Introduction of midwifery and obstetrical nursing

UNIT - 1
INTRODUCTION TO
MIDWIFERY AND
OBSTETRICAL NURSING

 Introduction to concepts of midwifery and obstetrical nursing
• Obstetrics word came from a Latin word “OBSTETRIX” means
“MIDWIFE”.
• Midwifery, as known as obstetrics, is a health science and health
profession that deals with pregnancy, childbirth and the
postpartum period (including care of newborn), besides sexual
and reproductive health of women throughout their lives.

 Terminology
• Midwifery is the knowledge necessary to perform the duties of
midwife.
• Obstetrics is that branch of medicine, which deals with the
management of pregnancy, labour and puerperium.
• Gynaecology is that branch of medical science, which treats
disease of the female genital organs.
• Reproduction means process by which a fully developed
offspring of its kind is produced.
• Pregnancy is a state of carrying fetus inside the uterus by a
woman from conception to birth.
• Gestation means pregnancy.
• Gravida is state of pregnancy irrespective of its duration.
• Multipara refers to woman who has given birth more than once.

• Nullipara is the woman who has not given birth before.
• Primigravida is a woman carrying first pregnancy.
• Multigravida is a woman carrying pregnancy more than once.
• Healthy women are the key to the health of any nation, primarily
because of their vital role in co - creating healthy infants and co –
caring for the family.
• Providing health care to women is not only a health issue but a
matter of human right issue.
• In women’s life childbirth is a special event.
• A mother will never forget a ‘midwife’ who delivered her baby,
and who was ‘with the woman’ during childbirth, which is the
very essence and identity of a midwife.
• Hence a midwife is an obvious catalyst in providing safe
motherhood in the fabric of our society.

 Midwifery in India before independence
• In ancient India, care of women and practice of midwifery were
totally in the hands of indigenous village ‘Dias’.
• These indigenous dais, not only helped during childbirth but
also acted as consultants for any condition of the mother
related to birth.
• When medical missionary women from England came to India,
the first striking observation they made was that, since dais
were unable to deal with difficult deliveries and pregnancies,
the maternal and neonatal mortality were very high.
• The first training school for dais was started in 1877 by Miss
Hewlett, an English missionary of the Zenana Missionary
Society.
• However, the training of dais was not taken up by Government
of India till 1900 when a fund was established by Lady Curzon to

improve the conditions of childbirth in the country.
• But before that, in 1872, a handful of Indian Christian nurses
were trained for two years at Delhi.
• In 1899 the Zenana Bible and Medical Mission started the training
of nurses, but until 1893 there was no generally accepted scheme
of training in the hospitals.
• In 1918 with the help of Dufferin Fund, Lady Reading Health
School was established to train Auxiliary Nurse Midwives (ANMs).
• In 1926 the Madras Registration of Nurses and Midwifes Act was
passed to promote the role of a registered midwife for service
during childbirth.
• In 1936 Dufferin fund sanctioned grant to a number of Dufferin
hospitals to build hostels, supply teaching materials and employ
qualified sisters in nursing schools.
• Thus Dufferin fund helped in raising the standards of nursing and
midwifery in India.

• In fact prior to independence, midwifery training started as a
separate course, in India.
• Young girls at the middle school level (8th) were selected to
undergo this training.

 Midwifery in independent India
• In 1946, the Bhore committee laid stress on the need for
qualified midwives, health visitors and the training of dais.
• In 1955, the Shetty Committee recommended the training of
Auxiliary Nurse Midwife (ANMs) in health centers for maternal
and child health services, provided there were adequate health
visitors to supervise them.
• In 1959 Bishoff, a technical Consultant supported the training of
two types of nursing personnel ANM and General Nurse Midwife
(GNM Nursing – 3 years and Midwifery – 1 year).
• In 1947, the first step the Indian Nursing Council took after its
inception was to combine the nursing and the midwifery courses
into a single course.
• The course was designed to be of three and a half years
duration, with the entry qualification being 10th class.

• In 1975 the Kartar Singh Committee recommended shortening
the two year course of ANM to one and a half years and entry
after class 10th.
• These ANMs were designed as female health workers. They
were specially trained in midwifery and child health care
services. Government of India also invested heavily in the
training of dais.

