Chapter 34 Physiology and care in the puerperium
Current post-birth care in the UK involves midwives, health visitors, general practitioners and others within the primary healthcare network working together on behalf of the new mother, baby and family members (DH 2005, NICE 2006, NMC 2004). The framework for this care differs from that offered to women once they have given birth in most other developed countries where the provision for regular contact with midwives as the main healthcare professionals responsible for post-birth care is less well defined. (Pathology and potential morbidity for the mother is discussed in Chapter 35.)
Following the birth of the baby and expulsion of the placenta, the mother enters a period of physical and psychological recuperation (Buckley 2006). The puerperium, starts immediately after delivery of the placenta and membranes and continues for 6 weeks. The overall expectation is that by 6 weeks after the birth all the systems in the woman’s body will have recovered from the effects of pregnancy and returned to their non-pregnant state. However, it is only comparatively recently that there has been any professional recognition or substantial interest in the diversity and extent of the morbidity experienced by women in the weeks after childbirth (RCM 2000). Some women continue to experience problems related to childbirth that extend well beyond the 6-week period defined as the puerperium, and the possibility of a longer duration is now accepted alongside the range of initial morbidity (Alexander et al 1997, Ball 1994, Glazener et al 1995, MacArthur et al 1991).
It has been customary to refer to the first weeks after the birth as the postnatal period; defined in the UK as a 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, 2006).
By no longer stating an endpoint in time when midwifery care can still be made available to women, it is to be hoped that offering more flexibility to the provision of midwifery care will in time also make a positive difference to the experiences of women and midwives of this aspect of midwifery care and services (Cattrell et al 2005, Redshaw et al 2007).
The provision of midwifery care to women following the birth of their baby aims to encompass aspects of observing and monitoring the health of the new mother and her baby as well as offering support and guidance in breastfeeding and parenting skills. Where the timeframe for attendance from the midwifery services might now be viewed as being more flexible, this could also be seen as an opportunity to extend the midwife’s role to include the broader aspects of public and social health and more specialized areas of neonatal care. In addition there is increasing interest in the use of healthcare assistants and other voluntary support networks during this time (NCT 2007, Sewell 2007).
The initial framework for hospital postnatal care in the early twentieth century involved a period of prescribed bed rest and compliance with hospital regimens that included vulval swabbing, separation from the baby and routine feeding times. Even where such strict adherence to these practices declined, the approach taken of the ‘sickness’ model, remained as the framework around which hospital postnatal care operated, and in particular in the undertaking of routine observations which were considered pivotal to the essence of ‘good’ and viewed therefore as effective care from the point of view of the maternity services (Garcia & Marchant 1996). The current practice where women return home in a few hours after the birth, is now considered both safe and desirable from the viewpoint of most women and most maternity services. However, it is only comparatively recently that the provision of postpartum care has been reviewed with regard to its content, purpose or effectiveness (Garcia & Marchant 1993, Marchant & Garcia 1993, Marsh & Sargent 1991, Twaddle et al 1993); as a result there have been increasing numbers of research studies that challenge the traditional pattern of postpartum care and its overall provision and value (Bick et al 2002, Shaw et al 2006, Walsh 1997, Winter et al 2001, Wray 2006).
In the UK, it is still usual for a midwife to ‘attend’ a postpartum woman on a regular, if not daily basis for the first 4–5 days regardless of whether the mother is in hospital or at home (NMC 2004). During the course of this contact, midwifery practice has been to undertake a regular physical examination to assess the new mother’s recovery from the birth (Garcia et al 1994, Marsh & Sargent 1991, Murphy-Black 1989). From an international perspective this practice is unusual; it is only comparatively recently that postpartum home visits, and postpartum support programmes, have been initiated in America and Canada (Boulvain et al 2004, Eaton 2001, Evans 1995, Gupton 1995, Peterson et al 2005) and that women in these countries have recognized a need for and their satisfaction with current services (De Clerc 2006). Recent studies have reviewed the use of support workers in the community in the UK (Morrell et al 2000) and the extension of care and support in the community, rather than in the form of direct care. Social intervention in the form of SureStart funding has proved effective in some areas (Wilyman-Bugter & Tucker 2004).
