IMPORTANT ASPECTS OF MIDWIFERY

Belangrike aspekte van verloskunde word beklemtoon, met die klem op die dringende rol van die vroedvrou gedurende swangerskap, baring en gedurende die puerperium. As ’n praktisyn in haar eie reg, is die vroedvrou in staat om die ouers te onderrig en ’n gevoel van vertroue daar te stel. Deur te weet wat as normaal beskou word, kan die vroedvrou vroegtydig abnormaliteite diagnoseer en dus ’n suksesvolle swanger­ skap, baring en puerperium, verseker. Die geboorte van ’n baba is maar een aspek in die algehele handhawing met betrekking tot die bekendstelling van ’n nuwe lid tot die familie, asook die gemeenskap. Dit is die “ komprehensiewe vroedvrousorg” soos gestipuleer in hierdie artikel, wat die maksimum gesond­ heid, geluk en sekuriteit van hierdie nuwe lid en die res van die gesin as ’n geheel verseker.


Introduction
T he art o f m idwifery m ust be one o f the oldest of acquired skills.In prehistoric times, the m ore ex perienced wom en assisted and com forted their younger relatives during p artu ritio n .There are scattered references to midwives in ancient literature, including the Bible.In Genesis 35:17 we learn that R achel's death was the result o f " hard lab o u r" .One should con gratulate the m idwife who delivered Sarah o f a son at the age o f 90 years -Genesis 17:17.M idwifery stagnated during the M iddle Ages due, partly to the ig norance o f the midwives as well as to a lack of knowledge o f hum an anatom y coupled with the ac cepted teaching o f the ancients, which was regarded as the ultim ate authority.G reat advances in the art and science o f m idwifery have occurred since the M iddle Ages, am ounting to a revolution in thought and prac tice.Less than 100 years ago, in 1898, in W .S. P la y fair's " Science and Practice o f M idw ifery" no m ention was m ade o f any form o f antenatal exam ination or even of the testing o f urine for album in.Times have indeed changed -today the whole concept o f m aternal and child care would be quite unrecognisable to a Victorian midwife.We have also accepted the male m idwife into our midst.
T H E M U LT I-FA C ET TED ROLE O F T H E M ID W IFE 1.She is prim arily a health educator.M idwifery is so essentially an integral part o f preventive and p ro m otive health care and the m idwife is able to m anipulate situations so that people regard their " needs" as their " w ants" .2. As a practitioner in her own right, she is a diagnosti cian and by her accurate observations, she is able to prevent com plications and by prom pt action in an emergency can save the life o f m other and baby.
3. As a " mother figure" her attitu d e is always empathetic, supportive and encouraging thus she is able to instil confidence in her patients, obtain in g their m axim um co-operation.Not only m ust she be know ledgeable but she m ust be able to com m unicate an d be able to " listen" .She m ust always be to leran t, understanding and kind.T oday, when the young m other is presented with a plethora o f in fo rm atio n , som etim es quite erroneous, gained from glossy m agazines, o f which she is an avid reader, the m id wife should be able to counteract m uch o f this in fo r m ation.
4. She should be able to treat the m other, at all tim es, as a unique individual, who has her ow n problem s, culture and fears.The m idwife m ust respect the per sonal dignity of the mother and m ust never im part a feeling o f inferiority in people or scoff at their beliefs.
5. T he midwife should always consider herself as a teacher and the practical nature o f her role should never be forgotten.How to alleviate fear: 1. Education and explanation in sim ple, u n d ersta n dable language o f the process o f pregnancy and p a r turition.

Breathing exercises and relaxation techniques:
The m other learns and practices assiduously the correct breathing techniques so th at, when in labour, she is able to control her breathing pattern.Irrespective of what method of relaxation exercises are taught, all aim at the same result -concentration on individual breathing p atterns, the rhythm thereof giving m ental release.
RO LE O F T H E FA TH ER P aren tcraft classes are invaluable and explanation to the father has a beneficial effect.The birth o f a baby is a " shared responsibility" and with knowledge and understanding gained from the classes, the father soon realises how im p o rtant he is in helping provide em o tional support for his wife.His fears are also assuaged.Some husbands come as enthusiastic participants to the classes, but, ju st as often they com e very reluctantly.Very often the reluctant husband becomes one o f the most com m itted o f m en!!!!
It is im perative th at patients be told that analgesic drugs are available if the m o th er's pain threshold is low.There is no need for any w om an to suffer excruciating pain.Sim ilarly they should know th at the breathing techniques practised by the m other will considerably alleviate the pain felt.

