Midwifery Skills at a Glance E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Wiley Series on Cognitive Dynamic Systems
• Sprache: Englisch

Seitenzahl: 452

Veröffentlichungsjahr: 2018

Beschreibung

Being an effective midwife requires a range of knowledge and skills, all of which are essential to provide competent and safe care to childbearing women and their infants. Midwifery Skills at a Glance offers an invaluable, straightforward guide for students and practitioners – offering readable, easily digestible information, supported with illustrations throughout to enhance application to practice.

Clear and concise throughout, Midwifery Skills at a Glance covers a wide range of skills – exploring issues such as infection control, personal hygiene care, and safeguarding; assessment, examination and screening skills; how to care for the woman and neonate with complex needs; drug administration and pain relief. 

• A comprehensive, highly visual guide to the skills essential for safe, effective, and compassionate midwifery practice
• Written by experts in their field
• Briefly describes each skill and provides clear illustrations — making it an ideal companion in clinical practice
• Offers instruction on the safe use of a wide range of essential skills required to deliver safe, evidence-based maternity care
• Includes service user viewpoints and key points to help consolidate learning and reflect on the experience of receiving care 

Written with the student midwife in mind, Midwifery Skills at a Glance is equally invaluable for all others providing care, including Maternity Support Workers, mentors, registered midwives and medical students. 

Leseprobe

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Midwifery Skills at a Glance

Edited by

Patricia Lindsay

RN, RM, MSc, PGCEA, DHC Registered Midwife

Carmel Bagness

MA, RN, RM, ADM, PGCEA Professional Lead for Midwifery & Women’s Health Royal College of Nursing London, UK

Ian Peate OBE

FRCN, EN(G), RGN, DipN (Lond), RNT, BEd (Hons), MA (Lond) LLM Editor in Chief British Journal of Nursing Visiting Professor of Nursing St George’s University of London and Kingston University London Head of School School of Health Studies Gibraltar

This edition first published 2018

© 2018 by John Wiley & Sons, Ltd.

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The right of Patricia Lindsay, Carmel Bagness, Ian Peate to be identified as the authors of the editorial material in this work has been asserted in accordance with law.

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The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by healthcare professional for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organisation, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organisation, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging-in-Publication Data

Names: Lindsay, Patricia, 1951- editor. | Bagness, Carmel, editor. |

   Peate, Ian, editor.

Title: Midwifery skills at a glance / edited by Patricia Lindsay, Carmel Bagness,

   Ian Peate.

Description: Hoboken, NJ : Wiley, 2018. | Series: At a glance series |

   Includes bibliographical references and index. |

Identifiers: LCCN 2017025965 (print) | LCCN 2017026824 (ebook) | ISBN

   9781119233985 (pdf) | ISBN 9781119235125 (epub) | ISBN 9781119233916 (pbk.)

Subjects: | MESH: Midwifery | Handbooks

Classification: LCC RG950 (ebook) | LCC RG950 (print) | NLM WQ 165 | DDC

   618.2–dc23

LC record available at https://lccn.loc.gov/2017025965

Cover design: Wiley

Cover image: © Monkey Business Images/Shutterstock

Contents

Contributors

Foreword

Preface

Part 1 The basics of care

1 Infection prevention and control

Identifying neonatal infection, and preventing and managing neonatal sepsis

2 Hand hygiene

Healthcare-associated infections

Hand hygiene

3 Infectious diseases in pregnancy

Organisms

Physiology

Pregnant women are vulnerable

Immune response

Signs and symptoms of infection in women

Refer appropriately

4 Modes of transmission

Modes of transmission

Disease prevention

5 Asepsis and sepsis

Aseptic versus clean technique

How to undertake aseptic technique

Asepsis and specimen collection

Sepsis

6 Moving and handling

Principles

7 The control of substances hazardous to health

Common hazardous substances in midwifery

8 Safety in the working environment

Accidents

Slips and trips

Equipment safety

Waste disposal

9 Sharps injuries

Reducing the risk of sharps injuries

Actions to take following a sharps injury

10 Working safely in the community

11 Personal hygiene care for women

General advice

Bed bathing

Oral hygiene

12 Perineal and vulval hygiene; use of bedpans and commodes

Perineal care

Vulval hygiene

Giving a bedpan

Use of commodes

13 Pressure area care

Pressure ulcers (also known as bed sores, pressure sores, decubitus ulcers)

14 Risk management, liability and avoidable harm

Liability

15 Types of incident, incident reporting, record keeping and duty of candour

Types of incident

Reporting incidents

Record keeping

Duty of candour

16 Audit and quality assurance in maternity care

Examining

Analysing

Changing

Testing

17 Safeguarding vulnerable women

Top tips for midwives

18 Safeguarding of children: key issues

The role of health and social care professionals in safeguarding unborn babies, children and young pregnant adolescents

