Birth of Occupational Safety in Labor and Delivery

By Ron Stoker

During one phase of my career I had the opportunity of participating in the development of a variety of obstetrical and gynecological medical devices.   I enjoyed the challenge of going into the field and participating in the clinical trials of these products.  I frequently went into labor and delivery rooms and witnessed hundreds of women in labor and dozens giving birth.  I recall those moments with great fascination. I have always felt that these were almost sacred moments as I watched new life come into the world.  It truly was an unforgettable experience. 

 During these clinical trials it was my privilege of watching dedicated nurses and physicians making a difference in the lives of the families involved.  Although childbirth is a joyous occasions for families, it can be a scary experience for the medical personnel involved, particularly when the procedures are complicated by adverse medical conditions and when the proper equipment has not been provided.

I often witnessed obstetricians, midwives, nurses, and surgeons work quickly with their patients.  Maybe, too quickly.   Although many practiced universal safety precautions, others did not.  Many of these harried clinicians felt that they were too busy to wear gloves, too busy to wear full-face safety masks or glasses, and even too busy to put on the ubiquitous face mask.  

I found myself wondering why so many healthcare workers didn’t use safety precautions with each and every patient.  Maybe they didn’t feel or believe the risk of bloodborne pathogens to themselves was real.  I have wondered if the hospitals that I visited were unique or if clinicians in other institutions were so cavalier about their own personal health.  Labor and delivery personnel are frequently exposed to blood and body fluids.  Look at the shoes or scrubs or glasses of these healthcare workers if you don’t believe that it is an issue!  You will see that they are frequently stained with blood and other bodily fluids.  Without precautionary measures, the risk of infection to these healthcare workers can be high.

According to the National Center for Health Statistics, there were 4,025,933 births in 2001.[1]  Although there is no universal source for sharps injuries in labor and delivery, it is obvious that a number of sharps injuries occur there.  A review of relevant literature indicates that a majority of reported sharps injuries in obstetrics are due to suture needlesticks.[2],[3] The Epinet study showed 33 percent of suturing injuries were inflicted on another worker by the person using the needle. Approximately 25 percent of suture needle injuries occurred during transfer between personnel.

The following story illustrates methods to provide greater safety for healthcare workers serving in the labor and delivery areas of a hospital.

In L&D

Melissa could not believe the pain that she was experiencing.  It seemed so concentrated.  She woke her husband, James, and informed him that the contractions were so bad that she needed to go to the hospital now. It was 2:30 a.m.

When they arrived at the hospital James grabbed a wheelchair and took Melissa to labor and delivery.  A nurse took them to a birthing room and proceeded to ask a number of questions about Melissa’s health history.

During the admission procedure a variety of information is gathered concerning prenatal examinations.  It doesn’t matter who the patient is or how long you might have known them.  Every clinician should protect themselves appropriately as if every patient they encounter is HIV and Hepatitis positive.

At 2:40 a.m. the nurse gloved and asked Melissa to lie back so she could perform a cervical exam to determine how far Melissa’s labor had progressed.  She told Melissa that she was dilated to 2 cm and her cervix was 50 percent effaced with the amniotic sack still intact.  After a phone call to the doctor, the nurse inserted a winged IV to provide fluids and medications to Melissa.  

Standard winged blood collection devices, often called butterfly needles, are one of the top causes of needlesticks.  Winged sets are hollow bore needles with attached tubing used for blood collection.  Safety winged blood collection systems are available that allow for one-handed safety activation as well as flexible wings for easy insertion. This protects the healthcare worker and others from being stuck with a blood-filled needle. [4] 

At 5:30 a.m. the nurse asked Melissa if she wanted anything for pain.  She yelled back: "Please, bring on the drugs!"  Melissa chose a mild pain reliever that took the edge off and allowed her to breath-through the pain.   At 7:00 a.m., the shift ended and a new nurse came in to check on Melissa’s progress.   The nurse performed a cervical exam with her gloved hand.  As the nurse’s finger pushed into the cervix an explosion of amniotic fluid greeted her hand, arm, hair, and face.  “I guess my water broke,” Melissa said. 

Spontaneous rupture of the amniotic sack can come without warning.  Even with scheduled inductions of patients, spontaneous amniotomies occur.  When the amniotic sack does not spontaneously rupture, an amniotomy must be performed.  This is typically done with a small amniotome, which looks similar to a crochet hook, or with an amnio cot, which slides over the clinician’s finger and allows the hook on the end to snag and tear the amniotic sack. The unpredictability of the procedure should be warning to clinicians to provide proper personal protection such as face masks, glasses and gloves to prevent exposure of amniotic fluid into eyes, nose and mouth.  Any amniotome or amniocot should be discarded in a sharps container.  If they are sharp enough to tear through the amniotic sack, they are sharp enough to potentially tear through gloved hands.

