Chapter 29 Supporting women becoming mothers
Learning ooutcomes for this chapter are:
1. To identify the normal physical, emotional and social responses to changes in the postnatal period
2. To assess the impact for each individual woman of the transition to parenting that occurs during the postpartum period
3. To discuss the importance of support for each woman (and her family) as she adapts to motherhood in the postnatal period
4. To explore the role of the midwife in assessing health during the postnatal period.
5. To describe and provide understanding of the importance of holistic assessment of maternal wellbeing which includes assessment of the physical, emotional and psychological health of the woman
6. To identify normal physical postpartum health and assess common discomforts that may affect the woman’s health postnatally
7. To identify the frameworks which guide midwifery practice when undertaking postnatal care
8. To explore the woman’s expectations of postnatal care provision.
This chapter discusses the midwife’s role in assessing maternal health and wellbeing in the postnatal period. In a partnership model of midwifery care there will be continuity of care and a holistic approach to assessing a woman’s health, with equal emphasis on the physical, emotional and social aspects of a woman’s wellbeing. Midwifery support and care that recognises a woman’s cultural heritage, existing knowledge, practices and values will enable the woman to have a positive experience in becoming a mother.
INTRODUCTION
Birth has been described as a journey to motherhood and is an integral part of setting the scene for family wellbeing (Edwards 2005). Becoming a mother is a time of major adaptation for the new mother and her partner/family/whānau. Whether it is a first baby or an addition to the current family, once a baby is born there is a change in roles for all members of a family. Each person adapts and accommodates to the needs of the baby. For the mother, this changing role can affect her own personal identity and understanding of herself as well as her status and social role. Transition and adaptation can be improved when there is positive emotional, physical and social support during this time.
Support can make a difference to the emotional wellbeing and coping ability of each woman and her family. It can be provided by her family, friends, professional helpers and social institutions in various ways (Ball 1994). In most societies throughout the world, women have traditionally helped each other by providing care and support following a birth. This help could be with domestic chores, care of existing children, or personal care (Goldsmith 1990; Marchant 2004; Podkolinski 1998).
Following the birth of a baby there is a period of adjustment and recovery for the mother from both the pregnancy and the birth. This adjustment period involves physical, emotional and social changes, and may take weeks or months. The six-week period following the birth has been referred to as the puerperium or the postnatal period. However, Coad and Dunstall (2001) suggest that the puerperium should be seen as a transitional phase, which begins at the birth of a child and ends with a return to fertility, although a woman does not return to the same physiological and anatomical state as before pregnancy. Davis (1997) discusses the postnatal period as the fourth trimester, suggesting that the first three months following birth are transformative and culminate in the reintegration of women as mothers into society (Davis 1997).
The parenting role requires adjustments to behaviour, lifestyle and relationships in the weeks and months following the birth (Percival & McCourt 2000). How women will react to motherhood does not become apparent until after the birth, so the continuity and support of the midwife in the first few weeks can have a significant contribution and influence on a woman’s coping process (Ball 1994).
THE MIDWIFE AND POSTNATAL CARE
During the early 20th century, midwifery care in New Zealand and Australia was strongly influenced by events occurring in the United Kingdom and Europe. At this time, because of high levels of maternal mortality due to postpartum infection, formalised postnatal care was instituted in order to identify poor health and pathological conditions in women (Donnison 1988; Marchant 2004). In the United Kingdom, legislation (in 1905) set 10 days as the time for ‘lying in’ after a birth when the woman was expected to rest, and a midwife would visit daily to ensure her physical recovery (Bick 2005). The midwife was expected to perform a complete examination of the woman’s physical health during the postnatal visit (Sweet 1989). The pattern of postnatal visits was determined as twice a day for the first three days and then daily until 10 days, with discharge generally at 14 days although visiting could be continued until 28 days (Gale 2008). The focus of the visits was to monitor the mother to determine if there was any pathology related to infection while also monitoring the health of the baby.
