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WELCOME

Sindhu Sebastian Lecturer FMCON

MIDWIFERY

Midwifery is as old as the history of human species.

MEANING
 

Mid With Wife - Woman

The art of assisting woman in child birth

The definition term midwife was developed by international confederation of midwives in 1972.

DEFINITION


Midwife: A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognized in the country in which it is located, has successfully completed the prescribed courses or studies in midwifery and has acquired the requisite qualifications to be registered and or legally licensed to practice midwifery.(WHO 1992)
Midwifery: is the knowledge necessary to perform the duties of a midwife.

CONTINUED .....  Obstetrics is a branch of medicine concerned with the treatment of women during pregnancy, childbirth birth.

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. (ICN 2002)

CONTINUED .....


Obstetrical nursing : Nursing care given to the pregnant patient before, during, or after childbirth.

SCOPE
Midwifery today: Midwifery education & practice go beyond scope of practice Outlined in the definition. Nurse- midwifery Education- midwifery + nursing+ medicine Practice- all midwifery + components of nursing+ medicine


QUALITIES OF MIDWIVES
       

Skill full Able to assess the women Health educator Managing care ability Professionally competent good communicator Team spirit Counselor

HISTORICAL REVIEW
 

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Midwifery is as old as the history of human species Archeological evidence of a women in squatting in childbirth supported by another women from behind existence of midwifery in 5000 BC References in old testament Hebrew midwives

Hippocrates (460 BC) trained & Supervised midwives  Aristotle(384-322BC) discussed the essential qualities of midwife


CONTINUED .....
 

Soranus -2nd centuaryspecialized in OBG 5th-15th century untrained midwives controlled practice of midwifery. In 1513 first book on midwifery was printed in Germany based on teaching of Soranus (2nd century first to specialize OBG-1,500 years). 1540 translated in English (used for 150 years) doctors excluded from labor room & midwives assisted in childbirth) Ambroise Pare founded a school for midwives in Paris

Louise Bourgeos a midwife recommended induction of labor for pelvic contraction.




Julius Caeser Aranzi wrote first book for Italian midwives-17 editions. Advised cesarean section for contracted pelvis. But term had come from Latin word caedere means to cut.
 

William Harvey (1578-1657), father of British midwifery,wrote 1st English textbook on midwifery. He described fetal circulation and placenta. First to deliver placenta by massaging the uterus

French king Louis XIV (1663) employed a Paris surgeon to attend his mistresses in labour- honoured with name accouchear -a person who assists women in childbirth.
 

Mauriceau (physician) in published a Treatise on midwifery. He described attitude of fetus in uterus

Hugh Chamberlen -1965 designed obstetrical forceps.




William smellie explained labour process .

 

Pelvimetry, Cephalometry Forceps delivery

The midwifery chair was founded in 1726 in university Edinburgh.  John Leake replaced it with delivery beds  Charles White stated that puerperal fever was infectious and Gordon explained puerperal sepsis  Fielding Ould described normal labour and performed episiotomy.  Francois recognized fetal heart sound.


James Young used Chloroform first in obstetrics for anesthesia. Florence Nightingale conducted training for midwives in 1862. Semmelweiss demonstrated causes & preventive measures for puerperal sepsis. Louis Pasteur wrote a thesis on it demonstrating presence of Streptococci in Lochia. Spencer & Ballyantyne promoted concept of antenatal care for pregnant women. Munro Kerr 1926 introduced technique LSCS.

DEVELOPMENT OF MATERNITY SERVICES IN INDIA


 

Earlier midwifery was practised by Dais. In early part of 20th century changes in practices began to occur. Health Organization

Director General of IM services+ Surgeon General of Civil hospitals in States Administration & maintenance of associated institutions

Public heath commissioner + Sanitation Commissioner in States

Preventive health services

The All India Institute of Hygiene & Public Health established in 1930 under Rockefeller foundation which provided programms for MCH. 1943- Govt. appointed Bhore committee which recommended PHC for every 40,000 population with having staff of each unit: 1 institutional nurse, 4 midwivwes & 4 trained dais. Programs for TD & ANMs were started based on its report.

Training programs for nurses were Mainly in mission hospitals.




