TRENDS IN MIDWIFRY AND OBSTETRICS

INTRODUCTION

Maternal mortality is a cause of great concen. Reduction of maternal mortality is an

important goal. The department of family welfare has took several new initiatives, during the
current ninth plan period, to make the programme broad based and client friendly. The focus
was accordingly. Interventions to a more shifted from individualized vertical intervention to
holistic and integrated life cycle approach giving more focussed attention to the reproductive
health care.

The maternal health programme which is a component of reproductive and child health
programme aims at reducing maternal mortality to less than 100 by the 2010. The major
interventions include:

1. Essential obstetric care.

2. Emergency obstetric care.

3. 24 hrs. delivery services at PHCs/CHCs.

4. Referral transport. 5. Safe abortion services.

6. The Medical Termination of Pregnancy Act, 1971.

History

 Since our mothers' and grandmothers' days, enormous changes have taken place in the
delivery of nursing care to the mother and the newborn. In their days, most babies.
were delivered at home by an untrained woman, neighbour, relative or friend or for
the fortunate few by a physician or trained midwife. Surround by loved ones with her
newborn brought promptly to her bed; the new mother received the attention and
support of her family.

 All that started changing in the second half of 20th century when parturition moved
into the hospital setting. Within the 'maternity ward; priority was often given to the
in situation’s procedures and practices, relegating the personal needs of the mother
and her newborn to second place. At that point, childbearing became far from a family
affair. The mother and newborn remained isolated from the family for a week to 10
days when the family had only visiting privileges. The infant separated from its
mother was placed in a newborn nursery and brought to its mother only at specified
times.

 Nursing was separated into three subspecialties;

  with one nurse caring for the mother during labor and delivery,
 another handling postpartum mothers
 and a third caring for the baby in the nursery.

 By 1940s, the 'rooming in' concept was advised. Full-term infants were placed in a
crib at their mothers' bedsides, where the mothers provided their care. Nursing care
remained fragmented with the nursery nurse responsible for infant care and
postpartum nurse at tending to the mother. The advantages of the system included a
reduction in neonatal infection from cross contamination, increased confidence and
independence for the mother and greater breastfeeding success. The infant showed
better weight gain and cried less. However, the downside was that the new mother
evidence problems in accepting full responsibility for the baby's care.

 It has been established that the new mothers experience three psychological phases
such as taking-in, taking-hold and letting-go. During taking-in, new mothers are
passive and dependent, requiring rest and supportive nursing care to promote bonding
and attachment. With rooming in, the mother lacked that supportive care. In taking-
hold phase, where the mother is ready to learn mothering skills, had been hoisted.
upon her too soon. Moreover, the letting-go phase, wherein she establishes maternal
role patterns and incorporates those changes into her personal and family life was
almost much neglected.

 In the 1960s, the focus changed from the person giving care to the recipient of that
care. With that change, terminology and obstetrical care became maternity care. The
broadened scope includes both prenatal and postnatal care and promotes the health
and well-being of the mother, the newborn and the entire family.

The World Health Organization (WHO) offers this 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 childcare, has a normal delivery and bears healthy children.
Maternity care in the narrower sense consists of the care of the pregnant woman, her safe
delivery, her postnatal examination and the care of her newly born infant, and the
maintenance of lactation. In the wider sense, it be gins much earlier in measures aimed to pro
mote the health and well-being of the young people who are potential parents and to help
them develop the right approach to family life and to the place of family in the community. It
should also include guidance to parent craft and in problems associated with in fertility and
family planning."

Trends

Changing Patterns of Childbirth and their Effects on Maternal-infant Mortality

Statistics

Increasing number of working women defers motherhood until they are in their 30s. As early
marriage practices continue, teenage pregnancies continue to occur. At both ends of the
spectrum, the older and the younger mothers face increased risks of complications during
pregnancy such as preterm delivery, low-birth-weight babies: maternal, fetal neonatal and
postnatal mortality.

In addition, women in increasing numbers are working outside the home during pregnancy
and shortly after delivery compounding the risks to themselves and the fetus of exposure to
toxic chemicals, excessive noise and other workplace stress.

