Midwife Means
Content
ROLE OF MIDWIFERY PRACTICE
INTRODUCTION Midwife means „with woman‟ or in France „wise woman‟. The midwife is recognized worldwide as being the person who is alongside and supporting women during birth. However the midwife also has a key role in promoting the health and well being of childbearing women and their families before conception, antenatally and postnatally, including family planning. If chosen as the primary care gives for pregnancy the role of the midwife will take place, of an obstetrician. For instance UK, approximately 75% of the prenatal care is performed by midwives for all low risk mothers and obstetricians only see high risk patients. ACTIVITIES OF A MIDWIFE The midwife has diverse and complex functions: 1. A midwife is a highly trained expert and carries out clinical examinations, provide health and parent education and support the mother and her family throughout the child bearing prices to help them adjust to their parental role. 2. Provides sound family planning information and advice. 3. She diagnoses pregnancies and monitor normal pregnancies to carry out examination necessary for the monitoring of the development of normal pregnancies. 4. She give advice regarding personal hygiene and nutrition to the pregnant mother, and cares throughout pregnancies and first six weeks of birth. 5. Care for and assist the mother during labour and monitors the condition of the foetus by the appropriate clinical and technical means. 6. Conducts spontaneous deliveries including where required an episiotomy and in urgent cases of breech delivery. 7. To recognize the warning signs of abnormality in the mother or infant which necessities referral to a qualified medical doctor„s absence, in particular, the manual removal of placenta, possibly followed by manual examination of the uterus. 8. To examine and care for the newborn infant, to take all initiatives, which are necessary in case of need and to carry out where necessary immediate resuscitation. 9. To care for and monitor progress of the mother in the post-natal period and to give all necessary advice to the mother on infant care to enable her to ensure the optimum process of the newborn infant. 10. To carry out the treatment prescribed by a medically qualified doctors. 11. To maintain necessary records. 12. Midwife teaches about pregnancy , the process of labor, birth and recovery, and parenting skills, this can promote significant improvement in maternal and infant health. 13. She plans care with each woman in labor that is tailored to meet her specific needs and expectations. 14. Puts the care plan into practice and evaluate the care given to measure its effectiveness.
15. She is a skilled professional providing continuous care for several months and assists in critical decision making regarding appropriate care in pregnancy, labor and the post-partum period. 16. Plays important role in disaster and complex humanitarian emergencies at the periphery of the health care system where there are no doctors. 17. The midwife should develop partnership with the woman from the beginning of her pregnancy. This requires a social rather than medical model of maternity care, endorsing the involvement of the woman and her partner in decision making and requiring the woman to be able to voice her needs and wishes freely. 18. The midwife should strive to build a relationship of mutual trust and create an environment in which expectations , wishes, fears, and anxieties can be readily discussed. This requires good communication skills. 19. She should provide emotional and psychological care to woman during labor. The attitude and reactions to childbirth vary considerably and are influenced by different social, cultural and religious factors. For a multigravida, the previous experiences of birth will also be important. 20. The midwife should forward as an advocate to support the woman in unknown and unfamiliar situations and people ; greater pain than expected or the effect of analgesic pain than expected or the feeling of vulnerability, loss of personal identity and powerfulness. Many women anticipate labor with mixed feeling of fear and excitement . They may be apprehensive about entering an unknown and perhaps threatening hospital environment and concerned about relinquishing her personal autonomy and identity. Alternatively, expectations of labour may be unrealistic and may be unfulfilled leading to feeling of disappointment, failure or loss .In these situations the midwife should support the mother‟s. Basic role: All maternal and child health function in a variety of settings are caregivers, client advocate, researcher, case manager and educator. 1. Care giver The midwife understands and facilitates normal childbearing and provides the adequate care to the mother and the baby, spreads health and well-being to women and their families 2. Client advocate The midwife supports, facilitates and implements the woman's choice. Helps the mother to protect her basic rights . 3.Researcher The midwife is a good researcher and does not implement interventions with a sound base on evidence and can critically evaluate the evidence-base for midwifery knowledge .She goes through various studies and conduct studies to provide the best care to the mother and child.
4.Manager A midwife quickly comprehends the range of normal maternal, fetal and neonatal well-being practice, diagnoses factors that may adversely affect maternal or fetal well-being, locates appropriate assistance or intervention while providing continued family support ,manages skilled emergency interventions and assists during bereavement 5.Educator The midwife provides health education to the mother and the family members . She is a resource to the women and their communities Expanded role As trends in maternal and child health care changes , so do the roles of maternal and child health nurses. Many nurses with a specified number of years of direct patient care, education programa are certified in their speciality . In addition, maternal and child health nurses function in a variety of advanced practice roles. 1.Clinical Nurse Specialist Clinical nurse specialist are nurses prepared at the master‟s- degree level who are capable of acting as consultant in their area of expertise, as well as serving as role models, researchers, and teachers of quality nursing care. Example of areas of specialization are neonatal, maternal , child and adolescent health care , childbirth education, and lactation consultation. 2.Case Manager A case manager is a graduate level nurse who supervises a group of patients from the time they enter a health care setting until they are discharged from the setting, or ina seamless care system, into their homes as well, monitoring the effectiveness, cost and satisfaction of their health care. Case management can be a vastly satisfying nursing role, because if the health care setting is „seaming‟ or one that follows people both during an illness and on their return to the community, it involves long-term contacts and lasting relationships. 3. Women health nurse practitioner A women health nurse practitioner is a nurse with advanced study in the promotion of health and prevention of illness in women. Such a nurse plays a vital role in educating women about their bodies and sharing with them methods to prevent illness, in addition, they care for women with illness such as STD‟s offering information and counseling them about reproductive life planning. They play a large role in helping women remain well so that they enter pregnancy in good health and maintain their health through out life.
4. Family Nurse Practitioner A FNP is an advanced practice role that provides health care not only to women but to total families. In conjunction with a physician, an FNP can provide prenatal care for a women with an uncomplicated pregnancy. The FNP takes the heath and pregnancy history, performs physical and obstetric examination, orders approximate diagnostic and laboratory tests and plans continued care throughout the pregnancy and for the family afterwards. FNPs then monitor the family indefinitely to promote health and optimal family functioning. 5.Neo-natal Nurse Practitioner A neonatal nurse practitioner(NNP) is an advanced practice role for nurses who are skilled in the care of newborn, both well and ill. NNPs may work in level1, level2 or level3 newborn nurseries; neonatal follow-up clinics or physician groups. They also transport ill infants to different care settings. The NNP‟s responsibilities include managing and carrying out patient care in INC , conducting normal newborn assessment and physical examination and providing high-risk follow up discharge planning.
SCOPE OF MIDWIFERY PRACTICES
Paramount to the practices of any health care provider is an awareness of the individual professional scope of practice. Understanding and adhering to one‟s scope of practice of recipient of health care practices, as well as in the safe- guarding of health care professionals themselves. For, instance, a person with a broken bone will not seek care from a psychologist. The prevention of such inappropriate and potentially dangerous scenarios is the very reason why defining one‟s scope of practice is vital to the wellbeing of individuals seeking health care . In midwifery education , students learn from the start of their training that safety is vital to offering quality midwifery care, and understanding one‟s scope of practice is a large part of achieving this. The scope of midwifery nursing practices is the range of roles , functions, responsibilities and activities which a registered nurse is educated, competent and has authority to perform. IMPORTANT CONSIDERATIONS IN DETERMING THE SCOPE OF MIDWIFERY PRACTISES A. COMPETENCE: Competence is the ability of the registered nurse r registered midwife to practice safety and effectivety, fulfilling his/her professional responsibilities within her scope of practice. A competent professional midwife possess many attributes.these include practical and technocal skills, communication and interpersonal skills, organizational and managerial skills, the ability to practice safely and effectively utilizing evidence , the ability to adapt a problem solving approach to care utilizing critical thinking , the ability to perform as part of a multidisciplinary team demonstrating a professional attitude, accepting responsibility and being accountable for once action.