 Present and future of midwifery in India
• The presence of a skilled midwife at birth is the single most
important factor for achieving safe motherhood (WHO).
• The number of midwives available as per population is an
important indicator of the maternal health status in a country.
• The maternal health status of women and maternal mortality
are closely related to the presence of trained attendants at
birth.
• As the percentage of births attended by trained personnel goes
up, the maternal mortality ratio goes down.

 In India there are the following cadres of midwives
1. The trained nurse midwife (RN, RM): Who has undergone a
diploma (Diploma in General Nursing and Midwifery), which is
of three and a half years duration. Or A degree nurse who has
done B.Sc. (Honors) Nursing, which is of four years duration.
2. The ANM, who is designated as the Multi – purpose health
worker (female), is registered as a midwife.
• Presently, this is a two years course with entry classification
being 12th class.
• India has a huge cadre of ANMs who are educated and trained
in Midwifery.
3. Skilled Birth Attendant (SBA) refers exclusively to people with
midwifery skills (e.g. doctors, nurses, midwives) who have
been trained to get proficiency in the skills necessary to
manage normal deliveries and to diagnose, manage or refer

complications to all levels of health care settings.
• Midwifery skills are defined as a set of cognitive and practical
skills that enable the individual to provide basic health care
services throughout the natal continuum period and also to
provide prompt actions in emergencies including life saving
measures, when required.

 Need for midwifery as a profession in India
1. To achieve safe motherhood.
2. To avoid duplication of services.
3. To give health education.
4. To participate in country’s concern i.e. maternal and child
welfare.
5. To get status and recognition in the society.

 Trends in midwifery and obstetrical nursing
 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.

 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.

 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.

 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

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

• As the technology has revolutionized and increasingly
sophisticated computers in today’s world, it has become
necessary for the nursing personnel to have thorough
knowledge of the new technology being used.
• Due to this advancement, ‘the hands on care’ of the client is
reduced, so also is the, quality nursing care.
• Today foetal monitoring has progressed from the use of
fetoscope to electronic foetal monitors. It can be used both,
directly and indirectly.

 Historical perspectives and current trends
 Historical perspectives
 Origin of obstetrics
• As we all know that birth is the complex final act of nature’s
greatest miracle i.e. formation and arrival of a child in the world.
And the science and art that deals with human reproduction is
and art that deals with human reproduction is called Obstetrics.
• “SORANUS OF EPHESUS” is the Father of obstetrics. He was the
first to write about the Podalic Version.
• Earlier man were not welcomed in this field. During Middle Ages
in Europe midwives were of low types and executioner and
barbers were called to help with difficult deliveries. Later on in
16th & 17th century Ambroise Pare of Paris and Chamberlens

stimulate men to take interest in obstetrics.
 Historical development in obstetrics
• In 1739, in London, Willam Smellie and his student Willam
Hunter become obstetrician and work for the same.
• In 1744, Willam Smellie introduce steel lock forceps.
• In 1752, Willam Smellie publish ‘Textbook of Obstetrics’.
• In 1760, Puerperal fever was on peak in London in Lying-in
hospital.
• On Jan 14th 1794 first Cesarean operation was performed by Dr.
Jesse Benaett of Virginia on his wife.
• First school of midwives was established at Pare instigation at
the hotel Dieu in Paris.
• In 18th century National regulation of education and practice of
midwifery begans.

• In 1807, Samuel Bard publish first book on obstetrics on four
stages of labour.
• In 1847, Semmelweis, in Vienna, demonstrate that washing of
hands in chlorine of lime solution before examining women in
labor reduce puerperal fever. Chloride of lime used as
antiseptic.
• Obstetrical forceps was developed by Dr. Peter Chamberlen. In
the past only Greeks used variety of hooks and tractors to
deliver dead fetus.
• In 1853, Dr. James Y. Simpson of Glasgow succeeded in
introducing the use of Chloroform anesthesia as an aid in
obstetrics called “ERA OF MODERN OBSTETRICS”.
• Then, Pinard Fetoscope was developed and 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

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

• 1974 – Family Planning Services Incorporated In MCH Care
• 1977 – Renaming Family Planning To Family Welfare
• 1978 – Expanded Programme on Immunization
• 1985 – Universal Immunization Programme
• 1992 – Child Survival & Safe Motherhood Programme
• 1996 – Target Free Approach
• 1997 – RCH Programme Phase-1 (15-10-1997)
• 2005 – RCH Programme Phase-2 (01-04-2005)

 Contemporary perspective of obstetrics
• In current view all the focus from obstetrics care shifted to
perinatal care.
• Advancement in Obstetrics care has reduces the MMR.
• Govt. has started programme to identify high risk mothers.
• Training of health personnels, Allocation of facilities &
equipment decreases MMR.
• MMR can be reduces:
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.

