred choices. It is here I feel the fractured relationship between myself as a midwife and health professional can be restored.  I am shattered and floored by the fact that I am one professional that women feel are ignoring their needs. In my consultations relating to birthing options I discuss with the woman what she wants, consider the requests of health professional’s interventions and provide information as to the procedures involved.

Additionally we talk about guidelines and why medical professionals may feel they must intervene. I nurture women who nurture their baby’s and arm them with the evidence based information they require to make informed choices about THEIR birth. If a woman’s labour doesn’t start in line with the health professional’s timescales, I know I have given my wonderful ladies all the information, methods that can help at home and treatments that may assist spontaneous labour to commence in a safe and natural manner for which they have control.