Infection Prevention
and Waste Disposal
Anuradha Sood, Tarun Sharma,
and Aradhna Sharma
2.1 Introduction
Nosocomial infections (hospital-acquired
infections, healthcare-associated infections)
are a signi cant cause of morbidity and mortality.
They are de ned as those infections acquired by
a person in a healthcare unit which are secondary
to the patient’s original condition. These infec-
tions also include infections acquired by the
patient but appearing after discharge. The symp-
toms usually appear after 48 h of admission. It is
estimated that 5–10% of patients admitted for
acute care and emergency procedures acquire
healthcare-associated infections (HAI). Of more
concern is that more than 70% of infections are
due to antibiotic-resistant organisms.
Pregnant females and their foetuses are at an
increased risk of acquiring HAIs. All labour
rooms, obstetric emergency evaluation areas and
operation theatres should have facilities for infec-
tion control as they can get puerperal sepsis, neo-
natal sepsis and other infections acquired during
delivery. HAIs also include occupational injuries
and infections which a healthcare worker (HCW)
A. Sood (*)
Department of Microbiology, DRPGMC,
Kangra at Tanda, Kangra, Himachal Pradesh, India
T. Sharma
Department of Medicine, DRPGMC,
Kangra at Tanda, Kangra, Himachal Pradesh, India
A. Sharma
Department of Pharmacology, SLBSGMCH Mandi
at Ner Chowk, Mandi, Himachal Pradesh, India
© Springer Nature Singapore Pte Ltd. 2020
A. Sharma (ed.), Labour Room Emergencies, https://doi.org/10.1007/978-981-10-4953-8_2
2
can get by virtue of his/her occupation. Needle-
stick injuries and injuries from other sharps
results in approximately 400,000 cases each year.
So, infection control measures should be of top
most priority for all HCW (doctors, nurses, mid-
wifes, safai karamcharis, etc.).
2.2 Importance of Infection
Control in Obstetrics
India accounts for about 1/5 of all maternal
deaths and 1/3 (approximately 30%) of all
neonatal deaths. Puerperal sepsis is a fairly
common entity especially in the rural and back-
ward areas of India. Most maternal and neonatal
deaths occur in the rst 7 days after delivery. It
accounts for about 19.2% deaths, and it is the
second leading cause of death in mothers after
haemorrhage and anaemia. In the mother sepsis
may lead to blood stream infections, endotoxic
shock, peritonitis and abscess formation.
Infections in neonates include neonatal septi-
caemia, decreased Apgar score and pneumonia.
Increased susceptibility of sepsis is more marked
in low birth weight neonates (<2500 g) and very
low birth neonates (<1500 g). This is due to their
poor immune defences and weak cellular and
humoral immunity. Vascular or urinary catheters,
other indwelling lines or contact with care givers
who have bacterial colonization are additional
factors contributing to neonatal septicaemia.
11
12
Table 2.1 Differentiating features of EOS and LOS
Feature EOS
Time of Infection within 72 h of birth
appearance
Mode of Vertically from mother to infant
transmission before or at time of birth (i.e.
HBV,HIV, TORCH)
Microorganisms Includes organisms harboured in
genital tract or which can cross the
placenta (e.g. group B streptococcus,
E.coli, CONS, H. in uenzae, Listeria
monocytogenes)
HBV Hepatitis B virus, HIV human immunode ciency virus, E. coli Escherichia coli, CONS coagulase-negative staphy-
lococcus, H. in uenzae Haemophilus in uenzae, TORCH Toxoplasma gondii, Rubella virus, Cytomegalovirus, Herpes
virus
Neonatal sepsis is broadly divided into two
main categories: early-onset septicaemia (EOS)
and late-onset septicaemia (LOS). The main fea-
tures of the two are tabulated in Table 2.1.
2.3 General Measures to Prevent
Spread of Infections
in Emergency Obstretic Care
To reduce the spread of infections in both baby
and the mother, the following have to be kept in
mind:
1. Infection control measures during admissions.
2. Availability of clean environment, clean
equipment and other supplies.
3. Availability of trained and skilled staff.
4. Hand washing.
5. Biomedical waste management.
6. Safety from sharps.
7. Safe blood transfusion.
8. Measures to prevent tetanus.
9. Neonatal resuscitation facilities.
2.4 Infection Control Measures
During Admissions
1. Proper initial assessment of every patient
should be done very carefully. If any patient is
assessed to be suffering from contagious ill-
ness (measles, rubella, chicken pox, etc.),
A. Sood et al.
LOS
Infection after 72 h of birth
At time of birth or during hospital stay
