Universal Precautions?

[636Jen]

In watching many homebirths and waterbirths I noticed that many midwives don't wear gloves. I've seen midwives dip their whole arms into birthwater (in a birthing pool) to check FHT without gloves.

Is that pretty common? I know they make arm-length gloves...does anyone use them? I thought it was just standard proceedure to use gloves but it seems like an option. (?)

I'm not saying anyone is wrong or right, it just seemed odd to me when I saw it. Can anyone comment on this? I know the reasons for wearing gloves but can someone give me a reason why they wouldn't?


Thanks!!

[sarahn4639]

I've wondered about this too.

[SublimeBirthGirl]

I think in a home environment, excluding vaginal exams, suturing, etc., there's no reason gloves would be necessary.

[sevenkids]

Universal Precautions are used to protect the care provider from patients who may be/are HIV, TB, or Hep positive, UPs are a totally different approach from clean technique or even sterility and include gowns, masks, protective eye gear or face shields, and aprons, as well as gloves. I don't know any midwives who routinely use UP's at a homebirth, because HIV, TB or Hep + patients would have been risked out of care, and I can't think of ANYONE who would agree to attend a waterbirth with someone who needed UP's.

Gloves for waterbirth...we can be pretty confident that our clients are not infected with HIV, TB, or Hepatitis, because most of us have a low-risk population and some of us like myself have a high-risk population and routinely screen, so for checking FHTs in water I don't really see the need for gloves any more than I see the need for using gloves to check during a prenatal. I would not under normal circumstances touch a woman's perineum or do an exam without gloves, though, but I've never used those veterinary gloves that go to the shoulder, reminds me of calving. Birth, especially waterbirth, is faaaaaaar from sterile, and a quick wash up after submerging arms is fine (which we should be doing before and after touching anyone anyway). A little bit of poop that can be scooped out is okay, it's so diluted in the amount of water in a birth pool it's not going to hurt anyone, but if there's a LOT of poop, I'll insist mom gets out, shower, and drain and refill the pool if there's time.
I have caught without gloves, usually because I don't plan on catching a baby at a waterbirth and something came up that I had to move fast and didn't have time to mess around with gloves. If the lady was my dd or dil or another close relationship, I may not wear gloves if she was comfortable with that.

[Malga]

Not only are gloves to protect the midwife from anything the client may have, but also vice-versa. Many times people wear gloves to be sure no bacteria is passed from care provider to client (for example, I definitely want my doc wearing gloves).

we can be pretty confident that our clients are not infected with HIV, TB, or Hepatitis

I think this is a naive statement. You cannot be sure that a client doesn't have something (people don't have a certain "look" or socioeconomic background-- I have been surprised many times). People can pick up something after you screen them in early pregnancy for sure (even without knowing from a wandering SO-- 50% of people have affairs).

[pamamidwife]

I don't wear gloves in waterbirths, aside from vaginal exams in the water.

One of the main reasons is there are very few viruses or bacteria that can survive the warmth of the water. THere's also the issue of dilution. Gloves are silly, they just get filled up with water anyway. Frequent handwashing is important. I just think the wearing of those long vet gloves are a bit silly, but that's my preference.

But I do work on wearing gloves other times, when handling bloody materials, etc. It's not always perfect, but I am aware.

[sevenkids]

Originally Posted by Malga

I think this is a naive statement. You cannot be sure that a client doesn't have something (people don't have a certain "look" or socioeconomic background-- I have been surprised many times). People can pick up something after you screen them in early pregnancy for sure (even without knowing from a wandering SO-- 50% of people have affairs).

Let me clarify........
I routinely screen for STDs/HIV. Most midwives do have a low-risk population. I don't, so I screen, and because I screen and repeat the screen in the third trimester, I can be fairly confident that my clients don't have an STD. I think I'd be naive if I didn't carefully screen, seeing as about 1 in 250 people in my city are HIV+. A midwife who works with the Amish or Mennonite can be fairly confident that her clients don't have an STD/HIV and be comfortable not screening.

Do you use universal precautions at a home birth?