B. ACCONTABILITY AND AUTONOMY: Accountability is the fullfillment of a formal obligation to disclose to referent others the purpose, principles, procedures, relationships, result, income and expenditures for which one has authority. In the course of his/her professional practice, a nurse or a midwife must be prepared to make explicit rationale for decisions in the make explicit the rationale for decision in the context of legislation, professional standards and guidelines, evidence based practice and professional and ethical conduct. Accountability can‟t be achieved unless the nurse or midwife has autonomy to practice . Nurse are autonomous in midwifery . This means that they have the freedom to make discretionary and binding decisions in accordance with their scope ofpractise. Authority is the legitimate power to fulfill a responsibility. C. CONTINUING PROFESSIONAL DEVELOPMENT Continuing professional development encompasses experiences, activities, and process that contribute towards the development of a midwife as a health care professional. This means, it is a lifelong process of learning, both structured and informal. Continuing education is a vital component of continuing professional development and takes place after the completion of the pre-registration education programme for midwives and nurse. It consists of planned learning experiences that are designed to augment the knowledge, skills and attitude of a registered nurse or registered midwife, for the enhancement of midwifery practices , patient care education, administration, and research. D. SUPPORT FOR PROFESSIONAL NURSING AND MIDWIFERY PRACTICE Inorder for the midwives to practice completely and to realize these potential in the interest of quality patient care; certain supports need to be in place. This include – local and national guidelines, policies and protocol that have been developed collaboratively with practicing nurses and midwives, and with reference to legislation and research- based literature. E. DELEGATION Delegation is the transfer of authority by a nurse midwife to another person to perform a particular role. Each registered midwife is accountable for his/her own practice. The midwife is accountable for his/ her own practice. The midwife who is delegating is accountable for the decision to delegate . This means that the delegate function is appropriate and that support and resourses areavailable to the person to whom the role has been delegated. The miwife is accountable for carrying out the delegated role in an appropriate manner. THE PRINCIPLES TO BE KEPT IN MIND WHILE DELEGATING ROLES The nurse midwife must ensure that the primary motivation for delegation is to serve the interest of the patient. The midwifery must ensure that the delegation is appropriate with reference to the definitions and philosophies of nursing or midwifery as appropriate .
The nurse or midwife must take the level of experiences , competence, role and scope of practice of the person to whom the role is being delegated into account. The nurse or midwife must not delegate to junior colleagues , tasks and responsibilities beyond their skill and experiences. The midwife must ensure appropriate assessment , planning, implementation and evaluation of delegate role. The midwife must communicate the role in a manner understandable to the person to whom it is being delegated. The midwife must communicate the role in a manner understandable to the person to whom it is being delegated. The midwife must decide on the level of supervision and feedback necessary. The Nurse to whom a particular role has been delegated should take account of the following principles. - The nurse or midwife must consider if it is within their scope of practice . If the delegated role is beyond the current scope of practice. If the delegated role is beyond the current scope of practice of the nurse or midwife need to consider the appropriateness of this delegation. - The midwife must acknowledge any limitations of competence. - The nurse or midwife must provide appropriate feedback to the delegator.
6. EMERGENCY SITUATION Nothing in this document will be constructed as preventing a nurse midwife from taking appropriate action in the case of an emergency . The best interest of the patient must be served by appropriate nursing or midwifery intervention in emergency situations. PRINCIPLES OF DETERMING THE SCOPE OF PRACTICE The following principles are the basis for making decisions with regard to the scope of practice for an individual nurse/midwife. The primary motivation for expansion of practice must be best interest of patient and promotion and maintenance of the best quality health services for the population. Expansion of practice must be made in the content of the definition of nursing midwifery and the values that underpin midwifery practice. Expansion of practices must only be made with due consideration to legislation , national policy, local policy and guidelines. If necessary at local level, appropriate protocols and guidelines should be devised and appropriate supports put in place. In determining the scope of practice the midwife must make a judgement as to whether she is competent to carry out the role function. The midwife must take measures to develop and maintain the competence necessary for professional practice . The midwife must acknowledge any limitation of competence. Expansion of practice must be based on appropriate assessment , planning, communication and evaluation.
The midwife who is delegating a particular role function is accountable for the decision to delegate . This means that the delegated role is appropriate and that, support and resources are available to the person to whom it has been delegated. The individual midwife is accountable for her practice. This means that she is accountable for decision and determines the scope of practice.
INDEPENDENT NURSE MIDWIFE PRACTITIONER
Definition
Independent midwives are fully qualified midwives who have chosen to work outside the National Health Scheme in a self employed capacity. The legal role of a midwife encompasses the care of women and babies during pregnancy, birth and the early weeks of motherhood. Usually one midwife gives care to a woman her family through out a pregnancy. Having established a trusting relationship , the same midwife would care for the woman and her baby and support afterwards. Research have shown that many women till want this type of midwifery care and that it help women to cope with the challenges of labor and the transition to parenthood. In recent times, health advisers and government policy makers have promoted independent midwives style of care as the‟ Gold Standard to which the National Health Scheme(NHS)‟ should aspire to independent midwives are currently working to ensure that all women can assess „ gold standard care in the future‟.
Working place
A pregnant women is entitled to choose where she wants to have her baby. Midwives can work with women at : Home, Hospital, In separate midwifery aid units ,Private birth centers.
Mode of Duties
Independent midwives have more freedom to practice individualized care compared to those working with the NHS, who can be restricted by guidelines and protocols. Independent midwives are regulated by the Nursing and Midwifery Council. They are subjected to the same supervision as NHS midwives are required to keep up to date with their practices and are only allowed to act within their sphere of competence as midwives. For instance, there are currently approximately 150 independent midwives in U.K. They often work in partnership or have close connection with other independent nurse midwives, enabling them to provide seamless care to the women who use their services. The independent midwives form relationship of trust with pregnant women, which then help women to feel safe and supported when they go into labor. Many independent midwives have become very
experienced and in areas of child birth; that within the NHS are usually dealt with by obstetric management . These include breech birth, twins and vaginal birth after caesarean . The majority of births attended by independent midwives at any stage during pregnancy , no matter how close you are to your due date. Some will give free consultations to women who are considering all their birthing options.
Practicalities to be aware
1. Cost: Independent midwife charge for their services. The amount will depend on the living status and the type of services they offer. 2. Place of Birth: Most of the midwives attend birth at home. There are a small number of independent midwife services in U.K. with their own centers. If a women is planning hospital birth or need to be transferred to hospital , she can do so and a midwife can accompany her if so she designs. 3. Independent midwifes have the same referral rights as NHS midwives and are able to arrange a consultant appointment or hospital admission if required.
Professional Autonomy of a Midwife
The midwife is responsible for all care unless she makes a referral to mother to another health professional. Any guidelines and policies should have been developed and approved by midwifery after process of consultation.