When the extraordinary changes in physiology that occur throughout pregnancy are considered, it should come as no surprise that the period of physiological adjustment and recovery following the end of pregnancy is both complex and closely related to the overall health status of the individual. The intricate relationships between physiological, psychological and sociological factors are all encompassed in the remit of caring for the postnatal woman and her newborn (Ball 1994, MaGuire 2000, Wiggins 2000). A common reference to postnatal services being the ‘Cinderella’ of the maternity service provision as a whole, has led to repeated reports from women of poor support, disappointment in the services and in some cases evidence of negligence as a result of sub-standard care (Garcia et al 1998, Lewis 2007, Lewis & Drife 2001, 2004, RCM 2000, Redshaw et al 2007).
The framework for assessing resources released from the NHS costs would appear to be based on a measurement of clinical need resulting in the main providers of health services having to make comparisons between postpartum women’s needs and other members of the population who are suffering from acute or chronic illnesses (O’Sullivan & Tyler 2007). Therefore, it is not unreasonable to realize that women recovering from what is seen as a positive health event in the birth of a baby does not attract the same level of funding as those with long-term conditions or terminal diseases. However, there has been a growing awareness that there are important aspects around maintaining optimal health of the developing fetus and neonate, that has an overall impact on the nation’s health and the costs of sustaining it. It would now appear that there is greater recognition in the UK of the need to allocate resources appropriately to improve services to new mothers and their babies so that postnatal care in the UK is recognized for the corner stone it is with regard to outcomes for the future population (Ladyman 2005, NICE 2006).
The background to the current postpartum observations routinely undertaken by midwives is unclear but it is likely that key observations associated with signs of potential morbidity became part of the routine procedures undertaken by those employed to care for the lying-in woman, her house and family as well as her health (Garcia & Marchant 1996, Reid 2005). With the introduction of the National Health Service in 1948, social changes influenced the duties of the midwife and focused care on assessment of health needs rather than domestic duties. The NHS aimed to provide a cost free service which should have improved care in many areas but after a time, it was clear that women were very dissatisfied with the care they were receiving after the birth of their baby (Garcia et al 1998, RCM 2000, Singh & Newburn 2000), and at the same time, midwives were also questioning the nature, purpose and value of what was being provided (Marchant 1997).
With the focus set on health assessment, it was common for midwifery textbooks on this topic to describe the activities of the midwife with regard to physical examination of the mother and the baby (Silverton 1993,). However, over the past decade there have been increasing moves to view care for postpartum women as a partnership where the woman is encouraged to explore how she is feeling physically and emotionally and to seek the advice and support of the midwife where she needs it (MaGuire 2000, Proctor 1999, RCM 2000). The importance for all postpartum women to have access to, and appropriately receive, postpartum midwifery care has been underpinned by the recent publication of a national guideline defining core care, and what should be provided for the mother and baby in the days and weeks following birth (NICE 2006). This might involve midwives assessing a woman’s capability with regard to self-knowledge and communication skills in order to provide the care needed for that woman as an individual. Midwives need to have the appropriate knowledge and skills to determine when to be proactive with regard to undertaking specific observations where these might be required. Therefore the midwife must be totally familiar with the range of normal outcomes following any birth and be able to identify signs of morbidity that require further investigation and discuss the future management of these with the woman. Such a model of care can be challenging to practitioners who lack confidence in their autonomy and decision-making skills (Marchant 2005), or where they feel there is a lack of support, both in hospital and community settings (McCourt & Percival 2000, Ridgers et al 2002).
