Infection Prevention

Part of Midwifery and Childbirth

How to prevent the infections that historically killed most mothers and newborns during and after childbirth.

Why This Matters

Puerperal fever — childbed fever — was the single greatest killer of new mothers throughout history. In 18th and 19th century hospitals, one in ten women died within days of giving birth, struck down by bacterial infections introduced during delivery. The tragedy is that Ignaz Semmelweis demonstrated the solution in 1847: handwashing. Within a generation, simple antiseptic technique transformed childbirth from a dangerous ordeal into a manageable event.

In a post-collapse world, you face the same microbial threats that killed women for millennia. The birth canal, placental site, and perineal tears all create open wounds — raw tissue exposed to the outside world. Bacteria that harmlessly colonize the skin and gut become lethal when introduced into these vulnerable sites. A birth attended with unclean hands, unsterilized instruments, or contaminated linens can trigger a rapidly fatal systemic infection.

Understanding infection prevention is not optional knowledge for a collapse midwife — it is the foundation upon which all other skills rest. A skilled birth attendant who neglects cleanliness will cause more deaths than they prevent. The principles here require no special equipment: soap, heat, and disciplined technique are sufficient to prevent the vast majority of birth-related infections.

Hand Hygiene

Hands are the primary vector for birth infections. The pathogens most likely to kill a postpartum mother — Group A Streptococcus, Staphylococcus aureus, E. coli — live on human skin and in the gut. Every internal examination, every assisted delivery, every contact with the birth canal carries infection risk if hands are not clean.

Pre-birth hand preparation:

1. Remove any rings, bracelets, or jewelry that harbors bacteria in crevices
2. Trim fingernails short — bacteria accumulate under long nails and cannot be fully removed
3. Wash hands with soap and clean water for a minimum of 60 seconds
4. Scrub between fingers, under nails, and up to the elbows
5. Rinse thoroughly with clean water flowing downward (wrists to fingertips)
6. Dry with a clean cloth reserved only for this purpose, or air dry
7. If available, apply an alcohol-based hand rub after washing

During labor:

• Rewash hands before every internal examination
• If you touch anything unclean (your face, the floor, contaminated linens), rewash immediately
• Keep the number of internal examinations to the minimum necessary — each one introduces risk
• If gloves are available, use them for all internal examinations, but remember gloves are not a substitute for handwashing

Making antiseptic wash without commercial products:

Alcohol solution: Distilled spirits above 60% alcohol (120 proof or higher) can be used as a hand antiseptic. Pour a small amount over hands, rub vigorously for 30 seconds, allow to evaporate.

Boiled water rinse: Boiled and cooled water is not sterile, but it is far cleaner than river or well water. Use it for the final rinse after soap washing.

Dilute iodine: If povidone-iodine or Lugol’s solution is available, a 1% dilution makes an effective skin antiseptic.

Equipment and Surface Sterilization

Every instrument that enters the birth canal or contacts open tissue must be sterilized — not just clean, but free of viable microorganisms.

Sterilization methods by reliability:

Method	Process	Notes
Boiling	20 minutes at full rolling boil	Kills most pathogens; not true sterilization but adequate for field use
Steam under pressure	Pressure cooker, 15 min at pressure	True sterilization; kills spores
Dry heat	Oven at 170°C for 1 hour	Effective for metal instruments; damages rubber/plastic
Chemical (alcohol)	Soak in 70% alcohol for 30 min	Kills vegetative bacteria; does not kill all spores
Flame	Pass through flame briefly	Inadequate for birth instruments — burns off surface only

Priority items to sterilize:

• Scissors or blade for cutting the umbilical cord
• Any instrument used to check dilation or assist delivery
• Cord ties or clamps
• Bulb syringe for clearing infant airways

Procedure:

1. Wash instruments with soap and water first — organic matter (blood, tissue) blocks sterilizing agents
2. Boil in clean water for a full 20 minutes from the time the water returns to a rolling boil
3. Remove with clean tongs (also boiled) — do not touch the instrument surfaces with bare hands
4. Place on a clean surface (boiled cloth or sterile container) and allow to cool
5. Use immediately or store in a clean covered container

Birth surface preparation:

• Cover the birth surface with clean cloths or plastic sheeting changed between uses
• Boil cloths that will contact the birth canal or newborn
• The floor should be swept and, if possible, mopped with a dilute soap or antiseptic solution before birth

Wound Care After Delivery

Perineal tears, episiotomies, and the placental attachment site all require post-delivery wound care to prevent infection.

