 Thanks Deb. Acknowledgement to the University College of Lilibet, Denmark and the Association of Radical Midwives. They thank you because without their support we wouldn't be able to do this. To set up your audio you go to a meeting on the top bar and work your way through the audio setup wizard. We have a chat window on the right. Please feel free to ask questions and make comments and if you'd like to start a private chat you may. To give us your feedback there's a little man on the top bar with his hands up. You just click on that and there's a drop down list and you can select what is appropriate. If you'd like to ask a question or make a comment please use the chat window. The chat is used for research purposes but we do remove the names and it's just for the information and if you use the chat facility consent will be assumed. If you want to speak to ask a question put your hand up and we will enable your microphone. To connect your microphone on the top bar there is a little picture of a mic. You select it and it turns green and allow the flat access to the flash player so we can hear you. If people can't hear you click on the microphone symbol and adjust the microphone volume and when you finished remember to switch off your microphone. Just click on it again. The recording is already on. Lovely. So if you have just joined us welcome to the ninth virtual international day of the midwife 2017. Our next speaker for session five is Katherine Bray. Kate studied as a midwife in the 1980s and moved to New South Wales Australia in 1986. Kate has been a member of the midwifery group practice and a lactation consultant and midwife in hospital and community settings. Currently Kate is taking a year out of clinical midwifery to focus on her PhD studies. Welcome Kate. Thank you Sarah. It looks my microphone is making little suggestions that you can hear me so all good so far. Yes I am taking a year out of clinical practice and on this international day of the midwife it makes me reflect on my clinical practice and how much I'm missing it and this little baby in the picture was one of my caseload midwifery practice birth beautiful water birth and I was just sitting here looking at this beautiful child as I was waiting to speak so hello and I'm going to speak to you today about this mysterious increase in the dose of intrapartum antibiotic prophylaxis from eternal briefly streptococcal infection and ask the question are we doing more harm than good and I'd like to acknowledge my supervisors Professor Marilyn Ferrer and Deb Davis and Doctors Christine Catlin Amy Monk and John Ferguson and my lovely research assistant Cat Flower and Elise Hutt. So the aims of our discussion this morning is to discuss the dilemma and I use that word word advisedly of eternal briefly streptococcus I'll call it GBS colonization and management to consider the evidence around intrapartum antibiotic prophylaxis which I'll call IAP for the reduction of early onset GBS infection which I'll call EOGBSI to look at the reasons why many areas are increasing their IAP dose in line with the American Centers for Disease Control and Infection the CDC recommendations and to ask that question what is it safe are we doing more harm than good this is Michel O'Donne he's a French obstetrician and he's written a lot on GBS and even in 1986 he declared from the moment we are born we live in a world of bacteria we need bacteria Dr. O'Donne understands the matter of GBS is complex we don't always understand why bacteria come and go and why they're there or even if this presents a problem but bacteria are historically seen as a problem in our community and 60 years ago a wonder drug was discovered that saved millions of lives. Penicillin of course has changed our lives but we're now over using this wonderful asset there's lots of information about that and in the case of GBS we're over using it perhaps by giving a prophylactic dose to millions of well-women just in case there is a risk-benefit analysis but there's no easy solution or answer to the GBS dilemma but we need to consider at least I think we need to consider are we doing more harm than good so just a few key terms a low vaginal perianal or anal swab reveals GBS maternal colonization which can be transient intermittent or persistent the swab's usually done by the woman herself towards the end of pregnancy a woman may be thought to be an increased risk of GBS colonization even though she hasn't had the swab taken if she presents with certain misfactors the baby's colonized with the bacteria either by swallowing infected amniotic fluid or the baby is colonized as she makes her way through the birth passage I've just realized actually there that infected is not a good term so she would swallow the amniotic fluid containing the GBS bacteria she wouldn't necessarily get sick it's thought that up to 50 percent of babies whose mothers carry GBS are colonized with GBS bacteria at birth a baby may be diagnosed with EOGBSI if the bacteria is discovered within 72 hours although some say seven days after the birth from a normally sterile site over 90 percent of babies with EOGBSI present within 24 hours so how common is maternal GBS bacteria colonization eternal GBS colonization well it's common most studies report a colonization rate of around 20 percent and my research my PhD research on a local cohort of over 30,000 women suggests that GBS levels are similar no matter where you birth or what your level of pregnancy complexity so you have a low risk pregnancy and yet you have the same risk of having GBS colonization as every other pregnant woman regardless of risk so it makes me ask the question if this bacteria is catagenic why would so many well women carry it if it's commensal meaning it's meant to be there why are we worrying about it well although rates are declining EOGBSI remains a leading cause of serious illness in newborns in much of the world including here in Australia so on the face of it maybe offering intra pyrton prophylaxis to lessen the risk would make good sense but does it although a leading cause of serious illness in neonates EOGBSI is uncommon incidence varies and difficult to estimate a recent systematic review health they estimated the global overall rate at around 0.3 per thousand births that's one in 2000 of all live births and rocog the royal college of obstetrician's gynecologist in their information list let's explain the figures well you can see them up here one in every 2000 babies in the UK are diagnosed with EOGBSI 70 percent of babies recover fully 20 percent of babies recover with some level of disability and 10 percent babies will die of infection of the infection sorry so these figures are all babies pre-term babies are far greater risk the mortality risk from EOGBSI is reported at four to 10 times more in pre-term and term babies and depends on which research you read as to what that figure is so you can see that these figures are very rubbery depending on who you're reading at the time that's overall one in 17 thousand babies die and 99.85 percent of babies are born to women who carry GBS will be unaffected by death or disability so let me just say that again 99 percent of babies born to women who carry GBS will be unaffected by death or disability so these figures show that EOGBSI is rare improved sanitation and huge advances in neonatal care have reduced the risk of infection disease as infectious diseases substantially but profile access is widespread so in order for GBS profile access to have a good chance of success women who are at greatest risk must be identified two approaches are recommended two standard approaches the universal or culture-based protocol where all women 35 to 37 weeks gestational offers GBS screening or a risk-based approach which uses certain pregnancy and or intrapodem risk factors to determine increased risk as we will hopefully illustrate in our poll later in this discussion different regions of the world advocate different approaches often based on the same evidence and it's good to have a a scattering of different countries because I think we will identify that there are different ways of looking at this so let's put it into context what GBS screening means for women and babies an Australian study found that over five and a half thousand women needed to be screened to prevent one case for the EOGBSI so screening how good are we at how sorry how good are our screening tests well we all tend to overestimate the benefits of screening and underestimate the risk generally contrary to what many health professionals think the average person undergoing screening tests want to and can understand the risks and benefits of the test if they're explained to them in a way that is accessible to that individual however we know that shared decision making between clinician and woman is yet to become the norm and universal screening is a good example of a test that's where we can overestimate the benefits and underestimate the risk given the consequences of being defined as at risk circumstantial this situation is not optimal so we know that the screening tests and cells aren't fabulous so that's not the whole story the test is only useful if it's performed correctly and then acted upon so how good do you think health professionals are at following protocols well I've done some work on this and I can tell you from my work that we're not good at following protocols for screening or following through with the correct prophylaxis so it's a bit of a mystery that early onset GBSI has reduced so dramatically over the last 30 years a recent study that I found after my literature review in a cohort of 488 women who were GBS positive there was a 40 percent IAP protocol failure however almost 80 percent of these failures were deemed unavoidable so it was seen that our screening techniques and our prophylaxis methods are inherently flawed yet despite this the reported rates that the GBSI have dramatically reduced which is quite mysterious what we offer to women who are at risk of having a baby with EO GBSI well the mainstay is in many high resource income countries high income countries is prophylaxis with penicillin which is given intravenously forally from active labour or induction