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Introduction
to Midwifery
• 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 a midwife.
• Obstetrics is that branch of medicine, which deals with the management of pregnancy, labor
and puerperium.
• Gynecology is that branch of medical science, which treats diseases 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 a 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 rights 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 mothers 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 Midwives Act was passed to promote the role of a
registered midwife for service during childbirth.

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Introduction to Midwifery.pptx

  • 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. Terminology • Midwifery is the knowledge necessary to perform the duties of a midwife. • Obstetrics is that branch of medicine, which deals with the management of pregnancy, labor and puerperium. • Gynecology is that branch of medical science, which treats diseases 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 a woman who has given birth more than once.
  • 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 rights 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. 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 mothers 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.
  • 6. 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 Midwives Act was passed to promote the role of a registered midwife for service during childbirth.
  • 7. • 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
  • 8. Midwifery in independent India • In 1946, the Bhore committee laid stress on the need for qualified midwives, health visitors and the training of nurses. • 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. • 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. 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. 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 worker (female), is registered as a midwife. purpose health Presently, this is a two year course with entry classification being 12th class. India has a huge cadre of ANMS who are educated and trained in Midwifery.
  • 12. 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 refercomplications 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. • 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. 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. • Expanded roles for nurses • Increasing nursing responsibility for assessment and professional judgment and providing expanded roles for nurse practitioners, such as the nurse - midwife. Family centered care More natural childbirth environment where partners, family members can 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. • 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. - 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.
  • 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. 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 to them.
  • 19. 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 is the, quality nursing care. Today fetal monitoring has progressed from the use of fetoscope to electronic fetal monitors. It can be used both, directly and indirectly stimulate men to take interest in obstetrics.
  • 20. Historical development in obstetrics In 1739, in London, William Smellie and his student William Hunter became obstetricians and worked for the same. • In 1744, William Smellie introduced steel lock forceps. In 1752, William Smellie published '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 Bennett of Virginia on his wife. • First school of midwives was established at Pare's instigation at the hotel Dieu in Paris. In 18th century National regulation of education and practice of midwifery began.
  • 21. • In 1807, Samuel Bard published the first book on obstetrics on four stages of labor. In 1847, Semmelweis, in Vienna, demonstrated that washing hands in chlorine of lime solution before examining women in labor reduces puerperal fever. Chloride of lime used as antiseptic. - Obstetrical forceps was developed by Dr. Peter Chamberlain. 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 introduced Ultrasound in Obstetrics. In 1950, Fritz Fuch of Copenhagen performed Amniotomy identified the fetal cells present in it which identify sex of the
  • 22. • 1974 - Family Planning Services Incorporated In MCH Care • 1977 - Renaming Family Planning To Family Welfare • 1978 - Expanded Program on Immunization 1985 - Universal Immunization Programme 1992 - Child Survival & Safe Motherhood Programme 1996 Target Free Approach 1997 RCH Program Phase-1 (15-10-1997) - • 2005 - RCH Program Phase-2 (01-04-2005)
  • 23. Contemporary perspective of obstetrics • In current view all the focus from obstetrics care shifted to perinatal care. Advancement in Obstetrics care has reduced the MMR. Govt. has started program to identify high risk mothers. Training of health personnel, Allocation of facilities & equipment decreases MMR. MMR can be reduced: Early registration of pregnancy. o At least three antenatal check-ups. o Dietary supplements can correct anemia. 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.
  • 24. • 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 have started which aims at reduction in morbidity and mortality rate of mother and baby. Baby friendly hospital scheme has been launched in 1993 for effective breastfeeding to children. . Genetic counseling to the couples. Screen the mother for HIV.
  • 25. • Morbidity in obstetrics occurs from any cause related to pregnancy or its management, any time during antepartum, intrapartum or the post partum period. Causes : • Direct causes, such as APH, PPH, sepsis, rupture uterus, ectopic pregnancy, eclampsia, obstructed labor etc. Indirect causes, which consist of those conditions which were present earlier also, but aggravated in pregnancy, such as anemia, tuberculosis, hepatitis, malaria etc.
  • 26. Maternal fertility- According to the Health Population Policy 2000, India was supposed to achieve replacement level of fertility by 2010, but experts find it a tall order. According to a Professor of Population Research Centre, Institute of Economic Growth, "Although fertility decline has set in all over India, its slow pace in some parts of the country remains a serious concern for population and development planners. As such, the target is likely to be achieved by 2018,” According to a latest data from the National Family Health Survey-III, an increasing number of couples want a maximum of 2 children. This data caused the fertility rate to drop from 2.9 in the year 2000 to 2.7 in the year 2006.
  • 27. Year FERTILITY RATE 2008 2.76 2007 2.81 2006 2.73 2005 2.78 2004 2.85 2003 2.91 2002 2.98 2001 3.11
  • 28. Definition of Total fertility rate: This entry gives a figure for the average number of children that would be born per woman if all women lived to the end of their childbearing years and bore children according to a given fertility rate at each age.
  • 29. The total fertility rate (TFR) • It is a more direct measure of the level of fertility than the crude birth rate, since it refers to births per woman. • This indicator shows the potential for population change in the country. • A rate of two children per woman is considered the replacement rate for a population, resulting in relative stability in terms of total numbers. • Rates above two children indicate populations growing in size and whose median age is declining. • Higher rates may also indicate difficulties for families, in some situations, to feed and educate their children and for women to enter the labor force. Rates below two children indicate populations decreasing in size and growing older. Global fertility rates are in general decline.
