Chapter 5. Hospital postnatal care
Introduction
Hospital postnatal care is available for all women in the UK. The options given vary between maternity units and range from a few hours to several days. However, many women, especially those expecting their first baby, are often led by what the midwife recommends. Women may ask, ‘What usually happens?’ and the response they receive often depends on local custom and practice. This chapter describes some of the issues to consider when caring for a woman in hospital after the birth. Bathing the baby is used to illustrate the principles of teaching parents new skills through involvement and role modelling. These principles could be applied to a range of skills that new parents need to learn.
Why stay in hospital?
A hospital stay following the baby’s birth may be chosen or advocated in order to address one or more of the following objectives on a 24-hour basis:
■ Provide support and care to women recovering from childbirth
■ Assess and monitor the wellbeing of the woman and/or her baby
■ Develop and enhance parental confidence in caring for their new baby.
Each woman’s needs should be individually assessed so that a package of care can be provided that meets her particular circumstances. The National Service Framework for Children, Young People and Maternity Services (Department of Health 2004:32) requires that:
In hospital settings, each woman receives an initial assessment of her needs and agrees a care plan with the midwife which takes into account the type of birth, expected length of stay in hospital and the timing of her transfer home.
This individualized approach to postnatal care is further endorsed by the postnatal care guidelines (NICE 2006) and the government policy document Maternity matters (Department of Health 2007). There is evidence to suggest that midwives value providing both emotional and physical suppport to women throughout the postnatal period and see it as an important aspect of their role (Cattrell et al 2005). However, it has been reported that women are most critical of the care they receive on hospital postnatal wards than at any other time (Redshaw et al 2007). For example, only 53% of women felt treated as an individual at all times during their postnatal stay (op cit: 48).
Women’s postnatal needs cannot be precisely predicted, and therefore require careful assessment following the birth. Although it is likely that a primiparous woman will take longer to feel confident handling her baby than a multiparous woman, this will not always be the case. A woman who has grown up caring for younger siblings may be very adept with all aspects of childcare, whereas one having a second baby following a long gap may take some time to regain her confidence. The events surrounding the birth will also have an impact on whether or not the woman and her baby stay in hospital afterwards:
Mode of birth: A woman who has an instrumental birth may need time to recover from the effects of anaesthesia, a painful wound and the unanticipated intervention. In addition, a woman who has had a caesarean birth will need advice and support to recover from major abdominal surgery while mastering her maternal role (see Chapter 6).
Time of birth: A woman who had intended having a 6-hour transfer home may be advised to compromise her wishes if the baby is born in the evening.
Health of baby: A period of observation is often advocated if the baby required assistance at birth, was cold, hypoglycaemic or has a high risk of infection. Babies who become jaundiced may also require hospital care for phototherapy and careful monitoring of serum bilirubin levels. Contentiously, many NHS Trusts have policies which state that the baby’s respiration rate should be closely observed (in hospital) if the liquor was meconium stained.This is particularly difficult to implement if the baby was born at home, as this would require both the mother and baby to be transferred to hospital. However, in practice, while some units have specific observation procedures, others do not and the baby remains under the observation of its mother – which, it could be argued, could be done in the comfort of their own home.
Health of woman: In a random survey of postnatal women, Glazener et al (1995) found that 85% reported at least one health problem in hospital. Many of these issues can be managed in the community setting; however, some require continued observation and treatment. For example, if a woman has had a postpartum haemorrhage (PPH) she should be closely observed for symptoms of anaemia, such as: breathlessness, syncope, lethargy and further excessive blood loss.Women with an underlying medical condition, for example diabetes or raised blood pressure, will need close observation to ensure that their drug therapy is adjusted to meet their postnatal needs.
Some women, because of current or previous psychiatric illness, will be advised to stay in hospital following the birth so that their mental health status can be closely observed. Care should be carefully coordinated and provided by the perinatal mental health team. In circumstances when psychiatric admission is required following childbirth, this should be in a specialist mother and baby unit, with her baby (Lewis 2004). Postnatal emotional wellbeing is the focus of Chapter 8.
When it has been agreed that the woman and her baby would benefit from hospital postnatal care, her transfer to the ward should be carefully coordinated.
