Midwifery at a Glance E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Wiley Series on Cognitive Dynamic Systems
• Sprache: Englisch

Seitenzahl: 455

Veröffentlichungsjahr: 2018

Beschreibung

Midwifery at a Glance offers an easy-to-read yet comprehensive overview of everything a midwifery student needs to know, from conception to care of the newborn.

This practical guide provides coverage of normal pregnancy, maternal and foetal physiology, and pre-existing medical conditions and how these affect pregnancy and birth. It also features vital information on the role of the midwife, evidence-based practice, health promotion education, and perinatal mental health, as well as neonatal care and an overview of emergency situations.

Midwifery at a Glance:

• Contains superb full colour illustrations throughout
• Is written specifically for midwifery students and includes all the concepts found on the midwifery curriculum
• Demonstrates links with other relevant multidisciplinary healthcare professionals

Midwifery at a Glance is the ideal guide, offering educational support for midwifery students in the application of midwifery knowledge into clinical practice.

Leseprobe

Midwifery

at a Glance

Edited by

Eleanor Forrest

Glasgow Caledonian University Glasgow, UK

Series Editor: Ian Peate OBE, FRCN

This edition first published 2019 © 2019 John Wiley & Sons Ltd.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Eleanor Forrest to be identified as the author of the editorial material in this work has been asserted in accordance with law.

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Library of Congress Cataloging-in-Publication Data

Names: Forrest, Eleanor, editor. Title: Midwifery at a glance / edited by Eleanor Forrest. Description: Hoboken, NJ : Wiley-Blackwell, 2018. | Series: At a glance series |    Includes bibliographical references and index. | Identifiers: LCCN 2018034897 (print) | LCCN 2018035390 (ebook) | ISBN    9781118873618 (Adobe PDF) | ISBN 9781118873601 (ePub) |    ISBN 9781118874455 (pbk.) Subjects: | MESH: Midwifery—methods | Postnatal Care—methods |    Prenatal Care—methods | Pregnancy—physiology | Handbooks Classification: LCC RG950 (ebook) | LCC RG950 (print) | NLM WQ 165 | DDC    618.2—dc23 LC record available at https://lccn.loc.gov/2018034897

Cover image: © SolStock/Getty Images Cover design by Wiley

CONTENTS

Cover

Contributors

About the companion website

Part 1 Introduction

1 Historical overview of midwifery

2 NHS values

Six values

Six ‘C's

3 Ethics

Micro and macro

Personal, professional and theoretical

Autonomy

Beneficence

Non-maleficience

Justice

4 Role of the midwife

Definition

Scope of practice

5 Drug exemptions

Exemption from restrictions on sale or supply

Exemptions from restriction on administration

Midwife's supply order

Student midwives and exemptions

6 Women's choice and care options

Access

Type of antenatal care

Place of birth and postnatal care

Part 2 Anatomy and physiology

7 Breast

Breast development

Physiology of lactation: how the breasts lactate and produce milk

8 Female reproductive system

Internal organs of reproduction

Vulva

9 Menstrual cycle

Control of the menstrual cycle

Endometrial change

10 Maternal pelvis

11 Maternal pelvis and fetal skull

Position of the vertex

Examination per vaginam

Moulding

Swellings on the head

Part 3 Preconception

12 Preconception care

Guidance for preconception care

Multidisciplinary preconception care

13 Follow-up after pregnancy loss

Referral process

First trimester miscarriage

Investigations

Late miscarriage and stillbirth

The appointment

Part 4 Antenatal

14 Maternal physiological adaptation 
to pregnancy

Cardiovascular system

Respiratory system

Renal system

Gastrointestinal system

Musculoskeletal system

Breast changes

Skin changes

Uterus, cervix and vagina changes

Weight gain

15 Taking a history

Why

Who

Where

When

How

What

16 Antenatal investigations and screening

Screening tests

Diagnostic tests

17 Preparation for childbirth

Psychological birth preparation

Active birth preparation

Adult learners

18 Post-term pregnancy

Definition

Accurate dating

Factors increasing the risks of post-term pregnancy

Features

Management and midwifery care

Key points

Part 5 Intrapartum

19 Physiology of labour

Fetal initiation

Prostaglandin

Corticotrophin-releasing hormone

Oxytocin

20 Mechanism of normal labour

Fetal journey in labour and birth

Passenger, power and passage

Fetal positioning and descent

Progress through the mechanism

Birth

Detecting deviations

21 Promoting normal labour

Physiology

The Midwife's role

Stages

22 Pain relief

Non-pharmacological methods

Pharmacological methods

23 Water birth

The baby, birth and third stage

The midwife’s role

24 Augmentation of labour

Definition of delay

Suspected delay

Following membrane rupture

The midwife’s role in prolonged labour

25 Induction of labour

Reasons for induction of labour

Methods of induction of labour

Criteria for induction of labour

26 Nutrition in labour

Lack of nutrition

Emesis

Fluid replacement

Food to eat in labour

Part 6 Postnatal care

27 Immediate care: 0–6 hours

Recording of vital signs

Blood loss

Uterine palpation

Circulation

Bladder and bowel function

Breasts

Pain

28 On-going care

Observations

Advice

29 Daily maternal examination

Time

Observations

Breasts

Blood loss and uterine involution

Perineum

Bladder and bowel

Legs

Documentation

30 Physiological changes

Uterine involution and vaginal fluid loss

Perineum

Breasts

Body systems

Role of the midwife

31 Pelvic floor

Muscles

Nerve supply

Risk factors

Pelvic floor muscle exercises

32 Sepsis

Who is most at risk of postpartum sepsis?