Includes mainly organisms acquired from the
environment (e.g. Staphylococcus aureus, CONS,
E.coli, Klebsiella spp., Pseudomonas spp., Candida
spp., Acinetobacter spp.)
separate room for delivery should be made
available. The staff of nursery/NICU (neona-
tal intensive care unit) should be noti ed
simultaneously so that adequate neonatal
facilities are arranged well in time.
2. Isolation facilities are also necessary for both
mothers and neonates suffering from puer-
peral sepsis, gastrointestinal infections, breast
abscesses and skin sepsis.
3. All the items which have been supplied/
bought by the patient should be marked
carefully.
4. Avoid overcrowding in labour rooms and
other procedural rooms to reduce cross infec-
tion. Limit the visitors inside these areas.
2.5 Availability of Clean
Environment, Equipment
and Other Supplies
1. Clean environment to be ensured by:
(a) Operation theatres and labour rooms
should ideally be cleaned after each oper-
ating session. Routine cleaning and mop-
ping with water and detergent is required.
A disinfectant should be used after known
contamination of oors with material
from infected patients.
(b) An interval of at least 10 min should be
there between two patients.
(c) It is the duty of every staff nurse in labour
room to clean thoroughly the furniture
2 Infection Prevention and Waste Disposal
and other articles in labour room with a
hospital-approved disinfectant.
(d) For cleaning of all contaminated surfaces
(labour table, procedure table, trolley sur-
face, Kelly’s pad or plastic sheet), use of
0.5% chlorine solution after every proce-
dure should be undertaken.
(e) Maintain a clean sterile eld around the
delivery/surgical site by placing sterile
towels or drapes around the surgical/pro-
cedure site. The sterile eld includes the
PPE (personnel protective equipment)
worn and that remains above the level of
waist. The back of the gown and shoul-
ders and also the area below the waist are
not considered sterile. The sterile opera-
tive eld includes all sterile drapes above
the level of operating table. To maintain a
sterile eld, only allow sterile items and
personnel within the eld. Hold the drapes
by edges or from underneath surface for
placing sterile drapes.
(f) For putting instruments use either a sterile
instrument container or sterile drapes.
(g) Do not mix sterile items with contami-
nated items.
2. Adequate availability of the equipment and
the following supplies:
(a) Soap, antiseptics, alcoholic scrubs and
plenty of running water for proper hand
hygiene should be available in emergency
care area.
(b) Hand washing basins should be placed in
labour rooms, maternity wards and
nurseries.
(c) Sterile delivery packs, episiotomy sets,
dressings, drapes and sterile sanitary pads
should be freely available.
(d) Equipment, containers and teats for pre-
paring special feeds should be sterilized
by central sterile supply department
(CSSD). In case of equipment (e.g. tub-
ings, resuscitation apparatus) which do
not withstand sterilization, high-level dis-
infection should be considered.
(e) Sterile disposable aprons, gloves, caps,
face masks and shoe covers collectively
13
called as personal protective equipment
(PPE) should be available in plenty.
(f) Availability of following drugs to be
insured.
(i) Antibiotics to prevent puerperal sep-
sis and neonatal sepsis.
(ii) Anticonvulsants for treatment of
preeclampsia and eclampsia.
(iii) Uterotonic drugs for postpartum
haemorrhage.
2.6 Availability of Skilled Sta
Highly skilled and adequate doctors, nurses and
birth attendants should be there who are capable
of dealing with any kind of emergency especially
manual removal of placenta, removal of retained
products following miscarriage or abortion,
assisted vaginal delivery and basic neonatal
resuscitation care. Also they should have the
capability of performing caesarean section and
blood transfusion. All staff should be screened
for MRSA (methicillin-resistant Staphylococcus
aureus), herpes and candida paronychia initially
before induction and from time to time.
2.7 Hand Washing
It is the single most important procedure which
can help in reducing the spread of infection in
healthcare settings. There are mainly three types
of hand washing:
(a) Simple hand washing.
(b) Hygienic hand washing.
(c) Surgical hand washing.
These have been summarized in Table 2.2.
2.7.1 When Is Hand Washing
Recommended?
World Health Organization (WHO) has advo-
cated use of hand washing in certain circum-
stances and these are known as “5 moments of
14 A. Sood et al.