Perinatal Risk Factors

The problems of society are reflected in the risks to today's neonates (Styles, 1990).
Among them are acquired immunodeficiency syndrome (AIDS) in mothers and newborns
and birth defects resulting from sexually transmitted diseases (STD). Low- birth-weight
babies account for about 30%-40% of live births in developing countries. Preterm babies
constitute two thirds of the low-birth-weight babies. In addition to maternal age, risk factors
of low-birth- weight infants include the mother's medical history during past pregnancies,
socio- economic status, education level and the presence or absence of prenatal care. STD can
result in infant death or in a baby born with pneumonia, cerebral palsy, epilepsy. deafness,
blindness or mental retardation.

Technological Advances

 Advances in technology have revolutionized the diagnosis and treatment of many

health conditions. Increasingly sophisticated computers have made swifter diagnosis
and continuous monitoring possible (McKenzie and Vestal, 1983).
 Among those with the greatest effect on maternal and newborn nursing are the
instruments available for fetal monitoring and care given by highly specialized
professionals in the neonatal intensive care unit (NICU). Because of these advances, it
became necessary for nursing personnel to become thorough in the procedures and
protocols developed for the use of these advanced equipment and treatment. Although
there is concern that the technological advances discourage the 'hands-on care of the
client, the nursing process must remain the foundation of quality nursing care.
 Fetal monitoring has progressed from the use of the fetoscope to electronic fetal
monitors (EFM), which allow for observation of the baby's heartbeat during
pregnancy and throughout labor, even during contractions. 'Indirect' methods of EFM
include ultra- sound, phonocardiography and abdominal fetal electrocardiography.
'Direct' (internal) fetal monitoring used during labor and delivery is done with a spiral
electrode attached to the baby's scalp. The strength of labor contractions can now be
measured by means of an internally placed catheter attached to a monitor. Telemetry
using radio transmission now makes it possible to monitor contractions and fetal
heartbeat even when the mother is not in the same room as the monitor. This new
development allows for more comfort mobility during labor.
 Experts predict that in the coming years births that are even more normal would
utilize 'hi tech' innovations with the result of lowering perinatal mortality and
morbidity.
 Risk assessment and genetic counseling may begin well-before pregnancy. Risk
situations may be monitored on a 24-hours basis for more active obstetric
management.
 Fetal assessment tools will become more sophisticated and new corrective techniques
will become increasingly available including in utero surgical correction and medical
management of defects, direct fetal blood transfusion and drug injection and genetic
 diagnosis. The challenges for nurses will be enormous as they will have to provide
humanistic, family-oriented care in a world of high technology.

Current Problems

Decreased Length of Hospital Stay

Our grandmothers' endured a 'confinement' of 2 weeks following childbirth. By the time our
mothers' had their babies, the average postpartum hospital stay had declined to 1 week. As
health care becomes increasingly ambulatory-dominant, today's new mother is up and out of
the hospital or health center in 2 or 3 days.

Early discharge poses a challenge to the nurse, who must provide nursing interventions
during a brief time frame and disseminate information, reinforce learning and affirm the
mother's role in hours rather than days. Since, early discharge often preludes extensive patient
teaching, the nurse will have to become adapt in individualizing teaching based on the unique
needs of each patient.

Higher Patient Acuities

Multiple socioeconomic problems coupled with lack of knowledge about prenatal care have
contributed to increasing number of women who have neglected their health during
pregnancy. Many have anemia, hypertension, chronic diseases and STDs. Large numbers go
into premature labour, delivering at risk low-birth-weight babies.

Lack of Facilities in the Rural Areas

About 30% of all births in India are conducted by trained dais (birth attendants), who lack
scientific education. Most of the villages in India still have the traditional dais (untrained
birth attendants) to help with deliveries. This results in lack of detection of pre natal problems
early enough for adequate management, lack of facilities to deal with childbirth
complications and inadequate reporting of morbidity.

