Midwifery Unit 1 OBG bsc nursing.....pdf

Nursing

1. UNIT -1
INTRODUCTION TO
MIDWIFERY AND
OBSTETRICAL NURSING

2. Introductiontoconceptsofmidwiferyandobstetricalnursing
•ObstetricswordcamefromaLatinword“OBSTETRIX”means
“MIDWIFE”.
•Midwifery,asknownasobstetrics,isahealthscienceandhealth
professionthatdealswithpregnancy,childbirthandthe
postpartumperiod(includingcareofnewborn),besidessexual
andreproductivehealthofwomenthroughouttheirlives.

3. Terminology
•Midwiferyistheknowledgenecessarytoperformthedutiesof
midwife.
•Obstetricsisthatbranchofmedicine,whichdealswiththe
managementofpregnancy,labourandpuerperium.
•Gynaecologyisthatbranchofmedicalscience,whichtreats
diseaseofthefemalegenitalorgans.
•Reproductionmeansprocessbywhichafullydeveloped
offspringofitskindisproduced.
•Pregnancyisastateofcarryingfetusinsidetheuterusbya
womanfromconceptiontobirth.
•Gestationmeanspregnancy.
•Gravidaisstateofpregnancyirrespectiveofitsduration.
•Multiparareferstowomanwhohasgivenbirthmorethanonce.

4. •Nulliparaisthewomanwhohasnotgivenbirthbefore.
•Primigravidaisawomancarryingfirstpregnancy.
•Multigravidaisawomancarryingpregnancymorethanonce.
•Healthywomenarethekeytothehealthofanynation,primarily
becauseoftheirvitalroleinco-creatinghealthyinfantsandco–
caringforthefamily.
•Providinghealthcaretowomenisnotonlyahealthissuebuta
matterofhumanrightissue.
•Inwomen’slifechildbirthisaspecialevent.
•Amotherwillneverforgeta‘midwife’whodeliveredherbaby,
andwhowas‘withthewoman’duringchildbirth,whichisthe
veryessenceandidentityofamidwife.
•Henceamidwifeisanobviouscatalystinprovidingsafe
motherhoodinthefabricofoursociety.

5. Midwifery in India before independence
•InancientIndia,careofwomenandpracticeofmidwiferywere
totallyinthehandsofindigenousvillage‘Dias’.
•Theseindigenousdais,notonlyhelpedduringchildbirthbut
alsoactedasconsultantsforanyconditionofthemother
relatedtobirth.
•WhenmedicalmissionarywomenfromEnglandcametoIndia,
thefirststrikingobservationtheymadewasthat,sincedais
wereunabletodealwithdifficultdeliveriesandpregnancies,
thematernalandneonatalmortalitywereveryhigh.
•Thefirsttrainingschoolfordaiswasstartedin1877byMiss
Hewlett,anEnglishmissionaryoftheZenanaMissionary
Society.
•However,thetrainingofdaiswasnottakenupbyGovernment
ofIndiatill1900whenafundwasestablishedbyLadyCurzonto

6. improvetheconditionsofchildbirthinthecountry.
•Butbeforethat,in1872,ahandfulofIndianChristiannurses
weretrainedfortwoyearsatDelhi.
•In1899theZenanaBibleandMedicalMissionstartedthetraining
ofnurses,butuntil1893therewasnogenerallyacceptedscheme
oftraininginthehospitals.
•In1918withthehelpofDufferinFund,LadyReadingHealth
SchoolwasestablishedtotrainAuxiliaryNurseMidwives(ANMs).
•In1926theMadrasRegistrationofNursesandMidwifesActwas
passedtopromotetheroleofaregisteredmidwifeforservice
duringchildbirth.
•In1936DufferinfundsanctionedgranttoanumberofDufferin
hospitalstobuildhostels,supplyteachingmaterialsandemploy
qualifiedsistersinnursingschools.
•ThusDufferinfundhelpedinraisingthestandardsofnursingand
midwiferyinIndia.

7. •Infactpriortoindependence,midwiferytrainingstartedasa
separatecourse,inIndia.
•Younggirlsatthemiddleschoollevel(8
th
)wereselectedto
undergothistraining.

8. Midwifery in independent India
•In1946,theBhorecommitteelaidstressontheneedfor
qualifiedmidwives,healthvisitorsandthetrainingofdais.
•In1955,theShettyCommitteerecommendedthetrainingof
AuxiliaryNurseMidwife(ANMs)inhealthcentersformaternal
andchildhealthservices,providedtherewereadequatehealth
visitorstosupervisethem.
•In1959Bishoff,atechnicalConsultantsupportedthetrainingof
twotypesofnursingpersonnelANMandGeneralNurseMidwife
(GNMNursing–3yearsandMidwifery–1year).
•In1947,thefirststeptheIndianNursingCounciltookafterits
inceptionwastocombinethenursingandthemidwiferycourses
intoasinglecourse.
•Thecoursewasdesignedtobeofthreeandahalfyears
duration,withtheentryqualificationbeing10
th
class.

9. •In1975theKartarSinghCommitteerecommendedshortening
thetwoyearcourseofANMtooneandahalfyearsandentry
afterclass10
th
.
•TheseANMsweredesignedasfemalehealthworkers.They
werespeciallytrainedinmidwiferyandchildhealthcare
services.GovernmentofIndiaalsoinvestedheavilyinthe
trainingofdais.