Principles
The National Nursing , midwifery and Health visiting practice(UKCC) describes seven guiding principles which establish autonomous midwifery philosophy and values in relation to expected outcomes of midwifery programmes: A.Provision of Women centered care Every woman expects to be treated as though she is special and important .Although at times maternity units and community workloads can be busy, individual women wants midwives to be there for them , not for someone else.It is essential that midwives have an understanding of social , cultural and context differences so that they can respond to the needs of women and their families in a variety of care setting and priorities and manage work appropriately. Of particular importance is working with families to draw up a plan of care and support and then evaluate and modify that care as circumstances. B. Ethical And Legal Obligations The practice of a midwife is controlled by law, under the Nurses Midwives and Health Visitors Act and Midwives Act. Midwives also need to be familiar with other Acts of Parliament and Statutory Instruments that impact on their practice. The code of professional conduct sets requirements for the behavior of midwives and nurses in relation to such things as confidentiality, respect and personal responsibility for ethical choices. For example, midwives may find themselves expected to care for women who have decided to terminate their pregnancy. Even though the midwife have objection regarding it, she cannot
refuse to provide care for the woman. Counselling services are normally provided for women and staff facing ethical dilemmas and stressful situations. C. Respect for Individuals And Communities Society is composed of people from many cultures, ethics, and religious backgrounds. Midwifery care must be provided in a non-discriminatory way without prejudice; Where midwives find they don‟t have the skill or expertise to provide effective care for individuals or groups then need to seek assistance. In areas where there are number of residents who don‟t speak the local language, link workers or an interpreting service can be more appropriate than asking another family member; especially a child, to communicate between the woman and the midwife. D. Quality and Excellence Individual midwives should strive for continuous improvement and excellence in midwifery practice. To protect the health and well-being of mother and babies , supervision of midwives is enshrined in statute. Clinical governance has more recently been established to assure the quality of all the health services provided by an individual NHS Trust and has many principles that mirror statutory supervision of midwives. Auditing of standards and discussion of difficult maternity care scenarios are ways in which all professional groups can work together to improve the quality of services. Involvement of mother in evaluating care and suggestion for areas that need improvement have become even more important in contributing to become even more important in contributing to quality and excellence in the maternity services. E.The changing nature and context of Midwifery Practices Midwives need to be flexible and also become change agents when necessary. Theu need to adapt to new technologies to improve the quality of care, providing quality care and there by developing their existing skills and identify changes needed. F.Evidence – based Practice and learning The practitioners of midwifery should have evidence for effective care and not assume that all research is of value but that it must be critically analysed. It intends to foster the use of sysytematic reviews such as effective care in pregnancy and childbirth. G.Life-long Learning Midwife should adapt a style of learning complex and problem solving skills and become expert practitioners with upto date knowledge of informations. Midwives also need to grasp opportunities to learn from each other by observing , discussing different ways of practicing and where necessary seeking out an education or training event.
The Independent Nurse midwifery management processes
Regardless of the practice setting, the nurse midwife care encompasses four aspects of management: 1.Independent Management Nurse midwife are responsible and accountable for the management decision they make in caring for the patient. Nurse midwife provides independent management when they sysytematically obtain or update a complete and relevant database for assessment of the patients health status. This includes the history the physical examination results, the laboratory data. On the basis and interpretation of this findings, nurse midwives accurately identical problems and diagnosis and implement a plan of action. 2.Consultation When nurse midwives identify problems or complication they seek advice from another member of the health care team often a physician. When they retain independence management responsibility for the patient while seeking advice, this is called consultation, may centre on an ongoing health problems, a non obstetrical , time limited problem that arises during pregnancy. After consultation the nurse midwife and the women discuss the recommendations if any and modify the plan of care accordingly. In this process nurse midwife retain responsibility for decision. 3.Co management or collaborative care One out come of consultation may be the decision to shift to co management or collaborative care. This usually occurs if part of the women‟s care is related to an ongoing medical or gynecological complication beyond the scope of the nurse midwives practice. In this situation the nurse midwife and the physician collaboratively treat the patient.
The range of services provided:
Pre-pregnancy advice Advice about birth options Childbirth education classes Continuous midwifery care during pregnancy Preparation for and attendance at births in an appropriate environment of the parent‟s choice. Postnatal care following birth at home, birth centre or hospital. Separate postnatal care for women who want private midwifery care for this period only or who are discharged home early from hospital Lactation consultancy Referral to and advice about other health professional such as medical and natural health practitioners, eg obstetricians, paediatricians, GPs , chiropractors, osteopaths, naturopaths , homeopaths Some midwives have a special interest and expertise in supporting women in special areas such as vaginal birth after caesarean section(VBAC), breech births, water births and postnatal depression.
Independent practice Midwife in India
In India 1,00,000 women die every year due to pregnancy related cause (GOI 2005). Over 50 million women suffer from malnutrition in India. Morbidity due to pregnancy is 18 times higher in developing countries and IMR is 7 times higher in developing countries. Risk to a woman of dying from pregnancy related causes: developed countries 1: 4000 to 10,000 where as in India it is 57/1000. IMR in developed countries 1 in 5000 to 10,000 and in India 64/1000.
Major contributing factors for these problems are:
Lack of skilled health care Posts for doctors with obstetric skills in rural and tribal areas often lie vacant Nurse midwives are available at the first level of referral but are unskilled for the level of management required to supervise at-risk deliveries. Poor utilization of midwifery skill. Lack of a supportive policy environment
In order to improve this conditions, the Nursing Council (INC), the parent body of the nursing councils in the country, has rolled out a series of initiatives, many of which are in the early implementation stage, while the rest have been forwarded by INC for approval to the Union Health ministry. Aimed to ease the impact of the shortage of gynecologists in community health centres, INC performed a pilot study for the „ Independent Nurse Practitioner Project‟ in Infant Mortality Rate(MMR) in West Bengal at SSKM Hospital female medical and surgical wards. The project provided an 18 months training in midwifery, besides an additional training in emergency obstetric care to candidates who have completed their BSC in nursing and have two to three years of experience in OB-GYN wards to take care of ANMs in rural sectors. These nurses were called independent nurse as they were trained to prescribe medicines following approved protocols and take decisions independently in absence of gynecologists. The result of the pilot study has been submitted to health ministry and the government of India examined the protocol to extent this project all over India. The GOI response to the challenge: – INC entrusted with responsibility of developing a new cadre of midwives who will work in rural and tribal areas of India Phase 1 – – Funded under the India-Australia Training and Capacity Building Project (IATCBP) as “The Specialist Midwifery Sub-Project”. Supported by technical assistance from Faculty of Nursing, University of Newcastle, Australia
Development of new cadre • • • Consensus building Development phase Implementation phase
Consensus building Step 1: Need for a new cadre of specialist midwifery identified Step 2: Consensus on key issue related to the new cadre. Step 3: Consensus on role and function of nurse practitioner in midwifery Development phase Step 4: Base-line data collected
Step 5: Development of code of ethics Step 6: Development of practice standards Step 7: Development of a framework for service standards Implementation phase Step 8: Development of clinical guidelines Step 9: Development of curriculum framework Step 10: Writing the curriculum Step 11: Development of assessment tools Step 12: Piloting selected modules and assessment Step 13: Review and revision Outcomes The provision of qualified NP in midwifery with skills and knowledge to manage ob and gynae emergencies in rural and tribal areas of India To increase the number of women and infants seeking treatment at the CHCs where the NP is placed thus reducing the risk of maternal and infant mortality and morbidity To decrease maternal and infant mortality and morbidity in the rural and tribal areas of India by providing quality ob and gynae services through NP placed in CHCs.