Transfer to the ward
Coming out of a birthing room, where the woman has some degree of privacy, onto a ward with lots of hustle and bustle, can be overwhelming. There are many ways in which the midwife can ease this transition, enabling the woman to feel part of a community rather than one of many.
Before the woman leaves the labour ward, the midwife who has been caring for her should telephone the postnatal ward to establish that there is a bed available. Brief details can be given regarding the way that the birth had progressed so that the postnatal midwife can allocate the most appropriate location. For example, some units put women who have had a caesarean delivery or who are breastfeeding together in the same bay.
If there will be a delay in transferring her, this should be explained to the woman, giving her a reason and a time by which the situation will be reviewed. When a bed is available, ideally the midwife who had looked after her should transfer her to the ward, so that a more detailed handover can be carried out. The midwife taking over her care should greet the woman by name, demonstrating that she is expecting her, and introduce herself, explaining her role and how long she will be providing her care. Baxter et al (2003) reported how some women on postnatal wards feel a sense of abandonment, often not knowing who is caring for them.
A postnatal examination of the woman should be undertaken to ensure that she is well. The baby’s identity tags should be checked and its temperature taken. All observations should be documented, in the woman’s presence, giving her the opportunity to ask questions and seek clarification. Any deviations from normal should be reported to the midwife who is coordinating the ward.
Introduction to the ward
Before the woman is left alone, she should receive sufficient information to enable her to summon help if she has any concerns and to know what to expect over the next few hours. The amount of detail given will depend on the time of transfer to the ward. If it is the middle of the night it may be sufficient to show her the buzzer system, where the toilet is and where and when breakfast is served. She should always feel able to buzz for assistance, whether with feeding or any aspect of baby care. It should be anticipated that she will need some help in the first few hours after the birth and while she adapts to her new surroundings. Most wards have introductory leaflets about ward routines and visiting hours that can be a useful resource for women who are unfamiliar with being in hospital.
Single rooms
Although the thought of a single room with its own washroom facilities might sound appealing, in reality being placed alone can be quite isolating for some women. New mothers often benefit from observing how other women handle their babies; seeing that their’s is not the only one that does not settle easily, or go straight to the breast without some help, can be reassuring.
However, there are circumstances when a single room away from the throng of the main ward is the best option. Women whose baby is in special care may find it difficult to be on the main ward, constantly reminded that their baby is not with them. Also, particularly if the baby is ill, she may have a constant stream of visitors who need privacy as they try to adapt to the challenge and uncertainty of the baby’s condition.
Women in single rooms should be visited by a midwife regularly throughout the day. Some women do not like to ring their buzzer to ask for help when they can see how busy the staff are. Women should be encouraged to seek assistance when needed – after all, that is why they are in hospital. Ideally, women should have the choice regarding their postnatal accommodation, but availability is a limiting factor.
Security
Most maternity units have made security arrangements for the prevention of baby abduction. This may involve a combination of some or all of the following:
Locked doors: All visitors must either buzz to gain entry or have privileged access because of the nature of their work. This might be through the use of a swipe card or a keypad. Often, exit from the ward is also controlled by a similar arrangement, with visitors having to ask a member of staff to let them out.
Security cameras/videophone: A closed-circuit television camera is positioned just outside the entrance to the ward. In order to gain access to the ward, the visitor must ring a buzzer and wait for a response. The person on the ward can both see the visitor and also talk to them to establish the purpose of their visit or do the same via a telephone arrangement.
Baby tagging: There are various systems in use, and these may involve the baby having a special tag attached to its ankle that would trigger an alarm if it passed a certain point on the ward. Some wards have cots that sound an alarm when a baby is removed from it (which can be over-ridden for baby carers).
Vigilance: The most important means of protecting babies from abduction is the constant awareness of staff and parents. It is essential that you do not let anyone into the ward who cannot state a legitimate purpose for being there. For example, if a visitor says they are there to visit Mrs Jones and you are not sure if such a woman exists on the ward, then you must ask them to follow you to the desk so that you can confirm Mrs Jones’ whereabouts. If they say they know where she is and promptly walk towards a bay or room, you should follow to confirm they have found the right person. If you are leaving the ward and someone is waiting outside, do not let him or her in as you exit. If you have time, ask them who they are visiting and escort them in. If not, politely ask them to ring the buzzer, stating that a member of staff will be with them shortly.
