UINIT-1

INTRODUCTION TO CONCEPTS OF MIDWIFERY AND OBSTETRICAL NURSING

 Obstetrics word came from a Latin word "OBSTETRIX" means "MIDWIFE".

 Midwifery, as known as obstetrics, is a health science and health profession that deals with

pregnancy, childbirth and the postpartum period (including care of newborn), besides

sexual and reproductive health of women throughout their lives.

TERMINOLOGY

 Midwifery is the knowledge necessary to perform the duties of midwife.

 Obstetrics is that branch of medicine, which deals with the management of pregnancy,

labour and puerperium.

 Gynaecology is that branch of medical science, which treats disease of the female genital

organs.

 Reproduction means process by which a fully developed offspring of its kind is produced.

 Pregnancy is a state of carrying fetus inside the uterus by a woman from conception to

birth.

 Gestation means pregnancy.

 Gravida is state of pregnancy irrespective of its duration.

 Multipara refers to woman who has given birth more than once.

 Nullipara is the woman who has not given birth before.

 Primigravida is a woman carrying first pregnancy.

 Multigravida is a woman carrying pregnancy more than once.

 Healthy women are the key to the health of any nation, primarily because of their vital role

in co-creating healthy infants and co- caring for the family.

 Providing health care to women is not only a health issue but a matter of human right issue.

 In women's life childbirth is a special event.

 A mother will never forget a 'midwife' who delivered her baby, and who was 'with the

woman' during childbirth, which is the very essence and identity of a midwife.

 Hence a midwife is an obvious catalyst in providing safe motherhood in the fabric of our

society.

MIDWIFERY IN INDIA BEFORE INDEPENDENCE

 In ancient India, care of women and practice of midwifery were totally in the hands of

indigenous village 'Dias'.

 These indigenous dais, not only helped during childbirth but also acted as consultants for

any condition of the mother related to birth.

 When medical missionary women from England came to India, the first striking

observation they made was that, since dais were unable to deal with difficult deliveries and

pregnancies, the maternal and neonatal mortality were very high.

 The first training school for dais was started in 1877 by Miss Hewlett, an English

missionary of the Zenana Missionary Society.

 However, the training of dais was not taken up by Government of India till 1900 when a

fund was established by Lady Curzon to improve the conditions of childbirth in the country.

 But before that, in 1872, a handful of Indian Christian nurses were trained for two years at

Delhi.
 In 1899 the Zenana Bible and Medical Mission started the training of nurses, but until 1893

there was no generally accepted scheme of training in the hospitals.

 In 1918 with the help of Dufferin Fund, Lady Reading Health School was established to

train Auxiliary Nurse Midwives (ANMs).

 In 1926 the Madras Registration of Nurses and Midwifes Act was passed to promote the

role of a registered midwife for service during childbirth.

 In 1936 Dufferin fund sanctioned grant to a number of Dufferin hospitals to build hostels,

supply teaching materials and employ qualified sisters in nursing schools.

 Thus Dufferin fund helped in raising the standards of nursing and midwifery in India.

 In fact prior to independence, midwifery training started as a separate course, in India.

Young girls at the middle school level (8th) were selected to undergo this training.

MIDWIFERY IN INDEPENDENT INDIA

 In 1946, the Bhore committee laid stress on the need for qualified midwives, health visitors

and the training of dais.

 In 1955, the Shetty Committee recommended the training of Auxiliary Nurse Midwife

(ANMs) in health centers for maternal and child health services, provided there were

adequate health visitors to supervise them.

 In 1959 Bishoff, a technical Consultant supported the training of two types of nursing

personnel ANM and General Nurse Midwife (GNM Nursing - 3 years and Midwifery - 1

year).

 In 1947, the first step the Indian Nursing Council took after its inception was to combine

the nursing and the midwifery courses into a single course.

 The course was designed to be of three and a half years duration, with the entry

qualification being 10th class.

 In 1975 the Kartar Singh Committee recommended shortening the two year course of ANM

to one and a half years and entry after class 10th.

 These ANMs were designed as female health workers. They were specially trained in

midwifery and child health care services. Government of India also invested heavily in the

training of dais.

