South African Nursing Council

Regulations Relating to the Conditions under which Registered Midwives and Enrolled Midwives may Carry On Their Profession

The Minister of National Health and Population Development has, on the recommendation of the South African Nursing Council, in terms of section 45(1)(q) of the Nursing Act, 1978 (Act No. 50 of 1978), made the regulations set out in the Schedule hereto.

SCHEDULE

CHAPTER 1

DEFINITIONS

1.    In these regulations “the Act” shall mean the Nursing Act, 1978 (Act No. 50 of 1978), and any expression to which a meaning has been assigned in the Act shall bear such meaning, and, unless the context otherwise indicates-

“child” shall also mean an unborn child;

“confinement” shall mean pregnancy, labour and the puerperium;

“registered person” shall mean a person who is registered as a nurse or as a midwife in terms of the Act, or as a medical practitioner or dentist in terms of the Medical, Dental and Supplementary Health Service Professions Act, 1974 (Act No. 56 of 1974);

“specified officer” shall mean the medical officer of health of a local authority or, where such an office does not exist or is vacant, the registered nurse in charge of the nursing services of such local authority.

CHAPTER 2

CONDITIONS UNDER WHICH A REGISTERED MIDWIFE MAY CARRY ON HIS PROFESSION

2.    A registered midwife shall carry on his profession under the conditions set out in this Chapter.

Equipment and materials

3.    In the course of his practice a registered midwife shall at all times have available the equipment and materials that are required for the practice of midwifery, including-

(a)    an intravenous infusion set and at least 2 x 1 000ml of 5% dextrose in a normal saline solution;

(b)    the equipment and material necessary to perform an episiotomy and to suture an episiotomy or a first or second degree tear of the perineum.

Records

4. (1)    A registered midwife shall keep clear and accurate records of the progress of pregnancy, labour and the puerperium and of all acts, including emergency acts, which he performs in connection with a mother and child.

(2)    Such records shall be in accordance with the details set out in Annexure A of this Chapter.

(3)    A registered midwife shall retain the records referred to in subregulation (1) for at least three years and shall produce the records to the council when required to do so.

Breast-feeding

5.    A registered midwife shall promote breast-feeding unless it is contra-indicated.

The antenatal period

6. (1)    On being engaged to attend a confinement, a registered midwife shall-

(a)    advise the patient to be examined by a medical practitioner and undergo a blood test at least once during her pregnancy;

(b)    ascertain whether any abnormality which could have an adverse affect on the present confinement has occurred during a previous pregnancy, labour or puerperium and, if so, advise the patient to seek medical advice;

(c)    in the case of a primigravida, make all the assessments required to ascertain whether the pelvis is adequate for a normal delivery and where any doubt exists immediately refer the case to a medical practitioner;

(d)    instruct the patient in antenatal exercises, including preparation for labour and preparation for breast-feeding.

(2)    Where possible, the registrered midwife shall visit the patient at least once in her own home and shall examine the patient at least once a month until the 28th week, thereafter at least once a fortnight until the 36th week, and then at least once a week until the commencement of labour.

(3)    If it is not possible to comply with the provisions of subregulation (2), the registered midwife shall endorse the record of the case accordingly, giving reasons.

Labour

7. (1)    A registered midwife in attendance upon a patient in labour shall not leave the patient without giving an address at which he can be reached without delay.

(2)    When the second stage of labour is imminent the registered midwife shall stay with the patient till after the birth of the child and for as long thereafter as the condition of the patient or the child may demand: Provided that he shall stay with the patient for at least one hour after the expulsion of the placenta and membranes.

(3)    A registered midwife shall, in a case of postpartum haemorrhage when a medical practitioner is not available or pending the arrival of a medical practitioner, administer not more than 10 units of oxytocin at a time by intramuscular injection, but the administration may be repeated at intervals if and when necessary.

(4)    An internal examination shall not be carried out by a registered midwife in the case of vaginal haemorrhage.

(5)    An episiotomy may be performed by a registered midwife to prevent a severe tear of the perineum or complications relating to the child, provided the head is on the perineum.

Puerperium

8.    During the puerperium the registered midwife shall-

(a)    attend the mother and child at least once a day and shall not discharge them from his care until such time as the condition of both is satisfactory;

(b)    if possible, continue such attendance daily for at least the five days following the birth of the child;

(c)    if it is not possible to attend the mother and child at least once a day for at least the five days following the birth of the child, endorse the record of the case accordingly, giving reasons;

(d)    instruct the mother in-

(i)    post-natal exercises and breast-feeding unless contra-indicated;

(ii)    caring for herself and her child during the puerperium;

(iii)    recognising abnormalities that may occur, and when and where to obtain assistance;

(iv)    oral rehydration therapy for the child.

