Oxford Handbook of Midwifery (109 page)

This emergency may occur in the home, when the mother may be alone, and the community midwife may be the first person to arrive.

Afterwards

CHAPTER 21
Disorders of the postnatal period

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Secondary postpartum haemorrhage

Definition

• Profuse bleeding from the genital tract, occurring after the first 24h until 6 weeks after birth.
  
• It most commonly occurs between 7 and 14 days after birth.
  

  Signs and symptoms
  

• Often preceded by a heavy red loss, which may be offensive and accompanied by sub-involution of the uterus. Some clots or pieces of membrane may be seen.
  
• Tachycardia and low-grade pyrexia will indicate the presence of infection.
  

  Management
  

• Massage the uterus, if palpable, to encourage uterine contraction.
  

  •
  Summon medical aid, according to local policy.
  

• Ensure the bladder is empty; catheterize if necessary.
  
• To control bleeding:
  
  • If bleeding is severe, give 250–500micrograms of ergometrine maleate IV, or intramuscularly if you are unable/not trained and competent to administer IV drugs.
    
• Insert an IV cannula, if competent to do so, and start an IV infusion of sodium chloride 0.9%. Otherwise, get the equipment ready for the doctor or paramedic to carry out this procedure.
  

  Practice point
  

  3This emergency normally occurs in the home 7–14 days after birth. Transfer the mother to hospital as quickly as possible via paramedic ambu- lance and accompany her, continuing to carry out emergency procedures, as required.
  

  MATERNAL COLLAPSE WITHIN 24h WITHOUT BLEEDING
  

  499‌‌
  

  Maternal collapse within 24h without bleeding
  

  Possible causes
  

Midwifery management

• A
  irway—ensure it is patent
  
• B
  reathing—ensure she is breathing. Monitor respiratory rate and depth of respirations
  
• C
  irculation—check pulse rate.
  

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Disorders of the postnatal period

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Hypertensive disorders

• All women who have pre-existing hypertension and hypertensive disorders of pregnancy can develop eclampsia in the hours and days following birth.
  
• Although postnatal eclampsia is rare, it is not unknown for a woman with a history of a normal blood pressure to develop postnatal pre- eclampsia or eclampsia.
  
• Continue monitoring the blood pressure, twice daily for at least 3 days after birth, until you are sure it is back within normal range and there are no other signs of pre-eclampsia.
  
• Keep accurate records of the recordings in the mother’s records.
  
• If necessary, the doctor may prescribe antihypertensive treatment, in which case regular blood pressure recording must be continued until the blood pressure has been back within normal range and stable for at least 24h.
  

  Essential hypertension
  

• This woman was hypertensive prior to pregnancy and has probably required an increase in her medication in pregnancy.
  
• Continue monitoring the blood pressure daily for 48h, then daily while the antihypertensive medication is satisfactorily readjusted and the blood pressure is stable within normal limits.
  
• If the mother is breastfeeding, check that the medication is not harmful to the baby. If the medication is contraindicated in breastfeeding, discuss it with the doctor, to find one that is suitable.
  

  Practice point
  

• 2 It is essential that the blood pressure is controlled within the normal range, to prevent eclampsia, cerebrovascular accident, and renal damage.
  
• Monitor urine output, as well as monitoring the blood pressure in the early postnatal period.
  

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  CHAPTER 21
  Disorders of the postnatal period
  

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  Circulatory disorders
  

  Varicose veins
  

• Generally, these start in pregnancy and are due to hormonal relaxation of the veins, increased venous pressure, and increasing weight as pregnancy progresses.
  
• Most common in the legs, but may present as vulval or femoral varicosities.
  
• Generally they regress after birth.
  
• Some women have pre-existing varicose veins and for some women they become worse with successive pregnancies and increasing age.
  

  Signs and symptoms
  

• They may become inflamed and painful, particularly in the early postnatal period.
  
• Vulval varicose veins may rupture during the second stage of labour, from pressure of the fetal head or from perineal tearing, and can be a
  

  cause of significant haemorrhage.
  

• May predispose to increased risk of DVT.
  

  Treatment
  

• Early ambulation and walking out each day is encouraged.
  
• Rest with legs raised, whenever possible.
  
• Local anti-inflammatory treatment and oral analgesia.
  
• 2 Support stockings should
  not
  be worn, as they restrict blood flow in the legs. Support tights are better.
  
• In subsequent years some women will require surgical treatment for varicose veins.
  

  Superficial thrombophlebitis
  

  Signs and symptoms
  

  Localized inflammation and tenderness around the affected varicose vein, and, perhaps, a mild pyrexia.
  

  Treatment
  

• Support, anti-embolic stockings.
  
• Early ambulation. Support when sitting, with leg raised on a footstool or, preferably, on the bed, in the acute stage.
  
• Anti-inflammatory drugs (care if breastfeeding).
  

  Deep vein thrombosis
  

  Signs and symptoms
  

• Unilateral oedema in the affected leg
  
• Calf pain and stiffness
  
• Difficulty in walking
  
• Positive Homan’s sign.
  

  Treatment
  

• Urgent referral to the doctor is required.
  
• If necessary, transfer the woman back to hospital medical services by ambulance.
  
• Anticoagulant therapy must be started as soon as possible, IV heparin initially for 24–48h, followed by daily subcutaneous tinzaparin injection of 3500 or 4500mg.
  

  CIRCULATORY DISORDERS
  

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