Table 2.2 Types of hand washing

Type of hand Areas to be
washing Indication Agents used for hand washing Time included
Simple Routine procedures Soap and water 10 s Only hands
Hygienic Handling of infectious 60–70% alcoholic rub, 5–7.5% 30 s Hands and
patients, nurseries, outbreak povidone iodine, 2–4% chlorhexidine wrists
Surgical Before minor and major Same as hygienic hand washing 3–5 min Up to
surgery elbows
Simple hand washing is usually adequate in dealing with obstetric patients; use hygienic hand washing when dealing
with premature and low birth babies or during outbreaks and surgical hand washing before any surgical procedure is
done. In case of emergency stabilization procedures, a rapid scrubbing technique lasting for 1–2 min focusing on n-
gertips and hands is acceptable

Table 2.3 Management of HBV exposure

Source HBV Source
Vaccine status Source HBV positive negative unknown
Unvaccinated HBIG 0.06 mL/im vaccine for HBV initiation Vaccine Vaccine
initiation initiation
Previously vaccinated (written Check for anti-HBs antibody titre. If above 10 IU/ No No
documentation of three or mL, no vaccine/booster is required; otherwise give treatment treatment
more doses) HBIG 0.06 mL/im vaccine for HBV initiation
HBIG hepatitis B immunoglobulin
Infants borne to HBV-infected mothers should receive hepatitis B vaccine and hepatitis B immunoglobulin within 12 h
of birth

Hand Hygiene”. It is mandatory that hand
hygiene is performed in all patients:
1. Before undertaking any aseptic procedure in
the patient.
2. Before touching any patient.
3. After examining the patient.
4. After contact with patient surrounding.
5. After body uid exposure.
In case of emergency procedures in an obstet-
ric patient, if there is no time for hand washing,
gloves should be worn in all circumstances.
2.8 Management of Needle-
Stick Injuries (NSI)
1. Advice to staff or attendant with NSI regard-
less of the source of injection should be taken
seriously with the hospital providing access to
advice 24 h.
2. First aid involves immediate washing of the
injury site with plenty of soap and water.
3. Both the patient from whom NSI has been got
and the healthcare workers should undergo
baseline tests, namely, for HBV, HCV and
HIV.
4. In case of suspected HIV infection, postexpo-
sure prophylaxis (PEP) should be started
immediately and not later than 72 h. Monitor
for drug side effects. HIV antibody testing
should be done at baseline, 6 weeks, 3 months
and 6 months.
There are two regimes for PEP: Basic two-
drug and expanded three-drug regime depend-
ing upon the severity of exposure.
5. For management of HBV exposure, the fol-
lowing is to be done:
Wounds and skin sites which have come in
contact with blood or body uids should be
washed with soap and water. Mucus mem-
branes should be ushed with water (Table 2.3).
6. For management of hepatitis C virus follow
these things:
No PEP is available.
Management includes early identi cation
and treatment.
2 Infection Prevention and Waste Disposal
If source is HCV positive, baseline testing
for anti-HCV, liver function tests and subse-
quently follow-up at 4–6 months by ELISA/
PCR for HCV RNA are done.
7. Refrain all individuals of NSI from positive
sources of HIV, HBV and HCV from donating
blood, organ donation, tissue donation and
semen donation.
2.9 Blood Transfusion
2.9.1 Remember: Right Patient,
Right Blood, Right Time,
Right Place
Blood transfusion is essential in the management
of life-threatening blood loss due to PPH and
anaemia.
1. Avoid unnecessary and inappropriate blood
transfusion. Rational use of blood transfusion
and other blood products to be established by
clinical and laboratory assessment. The obste-
trician and anaesthetist should be careful
enough to decide which patient needs
transfusion.
2. Both the donors of blood and the blood of the
patient should be tested for blood type (ABO
group) and Rh type (+ or −) followed by
cross-matching of the two. The identity check
between blood of patient and donated blood is
the crucial nal step necessary to avoid fatal
mistransfusions.
3. All donated blood to be screened for at least
HIV, HBV, HCV, Treponema pallidum and
Plasmodium. A safe supply of blood and
blood products should be ensured by the blood
bank concerned.
4. All transfusion should be completed within 4
hours of receiving the blood unit from blood
banks ambient temperature for storage.
5. Monitor the patient for pulse, blood pressure,
temperature and respiratory rate at start of
blood transfusion, after 15 min and not more
than 60 min, after transfusion is complete.
15
2.10 Safety from Sharps
1. Whenever possible use safer needle devices
with built-in safety control or needleless
devices.
2. Never recap/bend or remove contaminated
needles and other sharps.
3. Never shear or break sharps which are
contaminated.
4. Always make needle cutters/containers avail-
able near areas where needles may be found.
5. Discard contaminated sharps immediately
into appropriate containers.
6. Use puncture-resistant and leakproof contain-
ers for sharp disposal. Dispose the containers
when 3/4 full.
7. Whenever razors have to be used, use dispos-
able razors.
2.11 Infection Control Measures
to Prevent Tetanus
1. All mothers should have received two doses
of tetanus toxoid (TT) 0.5 mL im at least
2 weeks apart.
2. In cases where proper sterilization and disin-
fection facilities are not available, a booster
dose (0.5 mL) im to the mother (who has
already received two doses) should be given.
If the mother has got no previous dose of vac-
cine, give anti-tetanus serum 1500 U im dur-
ing delivery, and another shot of tetanus
toxoid 0.5 mL im after 4 weeks is required.
2.12 Appropriate Use
of Antibiotics
Use prophylactic broad-spectrum antibiotics
especially before or during the procedure.
Do not indiscriminately use antibiotics in
every patient. Use prophylactic antibiotics in the
following circumstances:
In all immunocompromised patients.
After any invasive procedure is undertaken.
16
After any intrauterine procedures where con-
tamination by vaginal ora is unavoidable like
manual removal of placenta, bimanual compres-
sion of uterus caesarean section, etc.
2.13 Management of Spills
Spills by blood and body uids should be done
immediately. Wear gloves, masks, gowns and
shoe covers. Put sodium hypochlorite (5–6.5%)
1 in 100 dilution for 15–20 min, and cover with
an absorbent cloth/cotton/paper. Finally mop the
oor.
2.14 Biomedical Waste
Management Rules, 2016
De nition: “Biomedical waste” means any
waste, which is generated during the diagnosis,
treatment or immunization of human beings or
animals or research activities pertaining thereto
or in the production or testing of biological or in
health camps.
These rules shall apply to all persons who
generate, collect, receive, store, transport, treat,
dispose or handle biomedical waste in any form.
A. Sood et al.
These rules shall not apply to:
(a) Radioactive wastes.
(b) Hazardous chemicals.
(c) Solid wastes covered under the municipal
solid waste.
(d) The lead acid batteries.
(e) Hazardous wastes covered under the
hazardous.
(f) E-waste,
(g) Genetically engineered microorganisms.
The salient features of these rules are:
1. No untreated biomedical waste shall be mixed
with other wastes.
2. The biomedical waste shall be segregated into
containers or bags at the point of generation.
3. The containers or bags shall be labelled.
4. Bar code and global positioning system shall
be added by the occupier and common bio-
medical waste treatment facility in 1 year time.
5. Untreated human anatomical waste, animal
anatomical waste, soiled waste and biotech-
nology waste shall not be stored beyond a
period of 40–80 h.
6. Microbiology waste and all other clinical labo-
ratory waste shall be pretreated by sterilization.
2 Infection Prevention and Waste Disposal 17

