Fundamentals of Midwifery: A Textbook for Students (75 page)

Further reading activity

Read the sections on wellbeing of the mother and baby in National Institute for Health and Clinical

Excellence guidelines for postnatal care of women and their babies (NICE 2006) [Available online] http://www.nice.org.uk/nicemedia/live/10988/30143/30143.pdf

Additional information:

England, C. (2014) Recognizing the healthy baby at term through examination of the newborn screening. In: (eds) Marshall, J., Raynor, M.

, 16th edn. Edinburgh: Elsevier.

Following on from The House of Commons Health Committee (2005), who reported an esti-

mated 25,000 people in the UK to have died from preventable hospital-acquired deep vein thrombosis (more than the combined total of deaths from breast cancer, AIDS-related diseases and traffic accidents), the NHS has made prevention of deep vein thrombosis a priority (NICE 2010).

Despite falling to third place as a leading cause of death in the latest confidential enquiries into maternal deaths (Centre for Maternal and Child Enquiries (CMACE) 2011), thromboembo- lism still claimed the lives of 18 women between 2006 and 2008. This was a marked reduction from 41 between 2003 and 2005 and was largely attributed to the introduction of guidelines (RCOG 2004) superseded in 2009.

One of the main causative factors associated with venous thromboembolism (VTE) is obesity; NICE recommend all women to have assessment of their body mass index (BMI) at the first

antenatal appointment, with any women who have a BMI above 30 kg/m

being referred for additional care. Women should be assessed at the booking interview, during any hospital admis- sions, reassessed if further risk factors occur and assessed again during the postnatal period. It is the midwives’ responsibility to ensure risks are identified and appropriate referral for treat- ment is made – Figure 8.1 highlights the women who are at most risk for VTE.

When looking at the risk factors identified in Figure 8.1, it is important to consider how many women may be at increased risk due to the rising age of childbearing women, the rising rate of obesity, and the number of women undergoing instrumental and surgical deliveries. Maternity care providers therefore need to be confident and competent to teach women, their partners or family members to administer anticoagulant medication to ensure compliance is achieved. For many women this may be the first time they have held a medical syringe, let alone self- injected and some may feel less confident in being able to self-administer. It may be necessary to teach their partners or significant others how to administer the anticoagulant. With hospital stays becoming increasingly shorter, women may only experience one demonstration before being discharged to community care. Some units may therefore provide a supporting digital versatile disc (DVD).

Demands upon midwives to deliver high quality effective care have evolved over time: a shift

in public health priorities, increasingly higher risk vulnerable families, pressures to balance heavy workloads with early hospital discharge, and increased clerical work may have contrib- uted to midwives becoming disillusioned with the quality of care they are realistically able to provide in the postnatal period (Cattrell et al. 2005; Dykes 2005). A recent Royal College of Midwives (RCM) (2013) survey identified that over half of the midwives in the study said they would like to offer a lot more in terms of the standard of care in the postnatal period. Since the 1990s, the demand for postnatal care in the community within the UK has increased due to shorter hospital stays and an increasing number of mothers choosing to initially breastfeed, requiring support to establish effective lactation and ensure optimal infant nutrition (Walsh 2011). The responsibility and care does not always lie with the midwife alone. More commonly, midwives are seeking support offered by maternity support workers, Children’s Centre staff and peer supporters, although the midwife still remains the main provider of care in an uncompli- cated postnatal recovery of mother and baby.

The effects of global migration to the UK have contributed to the changing health needs of the population. Increasingly, midwives are working supported by interpreters and engagement with other services, increasing the demands upon the role of the midwife in the postnatal period. With increasing numbers of births to women aged 30 and over as a result of delayed marriage, increased participation in education and establishing a career (ONS 2013) this has also contributed to the increase in women with potentially complex needs, particularly for those women over 40 years. The number of live births to mothers aged 40 and over has more than quadrupled over the past three decades from 6519 in 1982 to 29,994 in 2012 (ONS 2013). Mills and Lavender (2011) cite risks associated with increased maternal age to include: hypertensive disorders; diabetes; chromosomal conditions, particularly trisomy 21 (Down syndrome) trisomy 13 (Patau syndrome) and trisomy 18 (Edwards syndrome); increased risk of multiple pregnancy; and increased risk of stillbirth. Women of this age group may also have co-existing morbidities, with some having conceived through assisted reproduction, both of which could lead to the woman being considered higher risk. With the ever-changing needs of the population and increasing pressure to provide effective postnatal care within a reduced timeframe, midwives

