Chapter 52 Morbidity following childbirth
Although for most women the postnatal period is uncomplicated, core postnatal care includes recognizing any deviations from the expected recovery after birth, evaluating the situation and intervening appropriately (NICE 2006). Health problems after birth are common, may persist over time and are often under-recognized by the care providers (Leah & Albers 2000).
The NICE guidelines (2006) provide recommendations for additional postnatal care that may be needed when deviations from the expected recovery pattern occur. These recommendations have been given appropriate status levels indicating the degree of urgency required in dealing with each problem. The status levels are defined as non-urgent, urgent or emergency. If additional care is required, it should be offered so as to minimize, as much as possible, any impact on the relationship between the woman, her baby and family.
All women in the UK are offered a postnatal examination at 6–8 weeks after childbirth and this has been considered to mark the end of the puerperium and a woman’s routine contact with the maternity services (NICE 2006). Although childbirth-related problems are known to occur after this time, some even requiring readmission to hospital, only recently have there been systematic investigations of longer-term postpartum morbidity. Studies, in the UK (Bick & MacArthur 1995, Glazener et al 1995) and elsewhere (Brown & Lumley 1998, Saurel-Cubizolles et al 2000), have investigated the occurrence and persistence of a range of health problems following childbirth. All these studies have identified substantial postpartum ill-health, much of which persists well past the end of the puerperium and is often not reported to health professionals, nor observed by them.
It is important to remember that not all the problems experienced following childbirth are attributable to the birth itself. Some morbidity is likely to be associated with the birth and some with pregnancy, whilst some will be due to the changes of childbirth or be unrelated to any of these events, occurring as part of a general background of morbidity present at any time in any population. Particular childbirth-related causal factors have been investigated in some of the studies and these will be referred to in the relevant sections.
NICE (2006) recommend that, at the first postnatal contact, women should be advised of the signs and symptoms of potentially life-threatening conditions (see Table 52.1). The incidence of these potentially life-threatening conditions is low, but they can lead to maternal mortality and morbidity that can be avoided or reduced if appropriate action is taken. NHS Trust guidelines should be in place to enable midwives to provide women with appropriate information about the conditions and the action they should take. Details about who to contact in these circumstances should be provided.
Table 52.1 Possible signs and symptoms of life-threatening conditions
| Possible sign/symptom | Evaluate for | Action |
|---|---|---|
| Sudden or profuse blood loss, or blood loss and signs/symptoms of shock, including tachycardia, hypotension, hypoperfusion, change in consciousness | Postpartum haemorrhage | Emergency action |
| Offensive/excessive vaginal loss, tender abdomen or fever. If no obstetric cause, consider other causes | Postpartum haemorrhage/sepsis/other pathology | Urgent action |
| Fever, shivering, abdominal pain and/or offensive vaginal loss. If temperature exceeds 38°C, repeat in 4–6 hours. If temperature still high or other symptoms and measurable signs, evaluate further | Infection/genital tract sepsis | Emergency action |
| Severe or persistent headache | Pre-eclampsia/eclampsia | Emergency action |
| Diastolic BP is greater than 90 mmHg and accompanied by another sign/symptom of pre-eclampsia | Pre-eclampsia/eclampsia | Emergency action |
| Diastolic BP is greater than 90 mmHg and no other sign/symptom, repeat BP within 4 hours. If it remains above 90 mm Hg after 4 hours, evaluate | Pre-eclampsia/eclampsia | Emergency action |
| Shortness of breath or chest pain | Pulmonary embolism | Emergency action |
| Unilateral calf pain, redness or swelling | Deep vein thrombosis | Emergency action |
Adapted from NICE guideline 37 (2006)
The majority of symptoms experienced after childbirth are rarely life-threatening but they can have an adverse effect on the quality of life (Bick & MacArthur 1995). Since women are often reluctant to initiate consultations about their own health, careful questioning from the midwife and other professionals is needed to enable them to discuss their symptons.
Symptoms of stress incontinence are the most common of the urinary problems that occur in association with childbirth, but some women also have retention and voiding difficulties or urinary tract infection. If urine has not been voided by 6 hours following the birth and measures, such as a warm bath or shower, are not immediately successful, the bladder should be palpated and catheterization should be considered as urgent action needs to be taken (NICE 2006). The bladder can only contain a certain amount of urine even when distended, and once that capacity is reached, the sphincter of the bladder relaxes and urine escapes. This is referred to as retention with overflow.
