The Edinburgh Postnatal Depression Scale (EPNDS) questionnaire has not been universally applauded as effective (Forman et al 2000; Shakespeare et al 2003). However, Barclay and Lie (2004), after a chart review conducted by investigators from the University of Rochester School of Medicine in New York, reported that ‘the EPNDS should be considered for use in screening for post partum depression (PPD) in the first year well-child visit setting’. ‘Adequate quality control measures need to be in place for consistent implementation’; they also stated that ‘the EPNDS results in higher rates of detection of maternal depression during the postpartum year’ (Barclay & Lie 2004). This screening device is used by some New Zealand midwife LMCs to assess the need to refer with possible pathological postnatal distress/depression.

Dr Gillian White compared the EPNDS with the Postpartum Depression Screening Scale (PDSS) (White 2008). She concluded that in the specific group of women tested, both had satisfactory reliability and validity. One caution related to the use of EPNDS with women who are highly anxious. The PDSS short form is available for download; see Online resources.

Kabir and his colleagues promote three key questions of the 10, questions 3, 4 and 5, which may result in better compliance with screening (Kabir et al 2008).

Box 33.1 Edinburgh postnatal Depression questions

Each of the questions has four catagories of answer on a sliding scale (prepared by JL cox, JL Holden and R Sagovsky, University of Edinburgh

In the past seven days:

1. I have been able to laugh and see the funny side of things

2. I have looked farward with enjoyment to things

3. I have blamed myself unnecessarily when things went wrong

4. I have been anxious or worried for no good reason

5. I have felt scared or panicky for no very good reason

6. Things have been getting on top of me

7. I have been so unhappy that I have had difficulty sleeping

8. I have felt sad or miserable

9. I have been so unhappy that I have been crying

9. The thought of harming myself has occured to me

Box 33.2 Support groups

Does the woman know what resources are available for support for postnatal distress? For example, the following website provides contact details of consumer mental health support groups in New Zealand and Australia: www.beyondblue.org.au/index.aspx?link_id=94

In considering the use of either tool for screening by LMCs at six weeks, White concludes that the EPNDS ‘may be an efficient method of screening for normal adjustment versus symptoms of PND’ (White 2008, p 19). White conceded that both tools are developed for the ‘western’ paradigm and that Indigenous peoples (Pacific Islanders, Māori, Australian Aborigines) need to develop screening tools of their own (White 2008).

It is expected that the issue of post-traumatic stress disorder (PTSD) would be on the midwife’s agenda, in appropriate cases, long before the six-week discharge. However, should the midwife believe that the woman may have consequences at a later time but at six weeks responds blankly, neutrally or negatively to professionally sensitive probing, the ‘Troubled by your birth experience’ pamphlet issued by the Trauma and Birth Stress Organisation (TABS; see Online resources) may be accepted on the basis of it being a useful future reference and self-help/monitor check. The organisation Beyond Blue in Australia provides a number of resources for women suffering from postnatal depression, as do all state and territory health departments, many of which also provide help lines. (See also Chapter 40.)

Spiritual health

Supporting the woman’s spiritual needs requires a carefully accrued knowledge of the woman and her pregnancy, childbirth and early parenting journey, and actively listening to her reflections. Some women can articulate these clearly; others require gentle, persistent delving if the midwife detects spiritual pain. You might not feel qualified to support the woman in spiritual difficulty. Rather, your role might be to involve the woman’s own spiritual guides through her family.

Sexual health

Many women may be reluctant to discuss sexual ill-health fully with their midwife, even at six weeks. A midwife is expected to raise the topic, inquire about dyspareunia, and impart the clear message (whether or not intercourse has resumed) that the woman does not need to tolerate any ongoing discomfort, and should seek help if she needs

Reflective exercise

Carol is a woman who, with her second pregnancy, approached you to be her labour and birth midwife on advice from her rural LMC midwife. She chose to birth at a secondary-care birth facility. Her first labour was complicated by fetal distress and she vividly remembers travelling in second stage in an ambulance from a birthing unit to a secondary-care maternity facility because of concern for the baby. The resulting tension and discomfort guided her choice this time, to labour and birth some 90 minutes away from home, to avoid a possible repeat of the transfer in late first stage.