Changes in Maternal Newborn Nursing

Social, economic, political and technological factors have contributed to the many chang es
that have occurred in maternal-newborn nursing within recent years. The focus is now on
childbirth as a familial process with less technical interference, greater human ism and a
reaffirmation of the natural birth process. In addition, recognition of the importance of
mother-baby bonding in the 1st hours and days of the newborn's life has led to the
encouragement of maximal mother infant contact.
Family-centered Care

Based on the philosophy that health includes physical, social, economic and psychological
dimensions. The family centered approach assumes that family is the basic unit of society and
should be viewed as a total unit with consideration given to each member. Thus, in family-
centered care, the emphasis is on the delivery of professional health care that fosters family
unity, while maintaining the physical safety of the childbearing unit-the mother, father and
the infant. The nurse at tends, educates and counsels all age groups. Integration and bonding
take high priority and much anticipatory counselling is offered. In family-centered care, the
nursery and postpartum staffs are combined to form one mother-baby unit.

Labor, Delivery, Recovery and Postpartum Care

Labour, delivery, recovery and postpartum care (LDRP) also called single room maternity
care, was devised as a replacement for traditional maternity unit. In it, the woman labors,
delivers and recovers in the same room, in the same bed and in most cases, the baby remains
with the mother during her stay. The LDRP physical setup is generally circular with single
birthing rooms surrounding a central area that contains all the equipment necessary for
routine or emergency care. From the time of mother's admission until her discharge, a
primary care nurse is assigned to the family. The LDRP system has the advantage of
providing comprehensive medical care within a single setting, in more homelike environment,
while maintaining all the advantages of hospitalization.

Mother-baby Couplet Care

Couplet care also known as dyad care is a system in which one-nurse cares for the postpartum
mother and her newborn as single unit. It focuses and adapts to both the physi cal and
psychosocial needs of the mother, the family and the neonate and fosters family unity, while
providing a secure environment in which nurses are available for consultation, reinforcement
and individual education. Nurses help both parents to assume responsibility for their baby's
care and assess the family's adaptation and attachment. This system facilitates parental infant
attachment, neonatal transition, lactation and involution, while supporting the taking-in and
taking-hold phases of the postpartum period.

RESEARCH :

The incorporation of research finding into practice is essential to develop a science based
practice . Practicing nurses can identify problem and read research literature to identify
studies that address their clinical concerns . They can develop procedure and protocols based
on published research . Health care providers need to support researchers in their works e.g.
they can participate in research as data collectors.

Others

 Delayed umbilical cord clamping after birth Delayed cord clamping

means waiting anywhere from 30 seconds to a few minutes to clamp and cut
the umbilical cord instead of immediately following delivery. By delaying cord
clamping, baby will get additional blood from mom, which contains oxygen-
carrying iron stores. Although this is something that many midwives and
doctors have been doing for a long time, it isn't universallypracticed.
ACOG has recently recommended that in healthy infants, cord clamping should be
delayed at least 30-60 seconds.

 Laboring in water(Water Birth)

Immersion in water can help decrease the need for an epidural or other pain
medications in women with healthy, uncomplicated pregnancies. However,
once it's time to begin pushing it's best to get out of the tub because delivering
 baby in the water hasn't been well studied and there have been reports of
serious complications.

 Cell-free DNA genetic screening

Cell-free DNA screening is the newest way to screen for genetic problems in
the baby. This is a simple blood test that can detect pieces of
the baby's DNA in mom's blood to determine if there may be a problem with
the pregnancy. 10. Immediate postpartum IUD insertion An IUD is one of
the most reliable methods of birth control available. In the past, you would need to
return to the office a few weeks postpartum to get an IUD. However now,
immediately following birth, an IUD can be inserted, eliminating the need for an
extra visit and an extra procedure.

Limiting interventions during low-risk labor

Physicians have gotten a bad reputation for unnecessary interventions during la

bor and delivery.While there are definitely times that interventions are needed f
or a safe delivery, limiting unnecessary interventions can also be beneficial.
They are encouraging the use of doulas, changingpositions during labor, intermi
ttent monitoring and non-pharmacologic methods of pain control in conjunction
with women's birth plans.

