By Caroline Flint

Midwives are concerned about reducing the risks of contracting AIDS. Caroline Flint suggests that less medical intervention could be the answer

Midwives sometimes express their concern at the danger of catching AIDS from undiagnosed women in labour. And midwives all over the country are now trying to wear gloves at even the quickest delivery while masks are reappearing at a rate of knots. But I wonder if we have given real thought to the problem of AIDS and, for that matter, Australia Antigen or Hepatitis B carriers.

For the midwife, the great dangers from these diseases come from needle stick injuries and from the ingestion of blood or amniotic fluid into the mucous membrane of the mouth, eyes or any open wound that she may have.

We need to look systematically at the dangers of needle stick injuries. For midwives these dangers are very real. They often use two instruments which are the source of many such injuries - the amnihook and the fetal scalp electrode - and they are also at risk when suturing a woman's perineum.

The conclusion I come to is that we must really question the need for indiscriminate rupturing of membranes and indiscriminate application of fetal scalp electrodes and use both instruments with great care. Artificial rupturing of membranes has been under question for many years and the adverse literature is legion.

Caldeyro-Barcia (1) has shown in 70 per cent of pregnancies the membranes do not rupture spontaneously before the end of the first stage of labour. So when we artificially rupture membranes, we are intervening in 70 per cent of women's labours and Dunn (2) lists many adverse effects of artificial rupture of membranes as does Inch' in her comprehensive study of all the interventions practised in modern childbirth. Inch demonstrates that labours are shortened by 40 minutes because of artificial rupture of membranes, but there is no evidence to show that a shortened labour is of benefit to either mother or baby. According to Robson (4), the mother has a 74 per cent chance of feeling indifferent towards her baby if her membranes have been artificially ruptured.

Electronic fetal monitoring has been questioned by many, especially in the randomized controlled trial carried out on 12, 964 women in Dublin by Macdonald, Grant and colleagues', who showed that there was a greater risk of instrumental delivery when electronic fetal monitoring was used. Nor was there any strong evidence to show that electronic fetal monitoring improved fetal wellbeing.

If these two procedures can also carry risks for midwives (and doctors), we need to question their routine use. It is a routine which is indiscriminately used in many units. These policies, which have questionable value for women, have undoubted dangers for the midwives and medical staff.

As for perineal suturing, some women will inevitably sustain a tear during the second stage of labour and the condition of some babies will inevitably demand the use of episiotomy. But Sleep at all showed that when episiotomies were restricted to fetal indications only, the number of women who did not need suturing was 31 per cent compared to 22 per cent when a liberal use was made of episiotomy. In other words, when episiotomy was restricted, more women had intact perineums.

What about midwives having open wounds on their hands? Well, midwifery is a stressful job; midwives are paid very low salaries; they experience all the disadvantages that poorly paid workers experience and they are under considerable stress. Like many under stress, some midwives chew their nails and pick at their hands. The way to remove this particular stress would be to do something realistic about midwives' salary structure, but in the meantime the employment of a manicurist on every labour ward or somewhere in the maternity unit would greatly help the promotion of strong nails and unblemished hands among midwives.

We also need to think about the most fundamental issue of all. That is, the only time midwives are in danger of getting amniotic fluid or blood in their mouths or eyes is when the woman is lying at eye-level on a high platform: in other words, on a normal delivery bed in the average labour ward. When the woman is walking about, swaying or sitting in a chair, the amniotic fluid cascades down her legs and on to the floor, and so does the blood and any other secretions. Perhaps this is the time to review our whole practice and, perhaps not surprisingly, we shall find that what women prefer is the same as what is best for midwives. It wouldn't be the first time!

1. Caldeyro-Barcia, R., Schwarez, R., Belizan, J.M., Martell, M., Nieto, E, Sabatino, H-Tenzer, S.M., (1975). `Adverse perinatal effects of early amniotomy during labour'. In Gluck, L., Chicago, M.L. (Eds.). Modern Perinatal Medicine.

2. Dunn, P M. (1978). `Problems Associated with Fetal Monitoring during Labour'. Proceedings of the Sixth European Congress of Perinatal medicine, Vienna. Stuttgart: Georg Thienne.

3. Inch, S.(1982). Birthrights. London: Hutchinson.

4. Robson, K. (1982).'l feel nothing...' Nursing Mirror, Vol.] 54: 25, pp.24-27.

5. MacDonald, D., Grant, A., Sheridan-Pereira, M., Boylan, P, Chalmers, 1.(1985). `The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring'. American Journal of Obstetrics and Gynaecology : Vol 152: pp.52439.

6. Sleep, J., Grant, A., Garcia, J., Elboume, D., Spencer, J., Chalmers, 1. (1984). 'West Berkshire perineal management trial'. British Medical Journal, Vol 289: 6445, pp.587-590.