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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

Oxford Handbook of Midwifery (105 page)

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To ensure optimal physical health and to detect deviations from normal.
A methodical top-to-toe examination, accompanied by a discussion about her health.
Exact interpretation of the findings will depend on:
- Whether the woman had a normal pregnancy and a spontaneous vaginal birth
- Pre-existing health or obstetric problems
- Problems occurring in labour.
  Physiological changes
Involution of the uterus and other parts of the genital tract.
Initiation of lactation.
Physiological changes in other body systems.
Vital signs
Temperature: normal range 36–37°C. Once returned to the normal range after birth, it is unnecessary to check it routinely, unless the mother complains of, or shows, signs that suggest infection: feeling unwell, flu-like symptoms, or actual signs of infection.
Pulse: normal range 65–80bpm. A rapid pulse rate may also indicate infection.
Respiratory rate: normal range 12–16 per min at rest.
Blood pressure: should return to normal within 24h of birth. Unless the blood pressure was raised pre-pregnancy, during pregnancy, and/or labour, there is no need to monitor routinely postnatally.
CHAPTER 20
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Involution of the uterus
Definition
The return of the uterus to its pre-pregnant size, tone, and position.
Process
- Ischaemia: the uterine muscle contracts and retracts, restricting the blood flow within the uterus.
- Phagocytosis: redundant fibrous and elastic tissue is broken down.
- Autolysis: muscle fibres are digested by proteolytic enzymes (lysozymes).
- All the waste products pass into the bloodstream and are eliminated via the kidneys.
- The decidual lining of the uterus is shed in the vaginal blood loss, and
  the new endometrium begins to develop from about 10 days after birth
  and is completed by 6 weeks.
- Uterine size decreases from 15cm × 11cm × 7.5cm to 7.5cm × 5cm × 2.5cm by 6 weeks.
- Uterine weight decreases from 1000g immediately after birth to 60g by 6 weeks. At the end of the first week it weighs about 500g.
- Rate of involution: there is a steady decrease by 1cm/day. On the first day it is 12cm above the symphysis pubis and by the 7th day is approximately 5cm above the symphysis pubis. By day 10 it is barely palpable, if at all.
- Involution will be slower after caesarean section.
- Involution will be delayed if there is retention of placental tissue or blood clot, particularly if associated with infection.
  Assessment of postnatal uterine involution
- Discuss the need for uterine assessment with the mother.
- Obtain verbal consent.
- Ask her to empty her bladder if she has not done so in the last half hour.
- Ensure privacy.
- Ask her to lie on her back, with her head well supported.
- Cover her legs and abdomen.
- Wash your hands thoroughly.
- Ask the mother to expose her abdomen.
- Talk to the mother throughout the examination, explain what you are doing and why, and answer her questions.
- Face the mother and place the lower edge of the examining hand on the abdomen at the level of the umbilicus.
- Palpate gently inwards towards the spine and gently move downwards until the uterine fundus is located.
- Note the level of the uterine fundus and the degree of uterine contraction and retraction.
- Note any pain, tenderness, or bulkiness.
- Ask her about her vaginal loss: odour, amount, abnormal colour, or any concerns at all about her loss.
- Discuss the findings with the mother.
  INVOLUTION OF THE UTERUS
  473
Document the findings in the mother’s records.
Report any abnormalities to the doctor without delay.
Practice points
2 It is important that:
Wherever possible, the same midwife carries out the regular postnatal examination, to monitor normal involution and detect early deviations from normal.
The uterus remains contracted and retracted and centrally positioned in the lower abdomen.
Daily uterine palpation is unnecessary after the first 3 days, unless there is any reason for concern or deviations from normal are apparent. The midwife should use her discretion.
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Vaginal blood loss
- Blood is the major component of vaginal loss in the first few days.
- As uterine involution progresses, the vaginal loss changes to stale blood products, lanugo, vernix and other debris from the products of conception, leucocytes, and organisms.
- Towards the end of the second week the discharge is yellowish white, consisting of cervical mucus, leucocytes, and organisms.
- This process may take as long as 3 weeks, and research has shown that there is a wide variation in the amount, colour, and duration of vaginal loss in the first 12 weeks postpartum.
  Practice point
  2 It is important that the midwife asks focused questions about the nature of the vaginal loss, to determine whether it is normal or not.
  THE PERINEUM
  475‌‌
  The perineum