Recognition of sepsis

How is postpartum sepsis diagnosed?

How is it treated?

How can postpartum sepsis be prevented?

33 Contraception

34 Lactation

Responsive feeding

Pattern of infant sucking: effective 
breast feed

Night feeds

Attachment for breastfeeding

Positioning for breastfeeding

Part 7 Common medical disorders

35 Hypertensive disorders of pregnancy

Chronic hypertension

Gestational hypertension

Pre-eclampsia

36 Diabetes

Pre-existing diabetes

Gestational diabetes

37 Thromboembolic disease

Pathophysiology

Classification of VTE

Identification

Prevention and thromboprophylaxis

38 Obesity

Weight, height and calculating BMI

Risks of obesity to childbearing women

Risks of maternal obesity to fetus/infant

Information to give during pregnancy

Surveillance and screening in pregnancy

Thromboembolism and thromboprophylaxis

Place and mode of birth

Challenges for the midwife

39 The thyroid gland and thyroid disorders

Thyroid gland

Thyroid disorders

40 Systemic lupus erythematosus

Diagnosis

Preconception

Pregnancy and birth

Postnatal

Midwifery care

41 Obstetric cholestasis

Part 8 Obstetric complications

42 Antepartum haemorrhage

Placental abruption

Placenta praevia

Presentation

Management

Complications

43 Shoulder dystocia

Predisposing factors

Recognising and managing

Care after birth

44 Cord presentation and prolapse

Definitions

Prevention

Management

After birth

Staff training

45 Embolism

Terminology

Type

Causes of VTEs

Importance of recognition

Symptoms

Timing of the emergency

Treatment

46 Obstructed labour

Diagnosis and presumptive signs 
in early labour

Causes

Signs and symptoms as labour progresses

Management

47 Uterine rupture

Classification

Prevention

Presentation

Management

Postnatally

48 Uterine inversion

Classification

Causes and risk factors

Recognition

Management

Aftercare

49 Preterm labour


Incidence and risk factors

Risks of preterm labour and birth

Management of preterm labour

Management of preterm prelabour rupture of membranes

50 Eclampsia

Management of eclampsia

Pre-eclampsia

Management of severe pre-eclampsia

Post birth

51 Disseminating intravascular coagulopathy, shock and high dependency care

Signs and symptoms of DIC

Shock

High dependency care

52 Malposition and malpresentation

Malposition

Malpresentation

53 Postpartum haemorrhage

Definitions

Risk factors

Causes

Signs

Management

54 Multiple pregnancy

Incidence and variation of type

Complications of pregnancy

Management

Part 9 Fetus and baby

55 Intrauterine growth restriction

Pathophysiology

Neonatal outcome

Long-term health effects

56 Intrauterine growth restriction monitoring

Symphysis–fundal height measurements

Non-stress and contraction stress tests

Biophysical profiles

Amniotic fluid volume

Umbilical arterial blood flow

Timing of birth

Intrapartum

57 Fetal circulation

Differences in the fetal and adult heart structure

Blood flow

58 Changes at birth

Heart and pulmonary system

Thermoregulation

Hepatic system

Gastrointestinal system

Renal system

Excretory system

Nervous system

59 Fetal skull

Regions of the fetal skull

Landmarks of the fetal skull

Areas of the fetal skull

Diameters of the fetal skull

60 Immediate care of the newborn

Instinctive newborn behaviour

Skin-to-skin contact

Thermoregulation

Vitamin K

Initial examination of the newborn

61 Normal neonate and care needs

Sleep

Crying baby

Infant feeding

Colic and wind

Sudden unexpected death in infancy (SUDI)

Spotting signs of an ill baby

62 Infant nutrition

Breastfeeding

Preconceptual nutrition

Nutrition in pregnancy

World Health Organisation guidance

Infant formula feeding

Weaning

63 Neonatal jaundice

Physiology of bilirubin metabolism

Causes of hyperbilirubinaemia

Aetiology of physiological jaundice

Investigations

Care of baby

Kernicterus

Part 10 Psychological dimensions

64 Becoming a parent

Becoming a parent

Bonding and attachment

Support for parenting

65 Maternal mental health


Perinatal mood disorders

66 Bereavement care

Grief

Breaking bad news

Encouraging memories

On-going support

67 Gender-based violence

What is gender-based violence?

68 Alcohol and drugs

Alcohol consumption

Drugs

69 Trafficking


Trafficking and childbirth

Health services

70 Homelessness

Possible homelessness priority groups

Homelessness and childbirth

Health services

71 Asylum seekers and refugees

Barriers to maternity care

Best practice

72 Teenage mothers

Health needs

Safeguarding

73 Disability

Disability awareness and duty of care

Impact of pregnancy on disabled women

Effective care provision

74 Health promotion education

Midwifery-related public health practices

Points to note

75 Psychological changes

Positive influences

Negative influences

Mother's adjustment

Father's adjustment

Relationship changes

Fetal/baby adjustment

Part 11 Midwifery skills

76 Antenatal abdominal examination

Terminology relating to prenatal abdominal examination

Preparation for examination

Components of examination

77 Vaginal examination

Antenatal examination

Intrapartum examination

Medicines per vaginam

Procedure

78 Artificial rupture of membranes


Timing of ARM

Considerations prior to ARM

Equipment for ARM

Preparation for ARM

Procedure

Considerations following ARM (Figure 78.7)

79 Urinary catheterisation


Intermittent or indwelling

Side effects

Indications

Procedure

80 Blood pressure and temperature, pulse and respiration: back to basics


Changes related to pregnancy, birth and the puerperium

Recognising pathology

81 Episiotomy

The pelvic floor

The perineal body

Infiltration of anaesthetic

Performing the episiotomy

82 Perineal repair

Anatomical structures

Degrees of perineal trauma

Identification of perineal trauma

Preparation prior to perineal repair

Infiltration of anaesthetic

Perineal repair

Post-perineal repair

83 Feeding support and breast expression

The law

Expressing breast milk

Storing expressed milk

84 Blood and blood products

Patient identification and documentation

Communication and collection 
of blood products

Administration equipment 
and infusion devices

Monitoring

Administration of drugs 
with blood products

85 Maternal resuscitation

Resuscitation in pregnancy

Basic life support

Advanced life support

86 Neonatal resuscitation

Drying and covering

Assessing condition

Airway

Suctioning

Breathing

Chest compressions

Drugs

87 Examination of the newborn

Preparation

Observation before examination

Physical and clinical examination

Following the examination

88 Newborn bloodspot screening

Maternity services

Newborn screening laboratory

Child health record team

89 Care of women having surgery

Preoperative care

Perioperative care

Postoperative care

References and further reading

Index

End User License Agreement

Guide

Cover

Table of Contents

Contributors

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Contributors

Lynda BatemanUniversity of Hull Hull, England

Sarah Bennett-DayUniversity of Suffolk Suffolk, England

Nicola BradleyNHS Greater Glasgow & Clyde Glasgow, Scotland

Jo ButlerUniversity of Suffolk Suffolk, England

Sam Chenery-MorrisUniversity of Suffolk Suffolk, England

Laura ColtartNHS Greater Glasgow & Clyde Glasgow, Scotland

Fenella CoweyNHS Tayside Perth, Scotland

Catriona HendryGlasgow Caledonian University Glasgow, Scotland

Cindy HoranQueen Elizabeth University Hospital Maternity Unit Glasgow, Scotland

Lyz HowieUniversity of the West of Scotland Paisley, Scotland

Anne LenniePrincess Royal Maternity Hospital Glasgow, Scotland

Helene MarshallNES Scotland Edinburgh, Scotland

Marion McPhillipsFamily Nurse Partnership National Unit Edinburgh, Scotland

Ola OgbuehiUniversity of Hull Hull, England

Heather PassmoreUniversity of Suffolk Suffolk, England

Lorna PenderGender Based Violence Resource Unit Glasgow, Scotland

Angela PoatUniversity of Hull Hull, England

Liz TeigerGlasgow Caledonian University Glasgow, Scotland

Jane TylerUniversity of Hull

About the companion website

This book is accompanied by a companion website:

www.wiley.com/go/forrest/midwifery

The website includes over 260 interactive multiple-choice questions

Part 1Introduction

Chapters

1   Historical overview of midwifery

2   NHS values

3   Ethics

4   Role of the midwife

5   Drug exemptions

6   Women’s choice and care options

1Historical overview of midwifery

Midwifery is one of the oldest occupations in the world, if considered simply as the presence of a woman accompanying another woman during her childbearing event, with knowledge passed from one generation to another. The term midwife is understood to mean ‘with woman' but older terms have existed such as ‘howdie' in Scotland. Midwives' status in the community rose and fell over the centuries, influenced by medical men and concern over their mysterious powers. Soranus of Ephesus (2nd century AD) is credited with writing the first textbook on midwifery, which described desirable characteristics of a good midwife to be ‘literate, with her wits about her, good memory, loving work, respectable, not unduly handicapped as regards her senses, sound of limb, robust, long slim fingers and short nails, soft hands, free from superstition and of sympathetic disposition.' The contemporary concept of a ‘good midwife' is related to the complementary areas of theoretical knowledge and skilled competence underpinned by lifelong learning, communication skills, and personal qualities including emotional intelligence, with a midwife's professionalism being central to women's empowerment during childbirth. However, often women became midwives by default of attending a birth with a midwife and then being asked to attend others.

The first school to train midwives was founded in Edinburgh in 1726, followed by Glasgow in 1739, with others following in England. However, training was mainly under the auspices of the Faculty of Physicians and Surgeons. The 18th century also saw the rise of male midwives among controversy regarding their role in attending women. Smellie (c. 1750) provided anatomical knowledge that contributed to understanding the mechanism of normal labour, while Chamberlen (c. 1733) used forceps to aid delivery of a live baby rather than just to extract the often dead fetus. During the 19th century, educated middle class women tried to improve the status of midwifery as a profession through the eradication of caricatures such as the uneducated, drunken Sarah Gamp portrayed by Charles Dickens. The Ladies Obstetrical College (1846) was formed by these educated women, offering theoretical and practical training, but was disbanded due to puerperal fever. The London Obstetrical Society Examining Board (1872) required candidates for midwifery to be aged between 21 and 30 years and have proof of attending a minimum of 25 cases; however only six took the exam.

Rosalind Paget and Zepherina Veitch were influential women in the establishment of the Midwives Institute (1881; to become the Royal College of Midwives (RCM)), which campaigned for the registration of midwives, culminating in the Midwives Act 1902 (England and Wales) which specified the education and training, registration and certification, supervision and control of midwifery practice. Therefore it was not until the 20th century that legislation existed to regulate midwifery practice. The roll of qualified midwives maintained by the Central Midwives Board (CMB), included women who already possessed a recognised qualification in midwifery and women of good character who had already practiced as a midwife for at least 1 year (bona fide midwives). Legislation laid down several aspects of midwifery practice and rules concerning equipment, clothing and standards of hygiene that were considered essential, which continued until the 1970s.

Improvements in midwifery practice focused on strategies to reduce maternal and perinatal mortality rates, aided by social and environmental and technological advances, combined with changes in working practices and education and training for midwives. Pressure groups such as the Association of Radical Midwives (ARM) and the National Childbirth Trust (NCT), together with the RCM as a professional and trade union-affiliated organisation, through various reports and campaigns, have influenced both the provision of care and status of the midwife as professionals (Table 1.1).

Changes in the regulatory body (CMB to UK Central Council (UKCC) to Nursing Midwifery Council (NMC)) over the years have seen modifications to the Midwives Rules and Standards (NMC, 2012) and The Code (NMC, 2015) to less specified activity with greater use of professional knowledge and competence. Supervision of midwives increased after 1996, with their role and function being prescribed within the Midwives Rules and Standards; however recent investigations into the practice of midwifery supervision (such as Morecombe Bay and Guernsey) have led to the demise of this within the regulatory function of the NMC (Chapter 5).

In 1986, Project 2000 recommended a 3-year curriculum, with midwifery being seen as a branch of nursing. This was fiercely rejected by the profession and a year later the RCM advocated a 3-year curriculum for midwifery in the UK with direct entrant midwifery, which was supported by the English National Board in 1988. Whilst two hospitals continued some direct entrant training (Edgware and Derby), in 1989 seven ‘midwifery schools' commenced 3-year direct entrant midwifery training, and by 1994 there were 35 three-year pre-registration programmes, at both degree and diploma level, linked to higher education institutions. The formation of the UKCC in 1989 had led to removal of the requirements for specified hours of medical practitioner input into the midwifery curriculum and examination. By 2009, the NMC, within their standards for pre-registration midwifery education, stipulated that midwifery should became an all degree profession.

Midwifery remains an important occupation and is highly valued by women. However, constant tension between personal qualities, as aligned to the NHS values and the six ‘C's of Care (Chapter 2), and professional competencies of midwives and other occupations have all had an impact on the status of midwifery and the autonomy and control of midwives. Changes in relation to the skill mix in maternity services and in midwifery supervision and the future of the Midwives Rules and Standards have set the scene for the potential of professional control remaining an important issue in the future of midwifery practice.

2NHS values

The NHS was founded in 1947 to improve health and wellbeing within a common set of principles. The NHS Constitution was first published in 2009 by the Department of Health as part of a 10-year plan to provide the highest quality of care and service for patients in England. Updated in 2015, it explicitly states the principles (Box 2.1), values and pledges that patients, the public and staff can expect from the NHS and what the NHS expects from them in return.

NHS Scotland has published the 10 Essential Shared Capabilities supporting person-centred approaches to care (Box 2.2) that has themes comparable to the NHS Constitution. Following the failings at the Mid Staffordshire NHS Foundation Trust, it is vital that everyone involved in the NHS learns from the findings of the subsequent Francis Inquiry and Keogh and Berwick Reviews (Box 2.3). The NHS values describe how everyone using or working within the NHS should be treated and the updated constitution reflects that the NHS's most important value is for patients to be at the heart of everything the NHS does.

Six values

The six NHS values are respect and dignity; compassion; working together for patients; improving lives; everyone counts; and commitment to quality of care. These apply to all recipients and providers of care and describe the aspiration to facilitate co-operative working at all levels of the NHS.

Applied to midwifery practice these values can be considered as:

Respect and dignity

– every person is valued as an individual and respect is given to their aspirations and commitments in life, and their priorities, needs, abilities and limits should be understood, irrespective of whether they are a mother/baby, family member or staff. Care should be provided with honesty and integrity and listening to the views of others, for example when formulating a birth plan, to enhance provision of safe and effective care.

Compassion

– midwives should respond with humanity and kindness to each mother's need, pain or distress and find things that will provide comfort and relieve suffering to mothers and their families but also their colleagues, for example during labour and in times of bereavement.

Working together for patients

– mothers, babies and their family come first in everything a midwife does. Collaboration with the multidisciplinary team and networking plus seeking the views of service users will contribute to effective care delivery.

Improving lives

– the public health role of the midwife and health promotion can affect the mother's health. Midwives can innovate and improve care to improve health and wellbeing plus the mother's experience of the NHS, for example establishing teams to support vulnerable women.

Everyone counts

– midwives should maximise resources for the benefit of the whole community of mothers, babies and their families, whatever their social or educational background, their race, religion or culture; for example all women should have equal access to antenatal classes.

Commitment to quality of care

– midwives must provide safe and effective care. The right care, in the right way at the right time is dependent upon midwives' knowledge and skills, communication and competence and ability to work with others. Midwives should offer evidence-based care, for example using National Institute for Health and Care Excellence (NICE) guidance and participate in clinical audits.

Six ‘C's

In 2012 the Chief Nursing Officer for England launched a vision for nurses and midwives entitled Compassion in Practice, to provide for basic human needs with care and compassion; all patients can expect to receive such care within the NHS. This applies to midwives as well as nursing. The 6 ‘C's – care, compassion, commitment, courage, communication and competence – are the core elements of the vision (Box 2.4). Care is the core business of midwives, which improves the lives of mothers, babies and their families. Mothers expect care to be right for them, consistently, throughout every stage of their childbearing process. Compassion is how care is given through relationships based on empathy, respect and dignity – it can also be described as emotional intelligence, and is central to how people perceive their care.

The 6 ‘C's reaffirm the qualities and standards that the public can expect from midwives, and those in the profession are aware that no matter how midwifery changes, the six values remain at the core. If midwives work in accordance with the 4 ‘P's of professional practice (Box 2.5) as defined by the Nursing and Midwifery Council (NMC) in The Code (NMC, 2015), their practice will be congruent with the NHS principles and values. This will enable practitioners to maintain their professional knowledge and competence to perform safely but also report when care does not fulfil these standards.

Quality is defined as excellence in patient safety, clinical effectiveness and patient experience and is an organising principle of the NHS. Clinically effective care delivery is supported through the remit of NICE (Box 2.6) and numerous guidelines support midwives and their colleagues in the delivery of high-quality care, for example intrapartum care and antenatal and postnatal mental health. An effective healthcare system should: (i) prevent people from dying prematurely, (ii) improve the quality of life for people living with long-term health conditions, and (iii) aid recovery for those with ill health. The NHS Outcomes Framework identifies five overall principles, three of which relate to midwifery care (domains 1, 4 and 5) (Figure 2.1).

The NHS values require the development of a culture where it is the ‘norm' to Observe others, Praise good practice, Challenge poor practice and Escalate concerns readily (OPCE). Adherence to this will improve outcomes and satisfaction for mothers and their families.

3Ethics

Ethics are pervasive in midwifery practice. Ethics is a term used to cover fundamental principles of what is right and wrong and what people should or ought to do. Ethical principles can be explored at the micro or macro level or from a personal, professional and societal viewpoint.

Micro and macro

Micro-level ethics promotes good interactions between women and midwives, based on mutual respect and trust. It offers all women equitable care and promotes truly individualised information so each woman can make the right choice according to her needs, religious beliefs and values. Macro-level ethics looks at policies, technologies and practices across the reproductive health span. These include issues of sexual consent, the rights of women to choose contraception, abortion or to be sterilised, or where to give birth to their baby.

Personal, professional and theoretical

Everyone has a right to their own ethical values and beliefs. Beliefs come from our parents, upbringing, schooling, education, religious figures and the media. Most people have views on what they believe to be morally right or wrong on issues such as life or death and reproductive choices.

As midwives our personal beliefs need to be set aside when offering professional midwifery care and information to pregnant women or new mothers. Across the globe each country will have their own professional code of ethics which generally follow those produced by the International Confederation of Midwives (ICM) based around four concepts (Figure 3.1). In the UK, the Nursing and Midwifery Council publishes The Code (NMC, 2015) which includes the ethical principles nurses and midwives must understand and adhere to (Figure 3.2). These include: making the people in your care your first priority, protecting and promoting others' wellbeing, providing a high standard of care, being open and honest and acting with integrity to uphold the reputation of your profession. Key terms like gaining informed consent and maintaining professional barriers and confidentiality are explained in further detail. How you offer informed consent to any treatment or intervention in midwifery, from screening tests to suturing, matters. What you say and how you say it either enables or acts as a barrier to empowering the individual women to make autonomous decisions about what is acceptable to her. Doing or saying what we think is right is not acceptable, we need to give women the evidence, carefully describing the risks and benefits so they can make their own decisions whether to accept or decline care options.

There are only two areas of professional practice where your views as a person matter. The term used is contentious objection and the two practices are: providing abortion care and technological procedures to achieve a pregnancy. However, if the woman needs emergency treatment in either case, the midwife has a duty to provide this, regardless of their personal views.

Theoretically, one of the most prevalent ethical frameworks used in healthcare was devised by Beauchamp and Childress (Figure 3.3). Their four principles were originally non-hierarchical, meaning each principle had equal weight, but now the principle of respect for autonomy is seen as paramount.

Autonomy

The word originates from the Greek for self-govern. It is often applied to midwifery practice but in ethics it means the individual is capable to decide for themselves what matter in their life. The moral obligation of a midwife regarding autonomy of another person is to respect their choices. In order for women to make informed choices the midwife imparts information that must be factual and complete. The midwife's role is not to bombard individual women with information but to have conversations in language they understand so they can choose which care and which tests they want and where to have their baby. Not giving enough information is not acceptable, it assumes you are treating the woman as a child (paternalism) and disengages the woman and her family actively in her care decisions. Legally, information is required prior to consent, whether this is to take a blood pressure measurement, an ultrasound scan or examination. If a woman lacks autonomy, her competence or capacity to consent to care may be undertaken by another person in her best interest. This is unusual in midwifery.

