Chapter 51 Content and organization of postnatal care
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Introduction
The ‘puerperium’ is traditionally defined as the time from immediately after the end of labour until the reproductive organs have returned as nearly as possible to their pregravid condition, a period estimated to be around 6–8 weeks, although the evidence base to support this duration is lacking. Recent studies suggest that, for some women, adaptation to motherhood and recovery from childbirth can take much longer than this (Bick & MacArthur 1995a, Brown & Lumley 1998).
The postnatal period is defined in the Nursing and Midwifery Council’s (NMC) Midwives rules and standards (NMC 2004a) as ‘the period after the end of labour during which the attendance of a midwife upon a woman and her baby is required, being not less than ten days and for such longer period as the midwife considers necessary’. The National Service Framework (NSF) (DH 2004) describes postnatal care as professional care provided to meet the needs of women and their babies up to 6–8 weeks after birth, depending on individual need.
Physiological Changes during the Puerperium
During the puerperium, physiological changes take place in all women as the body returns to its pre-pregnant state (Ch. 25) and it is important that the midwife is familiar with these to ensure that appropriate care and advice is given.
Involution of the uterus
The term involution describes the return of the uterus to being a pelvic organ. This includes a process of contractions, autolysis, and epithelial regeneration and proliferation. After the birth of the baby and the expulsion of the placenta, the muscles of the uterus constrict the blood vessels so that the blood circulating in the uterus is considerably reduced. This is known as ischaemia. There needs to be disposal of redundant muscle, fibrous and elastic tissue. The phagocytes of the bloodstream deal with the last two by phagocytosis, but the process is usually incomplete and some elastic tissue remains, so that the uterus never returns to its nulliparous state. Muscle fibres are digested by proteolytic enzymes, a process known as autolysis. The lysosomes of the cells are responsible for the removal of the waste products which pass into the bloodstream to be eliminated by the kidneys (Blackburn 2007, Coad & Dunstall 2005).
The decidual lining of the uterus is shed in the lochia, which also contains blood and serum. A new endometrium develops from the basal layer, beginning around the 10th postnatal day and estimated to be completed in about 6 weeks, although the evidence base for this is absent. Variations in the duration of shedding of lochia have been reported, with a range of 4 to 8 weeks (Abbott et al 1997), although duration of loss appears to be based on assumption rather than evidence. The changes in lochia have been described in three stages: lochia rubra (red), lochia serosa (pink) and lochia alba (white). These terms describe changes in the colour of the lochia, which together with the assumed duration of loss, have formed the basis for practice. However, they do not accurately represent the wide variability in the colour or duration of vaginal loss experienced by most women in the postnatal period (Marchant et al 1999).
The cervix and vagina lose the increased vascularity within 3 days of delivery, any oedema is reabsorbed and any bruising and tears heal rapidly (Stables & Rankin 2005). The ovaries and uterine tubes become pelvic organs again as the uterus returns to the pelvic cavity.
Hormonal changes
Following the delivery of the placenta, the circulating levels of oestrogen and progesterone fall abruptly, but prolactin levels increase, stimulating milk secretion. (The initiation of lactation is described in full in Chapter 43.) An increase in the concentration of oxytocin occurs especially when the baby is suckling and may be experienced by the woman as a ‘tingling’ sensation in the breasts, as the intra-alveolar pressure is increased. There may be a cramping pain in the abdomen as a result of uterine contraction.
Eventually, negative feedback mechanisms trigger the release of the follicle-stimulating and luteinizing hormones, responsible for the resumption of the ovarian menstrual cycle. Ovulation takes place before menstruation, so that a woman may become pregnant again before she has a period; thus, all women should be advised of the need to use contraception prior to resuming sexual intercourse (Ch. 27). The re-establishment of hormonal stability in the early postnatal period will affect the emotional state of the woman (Hall 2005).
Respiratory system
Changes in the respiratory system are effected by the full ventilation of the basal lobes of the lungs which are no longer compressed by the enlarged uterus. Chest wall compliance, tidal volume and respiratory rate return to normal within 1 to 3 weeks (Coad & Dunstall 2005).
Musculoskeletal system
The musculoskeletal system returns gradually to its pregravid state over a period of around 3 months following the birth (Wylie 2005). Ligaments of the uterus and muscles of the pelvic floor and abdomen return to their pre-pregnant state as the progesterone levels fall. This process can be aided by early ambulation and undertaking postnatal exercises (Logan 2001, NICE 2006). The rectus abdominis muscles may remain separated at the midline, a condition known as diastasis recti, which is most likely to occur in grande multiparous women or in those who have had a multiple pregnancy or polyhydramnios.
