Introduction
The Midwives’ Rules and Standards (NMC 2012) describe the postnatal period as:
the period after the end of labour during which the attendance of a midwife upon a woman and baby is required, being not less than 10 days and for such longer period as the midwife considers necessary.
This chapter focuses on the essential care that each woman and her baby should receive from the midwife during the postnatal period. Particular reference will be made to current guidelines issued by the National Institute for Health and Clinical Excellence (NICE) on postnatal care of women and babies (NICE 2006). In this chapter the baby will be assumed to be male, to reduce confusion when referring to both woman and baby.
Principles of postnatal care
The postnatal period is a time of change and adjustment for the woman and those close to her. The focus of attention is no longer on the woman alone but on her baby too; therefore the midwife’s role is not only to care for them both (NMC 2012) but also to empower the mother to provide the best care for her baby (NMC 2009).
The NICE guideline 37 (NICE 2006) stresses that women should at all times be treated with dignity, kindness and respect. Women should be encouraged to become fully involved in the planning of their postnatal care, which should centre on their individual needs rather than on routine patterns of care. There are many factors which influence the decision on how to plan the woman’s postnatal care. These include the state of the mother and baby’s health, whether or not the mother has had other children before, her chosen method of infant feeding, her ability to understand and assimilate information, her domestic background and her psychological state. The woman’s cultural and family background should always be taken into consideration when planning postnatal care (NICE 2006).
Advice and support should build on women’s existing knowledge, responding to their individual needs; a new mother may welcome advice on basic matters such as how to hold her baby, whereas an experienced mother may find such advice patronising, thus building barriers to further communication.
Kelly and her husband arrived home from hospital yesterday with their newborn baby. Kelly’s mother-in-law is visiting from Poland. Kelly bottle fed her two older children but has decided to breastfeed baby Michael. The community midwife who visited the family today assumed that as Kelly was an experienced mother and had good family support, she would not need much advice. After making sure that both Kelly and Michael were physically well, the midwife left Kelly some breastfeeding information leaflets and promised to call back in a few days’ time.- Why might the midwife’s assumption be wrong?
- List ways in which Kelly’s postnatal care could be individualised.
Plan of care
Each woman should have ‘a documented, individualised care plan’ which should be reviewed regularly (NICE 2006). The usual place to document this is in the woman’s hand-held maternity notes. This allows the woman to read it whenever she wishes and to add to it or alter it as necessary. She should be advised to discuss any changes with her community midwife in case there is any conflict with other aspects of her care plan. It is vital that the information, advice and care given to women and their babies in the postnatal period are consistent, as they may be cared for by many different midwives and other health professionals. Any symptoms, tests performed, deviations from the norm or referral to other professionals should be discussed with the woman and meticulously followed up and documented so that progress can be continuously mapped (NICE 2006).
Immediate postbirth care of the woman: physical assessment and care
Before leaving the new family alone for some private bonding time, the midwife must undertake some basic observations to ensure that the woman’s health is not at immediate risk.
Observation and estimation of blood loss
The volume of blood loss is estimated following delivery of the placenta and then observed frequently in the early postnatal period. The midwife will be observing for any signs of postpartum haemorrhage (PPH), a potentially life-threatening condition which is more common if the woman has had a prolonged or complicated labour or birth.
A blood loss of 500 mL or more at or around the time of birth is classed as a ‘primary PPH’. However, this figure is not a good indicator of maternal well-being: some women can withstand a blood loss of 500 mL or more with little or no detriment to their health, whilst others will show symptoms of hypovolaemia (low blood volume) well before 500 mL has been lost. The midwife must call for urgent medical assistance if PPH occurs or is suspected or if the woman is showing signs of hypovolaemia (raised pulse, drop in blood pressure, dizziness, fainting) regardless of the volume of blood lost. Assessing blood loss is not easy: blood is soaked up by pads, bedding and clothing and is often clotted or mixed with amniotic fluid.
Fill a large measuring jug with water and colour it red using food dye. Gather several bowls of varying sizes and place inside them an assortment of absorbent items. To each bowl, add a measured amount of liquid and allow the contents to soak it up. Ask other people to estimate the volume of liquid in each bowl.Observation of fundal tone and position
Poor uterine tone following delivery of the baby and placenta may lead to excessive bleeding. The midwife should gently palpate the fundus, which should feel very firm and central, just below the level of the umbilicus. If the uterus feels soft and broad, it is likely to be poorly contracted and the midwife will ‘rub up’ a contraction until the uterus feels firm. If the woman is well enough, putting the baby to the breast may also help, as this stimulates the release of the hormone oxytocin, which helps the uterus contract.
