Here are the answers to the most common Frequently Asked Questions or FAQs that we are asked about group B Strep in pregnancy and beyond.
Simply carrying GBS (detected from vaginal or rectal swabs) does not require treatment. However, GBS detected in the urine/ blood usually signifies a GBS infection, which may require antibiotics treatment – your doctor can advise further. More information on GBS can be found by clicking here.
It’s good to know whether you carry GBS during pregnancy – if detected during your current pregnancy, you should be offered intravenous antibiotics in labour. These massively reduce the risk of your newborn baby developing a group B Strep infection. There are no symptoms of carrying GBS, so the only way to find out whether you are is through testing.
Intravenous antibiotics, given in labour to women who carry GBS late in pregnancy, have been shown to be highly effective at reducing the risk that a newborn baby will develop early-onset GBS infection (GBS infection developing in the first 6 days of life). They do not reduce late-onset GBS infection (developing from age 7 days and typically by age 3 months). Researchers around the world are working on developing a vaccine that will one day prevent almost all GBS infection in babies, but it’s not available yet.
Our understanding is that all of these countries routinely offer pregnant women screening tests, with the exception of Australia (where one state uses a risk-based prevention strategy and the remaining 5 out of the 6 States screen) and New Zealand (which uses a risk-based prevention strategy).
Well, no actually. Not all countries publish data, but in the USA, for example, screening has reduced the rate of GBS infection in newborn babies (early onset) to 0.23 per 1,000 live births and for babies aged 7-90 days (late onset) to 0.34 in 2015 (click here). For 2014-5 in the UK & Republic of Ireland, the rates were 0.57 for early-onset and 0.37 for late onset per 1,000 live births (click here – page 11). The US rate had been much higher before prevention measures were introduced, but now the rate in the UK & Republic of Ireland for early onset GBS infection is two and a half times the US rate.
Not everyone carries GBS. Pregnancy does not ‘bring it on’ or cause a ‘flare-up’. The bacteria can be passed from mother to baby around labour and this causes no problems for most babies, although for a small number it can be life-threatening, causing blood poisoning, pneumonia and meningitis.
The tests widely available in the NHS (the standard direct plating tests) are not very reliable when they give a negative result – they give a negative result up to 50% of the time when they should be positive. On the other hand, a positive conventional test result is very reliable (they rarely find something that’s not there). See Which Test for GBS?
The GBS-specific ECM (enriched culture medium) tests are highly reliable and are good predictors of your GBS carriage status for 5 weeks after the swabs have been taken. An increasing number of NHS trusts offer the ECM test to some or all pregnant women, as do private services, including offering home-testing packs – click here for more information.
If you are or have recently taken antibiotics, this may affect the test result so discuss this with your midwife or doctor. If you can, leave it for a couple of weeks after completing the antibiotics before testing.
Any test detecting group B Strep during your current pregnancy means you should be offered intravenous antibiotics as soon as possible once labour has started to protect your newborn baby from GBS infection.
GBSS fully endorses the availability of reliable antenatal testing for GBS carriage. We want ECM testing to be freely available to all pregnant women on the NHS. We don’t sell ECM tests, but signpost to reputable organisations that do – click here.
There are no known harmful effects of carriage itself and the GBS bacteria do not cause genital symptoms or discomfort. GBS carriage is not a sexually transmitted disease, nor is GBS carriage a sign of ill health or poor hygiene.
No-one should ever feel guilty or dirty for carrying GBS – it’s normal.
Because GBS may be passed from one person to another by skin to skin contact, everyone (regardless of whether they know they carry GBS) should wash their hands properly and dry them properly before handling a newborn baby.
Some of the confusion of UK health professionals may be because the standard NHS tests – with samples taken using a high vaginal swab, or HVS, which is then cultured on a standard agar plate not designed specifically for detecting GBS and are not great at finding it. Research has found these methods will miss up to 50% of the women carrying GBS. Clearly a positive test result obtained by this method is highly reliable, but if you get a negative result, you can’t be sure it’s because the GBS wasn’t there when the swab was taken, or whether the test simply didn’t detect it.
For information about where you can obtain the ‘gold standard’ ECM test, click here.
Doing the test earlier means that the gap between testing and giving birth is more likely to be longer, so there’s a greater chance your carriage status will have have changed by then (ie you may either pick up GBS carriage, or have lost it in the intervening weeks). Doing the test between 35-37 weeks means that you are most likely to give birth within 5 weeks of testing, so your GBS carriage status is much less likely to change.