10. Present and future of midwifery in India
•Thepresenceofaskilledmidwifeatbirthisthesinglemost
importantfactorforachievingsafemotherhood(WHO).
•Thenumberofmidwivesavailableasperpopulationisan
importantindicatorofthematernalhealthstatusinacountry.
•Thematernalhealthstatusofwomenandmaternalmortality
arecloselyrelatedtothepresenceoftrainedattendantsat
birth.
•Asthepercentageofbirthsattendedbytrainedpersonnelgoes
up,thematernalmortalityratiogoesdown.

11. In India there are the following cadres of midwives
1.Thetrainednursemidwife(RN,RM):Whohasundergonea
diploma(DiplomainGeneralNursingandMidwifery),whichis
ofthreeandahalfyearsduration.OrAdegreenursewhohas
doneB.Sc.(Honors)Nursing,whichisoffouryearsduration.
2.TheANM,whoisdesignatedastheMulti–purposehealth
worker(female),isregisteredasamidwife.
•Presently,thisisatwoyearscoursewithentryclassification
being12
th
class.
•IndiahasahugecadreofANMswhoareeducatedandtrained
inMidwifery.
3.SkilledBirthAttendant(SBA)refersexclusivelytopeoplewith
midwiferyskills(e.g.doctors,nurses,midwives)whohave
beentrainedtogetproficiencyintheskillsnecessaryto
managenormaldeliveriesandtodiagnose,manageorrefer

12. complicationstoalllevelsofhealthcaresettings.
•Midwiferyskillsaredefinedasasetofcognitiveandpractical
skillsthatenabletheindividualtoprovidebasichealthcare
servicesthroughoutthenatalcontinuumperiodandalsoto
providepromptactionsinemergenciesincludinglifesaving
measures,whenrequired.

13. Need for midwifery as a profession in India
1.Toachievesafemotherhood.
2.Toavoidduplicationofservices.
3.Togivehealtheducation.
4.Toparticipateincountry’sconcerni.e.maternalandchild
welfare.
5.Togetstatusandrecognitioninthesociety.

14. Trendsinmidwiferyandobstetricalnursing
Changesinsocialstructure,variationsinfamilylifestyle
•Ithasalteredhealthcareprioritiesformaternalandchildhealth
nurses.Today,clientadvocacy,anincreasedfocusonhealth
educationandnewnursingrolesarewaysinwhichnurseshave
adaptedtothesechanges.
Costcontainment
•Costcontainmentreferstosystemsofhealthcaredeliverythat
focusonreducingthecostofhealthcarebycloselymonitoring
thecostofpersonnel,useandbrandsofsupplies,lengthof
hospitalstays,numbersofprocedurescarriedout,andnumberof
referralsrequested.

15. Expandedrolesfornurses
•Increasingnursingresponsibilityforassessmentand
professionaljudgementandprovidingexpandedrolesfornurse
practitioners,suchasthenurse–midwife.
Familycenteredcare
•Morenaturalchildbirthenvironmentwherepartners,family
membersmayremaininahomelikeenvironmentand
participateinthechildbirthexperience.
•Byadoptingaviewofpregnancy,childbirthasafamilyevent,
nursescanbeinstrumentalinincludingfamilymembersincare
andconsultfamilymembersaboutaplanofcareandprovide
clearhealthteachingsothatfamilymemberscanmonitortheir
owncare.

16. Accesstohealthcare
•Strongpredictorsofaccesstoqualityhealthcareincludehaving
healthinsurance,ahigherincomelevelandaregularprimary
careproviderorothersourceofongoinghealthcare.Useof
clinicalpreventiveservices,suchasearlyprenatalcare,can
serveasindicatorsofaccesstoqualityhealthcareservices.
•Theobjectivesselectedtomeasureprogressinthisareaare:
oIncreasetheproportionofpersonswithhealthinsurance.
oIncreasetheproportionofpersonswhohaveaspecific
sourceofongoingcare.
oIncreasetheproportionofpregnantwomenwhobegin
prenatalcareinthefirsttrimesterofpregnancy.

17. Shorteninghospitalstays
•Womenwhohavebegunpretermlaborstayinthehospital
whilelaborishaltedandthenareallowedtoreturnhomeon
medicationwithcontinuedmonitoring.
•Routinehospitalstayformothersandnewbornsafteran
uncomplicatedbirthisnow2daysorless.
•Shorttermhospitalstaysrequireintensivehealthteachingby
thenursingstaffandfollowupbyhomecareorcommunity
healthnurses.
Increaseduseofalternativetreatmentmodalities
•Thereisagrowingtendencytoconsultalternativeformsof
therapy,suchasacupunctureortherapeutictouch,inaddition

18. to,orinsteadof,traditionalhealthcareproviders.Nurseshavean
increasingobligationtobeawareofcomplementaryoralternative
therapies.
Increaseduseoftechnology
•Thefieldofassistedreproduction(e.g.invitrofertilization),
seekinginformationontheinternetandmonitoringfetalheart
ratesbyDopplerultrasonographyareanotherexamples.
•Inadditiontolearningthesetechnologies,maternalandchild
healthnursesmustbeabletoexplaintheiruseandtheir
advantagestoclients.Otherwise,clientsmayfindnew
technologiesmorefrighteningthanhelpfulthem.
Technologicaladvances

19. •Asthetechnologyhasrevolutionizedandincreasingly
sophisticatedcomputersintoday’sworld,ithasbecome
necessaryforthenursingpersonneltohavethorough
knowledgeofthenewtechnologybeingused.
•Duetothisadvancement,‘thehandsoncare’oftheclientis
reduced,soalsoisthe,qualitynursingcare.
•Todayfoetalmonitoringhasprogressedfromtheuseof
fetoscopetoelectronicfoetalmonitors.Itcanbeusedboth,
directlyandindirectly.