In the area of postpartum physiology, information has been inconsistent and lacking in what is now considered to be authoritative evidence based on research (Hytten 1995, Marchant et al 1999). Although there has been increased interest in women’s health after birth, research in the area of physical morbidity remains relatively sparse. This was demonstrated by the lack of robust evidence that was available to support the NICE guidelines for core postnatal care (Marchant 2006, NICE 2006). The framework adopted by the NICE guidelines, was to set out the initial context of establishing what should be viewed as core care. This is defined as the care that every woman should be offered in order to establish her needs and wishes with regard to her care and that of her newborn infant. This is a philosophical stance which replaces what has become the conventional more didactic approach which approached care needs as being what everyone would receive regardless of whether or not they needed it, which is the framework that underpins a routinized approach to the provision of care. This chapter follows a similar framework to that of NICE and aims to assist the practitioner to explore the environment surrounding the woman as a new mother as well as a woman recovering from the physical exertions, and sometimes psychological, trauma, of giving birth. Within this context, any decisions made by the midwife in relation to reassurance of normality or referral for actual or potential morbidity must centre on the circumstances of the individual woman.
The majority of post-birth care in the UK now occurs in the community setting of the woman or a relative’s home. Expectations of women about the nature and purpose of the visits by the midwife may vary according to their cultural backgrounds, from one of welcoming enthusiasm to views that reflect negativity and suspicion. For example, some faiths hold important ceremonies for the baby soon after the birth. This might involve many family members gathering in the home and the visit from the midwife in the middle of these celebrations might not be convenient (McCourt & Percival 2000, Schott & Henley 1996). Other women who have experienced motherhood before and feel the need for only minimal support from the maternity services might consider visits from the midwife as interrupting their day-to-day activities with no real particular benefit to them (Murphy-Black 1989). The concept of postpartum care is one that aims to assist the mother and her baby towards attaining an optimum health status. Where the visit from the midwife can be seen as supportive and useful to the mother and her family, this purpose is more likely to be achieved. The social changes that have occurred over the past 20 or more years will have had an effect on how different members of society view the need for care for new mothers, both from health professionals and from family members. Research that has explored the experiences of women from different ethnic backgrounds have demonstrated very marked inequalities in both the provision of services as well as the actual direct contact with care givers (Hirst & Hewison 2002). In contrast, where the timing of midwifery postpartum care is extended beyond 28 days, there is greater opportunity for midwives to continue midwifery support where this might be appropriate, and this has been welcomed as progress although the focus would appear to be more on social or psychological outcomes, or for breastfeeding support than overt clinical or physical morbidity (Bick et al 2002, Winter et al 2001).
Regardless of place of birth, the midwife is primarily concerned with the observation of the health of the postpartum mother and the new baby. As such, it has been common practice to have an overall framework upon which to base the assessment of the mother’s state of health and for the observations contained within the examination to link with pre-stated categories in the postnatal midwifery records. This formalized approach to the postpartum review might be an appropriate tool to use if there is concern about a woman who is feeling unwell and there is a need for a comprehensive picture of the woman’s state of health (see Ch. 35). Where this is not the case such an approach might be less useful from the viewpoint of the needs of a healthy woman who has recently given birth (Gready et al 1997, Redshaw et al 2007, Ridgers 2007). The concern centres on whether, by taking the time to complete a ‘top to toe’ examination as a thorough review of someone who is generally well, the midwife might ignore or give less attention to what the mother really wants to talk about (Garcia et al 1998, Ridgers 2007) (Box 34.1).
Box 34.1 Thinking about the parameters that constitute ‘postnatal care’
(Extract from Ridgers 2007 Passing through but needing to be heard; an ethnographic study of women’s perspectives of their care on the postnatal ward. Unpublished PhD thesis, Ch. 8.)
The setting is on a postnatal ward where the midwife is undertaking the daily ‘check’ on a postpartum mother. This was recorded as part of an observation study into hospital postnatal care (Ridgers 2007):
‘… the woman tells the midwife – “I’m going back to an empty house”
Brief pause, followed by the midwife asking the mother “Have you had your bowels open?”
Further brief pause. Following which the midwife said to the woman – “it’s a lovely time to have a baby.” (it is December and Christmas is coming up).
The midwife opened the bed curtains by the foot of the bed and then left the woman’s bed space. As she passed the woman in the adjacent bed, she informed her – “I’ll come and see you shortly.”
The midwife left the bay. The first woman remained behind the partially opened bed curtains; at no time did she move around or attempt to converse with any of the other women in the bay.