Tests done after 37 weeks will still give you a very good indication of what your GBS carriage status is for the next 5 weeks but there’s an increasing chance that your results will not be available when you go into labour, so your baby may arrive before the results. It would be a shame to do the test then get the results after your baby is born!
So the 35-37 weeks window is suggested as being probably the best time to test for most people.
If a woman has not had a negative result from a sensitive test for GBS carriage OR the less reliable conventional test has been negative during the pregnancy, she should be offered intravenous antibiotics from the onset of labour if one or more risk factors (listed at Risk Factors for GBS) are present.
A woman who has previously had a baby who developed GBS infection should ALWAYS be offered intravenous antibiotics in subsequent labours, from the onset of labour or waters breaking until delivery, regardless of any test results (although if she’s had a negative result from a sensitive test for GBS carriage within the last 5 weeks of pregnancy, she may choose not to have them).
A woman who has had any positive test result (from the urine, vagina or rectum) during the current pregnancy should also be offered intravenous antibiotics from the onset of her labour or waters breaking until delivery (although if she’s had a negative result from a sensitive test for GBS carriage within the last 5 weeks of pregnancy, she may choose not to have them).
Antibiotics have been shown to be highly effective at preventing GBS infection in newborn babies when they’re given as soon as possible once labour has started and at regular intervals until the baby is born. This dramatically reduces the risk of GBS infection in a newborn baby. To find out more about our medical panel’s recommendations for prevention, click here.
*All UK national guidelines recommend that Mum should be offered intravenous antibiotics in labour if GBS has been detected during the current pregnancy.
Antibiotics for GBS carriage are not indicated until labour starts. No antibiotics tested so far have been shown to eradicate GBS reliably from the body so, even if antibiotics were to clear the GBS colonisation of the vagina (and they may not), recolonisation from the intestines will occur. The time when antibiotics have been proven to be effective against GBS infections in babies is when they are given intravenously to the mother once her waters have broken or as soon as labour has started and at intervals until she has given birth.
If GBS is detected from a urine sample or from a vaginal or rectal swab at any level during pregnancy, you should be offered intravenous antibiotics once labour has started.
Treatment for GBS found in the urine depends on the level of GBS found and whether or not you have any symptoms. When detected during pregnancy:
- GBS in the urine ≥ 10^5 cfu/ml with or without Mum having symptoms of a urinary tract infection (for example, frequent or painful urination or fever) – this is considered as bacteriuria and treated with oral antibiotics. Mum should also be offered intravenous antibiotics when she goes into labour.
- GBS in the urine ≥ 10^4 cfu/ml with Mum have symptoms of a urinary tract infection – this is treated with oral antibiotics. Mum should also be offered intravenous antibiotics when she goes into labour.
- GBS in the urine 10^4-10^5 cfu/ml with Mum having no symptoms of a urinary tract infection – usually the midstream stream urine test (preferably with labia separated) is repeated. If the same level of GBS is still present, then treatment will be considered. Mum should also be offered intravenous antibiotics when she goes into labour.
- GBS in the urine ≤ 10^3 cfu/ml or less with Mum having no symptoms of a urinary tract infection – this is considered to be contamination and no treatment is offered. Mum should be offered intravenous antibiotics when she goes into labour.
When treatment is recommended for GBS bacteria in the urine during pregnancy, oral antibiotics are given, usually for 5 days. The urine should be retested 7-10 days after finishing the antibiotics and treatment repeated if necessary until the urine tests come back clear.
Treatment for a urine sample which detects the growth of GBS in the urine ≥10^5 cfu/ml, whether you have symptoms of a urine infection or not, is important since, if left untreated, such infections can cause kidney damage and have been linked to preterm labour.
GBS detected from a urine sample or from a vaginal or rectal swab at any level during pregnancy means Mum should be offered intravenous antibiotics once labour has started.
However, if the positive result was early in your pregnancy, you may not be carrying GBS by the time your baby is born. If you want to find out whether you are still carrying GBS, you can have a sensitive test at 35-37 weeks. If the sensitive test result is negative, then intravenous antibiotics are probably not indicated, since research shows that a sensitive test giving a negative result within 5 weeks of delivery is highly predictive of Mum not carrying GBS during those 5 weeks. The risk of acquiring carriage between doing the test and giving birth is very small. Click here for the availability of sensitive tests for GBS carriage.
