OBG unit 1

UNIT-1

DEFINITION:

Midwifery, also known as obstetrics, is the health science and the health profession that deals with pregnancy,childbirth, and the postpartum period (including care of the newborn),^[1] besides sexual and reproductive health of women throughout their lives.^[2] A professional in midwifery is known as a midwife.

Maternity nursing focuses on the care of childbearing women and their families through all stages of pregnancy childbirth, as well as the first 4 weeks after birth

Contemporary issues

·         1/6 (44,3 million) people have no health insurance

·         3,9% of all women had late or no prenatal care

·         Cesarean birth   (22,9%) &    vaginal birth after    CS

·         one nurse care for both the mother and baby

·         To stay in the hospital for at least 48 h. after VB and & 72 h. – CS

HISTORY OF MIDWIFERY

·         The history of midwifery is a long and interesting one.

·         Women of all countries have done noble work as midwives throughout the countries.

·         Socrates mother was a midwife and he considered it “a most respected profession”.

·         According to Aristotle, a midwife is a most necessary and honourable office, being a helper of nature.

·         Midwife carries a huge responsibility in helping women during childbirth.

·         Biblical references to midwives have always been to their honour. There are instances in the Old Testament to show that midwives play vital role.

·         Until the end of the sixteenth century, midwifery was practiced entirely by women. Men could be severely punished for attending women in childbirth.

·         In the seventeenth century male midwives began to take up midwifery.

·         By the middle of the eighteenth century the number of male midwives had increased, though there was great opposition and competition from the midwives and from the general public.

·         In English the word midwife means “With woman” (the person with the woman who is in labour).

·         Midwives hold an important key to positive care at the time of childbirth that will contribute to a good start for the baby and parents. The midwife is able to do so only by virtue of her expert knowledge. The education of the midwife is designed to enable her to fulfill her wide and varied role.

·         During the last 25 years of the nineteenth century, several hospitals began to train midwives and to issue certificates.

·         In 1902 Midwives Act in United Kingdom entitled an act to secure better training and supervision of midwives.

TERMINOLOGY USED IN MIDWIFERY

·         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 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-pregnancy or maternal condition of having a developing fetus in the body.

·         Embryo-human conceptus up to the 10th week of gestation (8th week postconception).

·         Fetus-human conceptus from 10th week of gestation (8th week postconception) until delivery.

·         Viability-capability of living, usually accepted as 24 weeks, although survival is rare.

·         Gravida (G)-woman who is or has been pregnant, regardless of pregnancy outcome.

·         Nulligravida-woman who is not now and never has been pregnant.

·         Primigravida-woman pregnant for the first time.

·         Multigravida-woman who has been pregnant more than once.

·         Para (P)-refers to past pregnancies that have reached viability.

·         Nullipara-woman who has never completed a pregnancy to the period of viability. The woman may or may not have experienced an abortion.

·         Primipara-woman who has completed one pregnancy to the period of viability regardless of the number of infants delivered and regardless of the infant being live or stillborn.

·         Multipara-woman who has completed two or more pregnancies to the stage of viability.

·         Living children-refers to the number of living children a woman has delivered regardless of whether they were live births or stillborn births

GPLAM

·         In some institutions, a woman's obstetric history can also be summarized as GPLAM.

·         G-represents gravida.

·         P-represents preterm deliveries, 20 to less than 37 completed weeks.

·         L-represents the number of children living. If a child has died, further explanation is needed for clarification.

·         A-represents abortions, elective or spontaneous loss of a pregnancy before the period of viability.

·         M-represents the number of Multiple pregnancy/ Medical Termination of Pregnancy done.

•      A woman who delivered one fetus carried to the period of viability and who is pregnant again is described as Gravida 2, Para 1.

•      A woman with two pregnancies ending in abortions and no viable children is Gravida 2, Para 0.

•      A woman who is pregnant for the first time is a primigravida and is described as Gravida 1 Para 0 (or G1P0).

MATERNAL AND CHILD HEALTH INDICATORS

·         Birth rate: The number of births per 1,000 population. (22.1)

·         Fertility rate: The number of pregnancies per 1,000 women of childbearing age.  (2.6)

·         Fetal death rate: The number of fetal deaths (over 500 g) per 1,000 live births. (7.2)

·         Neonatal death rate: The number of deaths per 1,000 live births occurring at birth or in the first 28 days of life. (33)

·         Perinatal death rate: The number of deaths of fetuses more than 500 g and in the first 28 days of life per 1,000 live births. (32)

·         Maternal Mortality Rate: The number of maternal deaths per 100,000 live births that occur as a direct result of the reproductive process. (200)

·         Infant Mortality Rate: The number of deaths per 1,000 live births occurring at birth or in the first 12 months of life. (44)

·         Childhood Mortality Rate: The number of deaths per 1,000 population in children, 1 to 14 years of age. (59)

TRENDS IN THE 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, number of procedures carried out, and number of referrals requested.

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 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:

·                     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

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 other 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.

ROLE OF NURSE IN MIDWIFERY

Definition of Midwife

In 1992, The World Health Organization defined that -

“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 practise midwifery”.

GOAL OF MIDWIFE

·                     The midwife has a unique role in care of mothers and babies.

·                     To give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period.

·                     To conduct deliveries on her own responsibility and to care for the mother and the newborn.

·                     To promote normal birth and detect complications in mother and child, access to medical or other appropriate assistance and the carry out emergency measures.

·                     To involve in health counselling and education, not only for the woman, but also within the family and community.

·                     To involve antenatal education and preparation for parenthood.

·                     To promote women's health, sexual or reproductive health and childcare.

EXTENDED ROLE

A perinatal nurse today may function as:a nurturer, educator,

·         physical care provider,

·         critical thinker,

·         support person,

·         counselor,

·         case manager,

·         research

 EXPANDED ROLE

·         Nurse, Nurse practitioner, Nurse midwives

·         Certified nurse-midwives

·         Certified midwives

 

LEGAL AND ETHICAL ISSUES IN OBSTETRICS

PRINCIPLES OF ETHICS

 Beneficence Beneficence is to act in the best interests of the patient, and to balance benefits against risks. The benefits that medicine is competent to seek for patients are the prevention and management of disease, injury, handicap, and unnecessary pain and suffering and the prevention of premature or unnecessary death.

         Autonomy › Autonomy means to respect the right of the individual. Respect for autonomy enters the clinical practice by the informed consent. This process usually understood to have 3 elements, disclosure by the physician to the patient’s condition and its management, understanding of that information by the patient and a voluntary decision by the patient to authorize or refuse treatment.

        Non maleficence › It means that a health personnel should prevent causing harm and is best understood as expressing the limits of beneficence. This is commonly known as ‘primum non nocere’ or first to do no harm.

