Introduction

The face of postnatal care is gradually changing, although this evolution has been slower in some maternity units than in others. There is more emphasis on assessing the individual needs of women rather than on applying a standard protocol to all women during every postnatal examination. However, each student midwife will need to work within locally developed guidelines and will learn ‘how things are done here’ from the mentorship she has and the observations she makes. This chapter outlines the underlying principles and basic content of the postnatal examination, which can be adapted to meet the individual needs of women and their babies.

What is the postnatal period?

This period has, until recently, been very strictly defined as not less than 10 days, or more than 28 days, after the end of labour (United Kingdom Central Council (UKCC) 1998). However, it has since been acknowledged that the public health role of the midwife should be further developed (Department of Health 1999), and proposals for an extension of the midwife’s role within women’s health were further outlined in the ‘Midwifery Action Plan’ (Department of Health 2001). This concept has been reflected in the Midwives Rules and Standards (NMC 2004), which state that the ‘postnatal period’ is:

…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.

(NMC 2004:07)

In practice, however, the number and content of postnatal examinations varies between individual midwives and National Health Service (NHS) Trusts. Capacity to extend postnatal visiting beyond 28 days (or even 10 days in some areas) is dependent on sufficient midwifery staffing levels and supportive evidence-based guidelines.

Postnatal care

Access to care

In the government policy document Maternity matters (Department of Health 2007), as part of the national choice guarantees, it was stated that when women leave hospital they should have a choice regarding where they access postnatal care. It was recommended that these choices should include in their own home or via a community service, such as in a Sure Start children’s centre (Department of Health 2007:13). Some community midwives offer ‘drop-in’ sessions for postnatal mothers whilst others continue to provide the majority of care in the woman’s home. Greater flexibility and widening access to care is also an objective of postnatal care in other developed countries (Declercq et al 2008,McLachlan et al 2008).

What does postnatal care include?

The Midwives Rules and Standards (NMC 2004) include the ‘Activities of a midwife’, an extract from The European Union Second Midwifery Directive, Article 4. These activities are those that midwives are entitled to pursue within the member states, and include:

to care for and monitor the progress of the mother in the postnatal period and to give all necessary advice to the woman on infant care to enable her to ensure the optimum progress of the new born infant

(NMC 2004:37)

A key aspect of this statement is that the midwife should care for the mother. This is an essential underlying facet of midwifery practice. The woman should feel that the midwives have her best interests at heart. She needs to be listened to and heard, safe in the understanding that her values and beliefs as an individual will be honoured wherever possible. Her unique needs should be carefully assessed and her care planned to address them specifically. For example, if a midwife was caring for a woman who had symphysis pubis dysfunction (SPD), and asked her to walk down to the dining room for her meal, this could convey to the woman that she had not taken the time to find out about her individual circumstances. It would have been much more caring if the midwife had introduced herself and acknowledged that she was aware of her SPD and that she would bring her meals to her bedside.

While most midwives will care about the women they look after, not all will demonstrate this. To ask a woman who had an episiotomy if she has any stitches, or a primiparous woman if she has breastfed before, could leave her feeling like one of many – to be processed rather than cared for.

Another element of the activity quoted is that it advocates that the midwife should provide advice to the woman to enable her to undertake her mothering role. She can do this in a number of ways. For example, the midwife who talks to the baby while undressing it acts as a role model to the woman. She demonstrates that this is appropriate behaviour, and can encourage her to do the same by informing her that the baby will probably already recognize her voice and pay particular attention to it (Damstra-Wijmenga 1991). The midwife can also praise the woman as she learns and masters her new role. Just as the student midwife needs feedback from her mentor that she is performing well, so does the new mother. We all recognize the boost that is felt when someone tells you that you did something really well. New parents also need a boost to their confidence, and this will help them develop new skills (Cronk & Flint 1989).

Giving advice and providing care for women should be based on an assessment of need. This applies to all women irrespective of parity. Rather than giving ‘one size fits all’ advice, which is inappropriate and rather tedious, it is more pertinent to find out what the woman already knows about a particular issue. This enables you to tailor your advice to fill the gaps in her knowledge or understanding and also, importantly, to correct misinformation.

Assumptions should not be made about the level of a woman’s knowledge or her desire to receive information. A well-educated woman may need reminding not to leave her baby unattended on the bed, and a childminder may not be aware of the latest advice regarding cot death prevention. Where possible, verbal information should be supplemented by another means of reinforcement, such as written guidance or a practical demonstration. Every care should be taken to provide consistent information; conflicting advice was highlighted as a source of distress to women by the Audit Commission survey (1998). A decade later, in a subsequent survey (Commission for Healthcare Audit and Inspection 2007), lack of information remains an issue for postnatal women with only 58% saying that they always had the information and explanations they needed after the baby’s birth (op cit: 14).

Quality of care

In an exploratory study of what constitutes quality in maternity care (Proctor 1998), women focused on the need for information and help to develop mothering confidence during the postnatal period. Of the midwives who were asked about what they thought were the components of good care, few identified areas of postnatal care that women had raised as important, other than support for breastfeeding. Women’s perceptions of postnatal care in England have subsequently been measured in detail. In 2006 in a study of a random sample of 4800 women (Redshaw et al 2007), new mothers were more critical of the staff who cared for them than at any other time throughout their pregnancy and birth. Poor communication by one or more members of staff was an issue for 16% women and 22% reported that they had not always been treated with respect. Only 53% of the women who responded to the survey felt that they received individualized care.

Quality of postnatal care in hospital is related to staffing levels and this problem is not unique to the United Kingdom. In an Australian study (Forster et al 2006) significant issues highlighted as a result of low staffing levels included: poor staff/client ratios; inappropriate staff skill mix; high dependency of clients; labour wards taking priority and the use of agency staff. These issues require further exploration so that appropriate workable solutions can be agreed to address the impact of this deficit.

Cultural differences

Within each culture there are specific practices in relation to postnatal activity and behaviour. It is incumbent on any midwife working in a culturally diverse area to find out about the specific postnatal norms for the women she cares for. However, it is important not to make assumptions. Belonging to a particular religion or race does not necessarily mean that an individual woman will practise its doctrine to the letter. Do not be afraid to ask a woman about how her faith or ethnicity impacts on her postnatal activity; she is likely to value the interest you have taken in her own particular circumstances.

The postnatal examination

The postnatal examination involves assessment of the woman’s emotional and physical wellbeing and includes evaluation of the baby’s health and behaviour. It is usually performed daily in the first few days after the birth, although this pattern will vary according to need. As the woman becomes more confident and recovers from the birth, the midwife will space out the examinations, in consultation with her. For the midwife to undertake this aspect of her role, she therefore needs a clear understanding of what is normal postnatal recovery and expected neonatal behaviour. The emphasis is on confirming normality and providing the woman with feedback about her own progress. The woman should be given sufficient information to enable her to identify for herself if her health gives cause for concern.

Box 2.1 provides a summary of the possible components of a postnatal examination for the woman. On occasions it will be important to undertake most or all of these steps, but as the woman recovers from the birth the examination should become less clinical and focus more on her wellbeing. A general principle is that observations should be continued until they maintain a normal result, unless underlying disease is suspected and a more conservative approach is required. Verbal consent from the woman must be gained before any aspect of the examination is undertaken on either herself or her baby. All abnormal findings observed by a student midwife should be documented and reported to a practising midwife.

Box 2.1

Components of the postnatal examination