If you have had any positive test result for GBS during your current pregnancy, you should be offered intravenous antibiotics from the start of your labour, until delivery.
The ‘gold standard’ ECM test for GBS carriage is not yet widely available from NHS hospitals, although it is available privately – for details, click here.
Carrying GBS in your last pregnancy isn’t a good indicator that you’re carrying it this time, though you are more likely to (about double the chance of carrying it this time compared with the background population).
If you carried GBS in a previous pregnancy and your baby was not unwell, a new recommendation in the September 2017 Royal College of Obstetricians & Gynaecologists’ GBS guideline is that you should be offered either:
- intravenous antibiotics as soon as labour starts or
- an ECM test at 35-37 weeks of pregnancy, with the intravenous antibiotics offered as soon as labour starts if the test result is positive.
Taking antibiotics is never without risk – so it is important they are used only when the potential benefit outweighs the risk. The only way to find out if you’re carrying GBS during your pregnancy is to test for it during that pregnancy. Although the ECM test is not yet widely available within the NHS, it is available privately from under £40 for a home-testing pack. For information on availability, click here.
In the UK, just under one in every 1,000 babies between the ages of 0-90 days and born during 2014/5 were reported as having had a group B Strep infection. Approximately 6 in every 10 of those babies developed in the first 6 days of life, with the remaining 4 in every 10 developing GBS infection between ages 7-90 days. UK research has suggested this may be a serious underestimate of the true incidence of GBS infection in newborns, which could be as high as 3.6 per 1,000.
The following are estimates of the chances a baby in the UK will develop GBS infection in their first 6 days, assuming no preventative measures are taken and assuming no other risk factors are present:
• 1 in 5,000 where a woman has had a negative sensitive test for GBS carriage in the last 5 weeks of pregnancy;
• 1 in 1,000 where a woman’s GBS carriage status is unknown;
• 1 in 400 where the woman is carrying GBS during the pregnancy; and
• 1 in 100 where the woman has had a previous baby infected with GBS.
If a woman who carries GBS is given antibiotics in labour in accordance with our medical advisory panel’s recommendations at Prevention, the baby’s risk is reduced by an estimated 85-90%. So, again assuming no other risk factors are present:
• 1 in 4,000 where the mother carries GBS during pregnancy;
• 1 in 1,000 where the mother has previously had a baby infected with GBS.
The large majority of pregnancies can be managed so that babies are protected and born free from early-onset GBS infection.
21. Must I have intravenous antibiotics if I’ve had a positive result for GBS during this pregnancy?
However, if the positive test result was from a urine sample, this means that the GBS was more invasive, and so antibiotics will be recommended.
Taking antibiotics should not be done lightly – they can have side effects that need to be considered in relation to the potential benefits and it is important that you tell your health professionals if you have an allergy to penicillin (or any other antibiotic). If you are allergic to penicillin, there are alternative antibiotics.
Although good data is hard to find on this subject, the generally quoted estimated risks for penicillin are:
• 1 in 10,000 of the mother developing a severe allergic reaction (anaphylaxis*); and
• 1 in 100,000** of the mother developing fatal anaphylaxis, resulting in her death.
Severe complications can occur in the unborn baby even when the anaphylaxis developed by the mother is not life threatening, although this risk is probably overstated.
*Anaphylaxis is a severe, potentially life-threatening allergic reaction that can develop rapidly. It is also known as anaphylactic shock. Signs of anaphylaxis include itchy skin or a raised, red skin rash, swollen eyes, lips, hands and feet, feeling lightheaded or faint, swelling of the mouth, throat or tongue, which can cause breathing and swallowing difficulties, wheezing, abdominal pain, nausea and vomiting, collapse and unconsciousness.
**Although often quoted, these figures are generally accepted as being a significant over-estimate of the risk – a recent paper stated that, in the US between 1997 (the year after the CDC recommended intravenous antibiotics in labour for women whose babies were at higher risk of developing GBS infection) and 2001, an estimated 1.8 million women were given penicillin in labour and no deaths occurred, so an estimate of a 1 in 100,000 risk of death from penicillin anaphylaxis is likely to be an over-estimate. The prevention of neonatal group B streptococcal disease. MR Law, G Palomaki, Z Alfirevic, R Gilbert, P Heath, C McCartney, T Reid, S Schrag on behalf of the Medical Screening Society Working Group on GBS Disease. J Med Screen 2005;12:60-68.