Pre-mixed gas and air analgesia

9.    A registered midwife may administer pre-mixed gas and air analgesia to a patient only on the prescription of a medical practitioner.

Medical assistance

10. (1)    In the event of any of the following illnesses, abnormalities or complications occurring during pregnancy, labour or the puerperium or in the child, the registered midwife shall, subject to the provisions of subregulation (4), with the consent of the mother, call in a medical practitioner or refer the patient to a medical practitioner:

(a)    During pregnancy:

Excessive nausea and vomiting;
abortion, actual or threatened;
vaginal bleeding;
apparent intra-uterine growth retardation;
hypertension;
albumin or sugar in the urine;
oedema of the hands, face or feet;
convulsions;
abnormal vaginal discharge;
sores on the genitals;
any condition suggesting a disproportion between head and pelvis;
abnormal presentation after the 32nd week;
multiple pregnancy;
tenderness or abnormal distension of the abdomen.

(b)    During labour:

Convulsions;
abnormal vaginal discharge;
sores on the genitals;
excessive vaginal bleeding;
premature labour before the 37th week;
presentation other than an uncomplicated head presentation;
when no presentation can be determined;
multiple pregnancy;
non-engagement of the head in the case of a primigravida;
undue prolongation of any stage of labour;
disordered or abnormal uterine action;
presentation or prolapse of the cord;
foetal distress;
placenta not completely expelled one hour after the birth of the child;
third degree perineal tear.

(c)    During the puerperium:

Convulsions;
abdominal distension and tenderness;
malodorous lochia;
rigor;
rise in body temperature to 37,7°C for 24 hours, or its recurrence within that period, or a rise in body temperature to 37,4°C on two successive days;
continuously rapid or steadily rising pulse rate;
unusual swelling of the breasts with local tenderness or pain;
excessive or prolonged bleeding;
pain in the lower limbs, especially pain in the calves.

(d)    The child:

Injuries received during birth;
malformation or deformity (whether endangering life or not);
undue feebleness, whether the child is premature or not;
inflammation of or any discharge from the eyes;
serious skin eruptions, especially those marked by the formation of watery blisters;
inflammation of or haemorrhage from the umbilicus;
jaundice;
convulsions;
neonatal haemorrhage.

(2)    Where any illness, abnormality or complication other than the illnesses, abnormalities or complications referred to in subregulation (1), occurs during pregnancy, labour or the puerperium or in the child, a registered midwife may if he deems it necessary, subject to the provisions of subregulation (4) and with the consent of the mother, call in a medical practitioner or refer the patient to a medical practitioner.

(3)    Where a medical practitioner is called in or consulted as contemplated in subregulations (1) and (2), a registered midwife shall-

(a)    remain with the patient and deal with the emergency to the best of his ability until the medical practioner arrives; or

(b)    accompany the patient if she is to be sent to medical assistance.

(4)    When calling in medical assistance as contemplated in subregulations (1) and (2) the registered midwife shall call in the medical practitioner desired by the mother.

(5)    Where, in the course of pregnancy, labour or the puerperium a registered midwife-

(a)    advises the patient to consult a medical practitioner;

(b)    refers the patient to a registered person other than a medical practitioner;

(c)    consults the patient with a view to calling in medical assistance, the relevant particulars, as well as any refusal by the patient to consent to any of the above, shall be recorded as set out in Annexure A of this Chapter.

ANNEXURE A

RECORDS OF MATERNITY CASES ATTENDED

Date of booking ………………..

Name and address of patient ………………..

Age ………………..

Gravida ………………..

Para. ………………..

Estimated date of delivery ………………..

Obstetric and other history

History of previous general health ………………..

History of previous pregnancies ………………..

History of previous children ………………..

Mass at birth of previous children ………………..

History of previous labours ………………..

History of previous puerperia ………………..

Any other illnesses, complications or abnormalities ………………..

Any medication taken in the course of this pregnancy ………………..

Antenatal visits

Dates of visits ………………..

Dates of visits in patient’s own home ………………..

Weeks of gestation ………………..

Abnormal findings, if any ………………..

Referral to medical practitioner ………………..

If referred, name of medical practitioner ………………..

Medication or treatment prescribed ………………..

