5
Asepsis and sepsis
Originating in the operating theatre, aseptic technique is now commonly used to reduce the risk of infection. Aseptic technique avoids contamination of susceptible body sites or sterile equipment/specimens by micro-organisms (Figure 5.1). Contamination may occur via contact with hands of healthcare professionals or the women or equipment. Contamination via the environment may also occur (for example dust on a sterile dressing pack).
Aseptic versus clean technique
These techniques are different; however, confusion occurs as the language is used interchangeably.
- Aseptic technique – avoids contamination with micro-organisms during a procedure.
- Clean technique – reduces the number of micro-organisms present (commonly used on chronic wound dressings as these are often heavily colonised with bacteria).
How to undertake aseptic technique
There is no evidence that any specific technique results in better outcomes for the woman or neonate. Aseptic technique reduces risks by interrupting the chain of infection. Traditionally, use of a dressing trolley (Figure 5.2) has enabled midwives to meet the requirements of an aseptic technique in hospital settings by providing a structure to enable both carriage of equipment and a surface to support a sterile field. Midwives working in community settings will need to adapt to meet requirements and may find the use of dressing trays (Figure 5.3) of help. All techniques should meet the following principles:
- Healthcare professionals must be assessed as competent to undertake the procedure.
- Explain the procedure to the woman, and gain her informed consent.
- Hand hygiene is undertaken before any contact with the woman/neonate, sterile equipment and following the procedure.
- Gloves are only used when needed. Sterile gloves are only required in specific circumstances where the woman is severely immunocompromised or for specific procedures where maximum sterile precautions are required, e.g. insertion of central line.
- Personal protective equipment (PPE) such as gloves and aprons should be worn if contact with blood or body fluids is anticipated.
- Assess the procedural requirements before undertaking it, ensuring all equipment is available; avoid interruptions.
- Where large wounds are exposed, avoid undertaking aseptic technique if cleaning or bed making is occurring due to risk of airborne contamination to the vulnerable site.
- Consider the use of analgesia prior to the procedure.
- Remove/loosen soiled dressings before creating a sterile field.
- Ensure only sterile items come into contact with a susceptible site.
- Ensure sterile and non-sterile items do not touch.
- Dispose of waste in line with the risk assessment.
- Preprepared dressing packs are available (Figure 5.4).
Following the procedure:
- Perform hand hygiene.
- Make the woman/neonate comfortable.
- Document procedure and any findings.
Asepsis and specimen collection
The collection of specimens without contamination is essential for accurate laboratory interpretation and antibiotic recommendations (where required).
Not all specimens are free from contamination (e.g. faeces). Particular care should be taken with urine samples, wound swabs and blood cultures to avoid contamination.
Top tips for quality specimens are:
- Is there a need for the specimen? ‘Just in case’ specimens are not of value and are costly.
- Identify the woman/neonate correctly.
- Obtain the specimen without contamination.
- Document specimen collection.
- Ensure all clinical information is recorded on the specimen and laboratory form including any antibiotic therapy.
- Store appropriately – do not leave at room temperatures for long periods to preserve any micro-organisms present and/or avoid overgrowth of ‘contaminants’.
- Check and act on results.
Sepsis
Sepsis is a life-threatening condition, and is also known as blood poisoning or septicaemia. It occurs when the body’s immune system is triggered by the presence of an infection. Instead of the immune system successfully combatting the infection, an uncontrolled immune (complement) cascade occurs, leading to shock and organ failure and in some cases death. Sepsis cannot be predicted – any infection can trigger it. Rapid identification of possible cases of sepsis is key to avoiding poor outcomes for the mother or baby.
Sepsis is a leading cause of maternal death globally. In 2012–14, sepsis was the second leading cause of maternal mortality in the UK after cardiovascular disease.
Postpartum sepsis occurs within the postpartum period – historically, the identification of puerperal sepsis associated with a lack of hand hygiene led to the implementation of hand washing by Semmelweis (Chapter 2). Within the maternity setting, causes of sepsis may be pregnancy related or entirely unrelated.
- Pregnancy or delivery related:
- Sepsis in pregnancy from miscarriage or abortion
- Post-delivery infection – for example genital tract, uterine or perineal infection
- Following caesarean section
- Mastitis
- Urinary tract infection
- Obesity
- Instrumental vaginal delivery.
- Sepsis in pregnancy from miscarriage or abortion
- Non-pregnancy related
- Respiratory infection – pneumonia, influenza
- Wound or skin infection.
- Respiratory infection – pneumonia, influenza
Signs and symptoms of sepsis
Early indications of sepsis can be vague, appearing as flu like symptoms. As sepsis develops the following symptoms can occur – action is must be taken immediately to assess if the mother or baby may have sepsis.
- For the mother:
- Slurred speech
- Shivering and/or muscle pain
- Reduced urine output
- Severe breathlessness
- Mottled skin/blotching
- Complaining of feeling ‘like I might die’.
- Slurred speech
- For the baby:
- Tachypnoea
- Seizures or convulsions
- Skin appears mottled, pale or blue
- Lethargic, difficult to rouse
- Feels cold to the touch.
- Tachypnoea
More details of neonatal sepsis are given in Chapter 1.
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