This mother was later heard to confide to a telephone caller:
“This week has been a bit tough … a bit raw … it’s a bit tricky”.’
The skill of the midwife’s care is to achieve a balance when deciding which observations are appropriate so that she does not fail to detect potential aspects of morbidity. The next part of this chapter identifies areas of physiology that are likely either to cause women the most anxiety or to have the greatest outcome with regard to morbidity. These descriptions relate to observations undertaken for women who have had vaginal births and uncomplicated pregnancies.
After the birth, oxytocin is secreted from the posterior pituitary gland to act upon the uterine muscle and assist separation of the placenta. Following expulsion of the placenta, the uterine cavity collapses inwards; the now opposed walls of the uterus compress the newly exposed placental site and effectively seal the exposed ends of the major blood vessels. The muscle layers of the myometrium are said to simulate the action of ligatures that compress the large sinuses of the blood vessels exposed by placental separation. These occlude the exposed ends of the large blood vessels and contribute further to reducing blood loss. In addition, vasoconstriction in the overall blood supply to the uterus results in the tissues being denied their previous blood supply; de-oxygenation and a state of ischaemia arise. Through the process of autolysis, autodigestion of the ischaemic muscle fibres by proteolytic enzymes occurs resulting in an overall reduction in their size. There is phagocytic action of polymorphs and macrophages in the blood and lymphatic systems upon the waste products of autolysis, which are then excreted via the renal system in the urine. Coagulation takes place through platelet aggregation and the release of thromboplastin and fibrin (Cunningham et al 2005, Hytten 1995).
What remains of the inner surface of the uterine lining apart from the placental site, regenerates rapidly to produce a covering of epithelium. Partial coverage occurs within 7–10 days after the birth; total coverage is complete by the 21st day (Cunningham et al 2005).
Once the placenta has separated, the circulating levels of oestrogen, progesterone, human chorionic gonadotrophin and human placental lactogen are reduced. This leads to further physiological changes in muscle and connective tissues as well as having a major influence on the secretion of prolactin from the anterior pituitary gland.
Once empty, although the uterus retains its muscular structure, it can be likened to an empty sac. It is therefore important to remember that the uterus, although at this point markedly reduced in size, still retains the potential to be a much larger cavity. This underpins the requirement to undertake immediate and then regular observations of fundal height and the degree of uterine contraction in the first few hours after the birth. Abdominal palpation of the uterus is usually performed soon after placental expulsion to ensure that the physiological processes are beginning to take place. On abdominal palpation, the fundus of the uterus should be located centrally, its position being at the same level or slightly below the umbilicus, and should be in a state of contraction, feeling firm under the palpating hand. The woman may experience some uterine or abdominal discomfort especially where uterotonic drugs have been administered to augment the physiological process (Anderson et al 1998).
Traditionally textbooks have described precise measurements for the size of the uterus at various points in this process. Inconsistencies in these descriptions in the various textbooks cast doubt on the validity of the information overall (Marchant et al 1999). The process of involution, however, is essential background knowledge for midwives monitoring the physiological process of the return of the uterus to its non-pregnant state. Research findings would suggest that the information required by both midwives and women is that a well-contracted uterus will gradually reduce in size until it is no longer palpable above the symphysis pubis (Cluett et al 1997, Marchant et al 2000). The rate at which this occurs and the duration of time taken have been demonstrated to be highly individual (Cluett et al 1997) rather than occurring specifically at a daily rate.
Overall, the uterus should not be tender during this process and, although women may be experiencing afterpains, the presence of these should be defined separately from any uterine tenderness. The observations obtained by the midwife about the state of involution of the uterus should be placed into context alongside the colour, amount and duration of the woman’s vaginal fluid loss and her general state of health at that time.
There are several aspects to the abdominal palpation of the postpartum uterus that contribute to the observation as a whole. The first is to identify height and location of the fundus (the upper parameter of the uterus). Assessment should then be made of the condition of the uterus with regard to uterine muscle contraction and finally whether palpation of the uterus causes the woman any pain. When all these dimensions are combined, this provides an overall assessment of the state of the uterus and the progress of uterine involution can be described. Findings from such an assessment should clearly record the position of the uterus in relation to the umbilicus or the symphysis pubis, the state of uterine contraction and the presence of any pain during palpation. A suggested approach to how this is undertaken in clinical practice can be found in Box 34.2.