If not referred in case of illnesses, complications or abnormalities, reasons why not referred ………………..

Emergencies and action taken ………………..

Labour

Date and time registered midwife called in ………………..

Date and time of arrival ………………..

Date and time of commencement of labour ………………..

Record on arrival:

(a)    Maternal pulse rate, temperature and blood pressure ………………..

(b)    Foetal heart rate ………………..

(c)    Date and time of beginning of established labour, including contractions ………………..

Findings on abdominal palpations ………………..

Dates and times of findings of all internal examinations ………………..

Date and time of rupture of membranes ………………..

Date and time of beginning of second stage ………………..

Date and time of birth of child ………………..

Date and time of completion of third stage ………………..

Blood pressure, pulse rate and temperature on completion of third stage ………………..

Method of expulsion of the placenta ………………..

Condition of the placenta and membranes ………………..

Amount of blood loss ………………..

Any complications ………………..

Episiotomy, suturing ………………..

Perineal tears, suturing ………………..

Local anaesthetic administered ………………..

Name of medical practitioner, if called in, with the date, time and reason for calling him in ………………..

Details of and reasons for medication and treatment given to the mother and child, including any emergency action taken ………………..

The child

Sex ………………..

Whether full-term, premature or miscarriage (if premature or miscarriage, give approximate number of weeks) ………………..

Alive or stillborn (if stillborn, state whether macerated or not) ………………..

Mass at birth ………………..

Apgar rating at one minute after birth ………………..

Apgar rating at five minutes after birth ………………..

Medication: eyes or other for the child ………………..

Any physical abnormalities and any deviation from the normal at birth or during the puerperium ………………..

Name of medical practitioner, if called in, with the date, time and reason for calling him in ………………..

Discharge or last visit:

Date ………………..

Mass and condition ………………..

Method of feeding ………………..

Emergencies and action taken ………………..

The mother

Signature of patient/witness, if advice not accepted [regulation 6(1)] ………………..

If it is not possible to comply with the provisions of regulation 6(2), state the reasons ………………..

Name of medical practitioner, if called in, with the date, time and reason for calling him in ………………..

If a medical practitioner is not available, or if the patient refuses to call in a medical practitioner, state reason for requiring aid, the date and time and whether the medical practitioner was not available or was refused by the patient ………………..

Signature of patient/witness ………………..

If a medical practitioner is called in without the patients being consulted, state why it was not possible to consult the patient [regulation 10(1)] ………………..

Date ………………..

Record of daily pulse rate and body temperature, showing also daily progress of involution of the uterus and state of lochia ………………..

If it is not possible to comply with any of the provisions of regulation 8, state the reasons ………………..

Signature of patient/witness, if any treatment or referral is refused [regulation 10(5)] ………………..

Condition of mother on discharge or last visit ………………..

…………………………
Signature of registered midwife

CHAPTER 3

CONDITIONS UNDER WHICH AN ENROLLED MIDWIFE MAY CARRY ON HIS PROFESSION

11.    An enrolled midwife shall carry on his profession under the conditions set out in this Chapter.

Private practices

12. (1)    An enrolled midwife who conducts a private practice shall be entitled to practise as such only if he has been entered on a list of enrolled midwives by a specified officer in terms of Government Notice No. R.2489 of 26 October 1990.

(2)    An enrolled midwife referred to in subregulation (1) shall make written application to the specified officer in whose area of jurisdiction he conducts a private practice, and then present himself for a personal interview with the said specified officer at a place and time to be determined by the specified officer for that purpose.

(3)    An enrolled midwife referred to in subregulation (1) shall produce proof of enrolment with the council and such other information as the specified officer concerned may require.

(4)    If a specified officer, after consideration of an application in terms of subregulation (2), is satisfied that the applicant concerned is enrolled with the council as a midwife and complies with the requirements of regulation 13 he shall enter the name of the applicant concerned on a list referred to in subregulation (1).

(5)    An enrolled midwife referred to in subregulation (1) shall notify the specified officer concerned of any change of address by registered mail within seven days.

(6)    In the case of an enrolled midwife who immediately prior to the commencement of these regulations was conducting a private practice, the provisions of subregulation (1) shall come into operation-

(a)    on expiry of a period of six months after the date of such commencement, if application has not been made in terms of subregulation (2) within that period;

(b)    on the date of entry on a list as contemplated in subregulation (1), if such application has been made within that period.