PH Y SIC A L H E A L T H
A ntenatal exercises have a beneficial effect on the w o m a n 's re sp irato ry , circ u la to ry , and m uscular systems, besides im parting a feeling o f euphoria.Exer cises classes serve as a useful ad ju n ct to group therapy.The foetal circulation and well-being is also enhanced.

Cigarette Smoking and the effect of taking medicines not specificially ordered:
The dangers cannot be over-em phasised.

BREAST FEED IN G
Regrettably, " lip service" is paid to this most im por tant aspect o f m idwifery all too often.Successful breast feeding can be established if the midwife believes in the efficacy o f the "'p ro d u c t" she is " selling" and if she gives the proper advice to the patient about the care of breasts and nipples.

The most important advantages of breast feeding are:
-Bonding is established betw een the m other and her infant.
-There is a decreased risk o f infection by viruses, e.g.Poliom yelitis and by the Bacillus Coli and P rotozoa.C olostrum and breast milk contain Im m unoglobulins A, G and M and there is also the presence o f the Lactobacillus Bifidus.-Allergies such as Eczem a and A sthm a occur less frequently in breast fed infants.-M etabolic diseases, e.g.Rickets occur less fre quently as well.

Care of breasts and nipples:
The use o f soap and w ater daily, and drying with a rough towel is necessary.The nipples should be gently rolled between finger and thum b.A cream may be ap plied to the skin o f the areola if it is dry.Flat a n d /o r in verted nipples should be treated appropriately.In order to keep the lactiferous ducts patent, the m other should be shown how to express the fluid from the breasts from about the 26th week o f pregnancy -it is necessary for the technique to be properly understood and also that this m ust only be done for 1-2-minutes on each breast twice a day.Vigorous friction using nail-brushes or using m ethylated spirits m ust be avoided.
Brassiere: If brassieres are w orn, they should be wellsupporting and o f a reputable m ake.They should, preferably, be o f cotton, with wide straps and should not flatten the nipples.

Avoidance o f guilt-complex:
It is im perative that the m other be constantly reassured that she m ust not con sider herself a failure if she is not able to breast feed her baby or if she does not w ant to do so, for various reasons.

U N TO W A R D SIGNS A N D SYM PTOM S O C C U R IN G D U R IN G PREG N A N C Y :
It is necessary for both parents to know how to recognise Pre-Eclam psia and A ntepartum H aem orrhage and for them to know what action to take.They should also know that an increased frequency o f m icturition is quite norm al during pregnancy, bu t that any dysuria, burning on m icturition and a dim inishing urinary o u t put are abnorm al. Serious com plications can thus be prevented.

A N TEN A TA L VISIT TO LABOUR W ARD
There can surely be nothing m ore frightening for a wom an in labour to be confronted with machines and gadgets from which staccato noises are em anating, when she arrives at a busy labour ward.This fear can be obviated by simply, wherever and whenever possible, showing parents the labour ward and its varied equip m ent, at some stage antenatally.U nfortunately, the m achines found in the labour w ard are often accepted as " com m onplace" by nursing and medical staff.
The " language" o f labour should be explained to both parents to avoid confusion." Epidural Block" , " Indu ctio n o f L a b o u r" , " C aesarean S ectio n " , " E pisiotom y" , " Breech delivery" , and " Instrum ental delivery" are procedures that tend to cause concern to patients and explanations should be simple and truthful.(Articles appearing in glossy magazines tend to confuse parents).