Training & placement of Independent Nurse Midwife Practitioner Course Duration: 18 months (including 6 months internship) Eligibility/ Qualifications o o B. Sc. Nursing, 2 years experience (at least one year in midwifery) Age: < 45 yrs
Placement: CHC / PHC with facilities for supporting the role & function of new cadre Post: convert one post of staff nurse to NP in Midwifery Salary: equivalent to principal nursing school
Mode of Offer: Full-time only Proposed Course Locations: Colleges of Nursing and Medical Colleges in Calcutta (West Bengal) and Indore (Madhya Pradesh) Proposed Intake for the First 2 years: First year: 6 each from training location Second year: Intake to be reviewed based on the experience of the initial intake Professional Recognition and Accreditation: INC Responsibilities & practice o o o o Promotion of health of women throughout their life cycle with special focus on women during childbearing years and their new babies. Provide autonomous care to women prior to & during pregnancy, during & after childbirth, care of newborn & assume responsibility and accountability for their practice. Practice within the existing peripheral health system consisting of birth attendants, ANM‟s, nurses, doctors & specialists NP will be posted at a facility where no obstetricians are posted or available
Job description Promote health of women before pregnancy through education and counseling for healthy family life including planning for pregnancies. Promote health of women during pregnancy through: Quality, technically advanced antenatal care to women with normal pregnancy Early detection of risk situations and management that commensurate with their level of competence Management of minor disorders of pregnancy Referrals as required
Regulations of practice • INC Act (1947) amended to allow INC to: – – – • Regulate the practice of the NP in midwifery according to the code of ethics License the NP to practice independently (as per practice standards) Authorize & be responsible for preparing, approving & implementing the curriculum
Code of ethics & practice standards are key for licensing & regulation of NP
TEACHING INSTITUTIONS Government (State/Center/Autonomous) nursing teaching institution offering diploma or degree programs in nursing having parent/ affiliated Govt. Hosp. facilities of maternity, neonatal and pediatric units. Or Other non-Govt. nursing teaching institution offering diploma or degree programs in nursing having parent Hosp. facilities of maternity, neonatal and pediatric units The institution conducting this course should have a 50 bedded parent hospital having mother and neonatal units,Case load of minimum 500 deliveries per year, 8-10 level II neonatal beds, Affiliation with level III neonatal bed The number of seats available depend on the number of deliveries conducted in the parent institutions ie, 10 students for minimum 500 deliveries per year 20 students for minimum 1000 deliveries per year STAFFING PATTERN 1. Full time teaching faculty Ratio 1:5 Qualification: M. Sc. Nursing with Obstetrics and Gynaec/Community/Pediatrics Specialty Nurse practitioner in midwifery with B. Sc. nursing Experience: Minimum 3 years 2.Guest faculty - multi-disciplinary in related specialties Distribution of the Course: 1. Teaching: Theory & Clinical practice 42 weeks 2. Internship 3. Examination 4. Vacation 5. Public holidays 4 weeks 2 weeks 2 weeks 2 weeks -----------------52 weeks
Curriculum Theory Clinical Nursing-I
(Inclusive of foundation courses) 90 Hrs Clinical Nursing II90 hrs Paper III (i) Supervision & Management 30 Hrs (ii) Clinical Teaching 30 Hrs (iii) Elementary Research & Statistics 30 Hrs TOTAL 270 Hours
Practical Integrated Clinical Practice 1410 Hrs Internship 160 Hrs Total 1570 Hrs Clinical Experience Maternal and neonatal care Services 38 weeks Antenatal OPD including Infertility clinics /Reproductive medicine, Family welfare and post partum clinic / centre 6 weeks Antenatal and Postnatal ward 4 weeks Labour room 8 weeks Neonatal Intensive Care Unit 4 weeks Obstetric/Gynae operation Theatre 4 weeks Gynae ward 2 weeks Paediatric OPD/under five clinic 2 weeks Paediatric ward 2 weeks CHC,PHC,SC 6 weeks Total practical hours 38 weeks (1410 hrs) Internship 4 weeks in community Institutions conducting NP Course
Gujarat: o o Ahemdabad Baroda
o Bhavnagar: under process PROPOSED CADRE OF NURSE MIDWIFE PRACTITIONERS State Nurse Midwife Practitioner Admin PostProposed -4 Accepted -1 Chief Nurse Midwife Practioner at Regional Level Admin Post (6) Senior Nurse Midwife Practioner (26) at District/Med College attached Hospital Nurse Midwife Practioner (3016) at PHC,CHC, Taluka Medical College attached Hospital
SALARY SCALE OF NEW CADRES
s.no. 1. 2. 3. 4.
Designation Staff Nurse Midwife Practitioner Chief nurse Midwife Practitioner Senior nurse midwife practitioner Nurse Midwife Practitioner
Pay scale 10,000-15,200 8000-13,500 6500-10,000 5500-9000
No of post 4 6 30 3016
Total expenditure 12.02 lakh 14.76 lakhs 50.07 lakhs 43.43 lakhs
Research findings
1. Health Care–Seeking Practices of Pregnant Women and the Role of the Midwife in Cape Town,
South Africa
Naeemah Abrahams rn, rm, mphil†, Rachel Jewkes mbbs, msc, mfphm, md‡, Zodumo Mvo socsc (hon), mphil§ (Journel for Midwifery & women‟s health, volume 46, issue 4, page no:240-247) ABSTRACT The objective of this study was to investigate the health-seeking practices of pregnant women in a periurban area in Cape Town, South Africa. This qualitative study was based on 103 minimally structured in-depth interviews of 32 pregnant women. Most women were interviewed on several occasions, and a group discussion was held with women. The interviews were taped, transcribed, analyzed ethnographically, and, if necessary, translated into English. Antenatal care attendance was influenced by a number of factors, including women's knowledge of the role of antenatal care, perceived health needs, booking systems, nurse-patient relationships, economics, child care, and transport. The expected benefits were weighed against the anticipated costs before decisions about seeking care were made. The findings highlight the importance of women's perceptions of quality of care in influencing their health seeking practices. The study suggests that considerably more attention needs to be given to this aspect of maternity services.
2.Childbirth as healing: three women's experience of independent midwife care M Milan
120, Straight Road, Old Windsor, Berkshire 5LL 2SB, UK
Abstract This article sets out to demonstrate that, for some women, childbirth may be experienced as healing and life-changing. The author works as an independent midwife. Interviews with three ex-clients were analysed, and the common themes identified and grouped. The three women had negative memories of the birth of their first child, but all birthed their second babies at home. The quality of care received was described as empowering, reassuring and emotionally supportive. Practical inputs such as listening presence, information, referrals, touch, were all identified as facilitative. The women framed their perception of the changes which had occurred in terms of reassessment of themselves and their capabilities in the light of the achievement of the birth experience.
Conclusion
The role of midwife is very important. Every midwife should know the scopes of midwifery practices and the role played by independent nurse midwife practitioner in the society, to provide the best and safe care for the mother and the child.
