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OF NURSE MIDWIVES, MATERNAL AND NEONATAL NURSES OF NEWFOUNDLAND AND LABRADOR

FALL 1987

RESEARCH NEWS FROM GREAT BRITAIN

Alliance member Pearl Herbert, on leave from Memorial University of Newfoundland, is currently a postgraduate research student in the Department of Nursing Studies at the University of Edinburgh. Over the past two years, she has attended a variety of national and international meetings related to midwifery and child health. She has kindly sent information on speakers and topics of interest to members of the Alliance. What follows is a synopsis of some of these research rreetings.

Women's Attitude to Health Advice Delivered by Dr. Hilary Graham on April 2, 1987 at the Second International Study Conference and Exhibition on Child Health, Edinburgh, Scotland.

In a study of the perceptions of health of low income women, it was found that mothers apply concepts of health for themselves that are different from the concepts of health they have for the1r children. These concepts are positive for child health, e.g. happy, j u m p in g ; and neg at i v e f o r the m s e l v e s , e . g . not being i 11 , b e in g a b 1 e· to get through a day. As a study in the United States found, lower class mothers do not have time to be ill, even when they really are i 11. Thus, women accommodate to illness so as to carry on being the carer. Knowing about these concepts is important for health professionals who are giving preconceptual advice.

In a London study, 135 mothers were asked about what makes a preschool child healthy. They emphasized the physical and

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psychological care that they give their children. Mothers in this study expressed worry about abnormalities happening to their baby and also expressed responsibility if such abnormalities occur. Families living in poverty have to pay rent and fuel, costs which take priority over every day expenses such as clothes, food and travel. Often, food is the only thing that can be cut down. So mothers have to balance nutritious food with foods that fill the family so that they will not feel hungry. There are more smokers in the lower socio-economic groups. Mothers have less to spend on social outings and food but buying cigarettes can be a luxury and a necessity for coping "just for themselves".

In a London study, when children became too much to cope with, mothers looked for physical or symbolic separation from the children, e.g. going to another room and shutting the door or having coffee and a cigarette. They looked for space and luxury.

The Role of the Midwife in Genetic Counselling Delivered by Helen C. Sunter, International Child Health Conference, Edinburgh.

Helen Sunter, nursing officer at the Queen Mother's Hospital in Glasgow, has special responsibility for the nursing services at the Guthrie Institute of Medical Genetics. Here, midwives receive inservice education and work with an obstetrician in the diagnostic departrrent. Midwives follow and support women who require prenatal diagnostic screening procedures.

The screening procedures include maternal SAFP (serum alpha feto protein) levels and other blood tests at 16 to 18 weeks of pregnancy. High levels may be due to twins, wrong dates, intrauterine death as well as neural tube defects. Lower levels, below the 25th percentile, may indicate Down's Syndrome but this is still being investigated. Ultrasound screening is used throughout pregnancy to diagnose structural abnormalities. Amniocentesis is done in the second trimester, between 17 and 20 weeks of pregnancy when there is a history of chromosome abnormality, or biochemical or rhesus problems. It is also used to take off amniotic fluid to test for amniotic AFP. Fetal blood sampling is similar to the amniocentesis procedure; blood is withdrawn from the cord in order to obtain quick results for chromosomic diagnosis.

Chorionic villus sampling is done to study chromosomes and diagnose abnormalities. The sampling can be done either transabdominally or transcervically. Transabdominally provides a cleaner sample. The sampling must be done within the first trimester with 11 weeks being the optimal time. It is offered to women with a family history of problems and to those aged 38 years or older. The procedure takes 15 minutes and a technician is present to examine the tis sue. The woman waits an hour before going home and receives the

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• chromosome results in 24 hours. The results of DNA and other tests are available in 7 to 10 days. This time allows the couple to make decisions about the termination of the pregnancy. The fetal loss rate from the procedure is 4 to 7 percent.

Helping Parents of Prematures Delivered by Dr. D. B. Rosenblatt, International Conference on Child Health, Edinburgh.

About 10% of families will have a baby in a neonatal intensive care unit. Parents of these babies have:

1. separation from their baby 2. a sense of failure and fear that they may be responsible for

the baby's condition especially if the couple had sexual intercourse prior to the premature delivery

3. anxiety about the baby's condition and a worry that the baby may die

4. confusion about the technological and busy environment of the NICU -- not an easy place to discuss worries and fears.