Equipment and materials

13.    In the course of his practice an enrolled midwife shall at all times have at least the following equipment and materials at his disposal:

(a)    Foetal stethoscope;

(b)    a clinical thermometer;

(c)    an antiseptic, soap and nailbrush;

(d)    a pair of scissors;

(e)    ligatures to tie off an umbilical cord;

(f)    swabs and dressings;

(g)    surgical gloves;

(h)    cotton wool;

(i)    gauze;

(j)    two arterial clamps;

(k)    a watch with a second hand;

(l)    a scale;

(m)    equipment for the testing of urine;

(n)    a container for the removal of equipment used at the labour.

Records

14. (1)    An enrolled midwife shall keep a record of each case treated by him, in the form prescribed in Annexure A of this Chapter.

(2)    An enrolled midwife shall retain the record referred to in sub-regulation (1) for at least three years and shall produce such record to the council when required to do so.

Prevention of infection

15.    An enrolled midwife shall adhere strictly to the rules of asepsis and prevention of cross infection when assisting a patient.

Duties of an enrolled midwife during the antenatal period

16. (1)    On being engaged to attend a confinement, the enrolled midwife shall-

(a)    advise the patient to be medically examined at least once during her pregnancy and to undergo the necessary blood test;

(b)    ascertain whether any abnormality occurred during any previous pregnancy, labour or puerperium and, if so, advise the patient to seek medical advice.

(2)    If the patient for any reason does not accept the advice referred to in subregulation (1), the enrolled midwife shall endorse the record of the case accordingly and shall, subject to the provisions of subregulation (3), obtain the signature of the patient or another witness.

(3)    If the signature referred to in subregulation (2) cannot be obtained, the enrolled midwife shall endorse the record of the case accordingly.

(4)    Where possible, an enrolled midwife shall visit the patient at least once in her own home and shall examine the patient at least once a month until the 28th week, thereafter at least once a fortnight until the 36th week, and then at least once a week until the commencement of labour.

(5)    If it is not possible to comply with the provisions of subregulation (4), the enrolled midwife shall endorse the record of the case accordingly, giving reasons.|

Duties during labour

17.    An enrolled midwife shall make only the vaginal and rectal examinations that are necessary: Provided that in the case of vaginal bleeding no internal examination may be made.

Attendance upon a patient during labour

18. (1)    An enrolled midwife in attendance upon a patient in labour shall not leave the patient without giving an address at which he can be reached without delay.

(2)    When the second stage of labour is imminent the enrolled midwife shall stay with the patient till after the birth of the child and for as long thereafter as the condition of the patient or the child may demand: Provided that he shall stay with the patient for at least one hour after the expulsion of the placenta and membranes.

Duties during the puerperium

19. (1)    During the puerperium the enrolled midwife shall attend the mother and child at least once a day until such time as the condition of both is satisfactory: Provided that such attendance shall, if possible, be carried out daily for at least five days following the birth of the child.

(2)    If it is not possible to attend the mother and child at least once a day for at least five days following the birth of the child, the enrolled midwife shall endorse the record of the case accordingly, giving reasons.

(3)    An enrolled midwife shall advise the patient to be examined by a medical practitioner or at a post-natal clinic at least once during the three months following the confinement.

(4)    An enrolled midwife shall promote breast-feeding unless it is contra-indicated.

(5)    An enrolled midwife shall instruct the mother in-

(a)    caring for herself and her child during the puerperium;

(b)    recognising abnormalities that may occur, and when and where to obtain assistance;

(c)    oral rehydration therapy for the child;

(d)    the procedure for the registration of the birth of the child;

(e)    the procedure for taking the child to a clinic for immunisation.

Medical assistance

20. (1)    An enrolled midwife shall observe carefully the normal course of pregnancy, labour and the puerperium.

(2)    In all cases where any illness, abnormality or complication occurs in the mother or the child during pregnancy, labour or the puerperium, the enrolled midwife shall forthwith, in consultation with the mother or, where necessary, the family, call in a medical practitioner of the mother’s or family’s choice, or refer the patient to a medical practitioner and where possible state the reason for calling him in.

(3)    If the medical practitioner concerned is not available, another medical practitioner or a registered midwife shall be called in, if available.

(4)    If a medical practitioner or a registered midwife is not available, or if the mother or the family refuse to consent to the calling in of a medical practitioner or a registered midwife, the enrolled midwife shall assist the patient to the best of his ability and endorse the record of the case accordingly and shall, subject to the provisions of subregulation (5), obtain the signature of the mother or of another witness.

(5)    If such signature cannot be obtained, the enrolled midwife shall endorse the record of the case accordingly.