REFERENCE
1. Varney Helen, Kriebs M Jan, “Varney‟s Textbook of Midwifery “, All India Publishers and Distributors,2005, IVth edition, Page no: 3-4 2. Henderson Christine, Myles midwifery , A textbook of Midwifery , published by Davis Karlene Dame,2004, 13th edition, page no: 433-434 3. Wrong L Donna, Hockenberry J Marilyn, Perry E. Shannor, Lowermilk Leonard Dietra, Maternity Child nursing Care, published library of congress, 2006, 3rd edition, page no:299-300 4. http://scholar.google.co.in/scholar?q=independent+midwife&hl=en&as_sdt=2%2C5 5. http://scholar.google.co.in/scholar?hl=en&q=role+of+midwife&btnG=Search&as_sdt=2%2C5&a s_ylo=&as_vis=0
INTRODUCTION Midwife means „with woman‟ or in France „wise woman‟. The midwife is recognized worldwide as being the person who is alongside and supporting women during birth. However the midwife also has a key role in promoting the health and well being of childbearing women and their families before conception, antenatally and postnatally, including family planning. If chosen as the primary care gives for pregnancy the role of the midwife will take place, of an obstetrician. For instance UK, approximately 75% of the prenatal care is performed by midwives for all low risk mothers and obstetricians only see high risk patients. ACTIVITIES OF A MIDWIFE The midwife has diverse and complex functions: 1. A midwife is a highly trained expert and carries out clinical examinations, provide health and parent education and support the mother and her family throughout the child bearing prices to help them adjust to their parental role. 2. Provides sound family planning information and advice. 3. She diagnoses pregnancies and monitor normal pregnancies to carry out examination necessary for the monitoring of the development of normal pregnancies. 4. She give advice regarding personal hygiene and nutrition to the pregnant mother, and cares throughout pregnancies and first six weeks of birth. 5. Care for and assist the mother during labour and monitors the condition of the foetus by the appropriate clinical and technical means. 6. Conducts spontaneous deliveries including where required an episiotomy and in urgent cases of breech delivery. 7. To recognize the warning signs of abnormality in the mother or infant which necessities referral to a qualified medical doctor„s absence, in particular, the manual removal of placenta, possibly followed by manual examination of the uterus. 8. To examine and care for the newborn infant, to take all initiatives, which are necessary in case of need and to carry out where necessary immediate resuscitation. 9. To care for and monitor progress of the mother in the post-natal period and to give all necessary advice to the mother on infant care to enable her to ensure the optimum process of the newborn infant. 10. To carry out the treatment prescribed by a medically qualified doctors. 11. To maintain necessary records. 12. Midwife teaches about pregnancy , the process of labor, birth and recovery, and parenting skills, this can promote significant improvement in maternal and infant health. 13. She plans care with each woman in labor that is tailored to meet her specific needs and expectations. 14. Puts the care plan into practice and evaluate the care given to measure its effectiveness.
15. She is a skilled professional providing continuous care for several months and assists in critical decision making regarding appropriate care in pregnancy, labor and the post-partum period. 16. Plays important role in disaster and complex humanitarian emergencies at the periphery of the health care system where there are no doctors. 17. The midwife should develop partnership with the woman from the beginning of her pregnancy. This requires a social rather than medical model of maternity care, endorsing the involvement of the woman and her partner in decision making and requiring the woman to be able to voice her needs and wishes freely. 18. The midwife should strive to build a relationship of mutual trust and create an environment in which expectations , wishes, fears, and anxieties can be readily discussed. This requires good communication skills. 19. She should provide emotional and psychological care to woman during labor. The attitude and reactions to childbirth vary considerably and are influenced by different social, cultural and religious factors. For a multigravida, the previous experiences of birth will also be important. 20. The midwife should forward as an advocate to support the woman in unknown and unfamiliar situations and people ; greater pain than expected or the effect of analgesic pain than expected or the feeling of vulnerability, loss of personal identity and powerfulness. Many women anticipate labor with mixed feeling of fear and excitement . They may be apprehensive about entering an unknown and perhaps threatening hospital environment and concerned about relinquishing her personal autonomy and identity. Alternatively, expectations of labour may be unrealistic and may be unfulfilled leading to feeling of disappointment, failure or loss .In these situations the midwife should support the mother‟s. Basic role: All maternal and child health function in a variety of settings are caregivers, client advocate, researcher, case manager and educator. 1. Care giver The midwife understands and facilitates normal childbearing and provides the adequate care to the mother and the baby, spreads health and well-being to women and their families 2. Client advocate The midwife supports, facilitates and implements the woman's choice. Helps the mother to protect her basic rights . 3.Researcher The midwife is a good researcher and does not implement interventions with a sound base on evidence and can critically evaluate the evidence-base for midwifery knowledge .She goes through various studies and conduct studies to provide the best care to the mother and child.
4.Manager A midwife quickly comprehends the range of normal maternal, fetal and neonatal well-being practice, diagnoses factors that may adversely affect maternal or fetal well-being, locates appropriate assistance or intervention while providing continued family support ,manages skilled emergency interventions and assists during bereavement 5.Educator The midwife provides health education to the mother and the family members . She is a resource to the women and their communities Expanded role As trends in maternal and child health care changes , so do the roles of maternal and child health nurses. Many nurses with a specified number of years of direct patient care, education programa are certified in their speciality . In addition, maternal and child health nurses function in a variety of advanced practice roles. 1.Clinical Nurse Specialist Clinical nurse specialist are nurses prepared at the master‟s- degree level who are capable of acting as consultant in their area of expertise, as well as serving as role models, researchers, and teachers of quality nursing care. Example of areas of specialization are neonatal, maternal , child and adolescent health care , childbirth education, and lactation consultation. 2.Case Manager A case manager is a graduate level nurse who supervises a group of patients from the time they enter a health care setting until they are discharged from the setting, or ina seamless care system, into their homes as well, monitoring the effectiveness, cost and satisfaction of their health care. Case management can be a vastly satisfying nursing role, because if the health care setting is „seaming‟ or one that follows people both during an illness and on their return to the community, it involves long-term contacts and lasting relationships. 3. Women health nurse practitioner A women health nurse practitioner is a nurse with advanced study in the promotion of health and prevention of illness in women. Such a nurse plays a vital role in educating women about their bodies and sharing with them methods to prevent illness, in addition, they care for women with illness such as STD‟s offering information and counseling them about reproductive life planning. They play a large role in helping women remain well so that they enter pregnancy in good health and maintain their health through out life.
4. Family Nurse Practitioner A FNP is an advanced practice role that provides health care not only to women but to total families. In conjunction with a physician, an FNP can provide prenatal care for a women with an uncomplicated pregnancy. The FNP takes the heath and pregnancy history, performs physical and obstetric examination, orders approximate diagnostic and laboratory tests and plans continued care throughout the pregnancy and for the family afterwards. FNPs then monitor the family indefinitely to promote health and optimal family functioning. 5.Neo-natal Nurse Practitioner A neonatal nurse practitioner(NNP) is an advanced practice role for nurses who are skilled in the care of newborn, both well and ill. NNPs may work in level1, level2 or level3 newborn nurseries; neonatal follow-up clinics or physician groups. They also transport ill infants to different care settings. The NNP‟s responsibilities include managing and carrying out patient care in INC , conducting normal newborn assessment and physical examination and providing high-risk follow up discharge planning.
SCOPE OF MIDWIFERY PRACTICES
Paramount to the practices of any health care provider is an awareness of the individual professional scope of practice. Understanding and adhering to one‟s scope of practice of recipient of health care practices, as well as in the safe- guarding of health care professionals themselves. For, instance, a person with a broken bone will not seek care from a psychologist. The prevention of such inappropriate and potentially dangerous scenarios is the very reason why defining one‟s scope of practice is vital to the wellbeing of individuals seeking health care . In midwifery education , students learn from the start of their training that safety is vital to offering quality midwifery care, and understanding one‟s scope of practice is a large part of achieving this. The scope of midwifery nursing practices is the range of roles , functions, responsibilities and activities which a registered nurse is educated, competent and has authority to perform. IMPORTANT CONSIDERATIONS IN DETERMING THE SCOPE OF MIDWIFERY PRACTISES A. COMPETENCE: Competence is the ability of the registered nurse r registered midwife to practice safety and effectivety, fulfilling his/her professional responsibilities within her scope of practice. A competent professional midwife possess many attributes.these include practical and technocal skills, communication and interpersonal skills, organizational and managerial skills, the ability to practice safely and effectively utilizing evidence , the ability to adapt a problem solving approach to care utilizing critical thinking , the ability to perform as part of a multidisciplinary team demonstrating a professional attitude, accepting responsibility and being accountable for once action.