Schedule I

Colour and type of Category/type of waste Treatment and disposal options

bag or container

Yellow-coloured 1. Human anatomical waste Incineration or plasma pyrolysis

non-chlorinated 2. Animal anatomical waste
plastic bags or
3. Soiled waste
containers
4. Expired or discarded medicines
5. Chemical waste
6. Chemical liquid waste
7. Discarded contaminated linen,
mattresses and beddings
8. Microbiology, biotechnology and
other clinical laboratory wastes
or deep buriala
In the absence of above facilities,
autoclaving or microwaving
Expired cytotoxic drugs and items
contaminated with cytotoxic drugs to be
returned back to the manufacturer or
supplier for incineration
Bags containing residual or discarded
blood and blood components to be
hydroclaving followed by shredding or
mutilation or combination of sterilization
and shredding

Red-coloured Contaminated waste (recyclable) Autoclaving or microwaving/hydroclaving

non-chlorinated (a) Wastes generated from disposable followed by shredding or mutilation or
plastic bags or items such as tubing bottles, intravenous combination of sterilization and shredding
containers tubes and sets, catheters, urine bags,
syringes (without needles and fixed needle
syringes) and vacutainers with their
needles cut) and gloves

White (translucent) Waste sharps including metals:
puncture-proof, Needles, syringes with fixed needles,
leakproof, tamper- needles from needle tip cutter or burner,
proof containers scalpels, blades or any other contaminated
sharp object that may cause puncture
and cuts
Autoclaving or dry heat sterilization
followed by shredding or mutilation or
encapsulation in metal container or
cement concrete; combination of
shredding cum autoclaving; and sent
for final disposal to iron foundries or
sanitary landfill or designated concrete
waste sharp pit

Blue cardboard (a) Glassware: Disinfection (by soaking the washed

boxes with Broken or discarded and contaminated glass waste after cleaning with
blue-coloured glass including medicine vials and detergent and sodium hypochlorite
marking cardboard ampoules except those contaminated with treatment) or through autoclaving or
boxes with cytotoxic wastes. microwaving or hydroclaving and then
blue-coloured sent for recycling
(b) Metallic body implants
marking

aDisposalby deep burial is permitted only in rural or remote areas where there is no access to common
biomedical waste treatment facility