Principles of infection control: obtaining swabs
Groin
Because the skin of the groin is dry, it is important to moisten the end of the swab with sterile normal saline. The swab is then rolled along the groin, using the area of skin along the inside part of the thigh that is nearest the genitalia.
Umbilicus
The baby should be positioned to allow easy access to the umbilicus (e.g. cradled in someone’s arms or lying in a cot) and undressed to expose the umbilicus. The swab is moved gently around the umbilicus and rotated. The baby should be redressed following the procedure.
High vaginal swab
Using an aseptic procedure, a speculum is inserted and opened inside the vagina (Chapter 28). The swab should be inserted through the speculum to the top of the vagina and rotated around. When the procedure is completed the speculum should be removed and the woman assisted into a comfortable position.
Low vaginal swab
Self-swabbing does not appear to compromise the speci-men integrity and is less embarrassing for the woman (Eperon et al 2013, Page et al 2013). The swab is inserted into the lower vagina for 2–4 cm and rubbed irmly around the front, side, and back walls of the vagina while rotating the swab.
Wound
It is important to obtain the wound swab correctly. If only microorganisms from the wound surface are obtained and not those that penetrate the soft tissue, a false positive result may ensue as the microorganisms found on the wound surface are frequently different to the microorganisms responsible for the infection (Angel et al 2011, Kingsley 2003). Prior to obtaining a wound swab Pattern (2010) recommends using a gentle stream of normal saline to irrigate the wound to remove surface contamination, e.g.
slough, necrotic tissue, eschar, using an Aseptic Non Touch Technique (Chapter 10). Allow 1–2 minutes to pass before taking the swab. If the wound is dry, the swab should be moistened with sterile saline or transport medium.
The swab should be rotated across a 1 cm2 area of the wound (Levine’s technique) for at least 5 seconds using suficient pressure to release exudate or luid from the wound (Gardner et al 2006). If the wound is large, swab as with the swab. Usually just one swab is suficient. If
Gono-coccus is the suspected organism, the swab should not be refrigerated as there will be no recovery of the Gonococcus organism and a false negative will be reported.
Ear
It is important to withhold medication administered via the ears for 3 hours prior to obtaining the swab as the medication can interfere with the growth of the microor-ganism. To obtain a swab from the ear, the woman should be sat up with her head tilting to the unaffected side. When taking a swab from a baby, one of the parents or another midwife can hold the baby with the head up, tilted to one side. If the baby is too ill to be moved, lay the baby on the unaffected side. For both the woman and the baby, straighten the external canal by gently pulling the pinna upwards and backwards, the swab is inserted gently into, and rotated around the walls of the external canal. If neces-sary, the external canal can be cleaned with a moistened swab to remove any debris and/or crust before inserting the swab. A charcoal medium may be required to transport the swab.
Nasal swab
When taking a nasal swab, the woman should be sitting up or lying in a supine position with her head tilting back. If the swab is from a baby, he can be cradled in someone’s arms or laid on his back. The procedure may be easier if there is someone to hold the baby’s arms; alternatively wrap the baby in a blanket. The end of the swab should be moistened with sterile water and inserted gently into the nose, moving it upwards towards the tip of the nose, into the anterior nares (HPA 2013) while rotating it. Repeat the procedure using the same swab in the other nostril. Self-swabbing does not appear to compromise the specimen integrity and may be more comfortable for the woman (Akmatov et al 2012).
Throat
The woman should be sitting or lying facing a strong light source and asked to open her mouth widely and say ‘Ah’
as she sticks out her tongue (deWit & O’Neill 2014). The tongue should be depressed using a disposable spatula and the swab inserted to the back of the throat. The swab is then rotated quickly around the back of the throat around the tonsillar area and/or the posterior pharynx (HPA 2014), this is likely to make the woman gag. When removing the swab, ensure it does not come into contact with any part of the mouth, uvula, tongue, or saliva. A charcoal medium may be required to transport the swab.
•
Remove and dispose of gloves and apron.•
Wash and dry hands.•
Arrange transportation of the specimen to the pathology laboratory.•
Document indings and act accordingly.much of the wound as possible. The Levine technique is considered more reliable than the zigzag method of obtain-ing a wound swab (Angel et al 2011). If there is a sinus or pocket in the wound a separate swab should be used. Care should be taken to ensure the swab does not come into contact with the wound edge. The swab should be kept in room air and taken to the laboratory within 4 hours (Cooper 2010).
Placental swab
There are several ways of obtaining a placental swab so it is important that the midwife is aware of which surfaces require swabbing – the fetal surface, maternal surface, or between the membranes. If a swab of the fetal and or maternal surface is required, the swab should be moved around the surface(s) in a zigzag direction. Pettker et al (2007) found little correlation between placental swabs and the infectious and inlammatory status of the amniotic luid.
If sampling is required between the membranes, this can be obtained by cutting through the chorion at the base of the umbilicus (using a sterile scalpel) and swabbing the chorion-amnion interface on the underside of the amnion (Kraus 2011) or between the membranes at the edge of the placenta. Care must be taken not to cross-contaminate by touching the surface of the placenta or outer side of the membranes.
PROCEDURE: obtaining a swab
•
Discuss the procedure and obtain informed consent.•
Gather equipment:■ non-sterile gloves and apron (if required)
■ sterile swab and appropriate transport medium
■ speculum and lubricating jelly, e.g. KY Jelly®
(high vaginal swab only)
■ sterile water (nasal swab only)
■ sterile normal saline (groin or wound swab)
•
Wash and dry hands and apply apron and gloves.•
Position the woman or baby appropriately and obtain the swab specimen.•
Insert the swab into the transport medium and seal securely.•
Label the container with the name, hospital number and date of birth of the woman or baby, date and time the swab was obtained, nature of specimen, whether right or left (if applicable), and signature.Place into transport bag.
•
Assist the woman or baby into a comfortable position.ROLE AND RESPONSIBILITIES OF THE MIDWIFE These can be summarized as:
• recognizing the need for a swab to be taken
• using the correct swab and transport medium
• ensuring the procedure is undertaken correctly, with minimal discomfort to the mother or baby and with the use of appropriate standard precautions/personal protective equipment
• follow-up of swab results and instigating referral/
treatment as necessary
• correct documentation.
SUMMARY
•
Obtaining a swab is a signiicant, simple, but invasive procedure that may be undertaken on either the woman or the baby.•
It is important to take the swab correctly and avoid contamination from adjoining structures/debris to avoid false positive/negative results.SELF-ASSESSMENT EXERCISES
The answers to the following questions may be found in the text:
1. How would the midwife obtain a swab from:
a. the ear of a baby?
b. the eye of a baby?
c. the nose of a woman?
d. the throat of a woman?
2. How is an umbilical swab obtained?
3. Describe how a wound swab is obtained from a small wound.
4. What are the differences in procedures for obtaining high and low vaginal swabs?
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11| Chapter
Principles of infection control: obtaining swabs
REFERENCES
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Wound J. 8 (2), 176–185.
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Principles of hygiene needs: for the woman
Chapter
This chapter considers the skills required to meet the com-plete range of hygiene needs of the woman. Cleanliness and attention to physical appearance can be signiicant in promoting psychological wellbeing, as well as physical health. The principles of bed making are considered as well as personal, vulval, and oral hygiene.