When handling their feelings, parents may deny that they have any negative feelings at all or they may say that they have only negative feelings. A study of 40 mothers with babies less than 30 weeks gestation was conducted to find out whether their needs were normal, borderline or the same as for psychiatric inpatients. At five days, one third had clinical depression which decreased by 10 to 12 weeks. If the mother does not sleep or eat well, postpartum depression should be considered. Most depression was not when the baby_was in_crisis but when the rrother went hare without the baby. At this time, the mothers most appreciated a telephone call from another mother who has had the same experience. NIPPERS (National Information for Parents of Prematures: Education, Resources and Support) also helps these parents. The parents may also experience emotional numbness towards each other, espe~ially at the beginning of the crisis. They may only be able to concentrate on the baby and freeze-up with one another. It is important to recognize that people respond differently to crisis. They grapple with it and come up with novel responses and at the end they may understand each other better.

They may also experience psychosomatic problems such as headaches and ulcers. All parents need support at this stressful time especially those who are reluctant to ask for help, unable to help each other and argue with each other, those who deny any problems, and those who do not visit the unit.

Parents may not understand what is happening to their baby. When they visit the unit, they see not only their baby but also other babies who may have different problems but the parents consider all the babies to be the same. In addit ion, health professionals have dealt poorly with cultural factors. It is not known how families from

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different ethnic backgrounds grieve; this is not just a language problen.

Parents need to be prepared for the loss of their baby but they must be encouraged to get to know their baby and to become attached to their child. Parents have to work through the grief about the premature birth before they can accept that the baby has survived. They can then resume the process of mothering and fathering. A study by the National Association of the Welfare of Children in Hospitals found that parents were allowed to see their baby but one third of hospitals did not allow siblings to visit. But, visits were found to be more satisfactory especially if siblings were allowed to visit and were allowed to help with the baby's care, eg. help with tube feeding.

Mothers worry if the baby does not feed well, if the suck is weak or shallow or if the baby keeps falling asleep. The mothers become tense and concentrate on the feeding instead of stopping and waking baby up. They may feel guilty lf the baby cfoes not feed but feeding the baby can make the mother feel that the baby belongs to her and is getting better.

When the baby goes home he or she is not like a normal full term babe. The preterm baby will feed poorly, wake more as patterns of sleep and wakefulness are different. Because the baby is used to the bright lights and noise of the NICU, he has not established a diurnal pattern. Feeding and weight gain is different in the preter m l n fant · and this should be remembered when plotting the baby's weight on a p e r c en tile char t that has f u 11 t e r tn babies as its sta-nd a r d .

It is most important to show the parents what the baby can do. The optimal distance for the baby to be able to look at an object is between 6 and 12 inches. Parents will copy methods that they see the NICU staff using.

The parents have concerns about the baby and about their own long term relationships. There are now older parents who have had a history of infertility who are more concerned about the baby surviving. They may have more support available and more experience in facing crisis but they have less chance of having another baby.

Audio tapes are available for all of the above sessions Cont:4.Ct the e~itor of the Alliance Newsletter for more information.

Expectations and Experience of Childbirth in a Group of Working Class Primagravida Jim Mcintosh, MA., PhD., Research Fellow, Social Paediatric and Obstetric Unit, University of Glasgow.

This paper was presented at the Research and Midwives Conference held in Glasgow late in 1986. The data was collected in 1981-82 as part o f a prospective, longitudinal s tudy when 80 first time mothers

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• were interviewed and tape recorded at approximately two monthly intervals from the seventh month of pregnancy to the ninth month after the baby was born. Of these 80 women, 42 were aged 20 and under, 50 percent were from social class 3 and 50 percent from social classes 4 and 5 (the lowest), 20 percent were single parents. By the first postpartum visit there were 69 left in the study.

The findings of the study show that only 3 women had positive expectations for childbirth, 3 had mixed expectations both positive and negative) and 62 women plus the 3 mixed had negative expectations and of these 12 were terrified. Sixty two women reported that they obtained their information from lay sources, 7 women by television, 4 from professional persons and 7 said that they had no information of what to expect. Those who attended prenatal classes did not do so until the third trimester.