A full bladder may displace the uterus, causing it to feel higher than expected or deviated to one side. If the woman is unable to pass urine, it may be necessary to empty the bladder using a catheter, as a full bladder may impede involution of the uterus, leading to excessive blood loss. Subsequent midwives will then need to monitor the woman’s urine output so that any continuing disturbance to normal bladder function can be investigated and treated promptly.
Vital signs
Observation of vital signs (blood pressure, temperature, pulse, respirations) is undertaken shortly after completion of the third stage of labour and thereafter may be repeated on a regular basis according to local policy or the woman’s state of health. Any unexpected changes should be immediately investigated as these may be indicators of potentially life-threatening conditions such as PPH, pre-eclampsia or infection. In the homebirth setting, any deviations from the norm that do not quickly resolve may require the woman and baby to be transferred swiftly into hospital for further observation and treatment. Women who have had complications or health problems in the antenatal period or during labour will require more frequent monitoring of vital signs and the midwife will liaise closely with the obstetric team in accordance with the care plan or as necessary.
Inspection of the perineum and vagina
Following a normal vaginal birth, the midwife will inspect the woman’s perineum and vagina to assess the following:
- The presence of any trauma to the tissues.
- The extent of any trauma.
- Whether or not suturing is required.
- Whether or not referral to an obstetrician is required.
The procedure must be carefully explained to the woman and verbal consent obtained prior to commencing.
Examination of the placenta
A full examination of the placenta, cord and membranes should be undertaken as soon as possible after the birth to enable the midwife to assess whether any part has been retained. Retained placental products are a potential cause of PPH, as their presence may prevent full involution of the uterus. If not passed, they may also provide a route for pathogens, leading to infection (Johnson & Taylor 2010).
If there is any suspicion that part of the placenta or membranes have been retained, the midwife must refer to an obstetrician without delay. It may be necessary to evacuate the uterus under epidural or general anaesthetic. All findings must be documented in the woman’s notes.
Before wrapping and disposing of the placenta, the midwife should check whether the woman or her family wish to see it or even take it home. Some cultures object to the usual hospital practice of incineration and prefer to bury the placenta privately (Johnson & Taylor 2010).
Perineal repair
The majority of women suffer some degree of perineal damage during a vaginal birth (Steen 2012). The aim of perineal repair is to restore the integrity of the perineum and surrounding tissues and to reduce bleeding and risk of infection (Johnson & Taylor 2010). Learning to identify the extent of any perineal trauma is an important midwifery skill and failure to do so correctly may have serious long-term consequences for the woman (Steen 2010, 2012). Evidence suggests an association between the skill of the person carrying out the repair and subsequent perineal pain and healing (Kettle et al. 2010). The repair of any perineal trauma is normally the responsibility of the person who assists at the birth; however, some degrees of trauma may be beyond the midwife’s level of skill or the scope of her practice, so the ability to recognise when to refer to a senior colleague or obstetrician is paramount.
Table 10.1 Degrees of perineal trauma (data from RCOG 2007)
| Degree | Trauma involves… |
| First degree | The skin of the perineum only |
| Second degree | Perineal skin, posterior vaginal wall mucosa and the muscle layers of the perineum, but not the anal sphincter |
| Third degree: 3a 3b 3c | Less than 50% of the thickness of the external anal sphincter is damaged More than 50% of the external anal sphincter is damaged There is damage to both external and internal anal sphincter |
| Fourth degree | Trauma to the anal sphincter extending to the anal epithelium |
Degrees of perineal trauma
The Royal College of Obstetricians and Gynaecologists’ (RCOG) definition of the degrees of perineal trauma is summarized in Table 10.1.
Suitably trained and experienced midwives may repair first- and second-degree tears, episiotomies and straightforward labial tears if they feel it is within their competence to do so, but third- and fourth-degree trauma must always be repaired by an obstetrician. If the woman has given birth at home or in a stand-alone birth centre, she will need to be transferred to hospital for repair of a third- or fourth-degree tear. This is traumatic for the whole family and will require particularly sensitive care. Trauma to other parts of the genital tract (e.g. the clitoris, urethra, anterior vaginal wall) should always be referred to the obstetric registrar. Any bilateral labial grazes that are in apposition during normal postures should be sutured to avoid the risk of the labia healing together (Johnson & Taylor 2010).
Indications for repair of first- and second-degree trauma
It is usual practice to suture all episiotomies, regardless of their extent. The issue of when to suture first- and second-degree tears is contentious, but NICE (2007b) recommends that all second-degree tears should be sutured, plus those first-degree tears where the sides of the wound are not in direct apposition.
For further information about current practice in perineal repair, the Royal College of Midwives (RCM 2012) has an up-to-date practice guideline on suturing the perineum available online at: www.rcm.org.uk/college/policy-practice/guidelines/practice-guidelines/.