of labour until birth so when I looked at why this came about I was intrigued to find in the introduction of the 2002 CDC report on this topic the only study that informed the instigation of IAP for EO GBSI was the 1986 RCT by Boyer et al this study's been criticised by both the authors of our literature review and by the 2014 Cochrane review on this topic for a high degree of selective reporting bias and of incomplete outcome data so I did an integrative literature review we did we found 12 studies plus that Cochrane review and we concluded that IAP is not supported by conclusive evidence however the Cochrane says is however based on existing evidence and expert consensus IAP is and that's my bracket recommended to reduce the risk of early onset GBSI so we're using evidence that is not robust and expert opinion so why are we increasing the dose there are two issues although I've put dosage here in grams and million units the Americans would be familiar with the million units on the slide I'll discuss the changes in grams because otherwise it becomes a bit complex there are two issues one many areas including here in Australia are increasing their dosage of penicillin from the 1.2 grams to the 3 gram regime one issue the second issue separates this one separates this increase is the CDC added a change in the 2010 iteration which gave a recommendation that the 1.54 hourly dose could be safely increased to 1.8 if the lower dose was unavailable that's the second issue so first the 3 gram dose what's the evidence for this now the 3 gram dose is a huge increase for those of us that were familiar or are familiar with the 1.2 gram regime I was really interested to find that the 3 gram regime has been recommended by the CDC since their first report on GBS in 1996 so where did they what did they use to base this the evidence to base this 3 gram dosage well it was based on a study in a 1989 study by this fellow called Taperanian now I also we also retrieved him in our literature review in his study and like Boyer this study was deemed and again not just by us but the 2014 Cochrane Review picked us as well so this study was it was concluded that there is a high risk of bias and that's the study that the 3 grams were the evidence this evidence was used to inform the 3 gram dose now 28 years old it looked at women described as heavily colonised with GBS a swab was taken on admission in labour or induction or induction of labour on nearly 9,000 consecutive women and the swab was an agglutination test rather than a culture it's different it was described as rapid sensitivities and specific 199 women were eligible for this study and the intervention was the 3 grams of penicillin but in this case this study used 3 grams every six hours until in labour until birth so the study concluded that babies of women exposed to IAP had significantly lower incidence of EOGBSI than the control and they said IAP would reduce the total incidence of EOGBSI by 25 to 18 percent so the CDC introduced IAP at 3 grams that but and I don't know the reason for this they reduced the 4 hourly dose from a further 3 grams to 1.5 for 3 grams stats followed by 1.5 4 hourly because the CDC recommendation because of this recommendation some areas but not all around the world changed their own recommendations to reflect the American lead Australia continued to use the 1.2 grand regime so there were a variety of dose regimes but all no matter what the dose attributed IAP as reducing the rates for the EOGBSI which is usually stated that decrease is usually stated with around 80 percent then in 2014 here in Australia our therapeutic guidelines increased their recommendation from 1.2 to the 3 grand regime so a lot of us wondered why we had this sudden increase in dosage when EOGBSI rates were so low not only in Australia but worldwide and there was ever more research about the potential associated risks of antibiotics so I contacted our local drug information unit and they contacted the therapeutic woods focus guidelines on on my behalf and the TGA centre reply and they said formulation of the recommendation to increase the dose involved discussion with authors of the Australian Society for Infectious Disease Guidelines presumably the more expert in addition to the ROCOG green top guidelines which are 2012 they went on there isn't strong evidence to guide the dosing of benzoyl penicillin for this indication nevertheless the expert group decided to increase the dose of benzoyl penicillin in line with other national and international guidelines it is not uncommon for local guidelines to differ from national guidelines particularly when the evidence for recommendation is not strong we are aware that some hospitals are using the higher dose they say before we changed our recommendation and others have continued to use the lower dose since we've changed when they made that declaration the New Zealand Consensus which is a 2014 publication had not been published it has been published and gold started the New Zealanders because on based on their own local research they had but they have advised their clinicians to keep the dose