Beneficence

In order to act for the benefit of others, all the evidence must be considered. As a midwife it is your obligation to maintain contemporaneous research knowledge. As a practitioner you will know smoking in pregnancy is harmful to the woman and her developing fetus. You have a responsibility to offer smoking cessation advice (beneficence) but the woman has the right to decide whether to take this advice or not (autonomy). Her right to autonomy must be upheld, but you still have a duty to promote wellbeing. Open and honest interaction between you and the woman regarding her choices and informing her of the benefits of smoking cessation are required. The woman cannot choose to quit if she does not know the benefits of cessation for her and the baby.

Non-maleficience

Avoiding harm to others seems simple enough, yet there are many interventions in midwifery that may cause harm which should be considered. For example, a vaginal examination may be offered, especially in labour. This may be uncomfortable and an invasion of the woman's personal body, yet the information gained from performing a vaginal examination may be needed to offer her care options. So the benefit of undertaking this exam may outweigh the harm it causes. However, some women may experience significant harm from having this exam, so the concept of non-maleficience is not always straightforward. A woman may decline blood products due to her religious beliefs; although the blood may do no physical harm, her moral beliefs would be harmed in accepting it. All midwifery interventions require consideration for potential harm for individuals.

Justice

This is concerned with the distribution of healthcare, to make sure that everyone has access to a fair system. As midwives you have an obligation to treat all women equally.

4Role of the midwife

Definition

The International Confederation of Midwives (ICM) represents the midwifery profession worldwide. For the title ‘midwife' to be used; a person must demonstrate competency in the practice of midwifery through the acquisition of specific skills, leading to qualification by a recognised midwifery education programme.

‘The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife's own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures' (ICM, 2011).

Midwives are also professionals who engage with women and their families. This is an insightful time and an opportunity to make a lasting, positive impact. The midwife is in a prime position to assume a wider public health role, including preconception care, health counselling and education for the woman, her partner and other children. As the midwife's role is complex, the midwife continuously must adapt to the needs of the woman and her family. Women want a midwife to be with them through all aspects of their care. The midwife must be the expert in normality and health promotion and the co-ordinator when care falls outside her remit; knowing when to refer to other professionals such as obstetricians, general practitioners, health visitors, social workers and specialist services (such as mental health).

Scope of practice

The majority of midwives (96%) in the UK work within the NHS, with the remainder working in a self-employed capacity as independent practitioners, often as part of a small team. However, all qualified midwives must be registered with and are regulated by the Nursing and Midwifery Council (NMC). Midwives have a direct responsibility to the women in their care and for actions taken when providing care – professional accountability. Fundamental to practising as a midwife is the commitment to upholding the professional standards set out by the NMC (2015), published in The Code (Figure 4.1). To maintain registration and continue to practice in the UK, a midwife, as of April 2016, must ‘revalidate' with the NMC every 3 years. The NMC exists to protect the public and ensure that only those registered to practice midwifery can provide care in the UK. In serious cases, a midwife may have her registration suspended or revoked. Revalidation ensures not only that the public are safe from practitioners who have failed to meet the required standards of professionalism and competence, but maintains a culture of continued professional development and life-long learning for midwives, upholding a high, deeply respected public profile.

A midwife may work in a wide variety of settings, from community centres, to women's homes, stand-alone midwife-led birthing centres, co-located birthing units and hospitals. Her sphere of practice may include preconception care; she is the first point of contact for a woman upon conception, and for health promotion, education and support through the antenatal period, as well as clinical assessment and documentation. She is the primary care giver for a woman experiencing a normal pregnancy and documentation would include direct referral for ultrasound scans, all screening tests and referral to other practitioners, such as obstetricians. A midwife is the lead professional at a home birth or within a midwifery-led birthing centre/unit and a co-ordinator of care when a woman requires input from the medical team. Midwives provide immediate care to the newborn baby and must be competent in managing emergency situations. Midwives support women in the earliest days of parenting, ensuring this transition is a positive and life-affirming one, advising and offering support and education on breastfeeding, basic care and hygiene principles. The postpartum is an emotional and testing time for a new family, the midwife will care for a woman and her baby within the hospital environment and at home, typically for up to 10 days but this may be extended in some areas to 28 days postpartum. Midwives may look to progress in their career, entering varying levels of management, education and research (Figure 4.2).

In general, the midwifery model of care is social rather than medical and is underpinned by a philosophy of normality and the natural ability for the woman to give birth to her baby with minimum intervention, enhancing her wellbeing and feelings of empowerment, placing the woman at the centre of care. The midwife must then be competent in the planning, organisation and delivery of an individualised care plan, made with the woman at her first booking appointment and reviewed with the woman throughout her pregnancy. In this model, continuity is important. This may refer to continuity of carer or of care. A small team of midwives, based within a community setting, where their workload is organised by geographical location and where the midwifery team acts as the lead professional, may offer the greatest balance in ensuring the woman has such continuity of care, a deeper relationship with the midwives caring for her and the highest quality of care and satisfaction, maximising the chances of the best outcomes. The Royal College of Midwives is a professional organisation (Figure 4.3) and trade union that supports midwives in practice, providing legal and statutory information, guidance and support and works to promote the profession on an international level. The midwife has a unique place in society, working on a very personal level with women and their families, and much of the role cannot be quantified or measured because the midwife is as important emotionally to the individual woman as she is physically.