B. ACCONTABILITY AND AUTONOMY: Accountability is the fullfillment of a formal obligation to disclose to referent others the purpose, principles, procedures, relationships, result, income and expenditures for which one has authority. In the course of his/her professional practice, a nurse or a midwife must be prepared to make explicit rationale for decisions in the make explicit the rationale for decision in the context of legislation, professional standards and guidelines, evidence based practice and professional and ethical conduct. Accountability can‟t be achieved unless the nurse or midwife has autonomy to practice . Nurse are autonomous in midwifery . This means that they have the freedom to make discretionary and binding decisions in accordance with their scope ofpractise. Authority is the legitimate power to fulfill a responsibility. C. CONTINUING PROFESSIONAL DEVELOPMENT Continuing professional development encompasses experiences, activities, and process that contribute towards the development of a midwife as a health care professional. This means, it is a lifelong process of learning, both structured and informal. Continuing education is a vital component of continuing professional development and takes place after the completion of the pre-registration education programme for midwives and nurse. It consists of planned learning experiences that are designed to augment the knowledge, skills and attitude of a registered nurse or registered midwife, for the enhancement of midwifery practices , patient care education, administration, and research. D. SUPPORT FOR PROFESSIONAL NURSING AND MIDWIFERY PRACTICE Inorder for the midwives to practice completely and to realize these potential in the interest of quality patient care; certain supports need to be in place. This include – local and national guidelines, policies and protocol that have been developed collaboratively with practicing nurses and midwives, and with reference to legislation and research- based literature. E. DELEGATION Delegation is the transfer of authority by a nurse midwife to another person to perform a particular role. Each registered midwife is accountable for his/her own practice. The midwife is accountable for his/ her own practice. The midwife who is delegating is accountable for the decision to delegate . This means that the delegate function is appropriate and that support and resourses areavailable to the person to whom the role has been delegated. The miwife is accountable for carrying out the delegated role in an appropriate manner. THE PRINCIPLES TO BE KEPT IN MIND WHILE DELEGATING ROLES The nurse midwife must ensure that the primary motivation for delegation is to serve the interest of the patient. The midwifery must ensure that the delegation is appropriate with reference to the definitions and philosophies of nursing or midwifery as appropriate .
The nurse or midwife must take the level of experiences , competence, role and scope of practice of the person to whom the role is being delegated into account. The nurse or midwife must not delegate to junior colleagues , tasks and responsibilities beyond their skill and experiences. The midwife must ensure appropriate assessment , planning, implementation and evaluation of delegate role. The midwife must communicate the role in a manner understandable to the person to whom it is being delegated. The midwife must communicate the role in a manner understandable to the person to whom it is being delegated. The midwife must decide on the level of supervision and feedback necessary. The Nurse to whom a particular role has been delegated should take account of the following principles. - The nurse or midwife must consider if it is within their scope of practice . If the delegated role is beyond the current scope of practice. If the delegated role is beyond the current scope of practice of the nurse or midwife need to consider the appropriateness of this delegation. - The midwife must acknowledge any limitations of competence. - The nurse or midwife must provide appropriate feedback to the delegator.
6. EMERGENCY SITUATION Nothing in this document will be constructed as preventing a nurse midwife from taking appropriate action in the case of an emergency . The best interest of the patient must be served by appropriate nursing or midwifery intervention in emergency situations. PRINCIPLES OF DETERMING THE SCOPE OF PRACTICE The following principles are the basis for making decisions with regard to the scope of practice for an individual nurse/midwife. The primary motivation for expansion of practice must be best interest of patient and promotion and maintenance of the best quality health services for the population. Expansion of practice must be made in the content of the definition of nursing midwifery and the values that underpin midwifery practice. Expansion of practices must only be made with due consideration to legislation , national policy, local policy and guidelines. If necessary at local level, appropriate protocols and guidelines should be devised and appropriate supports put in place. In determining the scope of practice the midwife must make a judgement as to whether she is competent to carry out the role function. The midwife must take measures to develop and maintain the competence necessary for professional practice . The midwife must acknowledge any limitation of competence. Expansion of practice must be based on appropriate assessment , planning, communication and evaluation.
The midwife who is delegating a particular role function is accountable for the decision to delegate . This means that the delegated role is appropriate and that, support and resources are available to the person to whom it has been delegated. The individual midwife is accountable for her practice. This means that she is accountable for decision and determines the scope of practice.
INDEPENDENT NURSE MIDWIFE PRACTITIONER
Definition
Independent midwives are fully qualified midwives who have chosen to work outside the National Health Scheme in a self employed capacity. The legal role of a midwife encompasses the care of women and babies during pregnancy, birth and the early weeks of motherhood. Usually one midwife gives care to a woman her family through out a pregnancy. Having established a trusting relationship , the same midwife would care for the woman and her baby and support afterwards. Research have shown that many women till want this type of midwifery care and that it help women to cope with the challenges of labor and the transition to parenthood. In recent times, health advisers and government policy makers have promoted independent midwives style of care as the‟ Gold Standard to which the National Health Scheme(NHS)‟ should aspire to independent midwives are currently working to ensure that all women can assess „ gold standard care in the future‟.
Working place
A pregnant women is entitled to choose where she wants to have her baby. Midwives can work with women at : Home, Hospital, In separate midwifery aid units ,Private birth centers.
Mode of Duties
Independent midwives have more freedom to practice individualized care compared to those working with the NHS, who can be restricted by guidelines and protocols. Independent midwives are regulated by the Nursing and Midwifery Council. They are subjected to the same supervision as NHS midwives are required to keep up to date with their practices and are only allowed to act within their sphere of competence as midwives. For instance, there are currently approximately 150 independent midwives in U.K. They often work in partnership or have close connection with other independent nurse midwives, enabling them to provide seamless care to the women who use their services. The independent midwives form relationship of trust with pregnant women, which then help women to feel safe and supported when they go into labor. Many independent midwives have become very
experienced and in areas of child birth; that within the NHS are usually dealt with by obstetric management . These include breech birth, twins and vaginal birth after caesarean . The majority of births attended by independent midwives at any stage during pregnancy , no matter how close you are to your due date. Some will give free consultations to women who are considering all their birthing options.
Practicalities to be aware
1. Cost: Independent midwife charge for their services. The amount will depend on the living status and the type of services they offer. 2. Place of Birth: Most of the midwives attend birth at home. There are a small number of independent midwife services in U.K. with their own centers. If a women is planning hospital birth or need to be transferred to hospital , she can do so and a midwife can accompany her if so she designs. 3. Independent midwifes have the same referral rights as NHS midwives and are able to arrange a consultant appointment or hospital admission if required.
Professional Autonomy of a Midwife
The midwife is responsible for all care unless she makes a referral to mother to another health professional. Any guidelines and policies should have been developed and approved by midwifery after process of consultation.