Box 34.2 Suggested approach to undertaking postpartum assessment of uterine involution
Clear and accurate records of any observation that has been undertaken are essential tools to competent practice (NMC 2004). Although the usefulness of uterine assessment is not in doubt where this contributes to the confirmation of abnormality, it is questionable whether this assessment when it is carried out routinely (regardless of clinical indication) contributes to the prediction of potential problems associated with involution. Recording of the findings from assessment of uterine involution has been found to be inconsistent between midwives and a wide range of abbreviation and hieroglyphics have been used to describe the involuting uterus (Marchant et al 2000). Such activities are at variance to the professional guidance which states that the record of any assessment should be written contemporaneously, clearly and be devoid of abbreviation and ambiguity (NMC 2004).
Blood products constitute the major part of the vaginal loss immediately after the birth of the baby and expulsion of the placenta. As involution progresses the vaginal loss reflects this and changes from a predominantly fresh blood loss to one that contains stale blood products, lanugo, vernix and other debris from the unwanted products of the conception. This loss varies from woman to woman, being a lighter or darker colour, but for any woman the shade and density tends to be consistent.
‘Lochia’ is a Latin word traditionally used to describe the vaginal loss following the birth (Cunningham et al 2005). Medical and midwifery textbooks have described three phases of lochia and have given the duration over which these phases persist. Recent research has explored the relevance of these descriptions for women and raised questions about the use of these descriptions in clinical practice. One study identified that not all women were even aware that they would have a vaginal blood loss after the birth (Marchant et al 1999), but of more importance was the wide variation experienced by women in colour, amount and duration of vaginal loss in the first 12 weeks’ postpartum (Marchant et al 1999, Oppenheimer et al 1986, Sherman et al 1999). This suggests that, overall, descriptions of normality ascribed to the traditional descriptions of lochia are outdated and unhelpful to women and midwives in accurately describing a clinical observation. Women also appreciate the use of language that is familiar to them and therefore it is recommended that the description of vaginal loss as ‘lochia’ should be abandoned and replaced with postpartum ‘vaginal blood’ or ‘fluid’ loss.
Plate 14 illustrates the colour of vaginal blood loss reported by women in the first 28 days’ postpartum.
Most women can clearly identify colour and consistency of vaginal loss if asked and, more importantly, will be able to describe key changes from what has happened previously. Therefore it is of more use to the midwife to ask focused questions about the current vaginal loss: whether this is more or less, lighter or darker than previously and whether the mother has any concerns about it herself. When asking these questions, women should be asked an open question first: ‘can you tell me the colour/amount of your vaginal loss today?’ rather than asking whether the vaginal loss is brown or red, etc. It is of particular importance to record any clots passed and when these occurred. Clots can be associated with future episodes of excessive or prolonged bleeding postpartum (see Chs 29 and 35).
Assessment that attempts to quantify the amount of loss or the size of clot is problematic. The use of descriptions that are common to both woman and midwife can improve accuracy in these assessments. Examples are asking the woman to describe the size of the spread of the vaginal loss on a sanitary pad, the frequency of changing the pad because of the saturation level, or comparison of the size of clots to familiar items such as a 50 pence coin or a plum (Marchant et al 1999, 2000).
Regardless of whether the birth resulted in actual perineal trauma, women are likely to feel bruised around the vaginal and perineal tissues for the first few days after the birth. Women who have undergone any degree of actual perineal injury will experience pain for several days until healing takes place (Albers & Borders 2007, McCandlish et al 1998, Sleep 1995, Steen 2007, Wylie 2002). It has been said that the effects of perineal trauma significantly blight the first experiences of motherhood for many women because of the degree of pain experienced and the effects of this on the activities of daily living (McCandlish et al 1998, Sleep 1995). Long-term psychological and physiological trauma is also evident.
