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Lynn Ford, BScN, IBCLC

102 AWHONN Lifelines Volume 8 Issue 2

Lynn Ford, BScN,

IBCLC, is a staff nurse

in the family and new-

born unit at IWK

Health Centre in

Halifax, Nova Scotia,

Canada.

DOI: 10.1177/1091592304265559

The IWK Health Centre

holds a yearly competition

entitled the Dinosaur

Award for nurses to iden-

tify a practice within their clinical settings that

appears outdated or is questionable. The win-

ning project in 2001 focused on routine surface

swabs on newborns born to mothers who test

positive for Group B Streptococci (GBS). Nurs-

ing staff on the Family and Newborn Unit at

the IWK Health Centre in Halifax, Nova Scotia,

believed that routine swabbing was a redun-

dant practice because the treatment for infants

is based on clinical presentation of the symp-

toms of sepsis and not swab results.

Why Is the Identification andTreatment of GBS Important?

Group B streptococcus (GBS) is the most com-

mon single cause of sepsis in newborns in the

first week of life (Dobson, 1993) and is a lead-

ing bacterial cause of perinatal mortality and

morbidity, affecting 15 to 40 percent of infants

born in Canada (SOGC, 1997). Several profes-

sional organizations, such as the Centre for

Disease Control, American Academy of Pedia-

tricians, American College of Obstetricians and

Gynecologists and the Society of Obstetricians

and Gynecologists of Canada (SOGC), have

established guidelines for the detection, treat-

ment and management of GBS in mothers and

infants.

However, these recommendations vary and

do not specify the most effective management

for infants of women who are known carriers

of GBS. Several studies have examined how

best to treat the mother in the antenatal, intra-

partum and postpartum periods to prevent

transmission to the infant (Bromberger et al.,

2000; Parks, Yetman, Moyer, & Kennedy, 2000;

Schrag et al., 2000; Smaill, 2001; Turow &

Spizer, 2000). However, there has been far less

research done on how best to manage the

newborn.

The Canadian Paediatrics Society and

SOGC recommend further research on the

optimal management of newborns whose

mothers are known to be positive for GBS

(SOGC, 1997).

Practice at the IWK HealthCentre

When a mother is identified as having GBS in

her urine, vaginal or rectal cultures, the baby

will have a surface ear swab taken to determine

exposure to GBS, prior to her or his initial

bath. Current practice is to monitor all infants

daily for temperature, pulse, respirations and

Q4H visual assessments of color, tone and res-

pirations. Treatment for sepsis is initiated

StreptococcusGroup B

Re-examining thePractice of Routine

Swabs for Newborns

through the nursing assessment that identifies

one or more of the following symptoms:

• respiratory distress • lethargy

• fever • poor feeding

• hypothermia • seizures

It should also be noted that even if the ear

swab is positive for GBS, interventions are not

initiated for asymptomatic newborns.

Practice in Other CanadianCenters

In an effort to obtain information about the

management of GBS in other Canadian hospi-

tals, a country-wide review was undertaken by

nurses on the Family and Newborn Unit at the

IWK Health Centre. Health professionals at

seven Canadian hospitals, specializing in

maternal and newborn health, were contacted

regarding treatment guidelines for infants

whose mothers tested positive for GBS. Practice

guidelines from these centers include but are

not limited to:

• routine observation

• isolating the baby from his or her mother

• separating the mother/baby dyad from others

• blood cultures

• lumbar puncture

• intravenous antibiotics

• complete blood cell counts

• chest x-ray

None of the practice guidelines from these

facilities described using ear swabs in deter-

mining GBS management in newborns.

Practice Change

Based on the evidence, the practice of routine

ear swabbing of infants born to mothers who

test positive for GBS has been discontinued at

the IWK. This represents a saving to the Health

Centre of approximately $14,000 per year.

Treatment is based on nurses’ observation of

the physical signs seen in symptomatic new-

borns. Parental observation is also a critical

component in the early detection and treat-

ment of GBS in infants. As part of the change

in practice, nurses developed a comprehensive

discharge education program for these families

so that they could recognize and identify early

and late onset GBS illness in their newborns.

Exploration of evidence-based practice

through the identification of a “dinosaur prac-

tice” enabled nursing staff on the Family and

Newborn Unit at the IWK Health Centre to

have an impact on how care is provided and to

eliminate a redundant policy. Perhaps more

important, this process of gathering evidence

has highlighted the vital role of nurses and

their surveillance skills in caring for infants

with GBS. Undoubtedly the knowledge and

ability of nurses to monitor and recognize the

pattern of symptoms that indicate GBS is a

major component in maintaining low levels of

mortality and morbidity for these infants.

References

Bromberger, P., Lawrence, J. M., Braun, D.,Saunders, B., Contreas, R., & Petitti,D. B. (2000). The influence of intra-partum antibiotics on the clinical spec-trum of early-onset group B streptococcal interms infants. Pediatrics, 106(2), 244-250.

Dobson, S. (1993, July). Report from the taskforce on group B streptococcus perinatalinfections. Vancouver, BC: GraceHospital.

Parks, D. K., Yetman, R. J., Moyer, V., &Kennedy, K. (2000). Early-onset neonatalgroup B streptococcal infection:Implications for practice. Journal ofPediatric Health Care, 14(6), 264-269.

Schrag, S. J., Zywicki, M. S., Farley, M. M.,Reingold, A. L., Harrison, L. H.,Lefkowitz, L. B., et al. (2000). Group Bstreptococcal disease in the era of intra-partum antibiotic prophylaxis. The NewEngland Journal of Medicine, 342(1), 15-20.

Smaill, F. (2001). Intrapartum antibiotics ofgroup B streptococcal colonization(Cochrane Review). In The CochraneLibrary, Issue 2. Oxford, UK: UpdateSoftware.

Society of Obstetricians and Gynecologists ofCanada and the Canadian PediatricsSociety. (1997, June). Policy Statement:Statement on the prevention of early-onsetgroup B streptococcal infections in thenewborn. Retrieved fromhttp://sogc.medical.org/SOGCnet/sogc_docs/common/guide/library_e.shtml#infectious

Turow, J., & Spizer, A. R. (2000). Group Bstreptococcal infection early onset dis-ease. Pediatrics, 39, 317-326.

As part of the change

in practice, nurses

developed a

comprehensive

discharge education

program for these

families so that they

could recognize and

identify early and late

onset GBS illness in

their newborns

April | May 2004 AWHONN Lifelines 103