Taking Universal Precautions Seriously


The fifth annual World AIDS Day was held on December 1, 1992. The World Health Organization used this occasion to launch a worldwide campaign to increase AIDS awareness and adopted “AIDS: A Community Commitment” as its theme for the year. Accordingly, the World Health Organization recommends that governments, as well as nongovernmental and community organizations all over the world, sponsor events that will assist people to increase their understanding about AIDS and to encourage compassion for individuals infected with the human immunodeficiency virus (HIV) (1).

It is estimated that more than one million Americans are now infected with HIV. In addition, recent statistics clearly demonstrate that there is an alarming increase in the number of newly diagnosed HIV-positive cases among women of child-bearing age, many of whom are infected but are still asymptomatic (2). It is imperative, therefore, that all obstetric care providers keep informed and up-to-date regarding AIDS prevention, transmission, diagnosis, treatment, education, and counseling, as well as the use of universal precautions. It was with this goal in mind that the Journal of Nurse-Midwifery devoted its first Home Study Program to “A Special Focus on AIDS” (3), and features an “AIDS Update” in this issue.

Nurse-midwives take pride in providing personal, individual, quality care to their clients. To facilitate interpersonal communication and to remove any significant barriers that might interfere with the midwife–patient relationship, some nurse-midwives deliberately or unconsciously ignore the proper universal precautions recommended by the Centers for Disease Control (4). For example, some nurse-midwives routinely start intravenous infusions or draw blood for typing and crossmatch without the protection of gloves or may, on occasion, assist at a delivery without wearing a protective gown or eye shield. The thinking behind such careless behavior is often “I know my patient well, I do not believe that she is at risk for HIV infection, and I will not jeopardize the mutual trust that we've established by treating her as an untouchable.” However, this, unfortunately, is not the time to struggle with balancing personal touch and safety by gambling on the odds. Ample evidence shows that body fluids, especially contaminated blood, have resulted in HIV transmission (5). It is, therefore, highlys recommended that fluid-resistant gowns, face shields, double gloves (especially elbow-length gloves to prevent unprotected skin contact through garment soakage) be conscientiously used where contact with blood and/or amniotic fluid is anticipated. In addition, proper draping technique during delivery—using a sheet under the buttocks positioned so that blood and amniotic fluid will escape from the vagina into a bucket rather than onto the lap or the lower extremities of the midwife—should be employed. In addition, protective shoe covers should be worn to prevent fluid seepage into the shoes.

In 1989, Panlilo and coworkers (6) studied the blood and amniotic fluid contact sustained by attending obstetricians, midwives, obstetric house staff, pediatricians, medical students, and nursing personnel during deliveries at Grady Memorial Hospital in Atlanta, Georgia. Over 90% of the 8,200 women delivering at the hospital were tested for the HIV antibody; the HIV-positive rate was 0.8%. Approximately 87% of the births were vaginal deliveries; of these, one-third were attended by certified nurse-midwives. The use of universal precautions was the official hospital policy. Two observers were assigned to monitor a sample of deliveries. They observed that at least one blood or amniotic fluid contact (such as blood contact inside of gloves, garment soakage, splashing onto mucous membranes, and/or direct contact without barrier protection or gowns) occurred during 79 (39.1%) out of 202 vaginal births and 14 (50%) out of 28 cesarean deliveries. In addition, four providers sustained self-inflicted percutaneous injuries that were attributed to needle-sticks during the performance or repair of an episiotomy or laceration. All four of these individuals used single gloves during the procedure. The study concluded that more than half of the contacts sustained by obstetricians were potentially preventable with the use of additional barrier protection; fully half of the contacts sustained by midwives might have been prevented by the use of gowns during deliveries.

Due to these inherent risks, many educators are concerned with the question of how many episiotomies, if any, nurse-midwifery students should perform during their basic training. This invasive surgical procedure is a risk to the patient as well as to the care provider. Do we expose our students to unnecessary risk of percutaneous injury by teaching episiotomy technique, or is it better for students to refine this skill under supervised conditions?

In the past, nurse-midwives were taught to approximate deep-muscle layer by careful digital check to make sure stitches did not lodge in the rectal mucosa. The repair was achieved without the benefit of direct visualization. Students who are neophytes have a great chance of sustaining needle-stick while performing this part of the procedure. An alternative procedure has, therefore, been instituted that reduced the risk of needle-stick by starting the repair at the deep-muscle layer, where the opposing edges can easily be seen under an open vaginal mucosa. To lessen the chances of percutaneous injury, students are taught to practice handling and using a needle holder, as well as placing the atromatic needle on the needle holder for suturing. The optimal amount of episiotomies a student performs before a student becomes proficient is difficult to ascertain. However, in view of the potential risk and benefits, the teaching of this procedure is absolutely necessary, especially in the case of suspected shoulder dystocia.

Many of the certified nurse-midwives in this country work in inner cities or in socioeconomically deprived areas where the incidence of HIV infections among women are disproportionately high. Yet, most women's health care providers are ill-prepared to deal with the full range of needs and problems posed by HIV-infected patients. As medications and therapy for HIV infection improve, the lives of AIDS patients will also be extended. To prevent the further spread of HIV infection, and to control unnecessary occupational exposures to HIV infection, the health care provider must use the recommended universal precautions when caring for all patients. Current knowledge about the epidemiology of AIDS is necessary for care providers when it comes to history taking and recognizing early signs and symptoms of HIV infection in order to ensure prompt treatment and referral.

In recent years, a small number of nurse-midwives have committed themselves to working with women infected with HIV. The nurse-midwifery service at Johns Hopkins University, for example, participates with physicians, a nutritionist, a social worker, and a psychologist/psychiatrist in collaborative management care of women who are HIV positive. Their commitment and efforts are to be commended because women who are infected with HIV need more resources and care at a time when resources are scarce and inadequate. Their midwifery model of care for women with HIV disease is published elsewhere in this issue.

As health care professionals, nurse-midwives are at greater risk for frequent exposure to HIV-infected blood and amniotic fluid. Unless universal precautions are consistently followed during encounters with all patients, the high risk and thoughtless behavior of the caregiver will only exacerbate the spread of HIV infections. Unless there is a vaccine for AIDS, prevention of HIV infection is the only proactive and rational approach to prevent the AIDS epidemic, a major public health problem in this country and worldwide.


  1. Special thanks are extended to Janet Herskovits, snm, for her concrete ideas on universal precautions that are applicable to practicing nurse-midwives.