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4 oz-generic
$5.00

HIBICLENS (Exidine) ANTISEPTIC/ANTIMICROBIAL SKIN CLEANSER


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Lavage-this is from the Midwives Archives
In an informed consent/refusal form for group B strep, it is noted: A new protocol calling for use of chlorhexidine as a vaginal lubricant or wash for GBS moms to prevent or reduce vertical transmission. This surgical wash has proven effective against strep in dental use, and use of this product has been used in obstetric wards for many years, but not as a specific deterrent for strep.
Hibiclens (or Dyna-hex) is 4% of the solution. (At a birth center where i did an internship, if a woman was sensitive to betadine, we would use hibiclens in a bowl of warm water to clean the blood off her lower area. Not important info, just interesting to me that its been around a long time, but have not made the connection to GBS...)
The chlorhexidine used for vaginal antisepsis is topical chlorhexidine gluconate (Hibiclens). If waters are broken, it is especially important that you do not wash bacteria up into the cervical area. It makes most sense to have the woman do the vaginal wash herself in a standing position. This is a very effective means of washing the outer half of the vagina, where bacteria are most likely to reside. Use in this dilition: 2 Tbsp. Hibiclens to 20 oz. of water.
Vaginal disinfection with chlorhexidine during childbirth. Stray-Pedersen B, Bergan T, Hafstad A, Normann E, Grogaard J, Vangdal M. Int J Antimicrob Agents 1999 Aug;12(3):245-51
This prospective controlled trial demonstrated that vaginal douching with 0.2% chlorhexidine during labour can significantly reduce both maternal and early neonatal infectious morbidity. The squeeze bottle procedure was simple, quick, and well tolerated. The beneficial effect may be ascribed both to mechanical cleansing by liquid flow and to the disinfective action of chlorhexidine.
Can group B streptococci cause symptomatic vaginitis? Honig E, Mouton JW, van der Meijden WI. Infect Dis Obstet Gynecol 1999;7(4):206-9 After emergence of resistance to antibiotics, local application of chlorhexidine appeared to be the only useful treatment
I was reading Varney (3rd ed.) and in the HIV section I bumped into the following quote from pages 195-6. Helen references the 1992 Am. Journal of Obstetrics and Gynecology, 162(1):1171.
Current research is evaluating the effectiveness of vaginal lavage with a microbicidal agent during labor. Vaginal washing at 6-hour intervals in the period just before delivery has decreased the rate of neonatal group B strep infection, with no toxic side effects. A similar protocol may prove...
My questions to this are:
Have you ever used vaginal washing/lavage for group B strep? Why? Why not?
What microbicidal agent did you use?
If not a tablet, suppository, etc. specific for vaginal route, how did you change the application, dose.....?
If you cultured prior to and post treatment, were the results supportive of continuing this option for other clients? How did babys results pan out?
There seemed to have been a little flurry of activity in Scandinavia a few years back about studying the effects of vaginal lavage with chlorhexidine q6 during labour in women colonized with GBS. But nothing ever seemed to have come of it, and I dont know of anyplace in this country that has ever tried it.
There is one study published in the Lancet: Burman LG et al. Prevention of excess neonatal morbidity associated with group B streptococci by vaginal chlorhexidine disinfection during labour. Lancet 1992; 340: 65- 69.
A previous study done by Dykes et al. in the Eur J Obstet Gynecol Reprod Biol was assess by the Cochrane group as being of poor quality and that treatment should not be done on the basis of its results. I cant comment on the quality of the Lancet study, as I havent looked at it closely enough. However, a letter in response to that study was fairly scathing about its results. The other point it brought out is that chlorhexidine is not an innocuous substance, and could potentially be harmful to the baby, especially if membranes are ruptured and the baby is preterm.
Vaginal disinfection with chlorhexidine during childbirth. Stray-Pedersen B, Bergan T, Hafstad A, Normann E, Grogaard J, Vangdal M. Int J Antimicrob Agents 1999 Aug;12(3):245-51
Vertical transmission of microbes occurred in 43% of the reference deliveries. In the double blind study, vaginal douching with chlorhexidine significantly reduced the vertical transmission rate from 35% (saline) to 18%(chlorhexidine),. . . . This prospective controlled trial demonstrated that vaginal douching with 0.2% chlorhexidine during labour can significantly reduce both maternal and early neonatal infectious morbidity. The squeeze bottle procedure was simple, quick, and well tolerated. The beneficial effect may be ascribed both to mechanical cleansing by liquid flow and to the disinfective action of chlorhexidine.
See also: Related articles
Chlorhexidine versus sterile water vaginal wash during labor to prevent peripartum infection. Sweeten KM, Eriksen NL, Blanco JD.
Am J Obstet Gynecol 1997 Feb;176(2):426-30
CONCLUSIONS: Our findings suggest that a one-time 0.4% chlorhexidine vaginal wash does not decrease the incidence of infectious morbidity in parturients, compared with the use of sterile water. [Ed. It would have been nice if they would have mentioned how effective sterile water is!]
I think this was shown to not be particularly effective. It might do more harm than good, as it might wash the bacteria upwards. I think its felt the only valuable way of treating GBS is IV ABX or possibly po...I would guess I would not trust it. Also, would not the ABX be unstable in this situation? Did you try to do a search on this, or consider a Medline Search.

