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Postnatal Care

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Autor:  anton  21 December 2010
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The subject of discussion for this assignment will be the midwives role and responsibilities in delivering postnatal care and support to Rosie and her family, following the birth of her third child.

The Midwives rules and standards (Nursing and Midwifery Council (NMC) 2004) state that "the В‘postnatal period' mean's 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 ten days and for such longer period as the midwife considers necessary". In a previous publication of the Midwives Rules and Code of Practice by the United Kingdom Central Council (UKCC) (1998) this period of time was for up to twenty-eight days. Rule 6 of the Rules and Standards (NMC 2004), states that the primary focus of the midwives practice should be the needs of the mother and baby and that the midwife should work in partnership with the woman and her family to enable the woman to make informed decisions in her care. In providing the care to a woman the midwife will work within the boundaries of the NMC's Code of professional conduct (2004b), by gaining consent before giving care and in maintaining the woman's confidentiality and privacy in her home.

The puerperium, also known as the postnatal period, is the time immediately following the birth of a baby and represents the period of time when a woman's reproductive organs and structures are returning to their near pre-gravid state. This period is estimated to be between six to eight weeks depending on the individual woman (Coad and Dunstall 2005). For the purpose of the essay the definition of the post natal period will be the first ten days.

The role of the midwife during the postnatal period should include care of all aspects of the woman's health. During this time women are adjusting physically, emotionally and socially to a major life changing event. The care that a woman receives should be tailored to meet her individual needs (Royal College of Midwives 1997) and to ensure there are not any deviations from the normal in respect to health. The aim of good midwifery postnatal care is to build up the woman's, and her partner's confidence in their own abilities to care for their child competently, so that when the time comes for the midwife to cease calling; the parents and the midwife will feel confident that they are able to care for the child safely (Cronk and Flint 1989). Routine discharge from midwifery care is usually around the tenth to the fourteenth day depending on the individual needs of the woman, followed up with a postnatal check by the woman's General Practitioner (GP) at six to eight weeks.

While working in the community the author was able to visit many women postnatally and has gained an understanding of the importance in the provision of sound evidence based postnatal care and support. By providing continuity of care in visiting women more than once the author found that she was able to build up a rapport with some of the women. This can make it easier for a woman to confide in and talk about any problems they might have. Continuity of care is referred to as care provided by the same person or small group of people for a period of time, for example the postnatal period (Hodnett 2000). In a review of trials by Hodnett (2000), it was found that women who had continuity of care by a team of midwives were more likely to discuss postnatal concerns, feel better prepared and supported. In the author's experience she found that women like Rosie, who are having their second and subsequent children still require the same, if not more support, but in a different way, for example how to cope strategies and child care.

A postnatal visit by the midwife should include the following routine maternal observations:-

Blood pressure, if indicated Temperature, if indicated

Abdominal palpation Lochia

Perineum Examination of legs

Micturition Bowels

Breasts Abdominal wound (if present)

Information on sudden infant death syndrome (SIDS), exercise, family planning and registration of the baby, would also be given before Rosie is discharged from the midwife's care. The clinical observations would be performed and recorded as appropriate to the woman's condition (Bick 2004). In an evaluation by Takahashi (1998) on routine maternal temperature checking, it was suggested that routine observation of the maternal temperature in the puerperium has limited value as a screen test for detecting infection. This was due to variability of when it was taken, the reliability of how it was taken and pyrexia in itself is not always an indication of infection. In the author's Trust routine observation of temperature is not undertaken unless there is a clinical indication.

Rosie had indicated that this pregnancy was unplanned and she was concerned about how they were going to manage. With this in mind the midwife would be aware that Rosie may still be worried after the birth and that this could affect the way she recovers. From practice experience the author found that a routine postnatal check would begin with introductions if the midwife had not met the woman before, followed by a period of relaxed discussion (chatting) during which the midwife would observe how the woman responded. During this time questions would be asked about how the woman felt in herself, if she was getting enough sleep at night to cope during the day and if she had any concerns about herself or the baby. The midwife would be looking for any signs that Rosie maybe feeling down, such as being tearful and withdrawn and appearing to not be coping very well generally. Lack of sleep can affect mental and physical wellbeing and after only two В– three days of reduced sleep the ability to perform even simple tasks is impaired (Ockenden2003).

