**4. Principles that guide midwifery care during virulent outbreaks**

The principles that guide midwifery care during virulent outbreaks will be discussed generally for all virulent disease outbreaks. These general principles will offer basic safety and educational guidelines that cut across all virulent outbreaks. During virulent outbreaks health workers are usually at high risk for contracting the infections. This poses a great risk to their patients, family members, and themselves. Rendering maternal antenatal, intrapartum, and postnatal care and immediate newborn care would be challenging during these outbreaks. The struggles involved in containing the outbreaks involves the dilemma of seeking for balance between obligation, heroic midwifery interventions, and the sense of professional calling. The solution would be to guide midwifery practice with fundamental principles to serve as frameworks for contextual evidence based midwifery interventions during deadly disease outbreaks.

These principles are discussed under domains of midwifery care; antenatal, intrapartum, postnatal, and immediate newborn care. General safety and education issues will also be explained.

#### **4.1 Antenatal care**

The care for pregnant women and their growing fetus is needful to ensure the desired outcome of a healthy pregnancy and fetus. The management of pregnancy during antenatal care during virulent outbreaks should be guided by the following principles:

1.Initial mandatory sensitivity screening test for all virulent infections such as Cholera, COVID-19, Ebola virus infection, and so on should conducted to rule out cases of infective patients. This involves the history taking and temperature screening for all women.


## **4.2 Intrapartum (delivery) care**

As soon as labour is established, the woman is advised to report to the hospital. The midwife is responsible to assess, plan, and implement care to address physical, emotional, and support needs of the woman in labour. In the first stage of labour the assessment procedures should include history taking, general examination, abdominal examination, vaginal examination, and fetal assessment. At admission history is taken first on behavioral patterns that might have put the mother at risk of contracting a virulent infection. Other history on details from previous births and babies, characteristics of uterine contractions (frequency, duration, and perception of strength), ruptured membrane/color and amount of amniotic fluid, vaginal discharge, fetal movement, medical history can follow.

Support from the relatives of the woman in labor should be encouraged so as to boost the woman's confidence and help her in decision making. However it is advised that all relatives stay out of the delivery room to reduce the risk of transmitting diseases or infections.

Procedures should be conducted under a clean field. Personal protective gears should be worn by the midwife always. All materials used should be clean. Mother can be encouraged to take a bath and clean the perineal area. Mothers and relatives should be required to wear protective masks at all times. This is predicated on the novel COVID-19 infections. Regular hand-washing and hand- sanitization should be ensured for mothers and relatives to prevent transmission of all types of diseases and virulent infections.

Vaginal examination should be conducted under aseptic measures. A full explanation of the procedure is given to the woman and her consent obtained. Take note of discharges or bleeding from the vaginal orifice, note the amount, excessive amount may indicate suspicion of symptoms of hemorrhagic fevers (EVD).

In the second stage of labor as long as the mother and baby are well, and there is good progress in labour, then the outcome will be good. The management of the second stage of labour consist of positioning, delivery of the head, and delivery of the shoulders and the rest of the body.

The management of the third stage of labour involves two main protocols: the use of uterotonics for the prevention of postpartum hemorrhage (PPH) during the third stage of labour is recommended for all births. Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH. In the situation where excessive bleeding does not respond to interventions and other physiologic indicators for bleeding are ruled out, caution should be applied to suspected EVD symptoms.

The second protocol is controlled cord traction (CCT) is recommended for vaginal births to achieve a small reduction in blood loss and a small reduction in the duration of the third stage of labour.

#### **4.3 Postnatal care**

The continuous screening and preventive measures for virulent diseases and infections continues in addition to typical postnatal care protocols; postnatal visitation appointment, infant feeding, reproductive and contraceptive plan, pregnancy complications follow-up care, postpartum complications detection and management, and mental health care. During postnatal care visitations the following should be observed by the midwives, mothers, and their relatives to prevent transmission of virulent infections; regular hand-washing or handsanitization, temperature checks, use of protective nose masks, social distancing, and barrier midwifery care (which involves the use of gloves, googles, boots, and masks).

#### **4.4 Immediate newborn care**

This could be summarized to include wiping, drying, warming (ideally skinto-skin contact) and wrapping. Providing skin-to-skin contact is indicated only for mothers and babies who test negative to any virulent infection. Evaluating breathing and resuscitation if necessary as usual in the management of the newborn infant. Use a sterile method to cut the cord and evaluate bleeding from the cord area as suggestive of possible EVD symptoms. The management of the newborn infant also include initiating exclusive breastfeeding in the first hour for infants whose mothers have been confirmed negative to virulent infection screening.

#### **4.5 General safety and education**

The safety and education of midwives, health care workers, mothers and their relatives should be assured by conducting several general safety and education activities. Some of these activites include;


The unique clinical skills which emerged from the perspective of the midwives working during the Ebola outbreak in Liberia [9] could be incorporated in the training of students midwives. This includes the training of hand washing techniques, and wearing and use of both basic and enhanced personal protective gears. There is need for nursing and midwifery professional boards and regulatory bodies to continue to assure continuous education on virulent infections preventive care and safety measures for midwives. Curricula in the schools of midwifery should include preventive care and safety measures. This could involve the training on the management of midwife-patient relationships, empowering midwife-midwife relationships, the proper use of the both basic and enhanced personal protective equipment and protective measures, and adjustment techniques. The training for virulent infections preventive care and safety measures should also involve ethical considerations and mental or psychological indications. Community health education on recent virulent disease outbreaks could be conducted by midwives to help communities understand the diseases and improve behavior towards health care workers. The role that faith plays in the decisions made by midwives should also be recognized when developing and implementing curricula.