  • 30. According to Registrar General of India Total fertility rate, 1970 Total fertility rate, 1990 Total fertility rate, 2006 Under-5 mortality rate, 2006 Infant mortality rate (under 1), 2006 Neonatal mortality rate, 2000 Annual no.of births(thousands), 2006 Annual no.of under-5 deaths(thousands), 2006 5.4 4 2.9 76 57 43 27195 2067
  • 31. PERINATAL MORTALITY AND MORBIDITY RATES Definition- It is defined as deaths among the fetuses weighing over 500gm or more at birth who die before and during delivery or within the first 7 days of delivery. It is expressed in terms of such deaths per 1000 total births. Perinatal morbidity implies the illness of the neonate from birth to first four weeks of life. Its results mainly due to birth trauma are asphyxia, prematurity and congenital malformations.
  • 32. • Perinatal and neonatal deaths are largely the consequences of inadequate and inappropriate care during pregnancy, during the crucial first few hours after delivery. The causes of perinatal and neonatal mortality are multi-factorial and include • low birth weight, • neonatal asphyxia, • birth injury, • congenital malformations and infections.
  • 33. Infant Mortality Rates in Asia China Pakistan India Bangladesh Thailand Sri Lanka 41 74 72 79 29 18
  • 34. Causes- 1. Clinical conditions related to perinatal deaths- main clinical conditions causing mortality are related to prolonged labor and difficult labor, any pregnancy complications. 2. Direct causes of death- Under direct causes, the deaths are due to prematurity, asphyxia and intracranial haemorrhage. Babies who have an increased risk of dying before their first birthday fall into three broad categories: • those born to very young mothers, • those born to women past their prime childbearing years and • those born too soon after a previous birth.
  • 35. Births to adolescents. Many adolescent women, especially in poor countries, are physically immature, which increases their risk of suffering from obstetric complications. • For example, malnourished young women may not have developed sufficiently for the baby's head to be able to pass safely through the birth canal. Teenage mothers also have an increased risk of giving birth to an infant who is premature or low- birth-weight-conditions that reduce the resilience and stamina babies need to overcome infection or trauma early in life. Additionally, pregnant adolescents are less likely than older women to receive good prenatal care and skilled medical care at delivery, and to be able to provide adequate care for an infant. For these reasons, babies born to teenage women are more likely to die than those born to women in their 20s and 30s. • The infant mortality rate averages 100 deaths per 1,000 births among mothers younger than 20, compared with 72-74 deaths per 1,000 births among mothers 20-29 and 30-39. Moreover, among the developing countries studied here, the higher risk of babies born to young mothers is found at every income level.
  • 36. Births to older women. At the other end of the reproductive spectrum, many poor women in their 40s suffer from anemia, malnutrition, damage to their reproductive systems from earlier births and the sheer physical depletion associated with frequent childbearing all conditions known to increase the likelihood of having a baby at increased risk of dying. The average infant mortality rate among women giving birth in their 40s-94 per 1,000 live births-is much higher than the rate among women in their 20s and 30s and almost as high as the rate among teenage mothers. As with adolescent mothers, high infant mortality rates among babies born to women in their 40s occur in countries at every income level.
  • 37. Closely spaced births. Babies born less than two years after a prior birth are much more likely than those born after a longer interval to be premature or low- birth-weight. As a consequence, the infant mortality rate is 117 per 1,000 live births when the interval is less than two years, compared with 64 per 1,000 when births are spaced 2-3 years apart and 47 per 1,000 when births are four or more years apart. This effect is found in every developing region.
  • 38. YEAR 2000 2001 2002 2003 2004 2005 2006 2007 2008 Infant mortality rate (deaths/ 1,000 births 64.9 63.19 61.47 59.59 57.92 56.29 54.63 34.61 32.31
  • 39. Definition of Infant mortality rate: • This entry gives the number of deaths of infants under one year old in a given year per 1,000 live births in the same year; included is the total death rate, and deaths by sex, male and female. • This rate is often used as an indicator of the level of health in a country.
  • 40. • It is estimated that about 7 percent of new-born infants perish within a year. • Poor maternal health results in low birth weight and premature babies. Infant and childhood diarrheal diseases, acute respiratory infections and malnutrition contribute to high infant mortality rates. • Additionally, in India, across the board (rural or urban areas), there are more female deaths in the age group of 0-14 than elsewhere. • Although the Infant Mortality Rate (IMR) has decreased from 146 per 1000 births in 1951 to 72 per 1000 births (1997), and the sex differentials are narrowing, again there are wide inter-state differences recorded in 1998.
  • 41. Prevention- Regular antenatal care. Screening of high risk cases and Counseling during pregnancy. pre-pregnancy state. Genetic counseling in early pregnancy to detect abnormalities. Correction of nutritional deficiencies and prevention of anemia, pre eclampsia. Immunization for tetanus. Avoiding traumatic delivery and careful monitoring of labor. Educating birth attendants. Updating hospital services as well as equipments for premature babies
  • 42. To improve health status of population, countries like India have two general options; (1) increase the level of resources available to health and/or (ii) improve the efficiency of health resources being used. In a resource poor country like India, increasing total resource availability in the health sector will be relatively difficult and slow, Irrespective of the level of resources available, it is important to use the existing resources in a more efficient manner. Substantial progress could be accomplished with better efficiency, both at national and sub-national levels. It is also possible that improving efficiency of the health system (in terms of child health outcome) may help lower socio-economic disparities in health.
  • 43. PREVENTION OF INFANT MORBIDITY & MORTALITY Well equipped hospitals to care premature babies Regular antenatal care Screening of high risk cases Counseling during pregnancy & pre-pregnancy state Correction of nutritional deficiencies Immunization of baby Training of birth attendants Careful deliveries by avoiding trauma