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need to ensure they are skilled in being able to optimise the care and support they provide. Every postnatal contact with a mother and baby counts and should be afforded appropriate assessment, planning, implementation and evaluation of care. The RCM (2014) have launched a new initiate ‘Pressure Points’ to push for improved funding and additional resource to improve postnatal care services.

Evidence of postnatal morbidity has been an area of research and focus of maternity policy for

many years. As early as the 1990s, research has highlighted the psychological and physical health problems women experience postpartum. The most common health problems include: back pain, urinary incontinence, perineal pain, intercourse problems, constipation and head- aches (Bick and MacArthur 1995; Glazener et al. 1995). Practical suggestions to address the common areas of morbidity have been recommended by Bick and colleagues and readers are encouraged to access the latest recommendations to assist them in providing appropriate care (Bick et al. 2009).

Sepsis has become the most common cause for direct maternal death in the UK, with an increase in deaths relating to genital tract sepsis, particularly from community-acquired Group A streptococcal disease, which mirrors the increased incidence of streptococcus A in the general population (CMACE 2011). One of the ten recommendations in the CMACE report highlights the need for health professionals to go ‘back to basics’, recommending healthcare providers are competent in recognising basic signs and symptoms of ill health. In some of the women described in the CMACE report, earlier recognition of the severity of the illness, recording and appropriate evaluation of vital signs may have prompted earlier action and possibly an improved outcome (CMACE 2011). Sepsis may have an insidious onset, whereby young, previously healthy women can maintain normal vital signs until the late stages of acute disease. Readers are encouraged to look at the latest CMACE 2011 report (Chapter 7: Sepsis) to raise awareness in the prevention and ability to recognise and respond quickly to antenatal, intrapartum and postpartum sepsis. The results of a recent prospective case-control study (Acosta et al. 2014), are consistent with the trend in maternal sepsis deaths in the UK identified in the CMACE 2011 report. The case-control study emphasises that all health care practitioners should remain aware that pregnant or recently pregnant women with suspected infection need closer attention than women who are not pregnant and that signs of severe sepsis in peripartum women particularly those with confirmed or suspected Group A streptococcal infection should be treated as an obstetric emergency (Acosta et al. 2014).

The recent survey by the RCM (2013) identified that a third of women are rarely or never advised of the signs and symptoms of potentially life-threatening conditions in the postnatal period that should prompt urgent referral and treatment. The importance of undertaking, inter- preting and acting appropriately on basic observations, understanding normality and improv- ing the exchange of information to women and families about the signs and symptoms of life threatening complications are highlighted by CMACE (2011). In addition, appropriate use of Modified Early Obstetric Warning Scoring Systems (MEOWS) is recommended to help reduce deaths through early detection of serious illness. All health professionals who care for pregnant and recently delivered women are expected to follow local infection control protocols, to inform women about the signs and symptoms of sepsis, and to explain the importance of regular hand hygiene, particularly if the woman has a perineal, or caesarean wound, or is in contact with those that have a respiratory tract infection or a sore throat. This is particularly pertinent to community midwives, who may be the first to recognise potentially abnormal signs during the

postnatal observations for all women, not just those who have had caesarean sections. If puer- peral infection is suspected, the woman must be referred back to the obstetric services urgently (CMACE 2011).‌

Further reading activity

Read the signs and symptoms of life-threatening conditions in a woman, requiring Emergency

Action in National Institute for Health and Clinical Excellence guidelines for postnatal care of women and their babies (NICE 2006) [Available online] http://www.nice.or

g.uk/nicemedia/ live/10988/30143/30143.pdf