Dear Maggie
Clare Winter and Margie Duff wrote a chapter on this issue in my edited book, Childbirth, Midwifery and Concepts of Time. You might find it interesting to read.
Dr. Christine McCourt
Professor of Maternal and Child Health,
City University
Alexandra Building
Philpot Street
London, E1 2EA
Mobile: 0791 235 1476
Email: [log in to unmask]
Tel: 0207 040 5863
Skype: chrismccourt
________________________________________
From: Maggie Banks [[log in to unmask]]
Sent: 25 October 2010 22:28
To: [log in to unmask]
Subject: Re: Aseptic technique and normal birth
Mary, I have read the JAN article you wrote but would be very interested to read your thesis. Is it available online?
While I know Pam was looking specifically at asepsis as far as avoiding infection goes, there is a very hidden side to vaginal examination as far as contamination goes and that is the contamination of birthing and midwifery with medicalisation. If one approaches midwifery care from a well woman or wise woman model then one avoids this ‘break and enter’ strategy and its routine ‘body as a machine’ strategies. There will of course always be an isolated incident when vaginal examination is necessary but why aren’t student midwives taught first line strategies for assessing labour – red/purple line, spinal curvature, heat, energy, behaviour and so on – and VE left to the once in a blue moon strategy? After all, how often does VE tell you something different to what you already know? I have often discussed this with educators and midwives providing practical experience for students and it is clear that non-invasive strategies are seen as alternatives to learn only after one is very experienced with VEs. Doesn’t this continue to value other than both the woman’s and the midwife’s wise woman knowing?
kind regards
Maggie Banks
Check out Birthspirit Midwifery Journal<http://www.birthspirit.co.nz/BirthspiritMidwiferyJournal/Issue5.php>
Birthspirit’s Mind, Body and Spirit Workshop<http://www.birthspirit.co.nz/Education/Intensives/Mind%20Body%20&%20Spirit%202010.php> 23-29 January 2011
15 Te Awa Road, RD 3, Hamilton 3283, New Zealand
Phone 64 7 8564612; Fax 64 7 8563070; Email [log in to unmask]
From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Lahiffe, Kathleen
Sent: Saturday, 23 October 2010 3:41 a.m.
To: [log in to unmask]
Subject: Re: Aseptic technique and normal birth
Excellent points, reflection and obvious discussion on a highly pertinent aspect of midwifery !
Thank you all for this great thread- lets keep asking the questions and give mothers a moral space to give their views and fully informed consent on this issue.
Kathleen
Midwifery/ Nurse Advisor
Ireland
-----Original Message-----
From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Stewart, Mary
Sent: 22 October 2010 11:24
To: [log in to unmask]
Subject: Re: Aseptic technique and normal birth
Thank you for this, Jenny! Yes, I have been fascinated by the discussion thread. My particular area of interest is vaginal examination in labour, rather than the birth itself. However, here are some random thoughts from my PhD, and reflections over the past few years …
There is no clear evidence that supports washing of the woman’s genitalia prior to vaginal examination. This doesn’t necessarily mean that washing is wrong or unhelpful, but it does mean that there is no clear evidence of its benefits. Vaginal examination is, by definition, an action that introduces a foreign object into the woman’s vagina so therefore the primary consideration must be whether the procedure actually needs to be done in the first place – is there a clear clinical indication (rather than simply following a meaningless timetable)? Has the woman given explicit consent – and, most importantly, does she not what the procedure entails? (We tend to shy away from explaining what is involved and use unhelpful and vague language. A common expression that midwives may use is ‘I’m just going to examine you, OK?’ This is problematic on three levels – the use of the word ‘just’ minimises the procedure; it assumes consent (‘OK’?); and, reasonably, women think that ‘an examination’ simply requires the midwife to look at the woman).
In my research, some midwives described with great pride the ‘wash down’ that they did prior to vaginal examination. This was a highly ritualised procedure. Of course, the wash down may be used a distancing/desexualising strategy – it is a technique that the midwife uses to denote that this is a strictly professional encounter and it serves to give ‘permission’ for touching a woman in this most intimate way. Of course, that in itself is highly problematic and flawed logic – however, I think it is a useful reminder that, as health professionals, we don’t tend to deal well with bodily taboos. There is a rich body of literature that highlights these issues in detail. My main concern is that we don’t always prepare students well enough for the ‘body work’ that they will do. I think discussions need to run throughout midwifery training along the lines of:
How do I feel about my own body?
How do I feel about touching my own body? (because surely we needed to feel comfortable touching ourselves before we can consider touching other women)
How do I feel about seeing other women’s naked bodies?
How do I feel about touching women’s bodies?
Etc etc. It’s all difficult stuff, with the potential to cause distress, embarrassment etc but I think it’s fundamentally important that we can have those conversations.
Finally (though I could discuss this endlessly), and on a slightly lighter note: In the trust where I worked previously we were advised to use non-sterile gloves if doing a vaginal examination on a woman with intact membranes. (I have to say I think the advice was simply based on economic considerations). I noticed that, though midwives followed this policy, they would always put two gloves on, even though they didn’t do a ‘wash down’, and therefore were only using one hand – so what’s that all about?!
Very best wishes
Mary
Mary Stewart
Consultant midwife
Room J334
Chelsea and Westminster Hospital NHS Foundation Trust
369 Fulham Road
London SW10 9NH
Tel: 07872 423085
________________________________
From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of jenny hall
Sent: Thursday, October 21, 2010 6:56 PM
To: [log in to unmask]
Subject: Re: Aseptic technique and normal birth
Hello
This is an interesting discussion and I am sure Mary Stewart on this list would like to contribute with her PhD work on vaginal examination? Her paper in the Journal of Advanced Nursing 2005 51 (6) 587-594 raises theses issues around cleansing and power.
‘I'm just going to wash you down’: sanitizing the vaginal examination
Best wishes
jenny
Jennifer Hall
The Practising Midwife
For information on subscriptions, advertising and contributors guides please contact [log in to unmask]<mailto:[log in to unmask]> or www.thepractisingmidwife.com<http://www.thepractisingmidwife.com/>
________________________________
From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Scamell, Amanda
Sent: 21 October 2010 18:31
To: [log in to unmask]
Subject: Re: Aseptic technique and normal birth
Hi all,
Great thread, it makes fascinating reading thanks everyone.
I think Christine's reference to Kirkham's work in this context raises an interesting point in relation to this issue which coalsces, to my mind at least, around understandings of location of risk.
If, as Sandra's and Maggie's posts suggest, the risk of contamination is thought to originate in the body of the mother, then I would venture that it's reasonable to assume that asceptic techniques have a suspicious grounding both politically and empirically? On the other hand, if we as midwives are the source of the contamination, through our active interventions under the auspices of surveillance during the spontaneous birth process (that is to say, if we are talking about iatrogenic risks here) then Maggie's point that such hazards can be largely overcome, not through compliance to strict asceptic techniques, but conversely, through the avoidence of those practices which render us a threat to both mother's and baby's well being, I think is a powerful one. I guess what I'm trying to say here is, couldn't professional concerns around this issue this be a window of opportuity for a reduction in the intensification of the medicalisation of normal birth rather than the other way round?
In an attempt to answer my own question, perhaps the answer lies in why midwives think asceptic technique are important in spontaneous, physiological birth in the first place? Clarification on that gratefully received.
Mandie Scamell MA, BA, RM
Midwifery tutor
King's College London
James Clerk Maxwell Building
57, Waterloo Road
London
SE1 8WA
0207 848 3580
________________________________________
From: A forum for discussion on midwifery and reproductive health research. [[log in to unmask]] On Behalf Of McCourt, Christine [[log in to unmask]]
Sent: 21 October 2010 09:55
To: [log in to unmask]
Subject: Re: Aseptic technique and normal birth
Dear all
Just throwing a more anthropological angle on this, there are some good articles in Mavis Kirkham's edited book 'Exploring the Dirty Side of Women's Health' including 'Birth Dirt' by Helen Callaghan and 'A clean front passage' by Pamela Wood and Maralyn Foureur
Chris
Dr. Christine McCourt
Professor of Maternal and Child Health,
City University
Alexandra Building
Philpot Street
London, E1 2EA
Mobile: 0791 235 1476
Email: [log in to unmask]
Tel: 0207 040 5863
Skype: chrismccourt
________________________________________
From: Ebanks Sandra [[log in to unmask]]
Sent: 21 October 2010 09:21
To: [log in to unmask]
Subject: Re: Aseptic technique and normal birth
Hi,
Delivery is not an aseptic technique. The vagina is not sterile. We do not wear sterile gloves for delivery it is a clean procedure. If suturing is required we wear sterile gloves.
________________________________
From: A forum for discussion on midwifery and reproductive health research. on behalf of margy hughes
Sent: Wed 20/10/2010 11:52
To: [log in to unmask]
Subject: Re: Aseptic technique and normal birth
Dear All,
This comment/question may seem very basic, but it is something I have a problem with in maintaining aseptic technique:
When caring for a woman who is classed as low risk, (ie: no CTG running) and if there is no one else available to auscultate the FHR during second stage, at what point do I put my sterile gloves on? At one time, Infection Prevention did not cavil at double gloving (stripping off the top glove for delivery); now it forbids it.
I would be very grateful for other Midwives sharing how they manage this (without using ten pairs of gloves!)
Thanks and regards,
Margy Hughes
________________________________
Date: Wed, 20 Oct 2010 09:59:33 +0100
From: [log in to unmask]
Subject: Re: Aseptic technique and normal birth
To: [log in to unmask]
Dear Pam and Kathy,
We have 'standards' imposed by the general nursing side about infection control.
After being in the UK NHS since 1977 when I first learnt aseptic technique I was assessed by a colleague who deemed me 'passable'.
In hospital though we have to remember we are not in an ideal environment as Florence taught us 'hospitals should do the sick no harm' http://womenshistory.about.com/cs/quotes/a/qu_nightingale.htm
Most importantly is maintaining the environment in hospitals and standards of clinical hygiene especially when a lot of midwives are pushed to deliver care with inadequate support workers, and or clinical cleaners. Who's role is grossly underestimated in the protection against infection.
I work in a flagship hospital, with a raising birthrate, it is important to maintain basic standards. Eventually we will run out of effective antibiotics then where will we be?
Regards,
Lorraine
--- On Tue, 19/10/10, Kathy Carter-Lee <[log in to unmask]> wrote:
From: Kathy Carter-Lee <[log in to unmask]>
Subject: Re: Aseptic technique and normal birth
To: [log in to unmask]
Date: Tuesday, 19 October, 2010, 10:25
Pam I too have no research, but I am glad you are looking into it as I think aseptic technique is an important issue to think about.
A few thoughts:
At a basic level universal prevention of infection measures are important. Having worked a short time in a labour ward during my time in Afghanistan, I feel great sympathy for staff there who are expected to give care where water, supplies and systems do not support such care. On one night shift I worked there were clean (possibly sterile) instruments and clean linen for 6 births, when perhaps 20 or more births could be expected. In such an environment people do the best they can and end up protecting themselves from contamination and possible infection. Here on the other hand, in my care as a caseloading midwife (at home, in birth units and in hospitals), I find myself thinking around the 'infection prevention' side of my care for women much more in terms of preventing myself or the environment passing on anything that might threaten to disturb the woman's natural balance of organisms.
Thanks
from
Kathy Carter-Lee
Caseloading MW, NZ
>
> Hi Pam, no research but over 2 decades of experience that when the woman is well, invasive
> procedures (VE, ARM, FSE) are not used and the environment has familiar organisms (woman's
> own home), postnatal uterine or vaginal infection is extremely rare - and this is with a high
> proportion of waterbirths.
>
> I can't say I have ever worn a sterile apron or glasses. Definitely clean clothes for each birth
> attendance (and each day J). Hand washing is soap and water, and dried with the woman's
> bathroom towel - but I do not examine cadavers before attending women in labour!