        Justice › Justice signifies, to treat patients fairly and without unfair discrimination, there should be fairness in the distribution of benefits and risks. Medical needs, and medical benefits should be properly weighed.

         Confidentiality › Confidentiality is the basis of trust between health personnel and patient. By acting against this principle one destroys the patient trust.

LEGAL AND ETHICAL PRINCIPLES IN THE PROVISION OF HEALTH SERVICES

1.       Informed decision making.

2.       The health care provider should disclose the following details:

3.        Autonomy:

4.       Surrogate decision makers:

5.       .privacy and confidentiality

6.       Patient’s right to know what their health care providers think about them.

7.       Competent delivery services

8.       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.

9.       Safety and efficacy of products:

10.     Code of ethical midwifery practice Midwives rights:

Midwives responsibilities:

1.       The obligation to serve as the guardian of normal birth, alert to possible complications, but always on guard arbitrary interference in the birthing process for the sake of convenience or the desire to use human beings in scientific studies and training.

2.       The obligation to honour the confidence of those encountered in the course of midwifey practice

3.       The obligation to provide complete, accurate and relevant information to patients

4.       The obligation, to remain responsible for the patient until she is either discharged or formally tranfered.

5.       The obligation never to comment on another midwife’s or other health provider’s care without first contacting that practitioner personally.

6.       The responsibility to develop and utilize a safe and efficient mechanism for medical consultation, collaboration and referral.

7.       The obligation to pursue professional development through ongoing evaluation of knowledge and skills and continuing education

8.       The obligation to know and comply with all legal requirements related to midwifery practice within the law to provide for the unobstructed practice of midwifery within the state

9.        The obligation to accurately document the patient’s history, condition, physical progress and other vital information obtained during patient care

Unprofessional conduct: › Knowingly or consistently failing to accurately document a patient’s condition, responses, progress or other information obtained during care. This includes failing to make entries, destroying entries or making false entries in the records pertaining to midwifery care. › Performing or attempting to perform midwifery techniques or procedures in which the midwife is untrained by experience or education.

 Failing to give care in a reasonable and professional manner, including maintaining a patient load, which does not allow for personalized care by the primary attendant. › Leaving a patient intrapartum without providing adequate care for the mother and infant. › Delegation of midwifery care or responsibilities to a person who lacks ability or knowledge to perform the function or responsibility in question.

 Manipulating or affecting a patient’s decision by withholding or misrepresenting information in violation of patient’s right to make informed choices in their health care. › Failure to report to the applicable state board or the appropriate authority in the association, within a reasonable time, the occurrence of any violation of any legal or professional code.

ETHICAL DECISIONS AND REPRODUCTIVE HEALTH OF WOMEN

 Ethics in gynaecologic practice › Beneficence-based and autonomy-based clinical judgements in gynaecologic practice are usually in harmony, like management of ruptured ectopic pregnancy. Sometimes they may come into conflicts. In such situation, one should not override the other. Their differences must be negotiated in clinical judgement and practice to determine which management strategies protect and promote the patient’s interest.

Ethics in obstetric practice › There are obvious beneficence-based and autonomy based obligation to the pregnant patient. While the health professional’s perspective on the pregnant woman’s interest provides the basis of beneficence based obligations, her own perspective on those intersts provides the basis for autonomy- based obligations. Because of insufficiency developed central nervous system, the fetus cannot meaningfully be said to possess values and on its interest. Therefore , there is no autonomy based obligation to the fetus.

› Ethics and assisted reproduction: It involves many issues like donor insemination, IVF, egg sharing, freezing and storing of embryos, embryo research and surrogacy.still many ethical issues are involved in IVF. First there is a big question whether the in vitro embryo is a patient or not. It is appropriate to think that it is a pre- viable fetus and only the woman can give it the status of a patient. Hence pre- implantation diagnostic counselling is non- directive and counselling about how many embryos to be transferred should be

 Donor insemination raises the issue whether the child should be told about his genetic father or not. Egg sharing is also surrounded by many ethical issues. Ethics changes from time to time keeping pace with changing social values, the surrogacy issue being example. It was considered unethical few years back, now in recent issue of India today, a lengthy article has appeared supporting surrogacy with the name of the center, the photos of the physician and number of happy surrogate mothers.

 Ultrsonography: › There are many issues involved like competence and referral, disclosure, confidentiality and routine screening. The foremost issue is that the sonologist must be competent enough to give a definitive option. Now routine screening is adopted at 18-20 weeks, but prior to screening the prenatal informed consent for sonogram must be taken. Strict confidentiality should be maintained.

Genetics and ethics: › The process of genetic research raises difficult challenges particularly in the area of consent, community involvement and commercialisation. However it must be recognized that many of these issues are not unique to genetics but rather represents variations and new twists on problems that arise in other types of research. Results of genetic research should be provided to subjects only if the tests have sufficient clinical validity. Results should never be disclosed to relatives, except in case of pedigree research.

. Policies regarding disclosure of test results should be included in the informed consent process. The genomic era posses challenges for the international community and research enterprises. Council for international organization of medical sciences[CIOMS] guideline should address the ethical issues of genetics. The goal is to care and protect greatest sources of human suffering and premature death and to relieve pain and suffering caused by the disorder.

 Conception and the young girl: Sometimes teenaged girls request for oral contraception. They are already in an active sexual relationship. They do not want that their parents should know about them taking contraceptives. Lord Fraser’s ethical recommendations include: › We should assess whether the patient understands advice.

 We should encourage the parent involvement. › We should take into account whether the patient is likely to sexual intercourse without contraceptive treatment. › We should assess whether the physical, mental health would likely to suffer, if contraceptive advice is not given.

 Embryonic stem cell research and ethics: This involves many ethical issues and first and fore most is, it is destroying a life by destroying the fertilized embryo. This raises the fundamental question of when life starts. Does human life begin at gastrulation[ next step after blastula] , at neurulation[ formation of a primitive streak, first signs of movement] or at the moment of sentience[consciousness]? When can embryo first feel pain or first suffer?. The goal should be minimize the exploitation of human embryos at any stage of development.

 The impact of law on ethics: › Ethics is involved with moral judgements, and the law, however, concerns public policy. At one level it defines what one can / cannot or must/ must not do to avoid risk of legal penalty. Ethics encompasses much more than law. Ethics can determine what is right in the sense that it is good. The intention of law is to define what is right in the sense that it is or is not permitted. It can be safely concluded that not only is determining that something is unethical, neither a necessary nor a sufficient reason to make it illegal, but also determining that something is lawful does not necessarily make it ethical. In many occasions the law assist clinical decision-making by setting parameters which helps both the patient and physician.