at 1.2 and to continue using a risk based approach which sounds quite sensible to me so then in 2010 and here comes the second point the CDC suggested the four hourly dose could go up from 1.5 to 1.8 in the three-gram regime why because there was a shortage in the 1.5 dosage in the USA so in order to reassure clinicians that the 1.8 instead of the 1.5 was safe they referred us to five references which some of you may be familiar with they make interesting reading the range of 1.5 to 1.8 is recommended and this is a quote from CDC 2010 that's recommended to achieve adequate drug levels in the fetal circulation and amniotic fluid while avoiding neurotoxicity so here are the five references they were tricky to find but they are they are in that 2010 guideline you just need to know where to look so they informed the increase in the four hourly dose these range from 1966 to 2005 and they're about pharmacology and pharmaconetics of penicillin so I looked at them and thought well what can we learn from them so I'm going to go through them because there are points of interest in the more so the first one Bray 1966 which I'm sure is well before most of you were born they looked at 17 women it was an observational study and they measured ampicillin in the amniotic fluid that's the interesting thing here in the amniotic fluid as well as the fetal maternal theorem and they suggested active participation with the by the fetus was suggested as a mechanism in establishing higher levels of ampicillin in the amniotic fluid probably by a fetal excretion the baby pasturin the more the baby pasturin after the ampicillin the more concentrated the drug in the amniotic fluid Bosseck in 74 this was a review and a case study and he says it would be possible that continuous high concentrations of penicillin could saturate the body's ability to clear this drug with elevations in CSF penicillin levels and resultant neurotoxicity so I just wondered about this because I have heard that some people because of the three gram dose I'm actually giving it over a period of time but actually these people are talking about mega doses mega units of penicillin over a long period of time which is not what we're doing with IAMP so Bloom in 96 he had 40 women in his observational study they found the minimum bacteriocidal concentrations were achieved in three minutes in all maternal and fetal blood samples but these levels were not achieved in 15 percent of women's amniotic fluid so he wondered well could that be because the babies hadn't passed urine so they concluded that the transfer of the drug from the mother to the fetus was acceptable but the transfer from the mother to the amniotic fluid was problematic and then they posed a question are these findings clinically relevant so he says if the goal of IAMP to the woman is to present fetal bacteria with GDS then these results would suggest that the bactericidal levels can be achieved almost instantaneously in fetal blood yes however if the fetus has already become septic before administration of IAMP tissue tissue invasion and injury by GDS may not be quickly reversible and this may account for the observation that IAMP given within four hours of birth has been reported to be ineffective in the prevention of the OGBSI interesting 2005 chow he explains the theories of pathogenesis and describes a seminal animal experiment from 1945 where animals appeared listless and uninterested in their surroundings after the administration of penicillin into the cerebral cortex so I couldn't see how this study was relevant to the question of neurotoxicity in pregnant women and babies however they concluded that since this and other experiments adverse effects of penicillin on the cns have become more widely recognized but it is only recently that we've become to be begun to understand the mechanisms that govern neurotoxicity caused by penicillin they envisage the potential impact of better-designed antimicrobial therapy or result in a lower likelihood of neurotoxicity here it's hoping the final 2006 with a prospective observational study and it went back to consider the optimum timing they use ampicillin so similar to bloom study he had 21 women scheduled for electrosizarion and they were given ampicillin before the surgery board and maternal blood samples collected at time of birth showed bacteriocidal levels of ampicillin in the port of blood rapidly achieved within 30 minutes and continued to be above the baxiocidal levels 5.6 hours after administration but then really on another note the authors went on to say most pharmacological research including the dosage of penicillin and ampicillin were obtained from non-pregnant individuals and only indirectly addressed tissue levels which is why I've been before so they look at the maternal and fetal serum but not the amniotic fluid and fetal tissue so what is at stake with all of this scary talk well we've gone through the background of the incident I didn't I skipped women's perspective because of time and we've talked about screening and the prophylaxis and the drug-raising so so what so what is at stake well the big so what