Week 6: The postnatal period Flashcards
Define the post natal period
the time following the thrid stage of labour (birth of placenta and control of bleeding) until 6 weeks which
involves the physiological return of the woman’s organs, hormones and blood volume to the pregnancy state, the establishment of breast feeding, and is also the period where mother and babys relationship is established.
What are the goals of postnatal care for a midwife?
▪ Promote and assess the woman’s physical, psychological,
emotional and social well- being
▪ Assist establishment and maintenance of infant feeding
▪ Foster development of maternal/infant/family relationships
▪ Promote health education, including newborn parent craft
skills
What is the role/some jobs of a post natal ward midwife?
▪ Past history: medical history and previous pregnancies and
births
▪ Current pregnancy and birth:
- G? P?
- normal pregnancy? any abnormalities or issues?
- normal vaginal birth (NVB) @ (time & date)?
- intact perineum?
- placenta & membranes? e.g. complete/incomplete
- ?ml blood loss
- blood group
- a supportive partner? student midwife?
▪ Infant details: E.g..
- VB?
- sex of baby
- @ time & date.
- Apgars @ 1min and @ 5min.
- Konakion (Vitamin K) and Hepatitis B vaccination given?
- HNPU, has passed meconium.
- Breast Feed happened? @ (time)?
After a handover from the birth sweet team, what should your next actions be?
▪ Welcome, introduce self and identify the woman
▪ Familiarise to the environment – call bell, bathroom, kitchen,
linen, TV hire, baby photographer, has she got her own blankets and what not
▪ Postnatal assessment
- Vital signs
- Fundus – firm and central (F&C), @ umbi
- Lochia – colour (rubra), amount (slight, moderate, heavy), ask but can also look at pad
- ? Voided – ensure bladder is empty (can inhibit the uterus from contracting)
- Perineum (can ask about pain or need ice, don’t always need to look)
- Breastfeed (BF)
- Analgesia needs
- Baby assessment
- Vital signs – axilla, temperature, heart rate auscultated with stethoscope
over apex of heart, respirations counted for 1 full minute
- BF
- HPU/Passed meconium
- Document findings on clinical pathways and infant feed chart
What are the components of a post natal daily assessment?
Components of assessment:
- Maternal physical wellbeing
- Maternal Mental Health
- Newborn Wellbeing
- Parent craft
What is involved in a postnatal daily maternal physical wellbeing assessment: vital signs?
Frequency
- depends on hospital policy
- often 15mins after baby is born, 4hrly- twice then daily
- other than this, just if clinically necessary e.g. reporting SOB
- Refer to local hospital policy for timing of vital signs
documentation requirements - ?Maternity Early Obstetric
Warning (MEOW) chart - Document all findings on the “Clinical Pathway” as well as vital signs
What is involved in a postnatal daily maternal physical wellbeing assessment: breasts?
Assess :
- Lactation stage – colostrum or milk coming in
- Breast comfort
- Reddened/inflamed areas
- Lumps
- Nipples for cracks, fissures, blisters or bruising (indicative of a poor latch or latch that is causing damage)
This is an issue as baby may not get enough food!
Could use cold packs to reduce these.
Discuss:
- Feeding patterns – timing, duration of feed, sucking action/looks like/feels like?, baby’s interest in feeding
The best indicator of feed is when it asked for it!
- ask women about how the latch feels? pain, discomfort?
- Perception of attachment
- Pain or discomfort
- Education – normal newborn behaviours (feed on demand etc)
What is involved in a postnatal daily maternal physical wellbeing assessment: Abdomen?
Assessment (at approximately 72 hours following birth)
– Ask the woman to lie flat with knees bent and no pillows
– Separation should be assessed at three sites
▪ at the umbilicus
▪ 4.5cm above the umbilicus and
▪ 4.5 cm below the umbilicus
– Assess with the flats of fingers in the midline as the woman lifts her head and shoulders off the bed during exhalation
– Feel for the amount of separation between the muscles
– Observe for midline bulging
▪ Refer women with symptoms and DRAM > 3 finger width gap to physiotherapy
What is DRAM and how do u assess for it?
Diastasis of the rectus abdominis muscle (DRAM)
- the stretching of the connective tissue of the lineae albae between the two bands of the superficial rectus muscles
- may be caused by hormonal and/or mechanical factors (contents pushing on these muscles that then is removed) during pregnancy.
Signs & Symptoms:
– Pendular-like abdomen when standing.
– Bulging of abdominal contents between the superficial rectus muscles
during postural changes such as getting out of bed.
– Impaired mobility or impaired ability to cough.
What is involved in a postnatal daily maternal physical wellbeing assessment: Fundus?