Principles
The National Nursing , midwifery and Health visiting practice(UKCC) describes seven guiding principles which establish autonomous midwifery philosophy and values in relation to expected outcomes of midwifery programmes: A.Provision of Women centered care Every woman expects to be treated as though she is special and important .Although at times maternity units and community workloads can be busy, individual women wants midwives to be there for them , not for someone else.It is essential that midwives have an understanding of social , cultural and context differences so that they can respond to the needs of women and their families in a variety of care setting and priorities and manage work appropriately. Of particular importance is working with families to draw up a plan of care and support and then evaluate and modify that care as circumstances. B. Ethical And Legal Obligations The practice of a midwife is controlled by law, under the Nurses Midwives and Health Visitors Act and Midwives Act. Midwives also need to be familiar with other Acts of Parliament and Statutory Instruments that impact on their practice. The code of professional conduct sets requirements for the behavior of midwives and nurses in relation to such things as confidentiality, respect and personal responsibility for ethical choices. For example, midwives may find themselves expected to care for women who have decided to terminate their pregnancy. Even though the midwife have objection regarding it, she cannot
refuse to provide care for the woman. Counselling services are normally provided for women and staff facing ethical dilemmas and stressful situations. C. Respect for Individuals And Communities Society is composed of people from many cultures, ethics, and religious backgrounds. Midwifery care must be provided in a non-discriminatory way without prejudice; Where midwives find they don‟t have the skill or expertise to provide effective care for individuals or groups then need to seek assistance. In areas where there are number of residents who don‟t speak the local language, link workers or an interpreting service can be more appropriate than asking another family member; especially a child, to communicate between the woman and the midwife. D. Quality and Excellence Individual midwives should strive for continuous improvement and excellence in midwifery practice. To protect the health and well-being of mother and babies , supervision of midwives is enshrined in statute. Clinical governance has more recently been established to assure the quality of all the health services provided by an individual NHS Trust and has many principles that mirror statutory supervision of midwives. Auditing of standards and discussion of difficult maternity care scenarios are ways in which all professional groups can work together to improve the quality of services. Involvement of mother in evaluating care and suggestion for areas that need improvement have become even more important in contributing to become even more important in contributing to quality and excellence in the maternity services. E.The changing nature and context of Midwifery Practices Midwives need to be flexible and also become change agents when necessary. Theu need to adapt to new technologies to improve the quality of care, providing quality care and there by developing their existing skills and identify changes needed. F.Evidence – based Practice and learning The practitioners of midwifery should have evidence for effective care and not assume that all research is of value but that it must be critically analysed. It intends to foster the use of sysytematic reviews such as effective care in pregnancy and childbirth. G.Life-long Learning Midwife should adapt a style of learning complex and problem solving skills and become expert practitioners with upto date knowledge of informations. Midwives also need to grasp opportunities to learn from each other by observing , discussing different ways of practicing and where necessary seeking out an education or training event.
The Independent Nurse midwifery management processes
Regardless of the practice setting, the nurse midwife care encompasses four aspects of management: 1.Independent Management Nurse midwife are responsible and accountable for the management decision they make in caring for the patient. Nurse midwife provides independent management when they sysytematically obtain or update a complete and relevant database for assessment of the patients health status. This includes the history the physical examination results, the laboratory data. On the basis and interpretation of this findings, nurse midwives accurately identical problems and diagnosis and implement a plan of action. 2.Consultation When nurse midwives identify problems or complication they seek advice from another member of the health care team often a physician. When they retain independence management responsibility for the patient while seeking advice, this is called consultation, may centre on an ongoing health problems, a non obstetrical , time limited problem that arises during pregnancy. After consultation the nurse midwife and the women discuss the recommendations if any and modify the plan of care accordingly. In this process nurse midwife retain responsibility for decision. 3.Co management or collaborative care One out come of consultation may be the decision to shift to co management or collaborative care. This usually occurs if part of the women‟s care is related to an ongoing medical or gynecological complication beyond the scope of the nurse midwives practice. In this situation the nurse midwife and the physician collaboratively treat the patient.
The range of services provided:
Pre-pregnancy advice Advice about birth options Childbirth education classes Continuous midwifery care during pregnancy Preparation for and attendance at births in an appropriate environment of the parent‟s choice. Postnatal care following birth at home, birth centre or hospital. Separate postnatal care for women who want private midwifery care for this period only or who are discharged home early from hospital Lactation consultancy Referral to and advice about other health professional such as medical and natural health practitioners, eg obstetricians, paediatricians, GPs , chiropractors, osteopaths, naturopaths , homeopaths Some midwives have a special interest and expertise in supporting women in special areas such as vaginal birth after caesarean section(VBAC), breech births, water births and postnatal depression.
Independent practice Midwife in India
In India 1,00,000 women die every year due to pregnancy related cause (GOI 2005). Over 50 million women suffer from malnutrition in India. Morbidity due to pregnancy is 18 times higher in developing countries and IMR is 7 times higher in developing countries. Risk to a woman of dying from pregnancy related causes: developed countries 1: 4000 to 10,000 where as in India it is 57/1000. IMR in developed countries 1 in 5000 to 10,000 and in India 64/1000.
Major contributing factors for these problems are:
Lack of skilled health care Posts for doctors with obstetric skills in rural and tribal areas often lie vacant Nurse midwives are available at the first level of referral but are unskilled for the level of management required to supervise at-risk deliveries. Poor utilization of midwifery skill. Lack of a supportive policy environment
In order to improve this conditions, the Nursing Council (INC), the parent body of the nursing councils in the country, has rolled out a series of initiatives, many of which are in the early implementation stage, while the rest have been forwarded by INC for approval to the Union Health ministry. Aimed to ease the impact of the shortage of gynecologists in community health centres, INC performed a pilot study for the „ Independent Nurse Practitioner Project‟ in Infant Mortality Rate(MMR) in West Bengal at SSKM Hospital female medical and surgical wards. The project provided an 18 months training in midwifery, besides an additional training in emergency obstetric care to candidates who have completed their BSC in nursing and have two to three years of experience in OB-GYN wards to take care of ANMs in rural sectors. These nurses were called independent nurse as they were trained to prescribe medicines following approved protocols and take decisions independently in absence of gynecologists. The result of the pilot study has been submitted to health ministry and the government of India examined the protocol to extent this project all over India. The GOI response to the challenge: – INC entrusted with responsibility of developing a new cadre of midwives who will work in rural and tribal areas of India Phase 1 – – Funded under the India-Australia Training and Capacity Building Project (IATCBP) as “The Specialist Midwifery Sub-Project”. Supported by technical assistance from Faculty of Nursing, University of Newcastle, Australia
Development of new cadre • • • Consensus building Development phase Implementation phase
Consensus building Step 1: Need for a new cadre of specialist midwifery identified Step 2: Consensus on key issue related to the new cadre. Step 3: Consensus on role and function of nurse practitioner in midwifery Development phase Step 4: Base-line data collected
Step 5: Development of code of ethics Step 6: Development of practice standards Step 7: Development of a framework for service standards Implementation phase Step 8: Development of clinical guidelines Step 9: Development of curriculum framework Step 10: Writing the curriculum Step 11: Development of assessment tools Step 12: Piloting selected modules and assessment Step 13: Review and revision Outcomes The provision of qualified NP in midwifery with skills and knowledge to manage ob and gynae emergencies in rural and tribal areas of India To increase the number of women and infants seeking treatment at the CHCs where the NP is placed thus reducing the risk of maternal and infant mortality and morbidity To decrease maternal and infant mortality and morbidity in the rural and tribal areas of India by providing quality ob and gynae services through NP placed in CHCs.