MEDICO-LEGALASPECTS OF OBSTETRICS › REASONS FOR OBSTETRIC LITIGATION

› Displeasure against medical professional due to › Lack of communication Poor attitude or more so because of a poor outcome are causative factors for litigation.

 POTENTIALAREAS OF LITIGATION IN OBSTETRICS:

Antepartum care: History collection: Recently, pre-conceptional care is stressed more than only antenatal care, specially when viewed in the context of its effect on pregnancy. History taking right from the age of the patient with relevant complaints and relevant past and family history with special reference to the obstetrical history is very important. Only history can be a clue for further diagnosis and management of many cases. Avoidance of any relevant factors cause maternal and fetal hazards.

. Diagnosis › Clinical diagnosis of early pregnancy must be confirmed by biochemical and if necessary by USG.

Investigations › One must not forget to do routine check-up like Hb, ABO, Rh, grouping, blood sugar, HbsAg, VDRL and HIV. HIV testing must be done only after informed consent; otherwise the patient may sue the doctor. High risk pregnancies are only picked up by through history taking, routine examinations and investigations. High risk patients and failure of timely referral creates medicolegal problems.

Subsequent visits: Antenatal screening for congenital abnormalities › In patients having history of congenital abnormal babies at least basic screenings are very necessary to avoid litigations. The basic screening is mostly done by USG. Other examinations like CVS, amniocentesis or some biochemical investigations may be necessary depending on the individual case. Patient’s counselling is very necessary regarding false positive and negative test thereby avoiding legal problems.

Intrauterine growth retardation › Apart from clinical suspicion of IUGR modern gadgets like ultrasonography, CTG and ultrasonic Doppler study to detect the end diastolic flow volume- are important. Failure of timely detection of IUGR may cause intrauterine fetal death and the doctor may have to the court for this reason.

Multiple pregnancy › It is a high risk pregnancy involving two fetal lives. Management problem is such a case may cause fetal complication which will invite legal problems.

45. Intrauterine fetal death › The cause of IUFD must be explored. As routine autopsy in India is not performed and unexplained fetal death; may impose problems of medical litigation

46. Sex selection and PNDT act › In view of the falling sex ratio the Indian government promulgated Prenatal Diagnostic Technique Act in 1994. This test by this act was evolved to identify genetic and congenital abnormalities in relation t sex. Unfortunately this test was misused. Prenatal sex determination and selective female feticide became widespread allover in India inspite of the amendment of PNDT act in 2002, the amended act prohibits unnecessary sex determination without any disease problem and aims at preventing selective abortions of female foetuses. However, still unethical practice of selective abortions is going allover India.

Intrapartum care › Proper intrapartum management during labor is essential for a healthy mother and a healthy child. In majority of the mothers there is spontaneous onset of labor. Injudicious administration of oxytocics was the primary reason disciplinary action in 33 percent of cases. Randomised controlled trial of EFM and auscultation of fetal heart rate found that an increased incidence of caesarean delivery and decreased neonatal seizures in the EFM group but no effect on cerebral palsy or perinatal death. Newer methods like pulse oximeter or fetal electrocardiogram analysis can prevent birth asphyxia and thereby minimize litigations.

. Caesarean section: › With the advent of CPA; there is an increased incidence of caesarean section. The WHO global study 2005 revealed that high rate of caesarean section does not contribute to an improved pregnancy outcome, rather is associated with increased maternal morbidity and mortality with higher incidence of newborn illness due to low birth weight. › Delayed decision of CS must be avoided as this may lead to undesirable situations like obstructed labor causing maternal and fetal morbidity and mortality.

 › Difficult vaginal delivery: Shoulder dystocia › Various clinical risk factors like diabetes leading to big baby etc; must be identified to predict and prevent this condtion and associated injuries like erb’s palsy. But if we afce such situations in emergency obstetric care it must be tackled by experienced obstetrician otherwise litigation problem are there.

 Breech › Timely decision to be taken whether to deliver the breech by vaginal route or CS so as to avoid legal problems. Multiple pregnancy › Involves enormous risk and modern concept is to be delivered by CS.

. Instrumental delivery-forceps/vaccum › High forceps must be avoided; only low forceps can be indicated in special circumstances to expedite the labor process. Ventouse must be avoided in premature baby and fetal distress. Concerned personnel may be sued due to untoward effects like facial palsy or visceral injury of mother and baby.

Emergency obstetric care: › Every year more than 500000 women die during child birth in the world; out of which 1/5 th, ie 100000 women die in india alone. With present situation when there is no improvement of infrastructure yet doctors have the risk of facing medicolegal problems regarding EmOc.

 Postpartum care: › Postnatal complete perineal tear, Obstetric anal sphincter injuries[OASIS] Significant perineal pain, dyspareunia, maternal morbidity and mortality and anal incontinence are problem areas. Forceps delivery is associated with increased perineal injury. Patients must be counselled about the risk of anal sphincter injury when operative delivery is contemplated thus avoiding litigations.

 Perinatal morbidity › Brain damage: › Any neurological and psychological deficiencies is the major litigation issue where compensations are claimed. A health professional will be sued if it can be proved in the court that brain damage has occurred during intrapartum period due to negligence of the health professional.

  Damage to bones and visceras › This may occur specially during breech delivery. Health professional must be very conscious during face, legs and arm delivery in breech. › Analgesia and anaesthesia: › Expert anaesthetist is required; to prevent medical litigations.

 Drugs in pregnancy and lactation › Though only a small group of drugs are known to be harmful to the fetus; but it is a wise precaution to avoid vast majority of drugs; if not genuinely indicated, ie if there is less evidence of fetal safety. FDA recommendation of drug should be followed. The health professional must not use off- license drugs. If damage occurs; he will be blamed of negligence when a licensed alternative drug is used.

 Ethical issues in surrogacy: › Surrogacy is possible by AID and IVF, where a child is borne in another mother’s womb. A lady without uterus but functioning ovaries can have a child with the help of a surrogate mother. According to fertilization act 1990, the carrying mother is the mother in law. Genetic mother can get legal parenthood by legal procedures only. Surrogacy for convenience only; when the women is physically capable of bearing a child is ethically unacceptable.

 HIV- positive women and pregnancy › In an overwhelming number of cases, children of HIV positive women acquire the infection before or around the time of birth or through breast milk. The risk of vertical transmission can be potentially reduced to less than 2% by the judicious use of combination anti retro viral therapy during pregnancy and labour, delivery by caesarean section and avoidance of breastfeeding. › The legal standard of care in prenatal care and child birth is entitled to an HIV positive women if she decides to continue the pregnancy. Neither the woman nor her child should suffer any discrimination on their HIV status.