General well-being of the woman
Soiled bedding and pads will need to be changed and the woman assisted into a comfortable position. A bath or shower should be offered. The midwife should not leave the birthing room until she is satisfied that the woman’s condition is stable. She must ensure that the woman is aware of the danger signs that might indicate potentially life-threatening puerperal disorders (see Table 10.2) and has the means to call for help if necessary (NICE 2006).
Table 10.2 Signs and symptoms of potentially life-threatening conditions in the puerperium (adapted from NICE 2006)
| Condition | Signs and symptoms |
| Postpartum haemorrhage | Sudden and profuse vaginal bleeding or an increase in bleeding which does not settle Feeling faint, dizzy or experiencing palpitations |
| Pre-eclampsia | Headache plus one or more of the following:
(within 72 hours of birth) |
| Infection | Fever, shivering, abdominal pain, may be accompanied by offensive vaginal loss |
| Thromboembolism | Pain, redness or swelling in one calf Shortness of breath or chest pain |
Bladder care
The bladder and urethra sit interiorly to the uterus and are therefore vulnerable to damage during labour, particularly when labour has been prolonged or when forceps have been used. To prevent the risk of a full bladder obstructing uterine involution, the woman should be encouraged to pass urine soon after birth. However, where the bladder has been emptied using a temporary catheter shortly before the birth or during the third stage of labour, a woman may not feel the urge to pass urine until some hours later.
Reference should be made in the notes of the time that urine was passed and, if measured, the volume should be recorded. NICE (2006) recommends that all urine passed within 6 hours of labour should be documented, so that possible urinary retention may be detected and treated early. If no urine has been passed 6 hours after the birth, extra efforts should be made to encourage micturition: some women find it easier to pass urine in a warm bath or shower, if they find this aesthetically acceptable. If all efforts fail, catheterisation should be urgently considered (NICE 2006) as untreated urinary retention and bladder distension may lead to long-term problems with bladder function as well as impeding normal involution of the uterus.
Psychological factors also affect the ability to pass urine. Can you think of any psychological reasons why it may be difficult for a woman to pass urine in the first few hours after giving birth?Initiating breastfeeding
Maternity service providers which strive to promote excellence in evidence-based care in relation to infant feeding will in the past have based their care on the ‘10 Steps to Successful Breastfeeding’. These have now been superseded by the Baby Friendly Initiative standards (UNICEF UK BFI 2012). For a downloadable copy of these, go to: www.unicef.org.uk/BabyFriendly/Health-Professionals/New-Baby-Friendly-Standards/.
According to the standards, maternity care providers should:
- support all mothers and babies to initiate a close relationship and feeding soon after birth
- enable mothers to get breastfeeding off to a good start
- support parents to have a close and loving relationship with their baby (UNICEF UK BFI 2012, p3).
Prior to the birth, the midwife will have established from the woman whether she wants her baby to be given straight to her for immediate skin-to-skin contact. This is recommended for the following reasons:
- It helps the baby to maintain his body temperature.
- It promotes bonding and attachment.
- It facilitates early breastfeeding.
For evidence supporting the benefits of skin-to-skin contact, go to the following link: www.unicef.org.uk/BabyFriendly/News-and-Research/Research/Skin-to-skin-contact.
As long as both woman and baby are well, skin-to-skin contact should be initiated immediately after birth (or as soon as possible) and should continue uninterrupted at least until after the first feed and for as long as desired afterwards (UNICEF UK BFI 2012). It is quite possible for the midwife to undertake most if not all the necessary observations and procedures without separating the mother/baby pair. Healthy babies are usually alert and receptive to feeding in the first hour following birth, so the midwife should encourage the woman to take advantage of this opportunity to initiate breastfeeding, adopting a hands-off approach wherever possible.
A good first feed not only benefits the baby, but boosts the mother’s confidence in her ability to breastfeed successfully in future.Care after caesarean section
Rising rates of caesarean section across the UK mean that the postoperative care of women is becoming an increasingly large part of the hospital midwife’s workload. The woman recovering from a caesarean section requires particular care and attention, not just to her physical well-being but also her state of mind; she has had major surgery as well as giving birth, both of which are major life events (Johnson & Taylor 2010).
- Airway, respirations, heart rate, blood pressure and temperature
- Oxygen saturation
- Level of consciousness
- Control of pain
- Care of IV infusions and maintenance of fluid balance
- Care of wound
- Observation of blood loss per vaginam
- Care of urinary catheter/observation of urine output
- Observation for return of sensation following spinal or epidural anaesthesia
- General comfort, including posture and care of pressure areas
- General well-being, e.g. nausea, thirst
Care in the recovery area
The immediate postoperative care takes place in the recovery area of the operating theatre, where emergency equipment is on hand. The anaesthetist will hand over care to a midwife, who should remain constantly with the woman until she is fit to be moved to the postnatal ward.