[kate3]

A midwife who works with the Amish or Mennonite can be fairly confident that her clients don't have an STD/HIV and be comfortable not screening.

Why? Because they are Amish or Mennonite? Are they superhuman and perfect? This is an incredibly inflammatory and prejudical statement. I understand the tenets of their lifestyle and religion, but they are still human and capable of lapses in judgment, poor decisions, or behavior they might regret (not to mention sexual assault). No one should stereotype any group for any reason. When we do so, we put everyone at risk.

[homewithtwinsmama]

Originally Posted by kate3

Why? Because they are Amish or Mennonite? Are they superhuman and perfect? This is an incredibly inflammatory and prejudical statement. I understand the tenets of their lifestyle and religion, but they are still human and capable of lapses in judgment, poor decisions, or behavior they might regret (not to mention sexual assault). No one should stereotype any group for any reason. When we do so, we put everyone at risk.

You clearly have not worked with the Amish. Just lack of opportunity makes it pretty rare to ever see any kind of STD. They are rarely alone with non-family members or groups and make every effort not to associate with "English" unless they have to for their business. The Amish midwife I worked with used gloves for exams, but otherwise and in tubs did not. They are certainly not perfect, but their lifestyle does offer them some protections that most of our cultures do not.

[kate3]

You clearly have not worked with the Amish. Just lack of opportunity makes it pretty rare to ever see any kind of STD. They are rarely alone with non-family members or groups and make every effort not to associate with "English" unless they have to for their business. The Amish midwife I worked with used gloves for exams, but otherwise and in tubs did not. They are certainly not perfect, but their lifestyle does offer them some protections that most of our cultures do not.

I guess this is where we will have to agree to disagree. I think it is naive and dangerous to fall prey to stereotypes.

[Defenestrator]

You'll find very few midwives who don't wear gloves in situations where the client is threatened by our germs (like during vaginal exams or while suturing). I think that it is up to the midwife to determine how much she wants to do to protect herself in situations where the client might be passing pathogens to her.

There is no danger that the midwife brings to the client in a waterbirth simply by reaching her arms in the water to listen to heart tones. You could argue that her hands might have bacteria on them, but so do the client's feet which have been walking on her floor, etc. As far as disease transmission through water -- most of the viruses I am worried about live for very little time outside of the body and cannot survive the temperature or conditions of the water. Some midwives take additional steps to make the water hostile to pathogens -- the midwives I trained with used to treat it with sea salt, which is very hostile to bacteria.

I wear gloves during waterbirth, but it is as much out of habit as anything else and they do get water into them. I own the vet gloves, but can't imagine wearing them. They fit terribly and don't offer very good touch sensation -- I'm not willing, yet, to give up my ability to feel what I am doing when I need to use my hands.

I almost never touch the mother's vaginal/perineal area during birth, especially under water. Sometimes I don't touch the baby, either -- the parents catch. The one time in birth that I needed to perform a sterile, invasive procedure ( I had to remove a placenta -- this was on dry land) I was able to easily switch into surgical gloves. They are handy on my tray of supplies.

It is true that most of my clients are screened for Hep B, many for HIV. HIV is very fragile outside of the body and I am almost certain it could not survive the water. I am vaccinated for Hep B as an extra precaution. I am comfortable with my procedures for waterbirth. I know that there is a theoretical risk, but there is also a theoretical risk to my not wearing a face shield too. I have been at a couple of hospital waterbirths -- it looks like they are dressed for a toxic spill, not a birth.

The truth is that as a homebirth midwife, I don't catch babies off the end of a broken-down bed, with a hazardous waste bag and a fracture pan beneath the mom to catch all of the birth goo. I don't wear full gowns and face shields. I sometimes find myself underneath a mom at a moment when her water might break. I sometimes get meconium on my clothes. Sometimes I get peed on or vomited on. I bring clean clothes because sometimes they get dirty. Sometimes I accidentally sit or walk on birth goo. So, considering all of that, water leaking into my gloves might be the least of my problems

[Charmie981]

Originally Posted by Defenestrator

I have been at a couple of hospital waterbirths -- it looks like they are dressed for a toxic spill, not a birth.

