Infection Prevention & Control, Communicable Disease Surveillance and Antimicrobial Stewardship
Key Takeaways
Standard infection control precautions, including the WHO 5 moments for hand hygiene, apply to every woman and baby, whether or not infection is known.
Suspected notifiable diseases, such as measles, invasive group A streptococcal disease and tuberculosis, must be reported to the local health protection team.
The UK national action plan Confronting antimicrobial resistance 2024 to 2029 aims to reduce infections and use antimicrobials only when they are needed.
Start Smart then Focus means taking cultures before antibiotics, then reviewing every prescription at 48 to 72 hours to stop, switch, change or continue.
RCOG GTG36 recommends intrapartum benzylpenicillin 3 g IV, then 1.8 g every 4 hours, for women with group B streptococcus in the current pregnancy.
Infection Prevention & Control, Communicable Disease Surveillance and Antimicrobial Stewardship
The Future Midwife standards require midwives to demonstrate effective health protection by applying the principles of infection prevention and control, communicable disease surveillance, and antimicrobial resistance (AMR) and stewardship (3.10). Maternal sepsis remains a leading cause of death and serious illness, and newborn babies have immature immune systems, so these principles are central to safe maternity care.
Standard Infection Control Precautions (SICPs)
Standard precautions are used for every person, every time, whether or not an infection is known. In England they are set out in the National Infection Prevention and Control Manual (NIPCM):
- Patient placement and assessment for infection risk, including side rooms for women with suspected transmissible infection.
- Hand hygiene: following the WHO 5 moments:
- before touching a patient;
- before a clean or aseptic procedure;
- after body fluid exposure risk;
- after touching a patient;
- after touching a patient's surroundings. Use alcohol hand rub for routine hand hygiene, but soap and water when hands are visibly soiled or when caring for someone with diarrhoea and vomiting (alcohol does not kill Clostridioides difficile spores or norovirus). Staff are bare below the elbows in clinical areas.
- Respiratory and cough hygiene ("catch it, bin it, kill it").
- Personal protective equipment (PPE): gloves, aprons, gowns, eye protection and masks chosen according to the risk of exposure to blood and body fluids, which is high during birth.
- Safe management of the care environment, equipment, linen and waste.
- Safe management of blood and body fluid spillages, using chlorine-releasing agents for blood spills.
- Occupational exposure management, including sharps safety.
Transmission-Based Precautions
Additional precautions are used when an infection is suspected or confirmed:
- Contact precautions: for example, for some multi-drug-resistant organisms or diarrhoeal illness.
- Droplet precautions: for example, influenza and invasive group A streptococcal infection, with a fluid-resistant surgical mask within close range.
- Airborne precautions: for example, measles, chickenpox and pulmonary tuberculosis, with an FFP3 respirator for staff and a single room (ideally a negative-pressure room).
Sharps Safety and Exposure to Blood
The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 require employers to use safer sharps where practicable and prohibit recapping of needles. After a needlestick injury, the midwife should encourage bleeding, wash the area with soap and running water (without scrubbing or sucking), report the injury immediately and contact occupational health or the emergency department. HIV post-exposure prophylaxis, if indicated, should start as soon as possible and is not usually given after 72 hours.
Communicable Disease Surveillance and Notification
Surveillance is the continuous collection and analysis of data about disease so that outbreaks can be detected and prevented. In England, the UK Health Security Agency (UKHSA) leads health protection. Under the Health Protection (Notification) Regulations 2010, registered medical practitioners must notify the local health protection team of suspected notifiable diseases, and laboratories notify causative organisms. Examples relevant to maternity care include measles, rubella, whooping cough (pertussis), tuberculosis, invasive group A streptococcal disease and food poisoning. Midwives recognise possible cases, isolate where needed, escalate to the medical team and infection prevention team, and support contact tracing.
Screening and Vaccination in Pregnancy
- Infectious diseases in pregnancy screening: HIV, hepatitis B and syphilis are offered to all women at booking.
- Pertussis vaccine: offered in every pregnancy from 16 weeks, ideally by 32 weeks, to protect the baby through maternal antibodies.
- Influenza vaccine: offered at any stage of pregnancy during the flu season.
- RSV vaccine: offered from 28 weeks of pregnancy in the UK, to protect babies from respiratory syncytial virus.
- MMR vaccine: live vaccines are not given in pregnancy. Women without evidence of two MMR doses are offered MMR after the birth.
Group B Streptococcus (GBS)
GBS is the most common cause of severe early-onset infection in newborn babies. RCOG Green-top Guideline 36 recommends intrapartum antibiotic prophylaxis for women with GBS detected in the current pregnancy, a previous baby with GBS disease, or preterm labour. Women with intrapartum pyrexia (38°C or higher) receive broad-spectrum antibiotics that cover GBS. The regimen is benzylpenicillin 3 g IV as soon as possible after the onset of labour, then 1.8 g every 4 hours until birth; clindamycin is used if the woman is allergic to penicillin. Prophylaxis is most effective when the first dose is given at least 4 hours before birth.
Antimicrobial Resistance (AMR)
AMR occurs when bacteria, viruses, fungi and parasites stop responding to medicines that once killed them. It is driven by overuse and misuse of antimicrobials, poor infection control and spread of resistant organisms. Resistant infections, such as extended-spectrum beta-lactamase (ESBL)-producing E. coli in urinary tract infections, make sepsis harder to treat.
The UK's national action plan, Confronting antimicrobial resistance 2024 to 2029, aims to:
- reduce the need for, and unintentional exposure to, antimicrobials (by preventing infection);
- optimise the use of antimicrobials (stewardship);
- invest in innovation, supply and access.
Antimicrobial Stewardship
Stewardship means using the right antimicrobial, at the right dose, by the right route, for the right duration, only when needed. In hospitals, UKHSA's Start Smart then Focus toolkit guides practice:
- Start smart: do not start antibiotics without clinical evidence of bacterial infection; take cultures before the first dose where possible (without delaying treatment for suspected sepsis); follow local guidelines; document the indication, duration or review date.
- Then focus: review every antibiotic prescription at 48 to 72 hours and choose one of five options: stop, switch from IV to oral, change to a narrower-spectrum antibiotic guided by results, continue with a documented review date, or arrange outpatient parenteral therapy.
Examples of stewardship in maternity care include stopping neonatal antibiotics at 36 hours if NICE NG195 criteria are met, using single-dose prophylaxis at caesarean birth, taking a midstream urine sample before treating a urinary tract infection, and following culture results.
The Midwife's Role
Midwives contribute to stewardship and infection prevention by:
- Practising excellent hand hygiene and asepsis (including ANTT) and removing invasive devices such as cannulas and catheters as soon as they are no longer needed.
- Recognising sepsis early and ensuring that antibiotics are given within 1 hour for high-risk women, while also prompting review once results are available.
- Taking appropriate samples (blood cultures, swabs, urine) before antibiotics where this does not delay treatment.
- Explaining to women why antibiotics are not always needed, and advising them to take prescribed antibiotics exactly as directed and not to share or keep leftover tablets.
- Supporting vaccination, breastfeeding (which protects babies against infection) and safe infant feeding preparation.
A woman in labour has had group B streptococcus detected on a vaginal swab in this pregnancy. According to RCOG Green-top Guideline 36, what intrapartum antibiotic regimen should be offered if she has no penicillin allergy?
Benzylpenicillin 3 g IV as soon as possible after the onset of labour, then 1.8 g every 4 hours until birth
Oral amoxicillin 500 mg three times daily for 7 days after birth
A single dose of IV gentamicin at full dilatation
No antibiotics in labour; treat the baby only if symptoms develop
A woman has been on IV antibiotics for suspected endometritis for 48 hours. Her blood cultures are negative, and a high vaginal swab grew an organism sensitive to an oral antibiotic. She is now well and eating. Under the Start Smart then Focus approach, what should happen?
Continue IV antibiotics for at least 14 days to be safe
Review the prescription and consider switching to an appropriate oral antibiotic guided by the culture results
Stop all antibiotics immediately without medical review
Add a second broad-spectrum IV antibiotic to prevent resistance
A woman attends the antenatal day unit with a rash and fever, and recently had contact with a child who has measles. Which infection control action is most appropriate while she is assessed?
Assess her in the open waiting area using standard precautions only
Place her in a shared bay with other pregnant women and use a surgical mask
Use airborne precautions in a single room, staff with confirmed immunity and FFP3 respirators, and escalate so the health protection team can be notified
Send her home immediately without assessment to protect other women
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