Introduction
Women are still dying postpartum, even as medicine and technology advances. Globally sepsis was the most common cause of direct maternal death between 2006 and 2008 (Wray and Steen, 2014), and within the UK sepsis was the second leading cause of maternal deaths between 2012-2014 (Gallagher, 2018), signifying a high level of women becoming contaminated with harmful bacteria during these periods. The World Health Organisation (WHO) (2018) advise that there are two techniques to prevent sepsis. Preventing infection in the community, is the first listed and can be achieved through effective hygiene procedures, specifically hand washing, which is a fundamental Infection Prevention Control (IPC) (WHO 2018) as it disrupts one of the five requirements for healthcare associated pathogens to transmit to a patient through healthcare worker’s (HCW) hands (Appendix 1) and thus is a skill which all midwifes should conduct ritually.
History
Semmelweis was an innovator for the improvement of IPC through handwashing, his interest igniting during his time at Vienna General Hospital where he supervised students and medical autopsies in the 1840’s. During this time childbed fever was a deadly condition affecting women in Europe (Pittet and Allegranzi, 2018). Translated excerpts from The Etiology, Concept and Prophylaxis of Childbed Fever, document Semmelweis observation of a much higher mortality rate in a ward overseen by doctors and medical students, than a ward which midwives were responsible for, averaging three times greater over a six-year span (Semmelweis, 2008). It should be noted that in addition to working on the ward, the medical students and doctors came into contact with cadavers whilst conducting autopsies (Pittet and Allegranzi, 2018).
Semmelweis was able to conclude the increased rate of mortality was due to the women becoming contaminated with cadaverous particles carried on both the medical students and doctor’s hands following the death of Jakob Kolletschka, whose finger had been pricked by a knife a student had also used on a cadaver (Semmelweis, 2008).
After the initiation of hand scrubbing by Semmelweis on the 15TH May 1847, there was an instant reduction of morbidity rates (Semmelweis, 2008).
In 1848 a female cancer patient was examined who had persistent discharge. All but one of the women examined immediately after her contracted childbed fever. Semmelweis theorised that necrotic discharges from living patients was also able to spread disease, thus hand scrubbing should occur between each patient (Semmelweis, 2008), a regulation which is campaigned by WHO in their ‘My 5 moments for hand hygiene’ today (WHO, 2018). Prior to the global recognition of the importance of handwashing by WHO, an evolution in the development of hand hygiene in healthcare occurred in the 1980’s, with the first publication of national guidelines on hand hygiene (Bjerke, 2004). Nevertheless, many decades on from this breakthrough development, implementation is still not entirely adhered to, resulting in half of healthcare associated infections potentially being avoidable (Pittet and Allegranzi, 2018). If correct IPC programmes were followed sepsis could be reduced (WHO, 2018), not only benefiting the mother’s health and her family’s lifestyle, but also contributing to target 3.1 of the Sustainable Development Goals (United Nations, 2018).
Hand hygiene procedures
WHO (2018) state handwashing is of the upmost importance for the prevention of infections acquired through receiving healthcare, resulting in the deaths of thousands of people daily. Nationally for midwives, hand hygiene is an integrated part of the very foundations they must practice towards, the Nursing and Midwifery Council (NMC) Code (2018). The NMC Code (2018) states that a midwife must “preserve safety”, further detailed as being “aware of, and reduce as far as possible, any potential for harm associated with your practice”. Additionally, another underpinning of the NMC Code is to “promote professionalism and trust”, particularly through maintaining the standards laid out in the Code and being aware of the impact of your behaviour on others.
“Your 5 Moments for Hand Hygiene’ championed by WHO (2018), acknowledges five instances when hand washing is imperative (Appendix 2). The first moment protects the woman from any harmful bacteria on your hands being transferred to her. An obvious time when this may be practised is before delivering care, such as taking observations, however aiding the woman with personal actions including moving, are interactions which shouldn’t be overlooked. The second moment prevents harmful germs from penetrating the woman through her body. Hands should be cleaned immediately prior to the procedure, for instance a C-section, or when using medical instruments to aid with delivery such as forceps, as well as prior to conducting vaginal examinations. The third, fourth and fifth moments are necessary to both protect yourself from becoming contaminated with the woman’s potentially harmful germs, whilst also preventing the spread of bacteria to the healthcare environment. In relation to moment three, hands should be cleaned as soon as the task has ended, even if gloves have been worn. Instances when this is relevant to a midwife include the insertion or removal of a catheter, or after handling urine samples. Moment four, requires hands to be cleaned once you have left the patient if you have touched her. Examples of these instances are the same as mentioned in moment one. The last moment can apply even if you haven’t had physical contact with the woman, as her bed or other inanimate object may be contaminated. It is advised to minimise this risk not to lean on the woman’s bed or chair which she is using, however there are instances when you cannot avoid touching an object, including when changing their bedding. It is critical to be aware that all of the moments require hand washing to be conducted regardless of whether or not gloves were worn.
In addition to the worldwide principles, the National Institute for Health and Care Excellence (NICE) (2012) included the measure that hands are to be washed before and immediately after the removal of gloves, and that when providing direct care, professionals should be bare below the elbows. Benefits, technique and when applicable to wash hands should be understood and be reinforced by an appropriate supply of hand decontamination resources.
Additional indications for decontaminating hands recognised by midwives include prior and after handling food, immediately following exposure to bodily fluids, after using the toilet and specifically hand washing should be conducted after using handrub several times consecutively (Johnson and Taylor, 2016).
General maintenance of your hands works in conjunction with effective hand washing. It is important prior to a shift to inspect your hands for grazes or cuts, as well as torn nail cuticles, as the midwife’s own health is at risk if an infection is ascertained through the open wound, thus the correct waterproof dressing should be applied if any are found. Nails must be short, with any ragged nails filed down and false nails are not permitted. This is not only beneficial from an infection control perspective, as bacteria can harbour under the nails, but also protects the mother and baby from being scratched whilst the midwife is performing an examination or giving care, thus creating an open site for harmful pathogen to enter their body. The use of hand moisturisers will aid in the prevention of hands drying out and skin breaking (Johnson and Taylor, 2016).
Prior and during washing hands there should be minimal contact with the sink, taps, soap dispensers and hand driers, especially after washing hands. Procedures to aid this are using the elbows to turn off taps and having access to bins which are operated with a foot pedal. The water used to wash hands should be warm. Hot water can expose the midwife to potential skin irritation due to the pores opening up. Special care should be paid to avoid water coming into contact with the midwife’s clothes, as bacteria thrives in moisture (Johnson and Taylor, 2016).
Appendix 3 details the correct procedure to perform a medical/social scrub. The removal of all jewellery has an exception of a plain wedding band, with this step also coinciding with protocol that a midwife should always be bare below the elbows. A medical/social scrub should always be used if hands are visibly soiled and is advised to take between 40 and 60 seconds (WHO, 2018). If hands are not visibly soiled an alcohol-based formula may be used to wash the hands, the procedure being outlined in appendix 4. When using a hand rub approach, the technique should take between 20 to 30 seconds (WHO, 2018). An exception to the rule of being able to use alcohol-based rub to clean hands when they are not soiled occurs when midwives come into contact with women who have Clostridium difficile (C. diff). C. diff is a bacteria which can cause diarrhoea due to the bowel becoming infected and to prevent this bacteria being transmitted through HCW’s hands, hand washing must be conducted as alcohol-based formulas are not effective (NHS, 2018).
A surgical hand scrub (appendix 5) can occur in delivery rooms in addition to operating rooms where a patient may undergo a C-section (Bjerke, 2004). It is a more extensive procedure to remove dirt, transient bacteria, transient flora and reduce resident flora, in case of an event where a glove tears and the HCW’s skin comes in contact with the patient. Surgical procedures last between 2 to 6 minutes, irrespective of how many surgical scrubs have already been undertaken (Bjerke, 2004). Hands must be kept away from the HCW’s uniform, with a sterile towel used to dry the disinfected area (Mangram et al, 1999).
Compliance
The NMC Code (2018) states that midwifes should “always practise in line with the best available evidence”, however studies by WHO (2009) found that there was a wide variance of hand washing practice, although it should be acknowledged that opportunities for hand hygiene will vary depending on the care required.
Pittet (2001) listed reasons for not fully committing to practicing hand hygiene as prioritising the wearing of gloves and insufficient time. The second stage of labour can range from 3 hours to only lasting a few minutes (Rankin, 2017). This unpredictability may catch midwives out on occasion, thus correct hand hygiene protocol may not always be conducted. Staffing levels and extreme workload are other reasons for not washing hands (Pittet, 2001). This idea is reinforced by a midwife shortfall of 3,500 both this and last year (RCM, 2018). Additionally, a lack of understanding of guidelines is given for poor adherence (Pittet, 2001), yet all midwives must complete hand hygiene training under the Health and Social Care Act 2008 (Parliament of the United Kingdom, 2008). Lastly, WHO (2009) recognise that poor compliance may also run in accordance with limited resources, thus having the correct facilities in optimum places is necessary, which is why local NHS trust guidelines state there should be sufficient facilities to encourage washing of hands amongst staff (Hull and Jones, 2015). However, the guidelines do not take into consideration when midwives are working within the community. When conducting appointments at a woman’s house, the midwife’s ability to wash their hands correctly is reliant upon each individual woman being able to provide adequate handwashing facilities, if not they may only be able to use alcohol-based formula which they can carry themselves, and as mentioned previously this may not be sufficient in all situations.
Although not individually recognised as midwives, the statistics for nurses in general compliance with handwashing is much greater than other physicians, 48% compared to 32%. However, compliance was only 21% prior to patient contact compared to after patient contact, with a 47% compliance rate (Erasmus et al., 2010). This statistic is concerning when relating to midwifes working within the community. Even if hands are washed after seeing the first woman, on leaving her to travel to the next woman the midwife will come into contact with various objects which may contain harmful bacteria, which she will contaminate the next woman with if the low compliance rate is perceived to be an accurate perception that the midwife won’t wash her hands again. Furthermore, for midwifes working within a hospital environment, when conducting care on the wards the beds are often close together and are separated by curtains. The midwife may have washed her hands after completing her care with the first woman, however the moment the midwife touches the curtains to access the next woman she has contaminated her hands, passing on harmful bacteria to the woman whilst giving care if hands aren’t washed again.
Hand hygiene initiatives
WHO introduced their first global initiative to address HCAI in 2005, centring around hand hygiene for HCWs. This was extended upon in 2009 with the “SAVE LIVES: Clean Your Hands” campaign, which had a continual focus on hand hygiene on a global platform, filtered down to address hand hygiene improvements, regionally, nationally and locally for HCWs. This project reiterates the “My 5 Moments for Hand Hygiene”. Continuous training for HCWs should be provided, reinforced by reminders in the workplace (WHO, 2018). In accordance with the Health and Social Care Act 2008 (Parliament of the United Kingdom, 2008) local trusts, e.g. UHL (Hull and Jones, 2015) adhere to these recommendations, thus all midwifes should have access to the components mentioned within WHO (2009) guidelines. This year WHO’s campaign is even more prominent to midwifes as it addresses the link between hand hygiene and sepsis.
Conclusion
In conclusion effective hand hygiene is of the upmost importance. The midwife is responsible for acknowledging when and how they need to decontaminate their hands (Johnson and Taylor, 2016). The ability to conduct both of these responsibilities with competence is facilitated by NHS trusts who provide necessary supplies of equipment in line with NICE (2012) guidelines. Due to both low compliance rate and substandard hand hygiene techniques, highlighted in one observational study where hand washing times ranged between 6.6 to 30 seconds (Allegranzi, Stewardson and Pittet, 2017), initiatives to implement the importance and correct practice of hand hygiene are relevant. A focus on understanding barriers to compliance both locally and nationally, alongside highlighting incorrect views of personal performance will aid in the reduction rates of HCAI. Practising the NMC Code (2018), understanding the affect your conduct can have on peers and using this to be a platform for positive influence to encourage correct hand hygiene protocols, will not only improve the safety of midwives and their colleagues against HCAI but also the mother and her infant.