Even if the perineum remains intact at the time of birth, women experience bruising of the vaginal and perineal tissues for the first few days.
Women may be embarrassed about exposing the perineum after birth, so, unless there is a clinical indication, i.e. pain or evidence of infection, routine daily observation by the midwife is unnecessary, and may actually serve to introduce infection, when strict hand washing before and after the procedure and the wearing of disposable gloves is not carried out.
Ask her specific questions about perineal pain and soreness.
Dependent on the suturing technique used, and on the suture material, sutures may have to be removed approximately 1 week after birth. However, absorbable, non-irritant suture material is now
increasingly used.
Practice points
The first few days after birth can be difficult physically, emotionally, and psychologically for a woman with perineal trauma, restricting her mobility, her rest and sleep, the enjoyment of her baby, and the ability to find a comfortable position for feeding, particularly if breastfeeding.
Long-term physical and psychological trauma may be the result, and the midwife must be sensitive and supportive of the mother at this time.
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Perineal pain
- If the mother has sustained perineal trauma, the midwife may wish to inspect the perineum daily for the first few days, to ascertain the comfort of any sutures, wound healing, and cleanliness.
- If she has interrupted sutures, removal of a particularly tight suture may be all that is required to ease perineal pain and tension.
- Advice should be given, as appropriate, about cleansing and changing the sanitary pad regularly, to avoid infection.
- Vaginal blood loss can also be assessed, as can the presence of haemorrhoids.
  Pain relief may be achieved in a number of ways:
- Try the simple remedies first, such as a bath, bidet, or cool water poured over the perineum.
- Bath additives, such as salt or Savlon
  ^®, have been shown in research
  to be of no added value, neither have treatments such as ultrasound,
  infrared heat, or pulsed electromagnetic energy in promoting healing or reducing pain.
- Keeping the area clean and dry, with pain relief, as above, allows healing.
- Oral analgesia such as paracetamol may be administered 4–6h.
- Lavender oil or tea tree essential oils, five drops added to bath water or applied as a topical compress. Homeopathic remedies, such as arnica, calendula and Bellis perennis may be applied topically or taken orally (b see Homoeopathy, p. 120 for detailed information).
  Practice points
- If administering any of the above treatments, ensure personal knowledge and competence with regard to the current research evidence, and the use of complementary therapies, or refer the mother to an appropriately trained complementary therapist
- Document all examination, findings, and treatments clearly in the mother’s and/or your notes.
  CIRCULATION
  477‌‌
  Circulation
The increased blood volume of pregnancy is gradually reabsorbed and excreted in the diuresis of the first few days after birth.
Oedema of the feet and ankles may be experienced, even if not experienced in pregnancy.
Check that the woman’s blood pressure is not abnormally raised, and advise her to mobilize, avoid long periods of standing, and elevate the feet and legs when sitting.
The swelling should be bilateral and without pain. Swelling in one leg, accompanied by pain in the calf or femoral area may indicate deep vein thrombosis (b see Deep vein thrombosis, p. 502 and Principles of thromboprophylaxis, p. 190, for further details).
Legs
2 It is important to observe for swelling, oedema, inflammation,
colour, and pain, particularly in a woman confined to bed or mobilizing
in a limited way, particularly after operative delivery.
3 Any abnormality may be due to a DVT and medical aid should be sought immediately.
Haemoglobin level
In some maternity units it is routine to check the maternal haemoglobin level on the 2nd or 3rd postnatal day.
This practice is now occurring much less, as women are transferred home from hospital much earlier, often 6h after birth.
It should not be necessary in fit, healthy women, where blood loss at birth has had no detrimental effect.
In a mother who has had a traumatic birth and/or sustained a heavy blood loss, a FBC may be undertaken on the third postnatal day.
Generally it is not now done unless clinically indicated.
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General health
General observations
- Overall body temperature.
- Abnormal body odour that may suggest infection.
- Overall colour and complexion, e.g. flushed or pale.
  Skin
- Skin texture and tone will return to normal soon after birth.
- Any skin irritation caused by obstetric cholestasis or skin stretching will soon resolve. A moisturizing lotion is all that is normally required to ease irritation and any dry feeling.
  Nutrition
- Encourage the mother to maintain a balanced diet as much as possible
  and to include as much fresh food as possible.
- Adequate water intake is important, at least 2L a day.
- Adequate fluid and nutrition are essential for lactation, to encourage normal gastrointestinal activity, and resume normal bowel action as soon as possible.
  Bowel action
- This should return to normal in 2–3 days after birth.
- Fresh fruit, vegetables, and a good fluid intake will encourage this.
- After caesarean section it may take a day or so longer, particularly if diet and fluids have been restricted in the first few hours after operation.
  Practice point
  The mother may be afraid of rupturing any perineal sutures, so supporting the perineum with a pad may help during the first bowel action.
  URINARY OUTPUT
  479‌‌
  Urinary output
A marked diuresis will occur in the first 2–3 days after birth, but there should be no dysuria (pain on micturition).
There may be some soreness from perineal trauma.
Ask the mother whether she is passing urine normally and whether there is any discomfort or any stress incontinence.
The bladder neck and urethra may have been damaged during labour and birth, which could result in a lack of sensation to pass urine in the first couple of days. This can lead to retention with overflow, causing intense pain and discomfort, urinary tract infection, and sub- involution of the uterus, a cause of primary or secondary postpartum haemorrhage.
Practice points
2 Passing very small amounts of urine is often a sign of retention with
overflow. Palpate the bladder after she has been to the toilet. If a
portable ultrasound bladder scanner is available, the midwife may scan the bladder to estimate the amount of urine retained.
If the mother has difficulty in passing urine, try the simple remedies first, such as running water, asking her to sit on the bidet or in a bath of warm water, in an attempt to stimulate micturition.