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.

 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

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

reduced, so also is the, quality nursing care.
• Today foetal monitoring has progressed from the use of
fetoscope to electronic foetal monitors. It can be used both,
directly and indirectly.
• Experts believe that in coming years, births are going to be by
high-tech innovations, resulting in low prenatal mortality and
morbidity.
• In future, there are challenges for nurses, as they will provide
care in the world of high technology.
 Increased Cost of High - Tech Care
• As the high and sophisticated technology is being introduced
into today’s world, the costs are also increasing. For the
procedures such as ultrasound, foetal monitoring etc. the couple
has to pay good amount of money. Gradually, obstetric care is

becoming a business for the care providers.
 Changing Patterns of Child Birth
• 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.

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

monitoring and ultrasound for prenatal evaluation of foetal
condition, has come and increased rate of caesarean birth rates.
 Early Discharge
• In earlier days, women were hospitalized for longer duration and
physical activity was increased very gradually. Over the years
now, however, health care personnel have realized that early
return to normal activities is the best course for uncomplicated
births.
 Role of Fathers
• With increased societal emphasis on shared parenting and the
recognition of parental bonding, many fathers are active in care
giving and enjoy the closeness it brings.

 Legal and ethical principles in the provision of health services
 Informed decision making
• Patients or individuals who require health care services have
right to make their own decision about the opinions for
treatment or other related issues. The process of obtaining
permission is called informed consent.
• The health care provider should disclose the following details:
1. The individual is currently assessed health status regarding the
general or reproductive health.
2. Reasonably accessible medical, social and other means of
response to the individual’s conditions including predictable
success rates, side effects and risks.
3. The implications for the individual’s general, sexual and
reproductive health and lifestyle declining any of the options

or suggestions.
4. The health provider’s reasoned recommendation for a
particular treatment option or suggestion.
 Autonomy
• Autonomous persons are those who, in their thoughts, work and
actions are able to follow norms chosen of their own without
external constraints or coercion by others.
• It is to be noted that autonomy is not respect for patient’s wish
against good medical judgement.
• Simply put, a health provider can refuse a treatment option
chosen by the patient, if the option is of no benefit to the
patient.

 Surrogate decision makers
• Surrogate decision makers (parents, caregivers, guardians) may
take the decision if the affected individual’s ability to make a
choice is diminished by factors such as extreme youth, mental
processing difficulties, extreme medical illness or loss of
awareness.
 Privacy and confidentiality
• A patient’s family, friend or spiritual guide has no right to
medical information regarding the patient unless authorized by
the patients. The following points of confidentiality are to be
kept in mind:
o Health care providers duties to protect patient’s information
against unauthorized discoloures.

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.

 Breach of the established legal duty
• Of care must be shown, which means a health care provider
has failed to meet the legally determined standards of care.
• Damage must be shown.
• Causation must be shown.
 Safety and efficacy of products
• Health care providers are responsible for any accidental or
deliberate use of products that differs from their approved
purposes or methods of use, for instance, the dosage level for
drugs. Look for the drug contraindications, drug expiry, damage
of diluted sterilization solvents etc.

 Preconception care and preparing for parenthood
 Preconception care
• Care about pregnancy, its course and outcome well before the
time of actual conception is called preconceptional care.
• It ensures that a woman enters pregnancy with an optimal state
of health which would be safe both for herself and for her fetus.
• If the woman is seen first in the antenatal clinic, it is often too
late to advice as organogenesis is already completed.
 Uses
• Maternal health is optimized preconceptionally. Problems of
overweight, underweight, anaemia, abnormal papanicolaou
smears are evaluated and treated appropriately.

