Oxford Handbook of Midwifery (108 page)

1
Lewis, G (ed.) (2007).
The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Live; Reviewing Maternal Deaths to Make Motherhood Safer
—
2003–2005.
The 7th Report on Confidential Enquires into Maternal Deaths in the United Kingdom. London: CEMACH.

CHAPTER 20
Postnatal care

490‌‌

Postnatal care of the breasts

The advice that is given to the mother on the care of the breasts postna- tally will depend upon her choice of infant feeding method.

Postnatal care for breastfeeding mothers

• Mothers are no longer advised to wash their breasts before each feed, as the use of soap may remove the natural oils that keep the nipples and areola supple.
  
• Advise mothers that adequate personal hygiene is sufficient.
  
• A supportive well-fitting maternity bra may add to the mother’s comfort but care should be taken that it does not dig into the breast tissue.
  
• There is no evidence to support the use of creams, ointments, sprays, or tinctures to prevent nipple soreness and, in some cases; these have
  

  been shown to increase the incidence of soreness.
  

• Provide help and assistance to ensure correct positioning and attachment of the baby at the breast.
  
• The duration and frequency of feeds should not be restricted.
  
• For mothers with specific problems, b see Breastfeeding problems, p. 690).
  

  Breast care for mothers who are bottle feeding
  

  The mother should be informed that although she is not breastfeeding the milk will still ‘come in’ between 2 and 4 days postnatally. Advise the mother:
  

• To handle her breasts as little as possible
  
• To wear a good supporting bra
  
• Not to express the milk as this will encourage further milk production
  
• To use heat and cold, either via a shower or soaking in the bath, to help relieve discomfort
  
• Take mild analgesics, e.g. paracetamol to help relieve the discomfort.
  

Reassure the mother that this is a transient condition that will resolve within 24–48h.

Occasionally, pharmacological preparations (bromocriptine and cabergoline) may be used for the suppression of lactation. Bromocriptine has adverse side-effects and therefore cabergoline is usually the drug of choice.

CARE OF THE MOTHER WITH PRE-EXISTING MEDICAL CONDITIONS

491‌‌

Care of the mother with pre-existing medical conditions

Diabetes

Most diabetic women can return to normal management of their diabetes after the birth, as soon as the first meal is taken. In gestational diabetes there is a rapid return to normal and usually no further insulin is required.

If the mother is insulin dependent:

need a snack when feeding her baby at night.

because of the energy expenditure of lactation. This remains so while fully breastfeeding and needs adjustment when the baby starts weaning.

Epilepsy

Women are often concerned about how they will manage once their baby is born, and there may be safety issues for some women with epilepsy. Precautions aim to minimize any risk to the baby and mother but maxi- mize opportunities for bonding. The mother should be advised to avoid extreme tiredness (this makes seizures more likely), which can be difficult with the demands of a new baby! The woman’s partner helping to settle the baby after feeds at night or helping with formula feeds helps protect against exhaustion. Where the mother has sudden, frequent, or unpre- dictable seizures, the following safety measures are recommended:

0 Antiepileptic drugs (AEDs) are excreted in breast milk, but breastfeeding is safe, and it should be recommended if this is the mother’s preferred choice, as it may even help wean the baby from the higher levels of AEDs to which he or she was exposed
in utero
. Mothers should watch for drowsiness in their infants.

A postnatal epilepsy review should take place at 6 weeks and the mother should be seen by a specialist at 12 weeks.
¹
If the dose of AEDs was increased during pregnancy, this may need to be gradually reduced under supervision.

Effective contraception must be discussed with a woman taking anti- epileptic drugs and the contraceptive pill should be avoided if possible, because drug interactions reduce its effectiveness.

1
National Institute for Health and Clinical Excellence (2004).
Epilepsy in Adults and Children
. Clinical guideline No.20. London: NICE. Available at: M www.nice.org.uk/nicemedia/pdf/ CG020niceguidline.pdf.