In New Zealand, up until the 20th century lay midwives were engaged by pregnant women to provide support during birth and take over the household chores for a few days following the birth to ensure the new mother was able to rest and establish breastfeeding (Donley 1998). With the growth of the urban population in New Zealand, many midwives established ‘lying in’ homes where women could give birth and spend some time away from the household chores recovering and establishing breastfeeding (Donley 1998). With the passing of the Midwives Act in New Zealand in 1904, training of midwives for registration was undertaken in hospitals. Doctors became more involved with birth and there was a move to hospital births for all women (Donley 1998). With the move to hospitals came an increase in puerperal fever and maternal mortality (Donley 1998). To combat puerperal sepsis, the hospitals introduced strict aseptic techniques for the birth and postnatal periods. The ‘general principles of maternity nursing and the management and aseptic technique of labour and the puerperium’ was introduced in 1925, and subsequently referred to as the H.Mt.20 (Donley 1998). This involved women having their perineums swabbed with sterile swabs and antiseptic solution every four hours following the birth, to reduce the incidence of infection (Donley 1998). Women were confined to bed for 10 days postnatally and babies were nursed in a nursery and brought to the mother every four hours for feeding (Donley 1998). Early ambulation and rooming-in were introduced during the 1970s and 1980s, but many women in both New Zealand and Australia experienced a postnatal hospital stay of 10 days as a normal length of stay (Donley 1998; Forster et al 2008). In contemporary society, the majority of women continue to give birth in hospital but the length of postnatal stay has reduced to between two hours and five days, so most mothers are now experiencing postnatal care within their own home.
Critical thinking exercise
Consider the following questions:
1. Where is the best place for a woman to recover following the birth? Give your reasons.
2. Is there an optimal length of stay on a postnatal ward? What do you think it should be? Give your reasons.
3. How long do women stay in your local maternity facility? What is the average hospital stay? Is there an ability to stay longer or shorter, depending on the woman’s needs?
Many women recover well following birth although there are often ongoing physical and psychological health problems, many of which are regarded as transitory but can limit a woman’s physical recovery and emotional health (Webb et al 2008). Often health problems in the postnatal period are underreported or not identified (Brown & Lumley 1998).
Until recently, postnatal care has had a low status in society and for healthcare professionals, but increasingly, women’s health following childbirth and the role and impact of postpartum care is becoming a focus of research. This is due to the recognition of this period as a major developmental and adjustment time for parents which, when optimal, ensures good health outcomes for women and their babies (Deave et al 2008). Postnatal care can also be a major contribution to the public health agenda and support national priorities in public health by way of consistent messages about healthy behaviours for families (Bick 2005).
The aim of maternity care should be to help women become successful mothers, with as much emphasis placed on the psychological and emotional processes as on the physiological processes (Ball 1994). Ball (1994, p 117) has defined three objectives of postnatal care:
• to promote the physical recovery from the effects of pregnancy, labour and birth
• to establish good infant-feeding practices and foster good maternal–child relationships
• to strengthen the mother’s confidence in herself and her ability to care for her baby in her own social, cultural and family situation.
In New Zealand, a consensus workshop on postnatal care in 1993 suggested that the following were desired outcomes of care:
• The mother is comfortable, free of pain and physiologically stable, in an environment that provides safety, rest and nourishment.
• The mother feels in control of the pace and framework of events.
• The mother is given information specific to her cultural needs (integrity, identity or safety) and knows when and how to get help for herself or her baby.
• Information is shared between the mother, family and care providers.
• The transition to motherhood is individual but each mother goes through naturally occurring phases at her own pace. Good-quality care recognises this and provides guidance and intervention as appropriate (NACCHDSS 1993).
Infant feeding and transition to parenthood are discussed in Chapters 11 and 31, so this chapter focuses on supporting women during the postnatal period. It includes discussion of a woman’s response to the physiological changes of the postnatal period, and practical aspects of assessment and support. Caring for women during the postnatal period involves being aware of the physical, emotional and social adaptations that women make, and how these are interrelated. The postnatal period can be seen as the time of maximum change and growth for women and families as they complete the transition to parenthood.
Summary
The aim of postnatal care is to support each woman in her adaptation to becoming a mother. This involves supporting the physical recovery from pregnancy and birth as well as the psychological and social changes that may occur following birth and which aid transition into motherhood. Each woman should be provided with information which supports her to feel in control and able to care for her baby and herself.
ASSESSMENT OF WOMEN’S HEALTH
The midwifery partnership model, which encompasses continuity of care, enables the building of a supportive relationship between a midwife and a woman and her family throughout pregnancy and childbirth (Guilliland & Pairman 1995). This relationship continues to be important during the postnatal period, when there is a time of physical recovery and emotional adaptation to parenthood. Assessment of a woman’s health includes assessment not only of her physical recovery but also of her emotional responses to the demands of parenthood and of the social supports that she has to help with these changes. Ussher (2004) argues that depression following childbirth is an understandable response to the difficulties of motherhood. She suggests that having good social support, realistic expectations of the difficulties of the mothering role, and practical help with child care can reduce the likelihood of becoming depressed following birth (Ussher 2004).
In New Zealand, the minimum specifications for postnatal care have been defined (Box 29.1) and each woman is entitled to at least this level of care (Ministry of Health 2007). There are no similar specifications for minimum levels of care in Australia; care varies across all states and territories depending on the models of maternity and midwifery care available to women.
Box 29.1 Postnatal care in New Zealand
As described in Chapter 1, all pregnant women within New Zealand are expected to choose a practitioner as their lead maternity carer (LMC). The LMC is responsible for ensuring the following services after the birth:
• Visits to assess and care for the mother and baby in a maternity facility and at home until 4–6 weeks after the birth. These visits include the following:
• Assistance with and advice about breastfeeding and the nutritional needs of the woman and baby
• Assessment for risk of postnatal depression and/or family violence, with appropriate advice and referral
• Provision of Ministry of Health information on immunisation and the National Immunisation Register
• Provision of or access to services, as outlined in the Well Child Tamariki Ora National Schedule
• Advice regarding contraception
Phases of the postnatal period
Each phase has different characteristics and each woman will go through these phases at her own pace (NACCHDSS 1993).
In phases 1 and 2, physical recovery is a main focus of concern for most women, along with caring for and being able to breastfeed the baby. Women need to be reassured regarding their physiological wellbeing, supported in a comfortable environment, and should be pain-free. High levels of physical discomfort can cause emotional distress and lessen the ability to cope with the physical and emotional changes. At this time the midwife needs to be aware of normal physiology and should be able to give practical help and advice.
Women should be encouraged to spend time holding, touching and breastfeeding the baby, as this will increase levels of oxytocin and prolactin. Prolactin contributes to the establishment of lactation and maternal behaviour; it also stimulates food intake during lactation and promotes energy storage (Grattan & Kokay 2008). Oxytocin is a neurohormone that regulates a variety of behaviours which are all associated with calm and connection, such as peacefulness, relaxation and a feeling of contentment (Uvnas-Moberg 2003). It has mainly been associated with maternal behaviour, although more-recent research suggests that it also has an impact on social memory, support and anxiety-related or stress-coping behaviours (Neumann 2008). High levels of oxytocin have also been associated with an increase in generosity towards others (Zak et al 2007). Oxytocin reduces anxiety and can increase the pain threshold (Foureur 2008).
Phase 4, the completion of the transition to parenthood, involves a woman and her family accepting the change in family dynamics and shared responsibility for the baby. In most cases this will occur during the six-week postnatal period and signals a time when a midwife is no longer needed because the woman and her family are independent. Completing the midwifery relationship is discussed fully in Chapter 33 and will not be discussed here.