Training & placement of Independent Nurse Midwife Practitioner Course Duration: 18 months (including 6 months internship) Eligibility/ Qualifications o o B. Sc. Nursing, 2 years experience (at least one year in midwifery) Age: < 45 yrs
Placement: CHC / PHC with facilities for supporting the role & function of new cadre Post: convert one post of staff nurse to NP in Midwifery Salary: equivalent to principal nursing school
Mode of Offer: Full-time only Proposed Course Locations: Colleges of Nursing and Medical Colleges in Calcutta (West Bengal) and Indore (Madhya Pradesh) Proposed Intake for the First 2 years: First year: 6 each from training location Second year: Intake to be reviewed based on the experience of the initial intake Professional Recognition and Accreditation: INC Responsibilities & practice o o o o Promotion of health of women throughout their life cycle with special focus on women during childbearing years and their new babies. Provide autonomous care to women prior to & during pregnancy, during & after childbirth, care of newborn & assume responsibility and accountability for their practice. Practice within the existing peripheral health system consisting of birth attendants, ANM‟s, nurses, doctors & specialists NP will be posted at a facility where no obstetricians are posted or available
Job description Promote health of women before pregnancy through education and counseling for healthy family life including planning for pregnancies. Promote health of women during pregnancy through: Quality, technically advanced antenatal care to women with normal pregnancy Early detection of risk situations and management that commensurate with their level of competence Management of minor disorders of pregnancy Referrals as required
Regulations of practice • INC Act (1947) amended to allow INC to: – – – • Regulate the practice of the NP in midwifery according to the code of ethics License the NP to practice independently (as per practice standards) Authorize & be responsible for preparing, approving & implementing the curriculum
Code of ethics & practice standards are key for licensing & regulation of NP
TEACHING INSTITUTIONS Government (State/Center/Autonomous) nursing teaching institution offering diploma or degree programs in nursing having parent/ affiliated Govt. Hosp. facilities of maternity, neonatal and pediatric units. Or Other non-Govt. nursing teaching institution offering diploma or degree programs in nursing having parent Hosp. facilities of maternity, neonatal and pediatric units The institution conducting this course should have a 50 bedded parent hospital having mother and neonatal units,Case load of minimum 500 deliveries per year, 8-10 level II neonatal beds, Affiliation with level III neonatal bed The number of seats available depend on the number of deliveries conducted in the parent institutions ie, 10 students for minimum 500 deliveries per year 20 students for minimum 1000 deliveries per year STAFFING PATTERN 1. Full time teaching faculty Ratio 1:5 Qualification: M. Sc. Nursing with Obstetrics and Gynaec/Community/Pediatrics Specialty Nurse practitioner in midwifery with B. Sc. nursing Experience: Minimum 3 years 2.Guest faculty - multi-disciplinary in related specialties Distribution of the Course: 1. Teaching: Theory & Clinical practice 42 weeks 2. Internship 3. Examination 4. Vacation 5. Public holidays 4 weeks 2 weeks 2 weeks 2 weeks -----------------52 weeks
Curriculum Theory Clinical Nursing-I
(Inclusive of foundation courses) 90 Hrs Clinical Nursing II90 hrs Paper III (i) Supervision & Management 30 Hrs (ii) Clinical Teaching 30 Hrs (iii) Elementary Research & Statistics 30 Hrs TOTAL 270 Hours
Practical Integrated Clinical Practice 1410 Hrs Internship 160 Hrs Total 1570 Hrs Clinical Experience Maternal and neonatal care Services 38 weeks Antenatal OPD including Infertility clinics /Reproductive medicine, Family welfare and post partum clinic / centre 6 weeks Antenatal and Postnatal ward 4 weeks Labour room 8 weeks Neonatal Intensive Care Unit 4 weeks Obstetric/Gynae operation Theatre 4 weeks Gynae ward 2 weeks Paediatric OPD/under five clinic 2 weeks Paediatric ward 2 weeks CHC,PHC,SC 6 weeks Total practical hours 38 weeks (1410 hrs) Internship 4 weeks in community Institutions conducting NP Course
Gujarat: o o Ahemdabad Baroda
o Bhavnagar: under process PROPOSED CADRE OF NURSE MIDWIFE PRACTITIONERS State Nurse Midwife Practitioner Admin PostProposed -4 Accepted -1 Chief Nurse Midwife Practioner at Regional Level Admin Post (6) Senior Nurse Midwife Practioner (26) at District/Med College attached Hospital Nurse Midwife Practioner (3016) at PHC,CHC, Taluka Medical College attached Hospital
SALARY SCALE OF NEW CADRES
s.no. 1. 2. 3. 4.
Designation Staff Nurse Midwife Practitioner Chief nurse Midwife Practitioner Senior nurse midwife practitioner Nurse Midwife Practitioner
Pay scale 10,000-15,200 8000-13,500 6500-10,000 5500-9000
No of post 4 6 30 3016
Total expenditure 12.02 lakh 14.76 lakhs 50.07 lakhs 43.43 lakhs
Research findings
1. Health Care–Seeking Practices of Pregnant Women and the Role of the Midwife in Cape Town,
South Africa
Naeemah Abrahams rn, rm, mphil†, Rachel Jewkes mbbs, msc, mfphm, md‡, Zodumo Mvo socsc (hon), mphil§ (Journel for Midwifery & women‟s health, volume 46, issue 4, page no:240-247) ABSTRACT The objective of this study was to investigate the health-seeking practices of pregnant women in a periurban area in Cape Town, South Africa. This qualitative study was based on 103 minimally structured in-depth interviews of 32 pregnant women. Most women were interviewed on several occasions, and a group discussion was held with women. The interviews were taped, transcribed, analyzed ethnographically, and, if necessary, translated into English. Antenatal care attendance was influenced by a number of factors, including women's knowledge of the role of antenatal care, perceived health needs, booking systems, nurse-patient relationships, economics, child care, and transport. The expected benefits were weighed against the anticipated costs before decisions about seeking care were made. The findings highlight the importance of women's perceptions of quality of care in influencing their health seeking practices. The study suggests that considerably more attention needs to be given to this aspect of maternity services.
2.Childbirth as healing: three women's experience of independent midwife care M Milan
120, Straight Road, Old Windsor, Berkshire 5LL 2SB, UK
Abstract This article sets out to demonstrate that, for some women, childbirth may be experienced as healing and life-changing. The author works as an independent midwife. Interviews with three ex-clients were analysed, and the common themes identified and grouped. The three women had negative memories of the birth of their first child, but all birthed their second babies at home. The quality of care received was described as empowering, reassuring and emotionally supportive. Practical inputs such as listening presence, information, referrals, touch, were all identified as facilitative. The women framed their perception of the changes which had occurred in terms of reassessment of themselves and their capabilities in the light of the achievement of the birth experience.
Conclusion
The role of midwife is very important. Every midwife should know the scopes of midwifery practices and the role played by independent nurse midwife practitioner in the society, to provide the best and safe care for the mother and the child.
REFERENCE
1. Varney Helen, Kriebs M Jan, “Varney‟s Textbook of Midwifery “, All India Publishers and Distributors,2005, IVth edition, Page no: 3-4 2. Henderson Christine, Myles midwifery , A textbook of Midwifery , published by Davis Karlene Dame,2004, 13th edition, page no: 433-434 3. Wrong L Donna, Hockenberry J Marilyn, Perry E. Shannor, Lowermilk Leonard Dietra, Maternity Child nursing Care, published library of congress, 2006, 3rd edition, page no:299-300 4. http://scholar.google.co.in/scholar?q=independent+midwife&hl=en&as_sdt=2%2C5 5. http://scholar.google.co.in/scholar?hl=en&q=role+of+midwife&btnG=Search&as_sdt=2%2C5&a s_ylo=&as_vis=0