>
> It's important to remember that exposure to blood and secretions is about 'delivery' and not
> about supporting women to give birth where the woman catches her own baby, wipes the baby
> down, births the placenta in a bucket in an active birth position (rather than lying on a bed with
> blood and other body fluids all over her back, buttocks and upper legs), and she cares for her
> own hygiene postnatally.
>
> It's important to teach the historical context but isn't asepsis (as a concept) contextual to care.
>
> kind regards
> Maggie Banks
> Check out Birthspirit Midwifery Journal
> Birthspirit's Mind, Body and Spirit Workshop 23-29 January 2011
> 15 Te Awa Road, RD 3, Hamilton 3283, New Zealand
> Phone 64 7 8564612; Fax 64 7 8563070; Email [log in to unmask]
>
>
> From: A forum for discussion on midwifery and reproductive health research.
> [mailto:[log in to unmask]] On Behalf Of Pamela Harnden
> Sent: Tuesday, 19 October 2010 1:37 p.m.
> To: [log in to unmask]
> Subject: Aseptic technique and normal birth
>
>
> Hi everyone,
>
>
>
> I am currently writing an online module for student midwives covering aseptic technique
> and infection control.
>
>
>
> I came across this in their recommended text book , Skills for Midwifery Practice,
>
>
>
> "It is important that delivery is an aseptic procedure for both the woman and the baby to
> reduce the incidence of postnatal infection. The midwife will use a sterile delivery pack,
> establishing a sterile field both on the working surface and in the area of the woman's
> perineum"p.216
>
>
>
> Whilst I agree that there needs to be adherence to hand washing, aprons, sterile gloves
> and eye protection I am concerned about aherence to an aseptic technique.
>
>
>
> I have attempted a search of CINAHL database regarding asepsis and normal birth.
>
>
>
> There were a couple of results,
>
>
>
> Roberts, J., Hammes, B., & Gundersen, J. (1986). Professional attire at delivery: effect on
> postpartum and neonatal infection. Journal of Nurse-Midwifery, 31(1), 16-19.
>
>
>
> "The implementation of many hospital alternative birthing centers has been accompanied
> by a relaxation in the use of surgical drapes or sterile professional attire. To determine if
> the use or nonuse of sterile attire was accompanied by any difference in postpartum
> maternal or neonatal infectious morbidity, a retrospective review of records for 1 year
> was done in a hospital that permits variation in professional attire for spontaneous birth
> to women at low obstetric risk. A comparison of the incidence of standard features of
> morbidity among six practitioners and three attire groups revealed no differences. Until
> contrary documentation is available, this supports the safety of allowing variation in
> attire under circumstances of low obstetric risk and minimal intervention deliveries"
>
>
>
> Cronin, W., Quansah, M., & Larson, E. (1993). Obstetric infection control in a
> developing country. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing,
> 22(2), 137-144.
> "In Ghana, infection has been identified as a major cause of birth-related mortality.
> Results of a 2-month observation of infection control practices among Ghanaian obstetric
> nurses and midwives indicated that most personnel did not practice basic rules of asepsis.
> Problems included frequent breaks in technique, inadequate sterilization and disinfection,
> and repeated exposure to large amounts of blood and vaginal secretions. Supplies were
> limited and, even when available, not always used appropriately.. The situation in
> developing countries is different from that in the United States. Therefore, an
> observational needs assessment is essential to plan relevant and practical measures for
> change."
>
>
>
> I wondered if anyone knew of any research regarding modern use of aseptic technique
> during normal birth and whether it is strictly adhered to
>
>
>
> many thanks
>
> Pam Harnden
>
> --
> Pam Harnden
> http://pamdh.wordpress.com
> http://www.facebook.com/#/pages/Young-Mums-and-Maori-Antenatal-
> Classes/180461813792?ref=sgm
> http://pamdh.blip.tv/
> http://midwifeblogger.blogspot.com
> http://www.youtube.com/Midwifepam
> http://nzmidwiferypractisingreflection.blogspot.com
> http://midwifepam.wikispaces.com
> http://www.google.com/profiles/Pam.Harnden
>
>
==============================
Kathy Carter-Lee
Midwife
Mobile: 021 425 115
Home: 09 425 6749
Warkworth Birthing Centre: 09 425 8201
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