• Baseline health status and blood pressure are recorded.
• Women should be encouraged to stop smoking, alcohol and
addictive drugs intake.
• Identification of high risk factors by detailed evaluation of
obstetric, medical, family and personal history. Risk factors are
assessed by laboratory tests, if required.
• Importance of prenatal diagnosis for chromosomal or genetic
diseases are discussed.
• Patient with medical disorders and complications like diabetes
and heart disease should be optimally controlled before they try
pregnancy as there are effects of the disease on pregnancy and
also the effects of pregnancy on the disease. In extreme
situations, like Eisenmenger’s syndrome, diabetes nephropathy,
the pregnancy is discouraged. Pre-existing chronic diseases
(hypertension, diabetes, epilepsy) are stabilized to an optimal
state by intervention before conception.

• Drugs used before pregnancy are verified and changed, if
required, so as to avoid any adverse effect on the fetus during
the period of organogenesis. For example, anticonvulsant drugs
are changed to safer drugs. Warfarin is replaced with heparin,
oral antidiabetic drugs are replaced with insulin (though recent
studies have safety of metformin and glibenclamide during
pregnancy).
• 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.

 Preparation for parenthood
• Preparation for parenthood should make the woman realize and
accept childbirth as a normal physiological phenomena. She
needs to have a healthy attitude towards pregnancy so that she
might have a safe and emotionally satisfying experience of labour
and eventually both mentally and physically fit in the
puerperium.
• In a preparation of parenthood educational programme,
expectant parents and their families are recognized as having
different interests and needing different information as the
pregnancy progresses. Consequently such programmes are
designed to meet the informational needs of parents during the
three major stages of pregnancy first trimester classes, second
trimester classes, third trimester classes.
• First trimester classes provide basic information and focus on the

following topics:
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

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

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.

 Good posture during pregnancy
• Standing: Head should be held erect with chin tucked shoulders
relaxed and knees slightly bent.
• Sitting: Comfortable chair which supports both back and thighs,
knees should be at level with or higher than hips, a pillow may
be placed behind the lower back for comfort.
• Lying on your side: A pillow should be placed under the upper
leg, keeping the leg slightly flexed. A pillow also may be placed
under the abdomen for support.
• Lying on your back: A pillow should be placed under the knees
to elevate the legs. A pillow under the right hip displaces the
uterus and prevents vena cava syndrome. This position should
not be used after the fourth month of pregnancy.

 Childbirth preparation method
• Today most health care providers recommend child birth
preparation classes to expectant parents. The major methods
taught are the Dick-Read or natural childbirth method, the
Lamaze or psycho prophylactic method and the Bradley
method or husband – coached childbirth.
• Dick – Read method: To replace fear of the unknown with
understanding and confidence, Dick – Read’s program provides
information on labour and birth, as well as nutrition, hygiene
and exercise.
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.

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.

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

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.

 Relaxing and breathing techniques
 Focusing and feedback relaxation
• Some women bring a favourite object such as a photograph to
the labour room, then focus their attention on this object during
contractions.
• Other choose to fix their attention on some object in the labour
room. In either event, as the contraction begins, they focus on
the object to reduce their perception of pain.
• With imagery, the nurse encourages the woman to focus on a
pleasant scene, a place where she feels relaxed.
• She can imagine a walk through a restful garden or breathing in
light, energy and healing colour and breathing out worries and
tension.
• These techniques, coupled with feedback relaxation, help the

woman work with her contractions rather than against them.
 Music
• Music can also enhance relaxation during labour, use of a
headset or earphones may increase the effectiveness of the
music because other sounds will be shut out.
 Breathing techniques
• Different approaches to childbirth preparation use varying
breathing techniques to help the woman maintain control
through contractions. In the first stage of labour, such
techniques can promote relaxation of abdominal cavity.
Because muscles of the genitalia become relaxed, they do not
interfere with descent, breathing is used to increase abdominal

pressure thereby assist in expelling the fetus.
 Effeurage and counter pressure
• These two methods provide relief in first stage of labour. Gate
control theory explains the effectiveness of this method.
Effeurage is a light stroking usually of the abdomen in rhythm
with breathing during contractions.

 Role of nurse in midwifery and obstetric care
 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.