Urinary voiding difficulties and retention are generally immediate post-delivery complications. Zaki et al (2004) found that I in 60 women failed to resume normal voiding during the immediate postpartum period. Their national survey found that there was no consensus about the diagnostic criteria for retention or the optimum management for voiding dysfunction. Further research is needed, as, if it is not recognized, bladder overdistension can lead to denervation, detrusor atony and bladder dysfunction requiring, in extreme cases, self-catheterization for up to 5 weeks (Zaki et al 2004). Zaki et al reported that retention is being reported with increasing frequency, which could be due to greater awareness or an increasing use of epidural analgesia and instrumental deliveries. From day 2 onwards, pelvic floor exercises should be taught, to prevent any involuntary leakage of urine, especially if a woman reports leaking small amounts of urine. Persistent urinary incontinence should be referred for investigation and treatment (NICE 2006). A third of women are known to suffer from the problem following childbirth. Pelvic floor exercises will reduce the incidence, especially with one-to-one teaching and supervision. The exercises may be particularly beneficial for women who give birth to large babies or who have forceps deliveries (Hay-Smith et al 2008).
General population studies have shown that urinary stress incontinence among women, defined as the involuntary leakage of urine caused by pressure on the bladder from coughing, sneezing, laughing and exertion, is widely experienced (Pollock 2004). Childbirth is generally considered to be the most common cause. Viktrup & Lose (2001) reported a prevalence of stress incontinence 5 years after a first delivery of 30%, and the risk of stress incontinence at this time was related to the onset and duration of symptoms after the first pregnancy and delivery. The use of vacuum extraction or episiotomy during the first delivery also increased the risk. In their follow-up study, Glazener et al (2005) also found that about three-quarters of the women with urinary incontinence at 3 months after childbirth still had the problem 6 years later. They concluded that the moderate short-term benefits of conservative treatment may not persist. Further research is required so that appropriate management strategies can be identified. Women should be encouraged to discuss the problems of incontinence so that they can receive the advice and support that is currently available.
The risk factors in the aetiology of stress incontinence remain unclear, but it is generally considered to be linked to pelvic floor innervation damage (Allen et al 1990, Zaki et al 2004) which is more common after a longer second stage labour and the delivery of a bigger baby. Increasing maternal age, heavier infant birthweight and larger head circumference have also been identified as risk factors by Wilson et al (1996). Findings relating to the effect of forceps have been inconsistent (Brown & Lumley 1998). Delivery by caesarean section is generally associated with a lower prevalence of stress incontinence (Assassa et al 2000, Wilson et al 1996). However, Wilson et al (1996) found that a reduced occurrence only applied to women who had up to two caesarean sections.
The severity of postpartum stress incontinence and its effect on lifestyle appear to be variable. Many women practise pelvic floor exercises ineffectively and some not at all, since doing the exercises competes with all the other demands in the immediate postnatal period. A trial of treatment using pelvic floor exercise education given to women who had persistent stress incontinence at 3 months postpartum found a significant reduction in the number who still had the symptoms at 12 months (Glazener et al 2001).
There is limited information on the postpartum occurrence of urinary tract infections. Glazener et al (1995) found that 5% of women reported a urinary tract infection some time during the first postpartum year. A postpartum urinary tract infection is more common after a caesarean section and a recent Cochrane systematic review has shown that prophylactic antibiotics for women who have abdominal deliveries are effective in reducing the occurrence (Smaill & Hofmeyr 2010).
Constipation is common following delivery as the pain of perineal trauma or reduced dietary intake in labour can predispose to it. The few studies that have documented the prevalence of constipation have indicated that it occurs at some time following about 15–20% of births (Glazener et al 1995, Saurel-Cubizolles et al 2000), and is more common after instrumental delivery than after spontaneous vaginal or caesarean deliveries (Glazener et al 1995).
Haemorrhoids are also known to be common after childbirth, and faecal incontinence as well as anal fissure sometimes occur. Haemorrhoids can be extremely painful, but it has generally been considered that most cases regress within a few days of the birth (CKS 2005). However, childbirth-associated haemorrhoids can be longer lasting, with between 15% and 20% of women reporting symptoms at about 2 months after the birth (Glazener et al 1995).
Management should be as per local protocol, but severe, swollen or prolapsed haemorrhoids should be evaluated (NICE 2006). MacArthur et al (1991) found that two-thirds of the women with haemorrhoids still had them at least a year after giving birth, indicating that complete resolution of childbirth-related haemorrhoids is not common. The severity of persisting symptoms, however, is not known. Longer second stage of labour and heavier infant birthweight are associated with an increased likelihood of haemorrhoids (MacArthur et al 1991). Glazener et al (1995) found that they were more than twice as common after instrumental compared with spontaneous vaginal delivery and that women were much less likely to experience haemorrhoids after caesarean section delivery.
One study documented anal fissure, defined as a split or tear in the skin of the anal canal, as occurring in 9% of the women (Corby et al 1997). The authors noted that, without detailed investigation, many of these would have been diagnosed (if at all) as acute painful haemorrhoids, with over 90% of cases resolving without treatment. Type of delivery or perineal trauma were not associated with the occurrence of anal fissure, but postnatal constipation was much more common in the symptomatic group, which is why it is so important that midwives accurately identify and assess this problem by sensitive questioning of the woman. Midwives must also advise women on diet to ensure stools are soft and easily passed. After repair of a third or fourth degree laceration, several weeks of therapy with a stool softener, such as docusate sodium (colace), to minimize the potential for repair breakdown from straining during defecation, is recommended. Pain relief must be offered to reduce the risk of this adding to the fear of defecation (Premkumar 2005).
The occurrence of postpartum faecal incontinence, including frank incontinence, soiling and faecal urgency, is increasingly being documented. One factor associated with the development of faecal incontinence is birth injury, in particular third or fourth degree tear or disruption of the external anal sphincter muscle (Christianson et al 2003, Fenner et al 2003, Sultan et al 1999). Estimates of prevalence of faecal incontinence range from 17% to 62% if there has been severe perineal trauma at delivery, or forceps delivery. Prophylactic antibiotics can be helpful in preventing infection and breakdown of perineal wounds following third or fourth degree tears and reducing the risk of faecal incontinence (Duggal et al 2008). In addition to third or fourth degree tears, the main risk factor for postpartum faecal incontinence is instrumental delivery (Assassa et al 2000, MacArthur et al 1997, MacArthur et al 2001).
It had been considered that although obstetric injury was probably the most common cause of faecal incontinence in women, symptoms were unlikely to occur (except after a third or fourth degree tear) until later in life. Epidemiological studies of unselected obstetric populations have found that between 1% and 10% of women reported postpartum faecal incontinence. Wilson et al (1996) documented 4.9% with ‘faecal incontinence’ and MacArthur et al (2001) found that 9.6% reported ‘losing control of bowel motions between visits to the toilet at some time since the birth’. Hay-Smith et al (2008) reported that I in 10 women leak faeces following childbirth. Studies using endosonography and manometry to image the anal sphincter muscles have obtained data on symptoms of faecal and flatus incontinence and found even higher prevalences (Sultan et al 1993). These populations, however, are smaller and include women who agree to have the anal investigative techniques, who are therefore likely to have higher symptom rates.
Pathophysiological studies have shown that childbirth-associated structural damage to the anal sphincter is more likely to be a cause of faecal incontinence than are neurological factors affecting the pelvic floor. One small study has shown that women who had symptomless anal sphincter defects after a first birth were at higher risk of developing symptoms of faecal incontinence after a second delivery (Fynes et al 1999).
Caesarean section delivery is associated with lower symptom rates but faecal incontinence has been documented after emergency procedures. First or second degree perineal laceration has not been shown to be associated with an increased risk of faecal incontinence, nor generally has episiotomy. Women with faecal incontinence must be referred for treatment (NICE 2006).
Most women who have a vaginal delivery will have a degree of perineal pain. It is probably one of the most commonly experienced immediate postpartum symptoms (Sleep 1995). Studies have shown that at least a third of women report experiencing a painful perineum soon after birth, but it can be more persistent. When women complain of perineal discomfort, the perineum should be inspected for any signs of inadequate repair, wound breakdown, delay in the healing process or infection, and appropriate advice given or referral made (NICE 2006).