PRESENT AND FUTURE OF MIDWIFERY IN INDIA

 The presence of a skilled midwife at birth is the single most important factor for achieving

safe motherhood (WHO).

 The number of midwives available as per population is an important indicator of the

maternal health status in a country.

 The maternal health status of women and maternal mortality are closely related to the

presence of trained attendants at birth.

 As the percentage of births attended by trained personnel goes up, the maternal mortality

ratio goes down.

IN INDIA THERE ARE THE FOLLOWING CADRES OF MIDWIVES

1. The trained nurse midwife (RN, RM): Who has undergone a diploma (Diploma in General

Nursing and Midwifery), which is of three and a half years duration. Or A degree nurse who

has done B.Sc. (Honors) Nursing, which is of four years duration.

2. The ANM, who is designated as the Multi-purpose health worker (female), is registered

as a midwife.

• Presently, this is a two years course with entry classification being 12th class.
India has a huge cadre of ANMs who are educated and trained in Midwifery.

3. Skilled Birth Attendant (SBA) refers exclusively to people with midwifery skills (e.g.

doctors, nurses, midwives) who have been trained to get proficiency in the skills necessary

to manage normal deliveries and to diagnose, manage or refer complications to all levels of

health care settings.

• Midwifery skills are defined as a set of cognitive and practical skills that enable the

individual to provide basic health care services throughout the natal continuum period and

also to provide prompt actions in emergencies including life saving measures, when

required.

NEED FOR MIDWIFERY AS A PROFESSION IN INDIA

1. To achieve safe motherhood.

2. To avoid duplication of services.

3. To give health education.

4. To participate in country's concern i.e. maternal and child welfare.

5. To get status and recognition in the society.

TRENDS IN MIDWIFERY AND OBSTETRICAL NURSING

1. Changes in social structure, variations in family lifestyle

It has altered health care priorities for maternal and child health nurses. Today, client

advocacy, an increased focus on health education and new nursing roles are ways in which

nurses have adapted to these changes.

2. Cost containment

Cost containment refers to systems of health care delivery that focus on reducing the cost

of health care by closely monitoring the cost of personnel, use and brands of supplies,
 length of hospital stays, numbers of procedures carried out, and number of referrals

requested.

3. Expanded roles for nurses

Increasing nursing responsibility for assessment and professional judgement and

providing expanded roles for nurse practitioners, such as the nurse - midwife.

4. Family centered care

More natural childbirth environment where partners, family members may remain in a

homelike environment and participate in the childbirth experience.

By adopting a view of pregnancy, childbirth as a family event, nurses can be instrumental in

including family members in care and consult family members about a plan of care and

provide clear health teaching so that family members can monitor their own care.

5. Access to health care

Strong predictors of access to quality health care include having health insurance, a higher

income level and a regular primary care provider or other source of ongoing health care.

Use of clinical preventive services, such as early prenatal care, can serve as indicators of

access to quality health care services.

The objectives selected to measure progress in this area are:

 Increase the proportion of persons with health insurance.

 Increase the proportion of persons who have a specific source of ongoing care.

 Increase the proportion of pregnant women who begin prenatal care in the first trimester

of pregnancy.

6. Shortening hospital stays

 Women who have begun preterm labor stay in the hospital while labor is halted and then

are allowed to return home on medication with continued monitoring.

 Routine hospital stay for mothers and newborns after an uncomplicated birth is now 2

days or less.

 Short term hospital stays require intensive health teaching by the nursing staff and follow

up by home care or community health nurses.

7. Increased use of alternative treatment modalities

There is a growing tendency to consult alternative forms of therapy, such as acupuncture

or therapeutic touch, in addition to, or instead of, traditional health care providers. Nurses

have an increasing obligation to be aware of complementary or alternative therapies.

8. Increased use of technology

 The field of assisted reproduction (e.g. in vitro fertilization), seeking information on the

internet and monitoring fetal heart rates by Doppler ultra sonography are another

examples.

 In addition to learning these technologies, maternal and child health nurses must be able to

explain their use and their advantages to clients. Otherwise, clients may find new

technologies more frightening than helpful them.

9. Technological advances

 As the technology has revolutionized and increasingly sophisticated computers in today's

world, it has become necessary for the nursing personnel to have thorough knowledge of

the new technology being used.

 Due to this advancement, 'the hands on care' of the client is reduced, so also is the, quality

nursing care.
 Today foetal monitoring has progressed from the use of fetoscope to electronic foetal

monitors. It can be used both, directly and indirectly.

HISTORICAL PERSPECTIVES AND CURRENT TRENDS

 Historical perspectives

 Origin of obstetrics

 As we all know that birth is the complex final act of nature's greatest miracle i.e. formation

and arrival of a child in the world. And the science and art that deals with human

reproduction is and art that deals with human reproduction is called Obstetrics.

 "SORANUS OF EPHESUS" is the Father of obstetrics. He was the first to write about the

Podalic Version.

 Earlier man were not welcomed in this field. During Middle Ages in Europe midwives were

of low types and executioner and barbers were called to help with difficult deliveries. Later

on in 16th & 17th century Ambroise Pare of Paris and Chamberlens stimulate men to take

interest in obstetrics.

HISTORICAL DEVELOPMENT IN OBSTETRICS

 In 1739, in London, Willam Smellie and his student Willam Hunter become obstetrician and

work for the same.

 In 1744, Willam Smellie introduce steel lock forceps.

 In 1752, Willam Smellie publish 'Textbook of Obstetrics'.

 In 1760, Puerperal fever was on peak in London in Lying-in hospital.

 On Jan 14th 1794 first Cesarean operation was performed by Dr. Jesse Benaett of Virginia

on his wife.

 First school of midwives was established at Pare instigation at the hotel Dieu in Paris.
 In 18th century National regulation of education and practice of midwifery begans.

 In 1807, Samuel Bard publish first book on obstetrics on four stages of labour.

 In 1847, Semmelweis, in Vienna, demonstrate that washing of hands in chlorine of lime

solution before examining women in labor reduce puerperal fever. Chloride of lime used as

antiseptic.

 Obstetrical forceps was developed by Dr. Peter Chamberlen. In the past only Greeks used

variety of hooks and tractors to deliver dead fetus.

 In 1853, Dr. James Y. Simpson of Glasgow succeeded in

 introducing the use of Chloroform anesthesia as an aid in

 obstetrics called "ERA OF MODERN OBSTETRICS".

 Then, Pinard Fetoscope was developed and lan Donald from Glasgow introduce Ultrasound

in Obstetrics.

 In 1950, Fritz Fuch of Copenhagen performed Amniotomy identified the fetal cells present

in it which identify sex of the baby by barr bodies.

 Later on emphasis on Antenatal check-ups, blood pressure, urine analysis was came in

attention.

 In 1892, Dr. Pierre Budin initiated consolation for nursing mothers.

 In 1949, first world health organization expert committee on maternal child health met in

Geneva.

 In 1950, Oral contraceptives was introduce for the control of fertility.

 Then B-hCG tracing was done with chorion villus sampling at 10th wk.

 Identification of IUGR was done by Non Stress test.

 Later on Raoul Palwer & Patrick steptol discover Laparoscopic Sterilization.

 In 1960, Witness abortion get started.

 1971 - MTP Act

 1974 - Family Planning Services Incorporated In MCH Care

 1977 - Renaming Family Planning To Family Welfare

 1978 - Expanded Programme on Immunization

 1985 Universal Immunization Programme

 1992 Child Survival & Safe Motherhood Programme

 1996 Target Free Approach

 1997 - RCH Programme Phase-1 (15-10-1997)

 2005-RCH Programme Phase-2 (01-04-2005)

CONTEMPORARY PERSPECTIVE OF OBSTETRICS

 In current view all the focus from obstetrics care shifted to perinatal care.

 Advancement in Obstetrics care has reduces the MMR.

 Govt. has started programme to identify high risk mothers.

 Training of health personnels, Allocation of facilities & equipment decreases MMR.

 MMR can be reduces:

 Early registration of pregnancy. o At least three antenatal check-ups.

 Dietary supplements can correct anaemia.

 Prevention of infection and haemorrhage during puerperium.

 Prevention of complications e.g. Eclampsia, Malpresentation, ruptured uterus.

 Treatment of medical conditions e.g. hypertension, DM, TB.

 Anti-malaria and tetanus prophylaxis.

 Clean delivery practice.

 Institutional deliveries for women with Bad Obstetric History and risk factors.

 Promotion of family planning.

 MCH services has started which aims at reduction in morbidity and mortality rate of

mother and baby.

 Baby friendly hospital scheme has launched in 1993 for effective breastfeed to child.

 Genetic counselling to the couples.

 . Screen the mother for HIV.

CURRENT TRENDS

 In our mothers and grandmothers days, an untrained woman, neighbors, relative or friend

delivered most babies at home. All the changes started in 29th century, when parturition

moved into the hospital setting. At that point, child bearing became far from a family affair.

 The mother and newborn remained isolated from the family for a week to ten days, when

family had only visiting privileges.

 Nursing was separated into three specialties, with one nurse caring for the mother during

labour, and delivery, another handling postpartum mothers and third caring for the baby.

 In the year 1940s, 'rooming in' concept was devised.

 The advantages of the system included a reduction in neonatal infection from cross-

contamination, increased confidence and independence for the mother and greater breast-

feeding success.

 In 1960s, the focus changed from the person giving care to the recipient. With that change,

came a change in terminology and obstetrical care became Maternity care.

 WHO offers definition of maternity care the object of maternity care is to ensure that every

expectant and nursing mother maintains good health, learns the art of child care, has a

normal delivery and bears healthy children.

 Technological advances

 As the technology has revolutionized and increasingly sophisticated computers in today's

world, it has become necessary for the nursing personnel to have thorough knowledge of

the new technology being used.

 Due to this advancement, 'the hands on care' of the client is reduced, so also is the, quality

nursing care.

 Today foetal monitoring has progressed from the use of fetoscope to electronic foetal

monitors. It can be used both, directly and indirectly.

 Experts believe that in coming years, births are going to be by high-tech innovations,

resulting in low prenatal mortality and morbidity.

 In future, there are challenges for nurses, as they will provide care in the world of high

technology.

 Increased Cost of High-Tech Care

As the high and sophisticated technology is being introduced into today's world, the costs

are also increasing. For the procedures such as ultrasound, foetal monitoring etc. the

couple has to pay good amount of money. Gradually, obstetric care is becoming a business

for the care providers.

 Changing Patterns of Child Birth

o There are increasing numbers of working women, until they are in there thirties.
o As early marriage practices still continue, both ends, the older and younger mothers face

increased risks of complications during pregnancy, such as preterm delivery, LBW etc.

 Perinatal Risk Factors

 The problems of society are reflected in risks: among them are AIDS in mothers and

newborns.

 LBW account for about 30-40% of live births in developing countries.

 In addition to maternal age, risk factors of LBW include mother's medical history, past

pregnancy, socioeconomic status and prenatal care.

 Family Centered Care

 Maternity care today has enhanced to family centered care. Definition of health include

physical, social, psychological and economic dimension. Family centered approach is basic

unit of society. Thus emphasis on his aspect is must that fosters family unity. Integration

and bonding takes high priority and much anticipatory counselling is offered.

 Rising Caesarean Birth Rates

 With the use of foetal monitoring and ultrasound for prenatal monitoring and ultrasound

for prenatal evaluation of foetal condition, has come and increased rate of caesarean birth

rates.

 Early Discharge

In earlier days, women were hospitalized for longer duration and physical activity was

increased very gradually. Over the years now, however, health care personnel have realized

that early return to normal activities is the best course for uncomplicated births.

 Role of Fathers
 With increased societal emphasis on shared parenting and the recognition of parental

bonding, many fathers are active in care giving and enjoy the closeness it brings.

LEGAL AND ETHICAL PRINCIPLES IN THE PROVISION OF HEALTH SERVICES

 Informed decision making

Patients or individuals who require health care services have right to make their own

decision about the opinions for treatment or other related issues. The process of obtaining

permission is called informed consent.

The health care provider should disclose the following details:

1. The individual is currently assessed health status regarding the general or reproductive

health.

2. Reasonably accessible medical, social and other means of response to the individual's

conditions including predictable success rates, side effects and risks.

3. The implications for the individual's general, sexual and reproductive health and lifestyle

declining any of the options or suggestions.