 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.

 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

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.

 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.

 National policy and legislation in relation to maternal health
and welfare
 National population policy
• Address the unmet needs for basic reproductive and child
health services, supplies and infrastructure.
• Reduce infant and maternal mortality.
• Achieve universal immunization of children against all vaccine
preventable diseases.
• Promote delayed marriage for girls, not earlier than 18 and
preferably after 20 years of age.
• Achieve 80% institutional deliveries and 100% deliveries by
trained persons.
• Achieve universal access to information/ counselling and
services for fertility regulation and contraception with wide

basket of choices.
• Achieve 100% registration of birth, marriage and pregnancy.
• Contain the spread of AIDS and promote greater integration
between the management of reproductive tract infections and
sexually transmitted infections and the National AIDS control
organization.
• Integrate Indian System of Medicine in the provision of
reproductive and child health services and in reaching out to
households.
• Promote vigorously the small family norm to achieve
replacement levels of TFR.

 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.

 Establishment of Indian nursing council and state nursing
council
• The INC was constituted to establish a uniform standard of
education for nurses, midwives, health visitors and auxiliary
nurse midwives. The INC act was passed following an ordinance
on December 31st 1947.
 The pre conception & pre natal diagnostic techniques act –
1994
• This act may be called “the prenatal Diagnostic Techniques
Amendment Act, 2002.
• The Consumer Protection Act, 1986. Right to safety, Right to
informed, Right to choose, Right to be heard, Right to seek
compensation.

 National programs related to mother and child health
• Maternal and child health program
• Integrated child development service scheme
• Child Survival and Safe Motherhood program
• Reproductive and child health program
• Janani Suraksha yojna
 Maternal and child health program
• To reduce maternal, infant and childhood mortality and
morbidity
• Promote reproductive health
• To promote physical and psychological development of children
• Integrated child development service scheme
• Promotion of maternal and child health and nutrition

 Child Survival and Safe Motherhood program
• Newborn care
• Immunization
• Prevention of hypothermia & infection
• Promotion of exclusive breast feeding
• Referral of sick newborns
• Management of acute diarrhoea
 Reproductive and child health program
• Prevention and management of unwanted pregnancy
• Antenatal, delivery and postnatal services
• Child survival services for newborns and infants
• Management of reproductive tract infections and sexually
transmitted diseases.

 Janani Suraksha Yojana
• Reduction of MMR & IMR
• Focus on institutional delivery
• NRHM
• Accredited Social Health Activists – ASHA – Contraception,
Immunization, supply folic acid tablets.
• Reduction in infant mortality rate, maternal mortality rate
 Janani Shishu Suraksha Yojana
• Targeting mother and baby together for betterment of both.

 Maternal child health indicators
• Birth rate: The number of births per 1,000 population.
• Fertility rate: The number of pregnancies per 1,000 women of
child bearing age.
• Fetal death rate: The number of fetal deaths (over 500g) per
1000 live births.
• Neonatal death rate: The number of deaths per 1000 live births
occurring at birth or in the first 28 days of life.
• Infant mortality rate: The number of deaths per 1000 live births
occurring at birth or in the first 12 months of life.
• Childhood mortality rate: The number of deaths per 1000
population in children, 1 to 14 years of age.
• Maternal mortality rate: MMR is the annual number of female
deaths per 100000 live births from any cause related to or
aggravated by pregnancy or its management.

• Maternal morbidity rate: Any departure, subjective or
objective, from a state of physiological or psychological well
being. (during pregnancy, child birth and the postpartum period
upto 42 days or 1 year)
• Perinatal mortality rate: The WHO defines perinatal mortality as
the “number of still births and deaths in the first week of life per
1000 total births, the perinatal period commences at 22
completed weeks (154 days) of gestation and ends seven
completed days after birth”.

 Fertility rates
• Women reproductive period is roughly from 15 – 45 years.
Fertility depends upon several factors. The higher fertility in
India is attributed to lower age of marriage, low level literacy,
poor level of living, limited use of contraceptives, traditional way
of life.
• Total fertility rate: It represents the average no. of children a
woman would have if she were to pass through her reproductive
years bearing children at the same rate as the women now in
each age group.

Introduction of midwifery and obstetrical nursing

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