Neglect

19 Female genital mutilation

Identification and assessment of FGM

Promoting normality

Legislation and safeguarding

Part 2 Assessment, examination, screening and care of the woman and baby

20 ‘Booking’: the initial consultation with the midwife

21 The antenatal appointment: physical and psychological assessment of the woman in pregnancy

22 Abdominal examination in pregnancy

Inspection

Palpation

Measuring fundal height

Auscultation

23 Physical and emotional assessment after birth

24 Assessing the woman in labour

25 Abdominal examination in labour

Preparation

Observation

Uterine size

After the abdominal examination

26 Vaginal examinations in labour

27 Positions in labour and birth

28 Supporting and caring for women in labour

First stage of labour

Second stage of labour

Third stage of labour

29 Supporting and caring for the partner

Antenatal and postnatal care

Normal birth

Other family types

Emergencies

30 Care of the perineum in labour including episiotomy and suturing

Perineal care in labour

Episiotomy

31 Examination of the placenta and membranes

Preparation for examination

Examination

32 Urinary catheterisation

Complications

Procedure

33 Assessing fetal wellbeing in pregnancy and labour

Ultrasound scan

Fetal movements

Measuring the fundal height

Liquor volume

Auscultation of the fetal heart

Fetal wellbeing in labour

Liquor colour and smell

34 Monitoring the fetal heart in pregnancy and labour

Auscultation of the fetal heart

Electronic fetal monitoring

35 The Apgar score

Assessment at birth

The Apgar score

36 The midwife’s examination of the baby at birth including identification of the neonate

Identification of newborns

Documentation/communication

37 Appearance and characteristics of the well term neonate

Appearance

Physiology

Reflexes

Feeding

Elimination

Minor abnormalities

38 Overall daily assessment of the term neonate including vital signs and bladder and bowel function

39 Newborn and infant physical examination

40 The term, preterm and growth-restricted baby

Assessment of gestational age

Preterm babies

Small for gestational age babies

41 Providing daily hygiene for the neonate including changing a nappy

General information to discuss with parents

Equipment and environment

42 Bathing the newborn

When and how often?

43 Breastfeeding

First feed

Responsive feeding

Assessing breastfeeding

44 Formula feeding

Constituents of first infant formula milk

Advice for parents regarding types of formula milks

Sterilisation and preparation of formula milk

How to give a formula feed

Baby-led, responsive formula feeding

Making up a formula feed

45 Other feeding methods

Basic principles of cup and syringe feeding

Cup feeding

Syringe feeding

Tube feeding

Infants with orofacial clefts

46 Neonatal blood screening (‘heel prick’)

Congenital hypothyroidism

Sickle cell disease

Cystic fibrosis

Inherited metabolic diseases: Phenylketonuria

Medium-chain acyl-coA dehydrogenase deficiency

Communication and documentation

Taking the NBS sample

47 Maternal venepuncture, including glucose tolerance testing

Indications for venepuncture

Midwives’ role and responsibility

Choosing the site and vein

Procedure

Glucose tolerance test

48 Cord blood and neonatal capillary blood sampling

Obtaining cord bloods for blood gas analysis

Neonatal capillary blood sampling

Taking capillary sample

49 Venous cannulation of the woman

Equipment

Procedure

Ongoing care

Removal

Potential complications

50 Urinalysis

51 Specimen collection – stool specimen

Collecting a faeces specimen from an adult

Collecting a faeces specimen from a neonate

52 Taking a wound swab

Storing specimens

The swabbing procedure

Pus

Swabbing large wounds

Swabbing chronic wounds

53 Use of a vaginal speculum and taking a vaginal swab

Examination procedure

Vaginal swab

Part 3 The woman or neonate with different needs

54 Membrane sweep

Procedure for undertaking a membrane sweep

55 Insertion of vaginal prostaglandin E2

Procedure for insertion of prostaglandin gels, tablets, Propess

56 Artificial rupture of membranes

Procedure for undertaking ARM

57 Recognising the deteriorating woman

Top tips

58 CVP,

S

p

o

2

and ECGs

Central venous pressure

Pulse oximetry

Three-lead ECG monitoring

59 Fluid balance monitoring

How to undertake accurate fluid balance

60 Peak flow measurement in the woman

How to assist a woman in doing a peak flow reading

61 MEOWS, AVPU, GCS and SBAR

62 Care of the deceased

Care of a deceased woman

Care of a deceased infant

63 Recognising deterioration in 
the neonate

Signs of deterioration

Referral

Causes of deterioration

64 Neonatal jaundice

Physiological versus pathological jaundice

Toxicity

Assessing for jaundice

Management of neonatal jaundice

65 Hypoglycaemia

Managing infants at risk

66 Hypothermia

Adaptation

Temperature control

Modes of heat loss/ transfer

Why preterm losses are greater than that of term infants

Neutral thermal environment

67 Wound assessment

Wound assessment

Promoting wound healing

68 Wound dressings and drains

Wound drains

69 Wound closures

Removal of sutures and staples

70 Assessment of venous thromboembolism risk and prevention of deep vein thrombosis in childbirth

Antenatal assessment

Preventing VTE

Intrapartum care

Postpartum care

Women’s experiences

71 Application and use of compression stockings

Application of compression hosiery

Part 4 Drug administration in midwifery

72 Drug administration, handling and storage

Legal framework and professional standards

Ensuring safety and accountability

Routes of administration

Storage and handling

73 Administration by injection to the woman

Procedure

74 Intravenous administration of drugs

Methods and equipment

Procedure

75 Medicine administration by oral, rectal, vaginal, topical and inhalation routes

Oral

Rectal

Topical

Vaginal

Inhalation

76 Neonatal drug administration

Preparation for administration

Oral administration

Intramuscular administration

77 Immunisation

78 Regional analgesia

Before the procedure

During the procedure

After the procedure

79 Non-pharmacological methods of pain relief

Hydrotherapy

Transcutaneous electrical nerve stimulation

Complementary, alternative therapies and coping strategies

80 Transfusion of blood and blood products

Administration

Observations

Management of a transfusion reaction

81 Anti-D: preventing rhesus isoimmunisation

Preventing rhesus isoimmunisation through administration of anti-D

Administration of anti-D

Errors in administration of anti-D

Glossary

Index

EULA

Guide

Cover

Table of Contents

Preface

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Contributors

Adelaide Aduboffour RN, RM, MSc, Fellow HEA, ITEC

Chapters 30, 67

Midwifery Lecturer

University of West London;

Perineal Specialist Midwife

Chelsea and Westminster and West Middlesex University Hospital;

Director

Peri Health Limited, London, UK

Andrea Aras-Payne MA, PGDip, BSc (Hons), RM, RGN, FHEA fe

Chapter 27

Senior Lecturer

University of West London

London, UK

Carmel Bagness MA RN RM ADM PGCEA

Chapters 10, 17, 20, 21

Professional Lead for Midwifery and Women’s Health

Royal College of Nursing

London, UK

Karen Bartholomew RN, RM, BA (Hons) MSc, PGCEA

Chapter 33

Senior Lecturer/Course Leader

Anglia Ruskin University

Chelmsford, Essex, UK

Marcia Bartholomew RN, RM, MSc Health Promotion, PgDip Teaching and Learning in Health Care