4. The health provider's reasoned recommendation for a particular treatment option or

suggestion.

 Autonomy

• Autonomous persons are those who, in their thoughts, work and actions are able to follow

norms chosen of their own without external constraints or coercion by others.

• It is to be noted that autonomy is not respect for patient's wish against good medical

judgement.

Simply put, a health provider can refuse a treatment option chosen by the patient, if the

option is of no benefit to the patient.

 Surrogate decision makers

• Surrogate decision makers (parents, caregivers, guardians) may take the decision if the

affected individual's ability to make a choice is diminished by factors such as extreme

youth, mental processing difficulties, extreme medical illness or loss of awareness.

 Privacy and confidentiality

 A patient's family, friend or spiritual guide has no right to medical information regarding

the patient unless authorized by the patients. The following points of confidentiality are to

be kept in mind:

 Health care providers duties to protect patient's information against unauthorized

discoloures.

 Patient's right to know what their health care providers think about them.

 Health care provider's duties to ensure that patients who authorize releases of their

confidential health related information to others, exercise an adequately informed and free

choice.

 Competent delivery services

 Every individual has a right to receive treatment by a competent health care provider who

knows to handle such situations quite well. According to the laws, medical negligence is

shown when the following elements are all established by a complaining party.

 A legal duty of care must be owed by a provider to the complaining party.

 Breach of the established legal duty

Of care must be shown, which means a health care provider has failed to meet the legally

determined standards of care. Damage must be shown. Causation must be shown.

 Safety and efficacy of products

 Health care providers are responsible for any accidental or deliberate use of products that

differs from their approved purposes or methods of use, for instance, the dosage level for

drugs. Look for the drug contraindications, drug expiry, damage of diluted sterilization

solvents etc.

PRECONCEPTION CARE AND PREPARING FOR PARENTHOOD

 Preconception care

 Care about pregnancy, its course and outcome well before the time of actual conception is

called preconceptional care.

 It ensures that a woman enters pregnancy with an optimal state of health which would be

safe both for herself and for her fetus.

 If the woman is seen first in the antenatal clinic, it is often too late to advice as

organogenesis is already completed.

Uses

 Maternal health is optimized preconceptionally. Problems of overweight, underweight,

anaemia, abnormal papanicolaou smears are evaluated and treated appropriately.

 Baseline health status and blood pressure are recorded.

 Women should be encouraged to stop smoking, alcohol and addictive drugs intake.

 Identification of high risk factors by detailed evaluation of obstetric, medical, family and

personal history. Risk factors are assessed by laboratory tests, if required.

 Importance of prenatal diagnosis for chromosomal or genetic diseases are discussed.

 Patient with medical disorders and complications like diabetes and heart disease should be

optimally controlled before they try pregnancy as there are effects of the disease on

pregnancy and also the effects of pregnancy on the disease. In extreme situations, like
 Eisenmenger's syndrome, diabetes nephropathy, the pregnancy is discouraged. Pre-

existing chronic diseases (hypertension, diabetes, epilepsy) are stabilized to an optimal

state by intervention before conception.

 Drugs used before pregnancy are verified and changed, if required, so as to avoid any

adverse effect on the fetus during the period of organogenesis. For example, anticonvulsant

drugs are changed to safer drugs. Warfarin is replaced with heparin, oral antidiabetic drugs

are replaced with insulin (though recent studies have safety of metformin and

glibenclamide during pregnancy).

 Preparation for parenthood

 Preparation for parenthood should make the woman realize and accept childbirth as a

normal physiological phenomena. She needs to have a healthy attitude towards pregnancy

so that she might have a safe and emotionally satisfying experience of labour and

eventually both mentally and physically fit in the puerperium.

 In a preparation of parenthood educational programme, expectant parents and their

families are recognized as having different interests and needing different information as

the pregnancy progresses. Consequently such programmes are designed to meet the

informational needs of parents during the three major stages of pregnancy first trimester

classes, second trimester classes, third trimester classes.

 First trimester classes provide basic information and focus on the following topics:

 Early fetal development, physiologic and emotional changes in pregnancy, human sexuality,

birth settings and types of health care providers, rest, exercise and measures for relieving

common discomforts, the nutritional needs of the mother and fetus, and the development

of a birth plan.
 Environmental and workplace hazards have become important concerns in recent years, so

even though pregnancy is considered a normal process, exercises, warning signs, drugs,

and self medication are topics of concern.

 Second trimester classes emphasize the woman's participation in self care and provide

information about preparation for breastfeeding and formula feeding, basic hygiene,

common complaints, safe remedies, continued fetal development, infant health and

parenting.

 Support systems that are available during pregnancy and after birth are discussed

throughout the series of classes.

 Such support systems can help parents function independently and effectively. During all

the classes, participants are encouraged to openly express their feelings and concerns

about any aspect of pregnancy, birth and parenting.

 During the third trimester, child birth education focuses on preparation for the experiences

of labour and birth.

 Antenatal exercises

 Specific exercise can be taught to clients to help strengthen muscle tone in preparation for

birth.

 The pelvic tilt reduces back strain and strengthens the abdominal muscles. Exhale, roll the

hips and buttocks forward, hold for a count of five, then inhale and relax.

 Abdominal muscle tightening with every breath increases abdominal muscle tone. This can

be done anywhere in any position.

 Slowly taking in a deep breath, expand the abdomen. Then exhale slowly while pulling

abdomen in until the muscles are completely contracted. Relax, a few seconds and repeat

exercise.

 Kegel's exercises strengthen and tighten perineal muscles. Tighten these muscles, pull them

up towards the vagina as if trying to stop urination midstream. This exercise can be done

anytime at anyplace.

 The tailor sit (cross legged sit) stretches inner thigh muscles, adding arm stretches the

sides and upper body and helps relieve upper backache. Sit cross legged stretch one arm

high over your head, then release and exhale. Repeat on other side.

 Good posture during pregnancy

 Standing: Head should be held erect with chin tucked shoulders relaxed and knees

slightly bent.

 Sitting: Comfortable chair which supports both back and thighs, knees should be at level

with or higher than hips, a pillow may be placed behind the lower back for comfort.

 Lying on your side: A pillow should be placed under the upper leg, keeping the leg

slightly flexed. A pillow also may be placed under the abdomen for support.

 Lying on your back: A pillow should be placed under the knees to elevate the legs. A

pillow under the right hip displaces the uterus and prevents vena cava syndrome. This

position should not be used after the fourth month of pregnancy.

 Childbirth preparation method

Today most health care providers recommend child birth preparation classes to expectant

parents. The major methods taught are the Dick-Read or natural childbirth method, the
 Lamaze or psycho prophylactic method and the Bradley method or husband - coached

childbirth.

 Dick - Read method: To replace fear of the unknown with understanding and confidence,

Dick - Read's program provides information on labour and birth, as well as nutrition,

hygiene and exercise.

 Classes include practice in three techniques: physical exercise to prepare the body for

labour, conscious relaxation and breathing patterns.

 The method has been formulated to include labour support by father or other support

person chosen by the mother.

 Conscious relaxation involves progressive relaxation of muscles groups in the entire

body. With practice, many women can relax on command, both during and between

contractions.

 Some woman actually sleep between contractions. Breathing patterns include deep

abdominal respirations for most of labour: shallow breathing toward the end of the first

stage and until recently breath holding for second stage of labour. The woman is taught

to force her abdominal muscles to rise as the uterus rises forward during a contraction.

 Lamaze method: the Lamaze (psycho prophylaxis) method grew out of Pavlov's work on

classical conditioning.

 According to Lamaze, pain is a conditioned response. Therefore, women can also be

conditioned not to experience pain in labour.

 The Lamaze method does this by conditioning women to respond to mock uterine

contractions with controlled muscular relaxation and breathing patterns instead of

crying out and losing control.

  Coping strategies also include concentrating on a focal point, such as a favourite picture

to keep nerve pathways occupied so they cannot respond to painful stimuli.

 The woman is taught to relax uninvolved muscle groups while she contracts a specific

muscle group. She applies this in labour by relaxing uninvolved muscles while her

uterus contracts.

 Lamaze teachers believe that chest breathing lifts the diaphragm off the contracting

uterus, thus giving it more room to expand. Chest - breathing patterns vary according to

the intensity of the contractions and the progress labour.

 Bradley method: also called husband - coached childbirth, was devised based on

observations of animal behaviour during birth.

 It emphasizes working in harmony with the body, using breath control and abdominal

breathing and promoting general body relaxation.

 The husband or partner takes an active role in assisting the woman to relax and use

correct breathing techniques. This method also stresses environmental factors such as

darkness, solitude and quite to make child birth a more natural experience.

 Most proponents of prepared childbirth agree that the major causes of pain in labour

are fear and tension. All childbirth methods attempt to reduce these two factors and

eliminate pain by increasing the woman's knowledge of the labour and birth process,

enhancing her self confidence and sense of control, preparing a support person and

training the woman in physical conditioning and relaxation breathing.

 Relaxing and breathing techniques

 Focusing and feedback relaxation

 Some women bring a favourite object such as a photograph to the labour room, then focus

their attention on this object during contractions.

 Other choose to fix their attention on some object in the labour room. In either event, as the

contraction begins, they focus on the object to reduce their perception of pain.

 With imagery, the nurse encourages the woman to focus on a pleasant scene, a place where

she feels relaxed.

 She can imagine a walk through a restful garden or breathing in light, energy and healing

colour and breathing out worries and tension.

 These techniques, coupled with feedback relaxation, help the woman work with her

contractions rather than against them.

 Music

Music can also enhance relaxation during labour, use of a headset or earphones may

increase the effectiveness of the music because other sounds will be shut out.

 Breathing techniques

Different approaches to childbirth preparation use varying breathing techniques to help

the woman maintain control through contractions. In the first stage of labour, such

techniques can promote relaxation of abdominal cavity. Because muscles of the genitalia

become relaxed, they do not interfere with descent, breathing is used to increase

abdominal pressure thereby assist in expelling the fetus.

 Effeurage and counter pressure

These two methods provide relief in first stage of labour. Gate control theory explains the

effectiveness of this method. Effeurage is a light stroking usually of the abdomen in rhythm

with breathing during contractions.

Role of nurse in midwifery and obstetric care

1. Care giver

Midwives provide high quality antenatal and postnatal care to maximize the women's

health during and after pregnancy. Detect problems early and manage or refer for any

complications.

2. Coordinator

Midwives coordinate care for all women. Coordinator ensures holistic, voluntary and social

services for pregnant women when appropriate so that every women's birth experience

regardless of risk factor.

3. Leader

The role of leader is to plan, provide and review a women's care, with her input and

agreement, from the initial antenatal assessment through to the postnatal period. midwife's

leading role reduces admission to hospital and results in significantly less intervention

during birth.

4. Communicator

As a communicator, the midwives understand that effectiveness of communication. It helps

to develop trust relationship with pregnant women and family members. The midwife has

to communicate effectively with pregnant women and family members as well as others so

that they can share their all problems.

5. Manager

Manager is a great role for midwife. Midwives manage all the circumstances where

appropriate and can recognize and refer women to obstetricians and other specialists in a

timely when necessary.

6. Educator

As an educator, midwives provide high quality, culturally sensitive health education in

order to promote healthy, helpful family life and positive parenting.

7. Counselor

Midwives provide information and counsel pregnant women on prenatal self care including

nutrition, hygiene, breastfeeding and danger signs in pregnancy and childbirth.

8. Family planner

They also counsel people as a family planner. They provide all information about all kind of

family planning methods and help couple to take decision.

9. Advisor

Midwives give advice on development of birth plan and promote the concept of birth

preparedness. They also give advice during complicating situation so that it will help them

to take decision.

10. Record keeper

Record keeping is an integral part of midwifery practice. It helps making continuity of care

easier and enabling identify problem in early stage.

11. Supervisor

Supervising and assisting mothers during antenatal period, monitoring the condition of the

fetus and using their knowledge to identify early sign complication.

 NATIONAL POLICY AND LEGISLATION IN RELATION TO MATERNAL HEALTH AND

WELFARE

 National population policy

 Address the unmet needs for basic reproductive and child health services, supplies and

infrastructure.

 Reduce infant and maternal mortality.

 Achieve universal immunization of children against all vaccine preventable diseases.