Subject: RE: [sagefemmes] GBS/Vaginal Wash Alternative-long
J Matern Fetal Med 2002 Feb;11(2):84-8 Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.
Facchinetti F, Piccinini F, Mordini B, Volpe A.
Department of Gynecology, Obstetrics and Pediatric Sciences, University of Modena and Reggio Emilia, Modena, Italy.
OBJECTIVE: To investigate the efficacy of intrapartum vaginal flushings with chlorhexidine compared with ampicillin in preventing group B streptococcus transmission to neonates.
METHODS: This was a randomized controlled study,including singleton pregnancies delivering vaginally. Rupture of membranes, when present, must not have occurred more than 6 h previously.. Women with any gestational complication, with a newborn previously affected by group B streptococcus sepsis or whose cervical dilatation was greater than 5 cm were excluded. A total of 244 group B streptococcus-colonized mothers at term (screened at 36-38 weeks) were randomized to receive either 140 mlchlorhexidine 0.2% by vaginal flushings every 6 h or ampicillin 2 g intravenously every 6 h until delivery. Neonatal swabs were taken at birth,at three different sites (nose, ear and gastric juice).
RESULTS: A total of 108 women were treated with ampicillin and 109 with chlorhexidine. Their ages and gestational weeks at delivery were similar in the two groups. Nulliparous women were equally distributed between the two groups (ampicillin, 87%; chlorhexidine, 89%). Clinical data such as birth weight (ampicillin, 3,365 +/- 390 g; chlorhexidine, 3,440 +/- 452 g), Apgar scores at 1 min (ampicillin, 8.4 +/- 0.9; chlorhexidine, 8.2 +/- 1.4) and at 5 min (ampicillin, 9.7 +/- 0.6; chlorhexidine, 9.6 +/- 1.1) were similar for the two groups, as was the rate of neonatal group B streptococcus colonization (chlorhexidine, 15.6%; ampicillin, 12%). Escherichia coli, on the other hand, was significantly more prevalent in the ampicillin (7.4%) than in the chlorhexidine group (1.8%, p < 0.05). Six neonates were transferred to the neonatal intensive care unit, including two cases of early-onset sepsis (one in each group).
CONCLUSIONS: In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine.
PMID: 11995801 [PubMed - in process]
1: Int J Antimicrob Agents 1999 Aug;12(3):245-51 Related Articles, Books,LinkOut
Vaginal disinfection with chlorhexidine during childbirth.
Stray-Pedersen B, Bergan T, Hafstad A, Normann E, Grogaard J, Vangdal M.
Department of Gynecology and Obstetrics, Aker Hospital, University of Oslo,Norway.
The purpose of this study was to determine whether chlorhexidine vaginal douching, applied by a squeeze bottle intra partum, reduced mother-to-child transmission of vaginal microorganisms including Streptococcus agalactiae (streptococcus serogroup B = GBS) and hence infectious morbidity in both mother and child. A prospective controlled study was conducted on pairs of mothers and their offspring. During the first 4 months (reference phase),the vaginal flora of women in labour was recorded and the newborns monitored. During the next 5 months (intervention phase), a trial of randomized, blinded placebo controlled douching with either 0.2% chlorhexidine or sterile saline was performed on 1130 women in vaginal labour. During childbirth, bacteria were isolated from 78% of the women. Vertical transmission of microbes occurred in 43% of the reference deliveries. In the double blind study, vaginal douching with chlorhexidine significantly reduced the vertical transmission rate from 35% saline) to 18% (chlorhexidine), (P < 0.000 1, 95% confidence interval 0.12- 0.22). The lower rate of bacteria isolated from the latter group was accompanied by a significantly reduced early infectious morbidity in the neonates (P < 0.05,95% confidence interval 0.00-0.06). This finding was particularly pronounced in Str. agalactiae infections (P < 0.0 1). In the early postpartum period,fever in the mothers was significantly lower in the patients offered vaginal disinfection, a reduction from 7.2% in those douched using saline compared with 3.3% in those disinfected using chlorhexidine (P < 0.05, 95% confidence interval 0.01-0.06). A parallel lower occurrence of urinary tract infections was also observed, 6.2% in the saline group as compared with 3.4% in the chlorhexidine group (P < 0.01, 95% confidence p interval 0.00-0.05). This prospective controlled trial demonstrated that vaginal douching with 0.2% chlorhexidine during labour can significantly reduce both maternal and early neonatal infectious morbidity. The squeeze bottle procedure was simple,quick, and well tolerated. The beneficial effect may be ascribed both to mechanical cleansing by liquid flow and to the disinfective action of chlorhexidine