POTENTIALAREAS OF LITIGATION IN GYNAECOLOGY

 Intraoperative problems - 32% › Failure of diagnosis or delay in diagnosis-17% › Failure to recognize complications -7% › Failed sterilization - 6% › Failure to warn or inadequate consent- 3%

60. Examination of gyaecological patient › Professional and personal conduct › Not infrequently, the midwife has to face the charge of physical and sexual assault. prior to examination consent must be taken and she must be informed about the nature of examination. Examination should be done in a closed space in comfortable position maintaining the privacy in presence of a female attendant. The attendant should not be the relative of the patient.

Forensic gynaecology › Sexual assault and rape must be handled in a sensitive manner while complying with forensic procedure. Domestic violence and sexual violence in areas of conflict are now recognized as major factors in women’s health as studied by the united-nations and by human rights groups.

Consent The consent form is the single most important document, created in the presence of the patient, which removes obstacles to effective communication concerning choice. The key to effective communication is: › Engaging with the patientEmpathizing with her needs › Educating her as to the available options. › Enlisting her approval for the appropriate choice

Only after engagement, empathy, and education is it appropriate for a clinician to ask for the approval of the patient. It will always be appropriate to record the decision. It will sometimes be appropriate for the patient to append her signature to an appropriate form. Valid consent must be taken from the patient.

. Diagnosis of gynaecologic diseases › No step should be omitted in history collection and clinical examination. Investigative procedures should be suggested as needed. Opinion of other speciality is sought in doubtful diagnosis before instituting definitive therapy.

Medical termination of pregnancy Complications of abortion sometimes leads to complaints and litigation. The act was legally enacted in 1971 and implemented in April 1972 and amended from time to time. The basic principle is that pregnancy can be terminated when there are some maternal or fetal indications and in India it is done before 20 weeks.

66. Legal problems occur in certain conditions as follows: › Continuation of pregnancy after the procedure. › Excessive or continued bleeding due to incomplete evacuation. › Injury to the organs either to the uterus or to the other organs. › Failure to diagnosis ectopic pregnancy while performing MTP.

 Death following any procedure. › MTP done by a not authorized person. › MTP without proper counselling and informed consent. › Termination knowingly after 20 weeks of pregnancy.

68. Conditions under which pregnancy can be terminated › Continuation of pregnancy would never involve a risk to the life of the pregnant woman or grave injury to her physical or mental health. › There is a substantial risk for the child born to suffer from such physical or mental abnormalities as to be seriously handicapped. › Pregnancy resulting from rape and from failure of contraceptive methods constitutes grave injury to mental health of the woman. Actually a woman’s foreseeable environment should also be taken into account in determining the risk to her health.

        Experience or training required for MTP › For medical practitioners registered in a state medical register immediately before commencement of the act, minimum experience of 3 yr in the practice of OBG. › For practitioners registered on or after the date of commencement of act, 6 months of house job in OBG or one year of experience in the practice of OBG at a hospital or if the person has assisted a registered medical practitioner in performing 25 cases of MTP in an institution approved for training by the government. › Postgraduate degree or diploma holder in OBG.

Female sterilization Failed sterilization and the consequent wrongful pregnancy is historically the single operation most likely to give rise to litigation. Two aspects of sterilization failure attract litigation: › Inadequate consent › Defective surgery.

Failure: › Spontaneous recanalization is rare. In cases of male sterilization if contraceptive support is not advocated immediate after vasectomy, conception may occur. Incomplete occlusion or traumatic occlusion may give rise to failure. Sterilization when performed without diagnosing an existing pregnancy or done in the secretory phase with an existing preclinical pregnancy where implantation has just taken place may result in a pregnancy. Ligation of wrong structures[ eg. Round ligament] can lead to failure an in such cases legal threat is high.

 Ectopic pregnancy: › There is always a less chance of ectopic pregnancy after sterilization operation. Injuries: › Though not very common, injuries to bladder, bowel or large blood vessel may complicate the procedure. › Sterilization in emergency condition: › Risk of legal problem is more when sterilization is done in an emergency condition without adequate counselling prior to sterilization.

. Contraception IUCD › Perforation of uterus › Expulsion of device- confirmatory proof should be obtained › Complications of IUCD › IUCD failure.

Oral pill: › Pill failure or missed pill is an usual factor behind contraceptive failure; proper demonstration is needed. Equally important to inform the user about the minor-short term and major- long term side effects.

Injectable contraceptive › High incidence of amenorrhoea and irregular menstruation is poorly accepted by the women. Pros and cons to be informed. It should be remembered that a free- choice should be adopted for selection of the method of contraception provided the acceptor has no contraindications.

Endoscopic surgery › Diagnostic laparoscopy remains a common cause of complaint. Possible risks should be explained.

 Infertility and ART › Assisted conception is replete with ethical and legal problems involving statutory and case law. There is increasing litigation following the adverse outcome of multiple pregnancy, with criticism of poor counselling and overoptimistic forecasts, especially in the financial driven private sector. The replacement of more than 2 embryos is not recommended by the Human Fertilization and Embryology Authority.

 In management of infertility various investigative procedures may be needed. The patients may be needed. The patient’s may need maximum physical, mental and financial contribution. The couple should be informed about these things and they should be explained about the different methods of treatment applicable to them with the success rates and possible hazards

WAYS TO MINIMIZE MEDICOLEGAL PROBLEMS IN OBSTETRICS AND GYNAECOLOGY › Awareness of medico legal problems: Health practitioners should be aware about the changes in laws that may influence the practice. › Code of ethics: The code of ethics for the midwife should be followed.

 › Good interpersonal relationship and clear communication: The patient must not be given false guarantees and needs to understand what to expect from the treatment. The health professionals must be polite and courteous showing sympathy towards patient. › Proper counselling: Good counselling instills enormous confidence and faith. It helps to remove fear and misconceptions that may exist in the mind of the patient.

 › Informed consent: After proper counselling informed consent should be taken. › Standard health services: › Improving infrastructure: Facilities available in the institution should be displayed. Health authorities should set norms for the health sector as a whole.

 Quality of care: › A good consultant is needed. Also active pre and post operative care needed. › Adequate training: Nursing education: Improve the standard of nursing education as they come in direct contact with patients.

 › Continuing education: Regular CME and workshops should be attended. › Audits: Morbidity and mortality audits should be regularly done. Regular meeting of the staffs. › Second opinion/ referral Timely referral should be kept in mind.

Documentation and record keeping: › History, physical examination, drug allergies, chronic medications, plan of management, date and time of investigations done, operative and investigative notes, record of discussions with patient and relative, note to kept of patients not following instruction etc should be documented.