LABOUR
" H ow " labour com m ences, "'how " to time uterine contractions, " w hen" to come to hospital and " w hen" to contact the m idwife or doctor, " w here" to com e, " w h at" the telephone num ber o f the institution is, and " w h at" to bring with them , should be carefully ex plained to b oth parents and the midwife should m ake sure th at everything said is clearly understood.
During labour, the reassurance and encouragem ent of the m other is essential.There should be a reinforcem ent o f breathing and relaxation techniques learnt earlier.
The "'how " and " w hen" to " bear-dow n" should also be known.Instructions should be given by one person only who, in spite o f possible adverse conditions, re m ains calm , confident and capable at all times.The presence o f the father in the labour ward helps reassure and support the m other.The progress o f labour should be explained to the parents in simple language.

Recognition of normal labour
By diligent observation o f both m aternal and foetal conditions, the m idwife should be able to detect any deviation from normal and thus obtain medical aid ear ly.She should know what to do if an emergency situa tion arises." Be p rep ared " should be her m otto.Ac curate recording o f her observations cannot be over estim ated.

Position of the mother
The patient should be either in the lateral position or the upright sitting position during labour.It has been show n th at these positions lessen aortic-caval com pres sion, decrease levels o f pain and tension and reduce oxygen tension.They are also the best position for the baby.

Neonatal resuscitation
The indiscrim inate suctioning o f the infant should not be practised -suctioning is o f value when the liquor is not clear.It is im perative to clear the airpassages o f m econium and blood under direct vision, otherw ise the suctioning o f the infant is controversial.The neutral or head-up position m ay be o f greater benefit to the asphyxiated in fan t, because the liquor in the foetal lungs does not drain out by gravity from the ''head d o w n " position, but returned to the general circulation via the lym phatics.(Ref.1).

Physical appearance of the infant at birth
" Forew arned is forearm ed" , therefore parents should be prepared about the presence o f vernix caseosa, blood on the baby as well as the possible presence o f a Caput Succedaneum and the elongated head associated with m oulding.Also that it is norm al for the presence o f slight cyanosis.E xplanations should be given.A " frightening experience" can thus be av o i ded.In the event o f abnorm ality, the m idw ife should use her discretion.

Identification of baby
T he parents should be reassured th at "'m ixing-up" o f babies does not occur and the m ethod o f identification carefully explained.The term s " b o y /g irl" should be used instead o f " m ale/fem ale" .

B O N D IN G
This very im portant facet o f m idwifery is established at birth when the parents are advised to handle and to fondle the baby, with the m other putting the baby to the breast im m ediately after birth and establishing " eye c o n ta c t." A ttachm ent is thus begun and early parentchild relationship should proceed w ithout crisis.The m idwife is in a unique position to pro m o te optim al fam ily developm ent.The m other, by trial and erro r, develops a sensitivity in assessing the b ab y 's needs and she m odifies and expands her intervention to m ore suc cessfully com fort and entertain the in fan t.D uring feeding she fondles the infant and frequently looks at h im /h e r " face to face" which is the m ost effective stim ulus for eliciting visual fixation and sm iling." R oom ing-in" should be practised whenever possible.N ot only is bonding effectively established but the m other becomes m ore confident in the handling o f her infant.

P R E V E N T IO N O F C H IL D ABUSE
In the article, " Die gebeukte k in d " (C uratio n is -M arch 1980), P rofessor M. C .van H uyssteen showed how the m idwife can m ake a significant co n trib u tio n tow ards the prevention o f child abuse.The p red o m in an t factors responsible for child abuse, the m idw ife's awareness o f the patients at risk, the establishm ent o f m o th er-c h ild b o n d in g an d the in h e re n t d an g e r associated with the separation o f the baby from the m other are factors th at need re-iteration.

B O N D IN G A P P L IC A B L E S P E C IF IC A L L Y TO PR E -T E R M A N D TO IN FA N TS N EED IN G IN TEN SIV E CA R E
W henever the in fan t is nursed in an in cu b ato r, the parents should be encouraged to visit the in fan t fre quently and should not only " lo o k " at the in fan t, but should touch, caress and " ta lk " to the in fan t.W herever possible, the m other should be shown how and en couraged to tube-feed the infant under the m idw ife's supervision.Bonding and breast milk supply will be considerably im proved.