Some women experience dyspareunia, defined as pain or discomfort during sexual intercourse, which can be related to perineal problems. There is little information on the prevalence of dyspareunia or any other sexual problem, possibly because of the sensitivity of the subject and the reluctance of women to seek medical consultation. If a woman expresses anxiety about resuming intercourse, reasons should be explored with her and a water-based lubricant gel may be advised to ease discomfort during sexual intercourse (NICE 2006). Further evaluation would be required if problems continue to be experienced. Brown & Lumley (1998) found that 26% of women at 6–7 months postpartum reported that they had experienced ‘a sexual problem’ at some time since the birth. At 8 weeks postpartum, Glazener et al (1995) showed that among the women who had attempted sexual intercourse, 28% had found this to be sore or difficult and 9% reported a lack of interest in sex. In another study it was found that 62% recalled experiencing dyspareunia some time in the first 3 months and 31% still had this at 6 months (Barrett et al 2000).
The main risk factors for perineal pain and dyspareunia relate to the type of delivery and perineal trauma. Instrumental deliveries are associated with much higher rates of perineal pain, both immediate and longer term, than are spontaneous vaginal deliveries, and caesarean sections are associated with the lowest rates (Brown & Lumley 1998, Glazener et al 1995). The pattern of association with mode of delivery is similar for dyspareunia, although the differences are less marked (Barrett et al 2000, Brown & Lumley 1998).
Descriptions from women have suggested that there is more perineal discomfort following an episiotomy than there is after a laceration and several randomized controlled trials have been undertaken to examine this issue. A Cochrane systematic review (Carroli & Mignini 2008), including eight trials on this topic, concluded that there is little evidence to justify episiotomy as a means of limiting postpartum perineal pain. The effects on perineal pain and dyspareunia of different materials used and of different suture methods are described in Chapter 40.
Overall, the musculoskeletal system of the parturient woman seems to be more sensitive to various forms of injury, probably because of the laxity of ligaments resulting from the effects of progesterone and relaxin in pregnancy continuing in the postnatal period, changes in posture and positioning during the birth.
Numerous studies undertaken in the postnatal period have documented backache with prevalences that seem to be greater than that among the general population. The range of prevalence estimates of postpartum backache is wide, from 20% to 50%, (Breen et al 1994, Brown & Lumley 1998, Glazener et al 1995, Groves et al 1994, Saurel-Cubizolles et al 2000).
In a study examining postpartum backache and its risk factors in primiparous women, Russell et al (1993) found that 29% had backache that lasted for more than 6 months after the birth, and for 15% this was new backache starting since the birth. Backache during or before pregnancy is a predisposing factor for postpartum back pain (Breen et al 1994, Östgaard & Andersson 1992, Turgut et al 1998) and some studies have found physically heavy work during pregnancy to be a risk factor (Östgaard & Andersson 1992). Epidural anaesthesia during labour has been associated with subsequent longer-term backache (Brown & Lumley 1998, Russell et al 1993) but other studies have found no association (Breen et al 1994, MacArthur et al 1995). The postulated mechanism to account for a possible association relates to stressed positions in labour, women might remain for some time in a potentially damaging position. In addition, the physical demands of childcare, lifting, bending, carrying and feeding, especially as the child increases in size, are likely to be related to the occurrence of backache.
No specific studies have examined this, but the longitudinal studies have not shown postpartum backache to reduce over time (Glazener et al 1995, Saurel-Cubizolles et al 2000). Back pain is managed as in the general population (NICE 2006). An updated Cochrane review (Roelofs et al 2008) suggested that non-steroidal anti-inflammatory drugs are effective for short-term symptomatic relief. However, the effect sizes are small and there is moderate evidence that they are not more effective than paracetamol, which has fewer side-effects (Roelofs et al 2008).
Owens et al (2003) reported an incidence of pelvic girdle pain, formally known as symphysis pubis dysfunction, of 1 in 36 in their study, which suggests the condition is more common than previously thought. An early referral should be made to the physiotherapist so that an assessment of mobility needs may be made. Regular analgesia should be provided and help with positioning for breastfeeding and babycare activities. An occupational therapist or social services advisor should be consulted about the provision of aids and equipment that may be required in order to enable the mother to cope at home.
When menstruation returns, some women may have a recurrence of symptoms. Though these may resolve within a couple of months, they may persist for longer. It is likely to recur and becomes more severe in subsequent pregnancies (Owens et al 2003). The Association of Chartered Physiotherapists in Women’s Health have produced a leaflet, Pregnancy-related pelvic girdle pain (ACPWH 2007), to provide information and advice to women.