Whenever antibiotics are taken, there are always risks of antibiotic resistance developing. When antibiotics are given to pregnant women, this could affect the mother and her baby. When antibiotics are given around birth and in the early weeks of life, there is the chance they may increase the likelihood of the baby developing allergies. Although a lot of press space is given to this, data is unfortunately lacking on whether it’s the giving of antibiotics that causes the allergies, or whether there are other reasons (for example, genetics, environment, disease, etc.). This is yet another area where more research is needed.
Bearing all this in mind, you need to weigh up whether you consider the risks are acceptable in comparison with the potential benefits and, if so, in what circumstances you would want to the antibiotics.
There has been a lot of publicity recently about the inappropriate and excessive use of antibiotics (sparked by Prof Dame Sally Davies DBE, Chief Medical Officer, England – click here). We at GBSS are well aware of the risks of excessive use of antibiotics and have worked hard to stop misconceptions which result in their being given inappropriately – for example, in an erroneous attempt to eradicate carriage.
Research has shown that intravenous antibiotics (ideally penicillin), given in labour to women whose babies are at higher risk of developing GBS infection, is highly effective at reducing the risk of GBS infection in newborn babies, without any known long-term side-effects on the baby, and no apparent tendency to increase antibiotic resistance. Indeed, GBS has remained sensitive to penicillin for over 60 years.
Our medical advisory panel members are not persuaded that any therapy other than antibiotics in labour is effective in preventing early onset GBS disease.
One question we have been asked a lot recently is whether raw garlic, inserted into the vagina, will reduce the likelihood of GBS infection in a newborn baby. There is no good evidence that garlic will prevent GBS colonisation and, since the reservoir for GBS colonisation is the gut, garlic vaginally won’t impact colonisation there.
Unfortunately, although there is much discussion on this subject, particularly online, there simply are no natural, homeopathic or alternative medicines for which there has been good research and proof that they are effective at preventing group B Strep infection in newborn babies. It this changes, we’ll issue an update.
The members of our medical advisory panel are not persuaded that any therapy other than antibiotics in labour is effective in preventing early onset GBS disease.
For women known to carry GBS where it is not expected that the intravenous antibiotics can be given for at least 4 hours before delivery, an intramuscular injection of 4.8 MU (2.9 g) of Penicillin G at about 35 weeks of pregnancy may be useful in addition to intravenous antibiotics given from the onset of labour or membranes rupturing until delivery to try to eradicate GBS colonisation until after delivery.
Regardless of whether you have intramuscular antibiotics to try to eradicate GBS colonisation, it is recommended that all women in higher risk categories be offered intravenous antibiotics from the onset of labour or waters breaking, plus at 4 hourly intervals until delivery.
There are downsides of intramuscular penicillin – the injection is painful, there is a small risk of an allergic reaction and of antibiotic resistance developing (see below). These risks are repeated with the intravenous antibiotics given in labour.
For intramuscular antibiotics, there are no known alternatives to penicillin for penicillin-allergic women.
*(Bland ML, Vermillion ST, Soper DE. Late third-trimester treatment of rectovaginal group B streptococci with benzathine penicillin G. Am J Obstet Gynecol 2000 Aug;183(2):372-6)
28. Can GBS cause preterm birth, stillbirth and late miscarriage? And should I take long-term antibiotics?
For the antibiotics tested so far, their use throughout pregnancy does not prevent preterm delivery due to any cause, including GBS. Also, the effects of long-term antibiotics on the baby during pregnancy have not been assessed; although we know that short courses of, for example, amoxycillin, seem to be exceptionally safe.
If you live a long way from the hospital or have a history of very fast labours, then induction is one way to try and ensure you get sufficient intravenous antibiotics in labour. However, induction is not without risk itself, especially before the due date. You should discuss the potential risks and benefits of an induction with your obstetrician, because they will vary dependent upon your personal circumstances.
If you need to be induced for obstetric or medical reasons, the recommended intravenous antibiotics should be started as soon as possible once labour has started or waters have broken (naturally or artificially), and should be repeated 4-hourly until delivery, and ideally for at least 4 hours before delivery.
Not necessarily. Caesarean sections do not eliminate the risk of GBS infection since the bacteria can cross intact amniotic membranes to set up an infection in the baby, although they do reduce the risk.