 

 

Christian medical College Hospital Vellore in Tamil Nadu had nurses training program. NSs of Mission Hospitals felt need for an organization of their own by 1911. 1931- a formal institution of nurses was started- Nurses Auxiliary of Christian medical Association of India(CMAI) 1964- renamed as Nurses League. They had 2 boards of nsg.education. Mid India B.N.E+ B.N.E, south India branch.They had GNM +ANM courses


1949- Indian Nursing Council (INC) was Constituted.  It formulated standards for Nsg.Educ.in the country.  During last five decades N.Edu has advanced. Midwifery training is included into 3 yr basic general nsg.program i.e diploma in nsg & midwifery.  ANM program 2 yrs & MHW-multipurpose health worker program- 18 months  B.SC+ M.SC courses are also available now.  Edu & practice in institutions approved by SNC + INC are mandatory for practicing nsg +midwifery.


ANTENATAL CARE
Definition: Systematic supervision of a woman during pregnancy is called antenatal care. AIMS AND OBJECTIVES:  To screen the high risk cases  To prevent or to detect and treat at the earliest any complications  To ensure continued medical surveillance and prophylaxis  To educate the mother about the physiology of pregnancy and labour  To discuss with the couple about the place, time and mode of delivery  To motivate the couple about to the need of family planning and appropriate advice to couple seeking medical termination of pregnancy

Care during the first trimester of pregnancy:


Screening: - Determine the blood group Ultrasound: - Gestational age - Presence and absence of foetal life - Multiple pregnancy

Habits: - Tobacco - Smoking - Drug abuse - Alcohol Care during second trimester - Genetic screening - Amniocentesis - Triple screen - GDM- 24-28 weeks

Nullipara : is one who has never completed a pregnancy to the stage of viability. Primiparous: is one who has delivered one viable child Multigravida is one who has previously been pregnant. She may have aborted or have delivered viable baby. Parturient: is a woman in labour. Nulligravida is one who is not now and never has been pregnant. Primigravida: is one who is pregant for the forst time Multipara: is one who has delivered two or more children

HISTORY TAKING
Vital statistics Biodata Reason for admission Present obstetric history Antenatal history - I trimester II trimester III trimester Past obstetrical history Menstrual history Marital and sexual history Personal history

Rh issomerisation Care during the third trimester:


Aim to safe and timely labour and birth Antenatal visits: First visit: within 12 weeks of pregnancy Second visit : between 14-26 weeks Third visit: between 28-34 weeks Fourth visit: between 36 weeks to term

Marital and sexual history Personal history Family history Nutritional history Socioeconomic history Environmental history Past medical and surgical history Physical examination and obstetrical examination antenatal examination Vaginal examination Lab investigation Medication

ANTENATAL ADVICE
     

Diet Exercise Rest and sleep Bath and dental hygiene Care of the breast Bladder and bowel care

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Travel Coitus Alcohol and smoking Immunization General advice - To come to hospital Painful contractions Sudden gush of watery fluid from vagina

Any vaginal bleeding Reduced fetal movements

ANTENATAL EXERCISES: - Squatting - Pelvic floor exercises - Pelvic rocking

LABOUR
The labour process is an exciting and anxious time for the labouring woman and her significant others. Definition: Series of events that take place in the genital organs in an effort to expel the viable products of conception out of the womb through the vagina into the outer world is called labour. Causes of onset of labour
  

Unterine distension Feto-placental contribution Oestrogen

 

Progesterone Prostaglandins

Physiology of labour:

DISCOMFORTS DURING PREGANCY

First trimester: 1. Breast tenderness: - is often and noticeable symptoms - most noticeable when exposed to cold air - encourage the women to wear a bra with wide strap for support and wear warm dress