Depression is also related to fatigue and The National Institute for Health and Clinical Guidelines on postnatal care (NICE 2006) competencies include recognising the signs and symptoms of maternal mental health problems, which could include tiredness. The author feels that trying to understand Rosie's physical and mental concerns would be more likely through careful observation from a midwife who is able to visit on more than one occasion.

Rosie is breastfeeding this baby, her other children were bottle fed, so Rosie may need extra support with breastfeeding. This will include making sure that the baby is attaching to the breast correctly, so that the nipples do not become sore and cracked, appendix one.

Woolridge (1986) has written:

"Contrary to popular belief, attaching the baby to the breast is not an

ability with which the mother is [bornВ….]; rather it is a learned skill

which she must acquire by observation and experience."

Rosie would be familiar with the routine of regular bottle feeds, so she may need guidance in how often to feed. Breastfeeding mothers are encouraged to feed the baby whenever they wish, for as long as they need. This will help to establish successful lactation and prevent engorgement (Royal College of Midwives (RCM) 2002 and NICE 2006). Information will also be given on how to recognise infection/inflammation of the breast, mastitis, and what to do in the event of. If needed Rosie would also be given help and advice on general breast care to help prevent any problem occurring, such as engorgement and mastitis. It will be important to maintain a healthy diet and to drink plenty of fluids to avoid dehydration. Before Rosie is discharged from midwifery care she would be given information on the local breastfeeding support clinics near her home, which will be able to provide her with continued support if she needs it.

Involution is the returning of the uterus form its pregnant weight of approximately 1000grams to its pre- pregnant weight of approximately 60grams. On each postnatal visit the midwife will assess the height of the uterus above the symphysis pubis to check that it is decreasing in height at the expected rate. Assessment of uterine height forms part of the postnatal check and before this can be done consent should be obtained after a full explanation has been given. It would be usual to ask Rosie if she needed to empty her bladder or if she had done so within half an hour previously. This is because a full bladder would affect the lie of the uterus and can be uncomfortable for the woman. Maintaining Rosie's dignity, by ensuring her privacy, she would be asked to recline on her back. After washing hands or applying antibacterial gel to prevent cross infection, Rosie would be asked to expose her abdomen. A hand is placed on the abdomen with the lower edge level with the umbilicus. While talking to Rosie and explaining what is being done, the hand gently palpates the abdomen towards the symphysis pubis noting the height of the uterus and the degree of contraction and retraction. The midwife would be facing Rosie so she would be able to detect any facial signs of discomfort. Rosie, like most new mothers, will experience В‘after pains'. These are cause by the involution of the uterus and the pelvic muscles returning to normal after childbirth. Breastfeeding can exacerbate this discomfort in response to the baby suckling and the В‘let down' response, the process which stimulates the breast to release milk. (Medforth, et al.2006. p548).

Cluett et al (1997) performed an investigation into the rate of involution among women who had a normal puerperium, to find a screening tool that would facilitate early treatment and prevention of secondary postpartum haemorrhage. During the study twenty eight women were measured by the same person at the same period of time each day using a paper tape measure. During the study a decline in the symphysis pubis to fundal height measurement of less than 1cm over three or more days was considered to be a slow decline. This measurement was carried out until the uterus was no longer palpable. Cluett et al (1997) found that there was too much variability in the rate of involution with the women to provide a clinically useful screening tool and her implications for practice were that measuring the rate of involution using a tape should not form part of routine postnatal assessment.

In the author's Trust, routine measurement of involution is not performed and in light of the reduced postnatal visits to mother's, she feels that it would not be practicable. Should involution of a uterus not be as expected it could be an indication that there may be retained products of conception and infection. The uterus is not usually palpable after the twelfth day and has returned to its non-pregnant state by six weeks (Harrison 2000). During the abdominal examination is a good time to ask about vaginal loss, such as amount, odour, and colour. Checking the lochia loss of a woman is important in that it can be an indicator of infection if it is offensive and retained products of conception if heavier than expected for the time in postnatal days. Over exertion by the woman can increase the lochia loss so it is advised that the woman should rest as much as possible during the early postnatal days. Usually the checking of lochia loss is a question that would be asked of the woman, but if she had any concerns a midwife can check visibly at the request of the woman.