Caesareans are not recommended as a method of preventing GBS infection in babies: they don’t eliminate the risk to the baby, there are significant risks associated with a Caesarean section, and the recommended intravenous antibiotics during labour are both low risk and highly effective.
If you are having a Caesarean section, our medical panel’s recommendations with regard to GBS are as follows:
Elective Caesareans If a baby is at higher risk of developing GBS infection and the mother is having an elective Caesarean AND is in labour OR her waters have broken, she should be offered the recommended intravenous antibiotics as soon as possible after the start of labour. The baby would only need intravenous antibiotics against GBS infection if born prematurely or if there are signs of possible infection in either the mother or the baby.
Emergency Caesareans If a woman carries GBS or has previously had a baby infected with GBS and needs an emergency Caesarean, she should be treated as for an elective Caesarean – no intravenous antibiotics are indicated against GBS unless she is in labour or her waters are broken. If she is in labour, she should be treated as for a normal labour up until the time when an emergency Caesarean section becomes necessary, when she should be delivered immediately.
The treatment of the baby for GBS would follow the charity’s normal paediatric recommendations.
There is no good evidence that membrane sweeps are harmful in women known to carry GBS. The results of trials of membrane sweeps don’t show any increase in problems caused by GBS in women having sweeps, and it is highly likely these trials would have included many women carrying GBS at the time.
However, there remains a theoretical risk that a membrane sweep might occasionally introduce GBS into the uterus, and so our medical advisory panel advises caution in using a membrane sweep for women known to carry GBS when there are other acceptable alternatives (for example, induction of labour with prostaglandin gel introduced into the vagina)
Home births are becoming increasingly popular and, if you want a home birth with intravenous antibiotics during labour until delivery, it may be possible for your midwife to give you intravenous antibiotics prescribed for you by your GP. This is not widely available. Some areas won’t permit intravenous antibiotics to be given at home – there is a small risk that you would get a severe allergic reaction to the antibiotics (see What are the potential risks of antibiotics? above) and, obviously, there is no intensive care unit nearby. The risk is small and, of course, the antibiotics make the chance of the baby developing group B Strep infection much smaller, but nevertheless your health professionals may be anxious. Of course, around 25% of women having home births probably carry GBS in their vagina at delivery without knowing it. This issue needs to be discussed with your medical team.
Oral antibiotics are not recommended for women for GBS carriage during pregnancy or labour. Quite simply, there’s no evidence that they prevent GBS infections in babies. If you have set your heart on a home birth, you may wish to consider having intramuscular antibiotics as outlined in I’m worried I won’t get 4+ hours of IV antibiotics before my baby is born above, though our medical advisory panel does not recommend them in lieu of intravenous antibiotics during labour, but they may be better than nothing if that really is the only alternative.
Although there have been isolated cases describing GBS infection possibly related to breast milk contamination, the advantages of breast feeding will, in our medical advisory panel’s opinion, greatly outweigh the remote risk of transmitting GBS via breast feeding. High hygiene standards need to be maintained for all breastfeeding mothers, with the hands and nipple areas being kept clean.
The intravenous antibiotics recommended above (see Prevention) for pregnant women during labour through to delivery to protect her unborn baby from GBS infection are safe for breastfeeding mothers.
If you develop mastitis or a breast abscess, you should seek medical advice regarding breast-feeding.
Babies born at increased/high risk to mothers who have received antibiotics for MORE THAN 2 hours before delivery should be:
- Carefully assessed by an appropriately trained Paediatrician or Advanced Neonatal Nurse Practitioner.
- If completely healthy, no antibiotics for the baby are required.
- A period of monitoring (12-24 hours) may be appropriate for those at highest risk of infection.
- Parents should be made aware of the early signs of infection and given a handout about GBS.
Babies born at increased/high risk to mothers who have received antibiotics for LESS THAN 2 hours before delivery should be:
- Examined thoroughly and investigated by a Paediatrician as appropriate.
- Observed for a minimum of 12 hours, ideally 24 hours.
- If completely healthy, no antibiotics for the baby are required (antibiotics should be administered if there is any doubt).
Babies whose gestational age is less than or equal to 36 completed weeks of pregnancy and are born by Caesarean section (not in labour, no broken waters) where antibiotics were given to the mother for less than 2 hours before delivery should be:
- Examined thoroughly by a Paediatrician and a full sepsis work up done.
- Started on intravenous antibiotics unless a robust examination determines baby is completely healthy.