Observations
The woman will have intravenous (IV) infusions running plus an indwelling catheter. Observation of vital signs should be undertaken at 5-min intervals initially until the woman’s condition stabilises, then half-hourly for at least 2 hours and thereafter hourly until within satisfactory parameters. Where opioids have been administered, respiratory rate, sedation and pain levels should be monitored hourly for a minimum of 2 hours after treatment is discontinued (NICE 2011).
Routine assessments include those listed in Box 10.1. All observations should be carefully documented and any cause for concern reported immediately to the anaesthetist or obstetrician.
As well as caring for the mother, the midwife must also observe the baby to ensure that he is adapting normally to extrauterine life. Recovery areas may be quite cool and babies born by caesarean are more likely to have a lower temperature (NICE 2011) so the midwife should ensure that the baby does not become chilled, especially as babies born following caesarean section are at greater risk of respiratory distress (Johnson & Taylor 2010). The initial examination for the newborn should be carried out, if not done previously in theatre, and vitamin K administered in accordance with the parents’ wishes.
A midwife is caring for a woman alone in the recovery area. The woman’s partner is present. What should the midwife do in the following events?- Her pen runs out of ink whilst completing her records.
- The woman complains of increasing pain.
- The woman asks for help to sit up.
Care of the woman on the postnatal ward following caesarean section
The midwife who has cared for the woman in the recovery area should give a detailed handover to staff on the postnatal ward, including explanation of the documented care plan.
Psychological adjustment in the early postnatal period can be difficult for women who have undergone operative births: as well as physical discomfort, they may feel frustrated by their lack of mobility and their need to seek help with basic baby cares (Johnson & Taylor 2010). Seeing other women around them who need no assistance may increase their sense of inadequacy. The midwife will liaise with the multidisciplinary team, including nursery nurses to help with baby care, maternity care assistants (MCAs) to help with basic observations and hygiene needs and breastfeeding support workers to help establish feeding. The midwife will need to ensure that the woman receives the care and support she needs to develop independence and autonomy in caring for herself and for her baby.
Following a caesarean section, a woman will have very limited mobility for several hours. Once on the postnatal ward she should not be left alone without a call-bell to hand; neither should she be left alone with the baby in her arms unless she is able to place him in the cot safely without assistance.Pain management
Patient-controlled analgesia (PCA) using opioids is the recommended method of pain control in the immediate postoperative period (NICE 2011). This is set up by the anaesthetist in theatre or the recovery area and will continue in accordance with local protocol.
Non-steroidal anti-inflammatory drugs (NSAIDs) may be used in conjunction with a PCA (NICE 2011) if prescribed. Once the PCA has been discontinued, women should be offered regular analgesia, depending on the level of pain. Gas in the gut (flatus) and constipation are common causes of abdominal pain in the early days following a caesarean section and may be confused with normal ‘after-pains’ (Marchant 2009a). ‘After-pains’ are discussed in more detail further on in this chapter. If pain relief is unsatisfactory, the obstetrician should be contacted to review the woman’s drug regime.
Hygiene and wound care
The day after her operation, the woman should be offered assistance to take a shower, following which the midwife should help her to remove her wound dressing. The wound site should be inspected to ensure that there is no bleeding or signs of infection and that the suture or staples remain intact. The wound is usually left uncovered by dressings and if non-dissolving sutures or staples have been used, these will be removed by the midwife when local policy dictates. The midwife may take this opportunity to outline the healing process and what to expect in the coming weeks. She can also remind the woman about wearing loose clothing for comfort and advise her on the signs of infection, such as fever, redness, pain, abnormal lochia or wound discharge (NICE 2011).
Fluid balance and diet
The urinary catheter may be removed once a woman is mobile, but should remain in situ for at least 12 hours after the last epidural top-up (NICE 2011). Once the catheter is removed, the woman should be encouraged to pass urine frequently. It is important for urine output to be monitored to ensure return to normal bladder function.
Prevention of thromboembolism
Thromboembolism is one of the leading causes of maternal death in the UK (CMACE 2011). All women should be assessed for risk of venous thromboembolism (VTE) in early pregnancy, on admission to hospital for any reason and after delivery (RCOG 2009).This is particularly important for women undergoing caesarean section, as this increases the risk of VTE. Other postnatal risk factors for VTE are listed in Box 10.2.
All women who have had a caesarean section should be encouraged to mobilise as soon as they are able and to remain well hydrated (RCOG 2009). Women who are considered to be at high or intermediate risk of VTE will be given prophylactic anticoagulants in the form of low molecular weight heparin (LMWH) according to current guidelines.Women with three or more persisting risk factors listed in Box 10.2 should be given graduated compression stockings to promote venous return from the lower limbs (RCOG 2009).