20. Historicalperspectivesandcurrenttrends
Historicalperspectives
Originofobstetrics
•Asweallknowthatbirthisthecomplexfinalactofnature’s
greatestmiraclei.e.formationandarrivalofachildintheworld.
Andthescienceandartthatdealswithhumanreproductionis
andartthatdealswithhumanreproductioniscalledObstetrics.
•“SORANUSOFEPHESUS”istheFatherofobstetrics.Hewasthe
firsttowriteaboutthePodalicVersion.
•Earliermanwerenotwelcomedinthisfield.DuringMiddleAges
inEuropemidwiveswereoflowtypesandexecutionerand
barberswerecalledtohelpwithdifficultdeliveries.Lateronin
16
th
&17
th
centuryAmbroisePareofParisandChamberlens

21. stimulatementotakeinterestinobstetrics.
Historicaldevelopmentinobstetrics
•In1739,inLondon,WillamSmellieandhisstudentWillam
Hunterbecomeobstetricianandworkforthesame.
•In1744,WillamSmellieintroducesteellockforceps.
•In1752,WillamSmelliepublish‘TextbookofObstetrics’.
•In1760,PuerperalfeverwasonpeakinLondoninLying-in
hospital.
•OnJan14
th
1794firstCesareanoperationwasperformedbyDr.
JesseBenaettofVirginiaonhiswife.
•FirstschoolofmidwiveswasestablishedatPareinstigationat
thehotelDieuinParis.
•In18
th
centuryNationalregulationofeducationandpracticeof
midwiferybegans.

22. •In1807,SamuelBardpublishfirstbookonobstetricsonfour
stagesoflabour.
•In1847,Semmelweis,inVienna,demonstratethatwashingof
handsinchlorineoflimesolutionbeforeexaminingwomenin
laborreducepuerperalfever.Chlorideoflimeusedas
antiseptic.
•ObstetricalforcepswasdevelopedbyDr.PeterChamberlen.In
thepastonlyGreeksusedvarietyofhooksandtractorsto
deliverdeadfetus.
•In1853,Dr.JamesY.SimpsonofGlasgowsucceededin
introducingtheuseofChloroformanesthesiaasanaidin
obstetricscalled“ERAOFMODERNOBSTETRICS”.
•Then,PinardFetoscopewasdevelopedandIanDonaldfrom
GlasgowintroduceUltrasoundinObstetrics.
•In1950,FritzFuchofCopenhagenperformedAmniotomy
identifiedthefetalcellspresentinitwhichidentifysexofthe

23. babybybarrbodies.
•LateronemphasisonAntenatalcheck-ups,bloodpressure,
urineanalysiswascameinattention.
•In1892,Dr.PierreBudininitiatedconsolationfornursing
mothers.
•In1949,firstworldhealthorganizationexpertcommitteeon
maternalchildhealthmetinGeneva.
•In1950,Oralcontraceptiveswasintroduceforthecontrolof
fertility.
•Thenβ-hCGtracingwasdonewithchorionvillussamplingat
10
th
wk.
•IdentificationofIUGRwasdonebyNonStresstest.
•LateronRaoulPalwer&PatricksteptoldiscoverLaparoscopic
Sterilization.
•In1960,Witnessabortiongetstarted.
•1971–MTPAct

24. •1974–FamilyPlanningServicesIncorporatedInMCHCare
•1977–RenamingFamilyPlanningToFamilyWelfare
•1978–ExpandedProgrammeonImmunization
•1985–UniversalImmunizationProgramme
•1992–ChildSurvival&SafeMotherhoodProgramme
•1996–TargetFreeApproach
•1997–RCHProgrammePhase-1(15-10-1997)
•2005–RCHProgrammePhase-2(01-04-2005)

25. Contemporaryperspectiveofobstetrics
•Incurrentviewallthefocusfromobstetricscareshiftedto
perinatalcare.
•AdvancementinObstetricscarehasreducestheMMR.
•Govt.hasstartedprogrammetoidentifyhighriskmothers.
•Trainingofhealthpersonnels,Allocationoffacilities&
equipmentdecreasesMMR.
•MMRcanbereduces:
oEarlyregistrationofpregnancy.
oAtleastthreeantenatalcheck-ups.
oDietarysupplementscancorrectanaemia.
oPreventionofinfectionandhaemorrhageduringpuerperium.
oPreventionofcomplicationse.g.Eclampsia,Malpresentation,
ruptureduterus.
oTreatmentofmedicalconditionse.g.hypertension,DM,TB.

26. oAnti-malariaandtetanusprophylaxis.
oCleandeliverypractice.
oInstitutionaldeliveriesforwomenwithBadObstetricHistory
andriskfactors.
oPromotionoffamilyplanning.
•MCHserviceshasstartedwhichaimsatreductioninmorbidity
andmortalityrateofmotherandbaby.
•Babyfriendlyhospitalschemehaslaunchedin1993for
effectivebreastfeedtochild.
•Geneticcounsellingtothecouples.
•ScreenthemotherforHIV.