Risk management: Risk management involves limiting health risk to the patient and also reduce legal risks to the care provider. It does not primarily about avoiding or mitigating claims but rather a tool for improving the quality of care. › Public awareness program and health education: Public awareness include health awareness by professional bodies and media.

NATIONAL POLICY,LEGISLATIONIN RELATION TO MATERNALHEALTH AND WELFARE

2. MATERNAL HEALTH INMEDEVIAL PERIODn Dates back to Vedic period between3000BC – 1400BCn Indus valley civilization showed relies of planned cities and healthful living.n Ayurveda and other system of medicine practices by sages suggests comprehensive concept of health..

3. n 272 BC-236 BC King Ashoka a covert ofBuddhism built a number of hospitals. Midwives were given a lot of preference during his time. They were considered to be skilful and trustworthy.n 200-300AD Sushruta also defines idealrelationships..

4. n 500-600 AD Vagbhata wrote AshtangaHridaya (8 limbs and heart). Potency and procreative ability was one of the branch of the 8 limbs.n This book is the most concise exposition of Ayurveda..

5. n 1300-1600 AD Bhavaprakasha renowned Indian treatise contains an exhaustive list of disease and their symptom and a complete list of drugs.n It includes etiology and treatment of syphilis a disease brought to India by Portuguese seamen..

6. Maternal health in Pre-Independence periodn 1873-Birth and death registration Act was passed.n 1880-Vaccination Act was passed.n 1931-Maternity and child welfare Bureau was established under the Indian Red Cross.n 1946-Bhore Committee report wassubmitted..

7. n Republic of India is a federal Republic (union of states)n Indian Central Government has focussed on improving health of people since independence.n Life expectancy was 60 years then compared to 69 years at present.n Infant mortality rate was 150 compared to 32at present..

8. n A wide variety of programs were intended for various parts of the country to improve welfare of women and children..

9. Termsn Policies: course of actions, programme of actions adopted by a person, group or government.n Policy Environment: the arena the process takes place in, government, media, publicn Policy Makers.

10. Policy making in health administrationn Gives a concrete shape to political and social objectives which government lays down in the form of laws, rules and regulations.n It defines the objectives and determines the choice of actions.n While formulation of any policy government appoints an expert committee for decisionmaking..

11. n Eminent persons from different specializations may be appointed to constitute a committee.n Views of the committee have an influence on policy making..

12. Stategies for health planningn Constitution of Indian National development Counciln Planning Commissionn Advisory Bodiesn Ministry of health and family welfare.

13. n Health care measures formulated and implemented in the successive 5 year plans were based on approaches recommended by health Committees constituted by Government of India..

14. Committees and commissionsn NPC committee on National Health (ColSantok Singh Sochi)n Health Survey and development committee (Sir Joseph Bhore)n Nursing Committee to review conditions on nursing (Shri Shetty 1954)n Special Committee on NMEP (Dr. MSChadda).

15. n Committee to review strategy of familyplanning (Shri Mukherjee)n Committee on integration of health services(Dr Jungulwala)n Committee for reviewing staffing pattern and financial provisions for FFP (Shri Mukherjee)n Committee on Multipurpose workers under H and FW (Kartar Singh).

16. n Group on medical education and Support Manpower(Dr.JB Shrivastava)n National health Policy(1983)n Medical education review Committee (Shri Mehta)n Working group on Medical education and training Manpower (Planning Commission)n Committee on Health Manpower planning (Dr.Bajaj)n High Power Commission on nursing and Nursing Profession (Sarojini Varadappan).

17. Development of legislation in midwifery educationn William Rathbone formed VisitingNurse‟s Association at England.n It is influenced in India, because of terrible condition, under which children were born recognised as cause for high mortality rate. Because untrained „Dais “are attending women at the time of child birth..

18. n Dais were unwilling to trained and patients will to accept the old customary methods. In 1926 –Midwives Registration Act formed forth purpose of better training ofmidwives..

19. ESTABLISHMENT OF INDIANNURSING COUNCILn The INC was constituted to establish 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 council was constituted in 1949..

20. MAIN PURPOSES OF THECOUNCIL1. To set standards and to regulate the nursing education of all types in the country.2. To prescribe and specify minimum requirement for qualifying for a particular course in nursing.3. Advisory role in the state nursing council4. To collaborate with state nursing councils, schools and colleges of nursing and examination board..

21. STATE REGISTRATIONCOUNCIL.n 1. Inspect and accredit schools of nursing in their state .2. Conduct the examinations3. Prescribe rules of conduct.4. Maintain registers of nurses, midwives, ANM and health visitors in the state..

22. RECOMMENDATIONS OF VARIOUSCOMMITTEES PERTAINING TO NURSINGEDUCATION.1. Health survey and development committee ( Bhore committee 1946)a. Establishment of nursing colleges. Creation of an all India nursingcouncil..

23. n 2. Shetty committee 1954a. Improvement in conditions of training of nurses’. Minimum requirement for admission to be in accordance with regulation of the INC..

24. Health Survey and planning committee(Mudhaliar Committee 1959-61)1.Three grades of nurses viz. the basic nurses(4yrs), auxiliary nurse midwife (2yrs) and nurses with a degree qualification.2.For GNM minimum entrance qualification matriculation .3.For degree course passed higher secondary or pre university.4.Medium of instruction preferably English in General nursing.5.Degree course should be taught only inEnglish..

25. 4. Mukherjeecommittee, 1966.n a. Training of nurses and ANM‟Srequired for family planning.5. Kartar singh committee,1972-73a. Multipurpose health worker schemeb . Change in designation of ANM‟s andLHVc. Setting up of training division at the ministry of health and family welfare.

26. 7. Sarojini varadappan committee, 1990(A high power committee on nursing andnursing profession.)n a. Two levels of nursing personnel. Post basic BSc nursing degree tocontinuec. Masters in nursing programme to be increased and strengthened. Doctorate in nursing programme to be started in selected universities. Continuing education and staff development for nurses..

27. 8. Working group on nursing education and manpower,1991.n a. By 2020 the GNM programme to be phase-out. Curriculum of BSc nursing to be modified. Staffing norm should be as per INC. There should be deliberate plan for preparation of teachers MSc/Mphil and PhDdegrees.e. Improvement in functioning of INCf. Importance of continuing education fornurses..

28. DEVELOPMENT OF NURSINGEDUCATIION.n Training of dias The Dai training continued past independence. The goal was to train one Daiin each village and ultimate goal was to train all the practicing Dais in country Duration of training was 30 days. No age limit was prescribed, training include theory and practice, more emphasis on field practice. This training was done at sub centre and equipments provided by UNICEF..

