Midwifery: Care of the Perineum - Research Paper Example

Midwifery: Care of the Perineum Introduction It is undeniably true that most deliveries are undertaken by midwives giving their best care for the maternity. The most critical issue surrounding their role is the care of the perineum. In many countries, authorities given to the midwives concerning pregnancy (antepartum), childbirth (intrapartum), and post-natal (postpartum) were limited into certain extent. In Sweden, Finland, and Norway, midwives are authorized to use obstetric forceps under certain conditions while in some countries they were forbidden to perform a repair of the perineum or episiotomy and even to administer pain-relieving drugs. Most traditional midwives are simply attendants and do very little to interfere with the birth process unless complications arise. Providing prenatal care is rare, although postpartum care of mother and child is a duty of many midwives. The term that is used for midwife is often indicative of her primary function. In many languages, it can be translated roughly as "one who receives the child." For example, the southern Chinese midwives are tan-min, "women who catch birth." Among the Tiv of Nigeria, the midwife is "she who seizes the child." The Navajo term for midwife is awe-xai-zi-si, "the woman who pulls the baby out." The Tikopia midwife is te fafine o tesiki, "the woman of the catching." While there are some role restrictions, midwives endeavor to redefine it in their attempt to expand the maternal care and child welfare all throughout antepartum, intrapartum, and postpartum process. Antepartum Care Care given by the midwife during antepartum and in the labor process has been usually constricted by lack of equipment and facilities. A warm bath is a preferred way to promote relaxation and therefore stimulating labor but many hospitals have no bathtubs which seriously constraint the continued practice of midwifery. Moreover, there are also problems encountered by a lot of midwives in items and traditional techniques for supporting and relaxing the perineum during labor. All women having an epidural (anesthetic injection) must give birth in a delivery room under sterile conditions. Sterile condition entails the impossibility of the use of poultices and oils to minimize perineal pain and prevent lacerations. In response to this, midwives find their way in improvisation. Instead, they can use available sterile pads, doing a 'clean catch' of a lubricant into a sterile cup in order to allow it to be used in the sterile environment and for hot water in labor rooms. Midwives also has the critical responsibility of informing the mother in a caesarean operation wherein the care and protection of the perineum is compelling. In addition, they also have the responsibility of informing the mother that hormonal activity during pregnancy has an effect on the tone of the perineum. At one point in labor, as contractions become stronger and closer together, most women exhibit changes in behavior that include shaking, vomiting, difficulty in talking, anxiousness, and a state that can only be described as "spaciness." This marks transition and indicates that the first stage is drawing to a close, although it may last another 1-2 hours for primiparas. At times, women seem to lose control of themselves during the intense contractions of transition. Crying and whimpering increase. Finally the woman begins to make straining motions as she attempts to push the fetus out, marking the beginning of the second stage of labor. At this point, she may assume a variety of postures including squatting, standing, lying down, crouching on hands and knees, or, most commonly, reclining in a semi-sitting position. The contractions of the second stage are described as expulsive, and they are usually accompanied by straining and exerted pushing efforts on the part of the parturient. Muscle spasms and cramps are not uncommon with these contractions. Usually the woman holds her breath during the pushing contractions, and often exhalation commences with a sharp cry or "yelp." The woman does not appear to experience so much pain as was obvious in the late first stage contractions, but she is expending far more effort. It is during the second stage that "labor" with its meaning as "work" is most evident. She usually appears exhausted between contractions, but she seems to be more in control of her body and emotions than she was during transition. In most cases, midwife has her hands at the perineum and a husband, friend, or another support person is near the woman's head or sitting behind her, providing something for her to push against. During a contraction of the second stage, she pushes against something or someone with her legs and pulls up with her arms (Trevathan 1987). It appears that all muscles in her body are devoted to the task of pushing the baby out. Intrapartum Care Delivery process is a very sensitive and delicate situation in which midwives have to be careful in assisting the process. In cases of mothers not considering consent to an episiotomy even though the perineum remains thick and rigid through several labor processes, midwives can do nothing much to help until the mother gives her consent. Should this situation happen, then midwives are authorized to perform the necessary procedure even without consent from the mother in order to protect the fetus (Jones & Symon 2000). Even though the midwife carrying out episiotomy without consent could possibly face a claim of battery against her, jeopardizing the condition of the fetus is neither an ideal solution. As a support for this, Al-Mufti et al (1997) opted for a caesarian section for such situation. On the other hand, Robinson (1998) relied on the midwife's choice and commented that it would be interesting to know what they would choose notwithstanding most doctors and midwives supporting the notion of mother's choice (DOH 1993). Anecdotal evidence suggests that, where a midwife thinks that a certain course of action, contrary to the policy, is in the best interests of the woman, she will make appropriately worded suggestions to the woman. When the woman agrees with the midwife, the midwife writes something to the effect that the action or omission was according to the woman's wishes or request. It could be argued that this lacks a degree of veracity and is therefore unethical practice; however, if the midwife really believes that her actions were based on beneficence and non-maleficence, it could be deemed to be highly ethical. Postpartum Care While midwives are traditionally referred as simply attendants doing very little to interfere with the childbirth, postpartum care of mother and child is a duty of most midwives. Such duties include proper routine doses of antibiotics for the immediate recovery of the patient. Midwives play a vital role in postpartum care since even single-dose therapy will result in significant reductions in infectious outcomes (Enkin et al. 1995, 2000). Midwife's care is much more significant in a sensitive operation such as caesarian otherwise there will be potential for adverse effects on a future pregnancy: reduced fertility and increased chance of conditions such as placenta praevia and accreta (Page 1999), as well as some other possible long-term effects according to Amu et al. (1998). Although there have been unknown potential adverse consequences of routine antibiotic prophylaxis, there have been no reports of serious maternal side effects of antibiotics prophylaxis for caesarian delivery. Antibiotics administered to the mother prior to the delivery of the infant can result in transfer of the medication to the fetus. This can lead to diagnostic interventions to rule out sepsis in the newborn which are costly and distressing to parents and infant. The available evidence suggests that antibiotics administered after cord clamping are just as effective as those administered pre-operatively in preventing post-operative infection (Chalmers et al., 1989). References Al-Mufti, R. et al. (1997). Survey of obstetricians' personal preference and discretionary practice. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 73, pp. 1-4. Amu, O et al. (1998). Maternal choice alone should not determine method of delivery. British Medical Journal. 317(156), pp. 463-465. Department of Health (1993). Changing childbirth. Report of the Expert Maternity Group. HMSO, London. Enkin, M et al. (2000). A Guide to Effective Care in Pregnancy and Childbirth. Third Edition. Oxford University Press. Oxford. Enkin, M, E Enkin, I Chalmers, et al. (1989). Prophylactic antibiotics in association with caesarean section. In Effecitive Care in Pregnancy and Childbirth. Volume 2: Childbirth. Parts VI-X and Index. Editors Chalmers I, M Enkin, and MJN Keirse, pp. 1246-69. Oxford University Press. New York, NY. Enkin M, MJN Keirse, M Renfrew, et al. (1995). Labour and delivery after previous caesarean section. In A Guide to Effective Care in Pregnancy and Childbirth, Second Edition. Oxford University Press. New York, NY. pp. 284-327. Jones, S. R. & Symon, A. (2000). Ethics in Midwifery. Mosby. Edinburgh. Robinson, J. (1998). Caesarian section: women's choice. British Journal of Midwifery. 6(10), p. 669. Page, L. (1999). Caesarian birth: the kindest cut British Journal of Midwifery. 7(5), p. 296. Trevathan, W. R. (1987). Human Birth: An Evolutionary Perspective. Aldine De Gruyter. New York. Read More