Check for
- that it is contracted and firm
Involution
- aprox 1-2cm/day: below symphysis pubis by day 10
- after pains may be felt (uterus contracting and involuting)
- palpation of uterus should not be tender. Abdo may fell bruised from lots of poking and prodding but should not hurt
Fundus position SHould be - central (if not empty bladder) - firm - if its boggy that may mean clots are still in uterus and it may still be bleeding.
What is involved in a postnatal daily maternal physical wellbeing assessment: Lochia?
what are the 3 types
What is a regular amount?
Lochia= vaginal blood loss during puerperium
Approximately 250ml total
- more than 2 pads after day 10 is very abnormal
– Lochia Rubra [red]: Blood, decidua cells, vernix, lanugo, amnion, chorion, meconium.
1-3 days
– Lochia Serosa [pink]; Blood, erythrocytes, leucocytes, mucus, microorganisms.
4-10 days
– Lochia Alba [white]: Leucocytes, mucus, bacteria, epithelial cells.
11-21 days
Assess
– Amount: scant, slight, moderate or heavy (may be moderate the first
Abnormal to use more than one pad every 2 hours
day post birth)
– Colour: rubra, serous, alba
– Clots: may be congealed blood or may contain membrane or placenta
Small clots may be normal (e.g. she may have been laying down and bleeding couldn’t escape so it clots)
– Odour: lochia has a distinct odour. Offensive lochia may indicate uterine infection
What is involved in a postnatal daily maternal physical wellbeing assessment: Urinary?
Amount?
Offensive odours?
▪ Women often experience altered sensation and volumes passed following birth (may not feel they need to go but you should encourage anyway)
▪ urine is sterile and won’t cause infection in tears (this is different to bowel movements)
▪ Encourage women to void within 1-2 hours of vaginal birth. (help avoid UTI and my)
The maximum tolerance to void is six (6) hours.
▪ Normal volumes are 200 - 400 mL. However early postpartum voids may be larger (400 mL+).
▪ Diuresis (increased BV is being removed through renal system) may occur in the first 24 - 48 hours resulting in increased voiding frequency (normal 8 times in 24 hours).
▪ Women may experience stinging due to vaginal & perineal grazes/lacerations
- try using water or doing it in the shower
▪ The first void should be measured and documented to assess for the risk of urinary retention
What is involved in a postnatal daily maternal physical wellbeing assessment: Urine retention?
What are the risk factors?
Signs and symptoms?
Management?
Urinary Retention – Occurs in 10 – 15% of women
Risk factors:
▪ history of voiding difficulties
▪ instrumental birth/ shoulder dystocia
▪ prolonged second stage
▪ episiotomy, excessive perineal trauma/ significant oedema or haematoma
▪ change in sensation to void after birth
▪ suspected or reported incomplete bladder emptying
▪ epidural, spinal or pudendal block
▪ catheterisation during or after birth.
Signs and symptoms ▪ Frequency ▪ Urgency ▪ Lower abdominal pain ▪ Lack of sensation to void ▪ Difficulty in voiding ▪ Palpable bladder ▪ Overflow urinary incontinence ▪ Rising fundus
Perform bladder scan.
plan care; potentially catheterise
What is involved in a postnatal daily maternal physical wellbeing assessment: Urine incontinence?
▪ Urinary incontinence may occur in 30 – 60% of women
following childbirth; however often spontaneously resolves
▪ Report so this can be managed appropriately
▪ Encourage perineal floor exercises
▪ Refer to the physiotherapist
What is involved in a postnatal daily maternal physical wellbeing assessment: perineum?
Teach women to do this for themselves
- with their consent check peri for tears, episiotomy or pain/discomfort
▪ Assess healing, inflammation, oedema, bruising, haematoma, discharge and sticking
▪ check labia and assess inside also
▪ describe as your doing it so women knows how to do it on herself
▪ Discuss hygiene – bathing (table salt- kills bacteria and reduces odeama), showering, and regular sanitary pad changes to ensure a dry wound is kept
▪ Offer ice packs for oedema and analgesia
▪ Offer analgesia
▪ 3rd or 4th degree tears refer o physiotherapist, dietitian and
possibly a colorectal surgical referral
What is involved in a postnatal daily maternal physical wellbeing assessment: pelvic floor and exercises?
- refer to physio
- Teach to note pelvic floor
“think about what muscle you would use to stop urine and then squeeze this muscle for 10 seconds” - educate that they have low expectations
What is involved in a postnatal daily maternal physical wellbeing assessment: constipation?
- Following birth some women may experience constipation (particular if they have cesarian as they have had analgesia and little movement)
- women have fears opening their bowels and pushing after birth
- Bowels should be open within 3 days
- Encourage at least 30g fibre daily - Dietary fibre foods of plant
origin, cereals, vegetables, fruit, peas, lentils, nuts - Offer fibre supplement bulking laxative such as Fybogel or stool softeners
What is involved in a postnatal daily maternal physical wellbeing assessment: Haemorrhoids?