29. Auxillary Nurse Midwifen In 1950 Indian Nursing Council came out with an important decision that there should be only two standard of training nursing and midwifery, subsequently the curriculum for these courses wereprescribed.The first course was started at St. Marys Hospital Punjab,1951.Theentrance qualification was up to 7/8 years of schooling. The period of training was 2 years which include a 9 month of midwifery and 3months of community experience. In 1977, as a result of the decision to prepare multipurpose health worker& vocationalization of higher secondary education, curriculum was revised a designed to have 1.5 year of vocational zed AN programme and six months of general education. The entrance qualification was raised from 7th passed to matriculation passed. Under multipurpose scheme promotional avenue was opened to seniorANMS for undergoing six months promotional training for which course was prescribed by INC..

30. n Training of LHV course continued post independence. The syllabus prepared and prescribed by INC in 1951.Theentrance qualification was matriculation. The duration was two and a half years which subsequently reduced to 2 years..Lady Health Visitor Course

31. General Nursing And Midwifery Coursen GNM course existed since early years of century.n In 1951,syllabus was prescribed by INC.n In 1954 a special provision was made for male nurse.n First revision of course was done in 1963. The duration of course was reduced from 4 years to 3.5years.n Second revision was done in 1982. The duration of the course reduced to 3 years.n The Midwifery training of one year duration was gradually reduced to 9 months and then six months, finally three year integrated programme of GNM was prescribed in 1982..

32. Post-Basic/Post Certificate Short-Term Courses And Diploma Programmesn The ultimate aim of all the post-basic/post certificate programme is to improvement of quality of patient care and promotion of health..

33. University-Level Programmes.n Basic BSc Nursing First university programme started just before independence in 1946 at university of Delhi and CMCVellore.INC prescribes the syllabus which has been revised three times, the last revision was done in 1981.It was done on basis of the 10+3+2 system of general education.n At present the BSc Nursing programme which is recommended by the INC is of four years and have foundations for future study and specialization innursing..

34. Post Basic BSc Nursingn The need for higher training for certificate nurses was stressed by the Mudaliar Committee in1962. Two years post basic certificate BSc(N) programme was started in December 1962.n For nurses with diploma in general and midwifery with minimum of 2 years experience.n First started by university of Trivandrum.n At present there are many colleges in India offering BSc(N) Course..

35. Post Basic Nursing by Distance Education Mode.n In1985 India Gandhi National open university was established. In1992 Post Basic BSc Nursing programme was launched, which is three years duration course is recognized by INC..

36. Post- Graduate Education-MScNursingn First two years course in masters of nursing was started at RAK College of Nursing in 1959.and in 1969 in CMCVellore. At present there are many colleges imparting MSc Nursing degree course in different specialties..

37. M.Philn INC felt need for M.Phil programme as early on 1977,for this purpose committee was appointed. In 1986 one year full time and two years part time programme was started in RAK College of nursing Delhi..

38. Ph.D in Nursingn Indian nurses were sent abroad for PhD programme earlier. From1992 Ph D in nursing is also available in India.MAHIis one of the university having PhDprogramme..

39. Nurse practitioner in Midwifery.

40. n RCH (phase I) was launched in October1997n It incorporates the components covered under Child survival and safe Motherhood and an addition component of reproductive tract infection and sexually transmitted diseases..

41. Targets and achievement inRCH 1 (in %)Indicator Baseline Target EstimateIMR 74 60 63Contraceptive rate47.7 60 52Inst delve 35 60 40Childrenimmun52 60 44.6Not usingFP19.5 Less than1015.9.

42. n National Population Policy 2000 stressed theimportance to bring down maternal mortality rate.n Policy recommends a holistic strategy for bringing about total intersect oral coordination at grassroots level and involving NGO‟s ,CivilSocieties,Panchayat Raj institutions and womens group..

43. Maternal mortality Country Ratio India 407Sweden 8UK 10Greece 2Sri Lanka 60China 60Thailand 54.

44. MMR (India)States Ratio UP 707Rajasthan 670MP 498Bihar 451Assam 409.

45. Maternal Health Indicatorsn Antenatal checkupsn Institutional deliveryn Delivery by trained personnel.

46. RCH Phase IIn Begun from 1st April,2005.n Focus is to reduce maternal and child mortality with emphasis on rural health care.n Fifty percent of PHC‟s and all CHC‟s will beamed operational as 24 hours delivery centres in a phased manner by 2010.n These centres will provide basic emergency obstetric care and essential newborn care..

47. Essential Obstetric caren Institutional deliveryn Skilled attendant at deliveryn Policy decisionsn Operational sing emergency careobstetrics.

48. Other Maternal health interventionsn MTPn RTI/STD‟sn Infection management andenviournment Plan(IMEP).

49. NEW INITATIVESn Training of MBBS doctors in Life SavingAnesthetic skills for emergency Obstetric caren Setting up of blood storage in FRU‟sn ASHA‟Sn Janani Sureksha Yojna(JSY).

50. Scale of assistance perdelivery Category RURAL AREA URBAN AREAMother‟spackageASHA‟sPackageTotalRsMother‟spackageASHA‟sPackageTotalRsLPS 1400 600 2000 1000 200 1200HPS 700 700 600 600.

51. Independent nurse Practitionern 18 month post basic diploma in midwiferyn Imparts all necessary skill to handle obstetric emergenciesn Authorised to and can establish independent practisen Course has been pilots in West Bengal and 2of 4 trainees were assigned to a CHC to manage obstetric emergenciesn Eg:Srilankan Experience.

52. Other suggestions with regard to nursing educationn A dedicated Nursing and Paramedical Manpower Division / Unit should be established at the National and State levels.n All medical colleges should be mandated to establish a College of Nursing offering courses nib’s. Nursing, M. Sc. Nursing and Post-Basic Diploma courses in specialty nursing areas.n All District Hospitals should be mandated to establish a school of nursing offering ANM and Diploma in General Nursing and Midwifery,n Smaller hospitals in public sector having at least30 OBG beds should be encouraged to start ANMtraining.

53. 1. The NRHM has adopted a set of revised staffing norms for the Sub-centres, PHCs and CHCs which will add to the human resource needs in the rural areas. For the ANM, the requirement has doubled as 2 ANMs have been sanctioned forever Sub-centres. The Sub-centre will continue to be the critical facility for the delivery of health care of women and children in rural and remote areas where no other facility exists. The objective of making 2000 facilities as fully functional FRUs will require at least 2000 specialists in OBG,anesthesia and paediatrics (each) and 20,000 staff nurses. The objective of making 10,000 PHCs as 24/7 facilities equipped for institutional delivery implies an additional requirement of30,000 Public Health Nurse Practitioners / General Nurse and Midwives (GNMs). The NRHM provides for additional manpower at CHC, PHC & Sub-Centre levels..