Chapters 28, 78, 79

Senior Lecturer

University of West London

London, UK

Judy Bothamley RN, RM, ADM PGCEA, MA

Chapter 81

Senior Lecturer (Midwifery)

University of West London

London, UK

Maureen Boyle RN, RM, MSc, PGCEA

Chapter 50

Senior Lecturer (Midwifery)

University of West London

London, UK

Jenny Brewster RN, RM, BSc (Hons), MEd, PGCEA

Chapter 26

Senior Lecturer in Midwifery

University of West London

London, UK

Alison Busby BNurs, RN, RM, ADM, MSc, PGDE

Chapter 43

Senior Lecturer Midwifery

School of Health Sciences

University of Manchester

Manchester, UK

Helen Crafter RN, RM, FP Cert, PGCEA, MSc

Chapter 18

Senior Lecturer in Midwifery

University of West London

London, UK

Doreen Crawford MA, PGCE, BSc (Hons) SRN, RSCN

Chapter 1

Consultant Nurse Editor Nursing Children and Young People

Crawford-McKenzie Healthcare Consultancy

Nurse Advisor, Independent Healthcare Consultancy

Helen Donovan BSc (Hons) Med, RGN, RHV, RM

Chapter 77

Professional Lead for Public Health Nursing

Royal College of Nursing;

Visiting Senior Lecturer

University of Hertfordshire;

Independent Nurse Lead

NHS Barnet CCG Governing Body

London, UK

Sarah Emberley RM, BSc, MSc, PGDPE

Chapters 6, 22, 47

Midwifery Lecturer/Clinical Skills

Bournemouth University

Bournemouth

Dorset, UK

David Foster PhD, MSc, RN, RM, FCIPD

Chapters 14, 15, 16

Registered Midwife, formerly Head of the Nursing, Midwifery and Allied Health Professions Policy Unit and Midwifery Advisor at the Department of Health

London, UK

Sophie French RN, RM, MSc, PGCEA, Senior Fellow HEA

Chapters 41, 42, 59, 60

Midwifery Lecturer

King’s College London University

London, UK

Rose Gallagher

Chapters 1, 5, 9, 51, 52

Professional Lead for Infection Prevention and Control

Royal College of Nursing

London, UK

Shauna Gnanapragasam BSc (Hons), MSc

Chapters 48, 76

Midwifery Clinical Skills Tutor

Anglia Ruskin University

Cambridge, UK

Clare Gordon RM, SCPHN–SN, BSc (Hons), MSc, PG Cert Academic Practice

Chapters 32, 73

Senior Lecturer in Midwifery

Programme Leader Berkshire Midwifery

University of West London

London, UK

Caroline Hunter RM, MSc, FHEA

Chapter 44

Senior Teaching Fellow, Midwifery

Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care

King’s College London

London, UK

Louise Jenkins RN, RM, BSc (Hons), MSc, PGDip, SFHEA

Chapters 57, 61

Deputy Head of Department Midwifery, Child and Community Nursing

Anglia Ruskin University

Essex, UK

Julie Jones RM, Dip HE, BSc (Hons) Mid, BSc (Hons) Psych, PG Cert Academic Practice, MMedSci

Chapters 24, 53

Senior Lecturer in Midwifery

University of West London

London, UK

Lyn Jones RMN, RGN, RM, MSc

Chapters 54, 55, 56

Senior Lecturer Midwifery

Anglia Ruskin University

Cambridge, UK

Patricia Lindsay RN, RM, ADM, MSc, PGCEA, DHC

Chapters 11, 12, 13, 29, 37, 40, 45, 49, 62, 75

Registered Midwife

Jayne E Marshall PHFEA, PhD, MA, PGCEA, ADM, RM, RGN

Chapters 70, 71

Foundation Professor of Midwifery

NMC Lead Midwife for Education

School of Allied Health Professions

University of Leicester

Leicester, UK

Marianne Mitchell MA, BSc (Hons), DipHE, RM, RN, FHEA

Chapter 19

Senior Lecturer, Midwifery

University of Hertfordshire

Hertfordshire, UK

Martha Murtagh RM, RGN, RNT, MSc Ed

Chapter 80

Clinical Skills Facilitator

Regional Hospital Mullingar

Co. Westmeath, Eire

Kate Nash RGN, RM, BSc Hons, MSc

Chapter 72

Senior Lecturer in Midwifery

University of West London

London, UK

Ian Peate OBE FRCN, EN(G), RGN DipN (Lond), RNT BEd (Hons), MA (Lond) LLM

Chapters 2, 4

Editor in Chief British Journal of Nursing;

Visiting Professor of Nursing St George’s University of London and

Kingston University, London;

Head of School

School of Health Studies

Gibraltar

Elisabeth Podsiadly RN, BScN, MSc, PGCEA, Cert in Perinatal Nursing

Chapters 63, 64, 65, 66

Senior Lecturer, Neonatal Nursing

Faculty of Health, Social Care and Education

Kingston University and St George’s University of London

London, UK

David Quayle PGC, RGN, FETC

Chapter 58

Clinical Services Manager

Air Alliance Medflight UK

Birmingham Airport

Birmingham, UK

Hazel Ransome RM, BSc (Hons), PGCLTHE, HEA Fellow

Chapters 68, 69

Senior Lecturer in Midwifery

Kingston University

Kingston Upon Thames

Surrey, UK

Maureen D Raynor RMN, RGN, RM, ADM, PGCEA, MA

Chapter 36

Senior Midwifery Lecturer

Leicester School of Nursing and Midwifery

De Montfort University

Leicester, UK

Lindsey Rose MSc, RM, HEA Fellow

Chapter 39

Senior Midwifery Lecturer

Anglia Ruskin University

Cambridge, UK

Jancis Shepherd RN, RM, ADM, MTD, PGCEA, MA, Senior Fellow of the Higher Education Academy