Urinary system
The diuresis following delivery lasts for 2–3 days and fluid and electrolyte balance returns to normal by 21 days after the birth (Coad & Dunstall 2005). Dilatation of the urinary tract, which occurs in pregnancy due to increased vascular volume and increased progesterone, resolves and the renal organs gradually return to their pregravid state.
The Role of Health Professionals during the Postnatal Period
In the NSF (DH 2004) it states that women should receive coordinated postnatal care, delivered according to relevant guidelines with an agreed pathway of care, encompassing both medical and social needs of women and babies. Therefore the service should be delivered through the care pathway approach where linked groups of health professionals work together to ensure an equitable provision of high-quality care. All healthcare professionals caring for women and their babies should meet the relevant competences as outlined by Skills for Health (2005).
The role of the midwife
A midwife has to provide care and monitor the progress of the mother in the postnatal period and give all necessary advice to the mother on infant care (NMC 2004a). The NICE guidelines Routine postnatal care of women and their babies (NICE 2006) provide guidance for midwives on the pattern and content of postnatal care with discussion of the evidence available. The midwife may delegate some appropriate aspects of care to a Maternity Care Assistant but remains the lead professional.
The role of the GP
As part of routine postnatal care offered by the GP, a woman may receive up to five home visits and a final consultation at 6–8 weeks, following which she is discharged from the maternity services. Despite this being a routine part of care for around 50 years, the evidence of the contribution of GPs to routine community-based maternity care is hard to quantify and anecdotally there is wide variation in the extent to which GPs delegate their responsibilities to midwives (Smith & Jewell 1998).
Dowswell et al (2001) conducted a two-part study into the roles of primary care workers, in the care of childbearing women. Their survey identified that GPs had high levels of involvement in some aspects of maternity care, including postnatal visiting (76%), and the 6-week postnatal check (95%). Higher levels of GP involvement were not necessarily associated with higher levels of communication with midwives and there was some evidence of the opposite pattern. GPs within the same practice often worked and communicated with midwives in different ways.
No studies have examined the benefit to women’s wellbeing of routine GP home visits and whether they are an appropriate use of GP time and skills. The few studies that have examined the 6–8-week check found that the routine content and timing may not be appropriate to meet women’s health needs (Bick & MacArthur 1995b, Sharif et al 1993), although the generally high uptake suggests women value a consultation for themselves after childbirth. Discussion of contraception is routinely included as part of the 6–8-week consultation; however, one study found that more than half of postnatal women had resumed sexual intercourse within 6 weeks of the birth (Glazener 1998).
The role of the health visitor
A health visitor will visit the woman and her infant during the postnatal period and for a number of years afterwards, until the child reaches school age. These home visits may commence whilst the midwife is still attending the woman, especially if the midwife continues to visit for up to 6 to 8 weeks or even 3 months as suggested in Standard 11 of the NSF (DH 2004).
The health visitor role, in specialist community health nursing, aims to reduce inequalities by working with individuals, families and communities, promoting health and preventing ill health, with emphasis on partnership working that cuts across disciplinary, professional and organizational boundaries (NMC 2004b). In many areas of the UK, health visitors routinely administer the Edinburgh Postnatal Depression Scale (EPDS) to postnatal women (Shakespeare et al 2003) to assist in the identification of those at risk of developing depression (Ch. 69). It is considered to be good practice to ask women who have recently given birth about their emotional wellbeing (NICE 2006); however, several studies have shown that women may not find the EPDS, or the way it is used, to be acceptable, with the consequence that they may produce ratings that do not adequately reflect their feelings (Shakespeare et al 2003).
Content of Midwifery Postnatal Care
Recommendations have been identified in the NICE guidelines (2006). A documented, individualized postnatal care plan should be developed with the woman, ideally in the antenatal period or as soon as possible after birth. This should include relevant factors from the antenatal, intrapartum and immediate postnatal period. Details of the healthcare professionals involved in a woman’s and her baby’s care, including roles and contact details, should be provided and plans for the postnatal period should be identified. This care plan should be reviewed at each postnatal contact.
Aspects of core care and information that should be provided to maintain maternal health were also identified in the guidelines (see Box 51.1). These core observations and examinations should be performed to monitor recovery from the birth whether in hospital or the home. Midwives should perform them as appropriate, taking into account individual women’s health needs and wishes, as informed consent must always be gained before undertaking any physical examination (DH 2004, NMC 2008).
Box 51.1
Routine core postnatal care and information (Adapted from the NICE guidelines 2006)
Within the first 24 hours after birth
Between 2 and 7 days (24–168 hours)
Core information
Core care
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