54. Standing orders for first aid obstetric caren In order to save life of women with obstetric emergencies,ANM is allowed to use the following drugs:n Inj. Oxytocinn Inj. Magnesium sulphaten Misoprestol oraln Inj. Ampicillin.

55. Strengthen skills of ANMs in improving quality of ANC, especially forcounseling.n Introduce sticks-based rapid estimation ofhemoglobin and urine examination.n Provide mother-baby linked card to all,depicting key messages apart from clinicalinformation..

56. INDIAN LEGISLATIVE POLICYn Legislative programme: approved byparlimentary affairs department.n Scope of bill is determinedn Acceptance by cabinetn Formation of legislative policyn Reference to law departmentn Decision by Minister in charge in consultation with lawn Summary to cabinet drafted.

57. Acts in Obstetric Practisen MTPn Government of India set up the Satilla Shah Committee in 1964 to decrease the highmaternalmorbidity and mortality associated withillegalabortions, which, after deliberating on a wide range of evidence over 2 years, recommended broadening and rationalisation of laws related to abortion in 1966. MTP Bill was introduced in RajyaSabha in 1969, referred to Select Joint Committee Review and finally passed as the MTP Act in 1971and implemented in April 1972. Main objective font Act of India is reduction maternal morbidity duet illegal unsafe abortions..

58. n According to Section 3, Subsection (2) of the Impact, pregnancy may be terminated for the following indications:n a) As a health measure, when there is a danger t other life or risk to physical or mental health of the woman including rape and failure of contraception’s) On humanitarian grounds, such as when pregnancy arises from a sex crime like rape or intercourse with a lunatic woman, etc and) Eugenic grounds when there is a substantial risk that the child, if born, would suffer from deformities and diseases..

59. n According to Section 3, Subsection (2),for pregnancies up to 12 weeks. the certification of one qualified doctor insufficient but for pregnancies between12-20 weeks, two doctors must give their approval. Termination by medical methods of abortion is approved by GOItill 49 days of gestation..

60. n The necessary qualification of a medical practitioner registered with the State are broadly defined in Section 2, Clause (d) of the empty rules:n a) Postgraduate degree or diploma in Obstetrics and Gynaecology’s) Registered before commencement of the Act with over 3 years experience in the practice of Obstetrics and Gynaecology..

61. .

62. n THE PRE-CONCEPTION & PRE-NATAL DIAGNOSTIC TECHNIQUES(PROHIBITION OF SEXSELECTION) ACT – 1994..

63. n “ An Act to provide for the prohibition of sex selection , before or after conception, and for regulation of pre-natal diagnostic techniques forth purpose of detecting genetic abnormalities or metabolic disorders or chromosomal abnormalities or certain congenital malformations ores-linked disorders and for the prevention of their misuse for redetermination leading to female feticide and for matters connected therewith or incidental thereto”. This Act may be called “the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Amendment Act, 2002.It shall extend to the whole of India except the State Government of Jammu and Kashmir..

64. n The Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 is an Act to provide for the regulation of the use of pre-natal diagnostic techniques for the purpose of the detecting genetic or metabolic disorders or chromosomal abnormalities or certain congenital malformations or sex-linked disorders and for the prevention of the misuse of such techniques for the purpose of pre-natal sex determination leading to female foeticide; and for matters connected therewith or incidental thereto. Under Section 2(I) of that Act “pre-natal diagnostic procedure” means all gynaecological or obstetrical or medical procedure such as ultrasonography, foetoscopy, taking or removing samples of amniotic fluid, chorionic villi, blood or any tissue of a pregnant woman for being sent to Genetic Laboratory or Genetic Clinic for conducting pre-natal diagnostictests..

65. Monitoring through NRHMn Community awareness through ASHAs,n integration of the issue in training modules and programme and in IEC material,n adding information on sex selection to the medical curriculum,n including indicators on improvement in sex ratios and birth registration as a part of monitoring target/indicators under RCH 2/NRHM.

66. The Consumer Protection Act,1986§ The aims and objects of the Act as given in its Preamble, inter alia are: the better protection of the interests of the consumers and for settlement of consumer disputes..

67. n Deficiency in medical services gives patient as a consumer the right to claim compensation.n The consumer Protection Act is a piece of comprehensive legislation and recognises six rights of consumers ..

68. n Right to safetyn Right to informedn Right to choosen Right to be heardn Right to seek compensationn Right to consumer education.

69. Legal issues in maternity practisen Licence to conduct deliveryn Refer complicated cases appropriatelyn Monitoring of mother and fetes adequatelyn Assist in MTP but can refuse in cases of moral offense.n Proper identification of mother infant pair with finger prints, foot prints and waist bands as per hospital policy..

70. n Surrogate mother lending out her uterus for fertilised ovum also possess ethical issues mainly about monetary compensation.n In artificial insemination maintain confidentiality about donor and recipient.n It is considered unethical if conception misaimed at use of embryo for research purposeonly..

71. Legal safeguards as a staffn Licensuren Good Samaritarian Lawn Standards of caren Standing orders.

72. Woodrow Wilson,AmericanPresidentWe grow great by dreams. All big men are dreamers. They see things in the soft haze of aspiring day or in the red fire of a long winters evening. Some of us let these great dreams die, but others nourish and protect them; nurse them through bad days till they bring them to the sunshine dreams will come true.

FAMILY CENTERED MATERNITY CARE

 Position: The International Childbirth Education Association (ICEA) maintains that familycentered maternity care is the foundation on which normal physiologic maternity care resides. Further, family-centered maternity care may be carried out in any birth setting: home birth, birth center birth, hospital birth or emergent birth. In short, family-centered maternity care respects the family as a unit, the mind-body-spirit of the family, and provides evidence-based care accordingly.

 Introduction: Family-centered maternity care (FCMC) has been a hallmark of ICEA since its inception in 1960. At that time, “family-centered” meant including the father in childbirth preparation classes and in the birth itself. Over time, even as family members were welcomed in the birthing room, technology played an increasingly significant role in the birth experience. In response to this, Celeste Phillips wrote the textbook entitled “Family-Centered Maternity Care” (Phillips, 2003) in the mid 1970’s. A decade later, McMaster University published a definition of FCMC that was then adopted by ICEA. (ICEA, n.d.) In 1996, the Coalition for Maternity Services published the Mother Friendly Childbirth Initiative which was endorsed by many professional and consumer organizations. (CIMS, 1996) The Public Health Agency of Canada released its national guidelines for family-centered care in 2000 (PHAC, 2000). In response to the Institute of Medicine’s publication of “Crossing the Quality Chasm”, many professional organizations have published statements on “family-centered care” or “patient-centered care” (AWHONN, 2012; AAP, 2012).