5Drug exemptions

Midwives at the point of registration and on notifying their intention to practice may supply and/or administer on their own initiative any of the substances that are indicated in medicines legislation under midwives' exemptions, provided this is during their professional practice. They may do this without a prescription, patient-specific directive or patient group directive (PGD) from a medical practitioner provided the requirements of any conditions attached to the exemptions are met. The two main acts of parliament controlling the administration and use of medicines are the Medicines Act 1968 and the Misuse of Drugs Act 1971. There are, however, exemptions from the general rules provided specifically for midwives in the Prescription Only Medicine (Human Use) Order 1997, the Medicines (Sale or Supply) (Miscellaneous Provisions) Regulations 1980 and the Medicines (Pharmacy and General Sale – Exemption) Order 1980. In July 2011, new legislation came into force that amended the list of medicines which midwives are able to supply and administer in their professional practice. These specific amendments can be found on the Nursing and Midwifery Council (NMC) website.

Under the Medicines Act 1968, medicines classified as pharmacy (P) medicines may be sold or supplied only through registered pharmacies by or under the supervision of a pharmacist (section 52). Prescription only medicines (POMs) are subject to an additional requirement: they may only be sold or supplied through pharmacies against a prescription from an appropriate practitioner (section 58). General sale list (GSL) medicines may be sold through retail outlets other than pharmacies as they do not need to be sold or supplied under the supervision of a pharmacist (sections 51 and 53).

Under the Misuse of Drugs Act 1971 dangerous or otherwise harmful drugs are divided into Class A, B and C (Figure 5.1) according to the perceived degree of harm. Class A drugs are those considered the most harmful when misused. Class B drugs, although still dangerous, are classified as less harmful then Class A drugs. Class C are the least dangerous but still illegal.

Exemptions vary for prescribing, which requires the involvement of a pharmacist in the sale or supply of the medicine, and PGDs, where the midwife must comply with specific legal criteria and needs the PGD to be signed by a doctor or dentist and a pharmacist and authorised by an appropriate body.

Exemption from restrictions on sale or supply

Under the ‘sale or supply' exemptions for midwives, a registered midwife, in the course of her professional practice, may supply but not offer for sale:

All medicinal products on the general sales list and all pharmacy medicines

POMs containing

only

the substances in

Box 5.1

.

Exemptions from restriction on administration

Registered midwives may also administer parenterally (not through the oral route), in the course of their professional practice, POMs that contain any of the substances in Box 5.2. It is important to remember that midwives may not administer any other substance specified in column 1 of Schedule 1 of the -Medicines for Human Use Order 2011.

Midwife's supply order

As already explained, a registered midwife may administer in her own right, so far as is necessary for the practice of her profession, POMs for parenteral administration containing any of the substances in Box 5.2. However, the supply of controlled drugs may only be made to the midwife on the authority of a midwife's supply order signed by the appropriate medical officer who is a doctor authorised in writing by the Local Supervising Authority (LSA), or more commonly a Supervisor of Midwives (SOM). The order must specify the name and occupation of the midwife obtaining the drug, the purpose for which it is required and the total quantity needed. The pharmacist must retain the midwife's supply order for 2 years. A midwife is required to keep a record of supplies of diamorphine, morphine and pethidine received and administered in a book used solely for that purpose. The midwife must not destroy surplus stock but should surrender it to the supplying pharmacy. This is not to be confused with discarding any drug remaining in an ampoule after use. Diamorphine, morphine and pethidine are Schedule 2 Controlled Drugs; therefore, an appropriate entry is required in the Controlled Drug Register. Temazepam is a Schedule 3 
Controlled Drug and therefore no entry is required in the 
Controlled Drug Register.

A midwife's records relating to the administration of medicines should be regularly audited by her named SOM and any concerns should be reported to the Accountable Officer for Controlled Drugs and the LSA Midwifery Officer.

Student midwives and exemptions

Student midwives are allowed to administer medicines on the midwives' exemptions list, except for controlled drugs, under the direct supervision of a sign off midwife. Direct supervision means direct visual contact by the midwife during the act of administration of the medicine by the student midwife. Student midwives may participate in the checking and preparation of controlled drugs on the midwives' exemption list for administration under the direct supervision of a registered midwife.

6Women's choice and care options

Contemporary healthcare policy within the Western world has become focused on embracing women's right to choice within the provision of maternity services. However, childbirth in the UK still mainly occurs within a medical paradigm. The relationship a woman has with maternity care providers and the maternity care system during the childbearing period is essential as a woman's experience of her care may impact on her confidence and self-esteem. This can influence how empowered she might feel and affect her potential to uptake essential services.

People are entitled to fundamental human rights as recognised by societies and governments nationally and internationally (Chapter 3). Although no specific charter exists that outlines how human rights are applied to childbearing, it is widely accepted that in respecting women's basic human rights, they should have choices (Figure 6.1).

It has been opined that obstetrics and childbirth have historically been medically defined within a culture of risk and safety which precludes a woman's ability to having full choices. Beliefs driven by a culture of risk become norms within society and influence issues such as women's place of birth and how they give birth (Figure 6.2).

Although women want to have choices within maternity services, the reasons for the choices they make are often multifactorial and influenced by many issues. For example, although the obstetrician may respect the woman's wishes, ultimately these will only be carried out within the medical perception of risk to the woman and the fetus and as such upholds the role of expert who takes ultimate responsibility over the woman. In this context, childbirth is viewed as a medical event rather than a social one.