Melissa complained again because of the pain.  The nurse offered an epidural.  The doctor had authorized it even though Melissa was only dilated to 3 cm.  At 7:30 a.m., the epidural was administered by the anesthesiologist.  Melissa had only one contraction while curled up in the fetal position.  She was very surprised that the needle didn't hurt: as a matter of a fact, she felt nothing.

An epidural is a common method of administering anesthesia during labor. A small amount of anesthesia is inserted through a narrow catheter threaded thorough a needle inserted into the dura space near the spinal cord.  Once the catheter is advanced the needle is withdrawn.  This standard epidural needle is a threat for anyone that comes near it.  Once removed from the patient the needle should be stuck into a device intended for capping non-safety needles.  These safety receptacles[5] provide a convenient place to "park" a needle while finishing a procedure.  Once the procedure is completed the parking device and the needle can be disposed of in an approved sharps container.[6] 

A soon-to-be-released product is the new Perifix® Safety Epidural Needle from B. Braun Medical Inc. When the anesthesia provider has completed their epidural procedure, the needle is withdrawn from the patient's back. At this point, the anesthesiologist advances the deployment shroud containing the safety clip toward the tip of the epidural needle. The clip engages over the tip of the epidural needle and locks into place--neutralizing the sharps hazard. The entire assembly is disposed of in a nearby sharps container.

Some obstetricians use cervical blocks to numb the cervix prior to delivery.  Although cervical blocks are not real popular, they are still used.  The needles used to numb the cervix are longer than standard anesthesia needles.  The needles should be disposed of safely as described above.

Throughout the day, Melissa continued to dilate as expected, but the labor slowed down because of the epidural.  At 2:30 p.m., the doctor was becoming concerned with the amount of time Melissa had been in labor and wanted to help move things along since Mother Nature didn’t seem to be helping anymore.  The doctor ordered Pitocin to be administered in the IV that Melissa was receiving.  The Pitocin was administered through a needleless connector on the IV going into Melissa’s hand.   An intrauterine pressure monitoring catheter was placed inside of her uterus to monitor uterine contractions and a fetal scalp electrode was placed on the baby’s head so they could monitor her baby’s heart rate.    Melissa’s contractions became stronger and stronger, going off the page of the monitor. The nurse decided to check Melissa’s bedding, and discovered a lot of blood.  The doctor rushed in and found that Melissa had dilated to 10 cm.

James, Melissa’s husband, and Jeanie, Melissa’s mother, were there to witness the birth.  Jeanie was in the final stages of cancer treatment and did not know if she would live long enough to see another grandchild be born, so Melissa invited her to watch the delivery. 

The nurse advised Melissa to begin pushing, which was good because she was feeling intense pressure from the baby's head.  She had pushed for about 25 minutes when the doctor decided he would have to use the vacuum extractor on the baby’s head because it was so large.  The doctor placed the vacuum on the baby's head and pulled with Melissa’s contraction. As he pulled, the extractor popped off of the baby’s head and splashed amniotic fluid and blood across the room.  Some of the blood landed on Melissa’s immuno-compromised mother.

It is not an uncommon procedure to have a vacuum extractor pull off of the fetal head unexpectantly.  When this happens, amniotic fluid, blood, urine, and even fecal material can be sprayed around the room. The higher the vacuum is pumped, the more it seems to spray fluid around the room when it unexpectantly pulls off of the fetal head.  It is important that personal protective equipment such as gowns, masks, goggles and glasses are worn so the healthcare worker is protected from the unexpected events. Should family participants also be appropriately gowned and dressed to protect the hospital from potential legal liabilities?

Universal blood and body fluid precautions should be followed by all healthcare workers in the delivery room, including physicians, anesthetists, nurses, housekeepers and other assistants. In the delivery room, potentially infected fluids include maternal or fetal blood, amniotic fluid, the placenta and membranes. Individuals, including family members, exposed to the potential splash of potentially infectious material (e.g., during rupture of membranes or complicated deliveries) should also wear a mask and protective eyewear.

The doctor determined that Melissa needed an episiotomy, an incision made to the perineum, the muscle between the vagina and rectum, to widen the vaginal opening for delivery.  He took sterile scissors from off his sterile tray and made the cut.   Melissa watched the cut in a mirror but did not feel any pain from the episiotomy because of the epidural.  She continued to push with each contraction. 

Nationwide figures estimate that episiotomies were performed in 39 percent of vaginal deliveries in 1997, down from 65 percent in 1979.[7] Episiotomies are typically performed using reusable or disposable scissors, but scalpels are also used. Safety scalpels with retracting blades or shields help protect healthcare workers when not in use.  Blunt-tipped scissors should be used so that a sharp point cannot accidentally pierce a gloved hand.  These scissors are typically covered with a variety of body fluids including amniotic fluid, meconium, blood, urine and even bowel movements.  Clinicians should treat these scissors as seriously contaminated weapons and should handle and dispose of them appropriately.

Melissa pushed only three more times and at 5:14 p.m., Kylee was born into the world. The doctor removed the fetal scalp electrode from the baby’s head and put it onto the small table at his side.

Fetal scalp electrodes have a corkscrew needle that twists into the baby’s head to monitor heart rate.  Once removed, the contaminated fetal scalp electrode should be placed into a sharps container to prevent it from accidentally poking someone else.

The doctor held the baby up and instructed the father to come closer so he could help cut the umbilical cord.  James was instructed to place a Kelly clamp on the umbilical cord.   He was instructed to place another Kelly clamp not far from the first one.  He was then given scissors to cut through the cord.  James hesitantly started to cut through the umbilical cord but was not prepared for how grisly it was.  The scissors started to cut and blood squirted from the incision in the umbilical cord.  James finally was able to cut the umbilical cord all the way through.

The problem of having family members cut the umbilical cord exposes both professionals and family to the inherent dangers of bloodborne pathogens and sharps injuries.  Most clinicians and family members now cut the umbilical cord with scissors while trying to hold two clamps, isolating the cutting area, and using another hand to attempt to shield the blood splatter.  This procedure places a lot of hands in close proximity to a sharp.   There is also a lot of exposure to cord blood because the area between two Kelly clamps is now pressurized with nowhere for the blood to go but squirting out of the first incision in the vessels. Dr. James Ramsey, an obstetrician, recently remarked that "Blood frequently splashes into the face of family members when cutting the umbilical cord-- sometimes into their eyes and into their mouths."  He indicated that his staff has found umbilical cord blood eight feet up on the wall or ceiling following the delivery of a baby.

Several safety alternative products are now available.   Talon Medical’s Safe-T-Clamp® protects the person cutting the umbilical by encapsulating the cutting mechanism into a hand-held device that simultaneously clamps the cord, cuts the cord and traps the blood splatter inside the device. This simple-to-use, single-hand device can be used by a clinician or family member to quickly cut the cord without the danger of an inadvertent stick or cutting the cord in the wrong place.

Once the infant is separated from the mother, a clinician carries the infant to a warming table where the infant’s umbilical cord is trimmed and “permanently” clamped. The clinician can now take a mixed blood sample from the excess umbilical cord that has been trimmed from the infant. To take a mixed blood sample the nurse typically holds the slippery cord in one hand while using a syringe in the other hand to stick a vein in the cord to withdraw blood. Once the blood is withdrawn from the cord, the clinician needs to transfer the blood from the syringe to a “vacutainer," requiring another stick. Talon Medical’s CORD-X® can protect a clinician by eliminating the need to handle a slippery cord and or use a syringe. The clinician only needs to place the cord in the CORD-S® tray, place the CORD-X® cover on top of the tray and press down. The blood is quickly and safely milked out of the cord and into the tray’s collection area. The clinician then removes the cover from the protected needle on the front of the tray and presses a “vacutainer” on the needle to transfer the blood from the tray to the “vacutainer." A safe, easy and quick procedure that helps to prevent needle sticks while handling a slippery umbilical cord.

The physician handed the baby to the nurse who cleaned, weighed and measured her.   All signs of blood and amniotic fluid were wiped away from the baby’s face to protect the baby’s eyes.   Following the delivery of the placenta, the physician started to suture up vaginal tears and the episiotomy that was performed earlier. 

Episiotomy and perineal or vaginal laceration repair may be easily accomplished using blunt suture needles. Vaginal tears can keep bleeding and need to be repaired by the physician. Since they are deep the doctor has to use his non-dominant hand as a guide.   Blunt needles should be used whenever possible.  When the procedure is completed the blunt needle should be dropped into a sharps disposal container.

Conclusion

This story has illustrated the many different ways that healthcare professionals can protect themselves in the birthing areas of a hospital.   It is extremely important that personal protective equipment be used as the first “perimeter of defense” against sharps injuries.  Hospitals should examine their policies about the use of personal protective equipment for visiting families.  An annual review of sharps safety equipment is required to be in compliance with the law.  Hospital administrators should be proactive in working with frontline workers in evaluating new safety equipment and making them not only available but accessible to nurses and physicians.  Safety equipment doesn’t help anyone when it is in a supply room two floors away. 

Sharps safety is a requirement of the law, but it is much more than that--it is just good business.   Nurses need to feel that the hospital administration is just as concerned about their health as they are about the bottom line.  

There is a decreasing pool of experienced nurses to work in labor and delivery rooms as well as in emergency departments and other critical care units.  Hospitals can make a significant difference in alleviating the nursing shortage--a shortage that will become increasingly dangerous to the healthcare of every American, if we do not act quickly.   Hospitals can help retain their nurses by providing them with a safe environment in which to work.   Hopefully, a new day for occupational safety in labor and delivery has begun.

Author bio:

Ron Stoker is the executive director of the International Sharps Injury Prevention Society (ISIPS). For more information about ISIPS and sharps safety products, visit www.isips.org, or email Mr. Stoker at ron@isips.org.