Chapter 3. Hygiene and infection control
the immobile woman
Introduction
Being able to move around and attend to our own hygiene needs are activities that we often take for granted. Most of us have the choice about whether we want to wash, shower or have a bath on a regular basis without considering whether we can physically use the facilities that are available. We do not think about sitting or lying in a bed or chair for a long time without being able to move or the implications this may have on our bodies. Similarly, fit and healthy pregnant women may not consider the potential impact of an epidural or operative birth on their mobility and independence. Rising caesarean section and epidural rates (The Information Centre 2006) as well as increasing rates of obesity (Zaninotto et al 2006) mean that midwives require knowledge and understanding of how immobility may impact on women’s care needs. In addition, increasing numbers of women with reduced mobility are having babies. Thus some women will require assistance to maintain their personal cleanliness.
The aim of this chapter is to highlight the skills required by midwives to care for women who are immobile or in bed for a period of time. These include attending to women’s personal hygiene needs, maintaining skin integrity through appropriate pressure area care and taking action to reduce the introduction and spread of infection.
In the following scenario consider hygiene, mobility and infection control issues:
Samantha has given birth to Jessica, her first baby, at home. It has been a long labour for her and she is seated on the floor of the sitting room. ‘I don’t think I can make it into the bath,’ she says. It is clear she is splashed with meconium and blood. ‘Don’t worry, if you would like I will give you a bed bath,’ says Marion, the midwife.
The following questions may come to mind:
■ What is a bed bath?
■ Why did Marion choose to give a bed bath instead of putting Samantha in the bath?
■ What equipment is needed to carry out a bed bath?
■ How does the environment impact on Samantha’s mobility and hygiene needs?
■ What other issues may need to be considered if Samantha stays in bed for a long time? 
Skin integrity
Background physiology
The skin is the largest organ of the body. One of its many functions, along with the underlying tissue, is to act as a protective barrier to the rest of the body. It protects from impact, such as falls, from heat and cold and external contaminants such as bacteria. The skin also acts as a temperature control regulator, ensuring we are not too hot or too cold, and helps to excrete waste matter. It also has an important sensory function as well as synthesising vitamin D from sunlight.
Healthy skin requires adequate amounts of water and a balanced diet in order to function correctly. Underlying health conditions may have an effect on the skin functioning, for example, anaemia or thyroid conditions may lead to excessive dryness. Further issues such as poor diet or obesity may have an effect on the skin’s elasticity or integrity.
Physiology in relation to pregnancy
In a healthy non-pregnant situation the skin will be affected by the inner health and wellbeing of the person as indicated above. However, during pregnancy, the changes happening to the rest of the body will also have an effect on the integrity and functioning of the skin. The extra weight that the body carries, the circulating pregnancy hormones and the needs of the growing fetus will have an effect on all tissues within the body. Conditions that cause intense irritation of the skin may also lead the woman to scratch and break the integrity of the skin, leading to inflammation, pain and potential sites of infection.
The process of labour also challenges the skin’s capacity to fulfil its role. For example, the exertion of labour will increase the body’s heat production. The skin has an important function in maintaining an optimum body temperature. Flushing of the skin, due to vasodilation of the blood vessels beneath the skin’s surface, facilitates the loss of heat from the blood. Increased sweat production also aids heat loss through evaporation. It is important therefore that the woman remains well hydrated during labour and as mobile as possible.
Pressure area care
Potential damage to skin may occur in situations where women are immobile or have sensory loss, for example following administration of an epidural or postoperatively. Prolonged pressure on the tissues results in occlusion of the capillaries leading to a build-up of waste products and deprivation of oxygen in the tissues. This pressure, if not relieved, can result in tissue discoloration and damage and in the development of pressure ulcers. These are defined as:
identified damage to an individual’s skin due to the effects of pressure together with, or independently from a number of other factors for example shearing, friction and moisture
Such ulcers are also be known as ‘decubitus ulcers’, ‘bed sores’ or ‘pressure sores’. The care employed to prevent them is known as ‘pressure area care’.