Chapter 31

Lead Midwife for Education and Head of Midwifery

University of West London

London, UK

Antonio Sierra RN RM MSc

Chapter 74

Lead Midwife for Midwifery Education

West Hertfordshire NHS Hospitals

Hertfordshire,UK

Helen Simpson RN, RM, RSCPHN, HEA Fellow

Chapter 23

Senior Lecturer in Midwifery

University of West London

London, UK

Sheena Simpson RN, RM, 405 Course, BSc (Hons), PGDip in Education, MA, HEA Fellow

Chapter 25

University of West London

London, UK

Sara Smith RM, BSc, MSc, PGCE

Chapter 34

Senior Lecturer in Midwifery

Anglia Ruskin University

Essex, UK

Tina South RM, BA (Hons), BSc (Hons), PGCert (Research), PhD(c)

Chapter 38

Midwifery Lecturer

University of West London

London, UK

Kim Sunley CMIOSH

Chapters 7, 8

National Officer (Health and Safety)

Royal College of Nursing

London, UK

Maxine Wallis-Redworth RN, RM, BSc, MSc, PGCEA, IBCLC

Chapters 48, 76

Course Leader BSc (Hons) Midwifery

Anglia Ruskin University

Cambridge, UK

Helen Williams RN, RM, DPSM, MSc

Chapters 14, 15, 16

Associate Director and Head of Midwifery

Yeovil District Hospital NHS Foundation Trust

Somerset, UK

Nicola Winson MA, PGCEA, RN, RM

Chapter 3

Senior Lecturer in Midwifery

University of West London

London, UK

Sandy Wong MSc (Midwifery), ADM, RM, RGN, PgCert (HE), FHEA

Chapters 35, 46

Senior Lecturer Midwifery

University of Hertfordshire

Hertfordshire, UK

Foreword

I am delighted to have been asked to write the foreword for this text. The At a Glance series has supported nursing practice for many years; to have a Midwifery Skills text is a bonus for practitioners.

Midwives and student midwives are faced with a plethora changes and challenges in practice and finding relevant and up to date information, which is accessible to support practice, is essential.

Maternity care and services are provided in a variety of settings through different models of care, resulting in midwives and student midwives working in varied surroundings and situations; consequently, keeping current with practices and procedures can sometimes seem overwhelming. This text provides an easy access resource to fundamental aspects of practice.

The At a Glance series provides information in easy to digest bite-size pieces, practitioners can dip in to particular aspects of practice as needed. The text gives key messages supported by illustrations to provide clear guidance for practice.

The book is divided into four parts with further subdivisions and chapters, which makes navigation of themes and topics easy and the presentation of complex skills is made simple.

This text will be of great value to all student midwives, midwives and mentors who will appreciate the importance of the book when undertaking new midwifery skills and in preparation for practice assessment, for example OSCEs (Objective, Structured Clinical Examination) and professional conversations.

Midwives can be reassured that the content is appropriate for practice; many of the authors are renowned for their expertise in their midwifery practice and education as well as expertise provided by professionals from outside of midwifery care, for example in supporting safe practice in the work environment.

The editors bring their own experience to support the gravitas of the text. Dr Patricia Lindsay is an experienced midwife, midwife teacher and academic, who has supported the development of students and midwives throughout her career. Patricia is passionate about safe and effective care for women and families and appreciates the importance of ensuring that professionals have access to contemporary, relevant information for care. Professor Ian Peate shares his nursing experience and the application to midwifery practice. In addition, Ian has a long-established academic career and has produced excellent resources for professional development. Carmel Bagness is an experienced practitioner and academic and brings to the text her wide experience of midwifery practice and issues relating to women’s healthcare and health policy.

I have no doubt that this book will prove to be an invaluable resource for midwives, student midwives and other practitioners working in maternity services. Professionals will find themselves dipping in to the text to support their daily practice. The clear concise approach will provide midwives with the confidence to address practice safely as well as signposting to further information or evidence where appropriate.

Gail Johnson

Professional Advisor for Education

Royal College of Midwives

Preface

At the time of writing, midwifery as a profession, and the context of practice, are undergoing some changes. However, the needs of women, their babies and their families remain the same and midwives have a unique and privileged role in providing care to this client group. A high level of competence and confidence in skills ensures care is safe and of a high quality. In addition, the use of evidence and local knowledge, as well as understanding policy and services available, must be drawn on to provide the best care possible. Multiprofessional working and the judicious use of voluntary and other services are also required to provide a complete service to the childbearing woman and her family.

This text has been written with the student midwife in mind but is equally useful for others providing care, for example maternity support workers, registered midwives or medical students. It offers educational support for practitioners in the application of midwifery knowledge to clinical practice in relation to women, their babies and their families through the childbearing continuum. It follows the familiar At a Glance format, which has been shown to be beneficial to the success of student groups’ knowledge of many topics. This volume is unique in that it is related to midwifery practice, but demonstrates links with other relevant healthcare professionals across many disciplines who may also care for women during the childbearing period. The text therefore draws on the wisdom of expert practitioners in midwifery, or in fields pertinent to midwifery, and offers readable, easily digestible information, supported with illustrations to enhance application to practice. Wherever possible the voice of service users has been included to add a different, and important, perspective, one which is often absent from skills books.

The chapters reflect a variety of skills, ranging from fundamental personal care skills to more complex matters such as ECG monitoring or assessment of clinical deterioration. In addition, topics related to risk management and quality assurance are also addressed. When using the book, and carrying out clinical care, practitioners must remain aware of and abide by standards set and published by the regulatory bodies such as NMC Code (The Code, 2015. London: Nursing and Midwifery Council. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf). They must also remain aware that psychosocial care skills are equally important.

While the information in the chapters provides guidance and insight, the reader must ensure that they are competent to carry out the care and, where necessary, have had their competence assessed and confirmed. Everyone has a duty to ensure that care provided is safe and effective at all times, is based on the best available evidence and the woman must be central to every interaction.

