It is recommended that mothers exclusively breast feed their babies for the first six months of life as it builds immunity to infection, and aids the proper development of the brain. Breast feeding reduces the risk of many infections such as gastroenteritis (vomiting and diarrhoea), ear infections, urinary infections and chest infections. In fact, breast-fed babies are five times less likely to be admitted to hospital as a result of gastroenteritis or respitatory infections compared to bottle-fed babies.

Breast milk is sterile when given straight from the breast, however it is still important that the breast area is clean so infections are not transferred from the mothers skin to the baby. If the milk is expressed, the breast pump (automatic link to Decontamination website) should be sterile and the feeding equipment should be sterilised using the appropriate methods (see artificial feeds)

Problems associated with breast feeding include mastitis (inflammation of the breast) and is generally caused as a result of milk stasis. This in itself is not an infection, although it may result in one requiring antibiotic treatment. In some cases, the infection can lead to a breast abscess, which may require further intervention such as needle aspiration or surgical incision and drainage.

Some infections, such as HIV, can be transmitted from the mother to the baby via breast feeding. In these cases, artificial feeding may be more appropriate.

Infection after a Caesarean section is a considerable problem that occurs in as many as 34% of Caesarean section patients. Preventative treatment with antibiotics should be used as this considerably reduces the risk of wound infection and endometritis. Other ways in which the risk of infection can be reduced includes:

• delaying shaving of the operation site until immediately prior to operating
• adequate sterilisation of all swabs and instruments (automatic link to Decontamination website)
• good sterile and surgical technique during the procedure.

Hepatitis B virus (HBV) is a major health problem worldwide. It is a bloodborne virus that can be transmitted in several different ways, the most frequent of which is from mother to baby during pregnancy and childbirth. It can also be transmitted via the breast milk. Click here for further information on hepatitis B in pregnancy. 

It is important that measures are taken to prevent transmission from an infected patient to a healthcare worker and vice versa. General infection control measures to prevent transmission of bloodborne viruses in the healthcare setting are listed in the publication Protecting healthcare workers and patients from hepatitis B, which is housed on the Department of Health website. This publication includes the following guidelines.

• Apply good basic hygiene practices with regular hand washing.
• Cover existing wounds or skin lesions with waterproof dressings.
• Avoid invasive procedures if suffering from chronic skin lesions on hands.
• Avoid contamination of person by appropriate use of protective clothing.
• Protect mucous membrane of eyes, mouth and nose from blood splashes.
• Prevent puncture wounds, cuts and abrasions in the presence of blood.
• Avoid sharps usage wherever possible.
• Institute safe procedures for handling and disposal of needles and other sharps.
• Institute approved procedures for sterilisation and disinfection of instruments and equipment.
• Clear up spillages of blood and other body fluids promptly and disinfect surfaces.
• Institute a procedure for the safe disposal of contaminated waste.

Additional measures are required for those performing exposure-prone procedures. These are invasive techniques during which there is a risk that injury to the worker may result in the patient's open tissues becoming exposed to the worker’s blood. This may be the case in procedures where the worker may be using sharp instruments, needle tips or sharp tissues (such as spicules of bone or teeth), and also where the worker’s hands are inside a patient's open body cavity, wound or confined anatomical space and therefore may not be visible at all times.

In the case of midwifery, while normal vaginal delivery is not in itself an exposure-prone procedure, there are many activities associated with it that are. These include infiltrating local anaesthetic, suturing an episiotomy and instrumental delivery (such as with forceps). Therefore, most midwives can expect at least some involvement with exposure-prone procedures, and therefore immunisation is important.

The guidelines state that those performing exposure-prone procedures should be immunised against hepatitis B, unless they already have proven immunity to the hepatitis B virus. Not all people respond to the primary vaccination, therefore response to the vaccine should always be checked. True non-responders (that is those who do not respond to the vaccine but who are also not immune to hepatitis B) should either be given a booster or a further dose of vaccine.

Healthcare workers carrying the hepatitis B e-antigen (HbeAg) should not perform exposure-prone procedures due to the risk of transmission of the virus. In addition, personnel carrying the hepatitis B surface antigen (HbsAg) should not carry out exposure-prone procedures until they have been screened for the e-antigen. E-antigen carriers should be treated with alpha interferon. Once successfully treated, the person should be clear of the e-antigen for 12 months before carrying out any exposure-prone procedures.

All pregnant women are offered screening for hepatitis B in the UK. If the mother is found to be carrying the virus, her baby should be immunised with the hepatitis B vaccine as soon as possible after delivery (within 24 hours) and with parental consent. If the mother has an acute hepatitis B infection during the pregnancy, the baby should be given the hepatitis specific immunoglobulin (HBIg). Further information is contained in the Hepatitis B testing in pregnancy guidelines which are housed on the Department of Health website.

The Department of Health has produced a leaflet  Hepatitis B: how to protect your baby for midwives to give to women who are tested positive for hepatitis B.

Home births are considered as safe as hospital births for uncomplicated pregnancies, and could even be better for the mother and baby’s physical wellbeing. The risk of hospital-acquired infections is also removed. However, it may not be appropriate for women with pregnancies complicated by infection to have a home delivery. This depends on the nature of the infection.

The Royal College of Midwives guidance states that:

‘. . . it is good practice to support and promote home birth, so as well as responding positively to women's requests, midwives should offer home birth as a positive and realistic choice to all women who could benefit from it.’

It is therefore important that all midwives are competent and confident to attend home births. Maternity services should ensure that midwives obtain appropriate experience, training and support in order to do this.

However, standard precautions should be taken when delivering a baby in the home environment.

Notification was introduced in 1889 in order to identify and prevent the spread of infectious diseases. Under the Public Health (Infectious Diseases) Regulations 1988, diseases notifiable to Local Authority Proper Officers in England and Wales include:

• acute encephalitis
• acute poliomyelitis
• anthrax
• cholera
• diphtheria
• dysentery
• food poisoning
• haemophilus influenzae
• hepatitis A
• hepatitis B
• hepatitis C
• other
• leptospirosis
• malaria
• measles
• meningitis
• meningococcal
• meningococcal septicaemia (without meningitis)
• mumps
• ophthalmia neonatorum (in newborn babies only)
• paratyphoid fever
• plague
• pneumococcal
• rabies
• relapsing fever
• rubella
• scarlet fever
• smallpox
• tetanus
• tuberculosis
• typhoid fever
• typhus fever
• viral
• viral haemorrhagic fever
• viral hepatitis
• whooping cough
• yellow fever.

Leprosy is also notifiable, but to the Director, CDSC (Communicable Disease Surveillance Centre).

According to current law, any doctor caring for a patient whom he suspects has a notifiable disease or food poisoning within a district of a local authority, should send a certificate stating the name, age, sex and current address of the patient and the disease the patient is suffering from and the date that it started. If the patient is in hospital, details of admission dates and where the patient was before being admitted should also be given.

The doctor attending the patient when diagnosed is responsible for notifying the relevant authorities. If, as is generally the case, no urgent action is required, for example with diseases such as measles and rubella, notification should be carried out by filling in the appropriate form from the relevant local authority (usually from the consultant in communicable disease control, or CCDC). If urgent action is likely to be required (for example for meningococcal infections, typhoid, cholera and food poisoning) notification should be carried out by telephone, fax or other electronic means.

Requirements for disease notification vary between local authorities, so it is important to be aware of the requirements in your area.

Standard precautions (automatic link to Healthcare Practices website) are the precautions necessary to reduce the risk of transmission of micro-organisms from both recognised and unrecognised sources of infection. Standard precautions relevant to midwifery are listed in The World Health Organization’s guidelines Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice and include the following:

• wash hands (automatic link to Decontamination website)
• wear sterile gloves (within the section on Universal precautions)
• protect yourself from blood and other body fluids during deliveries (automatic link to Healthcare Practices website)
• practice safe sharps disposal (automatic link to Healthcare Practices website)
• practice safe waste disposal
• deal with contaminated laundry (automatic link to Decontamination website)
• sterilise and clean contaminated equipment (automatic link to Decontamination website).

Midwives are at risk from infection during procedures such as episiotomy suturing, inserting and removing urinary catheters, using umbilical catheters, with epidurals and with intravenous lines (for example to administer oxytocin to a woman in labour in order to augment the contractions) and assisted deliveries (with forceps or ventouse). During such procedures, standard precautions and general principles of asepsis (automatic link to Decontamination website) are vital.

For further details about standard precautions, refer to the NICE clinical guidelines (2003) the epic guidelines (2001), the US CDC guideline for isolation precautions in hospitals (1996) and the WHO guidelines for preventing hospital-acquired infections (2002).

Click here for information on standard precautions for healthcare workers in Scotland. Babies considered high risk for contracting infection, or those with a severe, transmissible infection, (for example those with MRSA) (automatic link to Childhood Diseases website) may need to be isolated in order to prevent direct or indirect contact transmission. This is because babies are unable to practice infection control precautions to prevent disease transmission. Click here for information on isolation nursing (automatic link to Healthcare Practices website). Care of such babies may require additional, transmission-based precautions (automatic link to Healthcare Practices website) to prevent disease transmission.

The Department of Health has published the ‘essential steps to safe, clean care’. This is a delivery programme which aims to reduce healthcare associated infections, including MRSA. The ‘essential steps’ programme provides tools and guidance to support different organisations and settings, including residential and nursing homes, as they work towards reducing and eradicating healthcare associated infections. Click here for more information on the ‘essential steps’ programme.

As part of the ‘essential steps to safe, clean care’ programme, the Department of Health has launched a specific step relating to preventing the spread of infection. The aim of this document is to reduce the risk of microbial contamination in everyday practice and to ensure there is a managed environment that minimises the risk of infection to patients, clients, staff and visitor. Please click here for further information.

Sterilisation (automatic link to Decontamination website) is a process by which a reusable medical device is made free from viable microbes, including bacterial spores and viruses. It is a vital decontamination process in the prevention of the spread of infection. Items specific to midwifery and care of newborn and premature babies, which need to be decontaminated, include:

• baby bath stand (automatic link to Decontamination website)
• baby bath/bowl (automatic link to Decontamination website)
• baby care tray (automatic link to Decontamination website)
• baby clothes (automatic link to Decontamination website)
• baby feeding equipment (automatic link to Decontamination website)
• bottle warmer (automatic link to Decontamination website)
• breast pump machine (automatic link to Decontamination website)
• breast pump (parts) (automatic link to Decontamination website)
• changing mat (automatic link to Decontamination website)
• cot mattress (automatic link to Decontamination website)
• feeding bottle (automatic link to Decontamination website)
• incubator (automatic link to Decontamination website)
• mattress (automatic link to Decontamination website).

Some antibiotics can also cause birth defects, or problems in the unborn baby. It is important to note that some antibiotics that are potentially harmful in early pregnancy are considered safer in the later trimesters and vice versa. For example, nitrofurantoin given at term can cause haemolysis in the newborn, but is considered relatively safe earlier on in pregnancy, and trimethroprim is thought to be teratogenic (cause birth defects) when given in the first trimester as it is a folate inhibitor. However, it is considered relatively safe in short-term use later on in pregnancy.

Antibiotic agents that should be avoided during pregnancy due to potential harmful effects include:

• tetracyclines
• aminoglycosides
• quinolones
• metronidazole at high doses.

There is also concern that if mothers are given antibiotics during pregnancy or labour, there is a possibility that if their babies get serious infections they will be resistant to antibiotics, however, this is as yet unproven.

As with all drugs, antibiotics should therefore be used with care in pregnancy, and only given when necessary. If possible, all drugs should be avoided, particularly in the first trimester.

The World Health Organization has produced some guidance surrounding antibiotics in pregnancy in their publication Managing Complications in Pregnancy and Childbirth - A guide for midwives and doctors.