2. Palmer erythema:
Caused due to increased estrogen level - Explain woman that this type of itching is common - Calamine lotion can be used 3. Constipation: - Encourage women to empty the bowel regularly - To increase the roughage in the diet - Recommend avoiding gas-forming foods asuch as cabbage or beans
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4. Nausea and vomiting : - Small and frequent food - Avoid fatty and spicy food 5. Fatigue: - Due to increased metabolic requirements - Much of it can be relieved by increasing the rest and sleep. - Fatigue can increase the morning sickness - Short rest period everyday
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maintain good resting position - Women who is working on her feet most of the day, can take rest during the lunch period and sit with leg elevated. 6. Muscle cramps: - Decreased serum calcium levels, increased phosphate levels interferes with circulation commonly causes muscle cramps - Best relieved by elevating her legs while sitting.
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Lowering the milk intakes - Restless leg syndrome is common ( walking at night due to frequent leg movements Hypotension:
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occurs when a woman lies on her back and the uterus presses on the vena cava, impairing blood return to her heart. Relieves when woman turns on her side, pressure will be relived from the vena cava. If a woman suddenly rise from lying or sitting position or stands for long time in warm or crowded

area, she may faint ( blood pooling in the pelvic area and extremities). -if woman feel faint sitting with her head lowered will alleviate the problem. Varicosities: -weight of the uterus puts the pressure on the veins - This cause pooling of the blood leading to engorged, inflamed and painful veins. - Sometimes varicosities may extend to vulva - Resting on Sims position or on back with legs raised against wall or on a footstool for 15-20 minutes twice a day is a good precaution.

Stockings such as TEDS for relief of varicosities. - Exercise is as effective as rest periods. - Advice the woman to break up the long periods of sitting or standing - Vit C is may be helpful in reducing the size of the varicosities. Hemorrhoids: - Because of the pressure on these veins from bulk of the growing uterus. - Daily bowel emptying and resting in modified sims position daily are both helpful.
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Heart Palpitation: - Sudden movement such as turning over in bed may experience a bounding palpitation of the heart. - It is probably due to the circulatory adjustments necessary to accommodate her increased blood supply during pregnancy. - Reassure the woman to know that palpitations are common in pregnancy. - Slow movements will help to prevent this from happening frequently.

Frequent Urination:
Occurs due to the pressure of the growing uterus on the anterior bladder. - Ask her about burning sensation - Advice Kegel exercise and relaxing perineal muscles. Abdominal Discomfort: - when women stands up quickly may experience a pulling sometimes sharp frightening pain in the right or left lower abdominal from tension on a round ligament.
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Leukorrhea: - Whitish viscous vaginal discharge occurs due to increase in estrogen levels. - Daily bath, wearing cotton underpants. - Women with vulvar pruritis needs evaluation may help to prevent vulvar and vaginal infections. Discomforts of middle to late pregancy: - Backache - Headache - Dyspnea

Ankle edema Braxton hicks contractions

LABOUR
Definition: Series of events that takes place in the genital

SECOND STAGE OF LABOUR: Is the period from full dilatation and cervical effacement to birth of the infant with uncomplicated birth, this stage takes about one hour. Physiological changes: Descent of the fetal presenting part Uterine action

Rupture of membranes Displacement of soft tissues and organs Symptoms experience by woman:  Powerful uterine contraction  Rupture of membranes  Sensation of passing motion  Appearance of fetal head at the introits

Mechanism of labour: Engagement descent Flexion Internal rotation Extension External rotation expulsion

Delivery of the head:


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Each contraction perineum bulges and vulvovaginal opening becomes almost circular. The largest diameter of the stretches the vulvovaginal opening The perineum becomes thins, anus is stretched and anterior wall of the rectum is easily seen. Encourage the women to pant or give small pushes Place the hand against the babys head to control

birth of the head - Gently support the perineum as the babys head delivers Ask the woman not to push once head delivered - Feel around the neck for the umbelical cord. Completion of delivery: - Allow the babys head to turn spontaneously - Once it turns place the hand on each side of the babys head and ask women to push gently with
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next contraction - Deliver one shoulder at a time - First deliver anterior shoulder then posterior shoulder - Lift the babys head and deliver posterior shoulder - Clamp and cut the umbelical cord - Dry the baby and wrap in soft clothes or blankets.

THIRD STAGE OF LABOUR


The classical signs of preparation of placenta:
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lengthening of the umbilical cord Gush of blood from the vagina Change in shape of the uterine fundus from discoid to globular

Placenta separation: - Schultzes mechanism - Duncans mechanism Technique of delivering placenta: - Controlled cord traction - Expression of the placenta by fundal pressure.

THANK YOU

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