Patricia Lindsay

Carmel Bagness

Ian Peate

Part 1The basics of care

Chapters

Infection control

1

Infection prevention and control

2

Hand hygiene

3

Infectious diseases in pregnancy

4

Modes of transmission

5

Asepsis and sepsis

Health and safety at work

6

Moving and handling

7

The control of substances hazardous to health

8

Safety in the working environment

9

Sharps injuries

10

Working safely in the community

Personal hygiene care

11

Personal hygiene care for women

12

Perineal and vulval hygiene; use of bedpans and commodes

13

Pressure area care

Quality and patient safety in maternity care

14

Risk management, liability and avoidable harm

15

Types of incident, incident reporting, record keeping and duty of candour

16

Audit and quality assurance in maternity care

Safeguarding

17

Safeguarding vulnerable women

18

Safeguarding of children: key issues

19

Female genital mutilation

1Infection prevention and control

The prevention of infection is a core element of safe and effective midwifery practice. Midwives and other healthcare professionals should consider the development of infection as an ‘adverse’ event, and monitor and investigate all infections as part of their organisation’s patient safety systems and learning culture. Box 1.1 indicates how infections may occur.

As knowledge of microbiology and the epidemiology of multiresistant organisms has increased, prevention now also includes the avoidance of colonisation of bacteria of clinical importance including (but not limited to):

Staphylococcus aureus

(including PVL strains)

Meticillin-resistant

Staphylococcus aureus

(MRSA)

Pseudomonas aeruginosa

Multidrug-resistant Gram-negative bacteria (MDR GNB) such as

Klebsiella pneumonia

and

Escherichia coli

(

E. coli

)

Mycobacterium tuberculosis

Fungi and yeasts.

Viruses can also be problematic, in particular blood-borne viruses (hepatitis B and C, HIV) and chickenpox.

Box 1.2 provides examples of common infections associated with pregnant and postnatal women.

A number of different practice interventions are described supporting the midwife to prevent or interrupt the development of infection or colonisation, which may lead to risks specifically in-patient care setting. They are:

The use of standard precautions (see Chapter 4)

Knowledge and compliance of organisational infection prevention and control policies and guidance

Active laboratory surveillance and reporting of cases of infection

Screening of women/babies

Vaccination of staff, women and babies

High standards of cleanliness

Education and information on hygiene, infection and prevention methods.

Many women and babies who develop an infection recover well; a small proportion go on to develop sepsis, a potentially life-threatening condition (Chapter 5). The importance of sepsis as a cause of maternal death has been recognised in reports such as MBRRACE UK.

Sepsis cannot be transmitted from person to person. It is a condition that occurs due to overwhelming infection, resulting in an immune cascade leading to septic shock. It can affect both mothers and neonates. Information on neonatal sepsis is detailed below. See Chapter 5 for the management of sepsis in adults.

Isolation: Physical (source) isolation has traditionally been used to separate people receiving hospital care from others due to a risk of spread of infection. In midwifery and neonatal care, isolation may be through the provision of single room accommodation (for mother or mother and baby) or an incubator/cot in the neonatal setting.

The route of transmission for the infection must always be known; this identifies which specific practice precautions are required. Box 1.3 indicates the requirements when source isolation is used.

Identifying neonatal infection, and preventing and managing neonatal sepsis

Midwives are uniquely placed to identify deviations from the normal in the newborn they care for as part of holistic family-centred care. There are some factors that can predispose to a higher risk of early-onset neonatal sepsis. The neonate may be exposed to organisms from the mother during pregnancy as well as vaginal delivery and in many cases of early-onset neonatal sepsis there have been intrapartum complications identified. Identifying these babies and providing the appropriate management will save lives.

Assessment of the neonate

NICE (2014a) recommends that all infants born to women who had prelabour rupture of the membranes at term are closely observed for the first 12 hours of life (at 1, 2, 6 and 12 hours).

The assessments recommended are:

Temperature

Heart rate

Respiratory rate

Presence of respiratory grunting

Significant subcostal recession

Presence of nasal flare

Presence of central cyanosis, confirmed by pulse oximetry if available

Skin perfusion assessed by capillary refill

Floppiness, general wellbeing and feeding.

If any of the above are present, a neonatologist assesses the baby and advises the family of any need for transfer to appropriate neonatal services if required. In the absence of a neonatal assessment (e.g. non-hospital settings) an urgent referral or transfer to a hospital will be required.

Neonatal sepsis can present with subtle and non-specific symptoms. By the time sepsis is considered the infant may already be very ill. NICE recommendations (2014b) include the use of the red flag to support clinical decision making and British Association of Perinatal Medicine (BAPM) have developed a Newborn Early Warning Trigger and Track (NEWTT) framework to alert midwives to babies who need further help. The framework provides a visual prompt, aiding the identification of abnormal parameters by using a colour code.

Signs and symptoms of sepsis are provided in Box 1.4.

The diagnosis of shock does not require that a neonate be hypotensive. This is a late finding in septic shock and when it occurs confirms progression towards decompensated shock (Robinson et al. 2008). A tense or bulging anterior fontanelle is suggestive of meningitis, common in late-onset sepsis. The assessment of the infant’s fontanelles should be made with the infant held and supported in an upright position.

Temperature instability can be an indication of infection. An neonate who is difficult to keep warm is a concern, as too is a baby who develops pyrexia due to pyrogens secreted by the bacteria.

Key references and further reading

Barnden J, Diamond V, Heaton P, Paul SP (2016) Recognition and management of sepsis in early infancy.

Nursing Children and Young People

, 28, 36–45.