The BLiPP study by Marchant et al. (1999) surveyed women's experiences with vaginal loss following childbirth and found that women reported a more varied account of the amount, colour and duration during the period of the survey than is described in current midwifery textbooks. The study highlighted the assessment of involution by midwives to be of value in determining the normal and in predicting the abnormal. From experience in the community the author also found that women's account of the colour of lochia was not what she had learnt and read. Most women that the author visited postnatally did report a loss of reddish brown and not the traditional description of lochia serosa, which is Latin and not a common word for a woman to use. As the survey reported it is difficult to measure how often women will change their pads as this would depend on their expected level of personal hygiene and there is no set standard as to how often they should be changed, it is personal to the individual women. It was identified by the survey that women wanted more information about involution and the implication for practice following the survey were to develop information leaflets for women and health professionals.

Rosie had sustained minor lacerations to her perineum, this alone could cause her some discomfort together with localised bruising. Routine daily inspection is not necessary unless there is a clinical indication, i.e. pain or evidence of infection, instead the midwife will ask specific questions about pain and trauma. The midwife would advise Rosie to have regular baths and keep the area clean and as dry as possible. If necessary to help relieve the pain Rosie could take oral analgesia such as Paracetamol every four to six hours as directed. It is now not shown to be any benefit in using additives to bath water such as salt or savlon. (Medforth et al.2006. p512).

Childbirth is a very traumatic episode on a woman's anatomy, especially the pelvic floor area. It is not uncommon for there to be pelvic floor damage after child birth that can involve trauma to the bladder, urethra or the urinary sphincter, which can cause stress incontinence of urine. Once Rosie is comfortable after the birth she will be advised by her midwife to routinely perform the pelvic floor exercises that she will be given. Although Rosie had a normal delivery urinary output should be discussed with Rosie to ensure that she is emptying her bladder. The lacerations that she sustained would be causing her some discomfort and this can impair micturition and bowel action. Advising Rosie to maintain a balanced high fibre diet and to drink plenty will help to avoid the problem of constipation, which will be especially important if her perineum is tender. (Logan 2005; Abbott et al.1997).

A woman is at an increased risk of thromboembolic disorders during the puerperium. This is due to circulatory changes after the birth where the increased blood volume of pregnancy is reduced. At this time women can experience varicose veins (from the pregnancy) and oedematous feet and ankles. Therefore it is important to observe for swelling, pain, colour and inflammation in the legs as this could be an indication of deep vein thrombosis, which would require an urgent referral for treatment. (Medforth et al. 2006. p514). Should Rosie have some oedema to her legs she would be advised to have a rest with her feet elevated to help alleviate the swelling and to keep a careful watch for other symptoms as mentioned previously.

After approximately ten days and if all is well, the midwife will discharge Rosie from her care to that of the health visitor, after ensuring that Rosie is happy with this decision and is coping well with breastfeeding. On this last visit Rosie will be given a variety of information relating to her health and that of her baby. Family planning may be the furthest thing from Rosie's mind at the moment but it is something that needs to be addressed early, especially as the last pregnancy was not planned. Rosie is breastfeeding and this does delay the return of ovulation after childbirth and can offer 98% protection, but this should not be relied on as the mother needs to breast feed fully and remain amenorrhoeic (Too 2003). Rosie will need to decide on the best form of contraception for her to use, if she chooses the contraceptive pill it would need to be a progestogen only pill and this should not be commenced until after at least six weeks post partum; as recommended by The World Health Organisation (WHO) (2001). Other forms that the midwife will discuss are the withdrawal method, condoms, intrauterine devices (coil), barrier creams, cervical caps and the natural method which involves calculating the date of ovulation.

Rosie will be reminded of the care needed for the baby in helping to prevent sudden infant death syndrome, not to let the baby become overheated and to lay him on his back with feet to the bottom of the cot to prevent him sliding under the covers. The new baby's birth will need to be registered and he will also need to be registered with a General Practitioner (GP). Rosie will also need to make an appointment for her six week postnatal check with the GP and for the baby as well. The midwife will give contact numbers for herself, the team of midwives and the hospital should Rosie have any concerns.

All the findings throughout the postnatal visits during this period would be discussed with Rosie each time and documented in her notes.

In conclusion a randomised controlled trial by MacArthur et al (2003) re-designing community postnatal care, discussed that given the longer term nature of many childbirth related health problems the discharge at around the tenth to the fourteenth day could be too early to allow a full midwife appraisal of postnatal health. During the trial home visit contact with the midwife continued to day twenty-eight and the postnatal discharge check was performed by the midwife at ten to twelve weeks, there was no GP input unless it was clinically indicated by the midwife or requested by the woman. The measures used to access the effect of the re-designed postnatal care were the mental and physical component scores (MCS and PCS) and The Edinburgh Postnatal Depression Scale (EPDS). When measured at four and twelve months postnatally both psychological measures were significantly better in the re-designed group compared with the group who received current postnatal care. The PCS health measure did not show any difference between the two groups (MacArthur 2005).

The author feels that although this trial showed an improvement in the psychological health and in the continuity of care that a woman would receive with the redesigned postnatal care. She feels that in reality and with the climate of our current National Health Service; it would probably be difficult to finance the extra hours needed to implement the trial, especially in view of the already over stretched maternity services.

In developing her own practice the author has recognised a way of systematically assessing a woman postnatally in her care. By starting at the top, with the head and working down the body, she finds this is a way of ensuring all aspects of the woman's health is discussed. This is done in a friendly conversational manner to the woman.

References:

Abbott, H., D. Bick and C. McArthur., eds. 1997. Health after Birth. In: Essential Midwifery. London: Mosby.

Bick, D. 2006. Prioritising postnatal care. The Practising Midwife 9 (10): 4-5.

Cluett, E., J. Alexander and R. Pickering. 1997. What is the normal pattern of uterine involution? An investigation of postpartum uterine involution measured by the distance between the symphysis pubis and the uterine fundus using a paper tape measure. Midwifery. 13: 9-16.

Coad, J. and M. Dunstall. 2001. Anatomy and Physiology for Midwives. Edinburgh: Mosby

Cronk, M. and C. Flint. 1989. Community Midwifery: A Practical Guide. Oxford: Heinemann Nursing.

Harrison, J., 2000. Physiological changes in the puerperium. British Journal of Midwifery. 8 (8): 483-488.

Hodnett, E.D. 2000. Continuity of caregivers for care during pregnancy and childbirth. Cochrane Database of Systematic Reviews 2000, Issue 1. Art. No.: CD000062. DOI: 10.1002/14651858.CD000062.

Logan, K. 2005. Incontinence and the effects of childbirth on the pelvic floor. British Journal of Midwifery, 13 (6): 374-377.

MacArthur, C., H. Winter, D. Bick, R. Lilford, R. Lancashire, H. Knowles, D. Braunholtz, G. Belfield and H. Gee. 2003. Re-designing postnatal care: a randomised controlled trial of protocol-based midwifery led care focused on individual women's physical and psychological health needs. HMSO: The National Coordinating Centre for Health Technology Assessment (NCCHTA).

MacArthur, C., H. Winter, D. Bick, C. Henderson and H. Knowles. 2005. Re-designed community postnatal care trial. British Journal of Midwifery. 13 (5): 319-324.

Marchant, S., J. Alexander., J. Garcia., H. Ashurst., F. Alderdice and J. Keene. 1999. A survey of women's experiences of vaginal loss from 24 hours to three months after childbirth (the BLiPP study). Midwifery. 15: 72-81.

Medforth, J. et al. 2006. Oxford Handbook of Midwifery. Oxford: Oxford University Press.

National Institute for Health and Clinical Guidelines (NICE). 2006. Quick reference guide: Routine postnatal care of women and their babies. London: NICE.

Nursing and Midwifery Council. 2004a. Midwives rules and standards. London: Nursing and Midwifery Council.

Nursing and Midwifery Council. 2004b. The NMC code of professional conduct: standards for conduct performance and ethics. London: Nursing and Midwifery Council.

Ockenden, J. 2003. After the birth is over. In: Midwifery: Best Practice, edited by S. Wickham. Edinburgh: Books for Midwives.

Royal College of Midwives. 1997. Debating Midwifery: Normality in Midwifery. London: Royal College of Midwives.

Royal College of Midwives. 2002. Successful Breastfeeding. 3rd ed. Edinburgh: Churchill Livingstone.

Takahashi, H. 1998. Evaluating routine postnatal maternal temperature check. British Journal of Midwifery. 6 (3): 139-143.

Too, S. 2003. Breastfeeding and contraception. British Journal of Midwifery. 11 (2): 88-93.

United Kingdom Central Council for Nursing, Midwifery and Health Visiting. 1998. Midwives rules and code of practice. London: United Kingdom Central Council for Nursing, Midwifery and Health Visiting.

World Health Organisation. 2001. Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for Contraceptive Use. 2nd edn. London. WHO.

Woolridge, M. 2005. The В‘anatomy' of infant sucking. Midwifery 2 (4): 164-171.



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