Chapter 8

Principles of infection control

Standard precautions

Learning outcomes

Having read this chapter, the reader should be able to:

• discuss the nature and significance of standard precautions, indicating the midwife’s role and responsibilities

• identify specific situations in which personal protective equipment (PPE) should be used

• describe source and protective isolation nursing.

Healthcare professionals are widely exposed to large numbers and varieties of microorganisms. This poses a threat both to the practitioner and to the women and babies in her care. The term ‘standard precautions’ (previously having incorporated ‘universal precautions’) refers to the measures taken universally, i.e. by all health professionals for all women and babies, all the time, (whatever the clinical environment, whether infection is known or suspected or not) to achieve mutual protection. The ultimate aim of standard precaution use is to prevent the transfer of infection. As an important area of care, the reader is required to keep up-to-date with developing protocols. The cost of infection to individuals (service users and staff), the NHS, and the community as a whole is large and the increasing incidence of healthcare-associated infections (HCAIs) all mean that the use of standard precautions has to be correct every time. This chapter reviews the nature and use of standard precautions and the principles of isolation nursing.

Standard infection control precautions

Childbearing women are considered to be in a high-risk category for standard precaution use because:

• unprotected sexual intercourse is likely to have taken place

• there is exposure to large amounts of blood and body fluid during episodes of care.

Applying standard precautions to everyone maintains safety and prevents any individual feeling isolated or ‘singled out’. In the UK the NHS encourages service users to be aware of, and involved in, the infection control issue with campaigns such as ‘It’s ok to ask’ (NPSA 2011), giving permission for women to ask midwives and doctors if they have washed their hands. Confidentiality may be compromised if some procedures are perceived to be used for some women and not for others. While there may be times when wearing protective clothing is potentially disruptive to the relationship that a midwife has built up with a woman, the midwife must consider the significance of protection, both for the woman and midwife, and that of other women, too. Simple explanations to the woman are usually sufficient and reassuring.

Standard precautions should be used when there is or expected to be contact with blood, vaginal and seminal secretions, urine or faeces, amniotic fluid, cerebrospinal fluid, saliva, breast milk or any other bodily fluid. Sweat is the only exception. While the principles need to be applied correctly, the midwife needs to be alert to these situations:

Principles of standard precautions

Hand decontamination

This is discussed in detail in Chapter 9; this is a summary.

• It should be practised routinely and thoroughly using approved liquid soap and running water at a comfortable temperature.

• Good-quality paper towels should allow the hands to dry with one or two of them and a hands-free clinical waste bin should be immediately available.

• There are five moments (WHO 2009 pp. 93–94, 113) when hand decontamination is necessary, Chapter 9 expands further on this. In summary, handwashing and drying must be undertaken (WHO 2009 p. 113):

1. before every episode of direct contact or care

2. after every episode of direct contact or care

3. before an aseptic procedure

4. immediately after contact with body fluids, mucous membranes and non-intact skin

5. immediately after contact with objects/equipment in the immediate patient environment and also when putting on and taking off gloves, prior to handling food, when hands are visibly soiled, after going to the toilet and after several applications of handrub.

• Alcohol handrub can be used but only if the hands are clean, i.e. not contaminated with body fluids or visibly dirty and if the woman being cared for is free from enteric infection (diarrhoea or vomiting-type illnesses) (Loveday et al 2014).

• Cuts or abrasions on the skin should be covered with a waterproof dressing that is an effective barrier to viruses and bacteria.

• Arms should be bare below the elbows.

Personal protective equipment

Personal protective equipment (PPE) is that which aims to protect healthcare practitioners from being infected and to stop the potential transfer of infection from one client to another via staff members. Such items include gloves, gowns, aprons, masks, goggles, visors, caps and theatre footwear. Wyeth (2013) suggests that there can be inappropriate and overuse of such items, this agrees with Wilson & Loveday (2014) who found that staff wanted to protect themselves and their families from the threat of infection. This has a safety and a cost implication.

The appropriate items should be selected following a risk assessment:

• What is the likelihood of transmission of microorganisms to the woman or midwife?

• What is the risk of the midwife/midwife’s clothing being contaminated by any of the woman’s body fluids?

• Is the equipment suitable for the proposed use? (Loveday et al 2014).

Determining the risk will aid the midwife in their choice of protection. The items should all be readily available at the point of use. Care should also be taken to remove PPE correctly and in the correct order: