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Introduction of midwifery and obstetrical nursing

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Introduction of midwifery and obstetrical nursing

  2. 2.  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.
  3. 3.  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.
  4. 4. • 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.
  5. 5.  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
  6. 6. 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.
  7. 7. • 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.
  8. 8.  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.
  9. 9. • 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.
  10. 10.  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.
  11. 11.  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
  12. 12. 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.
  13. 13.  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.
  14. 14.  Trends in midwifery and obstetrical nursing  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.  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.
  15. 15.  Expanded roles for nurses • Increasing nursing responsibility for assessment and professional judgement and providing expanded roles for nurse practitioners, such as the nurse – midwife.  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.
  16. 16.  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: o Increase the proportion of persons with health insurance. o Increase the proportion of persons who have a specific source of ongoing care. o Increase the proportion of pregnant women who begin prenatal care in the first trimester of pregnancy.
  17. 17.  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.  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
  18. 18. to, or instead of, traditional health care providers. Nurses have an increasing obligation to be aware of complementary or alternative therapies.  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.  Technological advances
  19. 19. • 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.
  20. 20.  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
  21. 21. 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.
  22. 22. • 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 Ian 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
  23. 23. 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 β-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
  24. 24. • 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)
  25. 25.  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: o Early registration of pregnancy. o At least three antenatal check-ups. o Dietary supplements can correct anaemia. o Prevention of infection and haemorrhage during puerperium. o Prevention of complications e.g. Eclampsia, Malpresentation, ruptured uterus. o Treatment of medical conditions e.g. hypertension, DM, TB.
  26. 26. o Anti-malaria and tetanus prophylaxis. o Clean delivery practice. o Institutional deliveries for women with Bad Obstetric History and risk factors. o 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.
  27. 27.  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. o 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. o In the year 1940s, ‘rooming in’ concept was devised. o 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
  28. 28. success. o 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. o 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
  29. 29. 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
  30. 30. becoming a business for the care providers.  Changing Patterns of Child Birth • There are increasing numbers of working women, until they are in there thirties. • 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. o LBW account for about 30-40% of live births in developing countries.
  31. 31. o 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
  32. 32. 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.
  33. 33.  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
  34. 34. 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.
  35. 35.  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: o Health care providers duties to protect patient’s information against unauthorized discoloures.
  36. 36. o Patient’s right to know what their health care providers think about them. o 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. o A legal duty of care must be owed by a provider to the complaining party.
  37. 37.  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.
  38. 38.  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.
  39. 39. • 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.
  40. 40. • 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). • Folic acid supplementation (0.4 mg per day in low risk women, 5 mg per day in high risk women) starting 6 weeks prior to conception up to 12 weeks of pregnancy can reduce the incidence of neural tube defects. • Rubella and hepatitis immunization in a non – immune woman is offered. • Fear of pregnancy is removed by preconceptional education.
  41. 41.  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
  42. 42. following topics: o 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. o 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. o Support systems that are available during pregnancy and after
  43. 43. birth are discussed throughout the series of classes. o 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. o 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. o Abdominal muscle tightening with every breath increases
  44. 44. abdominal muscle tone. This can be done anywhere in any position. o 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. o 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. o 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.
  45. 45.  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.
  46. 46.  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. o Classes include practice in three techniques: physical exercise to prepare the body for labour, conscious relaxation and breathing patterns. o The method has been formulated to include labour support by father or other support person chosen by the mother.
  47. 47. o 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. o 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. o According to Lamaze, pain is a conditioned response. Therefore, women can also be conditioned not to experience pain in labour. o 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.
  48. 48. o 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. o 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. o 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. o It emphasizes working in harmony with the body, using breath control and abdominal breathing and promoting general body relaxation. o The husband or partner takes an active role in assisting the
  49. 49. 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. o 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.
  50. 50.  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
  51. 51. 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
  52. 52. 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.
  53. 53.  Role of nurse in midwifery and obstetric care  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.  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.
  54. 54.  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.  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.
  55. 55.  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.  Educator • As an educator, midwives provide high quality, culturally sensitive health education in order to promote healthy, helpful family life and positive parenting.  Counselor • Midwives provide information and counsel pregnant women on
  56. 56. prenatal self care including nutrition, hygiene, breastfeeding and danger signs in pregnancy and childbirth.  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.  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.
  57. 57.  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.  Supervisor • Supervising and assisting mothers during antenatal period, monitoring the condition of the fetus and using their knowledge to identify early sign complication.
  58. 58.  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
  59. 59. 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 to achieve replacement levels of TFR.
  60. 60.  Legislation • The medical termination of pregnancy act – 1971 o Conditions under which pregnancy can be terminated. o Persons who can perform such terminations (Registered Medical practitioner). o The place where such termination can be performed (institution approved for the purpose). o 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.
  61. 61.  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.
  62. 62.  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
  63. 63.  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.
  64. 64.  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.
  65. 65.  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.
  66. 66. • 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”.
  67. 67.  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.