British Association of Perinatal Medicine (BAPM) (2015)

Newborn early warning trigger and track (NEWTT) A framework for practice

. Available at:

http://bapm.org/publications/documents/guidelines/NEWTT%20framework%20final%20for%20website.pdf

Caserta MT (2015)

Overview of neonatal infections

. Available at:


https://www.merckmanuals.com/professional/pediatrics/infections-
in-neonates/overview-of-neonatal-infections

Gibson E, Nawab U (2015)

Hypothermia in neonates

. Merck Manual Professional Version. Available at:

https://www.merckmanuals
.com/professional/pediatrics/perinatal-problems/hypothermia-in-neonates

Moldenhauer JS (2016)

Premature Rupture of Membranes (PROM)

. Available at:

https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-and-complications-of-labor-and-delivery/premature-rupture-of-membranes-prom

National Childbirth Trust (NCT) (2016)

Group B Streptococcus (GBS)

. Available at:

https://www.nct.org.uk/pregnancy/group-b-streptococcus-gbs

National Institute for Health and Care Excellence (NICE) (2014a)

Intrapartum care for healthy women and babies

. CG 190. Available at:

https://www.nice.org.uk/guidance/cg190/chapter/1-
recommendations

National Institute for Health and Care Excellence (NICE) (2014b) Neonatal Infection: Quality Standard. Available at

https://www.nice.org.uk/guidance/qs75/resources/neonatal-infection-pdf-2098849787845

National Perinatal Epidemiology Unit (NPEU).

MBRRACE – UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK

. Available at:

https://www.npeu.ox.ac.uk/mbrrace-uk

Robinson D, Kumar P, Cadichan S (2008) Neonatal sepsis in the emergency department.

Clinical Paediatric Emergency Medicine

, 9, 160–168.

2Hand hygiene

Healthcare-associated infections (HCAIs) cost the health service millions of pounds per year, as well as causing women and their families unnecessary suffering and concern.

In the mid 1800s, Semmelweis established that hospital-acquired diseases were transmitted via the hands of healthcare workers. He observed that maternal mortality rates, predominantly attributed to puerperal fever, were higher in one clinic than another. As a consequence, Semmelweis recommended that hands be scrubbed using chlorinated lime solution before every contact.

Healthcare-associated infections

An HCAI is described by the 2006 Health Care Act as any infection to which a person may be exposed or is made susceptible (or more susceptible) in circumstances where healthcare is being, or has been delivered, to that or any other individual, and the risk of exposure to the infection, or susceptibility (or increased susceptibility) to it, is directly or indirectly attributable to the provision of healthcare.

HCAIs are the most common complication affecting those in hospital; the problem does not just affect people in hospital and hospital workers. HCAIs occur in any healthcare setting, including the general practice setting, clinics and long-term care facilities. HCAI is a potentially preventable adverse event, as opposed to unpredictable complications. Anybody working in or entering any healthcare facility can transmit infection or become infected. This risk can be significantly reduced when effective infection prevention and control procedures are implemented.

It is acknowledged that not all infections are preventable. Managing infection control and ensuring best practice can improve care outcomes and service user safety significantly.

Transmission of infections can occur through contaminated hands of a healthcare worker, equipment and medical devices used.

All healthcare workers will come into contact with people who have infections and/or contagious diseases; they must know how to prevent or reduce the transmission of infection.

The National Institute for Health and Care Excellence has produced evidence-based guidelines regarding management and how to prevent and control HCAIs.

Hand hygiene

Hand hygiene is seen as the single most important activity for minimising the likelihood of infection. Pathogens on the hands of midwives can be removed by hand washing if transmission is to be prevented. Infection involves a cycle of events that permits the spread (transmission) of infection occurring (Figure 2.1).

Healthcare workers, including midwives, have the greatest potential to spread micro-organisms that can result in infection; this is related to the number of times that they have contact with people in the care environment. Hands, therefore, are very efficient vehicles for the transmission of micro-organisms.

Hands should be decontaminated before direct contact with women and after any activity or contact that contaminates the hands; this includes after gloves have been removed. Alcohol hand gels and rubs are a practical alternative to soap and water; however, alcohol is not a cleaning agent. Hands that are visibly dirty or potentially grossly contaminated must be washed with soap and water and dried thoroughly. Hand preparation increases the effectiveness of decontamination. Whenever feasible, staff should have access to the means to clean their hands at the point of care; where possible soap and water should be used. However, this is not always possible with the placement of sinks or access to sinks in the home. The ability to clean the hands is possible when the midwife uses alternative methods.

Detergent wipes should be used if soap and water is not available and this should be followed by drying the hands thoroughly with paper towels or air drying; then alcohol gel can be used. Only use alcohol gel if the hands are visibly clean; using alcohol gel on contaminated hands renders the solution ineffective. Detergent wipes and hand rubs should be readily available at the point of care; if not, the chance of using them will be lost and hands will retain potentially dangerous microbes. Alcohol gel should be used between different care activities with the woman or baby.

The midwife should keep nails short, clean and polish free and should avoid wearing wristwatches and jewellery, particularly rings with ridges or stones. Artificial nails must not be worn and any cuts and abrasions must be covered with a waterproof dressing.

Wristwatches and any bracelets should be removed and long sleeves rolled up before washing the hands and wrists. The NHS has implemented a ‘naked below the elbows’ rule that has banned healthcare workers from wearing long sleeves, wrist watches and jewelry to promote effective hand and wrist washing; this includes the avoidance of wearing ties when carrying out clinical activity.

Hospitals are unique places that differ considerably in terms of the risk of potential infection spread when compared to a ‘normal’ home environment. While risks occur wherever direct contact between people or equipment happens, inpatient hospitals have a large number of people who are living in a small physical area. Moreover, those being cared for may have direct contact with a large number of people as a result of their on going care needs, allowing for many more opportunities for micro-organisms to be spread from one person to another than would normally occur at home. Some of these micro-organisms may be resistant to antibiotics.

Figure 2.2 demonstrates the correct technique for hand washing.

The five moments of hand hygiene (Figure 2.3, which can be found in the Appendices at the end of the book) define the key times, providing a standardised approach to hand washing that is simple and straightforward.

Along with an understanding of hand hygiene, the midwife must also understand how infection is transmitted. Knowing how and when to apply the fundamental principles of infection prevention is key to controlling infection.