Pain and weakness in the arms and legs commencing after birth and persisting for months or even years was reported four times as often among Asian women as compared with Caucasian women in a study by MacArthur et al (1991). This could be caused by vitamin D deficiency, accentuated by the extra demands and postural stresses of pregnancy and delivery (MacArthur et al 1993a).
Paraesthesias in the legs, buttocks and lower back have been reported. MacArthur et al (1991, 1992) found that these paraesthesias, as well as those in the fingers and hands, although rare, were more common in women who had used epidural anaesthesia. Dizziness, fainting and visual disturbances, although again rare, were also more common after epidural anaesthesia and after spinal and general anaesthesia (MacArthur et al 1992).
The occurrence of short-duration postpartum headaches, in at least a quarter of women, has been reported (Stein et al 1984) and longer-term headaches have also been documented (Glazener et al 1993, Russell et al 1993). Management of mild headache should be based on differential diagnosis of headache type and treatment as per local protocols (NICE 2006). Most postpartum headaches are probably tension-type or ‘simple’ headaches, but the studies that have examined headache among postnatal women have not generally specified headache type. Advice on relaxation techniques and avoidance of factors associated with the onset should be offered. Severe or persistent headache, especially associated with the other symptoms of pre-eclampsia in the early postnatal period, should be referred for treatment (NICE 2006).
MacArthur et al (1991, 1993b) found that frequent headaches in association with backache were more common in women who had had epidural anaesthesia (see Ch. 38). Headaches without backache, however, were more common in younger, lower social class women with more than one child. Headache is a common complaint, generally related to stress and fatigue.
Tiredness in the early postpartum period is well recognized anecdotally, not surprisingly owing to the demands of childbirth, the additional childcare load and sleeplessness associated with night feeding. However, many women report longer-term exhaustion, which can have a significant effect on their relationships, social activities, employment and psychological health. Women rarely consult a doctor about this, possibly because they perceive it as normal at this time, or not a ‘medical problem’ (Bick & MacArthur 1995). Glazener et al (1993) found that 59% of the sample reported tiredness between hospital discharge and 8 weeks and 54% between then and 18 months. Brown & Lumley (1998) documented that at 6–7 months, 69% of women had experienced tiredness/exhaustion as a problem some time since the birth. In an Audit Commission study (Garcia et al 1998), women who were questioned four months postpartum said they had experienced fatigue or severe tiredness at times; 43% at 10 days, 31% at one month and 21% at 3 months. MacArthur et al (1991) asked about extreme tiredness and found that 12% of the women reported never having had such extreme tiredness before; half of these women saying it had lasted for longer than a year.
Various risk factors for postpartum fatigue shown in studies include older maternal age, being unmarried, having twins and breastfeeding (Milligan & Pugh 1994, Saurel-Cubizolles et al 2000). No significant relationship has been shown between longer-term fatigue and type of delivery, although caesarean section has been associated with increased short-term fatigue (Glazener et al 1995).
MacArthur et al (1991) found that women who had experienced postpartum haemorrhage reported more tiredness, which could plausibly be related to a low haemoglobin level. Postpartum haemorrhage still poses a risk of morbidity and mortality and estimating blood loss at birth from soaked pads and bedlinen can be challenging (NICE 2006). Postpartum anaemia is often poorly managed and Bodnar et al (2005) concluded that it warrants greater attention and higher-quality care. Haemoglobin testing is not a routine postnatal practice and it is often down to the individual women to seek treatment (Evans 2008). If women do report their tiredness and receive a prescription for iron tablets, the side-effects, most commonly constipation, may result in them taking the tablets sporadically.
One small study by Bhandal & Russell (2006) compared women having oral iron to correct postpartum anaemia with women given intravenous iron. Women treated with intravenous iron had significantly higher Hb levels on days 5 and 14 (P < 0.01) than those treated with oral iron, but by day 40 there was no significant difference between the two groups. More research is required to investigate the safety of this strategy. Liquid iron supplements which have higher absorption rates and reduced side-effects may be easier to continue for long-term therapy when tolerance is poor (Evans 2008). Advice about a well-balanced iron-rich diet should be provided by professionals who are knowledgeable about foods that can inhibit or enhance absorption.