Parents and visitors should be asked to act in the same way. Although visitors sometimes have to wait for a few minutes before they are seen, they will usually welcome the safe care of the babies on the ward. Women should be informed of the professionals who might be coming to see them during their hospital stay – for example, the paediatrician or physiotherapist. They should not allow the baby to be taken away from the bedside unless they know that person. A baby should only be taken to a treatment room if a procedure is necessary that might cause the baby to cry and disturb other women, such as venepuncture. The parents should always be invited to accompany the baby.
Women should be encouraged to ask to see formal identification if they are ever unsure of someone’s professional identity, and to ask a member of midwifery staff if they have any concerns. If they are going for a bath or to have a meal, they should either tell a member of staff or another mother to keep an eye on their baby.
Visiting hours
When a baby is born there is an intense desire to share the experience with close family and friends. Visiting time on the ward is often a flurry of pink and blue balloons and anxious parents looking for their daughter. Despite the joy and pride of showing the new baby to its admirers, there are times when the presence of visitors complicates the situation. If a woman has been having difficulties with breastfeeding, for example, she may have been on the receiving end of lots of well-meaning advice from her visitors. She may require extra support and reassurance when her visitors have left for the evening. Postnatal wards often have a time when visiting is for fathers only. Staff should respect this but there is also a need to be flexible – for example, when parents have travelled a long way or when the baby’s father is not currently part of the woman’s life. Women should be encouraged to let a midwife know if there are any potential problems regarding who visits the new baby.
Recovering from vaginal childbirth in hospital
The postnatal examination
The woman and her baby should be examined daily by the midwife during her stay in hospital, but more regularly if there is any deviation from normal (see Chapter 2 for content of the postnatal examination). Women should have the opportunity to talk through the events of their labour to ensure that they understand what happened and why. In a small study (Dennett 2003) exploring women’s views about having the opportunity to talk through what happened during the birth, women found it helpful to fill in the gaps and make sense of events, particularly if there were any complications. However, formal debriefing is not advocated (NICE 2006).
Length of stay
The length of hospital stay has reduced steadily over the last decade. However, there is a lack of evidence regarding the risks and benefits of early transfer home (Brown et al 2002). More than 70% of women who have a spontaneous birth leave hospital within one day of the birth (The Information Centre 2007). However women who have an instumental birth are likely to stay for 2 days. Perineal pain and discomfort is a considerable issue for women during their hospital stay.
Perineal pain
Non-steroidal anti-inflammatory drugs (NSAIDs) via suppository, given immediately after perineal suturing, are an effective analgesic for up to 24 hours after the birth (Hedayati et al 2004). However, women respond differently to analgesia and have varying degrees of laceration, oedema and bruising contributing to their individual pain or discomfort. It is important to listen to a woman who reports pain, and to find out what she has already tried to relieve her symptoms. If a woman reports severe or increasing pain, her perineum should be re-examined to ensure that a haematoma is not developing or that her wound has not become infected.
Oral analgesia followed by a warm bath is a useful means of treating mild to moderate perineal pain. The bath will help distract and then relax her while the analgesia is taking effect and also cleanse the wound. Bath additives should be avoided and a clean sanitary towel applied afterwards. A randomized controlled trial (Sleep & Grant 1988) found no difference between groups of women who were allocated to one of three 10-day bathing programmes: salt bath, Savlon bath or additive-free bathing. Cooling gel pads as a means of reducing perineal pain are highly acceptable to women (Steen & Marchant 2001) but a systematic review concluded that there is little evidence of their effectiveness (East et al 2007).
Perineal ultrasound and pulsed electromagnetic energy (PEME) are sometimes used for the treatment of a painful perineum. However, a systematic review of the limited evidence available (Hay-Smith 1998) concluded that there is insufficient evidence to evaluate the benefit or harm of such treatments, and that further research is necessary to inform practice. Similarly, there is insufficient evidence to advocate the use of topical anaesthetics for postnatal perineal pain (Hedayati et al 2005).