As with palpation of the uterus, the perineum is not easily viewed by the woman herself and so appropriate midwifery care might involve observing the perineal area to ascertain progress of healing from any trauma (WHO 1999). However, the woman will be well aware of how it feels with regard to degrees of pain and discomfort, or the absence of these. Appropriate care immediately after the birth or where suturing has taken place can help to reduce oedema and bruising (Bick et al 2002, NICE 2006, Sleep 1995, Steen et al 2000, Steen 2007). When the midwife is undertaking the postpartum review it is recommended that, particularly in the first few days after the birth, all women are asked about discomfort in the perineal area regardless of whether there is a record of actual perineal trauma. Clear information and reassurance are helpful where women have poor understanding of what happened and are anxious or embarrassed about urinary, bowel or sexual function in the future.
Where women appear to have no discomfort or anxieties about their perineum, it is not essential for the midwife to examine this area and arguably it is an intrusion on the woman’s privacy to do so. The basic principles of morbidity or infection (Cunningham et al 2005) indicate that it is unusual for morbidity to occur without inflammation and pain although these factors are also integral to the healing process (Steen 2007); therefore, although the area might be causing discomfort from the original trauma, where this is unchanged or absent a pathological condition should not be developing. There may be occasions, however, where the midwife might consider that the woman is declining this observation because she is embarrassed or anxious. In such cases, the midwife should use her skills of communication to explore whether there is a clinical need for this observation to be undertaken and, if so, to advise the woman accordingly. For the majority of women, the perineal wound gradually becomes less painful and healing should occur by 7–10 days after the birth.
Sleep (1995) identified a number of studies aimed at providing evidence of effectiveness in this area. Treatments included the use of salt or Savlon in bathwater, pulsed electromagnetic energy, infra-red heat and ultrasound. None of these trials produced evidence that was persuasive about overall benefit in the area of reducing pain or improving healing. Further enquiry is still needed within the overall aim of giving relief without destabilizing the most suitable environment for healing. However, women may still find soaking in a bath of great comfort to them regardless of any additive, and relief may be derived from the use of a bidet or cool water poured over the area that is tender. Research has supported the use of cool gel pads to reduce pain and these are readily available to purchase at minimal cost as opposed to more expensive medications (Steen et al 2000).
There is also increasing interest and research being undertaken into the use of complementary therapeutic preparations (see Ch. 50).
The following information is based on the premise that the midwife is exploring the health of the postpartum woman from a viewpoint of confirming normality. ‘Common sense’ although a concept that is very difficult to define is probably a well understood paradigm and taking such an approach is an important part of midwifery care with regard to addressing the issues that are visible before seeking out the less obvious. In this instance, an overall assessment of the woman’s physical appearance will add considerably to the management of what will be undertaken prior to continuing any further investigation for either the woman or her baby.
Making a note of the pulse rate is probably one of the least invasive and most cost-effective observations a midwife can undertake. If undertaken when seated alongside or at the same level as the woman, it can create positive feelings of care while also obtaining valuable clinical information. While observing the pulse rate, particularly if this is done for a full minute, the midwife can also observe a number of related signs of well-being: the respiratory rate, the overall body temperature, any untoward body odour, skin condition and the woman’s overall colour and complexion, as well as just listening to what the woman is saying.
It is not necessary to undertake observations of temperature routinely for women who appear to be physically well and who do not complain of any symptoms that could be associated with an infection. However, where the woman complains of feeling unwell with flu-like symptoms, or there are signs of possible infection or information that might be associated with a potential environment for infection, the midwife should undertake and record the temperature. This will enhance the amount of clinical information available where further decisions about potential morbidity may need to be made.
Following the birth of the baby, a baseline recording of the woman’s blood pressure will be made. In the absence of any previous history of morbidity associated with hypertension, it is usual for the blood pressure to return to a normal range within 24 hrs after the birth. Routinely undertaking observations of blood pressure without a clinical reason is therefore not required once a baseline recording has been taken, NICE suggest this should be within six hours of the birth (NICE 2006).