 Promote delayed marriage for girls, not earlier than 18 and preferably after 20 years of age.

 Achieve 80% institutional deliveries and 100% deliveries by trained persons.

 Achieve universal access to information/ counselling and services for fertility regulation

and contraception with wide basket of choices.

 Achieve 100% registration of birth, marriage and pregnancy.

 Contain the spread of AIDS and promote greater integration between the management of

reproductive tract infections and sexually transmitted infections and the National AIDS

control organization.

 Integrate Indian System of Medicine in the provision of reproductive and child health

services and in reaching out to households.

 Promote vigorously the small family norm achieve replacement levels of TFR.

 Legislation

 The medical termination of pregnancy act - 1971

 Conditions under which pregnancy can be terminated.

 Persons who can perform such terminations (Registered Medical practitioner).

 termination can be performed o The place where such termination (institution approved

for the purpose).

 Dais were unwilling to trained and patients will to accept the old customary methods. In

1926 Midwives Registration Act formed for the purpose of better training of midwives.

 Establishment of Indian nursing council and state nursing council

 The INC was constituted to establish a uniform standard of education for nurses, midwives,

health visitors and auxiliary nurse midwives. The INC act was passed following an

ordinance on December 31st 1947.

 The pre conception & pre natal diagnostic techniques act - 1994

 This act may be called "the prenatal Diagnostic Techniques Amendment Act, 2002.

 The Consumer Protection Act, 1986. Right to safety, Right to informed, Right to choose,

Right to be heard, Right to seek compensation.

 National programs related to mother and child health

 Maternal and child health program

 Integrated child development service scheme

 Child Survival and Safe Motherhood program

 Reproductive and child health program

 Janani Suraksha yojna

 Maternal and child health program

 To reduce maternal, infant and childhood mortality and morbidity

 Promote reproductive health

 To promote physical and psychological development of children

 Integrated child development service scheme

 Promotion of maternal and child health and nutrition

 Child Survival and Safe Motherhood program

 Newborn care Immunization

 Prevention of hypothermia & infection

 Promotion of exclusive breast feeding

 Referral of sick newborns

 Management of acute diarrhoea

 Reproductive and child health program

 Prevention and management of unwanted pregnancy

 Antenatal, delivery and postnatal services Child survival services for newborns and infants

 Management of reproductive tract infections and sexually transmitted diseases.

 Janani Suraksha Yojana

 Reduction of MMR & IMR

 Focus on institutional delivery

 NRHM

 Accredited Social Health Activists ASHA - Contraception, Immunization, supply folic acid

tablets.

 Reduction in infant mortality rate, maternal mortality rate

 Janani Shishu Suraksha Yojana

 Targeting mother and baby together for betterment of both.

 Maternal child health indicators

Birth rate: The number of births per 1,000 population. Fertility rate: The number of

pregnancies per 1,000 women of child bearing age.

 Fetal death rate: The number of fetal deaths (over 500g) per 1000 live births.

Neonatal death rate: The number of deaths per 1000 live births occurring at birth or in

the first 28 days of life.

Infant mortality rate: The number of deaths per 1000 live births occurring at birth or in

the first 12 months of life.

Childhood mortality rate: The number of deaths per 1000 population in children, 1 to 14

years of age.

Maternal mortality rate: MMR is the annual number of female deaths per 100000 live

births from any cause related to or aggravated by pregnancy or its management.

Maternal morbidity rate: Any departure, subjective or objective, from a state of

physiological or psychological well being. (during pregnancy, child birth and the

postpartum period upto 42 days or 1 year)

Perinatal mortality rate: The WHO defines perinatal mortality as the "number of still

births and deaths in the first week of life per 1000 total births, the perinatal period

commences at 22 completed weeks (154 days) of gestation and ends seven completed days

after birth".

 Fertility rates

Women reproductive period is roughly from 15 - 45 years. Fertility depends upon several

factors. The higher fertility in India is attributed to lower age of marriage, low level literacy,

poor level of living, limited use of contraceptives, traditional way of life.

Total fertility rate: It represents the average no. of children a woman would have if she

were to pass through her reproductive years bearing children at the same rate as the

women now in each age group.