is the effect of antibiotics on the microbiome and epigenome of the baby these processes that we know are fundamental to our health epigenetics is molecules they're molecules that lie literally on top of the genes and they are the interaction of our genes with our environment they can be switched on and off work by various scientific groups including the epic group are concerned with the effects the epigenome and the microbiome secondary to interventions in labour and they include the effect of IAP in the list of possible adverse effects on the epigenome and the microbiome leading to adverse health effects now I've put this in because I love this story this is a picture from the Sydney Morning Herald in 2006 and it says getting time at the zoom now the story here is this is the silverback gorilla mama and this is her baby who's seven days old and it says getting time at the zoo because the zookeepers didn't know the sex of the baby after seven days so I use this because I think how does the baby optimise her microbial and epigenetic inheritance and clearly this little baby is doing extremely well at that she had their healthy healthy mother and baby they had an undisturbed birth she clearly had immediate skin to skin contact and she's had exclusive and early breastfeeding and close contact with her immediate kin and nobody else because would you try and get this baby off of this beautiful silverback gorilla mama probably not so they're doing very nicely at the Taronga Zoo so what about then antibiotics and the microbiome what do we know well direct antibiotic exposure changes the micro the microbiome we've known that for some time if we have a course of antibiotics we get an upset gut so only just beginning to consider the microbial sex of IAP and the possibility of its long-term health consequences disturbances caused by antibiotics have been linked to the risk of a negative immune and inflammatory condition I did a literature review on the effect of the microbiome there was not much information on the on IAP specifically in the microbiome but the studies I found were small but all showed a decrease in the microbial diversity after IAP in particular the keystone taxa taxa lactobacillus and bifidobacteria both were reduced so to finish what can midwives and birth workers do right now well we can update and share our knowledge like we're doing here we can make a plan together to support and strengthen the antinatal microbiome and epigenetic health together with women and add this to the birth plan we can talk with colleagues educators obstetricians neonatologists I try to talk the infectious diseases physicians about the microbiome that's interesting but I will still keep talking we can read our policies and information for women and is the story of the microbiome is the microbiome and epigenome health is that written into our policies and if it isn't I believe we need to take action to update this now is there another way around the dilemma of GBS the GBS conversation with women is supposed to enable evidenced informed decisions about the risks women are prepared to embrace I believe that supporting a healthy antinatal and intrapartum microbiome so decreasing the incidence of well women having a spontaneous release of membranes before labour and the issues that they can run into because of that and increasing microbial health that the whole another story and also to reducing intervention so rather than having a universal approach to screening have a more targeted approach more like the risk-based approach where we watch and wait for signs of infection and then treat in labour so we know that maternal colonisation with GBS is common and EO GBS eyes rare we know that many thousands of women and babies are exposed to high doses of antibiotics in labour we know that there is no robust evidence to support the effectiveness of IAP or its alternative and I'm talking about chlorhexidine there or the dose of IAP that's currently recommended by many jurisdictions we know that a healthy microbiome is fundamental to human health but we don't know yet the full effect of IAP on the microbiome however I believe as midwives and maternity workers we have a duty of care to understand the current state of knowledge which is why I'm doing this PhD and path is on to people who need it most the women in our care so thank you so thank you um we do have some poll questions I wanted to wish everyone a happy international midwives day um and I will hand over I think to Sarah because she will put up some poll questions for us thank you Sarah thank you so much for that okay let's see uh sorry here we go made that huge can you see that there but it's not open it's not reopening I can see it okay um trying to clear it won't let me clear um oh wait here we go shall we there we go reopen here you go Kate can you see that well done yeah do you have a guideline do you have a guide yeah everyone well everyone who's said who's come into the poll has a guideline and it's going up so yes which is interesting because what I also should say to you is is it in date because a lot of people are holding back