The body has to reabsorb a quantity of excess fluid following the birth and for the majority of women this results in passing large quantities of urine, particularly in the first day, as diuresis is increased (Cunningham et al 2005, Hytten 1995). Women may also experience oedema of their ankles and feet and this swelling may be greater than that experienced in pregnancy. These are variations of normal physiological processes and should resolve within the puerperal time scale as the woman’s activity levels also increase. Advice should be related to taking reasonable exercise, avoiding long periods of standing, and elevating the feet and legs when sitting where possible. Swollen ankles should be bilateral and not accompanied by pain; the midwife should note particularly if this is present in one calf only as it could indicate pathology associated with a deep vein thrombosis.
Women who have suffered from urticaria of pregnancy or cholestasis of the liver should experience relief once the pregnancy is over. The pace of life once the baby is born might lead to women having a reduced fluid intake or eating a different diet than they had formerly (Tuffery & Scriven 2005). This in turn might affect their skin and overall physiological state. Women should be encouraged to maintain a balanced fluid intake and a diet that has a greater proportion of fresh food in it (DH 2007a, Tuffery & Scriven 2005). This will improve gastrointestinal activity and the absorption of iron and minerals, and reduce the potential for constipation and feelings of fatigue.
For some women, discussions about bladder and bowel functions may be personal and embarrassing. Midwives need to consider that women might either think that problems are ‘to be expected’ (because they have just had a baby) or that they are unique to them. Women may be unable to tell the midwife about it in case it is either worse than they had dreamed or too trivial to worry someone about. These primarily psychological and sociological barriers can result in women suffering from serious and debilitating urinary or bowel problems for years after the birth (Bishop 2005, MacArthur et al 1991, WHO 1998). Taking again the aspect of the range for normal function after childbirth, women need reassurance that, in the first few days after the birth, minor disorders of urinary and bowel function are common. These may be associated with retention or incontinence of urine or constipation, or both. The skill of midwifery care is to try to explore the possible cause of this and decide whether it will resolve spontaneously or requires further investigation.
It is reasonable for women to look forward to regaining their body for themselves once the baby is born (Gready et al 1997, MaGuire 2000). However, this is not the immediate outcome for many women and, once again, individual women will have their own expectations about the nature and speed at which they would like this recovery to occur. The role of the midwife at this point is to assist the woman to identify actual symptoms of disorder from the gradual process of reorder and advise what action the woman can do for herself in the way of progressive recovery. Advice for new parents in the matter of recovery from the birth is sparse and often superficial; also women may feel they should know what to do, or have unrealistic expectations of motherhood and their ability to cope with these new experiences (Bartell 2004, Marchant et al 2001, Proctor 1999). This is one area where taking the time to talk about what might seem to the midwife a range of peripheral or even superficial issues that might be worrying the otherwise healthy new mother could be of more benefit that day than a range of routine clinical observations (Redshaw et al 2007).
Increasing the understanding in the general population about the value of different forms of exercise and health has been shown to be of psychological as well a physical benefit (Armstrong & Edwards 2004). Exploring each person’s level of activity will encourage advice in relation to appropriate exercise and, by association, nutritional intake and rest or relaxation and sleep. Undertaking regular pelvic floor exercises is of benefit to women’s long-term health (see Ch. 16).
It has been traditional to associate afterpains with multiparity and breastfeeding. However, women experience afterpains regardless of whether they have had previous pregnancies and when they are not breastfeeding (Mander 1998, Marchant et al 1999). The description of afterpains in parent education books suggests that they are mildly uncomfortable and more an issue of inconvenience. Women themselves, however, have described the pain as equal to the severity of moderate labour pains (Marchant et al 1999). Management of afterpains is by an appropriate analgesic, where possible taken prior to breastfeeding, as it is the production of the oxytocin in relation to the let-down response that initiates the contraction in the uterus and causes pain. It is helpful to explain the cause of afterpains to women and that they might experience a heavier loss at this time, even to the extent of passing clots. Pain in the uterus that is constant or present on abdominal palpation is unlikely to be associated with afterpains and further enquiry should be made about this. Women might also confuse afterpains with flatus pain, especially after an operative birth or where they are constipated. Identifying and treating the cause is likely to relieve the symptoms or raise concern about a more complex condition that needs further attention.