- Reviewed at 48 hours.
For well babies at highest risk of infection, monitoring for 12-24 hours may be appropriate and this should be undertaken as a minimum if the baby is not screened and treated for infection.
If there’s any doubt about whether an infection is present, the baby should be started on intravenous antibiotics until it is known that he/she is not infected.
Around two thirds of GBS infections in babies are early-onset (developing in the baby’s first 6 days of life) and the remaining third are late-onset, occurring after the baby’s first 6 days. Most GBS infections show in the first 2 days of life, they are uncommon after a baby reaches one month old and very rare after age three months. Although intravenous antibiotics in labour are very effective at reducing the chance of a baby developing early-onset GBS infection, currently there are no known ways of preventing late-onset GBS infections so identifying signs and symptoms of these infections is vital for early diagnosis and treatment.
For more information about early- and late-onset GBS infections, including signs and symptoms, click here.
If a baby shows signs consistent with GBS infection or meningitis, call your doctor immediately. If your doctor isn’t available, go straight to your nearest Paediatric Casualty Department. If a baby has GBS infection or meningitis, early diagnosis and treatment are vital: delay could be fatal.
Babies with suspected GBS infection should be given appropriate antibiotic treatment, as there could be far more serious consequences than milk intolerance, if infection is not promptly treated. Many babies who never had any antibiotic exposure either directly or via their mothers, also suffer milk protein intolerance. Babies will normally grow out of milk intolerance once the immune system matures, usually in the second 6 months of life.
GBS is not a factor in the decision as to whether you should be vaccinated against flu, regardless of whether you know you carry GBS or not.
We know of no evidence that babies born to women who carry group B Strep or who have recovered from a group B Strep infection should not receive the normal childhood vaccinations.
The practice of ‘seeding’ babies born by Caesarean (putting a gauze swab in the vagina for 24 hours beforehand and then wiping the baby’s mouth and skin with that gauze after birth) is attracting attention. The hope is that exposure to bacteria will boost the baby’s immune system, thereby preventing illness and disease in the future, such as asthma and allergies.
The charity does not recommend this practice because there is no properly conducted clinical trial that has clearly evaluated the risks and benefits of seeding. To date, published data are very small and have not shown evidence of benefit – a number of trials are underway, and we look forward to seeing the results once published.
In the UK, where testing for group B Strep carriage is rarely available in the NHS, there is the potential Mums could inadvertently be exposing their babies to this bacterium, as well as others such as virulent coliforms, and viruses. While most babies exposed to group B Strep won’t develop infection – and we have not heard any reports of babies developing GBS infection as a result of this practice – it remains a theoretical risk, and of course group B Strep infection can be devastating.
This is yet another reason why good quality tests for group B Strep carriage should be made available to all pregnant women so they can make an informed decision about which is right for them and their babies.
Health professionals have a “duty of candour” to their patients. This includes being open and transparent about what happened, and telling you about things that could have been done differently. You can read more about this here.
All babies born at term and admitted unexpectedly to the neonatal unit undergo review and a Serious Incident Report or “root cause analysis” (RCA) report is made. This report should be shared with you.
Your hospital may invite you to meet with a senior obstetrician (pregnancy specialist), midwife and/or paediatrician/neonatologist (specialist in looking after newborn babies). If they haven’t, you can choose to contact them and request such a meeting. If you’re not sure of the name of your obstetrician or your baby’s paediatrician, you can make your request via the PALS (Patient Advice and Liaison Services), or to the Clinical Director for the service (maternity or neonatal or both).They have a duty ensure that your request is dealt with appropriately. It is very reasonable to ask for a meeting to explain what happened.
If you have any worries that the hospital’s health professionals are not giving you the full facts, you can ask for a report from a doctor from another hospital. This will usually be an obstetrician and/or neonatologist. The request is probably best made in writing to the Chief Executive of your Trust. Their contact details will be on the hospital website, or can be obtained from PALS.
If you feel that things were not done properly, then you have the right to go to a solicitor and ask them to investigate on your behalf. They will usually expect you to have already taken the steps described above to get as much information as possible, so that they can give you an opinion as to whether you might have a case which can be taken to Court. Legal processes are often very stressful for parents and can be expensive.
Unless a baby needs long-term care, many parents are satisfied with a proper explanation of what happened, and an apology for any mistakes made, especially if (as will happen in most cases) the baby makes a full recovery.