Vohra & McCollum (1994) summarize the risk factors for damage to pressure areas as follows.
Local risk factors:
■ Pressure
■ Capillary occlusion and disruption of lymphatic drainage
■ Shearing force
■ Increased temperature and moisture.
Systemic risk factors:
■ Ageing
■ Decreased mobility
■ Poor nutrition
■ Arterial disease and hypotension.
Women in labour may have many of these risk factors. Pressure can also be increased due to creases in bed linen and skin integrity compromised by contamination with fluids such as liquor or blood. Thus bed linen and clothing should be regularly inspected for creases and kept clean and dry. Further, there should be awareness of labouring women who spend lengths of time in the hands and knees position and whether the surfaces are suitable to support her appropriately. The increased levels of cortisol in labour may also potentially lead to a greater risk of pressure damage to the skin. During labour there should be adequate preparation to ensure the most appropriate equipment is available to aid mobility and that staff know how to use it.
Sit on a chair or in a bed for as long as you can without moving. How long did it take before you felt you had to move to get comfortable? Try this also kneeling on the floor or bed. Apply this to midwifery practice.
Assessment of pressure areas
Staying in one position for even a short time may lead to increased pressure on the area in contact with the bed or the floor and may cause skin damage. The risk is exacerbated for women who have underlying medical disorders affecting the elasticity and tone of the skin. In addition, women who have anaemia, poor nutritional status or have some form of disability that prevents mobility or skin sensation have an increased risk of ulcer formation.
To ensure appropriate assessment is made of pressure areas it is suggested a scoring system is used which enables recognition of those who are most at risk of skin damage. The most usual ones to be used are the Waterlow (2005) score and the Plymouth assessment scale, specifically for maternity pressure areas (Morison & Baker 2001). This latter scale enables the midwife to consider the needs of the woman in an holistic way; however, scales need to be used regularly as the woman’s condition changes and they should be regarded as risk assessment tools.
Pressure area care aims to protect the areas of the body in contact with the bed or floor and to maintain mobility where women are unable to do so themselves. This will involve regularly changing the person’s position but also considering ways of ensuring comfort on the surface on which they may be sitting, lying or leaning. This will include considering the type of mattress used, whether sheets are smooth and dry, and whether floor surfaces require carpets or cushions to aid comfort.
Hygiene
Midwives need to take note of their own personal hygiene and the cleanliness of the working environment, to avoid the transfer of infection to mothers and babies. A focus on clinical hygiene has become acute in recent years with the increased prevalance of ‘superbugs’ such as methicillin resistant Staphlococcus Aureus (MRSA) and Clostridium difficile, which remain difficult to treat and can have a devastating effect on those who contract them (Crowcroft & Catchpole 2002). This has led to an increased emphasis on techniques to contain or prevent infection and raised expectations of those accessing health services for scrupulous hygiene standards. Simple techniques such as careful handwashing and appropriate disposal of waste can significantly reduce the transmission of infection. It is ironic that our current understanding of cross infection developed through the observations of a Hungarian obstetrician, Ignaz Semmelweis, who in 1847 recognized that the spread of puerperal infection in hospital in Vienna was through the poor hygiene of medical students (Rotter 1998).
Carers should use appropriate handwashing techniques to prevent cross infection to either the mother or the infant. The newborn infant has a less efficient immune system than an adult and is therefore at greater risk of contracting infection. If in hospital it may be wise to minimize contact with the infant from others apart from the parents and ensure careful handwashing.
Access the poster at http://www.hse.gov.uk/skin/posters/skinwashing.pdf and learn how to wash your hands appropriately.
Consider your workplace and whether the facilities are available to ensure appropriate hygiene.
Asepsis is defined as ‘the prevention of microbial contamination of living tissue/fluid or sterile materials by excluding, removing or killing micro-organsims’ (Xavier 1999). The aim of this is to prevent infection. The different ways this can be done is by:
■ The use of antiseptic solutions as a preventative measure
■ Cleaning to remove dirt
■ Disinfection to remove micro-organisms
■ Sterilization to completely remove all micro-organisms and bacterial spores.
The later chapter on surgical care will consider the actual techniques used in asepsis for wounds. However, midwives may consider when the use of an aseptic technique may be required for other procedures such as catheterization of a woman or vaginal examination (Stewart 2005). For each type of procedure different gloves will be recommended according to the area in which you are working.
National guidance
Recognition of patient care needs has led to the development of the Essence of Care Framework as part of the Clinical Governance Strategy for the NHS (NHS Modernisation Agency 2003a). This has included benchmarks to be achieved for personal and oral hygiene.
Find out in your area of work which gloves are recommended for the following:
■ A non-sterile contact with a woman
■ Aseptic technique
■ Vaginal examination prior to membranes being ruptured
■ Vaginal examination after the membranes have been ruptured
■ Administration of suppositories
■ Cleaning equipment.
Consider Benchmarks for Personal and Oral Hygiene (NHS Modernisation Agency 2003b) by accessing the complete document at http://www.cgsupport.nhs.uk/downloads/Essence_of_Care/Personal_&_Oral_Hygiene.doc. How would you apply the information to midwifery practice?
The basic principles forming this document highlight that personal hygiene should be taken seriously for all women in the maternity services. Hygiene is also a significant issue in relation to the prevention of infection to the woman, her baby and also to the midwives and other people caring for them. As indicated in the introduction, infection control has become a major concern especially within hospitals (Crowcroft & Catchpole 2002, Healthcare Commission 2006). This has led to an increased focus on preventative measures for the protection of all. From a maternity service perspective the National Service Framework highlights the need to address poor standards of hygiene, particularly in relation to the postnatal period (Department of Health 2004).
In 2004 the National Patient Safety Agency introduced the ‘cleanyourhands’ campaign to encourage staff to adhere to more rigid handwashing techniques with ‘it’s ok to ask’‘policing’ by the client to ensure staff followed these principles (National Patient Safety Agency (NPSA) 2004). The NPSA in 2005 instructed the NHS to provide an alcohol handrub near the patient and to encourage its use.
Recognition of the need to reduce infection rates within the health services has led to a Code of Practice to prevent infections related to healthcare (Department of Health 2006). Managing structures of the NHS have responsibilities to those who are admitted to the premises as service users as well as to the members of staff who work there. Their responsibilities lie in a duty to have management systems and training in place to ensure the protection of everyone who enters hospitals from hospital acquired infection (HAI). They have responsibilities for cleanliness and isolation facilities and information. Uniform, handwashing, cleaning services and waste disposal are policies that are created to ensure that staff and patients are protected by the management guidelines.
Essence of care also has benchmarks in relation to mobility and the protection of the person’s skin while their mobility is reduced (NHS Modernisation Agency 2003c).
Consider the benchmarks for pressure ulcers by accessing the complete document at www.cgsupport.nhs.uk/downloads/Essence_of_Care/Pressure_Ulcers.doc How would you apply the information to midwifery practice?
Professional regulation
Midwives working within the NHS have a responsibility to abide by the directives of the Trust in which they work. However, the Professional Code of Conduct also applies for the responsibilities and duty you have towards the women and families in your care which would include any midwife practising in or out of the NHS (NMC 2008:06):
“you must report your concerns in writing if problems in the environment of care are putting people at risk.”
Standards of education require students to be giving care that is appropriate to the needs of the individual woman from the antenatal period through labour and birth and in the postnatal period (NMC 2004). Midwives should be trained to promote the health and wellbeing of the woman and her baby and specifically:
Care for and monitor women during the puerperium, offering the necessary evidence-based advice and support regarding the baby and self-care. This will include: providing advice and support on feeding babies and teaching women about the importance of nutrition in child development, providing advice and support on hygiene, safety, protection, security and child development.
(NMC 2004:40-1)
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