▪ Follow recommendations to avoid constipation
▪ Suitable ointments may be offered for the relief of
haemorrhoid pain or anal itching
▪ Escalate if there is severe, swollen or prolapsed haemorrhoids
and/or any rectal bleeding
What is involved in a postnatal daily maternal physical wellbeing assessment: fecal incontinence?
- very serious
- maybe be 3rd degree tear that was missed- this can cause major problems
- must make sure women feel comfortable telling us
What is involved in a postnatal daily maternal physical wellbeing assessment: legs?
- Encourage mobilisation
Main concern is the risk of;
▪ Venous Thromboembolism (VTE)
- screen risk factors present to see if require thromboprophylaxis including
compression stockings
▪ Deep Vein thrombosis symptoms – Pain/tenderness – Unilateral oedema – Redness Complication - Pulmonary embolism
▪ Oedema
– Take several weeks to totally return to normal
▪ Diagnosis
– Venous ultrasound
What are thr risk factors in both pregnancy of birth for developing a VTE
Pregnancy its self is a risk
Major
- Immobility (strict bed rest for ≥ 1 week antepartum)
- Major postpartum haemorrhage ≥1000mL with surgery
- Pre-eclampsia AND fetal growth restriction
- Thrombophilic disorder
- Medical conditions (SLE, sickle cell, heart disease)
- Blood transfusion
- Post partum infection
- BMI > 30kg/m2
Minor - Multiple pregnancy - Postpartum haemorrhage > 1000mL (no surgery) - Smoking >10 cigarettes/day - Fetal growth restriction - Preeclampsia - Age>35
What is a management of a women who is rhesus negative post birth?
- offered to every non-sensitised Rhese D-negative woman within 72hrs following birth of an Rh-positive baby
- baby of a negative mother will be tested for blood type and if they are positive the mother will be offered another dose of Anti-D to ensure she does not develop antibodies and that this will nor be a problem for future pregnancies.
- 625IM deep IM (preferably in deltoid muscle)
- Women with a positive Kleihauer will require a higher dose of Anti-D immunoglobulin as indicated by Blood Bank.
What is a Kleihauer?
The Kleihauer-Betke test (KB) is a blood test used during pregnancy to quantify the amount of fetal blood found in the maternal circulation.
- this test will determine how much/many does of Anti D a woman will need
- this is used when a negative mother has a positive baby and future babys will be at risk of haemolytic disease of the new born as the mother will kill of their good RBCs
What immunisations may a women need post birth?
When can these be offered?
Is breastfeeding a contra-indicated?
What are the contraindications of these immunisations?
MMR
Measles, Mumps, Rubella vaccine must be offered to women identified through antenatal screening with no or low immunity to Rubella.
▪ The vaccination can be offered at any time following birth and
before discharge from hospital.
▪ Breastfeeding is not contra-indicated
▪ Contraindications
– Known allergy
– Impaired immunity
– Recent administration of antibody containing blood products.
What is the recommended time to wait to get pregnant again after birth?
1 year
- pregnancy and birth is very tough on the body
- remind women that it takes a good 6 weeks to get comfortable with sex again
What recommendations should you give a woman regarding contraception?
Offer women education and written information:
▪ Natural methods
▪ The Billings method
▪ Breastfeeding
▪ Barrier methods
– Condoms
– Diaphragm – need fitting after 6 weeks
▪ Oral contraception
– progesterone only if B/F
– combined pill contraindicated in BF
▪ IUCD – e.g. Mirena usually inserted after the puerperium. Levonorgestrel is
slow released and the main action is on the cervical mucous and endometrium
▪ Implants
– Depo-provera – IM injection with slow release of progesterone
– Implanon – small rod implanted under skin of upper arm
- remind women that it takes a good 6 weeks to get comfortable with sex again
When assessing a woman’s physical wellbeing what important considerations should be made regarding cultural considerations?
Hot / cold balance (an indian practice to ensure their body is in balance)
– Special food
– Hygiene
▪ Social support
– ‘Lying in’ period (mother stays with baby and people around them do everything)▪ Ritual to welcome new mother/baby
▪ Recognition of need for new mother to rest
▪ 40 days of rest
What are some general points of education you should provide a woman?
▪ Fatigue – Discuss the need for rest when the baby sleeps
- endorphins after birth will run low soon
- sleep with baby
- be prepared for more feeds at night than at day
▪ Back ache – The abdominal muscles have been stretched and the woman may experience backache. Discuss correct posture
when handling, lifting and feeding.
- breastfeeding can cause back ache due to looking down
▪ Parenting (discussed later)