The main concern of these women was to retain composure; 49 wanted some pain relief, 18 did not know if they would want pain relief, 13 did not want anything for pain but several said that this was because they were afraid of needles. A few women in social class 3 had considered having natural childbirth.

After the birth, 68 women said that the best aspect was the actual delivery and the same number said that the worst aspects were the labor, forceps (24), and stitching (90 percent had an episiotomy). Fifty women were satisfied with the birth experience, 18 were dissatisfied and 12 had a caesarean section. It was found that the satisfaction of the mothers was related to the duration of labor (acceleration of labor was welcomed), the amount _of pain experienced (53 percent had an epidural) and the feeling of being in control. The 66 percent who had attended prenatal classes reported that these had been helpful. The conclusion was that the women from the lower socio­economic classes have different expectations than those women from the middle classes.

Association of Radical Midwives National Conference

On June 13, 1987, the first meeting of the Association of Radical Midwives (ARM) was held in Scotland. For those who have not heard about the ARM, it was started by a group of student midwives in 1976 i n r e s pons e to the inc rea s in g t e c h no 1 o g y o f c h i 1 db i r t h . A R 0,.1 membership, which includes a subscription to the ARM magazine, is available for midwives and interested non-midwives. Details are available from: Ishbel Kargar, 62 Greetby Hill, Ormskirk, Lancashire England L39 2DT.

Dr. Tricia Murphy Black, SCM, PhD, spoke on "Midwives and Research: Luxury or Necessity?" Research changes daily so that what was good yesterday is questioned today and is a disaster by tomorrow, as has been seen by the use of drugs such as thalidomide. Research carried out by midwives did not really start until the late 1970's.

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Why do midwives carry out certain procedures? In Myles' Textbook for Midwives (1975), it is recommended that babies should not ---------suck the nipple for more than 2 minutes at each breast on the first postpartum day. Why 2 minutes? Did midwives query what Myles had written? Of course, Myles does not cite her references. What about shaving the perineum, giving enemas etc? Those who teach midwifery need a research base for everyday teaching. They need to teach the research process, to use other educational research and to undertake research in midwifery education. Midwifery managers need clinical expertise as well as a knowledge of research in order to evaluate research that has been carried out and to implement the research that is applicable to their situation. Midwives have a duty to mothers and their babies as well as to the profession to look at the research carried out, to study it carefully and to intervene if it is decided that it will benefit the mothers and babies.

A research study was presented at the conference entitled "Let it Rip: Healing of the Perineum_ Following SVD". Clodagh Ross, SCM, recruited 57 women who had received either a tear ~ran episiotomy and followed them on postpartum days 1, 5, 10 and at 3 to 4 weeks pos tpar ttm. Three women were lost to the study. It was found .that the labor ward midwives were more likely to perform an episiotomy (medial lateral) and rotating midwives were more likely to allow tears. Of the 54 women, 50 were sutured by a doctor and 4 by a midwife; 49 had interrupted and buried sutures and 5 had subcutaneous suturing. On day 1, 1896 had no pain and 4% had agon-izing pain, but by the end of the follow-up time, 92% had no pain and none of the women had agonizing pain. Those women with a tear had less pain than those who had received an episiotomy. Of the 54 women, 10 who had an episiotomy and 1 who had a tear had the area break down. These 11 had all received interrupted suturing.

Don't forget the Alliance Workshop on

Maternal and Neonatal Nursing October 22 and 23, 1987

at the Airport Inn, St. John's

The Alliance needs new members for its 1987-88 Executive. If you are willing to serve, don't be shy! Talk to a member of the current Executive.

The Alliance Newsletter is published by the Alliance of Nurse Midwives, Maternal and Neonatal Nurses of Newfoundland and Labrador, P.O. Box 8352, Station A, St. John's, Newfoundland AlB 3N7.

Cover photo by Barry Bradbury, Janeway Child Health Centre.

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Objectives of the A.lliance

To provide an opportunity for midwives, maternal and neonatal nurses to share ideas and information through formal and in for mal education sessions.

To provide an organized group of midwives, maternal and neonatal nurses who can address issues relating to their profession.

To communicate with midwives, maternal and neonatal nurses on a provincial, na tiona! and interna tiona! level.

To provide a group of midwives, maternal and neonatal nurses who can jointly act as consumer advocates in issues relating to childbearing.

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