FREQUENCY OF MIDWIFERY VISITS
In New Zealand the minimum number of visits that a midwife should make for postnatal care is specified (see Box 29.1), but this is not the case in Australia, where opportunities for postnatal visiting in the woman’s home after discharge from hospital are limited according to models of care and funding. Ideally a midwife would decide, on an individual basis with each woman, the frequency and length of visits that are required and when these visits should cease (Ministry of Health 2007). There are many aspects of a mother’s or baby’s health that may indicate the need for more-frequent visits.
The New Zealand College of Midwives’ Handbook for Practice (2008) outlines decision points that can be used to help identify times when there should be full midwifery assessments during the postnatal period. Each decision point summarises the assessments that should be made, investigations that should be performed, possible treatments, legal requirements, and health information and education that should be shared. The timing of decision points should be based on individual need, but the first decision point should occur within the first 24 hours of the birth (NZCOM 2008). Subsequent decision points should be every 24–48 hours until the woman is confident in her home environment (NZCOM 2008) (see Box 29.2).
Box 29.2 Decision points in postnatal care
Examination
Full physical assessment of woman, including:
Full physical assessment of baby, including:
Possible tests:
Possible treatment:
Health information and education:
• Facilitate mother–baby relationship. Give opportunity for peace, quiet and breastfeeding if that is the woman’s choice.
• Facilitate rest and ongoing support if at home.
• Education for self-care related to:
• Identify when and how to call for assistance.
• Guide and assist with breastfeeding as required.
• Information given for baby care related to:
• National Immunisation Register.
• Information concerning development of parenting skills, including feeding.
Legal requirements:
Subsequent decision points in postnatal period every 24–48 hours until woman feels confident in her home environment
• discuss woman’s health status, both physical and psychological
• discuss lactation and ongoing feeding
Examination:
• full physical assessment to ascertain recovery from birth process, including breast examination and perineal examination if required
Tests:
Possible treatment:
Health information and education:
(Source: NZCOM 2008)
Munday (2003) suggests that postnatal care should include time for physical assessment as well as a discussion of the socio-emotional issues important to women. She contends that midwives should facilitate continued contact with the woman for as long as the woman feels that the contact is of benefit (Munday 2003). Different countries have individual legislation and expectations regarding the timeframe for formal postnatal care, as well as differences in frequency of home visits, so it is difficult to make comparisons about what constitutes the optimal amount of postnatal care.
In New Zealand it is usual for women to receive home visits from the midwife LMC following hospital discharge until six weeks following the birth. A survey of 2936 women who gave birth in New Zealand during March and April 2007 found that the majority of women (73%) had between five and 10 or more postnatal visits at home after the baby was born (Health Services Consumer Research 2008). This survey found that 90% of the women surveyed were either very satisfied (66%) or satisfied (24%) with the number of home visits they had received. There were 27% who had received less than five visits, and these women were less likely to be very satisfied with the number of visits they had received (Health Services Consumer Research 2008).
In Australia the availability of postnatal care in the home is limited, so gaining an understanding of women’s satisfaction with postnatal services is also limited. A survey of Australian mothers who had care in a hospital in Brisbane within the public healthcare system found that women wanted specific information about mothering, the creation of a restful environment, adequate pain relief, practical assistance, education and set visiting times. The survey was sent to 500 eligible mothers, of which 151 (30.2%) responded to the anonymous open-ended survey questions. For new mothers, early discharge made the need for rest and information a high priority, and the authors suggest that constraints within the public healthcare system and midwifery practice need to be examined to better serve mothers’ needs (Emmanuel et al 2001).
EMOTIONAL RESPONSES TO CHANGE
The transition from pregnancy through the birth to becoming parents is a challenging time for a mother and the wider family (Percival & McCourt 2000). A range of emotions is felt in the postpartum period, and many women describe relief, euphoria, joy, pleasure, and also despair, fear and concern. These emotions