Service user’s view

‘I was scared of coming in as you hear all sorts about infection but my midwife made a point of washing her hands each time she touched me and she made sure everyone else did as well!’

Comment from mother of twins

Key references and further reading

Dougherty L, Lister S (2015)

The Royal Marsden Manual of Clinical Nursing Procedures: Professional Edition

, 9th edn. John Wiley & Sons, Ltd., Oxford.

Loveday H, Wilson JA, Pratt RJ,

et al

. (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England.

Journal of Hospital Infection

, 86, S1–S70.

National Institute for Health and Care Excellence (NICE)

Quality Statement 3: Hand Decontamination

(QS61). Available at:

https://www.nice.org.uk/guidance/qs61/chapter/quality-statement-3-hand-decontamination

3Infectious diseases in pregnancy

The midwife’s responsibilities start with familiarity with which pathogens to consider and awareness of where to refer women. In the unwell woman, knowledge of symptoms as well as investigations that should be instigated at appointments are critical.

Organisms

Non-pathogenic organisms are essential to health. They can be found in the large intestine, referred to as ‘gut flora’, synthesising vitamins and controlling pathogenic organisms. They can be found in the vagina, where lactobacilli cause the mucoid secretions to be slightly acidic thereby preventing the growth of pathogenic organisms. Pathogenic organisms are ones that affect the woman’s health and wellbeing. They could be viruses, bacteria, fungi, protozoa or worms. Pathogenic organisms enter the body by different routes: some will enter via the lungs (respiratory transmission, inhalation); by the gastrointestinal tract (ingestion); into the blood circulation via the skin (inoculation); or through mucosa in the throat or vagina (direct contact). The incubation period is the length of time between the organism entering the body and symptoms appearing.

Physiology

The body has defences against the invasion of pathogens. Skin, sebum, (which contains antibacterial and antifungal properties), normal flora (non-pathogenic organisms) and mucous membranes prevent entry into the body. Ciliated epithelial cells waft unwanted material away. Saliva contains IgA and the stomach produces hydrochloric acid, which kills many swallowed pathogens. The lowered pH of the vaginal mucosa renders the environment hostile to pathogenic organisms.

The main defence against infection is the immune system. It produces phagocytic cells, enzymes and proteins that destroy pathogens.

There are various leucocytes (white blood cells) in the blood. B and T lymphocytes identify pathogens and mark them with a specific protein, indicating that cells with this protein need to be destroyed. Other leucocytes are neutrophils, monocytes, eosinophils and basophils. These are measured in haematological tests and identified by the levels and the ratio of each to the others. Bacterial or viral infections can be identified.

The immune system will, when identifying a specific pathogen, produce antibodies to that pathogen such that if it invades the body a second or subsequent time the antibodies are present to prevent illness occurring.

Pregnant women are vulnerable

Physiological changes in the anatomy in pregnancy make women vulnerable. Gut motility is slower. The pH of the stomach is less acid, so ingested pathogens will not be destroyed so effectively. Non-pasteurised cheese would not cause a problem in the non-pregnant state but in pregnancy the gut may not be able to neutralise the bacteria. The pH of the vagina is changed and pathogens are more able to grow in this less hostile environment. There is a higher risk of infectious disease transmission.

Immune response

In pregnancy, the maternal immune response is altered to permit tolerance of the semiallogeneic fetal–placental unit. This is achieved through the activity of uterine macrophages and regulatory T cells, and effectively protects the fetus from rejection by the maternal immune system. While the changes between T1 and T2 helper cells protect the fetus, this has implications for maternal protection from infection. The maternal immune response is not suppressed but is moderated to accommodate the fetus. This means that pregnant women have increased susceptibility to infections and may suffer more severe consequences if infected. For example, pregnant women with influenza have a higher risk of developing pneumonia. Maternal infection during pregnancy has been linked to an increased risk of brain disorders in the offspring, such as schizophrenia.

Signs and symptoms of infection in women

Table 3.1 lists some common infections and Box 3.1 indicates some signs of infectious disease in women. It is important to note where the rash is, where it started and were it spread to. The same applies if ulceration is present. These observations help with diagnosis.

The midwife should be aware of local or national outbreaks of infectious diseases and needs to be aware of how to prevent the spread of an infectious condition.

At every visit check whether the woman has travelled or lived in a high-risk area. If the woman has a rash, it is advisable that she separated from other pregnant women.

Give advice regarding the prevention or spread of infection. Demonstrate and maintain good practice such as hand washing, wearing of gloves where appropriate and use of Standard Precautions. The midwife should liaise with the infection control specialist nurse in the hospital.

The midwife must screen the woman appropriately. This may mean taking blood or urine samples. The results must be obtained and followed up.

Refer appropriately

If a positive diagnosis is made, the woman may now be considered to have a high-risk pregnancy so more frequent antenatal checks are required. Obstetric input together with skills from the virologist, fetal medicine specialist, neonatologist and GP are required. The woman (and partner) need to be informed of the risks of suspected or diagnosed infections.

A multidisciplinary meeting should be convened to discuss management of the woman and baby.

The midwife should remain up to date on diagnosis and vaccines that are becoming available. Postnatally the woman can be vaccinated against some infectious diseases but the midwife must check the suitability of vaccines if the woman is breastfeeding.

Service user’s view

‘We were asking them a lot about the baby and is everything alright, she says, “look, what we can see now is fine, you are like a normal pregnancy, don’t be worrying about it” ’

Kelly et al. 2013

Key references and further reading

Bothamley J, Boyle M (2015)

Infections Affecting Pregnancy and Child Birth

. Radcliffe Publishing, London.

Department of Health (2011)

Tuberculosis, Chapter 32. Immunisation Against Infections Diseases; the Green Book

. Department of Health, London. Available at:

www.gov.uk/government/publications

Gillespie SH, Bamford K (2012)

Medical Microbiology and Infection at a Glance

, 4th edn. Wiley Blackwell, Oxford.