I needed that tonight.

[Defenestrator]

Originally Posted by Malga

Not only are gloves to protect the midwife from anything the client may have, but also vice-versa. Many times people wear gloves to be sure no bacteria is passed from care provider to client (for example, I definitely want my doc wearing gloves).

I meant to address this post more specifically in my reply. One of the reasons why you want your doctor to be wearing gloves is that there is the assumption that he will be doing something invasive. If you are having a standard OB-attended birth, chances are that there will be many, many vaginal exams as the baby is descending, perineal massage/stretching, reaching up into the vagina to check for a nuchal cord, assisted delivery of the shoulders, etc.

Now you contrast that with a standard waterbirth in my practice. I might be resting a hand on a mom's back as she is kneeling, providing counterpressure. I might be holding her hand. I might be holding up a knee or a foot because she feels like the pool is too big and she needs something to push up against. I might not be touching her at all. I might be across the room. When the baby is born, it will usually emerge entirely into the water before I touch it. If the parents want to catch the baby I might not touch it at all. If they don't, I often just scoot it into reach, like sliding the baby through the water underneath a mom who is kneeling until it is in front of her.

Also, gloves are only clean when they come out of the package/box (and don't get me started about the cross-contamination that can occur in the hospital when everyone reaches into the same glove box again and again). If the provider isn't holding her hands up in the air, wrists above elbows and not touching anything, they are picking up the germs of the environment. I'm pretty aware of that and when I am doing land births I might go through 10-20 pairs of gloves, but I think it's a myth that just because someone is wearing gloves that her hands are clean.

[CarolynnMarilynn]

i will post more later but i wanted to say that all birth attendants are working in a high-risk environment as one of the biggest risk factors is exposure to semen - which pretty much defines the pregnant woman! "High risk population" is outdated as we know that the fastest growing group of women getting STIs and HIV are monogamous, heterosexual women who do not perceive themselves at risk.

Also, are people screening more than once for HIV in pregnancy, as recommended? At our clinic we offer a screen early in pregnancy, and then one later, after 12 more weeks has past, so that the semen exposure that resulted in the pregnancy has been screened for HIV. Viral loads of less than 50 come back as negative (kinda like saying that someone with a low, but rising, hcg, is not pregnant, when if you tested a bit later the hcg would be past the threshold of what is a positive).

Saying that, as a birth professional, I take on the risk that I will potentially expose myself and my family to a whole host of infectious diseases, from HIV, to Hep, to TB, to SARS. There is no way around it.

I also wear gloves to protect my clients against things I may have on my hands, and to give a professional barrier against my personal body touching their personal genitals. I don't wear gloves for venipuncture, but I mostly do for IVs because I often spill a drop or two in the process.

Anyways, being told to take the baby back, so I will write more later!

[CarolynnMarilynn]

i'd like to just second all that Defenestrator said to spare you all reading me paraphrasing just about everything

[sevenkids]

Originally Posted by kate3

Why? Because they are Amish or Mennonite? Are they superhuman and perfect? This is an incredibly inflammatory and prejudical statement. I understand the tenets of their lifestyle and religion, but they are still human and capable of lapses in judgment, poor decisions, or behavior they might regret (not to mention sexual assault). No one should stereotype any group for any reason. When we do so, we put everyone at risk.

Yes, because they're Amish or Mennonite (not because they're "superhuman" and "perfect") and their isolation, lifestyle and culture exposes them to very little risk. I don't see how that is "incredibly inflammatory" or "prejudical". Unless they're out partying with the rest of us, their risk is low. Neither would it be "incredibly inflammatory" and "prejudical" to say that the Amish are at a higher risk of genetic disorders because of the limited gene pool. It's not a stereotype, it's a fact.
Any lapses of judgment, poor decisions, regrettable behavior, and yes, even sexual assualt, is very likely to be confined within their own closed communities, simply because they do not want to mix with the rest of us "English" and the risk of contracting an STD remains low.

