Fundamentals of Midwifery: A Textbook for Students (73 page)

Learning outcomesBy the end of this chapter the reader will be able to:

understand the roles and responsibilities of the midwife in assessing, monitoring and evaluating the care of the mother and baby in the postnatal period

explain the basic anatomy and physiology of the puerperium

provide evidence-based information to promote health and well-being of the mother and baby

explain the provision, organisation and content of postnatal care

support involvement of fathers in the postnatal period

understand the responsibilities of the midwife in safeguarding vulnerable adults and children.

The postnatal period marks an important time of adaptation, encompassing many physical,

emotional, socioeconomic and life changing experiences for the mother and partner. The Nursing and Midwifery Council (NMC) of the United Kingdom, in ‘Midwives Rules and Standards’ (2012, p. 6) define the postnatal period:

The National Institute for Health and Care Excellence (NICE) (2013) suggest the postnatal period lasts six to eight weeks after the birth, concluding with a postnatal examination of mother and baby by an appropriately qualified practitioner, marking the end of the maternity care provision.

, First Edition. Edited by Louise Lewis.

© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd. Companion website: www.wileyfundamentalseries.com/midwifery

The aim of postnatal care is to facilitate a smooth transition to parenthood, promote a bio- psycho-social recovery in the mother, monitor the wellbeing of the newborn and provide evidence-based information to the parents. For many women and babies the postnatal period is uncomplicated; this chapter will provide an overview of the key aspects of midwifery care aiming to address the needs of the normal postnatal recovery of the healthy mother whilst offering an insight into recognition of deviations from the normal and the appropriate manage- ment (see Chapter 9: ‘Care of the newborn’, where the needs of the neonate are explored in more depth).

During the 17th century, childbirth in England was inherently a social domestic event, firmly

rooted in a female domain. Historically, women and infants were cared for by unqualified local women known as ‘gossips’ who were usually more mature, married and had themselves given birth. They provided support during labour and for up to six weeks after the birth, helping with domestic duties and supporting the mother to recuperate after the birth (Wilson 1995). Birth predominantly took place within the home and was followed by a ‘lying in period’ described by Calder in 1912 (cited in Marchant 2010, p. 17) as

The passing of the Midwives Act 1902 set the framework for the training and education of midwives along with provision of care for women and their families. Subsequent guidance and standards have regulated the profession, developing a family-centred, professional and safe service that women are afforded today.

Statistics show the number of births within England and Wales in 2012 to be 729,674 increas- ing by 0.8% from 723,913 in 2011 (Office of National Statistics 2013). With rising birth rates and increased pressures upon midwifery services to deliver a high quality service, traditional routine practices in the postnatal period have inevitably changed. The days of the ‘

’ where women were advised to stay in bed in hospital, have now been superseded by early ambulation, early discharge and the promotion of maternal independence. Even for women having under- gone caesarean sections, NICE (2011) suggest women who wish to be discharged may be dis- charged after 24 hours, with follow-up care at home, providing there are no other complications. It should be acknowledged, however that this applies to England and Wales and that interna- tional practice along with cultural beliefs will differ. For example, Greece and India continue to follow a traditional 40-day confinement period of recuperation, whilst China follows a 30-day confinement period after the birth.

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Activity 8.1

What are the potential complications associated with the ‘lying in period’ where women were

often kept in bed for in excess of ten days?

How are these issues addressed by current evidence-based guidelines?

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The puerperium is traditionally defined as the period of time from immediately after the birth

of the baby and placenta and membranes, until the reproductive organs have returned to their non-pregnant state. It is estimated to last six to eight weeks, although the evidence base to support this duration is lacking and health problems are known to exist beyond this period (Coad and Dunstall 2011). The puerperium is characterised by anatomic and physiological changes which relate to involution and lactation. It is also a time of major psychological, emo- tional and social change as the new mother emerges into the world with the new infant.

Involution of the uterus is the physiological process of the uterus returning to be a pelvic organ. It is a process of contraction, autolysis and epithelial regeneration and proliferation (Azulay Chertok 2013). Oxytocin is released from the posterior pituitary gland inducing strong intermit- tent myometrial contractions, which may be further increased by the infant suckling at the breast. Immediately following birth of the fetus, myometrial spiral fibres occlude compressing the blood vessels supplying the placental site, causing haemostasis and separation of the pla- centa from the uterine wall. Haemostasis is achieved by ischemia, pressure from the uterine walls becoming realigned in opposition to each other and the blood clotting mechanism (Coad and Dunstall 2011). The initial postpartum contractions known as ‘

’ may be strong, particularly in multiparous women which gradually reduce in intensity within the first week (Azulay Chertok 2013). The breakdown of excess myometrial muscle fibres is influenced by proteolytic enzymes within the cells; a process known as autolysis (Jackson 2011). The end products of autolysis are disposed of by phagocytosis. Following birth, the uterus lies about halfway between the umbilicus and the symphysis pubis and over the next 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus. According to Azulay Chertok (2013), the height of the fundus continues to decrease by about 1 cm per day and by 2 weeks, the uterus has descended into the pelvis and the fundus can no longer be palpated abdominally; it gradu- ally decreases in size over the next month to six weeks. Involution is checked by abdominal palpation, after a woman has been asked to empty her bladder.

Slow, delayed or incomplete involution of the uterus can be caused by ineffective uterine con- tractility, retained placental products, membrane fragments and infection (Azulay Chertok 2013), predisposing the patient to postpartum haemorrhage. The signs and symptoms of infec- tion can include fever, abdominal tenderness, and offensive and excessive vaginal blood loss, although, pyrexia is no longer favoured as a diagnostic category because it is not always present in the presence of infection (Sinha and Otify 2012). The signs and symptoms of postpartum haemorrhage can include tachycardia, hypotension and on palpation of the fundus, the uterus can feel soft described as ‘boggy’ and may palpate above the umbilicous (Azulay Chertok 2013). Postpartum haemorrhage is discussed in greater depth in Chapter 16: ‘Emergencies in mid- wifery’. If subinvolution is suspected immediate medical treatment is required. The presence of uterine fibroids can also distort the size and shape of the uterus, and requires medical assessment.

The decidual lining of the uterus degenerates and is shed in the postpartum blood loss; known as the lochia. The process of involution and restoration of the endometrium is reflected in the

characteristics of the lochia which varies in amount and colour as healing occurs. This varies between individuals and generally starts as a red to brown vaginal loss (rubra) lasting the first few days, changing to pinkish-brown discharge (serosa), becoming whitish-yellow (alba) which can last until 6 weeks postpartum (Azulay Chertok 2013).‌‌‌‌‌

Regeneration of the uterine epithelial lining rapidly grows, reforming a new epithelium layer over most of the surface within 10 days (Coad and Dunstall 2011). By 2–3 weeks, the endometrial lining is regenerated, reflecting the proliferative stage of the menstrual cycle, except the pla- cental site which takes around 6 weeks (Azulay Chertok 2013).

Following birth the vaginal walls are decreased in tone and oedematous. The vagina gradually reduces in size and regains tone, although following a vaginal birth it does not return to its pre-pregnant state (Azulay Chertok 2013). Over the next 3–4 weeks, the cervix and vagina decrease in vascularity and oedema is reabsorbed.