(6)    If it is not possible to consult the mother or the family, the enrolled midwife shall act on his own judgement and enter the facts in the record of the case.

(7)    In die application of subregulation (2), illness, abnormality or complication means any of the following:

(a)    During pregnancy:

Excessive nausea and vomiting;
excessive gain in mass;
sugar or albumin in the urine;
rise in blood pressure;
headaches and visual disturbances;
tuberculosis;
abortion, actual or threatened;
vaginal bleeding;
apparent lack of foetal growth;
puffiness of the hands, face or feet;
convulsions;
malodorous discharge;
sores on the genitals;
deformity or short stature of the mother;
abnormal presentation after the 32nd week;
multiple pregnancy;
any abnormality which is detected.

(b)    During labour:

Convulsions;
abnormal vaginal discharge;
sores on the genitals;
excessive vaginal bleeding;
premature labour before the 37th week;
any presentation other than an uncomplicated head presentation;
when no presentation can be determined;
undue prolongation of any stage of labour;
excessive or abnormal uterine action;
presentation or prolapse of the uterine cord;
foetal distress;
placenta not completely expelled 30 minutes after the birth of the child;
any perineal tear;
multiple pregnancy.

(c)    During the puerperium:

Convulsions;
distension and tenderness of the abdomen;
malodorous lochia;
rigor;
rise in body temperature;
continuously rapid or steadily rising pulse rate;
unusual swelling of the breasts with local tenderness or pain;
excessive or prolonged bleeding;
pain in the lower limbs, especially pain in the calves.

(d)    In the child:

Injuries received during birth;
malformation (whether endangering life or not);
undue feebleness, whether the child is premature or not;
failure to gain mass;
dehydration;
inflammation of or any discharge from the eyes, however slight;
serious skin eruptions, especially those marked by the formation of watery blisters;
inflammation of or haemorrhage from the umbilicus;
jaundice;
convulsions;
bleeding of any nature.

(8)    Where a medical practitioner or registered midwife is called in as contemplated in subregulations (2) and (3), an enrolled midwife shall-

(a)    await the arrival of the medical practitioner or registered midwife and carry out his instructions;

(b)    accompany the patient if the patient is sent to medical assistance.

ANNEXURE A

RECORDS OF MATERNITY CASES ATTENDED

Case number ………………..

Name of patient ………………..

Address ………………..

Population group ………………..

Age ………………..

Date of booking ………………..

Antenatal period

Estimated date of delivery ………………..

Number of previous confinements

(full term ……………………
 premature ……………………
 miscarriage …………………)

Abnormalities during any previous pregnancy, labour and puerperium ………………..

Present general condition of health of patient ………………..

Any abnormalities during current pregnancy ………………..

Advice given and findings ………………..

Signature of patient or other witness if advice is not accepted ………………..

Dates of medical examinations, if any ………………..

Dates of examinations by enrolled midwife and findings:

– height of fundus ………………..

– presentation ………………..

– foetal heart ………………..

– oedema ………………..

– urine ………………..

– pulse rate ………………..

Name of medical practitioner or registered midwife, if called in, with date, time and reason for calling him in ………………..

Labour

Date and time of arrival of the enrolled midwife ………………..

Body temperature and pulse rate of patient on arrival of the enrolled midwife ………………..

Date and time of birth of child ………………..

Presentation ………………..

Duration of labour ………………..

Condition of the placenta and membranes ………………..

Amount of blood loss ………………..

Complications, if any (including perineal tears) ………………..

Name of medical practitioner or registered midwife if called in for the mother, with the date, time and reason for calling him in ………………..

The child

Full term, premature or miscarriage ………………..

Sex ………………..

Alive or stillborn (if stillborn, state whether macerated or not) ………………..

Mass at birth ………………..

Length at birth ………………..

Any abnormalities ………………..

Date of severing of umbilical cord ………………..

Puerperium

The pulse rate, body temperature and condition of the lochia of the mother shall be recorded daily on the chart which shall be available for this purpose.

Name of medical practitioner or registered midwife, if called in for the mother or the child, with date, time and reason for calling him in ………………..

Additional information

Entries and signatures required in regulations 16(2), 16(3), 16(5), 19(2), 20(2), 20(4), 20(5) and 20(6).

Discharge or last visit

Date ………………..

Condition of mother ………………..

Condition and mass of child ………………..

Method of feeding ………………..

Referred to baby care clinic (if available) ………………..

Signature ………………..

Date ………………..