27. Currenttrends
•Inourmothersandgrandmothersdays,anuntrainedwoman,
neighbors,relativeorfrienddeliveredmostbabiesathome.All
thechangesstartedin29
th
century,whenparturitionmoved
intothehospitalsetting.Atthatpoint,childbearingbecamefar
fromafamilyaffair.
•Themotherandnewbornremainedisolatedfromthefamilyfor
aweektotendays,whenfamilyhadonlyvisitingprivileges.
oNursingwasseparatedintothreespecialties,withonenurse
caringforthemotherduringlabour,anddelivery,another
handlingpostpartummothersandthirdcaringforthebaby.
oIntheyear1940s,‘roomingin’conceptwasdevised.
oTheadvantagesofthesystemincludedareductioninneonatal
infectionfromcross-contamination,increasedconfidenceand
independenceforthemotherandgreaterbreast-feeding

28. success.
oIn1960s,thefocuschangedfromthepersongivingcaretothe
recipient.Withthatchange,cameachangeinterminologyand
obstetricalcarebecameMaternitycare.
oWHOoffersdefinitionofmaternitycare-theobjectof
maternitycareistoensurethateveryexpectantandnursing
mothermaintainsgoodhealth,learnstheartofchildcare,hasa
normaldeliveryandbearshealthychildren.
TechnologicalAdvances
•Asthetechnologyhasrevolutionizedandincreasingly
sophisticatedcomputersintoday’sworld,ithasbecome
necessaryforthenursingpersonneltohavethorough
knowledgeofthenewtechnologybeingused.
•Duetothisadvancement,‘thehandsoncare’oftheclientis

29. reduced,soalsoisthe,qualitynursingcare.
•Todayfoetalmonitoringhasprogressedfromtheuseof
fetoscopetoelectronicfoetalmonitors.Itcanbeusedboth,
directlyandindirectly.
•Expertsbelievethatincomingyears,birthsaregoingtobeby
high-techinnovations,resultinginlowprenatalmortalityand
morbidity.
•Infuture,therearechallengesfornurses,astheywillprovide
careintheworldofhightechnology.
IncreasedCostofHigh-TechCare
•Asthehighandsophisticatedtechnologyisbeingintroduced
intotoday’sworld,thecostsarealsoincreasing.Forthe
proceduressuchasultrasound,foetalmonitoringetc.thecouple
hastopaygoodamountofmoney.Gradually,obstetriccareis

30. becomingabusinessforthecareproviders.
ChangingPatternsofChildBirth
•Thereareincreasingnumbersofworkingwomen,untiltheyare
intherethirties.
•Asearlymarriagepracticesstillcontinue,bothends,theolder
andyoungermothersfaceincreasedrisksofcomplications
duringpregnancy,suchaspretermdelivery,LBWetc.
PerinatalRiskFactors
•Theproblemsofsocietyarereflectedinrisks:amongthemare
AIDSinmothersandnewborns.
oLBWaccountforabout30-40%oflivebirthsindeveloping
countries.

31. oInadditiontomaternalage,riskfactorsofLBWincludemother’s
medicalhistory,pastpregnancy,socioeconomicstatusand
prenatalcare.
FamilyCenteredCare
•Maternitycaretodayhasenhancedtofamilycenteredcare.
Definitionofhealthincludephysical,social,psychologicaland
economicdimension.Familycenteredapproachisbasicunitof
society.Thusemphasisonhisaspectismustthatfostersfamily
unity.Integrationandbondingtakeshighpriorityandmuch
anticipatorycounsellingisoffered.
RisingCaesareanBirthRates
•Withtheuseoffoetalmonitoringandultrasoundforprenatal

32. monitoringandultrasoundforprenatalevaluationoffoetal
condition,hascomeandincreasedrateofcaesareanbirthrates.
EarlyDischarge
•Inearlierdays,womenwerehospitalizedforlongerdurationand
physicalactivitywasincreasedverygradually.Overtheyears
now,however,healthcarepersonnelhaverealizedthatearly
returntonormalactivitiesisthebestcourseforuncomplicated
births.
RoleofFathers
•Withincreasedsocietalemphasisonsharedparentingandthe
recognitionofparentalbonding,manyfathersareactiveincare
givingandenjoytheclosenessitbrings.

33. Legalandethicalprinciplesintheprovisionofhealthservices
Informeddecisionmaking
•Patientsorindividualswhorequirehealthcareserviceshave
righttomaketheirowndecisionabouttheopinionsfor
treatmentorotherrelatedissues.Theprocessofobtaining
permissioniscalledinformedconsent.
•Thehealthcareprovidershoulddisclosethefollowingdetails:
1.Theindividualiscurrentlyassessedhealthstatusregardingthe
generalorreproductivehealth.
2.Reasonablyaccessiblemedical,socialandothermeansof
responsetotheindividual’sconditionsincludingpredictable
successrates,sideeffectsandrisks.
3.Theimplicationsfortheindividual’sgeneral,sexualand
reproductivehealthandlifestyledeclininganyoftheoptions

34. orsuggestions.
4.Thehealthprovider’sreasonedrecommendationfora
particulartreatmentoptionorsuggestion.
Autonomy
•Autonomouspersonsarethosewho,intheirthoughts,workand
actionsareabletofollownormschosenoftheirownwithout
externalconstraintsorcoercionbyothers.
•Itistobenotedthatautonomyisnotrespectforpatient’swish
againstgoodmedicaljudgement.
•Simplyput,ahealthprovidercanrefuseatreatmentoption
chosenbythepatient,iftheoptionisofnobenefittothe
patient.