Fatigue is commonly reported in association with depression and anxiety (Glazener et al 1993), although which problem arises first is not known. Brown & Lumley (2000) found that tiredness was over three times more likely to be reported by women with high scores on the Edinburgh Postnatal Depression Score (see Ch. 69).
A study in Australia demonstrated a relationship between physical health after birth and postnatal depression and fatigue (Brown & Lumley 2000). It is important, therefore, that health professionals ensure that depression in postpartum women is identified and treated (see Ch. 69). There is accumulating evidence of the adverse effects of postpartum depression on the cognitive and emotional development of the child (Cooper & Murray 1998).
MacArthur et al (1991) found that most symptoms lasted much longer than 6 weeks: 35% of the women reported new symptoms lasting over a year and 31% still had unresolved symptoms at the time of questioning, which was between 2 and 9 years after the birth of their most recent child, indicating that many women experience childbirth-related morbidity that becomes chronic. Since the recall period in this study was lengthy for some women, it is likely that some health problems that lasted for only a few weeks or were relatively minor may not have been reported. These levels of postpartum morbidity were confirmed in a later study (Bick & MacArthur 1995).
Glazener et al (1995) also identified considerable morbidity, with the prevalence of some symptoms reducing substantially over time but not that of others. A European longitudinal study of health after birth and mothers’ work, in Italy and France (Saurel-Cubizolles et al 2000), generally found very high symptom prevalences and for most symptoms these had increased at 12 months.
Even though studies have shown that many women experience health problems after childbirth, it has consistently been shown that these are often not reported to a relevant health professional (Brown & Lumley 1998, Glazener et al 1995). The proportion of women in one study who said they had consulted a doctor was on average only about a third (MacArthur et al 1991). There could be many reasons for this lack of consultation. The symptom might only be mild or occur infrequently; the problem might be considered by the woman as ‘normal’ after having a baby; or she may have thought that there is nothing that a doctor could do. For some symptoms it may be embarrassment that accounts for a woman not seeking professional help. Whatever the reason, the effect of this lack of consultation is that the full extent of the postpartum morbidity has remained unrecognized by health professionals, and women are left with unmet health needs.
Several randomized controlled trials of revisions to current postnatal care have been undertaken to assess if improvements in maternal health outcomes could be achieved (Gunn et al 1998, MacArthur et al 2003, Morrell et al 2000). These studies differed substantially in the content of the intervention but there were no documented improvements in maternal physical health in any of the studies. Maternal satisfaction scores were higher than controls in two of the studies (Gunn et al 1998, MacArthur et al 2003) and maternal mental health scores were significantly better than controls in one study (MacArthur et al 2003).
Reflective activity 52.1
Use the information in this chapter to devise a symptom checklist to find out about symptoms that women may experience after childbirth.
Have a consultation with a woman in the first month after giving birth and use the checklist. Find out if she has reported any of her symptoms, if not, why, and how they might be affecting her life. Refer to the NICE guideline 37 (2006) to assess the recommendations for their management.
Health problems after childbirth continue well past the routine discharge from maternity services and many remain unreported to the health services. This has implications for midwives and other members of the primary care team in developing strategies to identify as well as provide for women’s postpartum health requirements. There will be considerable variation in the health needs of individual women and care should be tailored flexibly to take this into account. Midwives must provide a high standard of care using the best available evidence (NMC 2008) and so must ensure that their skills and knowledge are up to date and that they keep clear and accurate records to support the health and wellbeing of the women in their care. When a deviation from the norm occurs which is outside the midwife’s sphere of practice, then an appropriate referral should be made to a qualified health professional who may reasonably be expected to have the necessary skills and experience to assist in providing care for the woman (NMC 2004). All relevant information must be shared with the multidisciplinary team (NMC 2008).
Allen RE, Hosker GL, Smith ARB, et al. Pelvic floor damage and childbirth: a neurophysiological study. British Journal of Obstetrics and Gynaecology. 1990;97(9):770-779.
Assassa RP, Dallosso S, Perry C, et al. The association between obstetric factors and incontinence: a community survey. the Leicestershire MRC Incontinence Study Team. British Journal of Obstetrics and Gynaecology 2000;107(6):822.
Association of Chartered Physiotherapists in Women’s Health (ACPWH). Pregnancy-related pelvic girdle pain (website). www.acpwh.org.uk/docs/ACPWH-PGP_HP.pdf, 2007. Accessed July 2009
Barrett G, Pendry E, Peacock J, et al. Women’s sexual health after childbirth. British Journal of Obstetrics and Gynaecology. 2000;107(2):186-195.