Her (second) labour was spontaneous and she birthed normally without fetal distress—a second daughter. However, you determined that her perineal laceration was beyond your skills to repair and sought advice and assistance from a senior registrar. He speedily repaired her wound, and she returned to her local primary facility for postpartum care and six-week assessment.

Five months later, Carol has phoned you, seeking your help in reviewing her perineal condition. She is experiencing severe dyspareunia, to the extent that sexual intercourse is impossible, and her marriage is under strain. She very much wants a third child.

1. What steps can you take within the system of referral in your area?

2. How does any lesson learned from such a scenario guide you in your approach to sexual function assessment in future six-week discharge visits?

it. Sensitive questioning may help elicit other sexual-health-related concerns and lead to a discussion about lack of desire. Several factors, such as a difficult birth, lochial discharge, tender secreting breasts, sore nipples, lowered levels of androgen and oestrogen, particularly in the first six weeks, are associated with vaginal dryness and lowered libido, altered physical appearance (some women may never have considered that the appearance of their genitals might be permanently changed), or fear of becoming pregnant again, and these can combine to depress the woman’s interest in intercourse. Breastfeeding also has an effect: ‘Although there are some physiological similarities between sexual arousal and breastfeeding, erotic stimulation and/or orgasm do not usually accompany breastfeeding. The hormonal basis of breastfeeding usually causes the woman to “fall in love” with her baby, thereby ensuring that she will respond to its needs’ (Auckland Homebirth Association 1993, p 139). Exhaustion, changes in libido, deterioration in general understanding and communication between the couple can all develop, whether or not there is discomfort. It is beginning to be understood that such difficulties are common. A wide range of feelings is normal (Dixon et al 2000; Force 2000). The woman may need advice about a lubricant; she may need support to foster open, frank communication with her partner.

Cultural health

Like spiritual health, cultural health is often less than ideally attended to by healthcare professionals in both Australia and New Zealand. In New Zealand, healthcare professionals are expected to develop and meet standards of cultural competence (Health Practitioners Competence Assurance Act 2003) and midwifery has embraced the frameworks of cultural safety, midwifery partnership und Tūranga Kaupapa as outlined in Chapter 16. The capacity of the midwife to acknowledge a culture that may be different from the dominant culture yet clearly potentially influential on the health status of her client is to be carefully nurtured. Australia and New Zealand both claim multicultural communities. However, in both, the dominant ethnic group has been Anglo-Saxon. This power imbalance between the groups requires constant vigilance in order not to abuse it.

At six weeks it is late in the day to begin assessment. Ideally the midwife will already have incorporated, within her holistic approach, attention to the language, customs, culturally sensitive aspects and safety measures relevant to her client and the family. These efforts will enable her now to seek valid feedback from her client. A midwifery ‘wisdom’ developing in New Zealand, at least, is the importance of regarding each pregnant woman as having her own unique culture. This approach is inherent in both cultural safety and midwifery partnership as described in Chapter 16. If this approach were adopted as standard within midwifery practice, then the woman’s safety, with regard to her wider ethnic cultural needs, would be assured of the necessary attention and respect.

Box 33.3 Breastfeeding resources

Is the woman aware of all the community-based breastfeeding resources available to her, such as:

• La Leche League (New Zealand)—provide information on breastfeeding, telephone counselling, and run breastfeeding support groups

• Plunket Society (New Zealand)

• hospital and community lactation consultants

• Australian Breastfeeding Association.

Clinical scenario

Heather and Tane conceived their twins by in vitro fertilisation. They live in a small town half an hour’s drive out of the city. The twins were born by caesarean section at 38 weeks, as it appeared that the second twin, their son, was in distress on a routine growth scan. Both babies had good Apgar scores; the girl weighed 2740 g, the boy 2500 g. The girl’s cord remnant swelled and oozed postpartum and the boy developed mild physiological jaundice. Heather began by exclusively breastfeeding, but the girl’s failure to gain weight and show good urine output, together with Heather’s exhaustion, meant that eventually she partially breastfed and partially bottle-fed, until the twins were stronger. At home, the girl was mainly bottle-fed, the boy mainly breastfed.