[sevenkids]

Originally Posted by CarolynnMarilynn

i will post more later but i wanted to say that all birth attendants are working in a high-risk environment as one of the biggest risk factors is exposure to semen - which pretty much defines the pregnant woman! "High risk population" is outdated as we know that the fastest growing group of women getting STIs and HIV are monogamous, heterosexual women who do not perceive themselves at risk.

That's interesting about high-risk being outdated......IMO, if only one partner is faithful it's not a monogamous relationship and even if the person does not know their risk status doesn't mean that they're not high risk. It seems to me that not knowing would put them at a higher risk because they would tend to not be as careful about protecting themselves. Yikes, I guess you could say that puts just about everyone at high risk since many people who believe they are in a monogamous relationship are not aware of their risk factors.

Also, are people screening more than once for HIV in pregnancy, as recommended? At our clinic we offer a screen early in pregnancy, and then one later, after 12 more weeks has past, so that the semen exposure that resulted in the pregnancy has been screened for HIV. Viral loads of less than 50 come back as negative (kinda like saying that someone with a low, but rising, hcg, is not pregnant, when if you tested a bit later the hcg would be past the threshold of what is a positive).

We do. We offer one at the prenatal profile and another at 28 weeks.

Saying that, as a birth professional, I take on the risk that I will potentially expose myself and my family to a whole host of infectious diseases, from HIV, to Hep, to TB, to SARS. There is no way around it.

This is true.....there's no way around it. I've gotten fluids in my eyes and in my mouth and jumped into birth tubs and jacuzzis and gotten wet up to my armpits. But I do think screening and knowing the status of my clients reduces MY risks.

I also wear gloves to protect my clients against things I may have on my hands, and to give a professional barrier against my personal body touching their personal genitals. I don't wear gloves for venipuncture, but I mostly do for IVs because I often spill a drop or two in the process.

yes, besides the protection, that to me is more respectful of the lady's personal body space, only her lover or someone intimately close to her should be touching her genitals with bare hands, IMO.

[3daughters]

This is an interesting thread. I also wondered how midwives can be comfortable wearing regular latex gloves and dipping their hands in body fluid filled water. It seems to me that shoulder length gloves would be safer for both parties.

On another note, I was just tested for every STD under the sun at a prenatal checkup. I do not remember this being done the last time I was pregnant except that I signed a waiver refusing HIV testing. This time I was not given a waiver or a choice. I tried explaining to the midwife that I am a member of a group that is low risk for exposure for STDs (I'm an Orthodox Jew and call me naive but we are low risk) and she still insisted on testing me. Is it for my protection or hers? I assume that the midwives employ universal precautions during visits and births no matter what their clients status may be.

[kltroy]

FWIW my midwife (CNM) asks that if you would like a waterbirth, that you be tested for HIV - and offers that to any client that wishes the option. And she DOES wear long gloves to attend these births. She requests the testing for her safety because even taking Universal precautions it is impossible to completely protect her from contact with her patients' blood etc. This makes sense to me. She sees a lot of people so it's as much for her safety as it is for ours.

[pamamidwife]

Originally Posted by kltroy

FWIW my midwife (CNM) asks that if you would like a waterbirth, that you be tested for HIV - and offers that to any client that wishes the option. And she DOES wear long gloves to attend these births. She requests the testing for her safety because even taking Universal precautions it is impossible to completely protect her from contact with her patients' blood etc. This makes sense to me. She sees a lot of people so it's as much for her safety as it is for ours.

The HIV virus outide a body is very unstable. You can no more get HIV from a hottub than you can from a drinking fountain or public restroom. If she's that worried, adding a small amount of sea salt would be an extra reassurance. Don't even get me started on the false positives from the ELISA test with pregnant women. Did you know that pregnancy is one of hundreds of instances where an ELISA test can falsely create a positive result for HIV?

I'm wondering if someone did come up HIV or Hep positive, does that mean she doesn't do their births? Why would she be MORE careful with someone with those conditions? Shouldn't universal precautions be just that - universal?