Advice on managing fertility is within the sphere of practice of the midwife and it is an important aspect of postpartum care (see Ch. 37). Midwives need to be aware of a range of different needs with regard to women’s sexuality and should be able to offer sensitive and appropriate advice on contraception where this is needed.
The midwife should have gained a considerable amount of information during her contact with the mother and baby. The wide range for normality and the individuality within this can make it difficult for the midwife to decide whether an observation is related to morbidity. It is more likely to be the relationship between several observations that raises cause for concern and, where these appear to be more related to abnormality than normality, the midwife has a responsibility to make appropriate referral to a medical practitioner or other appropriate healthcare professional. The midwife’s statutory framework (NMC 2004) is different from the overall guidance and frameworks for care provision developed under the auspices of various Departments of Health. This is an important distinction with regard to the professional accountability of the midwife and their obligation as an employee (NMC 2008).
It has been the presumption in this chapter that women will welcome or even actively seek the help and advice of the midwife once the baby has been born. Within this is also the assumption that the woman will have the capability to do this. There may be various reasons why some women do not seem to be so welcoming of the care offered as others. Women from different cultural backgrounds may have traditions that conflict with the current management of postpartum care (Hirst & Hewison 2002, Ockleford et al 2004), or consider that they already have sufficient skills and experience. Not being able to speak or understand English may also inhibit the woman from seeking advice, or may appear to the midwife as being withdrawn and uncommunicative (Schott & Henley 1996). Aspects of domestic disharmony may also lead the woman to decline visits from an outsider. The midwife may have an important role with regard to referral and support for these women, where the worst outcome has been identified within the statistics for maternal death (Lewis 2007, Lewis & Drife 2001, 2004).
Although a visit to the home might have been planned, there will also be times when women are not at home when the midwife visits. It is important to keep in mind individual circumstances and whether these might have any bearing on a failed visit. For example, people with disabilities such as hearing loss or poor mobility might not hear a doorbell. It is important to make arrangements for contact to be made by alternative means (e.g. using a visual alarm or telephone to alert women of the visit beforehand). A very loud television set can prevent the people inside from hearing a doorbell and, simplest of all, although the doorbell has been rung it is not working and no-one is aware that the midwife is standing on the doorstep. Such events may lead to misunderstandings and a breakdown of communication between women and the caregivers with a risk of deterioration in either the uptake or the provision of future services (Disability, Pregnancy and Parenthood International).
One research study reported how some women who have had previous children did not consider that the midwife or health visitor had much to offer them once they had returned home (Murphy-Black 1989). More recent surveys of postnatal care offer rather more insight into women’s needs underpinning the approach that offers recognition of each woman as an individual and not someone with an obstetric label, for example referring to women as ‘the section in bed 2’ or by the previous number of births ‘she’s a multip’ (Ridgers 2007). The midwife needs to recognize situations where the mother perceives that she has different priorities from those ‘routinely’ provided by the healthcare services. Recent innovations through the SureStart programmes have identified how services can be appropriately reconfigured to meet the needs of vulnerable groups (Wilyman-Bugter & Tucker 2004). The midwife can then ensure that the woman has access to sufficient information (in a format that she can utilize) and to feel able to make contact with any of the services if she or the baby requires it in the future (Gready et al 1997, McCourt & Percival 2000). Where there are concerns about the safety or protection of the newborn infant, the supervisor of midwives should be informed and advice sought from the local social services (the Safeguarding Children Board).
It is important that those undertaking postpartum care, whether in an active or passive format, are appropriately educated and supported so that they can meet the diverse health needs of the mother and baby over the postnatal period. In addition, recent government policy has re-enforced the urgent need for midwives to work in collaboration with other health and social care professionals during this time, and to incorporate midwifery services into a broader framework of a family network (DH 2005, DH 2007b). The social environment has a marked impact on the overall health outcomes for both mother and baby and the acknowledgement of this has drawn midwifery care into the overall public health arena and long term outcomes for health initiatives (or lack of them) at this time.
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