ROLE OF NURSE IN MIDWIFERY AND OBSTETRICAL CARE

Midwife or midwives are professional trained nurses who are concerned and believes in
providing care to healthy women during labor, delivery and after the birth of a baby. A
midwife also helps the mother in care of the newborn and assist her in breastfeeding her child.
They provide all necessary professional care and services during the process from conception
to childbirth.

Midwife: "A midwife is a professional nurse who has knowledge and skills related to prenatal
care, birth education for women and their partners and care for mothers, newborn babies after
birth".

"Midwifes also attain specialized course in normal,uncomplicated deliveries and help in

referral of high risk and complicated cases". A midwife may extend her skills to women's
health, sexual and reproductive health including planned parenthood".

Role and Responsibility of a Midwife

There are a number of roles a midwife plays as a member of health team. The important roles
are explained below:

1. Caregiver: Midwife impart exceptional antenatal, intranatal and postnatal care to a

pregnant woman She keenly observes any untoward problem at the earliest stage and handle
it or refer for any complication.
2. Implementer: Midwife organize and arrange care for all women. She ensures
comprehensive (holistic). voluntary and social services for pregnant women as and when
required, so that the pregnant women experiences a beautiful and healthy childbirth
irrespective of age, race, religion and financial situation.

3. Leader: A midwife acts as a leader in planning, guiding and reviewing a woman's care
with their knowledge experience and skills from the period of first antenatal assessment to
postnatal period and hence minimizing hospital stay.

4. Manager: A nurse midwife has a unique role as a manager. She knows how to promote
normal birth and detect complications. Moreover, she further carries out emergency measures
requiring referral services. Apart from this, she works as a part of a multidisciplinary team,
liaising with other health care professionals to provide the best care for childbearing women,
their babies and families.

5. Educator: As an educator midwives provide education and advice about health matters for
women, their families and the wider community. In addition, she answers questions related to
any problem and promotes positive parenting.

6. Counselor: Midwives act as guide by instructing pregnant women on antenatal care like:

a Diet and nutrition

b. Personal hygiene

c. Provide guidance on minor ailments in pregnancy d Importance of Immunization.

e. Educate about small family norm and family planning measures.

f. Explains the danger signs of pregnancy and childbirth.

7. Advisor: Midwife as an advisor, advises the women related to:

a Conception

b. Preparation of birth

Planned parenthood

d Mother craft classes

e Easy birth (Healthy mother and healthy child). She also provides advice
during any complicated situation, so that the couple may take appropriate
decision

8. Record Keeper: A midwife's prime duty is to keep an appropriate and a clean record of
each and every woman and her child for the safety of the patient and the midwife. It also
helps in quickly reviewing the plan and course of delivery for easier delivery and referred (if
any).
In general the role of the nurse can be expressed as

 Provides necessary supervision, care and advices to women in pregnancy, labour and
postnatal period. • Promotes women's sexual or reproductive health and child health.

 Facilitates and carries out the audits of maternal and neonatal care. Carries out
evidence based research and further implement it to clinical practice.
 Disseminates information to women and families about safe abortion, contraception
and spacing etc.

Conclusion

Maternity nurses specializes in providing care of the women throughout the child bearing
cycle. Recent trends indicate that a new approach to women health during the child bearing
cycle is critical to the improvement of the overall health and wellbeing of the women and
their infant . Increased access to preventive care must become the focus . Maternity nurse can
play a vital role in the process The maternal and child population is constantly changing
along with change in social structure, variation in family style, increased health care cost,
improvement in medical technology and change in pattern of illness. It is important
that know about the new trends in midwifery and obstetrics for better treatment and
prevention of diseases

Bibliography

 Fraser DM, Myles . Textbook of Midwives. 17th edition. Churchill livingstone . 2020.
Pg no: 6-12
 Annama Jacob. A Comprehensive textbook of Midwifery & Gynecological Nursing.
4th edition. Pg:2-12

 JB sharma. Midwifery And Gynaecological Nursing. Avichal publishing company. Pg:

3-16

 M Shally, Sanju. Midwifery and obstetrics for B.Sc. Nursing Students. Lotus
publisher. Pg :4-15