35. Surrogatedecisionmakers
•Surrogatedecisionmakers(parents,caregivers,guardians)may
takethedecisioniftheaffectedindividual’sabilitytomakea
choiceisdiminishedbyfactorssuchasextremeyouth,mental
processingdifficulties,extrememedicalillnessorlossof
awareness.
Privacyandconfidentiality
•Apatient’sfamily,friendorspiritualguidehasnorightto
medicalinformationregardingthepatientunlessauthorizedby
thepatients.Thefollowingpointsofconfidentialityaretobe
keptinmind:
oHealthcareprovidersdutiestoprotectpatient’sinformation
againstunauthorizeddiscoloures.

36. oPatient’srighttoknowwhattheirhealthcareprovidersthink
aboutthem.
oHealthcareprovider’sdutiestoensurethatpatientswho
authorizereleasesoftheirconfidentialhealthrelated
informationtoothers,exerciseanadequatelyinformedandfree
choice.
Competentdeliveryservices
•Everyindividualhasarighttoreceivetreatmentbyacompetent
healthcareproviderwhoknowstohandlesuchsituationsquite
well.Accordingtothelaws,medicalnegligenceisshownwhen
thefollowingelementsareallestablishedbyacomplaining
party.
oAlegaldutyofcaremustbeowedbyaprovidertothe
complainingparty.

37. Breachoftheestablishedlegalduty
•Ofcaremustbeshown,whichmeansahealthcareprovider
hasfailedtomeetthelegallydeterminedstandardsofcare.
•Damagemustbeshown.
•Causationmustbeshown.
Safetyandefficacyofproducts
•Healthcareprovidersareresponsibleforanyaccidentalor
deliberateuseofproductsthatdiffersfromtheirapproved
purposesormethodsofuse,forinstance,thedosagelevelfor
drugs.Lookforthedrugcontraindications,drugexpiry,damage
ofdilutedsterilizationsolventsetc.

38. Preconceptioncareandpreparingforparenthood
Preconceptioncare
•Careaboutpregnancy,itscourseandoutcomewellbeforethe
timeofactualconceptioniscalledpreconceptionalcare.
•Itensuresthatawomanenterspregnancywithanoptimalstate
ofhealthwhichwouldbesafebothforherselfandforherfetus.
•Ifthewomanisseenfirstintheantenatalclinic,itisoftentoo
latetoadviceasorganogenesisisalreadycompleted.
Uses
•Maternalhealthisoptimizedpreconceptionally.Problemsof
overweight,underweight,anaemia,abnormalpapanicolaou
smearsareevaluatedandtreatedappropriately.

39. •Baselinehealthstatusandbloodpressurearerecorded.
•Womenshouldbeencouragedtostopsmoking,alcoholand
addictivedrugsintake.
•Identificationofhighriskfactorsbydetailedevaluationof
obstetric,medical,familyandpersonalhistory.Riskfactorsare
assessedbylaboratorytests,ifrequired.
•Importanceofprenataldiagnosisforchromosomalorgenetic
diseasesarediscussed.
•Patientwithmedicaldisordersandcomplicationslikediabetes
andheartdiseaseshouldbeoptimallycontrolledbeforetheytry
pregnancyasthereareeffectsofthediseaseonpregnancyand
alsotheeffectsofpregnancyonthedisease.Inextreme
situations,likeEisenmenger’ssyndrome,diabetesnephropathy,
thepregnancyisdiscouraged.Pre-existingchronicdiseases
(hypertension,diabetes,epilepsy)arestabilizedtoanoptimal
statebyinterventionbeforeconception.

40. •Drugsusedbeforepregnancyareverifiedandchanged,if
required,soastoavoidanyadverseeffectonthefetusduring
theperiodoforganogenesis.Forexample,anticonvulsantdrugs
arechangedtosaferdrugs.Warfarinisreplacedwithheparin,
oralantidiabeticdrugsarereplacedwithinsulin(thoughrecent
studieshavesafetyofmetforminandglibenclamideduring
pregnancy).
•Folicacidsupplementation(0.4mgperdayinlowriskwomen,5
mgperdayinhighriskwomen)starting6weekspriorto
conceptionupto12weeksofpregnancycanreducethe
incidenceofneuraltubedefects.
•Rubellaandhepatitisimmunizationinanon–immunewoman
isoffered.
•Fearofpregnancyisremovedbypreconceptionaleducation.

41. Preparationforparenthood
•Preparationforparenthoodshouldmakethewomanrealizeand
acceptchildbirthasanormalphysiologicalphenomena.She
needstohaveahealthyattitudetowardspregnancysothatshe
mighthaveasafeandemotionallysatisfyingexperienceoflabour
andeventuallybothmentallyandphysicallyfitinthe
puerperium.
•Inapreparationofparenthoodeducationalprogramme,
expectantparentsandtheirfamiliesarerecognizedashaving
differentinterestsandneedingdifferentinformationasthe
pregnancyprogresses.Consequentlysuchprogrammesare
designedtomeettheinformationalneedsofparentsduringthe
threemajorstagesofpregnancyfirsttrimesterclasses,second
trimesterclasses,thirdtrimesterclasses.
•Firsttrimesterclassesprovidebasicinformationandfocusonthe

42. followingtopics:
oEarlyfetaldevelopment,physiologicandemotionalchangesin
pregnancy,humansexuality,birthsettingsandtypesofhealth
careproviders,rest,exerciseandmeasuresforrelieving
commondiscomforts,thenutritionalneedsofthemotherand
fetus,andthedevelopmentofabirthplan.
oEnvironmentalandworkplacehazardshavebecomeimportant
concernsinrecentyears,soeventhoughpregnancyis
consideredanormalprocess,exercises,warningsigns,drugs,
andselfmedicationaretopicsofconcern.
•Secondtrimesterclassesemphasizethewoman’sparticipation
inselfcareandprovideinformationaboutpreparationfor
breastfeedingandformulafeeding,basichygiene,common
complaints,saferemedies,continuedfetaldevelopment,infant
healthandparenting.
oSupportsystemsthatareavailableduringpregnancyandafter

43. birtharediscussedthroughouttheseriesofclasses.
oSuchsupportsystemscanhelpparentsfunctionindependently
andeffectively.Duringalltheclasses,participantsare
encouragedtoopenlyexpresstheirfeelingsandconcernsabout
anyaspectofpregnancy,birthandparenting.
•Duringthethirdtrimester,childbirtheducationfocuseson
preparationfortheexperiencesoflabourandbirth.
Antenatalexercises
•Specificexercisecanbetaughttoclientstohelpstrengthen
muscletoneinpreparationforbirth.
oThepelvictiltreducesbackstrainandstrengthenstheabdominal
muscles.Exhale,rollthehipsandbuttocksforward,holdfora
countoffive,theninhaleandrelax.
oAbdominalmuscletighteningwitheverybreathincreases

44. abdominalmuscletone.Thiscanbedoneanywhereinany
position.
oSlowlytakinginadeepbreath,expandtheabdomen.Then
exhaleslowlywhilepullingabdomeninuntilthemusclesare
completelycontracted.Relax,afewsecondsandrepeat
exercise.
oKegel’sexercisesstrengthenandtightenperinealmuscles.
Tightenthesemuscles,pullthemuptowardsthevaginaasif
tryingtostopurinationmidstream.Thisexercisecanbedone
anytimeatanyplace.
oThetailorsit(crossleggedsit)stretchesinnerthighmuscles,
addingarmstretchesthesidesandupperbodyandhelpsrelieve
upperbackache.Sitcrossleggedstretchonearmhighoveryour
head,thenreleaseandexhale.Repeatonotherside.

45. Goodpostureduringpregnancy
•Standing:Headshouldbehelderectwithchintuckedshoulders
relaxedandkneesslightlybent.
•Sitting:Comfortablechairwhichsupportsbothbackandthighs,
kneesshouldbeatlevelwithorhigherthanhips,apillowmay
beplacedbehindthelowerbackforcomfort.
•Lyingonyourside:Apillowshouldbeplacedundertheupper
leg,keepingthelegslightlyflexed.Apillowalsomaybeplaced
undertheabdomenforsupport.
•Lyingonyourback:Apillowshouldbeplacedundertheknees
toelevatethelegs.Apillowundertherighthipdisplacesthe
uterusandpreventsvenacavasyndrome.Thispositionshould
notbeusedafterthefourthmonthofpregnancy.

46. Childbirthpreparationmethod
•Todaymosthealthcareprovidersrecommendchildbirth
preparationclassestoexpectantparents.Themajormethods
taughtaretheDick-Readornaturalchildbirthmethod,the
LamazeorpsychoprophylacticmethodandtheBradley
methodorhusband–coachedchildbirth.
•Dick–Readmethod:Toreplacefearoftheunknownwith
understandingandconfidence,Dick–Read’sprogramprovides
informationonlabourandbirth,aswellasnutrition,hygiene
andexercise.
oClassesincludepracticeinthreetechniques:physicalexercise
topreparethebodyforlabour,consciousrelaxationand
breathingpatterns.
oThemethodhasbeenformulatedtoincludelaboursupportby
fatherorothersupportpersonchosenbythemother.

47. oConsciousrelaxationinvolvesprogressiverelaxationofmuscles
groupsintheentirebody.Withpractice,manywomencanrelax
oncommand,bothduringandbetweencontractions.
oSomewomanactuallysleepbetweencontractions.Breathing
patternsincludedeepabdominalrespirationsformostoflabour:
shallowbreathingtowardtheendofthefirststageanduntil
recentlybreathholdingforsecondstageoflabour.Thewomanis
taughttoforceherabdominalmusclestoriseastheuterusrises
forwardduringacontraction.
•Lamazemethod:theLamaze(psychoprophylaxis)methodgrew
outofPavlov’sworkonclassicalconditioning.
oAccordingtoLamaze,painisaconditionedresponse.Therefore,
womencanalsobeconditionednottoexperiencepaininlabour.
oTheLamazemethoddoesthisbyconditioningwomentorespond
tomockuterinecontractionswithcontrolledmuscularrelaxation
andbreathingpatternsinsteadofcryingoutandlosingcontrol.

48. oCopingstrategiesalsoincludeconcentratingonafocalpoint,
suchasafavouritepicturetokeepnervepathwaysoccupiedso
theycannotrespondtopainfulstimuli.
oThewomanistaughttorelaxuninvolvedmusclegroupswhile
shecontractsaspecificmusclegroup.Sheappliesthisinlabour
byrelaxinguninvolvedmuscleswhileheruteruscontracts.
oLamazeteachersbelievethatchestbreathingliftsthediaphragm
offthecontractinguterus,thusgivingitmoreroomtoexpand.
Chest–breathingpatternsvaryaccordingtotheintensityofthe
contractionsandtheprogresslabour.
•Bradleymethod:alsocalledhusband–coachedchildbirth,was
devisedbasedonobservationsofanimalbehaviourduringbirth.
oItemphasizesworkinginharmonywiththebody,usingbreath
controlandabdominalbreathingandpromotinggeneralbody
relaxation.
oThehusbandorpartnertakesanactiveroleinassistingthe

49. womantorelaxandusecorrectbreathingtechniques.This
methodalsostressesenvironmentalfactorssuchasdarkness,
solitudeandquitetomakechildbirthamorenaturalexperience.
oMostproponentsofpreparedchildbirthagreethatthemajor
causesofpaininlabourarefearandtension.Allchildbirth
methodsattempttoreducethesetwofactorsandeliminate
painbyincreasingthewoman’sknowledgeofthelabourand
birthprocess,enhancingherselfconfidenceandsenseof
control,preparingasupportpersonandtrainingthewomanin
physicalconditioningandrelaxationbreathing.

50. Relaxingandbreathingtechniques
Focusingandfeedbackrelaxation
•Somewomenbringafavouriteobjectsuchasaphotographto
thelabourroom,thenfocustheirattentiononthisobjectduring
contractions.
•Otherchoosetofixtheirattentiononsomeobjectinthelabour
room.Ineitherevent,asthecontractionbegins,theyfocuson
theobjecttoreducetheirperceptionofpain.
•Withimagery,thenurseencouragesthewomantofocusona
pleasantscene,aplacewhereshefeelsrelaxed.
•Shecanimagineawalkthrougharestfulgardenorbreathingin
light,energyandhealingcolourandbreathingoutworriesand
tension.
•Thesetechniques,coupledwithfeedbackrelaxation,helpthe

51. womanworkwithhercontractionsratherthanagainstthem.
Music
•Musiccanalsoenhancerelaxationduringlabour,useofa
headsetorearphonesmayincreasetheeffectivenessofthe
musicbecauseothersoundswillbeshutout.
Breathingtechniques
•Differentapproachestochildbirthpreparationusevarying
breathingtechniquestohelpthewomanmaintaincontrol
throughcontractions.Inthefirststageoflabour,such
techniquescanpromoterelaxationofabdominalcavity.
Becausemusclesofthegenitaliabecomerelaxed,theydonot
interferewithdescent,breathingisusedtoincreaseabdominal

52. pressuretherebyassistinexpellingthefetus.
Effeurageandcounterpressure
•Thesetwomethodsprovidereliefinfirststageoflabour.Gate
controltheoryexplainstheeffectivenessofthismethod.
Effeurageisalightstrokingusuallyoftheabdomeninrhythm
withbreathingduringcontractions.

53. Roleofnurseinmidwiferyandobstetriccare
Caregiver
•Midwivesprovidehighqualityantenatalandpostnatalcareto
maximizethewomen’shealthduringandafterpregnancy.
Detectproblemsearlyandmanageorreferforany
complications.
Coordinator
•Midwivescoordinatecareforallwomen.Coordinatorensures
holistic,voluntaryandsocialservicesforpregnantwomenwhen
appropriatesothateverywomen’sbirthexperienceregardless
ofriskfactor.

54. Leader
•Theroleofleaderistoplan,provideandreviewawomen’scare,
withherinputandagreement,fromtheinitialantenatal
assessmentthroughtothepostnatalperiod.midwife’sleading
rolereducesadmissiontohospitalandresultsinsignificantly
lessinterventionduringbirth.
Communicator
•Asacommunicator,themidwivesunderstandthateffectiveness
ofcommunication.Ithelpstodeveloptrustrelationshipwith
pregnantwomenandfamilymembers.Themidwifehasto
communicateeffectivelywithpregnantwomenandfamily
membersaswellasotherssothattheycansharetheirall
problems.

55. Manager
•Managerisagreatroleformidwife.Midwivesmanageallthe
circumstanceswhereappropriateandcanrecognizeandrefer
womentoobstetriciansandotherspecialistsinatimelywhen
necessary.
Educator
•Asaneducator,midwivesprovidehighquality,culturally
sensitivehealtheducationinordertopromotehealthy,helpful
familylifeandpositiveparenting.
Counselor
•Midwivesprovideinformationandcounselpregnantwomenon

56. prenatalselfcareincludingnutrition,hygiene,breastfeedingand
dangersignsinpregnancyandchildbirth.
Familyplanner
•Theyalsocounselpeopleasafamilyplanner.Theyprovideall
informationaboutallkindoffamilyplanningmethodsandhelp
coupletotakedecision.
Advisor
•Midwivesgiveadviceondevelopmentofbirthplanand
promotetheconceptofbirthpreparedness.Theyalsogive
adviceduringcomplicatingsituationsothatitwillhelpthemto
takedecision.

57. Recordkeeper
•Recordkeepingisanintegralpartofmidwiferypractice.Ithelps
makingcontinuityofcareeasierandenablingidentifyproblem
inearlystage.
Supervisor
•Supervisingandassistingmothersduringantenatalperiod,
monitoringtheconditionofthefetusandusingtheirknowledge
toidentifyearlysigncomplication.

58. Nationalpolicyandlegislationinrelationtomaternalhealth
andwelfare
Nationalpopulationpolicy
•Addresstheunmetneedsforbasicreproductiveandchild
healthservices,suppliesandinfrastructure.
•Reduceinfantandmaternalmortality.
•Achieveuniversalimmunizationofchildrenagainstallvaccine
preventablediseases.
•Promotedelayedmarriageforgirls,notearlierthan18and
preferablyafter20yearsofage.
•Achieve80%institutionaldeliveriesand100%deliveriesby
trainedpersons.
•Achieveuniversalaccesstoinformation/counsellingand
servicesforfertilityregulationandcontraceptionwithwide

59. basketofchoices.
•Achieve100%registrationofbirth,marriageandpregnancy.
•ContainthespreadofAIDSandpromotegreaterintegration
betweenthemanagementofreproductivetractinfectionsand
sexuallytransmittedinfectionsandtheNationalAIDScontrol
organization.
•IntegrateIndianSystemofMedicineintheprovisionof
reproductiveandchildhealthservicesandinreachingoutto
households.
•Promotevigorouslythesmallfamilynormtoachieve
replacementlevelsofTFR.

60. Legislation
•Themedicalterminationofpregnancyact–1971
oConditionsunderwhichpregnancycanbeterminated.
oPersonswhocanperformsuchterminations(Registered
Medicalpractitioner).
oTheplacewheresuchterminationcanbeperformed
(institutionapprovedforthepurpose).
oDaiswereunwillingtotrainedandpatientswilltoacceptthe
oldcustomarymethods.In1926MidwivesRegistrationAct
formedforthepurposeofbettertrainingofmidwives.

61. EstablishmentofIndiannursingcouncilandstatenursing
council
•TheINCwasconstitutedtoestablishauniformstandardof
educationfornurses,midwives,healthvisitorsandauxiliary
nursemidwives.TheINCactwaspassedfollowinganordinance
onDecember31
st
1947.
Thepreconception&prenataldiagnostictechniquesact–
1994
•Thisactmaybecalled“theprenatalDiagnosticTechniques
AmendmentAct,2002.
•TheConsumerProtectionAct,1986.Righttosafety,Rightto
informed,Righttochoose,Righttobeheard,Righttoseek
compensation.

62. Nationalprogramsrelatedtomotherandchildhealth
•Maternalandchildhealthprogram
•Integratedchilddevelopmentservicescheme
•ChildSurvivalandSafeMotherhoodprogram
•Reproductiveandchildhealthprogram
•JananiSurakshayojna
Maternalandchildhealthprogram
•Toreducematernal,infantandchildhoodmortalityand
morbidity
•Promotereproductivehealth
•Topromotephysicalandpsychologicaldevelopmentofchildren
•Integratedchilddevelopmentservicescheme
•Promotionofmaternalandchildhealthandnutrition

63. ChildSurvivalandSafeMotherhoodprogram
•Newborncare
•Immunization
•Preventionofhypothermia&infection
•Promotionofexclusivebreastfeeding
•Referralofsicknewborns
•Managementofacutediarrhoea
Reproductiveandchildhealthprogram
•Preventionandmanagementofunwantedpregnancy
•Antenatal,deliveryandpostnatalservices
•Childsurvivalservicesfornewbornsandinfants
•Managementofreproductivetractinfectionsandsexually
transmitteddiseases.

64. JananiSurakshaYojana
•ReductionofMMR&IMR
•Focusoninstitutionaldelivery
•NRHM
•AccreditedSocialHealthActivists–ASHA–Contraception,
Immunization,supplyfolicacidtablets.
•Reductionininfantmortalityrate,maternalmortalityrate
JananiShishuSurakshaYojana
•Targetingmotherandbabytogetherforbettermentofboth.

65. Maternalchildhealthindicators
•Birthrate:Thenumberofbirthsper1,000population.
•Fertilityrate:Thenumberofpregnanciesper1,000womenof
childbearingage.
•Fetaldeathrate:Thenumberoffetaldeaths(over500g)per
1000livebirths.
•Neonataldeathrate:Thenumberofdeathsper1000livebirths
occurringatbirthorinthefirst28daysoflife.
•Infantmortalityrate:Thenumberofdeathsper1000livebirths
occurringatbirthorinthefirst12monthsoflife.
•Childhoodmortalityrate:Thenumberofdeathsper1000
populationinchildren,1to14yearsofage.
•Maternalmortalityrate:MMRistheannualnumberoffemale
deathsper100000livebirthsfromanycauserelatedtoor
aggravatedbypregnancyoritsmanagement.

66. •Maternalmorbidityrate:Anydeparture,subjectiveor
objective,fromastateofphysiologicalorpsychologicalwell
being.(duringpregnancy,childbirthandthepostpartumperiod
upto42daysor1year)
•Perinatalmortalityrate:TheWHOdefinesperinatalmortalityas
the“numberofstillbirthsanddeathsinthefirstweekoflifeper
1000totalbirths,theperinatalperiodcommencesat22
completedweeks(154days)ofgestationandendsseven
completeddaysafterbirth”.

67. Fertilityrates
•Womenreproductiveperiodisroughlyfrom15–45years.
Fertilitydependsuponseveralfactors.Thehigherfertilityin
Indiaisattributedtolowerageofmarriage,lowlevelliteracy,
poorlevelofliving,limiteduseofcontraceptives,traditionalway
oflife.
•Totalfertilityrate:Itrepresentstheaverageno.ofchildrena
womanwouldhaveifsheweretopassthroughherreproductive
yearsbearingchildrenatthesamerateasthewomennowin
eachagegroup.