Bhandal N, Russell R. Intravenous versus oral iron therapy for postpartum anaemia. British Journal of Gynaecology. 2006;113(11):1248-1252.
Bick DE, MacArthur C. The extent, severity and effect of health problems after childbirth. British Journal of Midwifery. 1995;3(i):27-31.
Bodnar LM, Cogswell ME, McDonald T. Have we forgotten the significance of postnatal iron deficiency? American Journal of Obstetrics and Gynecology. 2005;193(1):36-44.
Breen TW, Ransil J, Groves PA, et al. Factors associated with back pain after childbirth. Anesthesiology. 1994;81(6):29-34.
Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based survey. British Journal of Obstetrics and Gynaecology. 1998;105(2):156-161.
Brown S, Lumley J. Physical health problems after childbirth and maternal depression at six to seven months postpartum. British Journal of Obstetrics and Gynaecology. 2000;107(10):1194-1201.
Carroli G, Mignini L: Episiotomy for vaginal birth, Cochrane Database of Systematic Reviews (3):CD000081, 2008.
Christianson LM, Bovbjerg VE, McDavitt E, et al. Risk factors for perineal injury during delivery. American Journal of Obstetrics and Gynecology. 2003;189(1):255-260.
CKS. ‘Haemorrhoids’ Clinical Knowledge Summaries Service, Clinical Topic (website). www.cks.library.nhs.uk, 2005. Accesssed June 2009
Cooper P, Murray L. Postnatal depression. British Medical Journal. 1998;316(7148):1884-1886.
Corby H, Donnelly VS, O’Herlihy C, et al. Anal canal pressures are low in women with postpartum anal fissure. British Journal of Surgery. 1997;84(1):86-88.
Duggal N, Mercado C, Daniels K, et al. Antibiotic prophylaxis can prevent postpartum perineal wound complications. Obstetrics and Gynecology. 2008;111(6):1268-1273.
Evans M. Iron deficiency through the female life cycle – who needs to care? MIDIRS Midwifery Digest. 2008;18(3):404-408.
Fenner DE, Genberg B, Brahma P, et al. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. American Journal of Obstetrics and Gynecology. 2003;189(6):1543-1549.
Fynes M, Donnelly V, Behan M, et al. Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study. Lancet. 1999;354(9183):983-986.
Garcia J, Redshaw M, Fitzsimons B, et al. First class delivery. A national survey of women’s views of maternity care. Abingdon: Audit Commission; 1998.
Glazener CMA, Abdalla M, Russell I, et al. Postnatal care: a survey of patients’ experiences. British Journal of Midwifery. 1993;1(2):67-74.
Glazener CMA, Abdalla M, Shroud P, et al. Postnatal maternal morbidity: extent, causes, prevention and treatment. British Journal of Obstetrics and Gynaecology. 1995;102(4):282-287.
Glazener CMA, Herbison GP, Wilson PD, et al. Conservative management of persistent postnatal urinary and faecal incontinence: a randomised controlled trial. British Medical Journal. 2001;323(7313):593-596.
Glazener CMA, Herbison GP, MacArthur C, et al. Randomised controlled trial of conservative management of postnatal urinary and faecal incontinence: six year follow up. British Medical Journal. 2005;330(7487):337-339.
Groves PA, Breen TW, Ransil BJ, et al. Natural history of post partum back pain and its relationship with epidural anesthesia. Anesthesiology. 1994;81(3A):A1167.
Gunn J, Lumley J, Chondros P, et al. Does an early postnatal check-up improve maternal health: results from a randomised controlled trial. British Journal of Obstetrics and Gynaecology. 1998;105(9):991-997.
Hay-Smith J, Mørkved S, Fairbrother KA, et al: Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women, Cochrane Database of Systematic Reviews (4):CD007471, 2008.
Leah L, Albers CNM. Health problems after childbirth. Journal of Midwifery and Women’s Health. 2000;45(1):55-57.
MacArthur C, Lewis M, Knox EG. Health after childbirth. London: HMSO; 1991.
MacArthur C, Lewis M, Knox EG. Investigation of long-term problems after obstetric epidural anaesthesia. British Medical Journal. 1992;304(6837):1279-1282.