A D O P T IO N O F BABIES
A doption procedures were outlined in the M arch 1980 issue o f C urationis.The im portance o f the com bined role o f social w orker and nurse is re-iterated.The m id wife should, however, rem em ber that her observations o f the in fa n t's condition, behaviour and feeding pattern are m ost necessary, and th at the slightest deviation from normal must be recognised and reported.As the m idwife is the surrogate m other, bonding should be be tween the baby and a very limited num ber o f s ta ff (at the m ost three m idwives).W herever possible, the same m idwife should be responsible for the care, feeding and handling o f the baby.Q uite often the infant for a d o p tion is in the m idw ife's care for some time.C o nfiden tiality should be respected.
The biological mother should be handled with tact and sym pathy during her pregnancy labour and peurperium with the m idwife working in close liaison with the social w orker." H anding over" of the baby to the adoptive parents should take place privately.The personal feelings o f the adoptive parents should be respected.W herever possible, some instruction in p aren tcraft should be given them .

G E N E T IC DISORDERS
M uch atten tio n and publicity has recently been given this im p o rtan t aspect o f m idwifery.The m idwife should be aw are o f what genetic services are available and w hat the indications are for referral to a genetic clinic, for sex chrom atin counts, for chrom osom al studies, for amnioncentesis and for m etabolic screening.(R eferral to the Genetic Services Bulletin no. 1 o f 1979, published by the D epartm ent o f H ealth is necessary).A t all times the m idwife should reassure and su p p o rt the parents.

LE G ISLA TIO N
The m idwife should be able to advise the parents ab o u t the registration o f the birth and to inform them where and when to do this, in term s o f the relevant legislation.

P O ST-N A TA L CA R E
Post-natal depression affects some women m ore than others, particularly the sensitive, artistic wom an.Ex planation to both parents during the antenatal period ab out the possibility o f this occurring, and the reason therefor, should be given to avoid fear later.The fact th at it is a n atural phenom enon should be m entioned.
Post-natal exercises are necessary in order to help in the return o f the reproductive organs to norm al, assist drainage o f lochia and help in the establishm ent o f lac tation.The midwife should encourage the m other to do these exercises.
Control of post-partum haemorrhage: Bleeding can be controlled by the m other if she is shown how to m assage the uterine fundus if she is bleeding and aid is not im m ediately available.
Vulval toilet and care o f the perineum: The m other should know exactly how to carry out these procedures.E xplanation o f the "'how " and " w hy" should preferably be given during the antenatal period.

M O T H E R C R A F T Bathing, handling and dressing o f the baby
The m other should be taught how to carry out these procedures and the m idwife should ensure th at the m other is fully confident before she is discharged from hospital.T he m other should know what is normal and should be constantly reassured and encouraged.Cognisance o f w hat facilities are available at hom e m ust be taken and inform ation tailored accordingly.M id wives, at tim es, tend to lose sight o f the fact th at not all homes have running w ater, stainless steel baths and basins or special liquid soap.

Care of the umbilical cord
In view o f the fact th at patients are discharged very early, it is im perative th at the m other knows the correct technique in the care o f the um bilical cord to avoid serious com plications later.The reason why abdom inal binders are not advocated is explained.

Observation of stools
M others, very often, tend to have a ''bowel com plex" , therefore it is necessary for midwives to reassure the m other that it is not necessary for a breast fed baby to have a stool daily and th at it is quite norm al for them not to have a stool for up to a week or longer.The " w hy" is explained.The m other should also know that the passage o f one or two green stools, providing th at the general condition o f the baby is unchanged, is also considered norm al.

Feeding
W hether the infant is fed on dem and or by fixed schedule depends on both m other and baby, but the m other should know th at the baby should never be awakened for a feed.

Artificial feeding
If the m other is not able to breast feed her baby, she should know exactly how to prepare the bab y 's feed.Using equipm ent th at is available at hom e, the m other is shown how and should undertake the preparation o f the feed.She should be w arned not to " chop and change" the feed w ithout professional advice.Gastro-intestinal disorders can be avoided.