: Lancet 1992 Jul 11;340(8811):65-9 Related Articles, Books, LinkOut
Comment in:
Lancet. 1992 Sep 26;340(8822):791; discussion 791-2. Lancet. 1992 Sep 26;340(8822):792.
Prevention of excess neonatal morbidity associated with group B streptococci by vaginal chlorhexidine disinfection during labour. The Swedish Chlorhexidine Study Group.
Burman LG, Christensen P, Christensen K, Fryklund B, Helgesson AM, Svenningsen NW, Tullus K. National Bacteriological Laboratory, Stockholm, Sweden.
Streptococcus agalactiae transmitted to infants from the vagina during birth is an important cause of invasive neonatal infection. We have done a prospective, randomised, double-blind, placebo- controlled, multi-centre study of chlorhexidine prophylaxis to prevent neonatal disease due to vaginal transmission of S agalactiae. On arrival in the delivery room, swabs were taken for culture from the vaginas of 4483 women who were expecting a full-term single birth. Vaginal flushing was then done with either 60 ml chlorhexidine diacetate (2 g/l) (2238 women) or saline placebo (2245) and this procedure was repeated every 6 h until delivery. The rate of admission of babies to special-care neonatal units within 48 h of delivery was the primary end point. For babies born to placebo- treated women, maternal carriage of S agalactiae was associated with a significant increase in the rate of admission compared with non- colonised mothers (5.4 vs 2.4%; RR 2.31,95% CI 1.39-3.86; p = 0.002). Chlorhexidine reduced the admission rate for infants born of carrier mothers to 2.8% (RR 1.95, 95% CI 0.94-4.03), and for infants born to all mothers to 2.0% (RR 1.48, 95% CI 1.01-2.16; p = 0.04). Maternal S agalactiae colonisation is associated with excess early neonatal morbidity, apparently related to aspiration of the organism, that can be reduced with chlorhexidine disinfection of the vagina during labour.
1: Eur J Obstet Gynecol Reprod Biol 1989 Apr;31(1):47-51 Related Articles,Books, LinkOut
Prevention of group B streptococci transmission during delivery by vaginal application of chlorhexidine gel.
Kollee LA, Speyer I, van Kuijck MA, Koopman R, Dony JM, Bakker JH, Wintermans RG. Department of Paediatrics, University Hospital, Nijmegen, The Netherlands.
In a prospective study in 227 parturients, carriership of group B streptococci was established to be 25%. In carriers, transmission of streptococci to the newborn occurred in 50%. 10 ml of a chlorhexidine gel containing hydroxypropylmethylcellulose was introduced into the vagina during labor in 17 parturients, who were known to be carriers of group B streptococci from the first trimester of pregnancy. In none of the newborns from these mothers colonization by group B streptococci did occur. Vaginal application of chlorhexidine may prevent transmission of group B streptococci, and serve as an alternative to intrapartum prophylaxis using antibiotics. A large multicenter randomized controlled study should be performed to confirm this hypothesis.
Eur J Obstet Gynecol Reprod Biol 1985 Apr;19(4):231-6 Related Articles, Books, LinkOut

Chlorhexidine for prevention of neonatal colonization with group B streptococci. III. Effect of vaginal washing with chlorhexidine before rupture of the membranes.
Christensen KK, Christensen P, Dykes AK, Kahlmeter G.
A single vaginal washing with 2 g/l of chlorhexidine was performed before rupture of the membranes in 19 parturients who were urogenital carriers of group B streptococci (GBS). Two (11%) of the infants became colonized immediately after birth, in contrast to 16 of 41 (39%) infants to controls (P = 0.02). A significant reduction of GBS colonization of the ear (P = 0.02) and umbilicus (P = 0.01) was noted. Taken together, 2 of 57 (4%) cultures obtained at birth were positive in the chlorhexidine group, in contrast to 30 of 123 (24%) among the controls (P less than 0.01). These findings raise hope for the design of a simple washing procedure which might prevent serious infections in the early neonatal period with GBS but also with other chlorhexidine-sensitive organisms.


How to mix:
The Swiss hexidrine studies used a .2% solution (point two percent). If your hibiclens is the common 4% then I think you dilute it w\ith water 1/20 to make a point 2 percent solution. one ounce to 20 of water would fit well in a liter pop bottle -- giving plenty for birth and postpartum.