What are your discharge priorities and preparations for this family?

Infant feeding

By six weeks, most women have settled into the method and implementation of the feeding choice they have made for their baby. However, a small number of women may continue to have difficulty with breastfeeding and may require ongoing support. Consumer support groups, such as the La Leche League and the Australian Breastfeeding Association, can provide useful support to all breastfeeding women, whether they have experienced problems or not. It is helpful to put women in touch with such community support services. Family can also play an important role with ongoing support.

Some women will gain valuable support and advice from their well child provider (such as a Plunket nurse, Te Puawaitianga, Pacific Trust healthcare worker, Australian Child Health Nurse or general practitioner), and it is important that your referral to this service provides appropriate information about the progress of infant feeding and any issues that may have arisen.

At the final examination it is important to find out how the woman feels the feeding is going and her reflections on the experience so far. The honest admiration you express of the thriving, smiling, healthy baby is invaluable and will leave a lasting, empowering impression on a first-time breastfeeding mother.

Physical assessment

The six-week check is so-timed as it is known that the endometrium is fully healed by six weeks (Fraser & Cooper 2003; Henderson & Macdonald 2004). Ideally, your timing management of this physical check for the mother will ensure that this is attended to prior to the baby waking/being woken. Much can be discussed during this one-to-one opportunity with the woman. Wider personal and public health information can be passed on (diet, exercise, smoking, cervical screening), and final questions asked, such as:

• Does she have any concerns regarding her breasts and nipples?

• If there is a caesarean scar and if she chooses midwife discharge assessment (as opposed to returning for an obstetrician clinic appointment), how well healed is this scar?

• You should find the uterus completely involuted and not palpable abdominally.

• Has her bleeding stopped? In New Zealand, funding for a scan of the uterus to detect retained products is part of the LMC budget only until six weeks postpartum. Ongoing lochial discharge, suggestive of non-involuted uterus and some retention of

Clinical point

Continuity and perineal care

Among the continuity-of-care midwife’s distinctive advantages in maintaining and improving good practice is the opportunity she has to gain insight regarding outcomes of her clinical judgement and skill with regard to perineal repair (or not) and eventual healing. Such a midwife has the opportunity to follow up on the outcome of her care and learn invaluble lessons; and often more than once if she cares for this woman in subsequent pregnancies.

In her recent review of midwives’ approaches to care of the perineum, Wickham noted (while commenting on another study) that: ‘midwives were able to reflect upon their practice in relation to the woman’s experience, something which midwives working in systems without continuity of partnership are not often given the opportunity to do’ (Wickham 2001, p S26). Those midwives were then able to alter their practice significantly.

membrane or other placental fragment, could be assessed at five weeks and an appropriate scan ordered with consent, to avoid the woman/couple sustaining the cost. However, studies suggest that ongoing loss up to 42 days is not unusual (Marchant et al 2002; Wickham 2001), and a decision regarding a scan may best be held over until 8 or 10 weeks and require general practitioner (GP) referral. Obviously the budget issue does not affect Australian midwives, and advice by them to see their GP at the more reasonable time of eight weeks with ongoing, non-period bleeding would suffice.

• If there is bleeding, is it lochial or menstrual? (See Chapter 28 for physiology of the puerperium.)

• If there has been any perineal, vaginal wall or labial damage (sutured or not), the area should be assessed for degree of healing. Use a good light, and gloved hands. If she has not done so already, the woman should be encouraged to look in a mirror herself to know how differently her genital area now appears.

Box 33.4 Family violence prevention

Do you know the process of documenting your concerns and conveying them to the appropriate agency?

Does your College of Midwives have best practice guidelines for your response in these situations?

New Zealand midwives can view the NZCOM Consensus Statement on family violence screening at: www.midwife.org.nz/content/documents/93/family%20violence.2002.doc.

The question of dyspareunia is a natural one to arise now (see Ch 27). The appropriateness of pelvic examination, cervical smear and vaginal swabbing to take place during this examination is dealt with elsewhere in this book (Ch 27). Do not overlook the state of the anus and the

Critical thinking exercise

Research and plan approaches to the following topics as part of your discharge visits: