Oxford Handbook of Midwifery (107 page)

• Establishing and maintaining lactation
  
• Correct fixing technique
  
• Hand expression technique
  
• Safe storage of expressed breast milk
  

• Sterilization of feeding and other equipment
  
• Making up feeds safely
  
• Choosing the correct formula
  
• Storage of made-up feeds
  
• The dos and don’ts of formula feeding
  

Emotional:

Father/partner:

Sexual:

CHAPTER 20
Postnatal care

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Postoperative care

• The most common reason for postoperative care is caesarean section, but reasons may include manual removal of the placenta or dealing with persistent post-birth bleeding from the genital tract.
  
• Immediate postoperative care is normally undertaken in the theatre recovery room by theatre staff, but in many cases the midwife will find herself undertaking this care.
  
• Clear and accurate documentation of all aspects of care is vital.
  
• Postoperative observations of the mother will consist of observation and management of:
  
  • Vital signs and level of consciousness, if she has had a general anaesthetic
    
  • Epidural site and degree of anaesthesia
    
  • Pain
    

    • Vaginal blood loss
    

  • Wound drain
    
  • IV fluids and the cannula area
    
  • Bladder drainage (if a urinary catheter is
    in situ
    ).
    
• As soon as possible after the birth, the mother should have skin-to- skin contact with her baby, as would happen in a normal birth. If her condition/level of consciousness do not immediately allow this, then the father could undertake the initial skin-to-skin contact, until the mother is able to (b see Skin-to-skin, p. 310).
  
• Once the mother’s condition is stable and she is fully conscious, she is transferred to the postnatal ward with her baby.
  
• A caesarean section is major abdominal surgery, and if it was undertaken following a complicated or traumatic labour, the mother has to recover from the physical and the mental stress of labour, as well as from the anaesthetic and the operation.
  

  Immediate care
  

  Position
  

• General anaesthetic: nurse her in the left lateral or ‘recovery’ position until fully conscious.
  
• Epidural or spinal anaesthesia: as directed by the anaesthetist, particularly noting her respiratory rate, because of the narcotic analgesia given.
  
• Gradually sit her up as soon as possible, provided her blood pressure is stable.
  

  Observations
  

  The frequency of the observations carried out will be according to local policy and practice guidelines, but generally will follow this pattern for the first 12h:
  

• Blood pressure and pulse rate: half hourly for the first 2h, hourly for 2h then 4h.
  
• Wound and wound drain inspection, as above.
  
• Vaginal blood loss, as above.
  
• Temperature: 2h for the first 4h then 4h.
  

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  487
  

  Analgesia
  

  Postoperative pain relief can be given in a number of ways:
  

An anti-emetic, such as cyclizine, may be prescribed and given intra- muscularly or subcutaneously, to counteract nausea or vomiting caused by opioid drugs.

Care in the postnatal ward

Unless the baby has been transferred to the neonatal unit, the mother and baby should be transferred together and stay together. Attachment

should be encouraged and a clip-on cot, which fits on to the mother’s

bed, will make it easier for the mother to touch and handle her baby.

The midwife should employ a model of care that ensures a holistic and integrated approach to meeting the individual woman’s needs and encouraging increasing self-care, but limiting over-exertion.

Observations

Continue the regimen begun in the theatre recovery room for the first 12h:

The IV infusion is usually removed 8–12h after operation, once the mother’s blood pressure is stable and she is tolerating oral fluids.

Wound care

dependent on local policy and practice, e.g. IV, intramuscularly, or oral.

• Infection
  : hot, tender, inflamed area, pyrexia; obtain a swab for laboratory culture.
  
• Haematoma
  : pain, hard to touch, tender.
  

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Thromboprophylaxis

b See Principles of thromboprophylaxis, p. 190.

• Pulmonary embolism and thromboembolic disease are the main causes of direct maternal death in the UK.
  ¹
  
• Encourage the mother to move her legs, with leg stretching and ankle rotation exercises, at least every hour.
  
• Administer low-molecular-weight heparin, tinzaparin, subcutaneously, daily for 48–72h.
  
• Measure the woman for thromboembolic prevention stockings prior to operation and ensure they are put on prior to operation and worn until full mobility is regained.
  
• Encourage mobilization as soon as possible.
  

  Urine output
  

• An indwelling catheter is usually
  in situ
  for the first 24–48h
  postoperatively, after which it is removed.
  
• Observe and record the urine output carefully and empty the catheter bag, measure and record the amount 6–8 hourly. Never let the drainage bag get too full, as this can be very uncomfortable, cumbersome, and embarrassing for the mother, as she begins to mobilize.
  
• The mother should be encouraged to use the bidet when she is able to get up, to keep the vulva and catheter area clean.
  
• It is good practice to obtain and send a catheter specimen of urine to the lab at the time of removal of the catheter, or any time before that if the mother is complaining of pain, which could be associated with urinary tract infection.
  
• After catheter removal it is important to ask the mother about her ability to pass urine and the amount passed.
  
• Observe and palpate the abdomen for evidence of retention of urine at least twice a day for the first day.
  
• At first the bladder may not be completely emptied and a bladder scan after passing urine will estimate the residual urine in the bladder. This should be <30mL as bladder tone gradually returns.
  
• Report any haematuria to the doctor.
  

  Fluid and nutrition
  

• The mother is encouraged to drink plenty and to gradually introduce a light diet. Plain water is the fluid of choice if there are any problems with nausea or vomiting following general anaesthesia, until this has passed.
  
• If there has been trauma to any part of the pelvic structures or handling of the bowel, the surgeon will usually request water only by mouth until bowel sounds return, 24–48h after surgery, to avoid the risk of paralytic ileus.
  
• Appetite will vary from woman to woman, and those who have had a general anaesthetic will be less keen to eat initially.
  

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  489
  

  Mood and feelings