MacArthur C, Lewis M, Knox EG. Comparison of long-term health problems following childbirth in Asian and Caucasian women. British Journal of General Practice. 1993;43(377):519-522.
MacArthur C, Lewis M, Knox EG. Accidental dural puncture in obstetric patients and long-term symptoms. British Medical Journal. 1993;306(6882):883-885.
MacArthur AJ, MacArthur C, Weeks S. Epidural anaesthesia and low back pain after delivery: a prospective cohort study. British Medical Journal. 1995;311(7016):1336-1339.
MacArthur C, Bick DE, Keighley MRB. Faecal incontinence after child birth. British Journal of Obstetrics and Gynaecology. 1997;104(1):46-50.
MacArthur C, Glazener CMA, Wilson PD, et al. Obstetric practice and faecal incontinence three months after delivery. British Journal of Obstetrics and Gynaecology. 2001;108(7):678-683.
MacArthur C, Winter HR, Bick D, et al. Redesigning postnatal care: a randomised controlled trial of protocol-based midwifery-led care focused on individual women’s physical and psychological health needs. Health Technology Assessment. 2003;7(37):1-98.
Milligan RA, Pugh LC. Fatigue during the childbearing period. Annual Review of Nursing Research. 1994;12:33-49.
Morrell CJ, Spiby H, Stewart P, et al. Costs and effectiveness of community postnatal support workers: randomised controlled trial. British Medical Journal. 2000;321(7261):593-598.
National Institute for Health and Clinical Excellence (NICE). Routine postnatal care of women and their babies (website). www.nice.org.uk, 2006. Accessed August 2008
Nursing & Midwifery Council (NMC). Midwives rules and standards. London: NMC; 2004.
Nursing & Midwifery Council (NMC). The Code: standards of conduct, performance and ethics for nurses and midwives. London: NMC; 2008.
Östgaard HC, Andersson GBJ. Postpartum low back pain. Spine. 1992;17(1):53-55.
Owens K, Pearson A, Mason G. Symphysis pubis dysfunction: a cause of significant obstetric morbidity. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2003;105:143-146.
Pollock L. SUI after childbirth. Midwives. 2004;7(12):504.
Premkumar G. Perineal trauma: reducing associated postnatal maternal morbidity. Midwives. 2005;8(1):30-32.
Roelofs DDMR, Deyo RA, Koes BW, et al. Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine. 2008;33(16):1766-1774.
Russell R, Grove P, Taub N, et al. Assessing long-term backache after childbirth. British Medical Journal. 1993;306(6888):1299-1303.
Saurel-Cubizolles M-J, Romito P, Lelong N, et al. Women’s health after childbirth: a longitudinal study in France and Italy. British Journal of Obstetrics and Gynaecology. 2000;107(10):1202-1209.
Sleep J. Postnatal perineal care revisited. In: Alexander J, Levy V, Roch S, editors. Aspects of midwifery practice: a research based approach. London: Macmillan, 1995.
Smaill F, Gyte G: Antibiotic prophylaxis versus no prophylaxis for preventing infection after caesarean section, Cochrane database of Systematic Reviews (1):CD007482, 2010.
Stein GS, Morton J, Marsh A, et al. Headaches after childbirth. Acta Neurologica Scandinavica. 1984;69(2):74-79.
Sultan AH, Kamm MA, Hudson CN, et al. Anal sphincter disruption during vaginal delivery. New England Journal of Medicine. 1993;329(26):1905-1911.
Sultan AH, Monga AK, Kumar D, et al. Primary repair of obstetric anal sphincter rupture using the overlap technique. British Journal of Obstetrics and Gynaecology. 1999;106(3):318-323.
Turgut F, Turgut M, Cetinsahin M. A prospective study of persistent back pain after pregnancy. European Journal of Obstetrics and Gynecology and Reproductive Biology. 1998;80(1):45-48.
Viktrup L, Lose G. The risk of stress incontinence 5 years after first delivery. American Journal of Obstetrics and Gynecology. 2001;185(1):82-87.
Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery. British Journal of Obstetrics and Gynaecology. 1996;103(2):154-161.
Zaki M, Pandit M, Jackson S. National survey for intrapartum and postpartum bladder care: assessing the need for guidelines. BJOG: An International Journal of Obstetrics and Gynaecology. 2004;111(8):874-876.