Immediate post-delivery:

• Inspect the perineum for tears requiring repair
• If suturing tears: use clean technique, boiled instruments, and suture material stored in alcohol
• Clean the perineal area with clean warm water after delivery — do not scrub vigorously
• Apply gentle pressure to any bleeding points with clean cloth

Ongoing perineal care (first 1-2 weeks):

• Clean with clean warm water after every urination and bowel movement — pour water over the area rather than wiping, which spreads bacteria toward the vagina
• Pat dry with clean cloth or allow to air dry
• Keep the area cool and dry when possible — warmth and moisture promote bacterial growth
• Avoid inserting anything into the vagina until fully healed (minimum 6 weeks)

Recognizing wound infection:

• Increasing rather than decreasing pain 2-3 days post-delivery
• Redness, swelling, warmth around any tears
• Pus or foul-smelling discharge from wounds
• Fever above 38°C (100.4°F)

Early wound infection can be treated by opening and draining the wound, cleaning with dilute antiseptic solution, and allowing healing by secondary intention. Systemic antibiotics (if available) are indicated for any wound infection with fever.

Recognizing and Responding to Puerperal Infection

Even with perfect technique, infections can occur. Early recognition and aggressive response prevent maternal death.

Classic puerperal fever presentation:

• Fever (38°C or higher) on any 2 of the first 10 days postpartum, excluding the first 24 hours
• Foul-smelling vaginal discharge
• Uterine tenderness on palpation
• Rapid heart rate, general malaise
• In severe cases: rigid abdomen, extreme tenderness, confusion

Response protocol:

1. Assess severity — is the mother systemically ill (confused, racing heart, not improving)?
2. Encourage fluid intake — infection rapidly causes dehydration
3. If antibiotics are available, begin broad-spectrum treatment immediately without waiting for confirmation
4. Promote uterine drainage — ensure the uterus is contracting and draining normally (massage if subinvoluted)
5. Keep the mother warm but ventilated
6. Monitor every 2-4 hours for deterioration

Antibiotic priorities (if available):

• Amoxicillin/ampicillin covers Group A Strep and many gram-positive organisms
• Metronidazole covers anaerobes and is critical for serious infections
• Combination therapy is more effective than single agents for established uterine infection

Sepsis Emergency

A mother who becomes confused, develops a very rapid heart rate (over 120 bpm), or stops making urine has septic shock — a medical emergency. Without intensive care, mortality approaches 50%. Priority: fluids, antibiotics, evacuation to any available medical facility.

Environmental Controls

Individual technique matters, but so does the birth environment. Reducing the overall microbial load around the birth decreases infection risk for both mother and newborn.

Ideal birth environment:

• Indoors, away from livestock and their waste
• Ventilated but not drafty (protect newborn from cold air)
• Clean surfaces — swept, wiped down
• Limited personnel: fewer people present means fewer bacterial sources

People in the birth room:

• Each additional person present increases bacterial contamination
• Anyone with active illness (respiratory infection, diarrhea, skin infections) should not attend the birth
• Attendants should wash hands and change into clean clothes before entering
• Children should generally be kept out of the birth room

Water supply:

• Identify and secure your cleanest available water source before labor begins
• Boil water in advance — you will need it for handwashing, cleaning the mother, bathing the newborn, and making clean compresses
• Store boiled water in covered containers to prevent recontamination

Post-birth cleanup:

• Dispose of the placenta and contaminated materials promptly — they attract insects and animals
• Launder all soiled linens before reuse — boiling is preferable
• Clean all surfaces and instruments before storing

The discipline of infection prevention must become automatic before it can be reliably practiced under the stress and exhaustion of attending a difficult birth. Midwives who internalize these habits save lives; those who cut corners in moments of distraction cause unnecessary deaths. Practice the procedures until they require no thought.