Health Protection Agency(HPA) (2011)

Guidance on Viral rashes in Pregnancy

. Available at:

www.hpa.org.uk/webc/HPAwebFile/HPAweb

Kelly C, Alderdice F, Lohan M, Spence D (2013) Every pregnant woman needs a midwife – the experiences of HIV affected women in maternity care.

Midwifery

, 29, 132–138.

World Health Organisation (2016)

Zika Virus Fact Sheet

. Available at:

www.who.int/mediacentre/factsheets/zika/en/

World Health Organisation (2017)

Zika Virus and Complications

. Available at:

www.who.int/features/qa/zika/en/

4Modes of transmission

When micro-organisms have been transferred from one person to another, from equipment or the environment to people or between staff, infection can occur. If there are any disorders of the person’s ‘normal bacterial flora’ this may predispose that person to infection. A woman is put at risk when bacteria are transferred from one part of her body to another where they are not usually resident, such as the movement of faecal bacteria from the perineum to the face during washing, or the administration of medication without performing hand hygiene or failing to change gloves in between caring for women.

Modes of transmission

Infectious agents are biological agents that have the potential to cause disease or illness in their hosts. Women and healthcare workers are often the most likely sources of infectious agents and are usually the most common susceptible hosts. Visitors and those working in healthcare may also be at risk of both infection and transmission.

Box 4.1 outlines the modes of transmission. Figure 4.1 illustrates the transmission of pathogens.

Disease prevention

Standard precautions

Standard precautions refer to those work practices applied to everyone, despite their perceived or confirmed infectious status; they aim to ensure a basic level of infection prevention and control. Standard precautions should be applied as a first-line approach to infection prevention and control, minimising the risk of transmission of infectious agents from person to person, even in high-risk situations.

Transmission-based precautions

The use of standard precautions is the first line of prevention of infection.

Transmission-based precautions are additional work practices for specific situations where standard precautions are inadequate to interrupt transmission. These precautions are adapted to the particular infectious agent and its mode of transmission.

Personal protective equipment

Personal protective equipment (PPE) is a requirement of health and safety legislation and is used to protect healthcare workers and women from risks of infection. The risk of infection is reduced by preventing the transmission of micro-organisms to the woman via the hands of staff or visa versa. The common types of PPE include items such as gloves, aprons, masks, goggles or visors. The decision to use PPE is based on a risk assessment.

Sharps

The safe handling and disposal of sharps are essential features of infection prevention and control. Sharps will include needles, scalpels, stitch cutters, glass ampoules and any sharp instrument. The chief hazards of a sharps injury are blood-borne viruses, such as hepatitis B, hepatitis C and HIV.

Unsafe or poor practice can cause injury to the individual or others, for example laundry workers who experience injuries as a result of sharps being misplaced in used linen. Sharps injuries can be prevented and learning after an incident can help to avoid recurrence. It is essential that sharps are used safely and disposed of carefully and staff must work to agreed policies regarding the use of sharps to reduce the risk of injury and exposure to blood-borne viruses.

Disposal of waste

Waste created by staff in the line of their work can include sharps, hazardous, offensive, municipal (household) and pharmaceutical (medicinal) waste. Reducing waste, segregation and disposal is key to maintaining a healthy environment and reducing the risk of ensuing public health implications.

Healthcare organisations and local authorities have policies on waste segregation and disposal, offering guidance on all aspects, including special waste, pharmaceutical waste and segregation of waste. This includes the colour coding of bags used for waste.

Spillage

When blood and bodily fluids have been spilt these must be dealt with quickly and with adherence to local policy and procedure for dealing with spillages. Policy and procedure dictate the chemicals to be used, ensuring that any spillage is disinfected correctly, taking into account the surface where the incident occurred.

Asepsis and asepsis technique

The aim of asepsis is to prevent or reduce micro-organisms from entering a vulnerable body site such as a surgical wound, an intravenous catheter or during the insertion of an invasive device, for example a urinary catheter. Asepsis reduces the risk of an infection developing as a result of the procedure that is being undertaken.

Aseptic technique includes a series of specific actions or procedures carried out under controlled conditions. The ability to control conditions varies according to the care setting; the principals are summarised in Box 4.2. These should be applied in all cases.

Indwelling devices

Intravascular or invasive devices, for example urinary catheters, IV cannulae or central venous catheters, are often responsible for healthcare acquired infections (HCAIs) such as urinary tract, insertion site infections or bloodstream infections. When these devices are used correctly they offer valuable assistance in providing care to the woman along with positive care outcomes. However, these devices are not without risk and the development of infection can occur as they bypass the body’s natural defence mechanisms such as skin and mucous membranes.

In order to ensure that the device is functioning effectively and to detect any signs or symptoms of infection, day to day management is essential and local policies and procedures must be adhered to. This includes, at a minimum, a documented daily review assessing the continuing need for the device, and regular documented checks for patency of the device, signs of infection and condition of the dressing. Implementation of hand hygiene prior to any contact with the device or associated administration sets must occur, and also cleaning/disinfection of any add-on devices/attachments and the replacement of peripheral intravascular devices after 72 hours (or as per local policy) or sooner depending on the woman’s individual needs.

Key references and further reading

Dougherty L, Lister S (2015)

The Royal Marsden Manual of Clinical Nursing Procedures: Professional Edition

, 9th edn. John Wiley & Sons, Ltd., Oxford.

Loveday H, Wilson JA, Pratt RJ,

et al

. (2014) epic3: National 
Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England.

Journal of Hospital Infection

, 86, S1–S70.

National Institute for Health and Care Excellence (NICE) (2014)


Infection Prevention and Control

(QS61). Available at:

https://
www.nice.org.uk/guidance/qs61/resources/infection-prevention-
and-control-2098782603205

Weston D (2013)

Fundamentals of Infection Prevention and Control: Theory and Practice

, 2nd edn. John Wiley & Sons, Ltd., Oxford.

5Asepsis 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.