with their update of the guideline because this is a very contentious area okay I'll end this poll and we'll open the second one you feel uncomfortable yeah so immediately you answer yes I feel uncomfortable all of you do most of you do feel uncomfortable um about the management of deeper in your area brilliant we broadcast those results okay yep we'll close those polls just get to meet your mic Deb it's quite noisy your end okay uh we have a question here from Gene Patterson in that's right Gene Patterson in New Zealand um thank you Kate there is also the issue of anaphylaxis and antibiotic resistance yes thank you Gene there certainly is and I I've just been to the Sarah Wickham workshop in New Zealand and I spoke to lovely a lot of lovely New Zealand midwives and the midwife that told me about a recent anaphylactic episode in her area and and how that episode affected the way that they used IAP because it's I think it's sort of something like one to four in 100 000 women but of course when it happens it's dire um and yes thank you for bringing it up because it certainly is an issue antibiotic resistance of course is a big issue but when I've spoken to infectious diseases physicians they've said yes but yes but not in penicillin and and that seems to be the case true and that of course why we use penicillin because of its narrow spectrum but I it's still up there as an issue for sure and there's a question from Mercedes asking what is the percentage of false positives in screening the figures are very rubbery Mercedes depending on what research you read and what reports you read but it's certainly an issue there are always because of the transient nature of GBS and because we swab women not at the time of labour but maybe up to six weeks hopefully within six weeks before then there are going to be women who are GBS negative at screening and GBS positive at birth and the right and the other way around so the figures often are not huge but they are in my opinion they are significant and they're always mentioned and I will say from some research I'm doing on early onset the amount of women who are GBS negative and then the baby has the disease was significant. Thank you for that Mercedes and Kat has just asked how can we reduce colonisation of GBS in practice I've read that these increase transfer and stretch and sweeps should also be avoided. Yeah in all the research I've read on this particular area everyone has said it doesn't make any difference however just for a minute a personal point of view I think well we know that GBS grows in the lower third of the vagina and by putting anything therefore into the vagina obviously into the lower third of the vagina then up and through the cervix has the potential to cause some transfer of bacteria sort of higher up the vagina so but there is no evidence to say either way whether that's an issue I think rather we need to be thinking overall is it useful to do this VE and is it useful because it's women which you really benefit from the so-called stretch and sweeps. Thank you for that Kat and Megan is typing so we just have time for a couple more questions oh we're just waiting oh she stopped. I figured I might just talk instead if that was okay because I was trying to spell prophylaxis and I couldn't really get there so I thought well maybe I should just talk it. I'm curious about the group B strip when it comes to elective especially caesarean sections because then you know the membranes haven't ruptured and the fact that they've found group B strip in babies who have who have been born by elective caesarean section or caesarean section without rupture of membranes but there doesn't seem to be a protocol for or any of this prophylaxis around group B strip when the caesarean section is planned. No it's Megan Cone sorry yep. No I missed a little bit but I think I understand the gist of what you're saying there is this Mercedes I'm talking to or Jean maybe it's Jean. Anyway sorry Megan hi Megan. This is one area where everyone seems to agree and lovely to hear someone talking Megan. Last one it's from Mercedes again in the case of a woman who is in her second pregnancy the previous one with positive screening and in this one it is negative by a reliable source is indicated the same as the antibiotic by neonatology. But for a different reason of course that's for the mother and that's for maternal risk of infection but the evidence is very or the guidelines are very clear I don't know about the evidence the guidelines are very clear that it's not required and the rationale is because the incidence is so very low. I'm not sure what that last bit means but what you're saying is that the first pregnancy the woman was positive but didn't have a baby affected and the second one she was screened and she is negative. Now if that's the correct situation yes then nothing should be done. I think you answered her question there Kate. Thank you Mercedes. Lovely thank you so much Kate I think we all learned a lot it's always a an interesting topic. Is that what you mean is that the situation that maybe Mercedes it's a common issue this one