Having choices implies that the onus to make a decision is on women opting for one particular choice. Women's decision making in relation to maternity care can be more informed if evidence-based information is provided and the support and care planning from midwives and other maternity healthcare professionals is woman centred and flexible. This includes respect for individual requirements and offering guidance on best and current options. Available services may vary in different areas, such as screening (Chapter 16), and giving women a choice of birthing place implies that home birth should be an option for all women.

Despite general awareness that women have choice, evidence suggests that many women still follow the belief that for safety reasons hospital is the best place in which to give birth, demonstrating a degree of fear and apprehension and that childbirth is perceived as unsafe. Women often do not exercise their right to informed choice due to constraints such as the opinions of doctors and midwives and the institution or environment within which maternity care takes place, such as the NHS in the UK. A re-evaluation of maternity care to focus on normality in childbearing may change the emphasis from risk to a more social and woman-led model of care.

Access

Although most women access services which are hospital based, there are choices available regarding how and where to access maternity care. Traditionally, once a woman initially suspects or confirms that she is pregnant, she will visit her GP. Women and their partners can choose to go straight to a midwife. By direct self-referral to their local midwifery service, their access to maternity services will be quicker; care planning and involvement in essential services can be initiated early (Figure 6.3).

Type of antenatal care

Women are being offered the option of attending a midwife as their first professional contact; however women should also be informed that they have the choice of seeing their GP at any point during pregnancy. Choice exists for women and their partners between midwifery care or care provided by a team of maternity health professionals, such as midwives and obstetricians. However, in most areas, this will be dependent upon their circumstances such as health and wellbeing factors. Following the initial history taking/booking visit, a flexible plan of care is usually made by the midwife in conjunction with the woman. Although women may choose midwife-led care, obstetric or team care may be deemed the safest option. As the pregnancy advances, this plan may alter, depending on individual circumstances. An example of this might be a woman who had been deemed initially suitable for midwife-led care, but who developed hypertension later in pregnancy and required transfer to joint obstetrician- and midwife-led care, or vice versa. Women with more complex needs should have joint care with other agencies such as social services or special needs in pregnancy teams (Figure 6.3).

Place of birth and postnatal care

Choice of place of birth is available to women and their partners. Midwives, obstetricians and other maternity care professionals should recognise that women have the right to choose their place of birth, in order to support them in their choice. This choice will again depend on a woman's particular circumstances. Options for place of birth are:

A home birth whereby the midwife supports a woman at home for the birth

A local midwifery unit, including a designated birth centre, with care led by a midwife, promoting normality

A hospital supported by a local maternity care team: midwives, obstetricians and anaesthetists (

Figure 6.3

).

Postnatal care can be provided at home or in the community and may include options such as Sure Start. At home, women will have a choice of how and where to access postnatal care. Most midwives visit at home initially and can provide advice about local community supports such as breastfeeding groups in the community (Figure 6.3).

Part 2Anatomy and physiology

Chapters

7   Breast

8   Female reproductive system

9   Menstrual cycle

10   Maternal pelvis

11   Maternal pelvis and fetal skull

7Breast

Breast development

Female breast development begins between 8 and 13 years of age under the influence of the female hormone oestrogen (Chapter 9)
and continues through puberty (Figure 7.1). Further maturation of the breasts takes place during pregnancy when glandular tissue proliferates. The primary function of the breasts, as mammary glands, is the feeding and nourishing with breast milk -during the maternal lactation period.

Breast development starts with the flat area around the nipple (areola) becoming enlarged and some breast tissue forms under the nipple (Figure 7.1). When breast development is complete, each breast is distinct and the areola no longer appears swollen. In a healthy adult female, the breasts lie either side of the sternum between the second and sixth ribs. The breasts are anchored to the pectoralis major muscle by the suspensory ligaments. These ligaments relax with age and time, eventually resulting in the breasts drooping, or ptosis. The lower pole of the breast is fuller than the upper pole and the tail of Spence extends obliquely up into the medial wall of the axilla.

Until recently, the commonly accepted anatomy of the breast was as described by Sir Astley Parson Cooper in 1840 (Figure 7.1).
More recent anatomical research involving imaging of the lactating breast using ultrasound has challenged a number of commonly accepted conclusions derived by Cooper (2005). These findings of breast anatomy have important implications for the way the breast is cared for, especially during surgery, and how breastfeeding is effectively supported. The major differences between the two models are (Box 7.1):

Milk ducts branch closer to the nipple

Lactiferous sinuses do not, in fact, exist

Glandular tissue is found closer to the nipple

Subcutaneous fat is minimal at the base of the nipple

The external shape or size of the breast is not predictive of its internal anatomy or of its lactation potential

The ratio of glandular to fat tissue rises to 2:1 in the lactating breast, compared to a 1:1 ratio in non-lactating women

65% of the glandular tissue is located within 30 mm from the base of the nipple

Between four and 18 milk ducts exit the nipple

The network of milk ducts is complex, not homogeneous. It is not always arranged symmetrically, or in a radial pattern

The milk ducts near the nipple do not act as reservoirs for milk.

Physiology of lactation: how the breasts lactate and produce milk

Lactation is under the control of two hormones, oxytocin and prolactin. Oxytocin is responsible for the ejection of milk from the breast and prolactin is responsible for the production of breast milk:

Oxytocin …

Is secreted by the posterior lobe of the pituitary gland in response to the baby suckling at the breast