Introduction o f solids
The m other should be advised not to introduce solids into her b ab y 's diet before the infant is at least 4 m onths o f age.She should know that fat babies are not necessarily healthy babies and she should know what mass the baby should " put o n " .Midwives should be aware o f the fact that the in fa n t's urinary system cannot adequately deal with a high solute load until the child is about 4 m onths o f age.

Defective Hearing
By teaching the m other how to carry out simple auditory tests at 8 -9 m onths o f age, the midwife will help in the early diagnosis o f defects o f hearing and thus ensure prom pt treatm ent.

Immunisation of infants
Parents should know o f the benefits o f im m unisation and w hat the legal im plications are and they should know the " w hen" and " w here" they should take the child.

Family Planning education
M ust not be overlooked as one o f the m ost im portant aspects o f m idwifery and the midwife m ust adequately fulfill her role in this respect.

Control of bodily functions
The midwife can influence the m other's approach to this process by advising her that, in spite o f w hat she may hear to the contrary, the child cannot be trained to control h is/h er bodily functions until they can stand on their own, because the tracts o f the spinal cord are only m yelinated to the anal level by then.If attem pts are m ade before this the child is being " conditioned" and not " train ed " with the result that there is frustration and dism ay later when the process " breaks d o w n ."The m ost suitable age is between 15 and 18 m onths o f age.

C O N C LU SIO N
Im p o rtan t aspects o f m idwifery have been outlined with the em phasis on the role o f the midwife during the m anagem ent o f pregnancy, labour and the puerperium .C ourses in advanced m idwifery are available, today, for the midwife w ho practices in a rural area, where medical assistance is virtually non-existent.These courses equip her to carry out procedures, norm ally the prerogative o f the D octor, in order to lessen m ortality and m orbidi ty.This is a trem endous extension o f her im portant role.But . . .w hat ab o u t the urban midwife, and her role with regard to the u rb an patient.Has the tim e not come for the midwife, once again, to m ore adequately fulfill her role as a p ractitioner in her own right.W ith the escalating costs o f hospitalisation, is it not m ore feasible for the m other, if she so wishes, to be delivered in her own hom e. W ithout electronic aid, the m idwife, by using her eyes, her ears, her hands and above all, her skills, could successfully deliver wom en o f selected categories.
The category of patient would be limited to: (1 ) M ultiparous wom en (P ara 2 and P ara 3) who have a good past and present obstetric history, (ii) T he environ m ent w ould be suitable and the necessary equipm ent w ould be readily available, (iii) Close proxim ity to m edical assistance or hospital, in case o f em ergency, (iv) T ran sp o rt would be easily available.
The advantages of domiciliary midwifery are manifold: they include the following: Fam ily bonding is enhanced; sibling jealousy is reduced; freedom from w orry, econom ic pressures and infection; fam iliar environm ent and m ore successful breast feeding.
T oday, in 1980, on the South A frican urb an scene, " operative obstetrics" does appear to predom inate, and the infant, m ore often than not, is delivered by the D oc to r in hospital.The delivery o f the infant is but one focal point in the overall m anagem ent involved in the introduction o f a new m em ber o f the fam ily and to society, It is the total midwifery care, as outlined in this article, th at will ensure the m axim um health, happiness and security o f this newest m em ber, as well as the fam ily as a whole.

FEA R :
Fear o f the unknow n, o f lab o u r, o f p ain, of responsibility, o f producing an abnorm al child and the fear o f responsibility are very real fears affecting m ost pregnant wom en.W om en themselves tend to keep m any o f these age-old fears alive.The fear-pain-tension syn drom e is known to affect the outcom e o f lab o u r.The m idwife, in her m ulti-facetted role m ust inculcate a feel ing o f confidence in her patient as well as the proper perspective with regard to the risk she is taking.
N U TR IT IO N Cognisance m ust always be taken o f the following, whenever advice on diet is given: Socio-econom ic, cultural and intellectual factors.Individuality o f the patients -personal likes and dislikes.Availability o f food and o f refrigeration.M ethod o f p reparation and cooking.The m idwife should em phasise the effect o f poor nutrition on the unb o rn child.