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Disorders of the postnatal period
‌‌

Chapter 21

493

The uterus
494

Primary postpartum haemorrhage
496

Secondary postpartum haemorrhage
498
Maternal collapse within 24h without bleeding
499
Hypertensive disorders
500

Circulatory disorders
502

Postnatal pain
504

Headache
505

Urinary tract disorders
506

Bowel disorders
509

Postnatal afterthoughts for parents
510
Postnatal afterthoughts for midwives
511
Psychological and mental health disorders
512
Postnatal depression
514

Bereavement care
516

CHAPTER 21
Disorders of the postnatal period

494‌‌

The uterus

• The uterus that is deviated to one side, usually to the right, is usually the result of a full bladder. If the woman cannot empty her bladder, or the bladder still palpates as full after voiding urine, catheterization of the bladder is required to remove the urine, allow the uterus to involute normally, and prevent urinary tract infection.
  
• As a precaution, an MSU should be sent to the laboratory for bacterial culture.
  
• Constipation may also inhibit the rate of uterine involution.
  

  Sub-involution of the uterus
  

• The uterus fails to involute at the expected rate, feels wide and ‘boggy’ on palpation.
  
• The vaginal blood loss is markedly brighter red and heavier than normal.
  
• The mother may be passing clots of blood and/or her loss may smell
  offensive. This may indicate genital tract infection or retained products
  

  of conception.
  

• The mother may also feel unwell and have a raised temperature and pulse rate.
  
• Seek urgent medical aid to investigate and treat the cause.
  
• The usual treatment is a course of antibiotics and, if retained products are suspected, an evacuation of the uterus under general anaesthesia, to prevent infection and PPH.
  
• Thereafter undertake twice-daily monitoring of vital signs, palpation of the uterus and monitor vaginal blood loss, until the situation returns to normal.
  

  Practice point
  

  2 It is so important that, at the birth, you check the placenta for complete- ness and note any apparent missing pieces of cotyledon or membrane in the birth records. This information must be passed to the midwife giving postnatal care.
  

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  CHAPTER 21
  Disorders of the postnatal period
  

  496‌‌
  

  Primary postpartum haemorrhage
  

  Definition
  

  Profuse bleeding from the genital tract from after completion of the third stage of labour until 24h after birth.
  

  Signs and symptoms
  

• Sudden or excessive vaginal blood loss
  
• The uterus may fell enlarged, soft, and ‘boggy’ on palpation
  
• Pallor
  
• Rising pulse rate
  
• Falling blood pressure.
  

  More serious
  

• Maternal collapse
  
• Altered level of consciousness: drowsy, restless
  

  •
  Heavy blood loss.
  

  Immediate action
  

• Summon medical aid.
  
• Summon other colleagues if able to.
  
• Stop the bleeding: if the uterus feels soft and relaxed:
  
  • Rub up a contraction by massaging the uterine fundus gently in a circular motion
    
  • When contracted, stop the massage.
    
• Administer a uterotonic drug:
  
  • Oxytocin 5–10 units intramuscularly (effective in 2–2.5min)
    
  • Oxytocin/ergometrine 1mL intramuscularly (effective in 2–2.5min)
    
  • Ergometrine 0.25–0.5mg IV (effective in 45s)
    
  • Consider further resuscitative measures according to maternal response.
    
• Put the baby to the breast.
  
• Empty the bladder by catheter.
  
• Empty the uterus: gentle pressure on the contracted uterus, in an attempt to expel any retained placental tissue, membranes, or blood clots.
  
• If the bleeding continues and the uterus is well contracted, consider other causes of bleeding:
  
  • Cervical tear
    
  • Deep vaginal wall tear
    
  • Perineal trauma
    
  • Uterine rupture (rare).
    
• Attempt to locate the source of the bleeding. Direct pressure can be applied to a lower vaginal or perineal tear.
  
• A vaginal pack can be inserted to attempt to arrest bleeding from higher up the genital tract, as a first-aid measure.
  
• Keep all pads and linen to assess blood loss.
  
• If possible, and if trained to do so, ask a colleague to cannulate a suitable vein in the arm or hand, with a cannula suitably large enough to administer blood, and commence IV fluids, sodium chloride 0.9%, or Hartmann's solution 1L.
  

PRIMARY POSTPARTUM HAEMORRHAGE

497