Definitions of patient-centered care, family-centered care, and FCMC differ between various disciplines.

In spite of this, there are common themes these publications share:

 ‚ Birth is a normal, healthy process for most women;

 ‚ Care must be individualized;

‚ Decision-making should be a collaborative effort between the pregnant woman and her healthcare providers;

 ‚ Education should reflect current, evidence-based knowledge;

‚ Information should be shared freely between the pregnant woman and each of her healthcare providers; and

 ‚ Mothers and babies should stay together (rooming in).

 In addition to these common themes, the following principles are also endorsed by one or more of these organizations:

‚ The presence of supportive people during labor and birth is beneficial to the mother and family;

 ‚ Mothers are the preferred care providers for their children;

‚ Freedom of movement is beneficial for the laboring woman and should be encouraged; continued on next page 2

‚ Routine interventions that are unsupported by scientific evidence should be avoided;

‚ All members of the healthcare team should be educated about physiologic birth and non-pharmacologic methods of pain management; and

‚ Skin-to-skin contact immediately after birth and exclusive breastfeeding should be standards of practice.

These organizations have provided a necessary framework of protocols for the delivery of healthcare, but what that care means to the family is only occasionally alluded to. MacKean (2005) suggests that healthcare providers, acting in the role as an expert in their field, not only define family-centered care, but also define the parents’ role in it. By doing so, they subtly undermine the desired collaborative relationship between providers and parents (MacKean, Thurston, & Scott, 2005). As professionals, they have made a decision for the parents. So the question must be asked: what does FCMC mean to the family? What is the goal of family-centered care as it pertains to the families themselves?

Respect : Mutual respect is foundational to FCMC – respect for pregnancy as a normal, healthy event in a woman’s life, respect for parents as the primary caregivers for their children, respect for each member of the circle of care.

 When pregnancy is acknowledged as a healthy life event rather than a condition that must be treated, intervention will be minimal. This attitude will convey support and encouragement to the pregnant woman and her family as opposed to the fear and stress that is so often experienced in an illness-oriented environment.

 Parents are the primary caregivers of their children (AAP, 2012; MacKean, et al., 2005). This starts even before birth. Women decide when – and even if – they will start prenatal care. They choose whether or not to modify their diet and other aspects of their lifestyle. This autonomy should continue throughout pregnancy, during labor and birth, and through the postpartum period

. As is mentioned in many of the position papers previously cited, respect should extend to each member of the healthcare team. The goal is to provide quality care for mother and baby. This requires the cooperation of all involved – nurse, doula, midwife, physician, lactation consultant, and any others that the woman may look to for help and advice.

 Openness: Open communication is necessary to provide the highest quality care. Each member of the circle of care is responsible for their own part in this. The pregnant woman and her family should be honest about their desires and beliefs, communicating clearly and early in the pregnancy to minimize the risk of misunderstandings. Healthcare providers should communicate just as clearly, not only with the parents but with others involved in their care. Collaboration cannot be effective if communication is hindered in any way.

Relational competency is also necessary to FCMC. This extends beyond simple communication to include sensitivity and compassion (MacKean, Thurston, & Scott, 2005). Communicating facts without sensitivity is not characteristic of the openness that defines FCMC.

Confidence:  Imbuing the woman and her family with confidence is central to quality family-centered care. Excellence in the technical, medical aspects of care is expected, but not adequate, in and of itself. Birth is more than just the mechanical event of moving the baby from the inside to the outside. It is one of the most significant developmental stages of life – emotionally and socially (Zwelling & Phillips, 2001; Jiminez, Klein, Hivon, & Mason, 2010). A goal of FCMC is to build the confidence of new parents. Supporting and encouraging new parents as they care for their infant builds trust in their own abilities (Karl, Beal, O’Hare, & Rissmiller, 2006). When professionals perform tasks parents can do on their own, they undermine the parents’ sense of competence. FCMC that is truly family-centered supports parents continued on next page 3 as they care for their newborn. In the case of high-risk infants, parents should participate as much as possible in the infant’s care including, but not limited to, the decision-making process, kangaroo care, and breastfeeding.

Knowledge:  Knowledge is necessary for women to be wise decision-makers. Part of prenatal care should include educating the woman about pregnancy, birth, and postpartum – making sure she is aware of evidence-based research and all options available to her. Knowledge is necessary in order for healthcare providers to provide quality care. Effort must be made to incorporate evidence-based research into current practice. This will not happen if those providing care are not aware of what the research says.

 Atmosphere In an atmosphere of FCMC, women will: 1. Choose the caregiver and place of birth that is most beneficial for her; 2. Work in collaboration with healthcare providers and other advisers that she chooses; 3. Have the support people she desires present whenever she wishes;; 4. Move around and use whatever position she feels is beneficial during labor; 5. Refuse routine procedures that are not evidence-based; 6. Practice uninterrupted skin-to-skin contact and breastfeeding immediately after birth, keeping her baby with her at all times (rooming in); and 7. Have access to a variety of support groups including those for breastfeeding, postpartum emotional health, and parenting. Facilities that promote FCMC will provide education for their staff that includes information and training in communication skills, labor support, non-pharmacologic forms of pain relief, breastfeeding support, and perinatal mood disorders. Cultural preferences of the mother should be honored. All medical staff should support the role of the mother as the infant’s primary care provider. Facilities will also provide evidence-based education for the mother and her family. In addition to specific classes for childbirth and breastfeeding, education should also be part of each prenatal and postpartum visit. Information about support groups for breastfeeding, perinatal mood disorders and early childhood parenting should be readily available.

Outcomes : FCMC results in greater satisfaction for all involved. Families that are cared for with a family-centered model will experience greater satisfaction with their birth experience. They will have participated in the decision-making process which will increase their self-confidence. They will have validated their learning with real life experience. Healthcare providers that work within a family-centered model will also experience greater satisfaction (AAP, 2012). Implications for Practice FCMC recognizes the significant transitions that occur during the childbearing year. Physical changes are obvious. Social and emotional adaptations are no less important. Care that is truly family-centered is safe – physically and emotionally. Medical expertise should be accompanied by compassionate and skillful communication. Collaborative decision-making should proceed out of relationships built on mutual respect. Both parents and professionals should have access to the latest evidence-based research. Many healthcare and governmental agencies have established various protocols to promote family-centered care. These are necessary and helpful. But as ICEA has always stated, “FCMC consists of an attitude rather than a protocol” (ICEA, n.d.). Attitudes, as well as organizational structures, must change before maternity care will be truly family-centered.