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

Oxford Handbook of Midwifery (111 page)

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Encourage her to void urine at regular intervals, to regain bladder tone.
If retention reoccurs, an indwelling catheter may be inserted for 24–48h, to help the bladder regain its tone.
Urinary tract infection
Signs and symptoms
Frequency of urine
Dysuria
Urine may be cloudy in appearance and have an offensive odour
Rise in temperature
Feeling unwell.
Treatment
Obtain an MSU and send to the laboratory for microscopy.
Report to the doctor.
Commence broad-spectrum antibiotics, and change, if necessary, once the results of laboratory microscopy are known.
Ask the mother to drink at least 3L of fluid a day.
Maintain an accurate fluid balance chart.
Repeat the MSU once the antibiotic course is completed to ensure the infection is successfully treated.
Pyelonephritis
Signs and symptoms
As above, but more severe.
The woman looks and feels very unwell, and has flu-like symptoms.
Pain radiating from the loin to the groin, usually unilaterally.
Pyrexia.
Rigors.
Vomiting.
Lack of any appetite.
Urine smells offensive, has an acid reaction, and is ‘cloudy’ in appearance.
On laboratory microscopy pus cells are seen in the urine.
Treatment
Notify the doctor.
Give antipyretic drugs.
Commence a broad-spectrum antibiotic immediately and change, if necessary, according to the result of the microscopy.
IV fluids for the duration of the period of vomiting.
She should drink at least 3L of fluid a day.
Maintain an accurate fluid balance chart.
Repeat MSU after the antibiotic treatment is completed.
Help with baby care.
Stress incontinence
The precise role of pregnancy and birth in the immediate and long-term problem is unclear, but stress incontinence is usually linked to pelvic floor stretching and nerve damage during childbirth. Twenty per cent of women
CHAPTER 21
Disorders of the postnatal period
508
complain of stress incontinence at 3 months postpartum,
^1,2and many of these women are still symptomatic several years later.
³
Most at risk:
- The older mother
- Long second stage of labour
- Vaginal birth of a large baby.
  Management
- Encourage postnatal pelvic floor exercises, as these have longer term benefits.
- Refer the woman to a specialist physiotherapist.
- Encourage regular exercise.
  Vesico-vaginal fistula
  A rare complication, when a fistula (hole) develops between the bladder or the urethra and the vagina, through the anterior vaginal wall. There are two main causes:
  •
  Damage during labour, caused by prolonged pressure of the fetal head against the symphysis pubis:
  - The damaged tissue takes 1–2 weeks to break down, after which the mother becomes incontinent of urine

- - Surgical repair and antibiotics are required
  - This should never be seen where there are professionally skilled attendants present during labour and birth. Prolonged labour and/ or obstructed labour should be quickly diagnosed and immediate delivery by caesarean section carried out. It is more common in situations where this skilled help is not available.
- Direct trauma to the bladder during difficult instrumental delivery, notably with forceps:
  - Incontinence occurs almost immediately
  - Initial treatment is antibiotics and continuous bladder drainage for 2–3 weeks, to encourage spontaneous healing
  - If this fails, surgical repair is required.
    1. Wilson PD, Herbison PW, Herbison GP (1996). Obstetric practice and the prevalence of urinary incontinence three months after delivery.
      British Journal of Obstetrics and Gynaecology
      103
      , 154–61.
    2. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I (1984). West Berkshire perineal management trial.
      British Medical Journal
      289
      , 587–90.
    3. Sleep J, Grace A (1987). West Berkshire perineal management trial. Three year follow up.
      British Medical Journal
      295,
      749–51.
    BOWEL DISORDERS
    509‌‌
    Bowel disorders
Difficulties in regaining normal bowel function are common in the first few postnatal days and are a common problem for the midwife to deal with.
Most women are embarrassed to talk about bowel problems, but it is important to ascertain her normal pre-pregnancy bowel habits, to determine what is normal for her.
Bowel problems are common in the latter stage of the pregnancy, due to the relaxing effects of progesterone on the smooth muscle of the bowel, diminishing peristaltic movement. The relative dehydration and lack of dietary intake in labour exacerbate this, along with pelvic pressure and pushing in the second stage of labour.
Inform the mother about the importance of drinking plenty of water and eating a diet high in fibre, fruit, and vegetables, to regain normal bowel action.
Haemorrhoids
These are swollen varicose veins of the lower rectum and anal margin.
They may be present in pregnancy and exacerbated by pelvic pressure and pushing in the second stage of labour.
Perineal trauma may exacerbate the pain and discomfort of haemorrhoids.
They may occur for the first time in the early postnatal period.
Instrumental delivery, particularly forceps, is twice as likely to cause haemorrhoids.
Management
Dietary advice: high fibre, plenty of fruit, vegetables, and fluids.
Avoidance of constipation.
Proprietary treatments in the form of creams or suppositories may be bought or prescribed by the doctor.
Compress of cypress and lavender essential oils in a 1% dilution of grapeseed or vegetable oil. This may also be added to the bath water. (lavender oil used alone: three drops on a pad may be applied directly to the perineal skin).
Oral analgesia, such as paracetamol. Codeine should be avoided, as it can cause constipation.
Constipation
A common problem of the early postnatal period.
It is usually 2–3 days after birth when the mother has a bowel movement, especially if perineal sutures are painful or after operative birth.
A mild aperient may be offered 24–48h after birth, but research has shown that laxatives are generally unnecessary.
Irritant laxatives, such as senna, bisacodyl, or other herbal remedies may cause maternal discomfort and diarrhoea in breastfed infants.
A balanced diet, with plenty of fruit and vegetables, and plenty of fluids is all that is required.
CHAPTER 21
Disorders of the postnatal period
510‌‌
Postnatal afterthoughts for parents
This is often referred to as debriefing, but the use of this term is contentious.
- Postnatal afterthoughts discussion is the responsibility of every midwife.
- 2 Offer every mother, and others present at the birth, such as partner, friend, or grandparents, the opportunity to discuss the events.
- Appropriate and effective communication is vital to this process and should be handled with empathy and understanding.
- Honesty is essential and euphemisms should be avoided.
- Even if you consider the birth to have been normal, with no complications, there still needs to be an opportunity for the parents to ask any questions and for you to ensure that explanations have been understood.
- As the midwife present at the birth, you should set aside time for discussion with the parents before you leave the labour ward or home,
  and definitely within 24h of the birth.
- It is particularly important to offer a clear explanation of events
  and the reasons for a particular course of action to those who have experienced traumatic events or complications in labour, as soon as possible. Appropriate documentation is essential to this process.
- The effects of intense pain, use of technological or operative intervention, and insensitive and/or disrespectful care from one or more carers in labour can cause intense distress.
- 0 One discussion may be insufficient; more questions may arise as the parents contemplate on events and possible/actual long-term
  consequences. Providing an opportunity to discuss these, together with good support from the midwife and, where appropriate, the doctor involved, will, in the majority of cases, prevent further long-term consequences, such as postnatal depression or post-traumatic stress disorder.
- Women (and their partners) will react differently. Experiences that some will understand as necessary and normal and will eventually overcome, will be intensely distressing to others, and may become ingrained in their psyche, adversely affecting their relationship with their partner and baby.
- In some cases parents may need more specialist help, such as professional counselling, psychological or psychiatric care.
- Women who experience nightmares and flashbacks need specialized help. The sensitive support of a midwife will be essential should they ever embark on a future pregnancy.
- 2 In the increasing litigious world, provision of a postnatal afterthoughts service could prove cost-effective in reducing complaints and legal action. The majority of complaints and threats of legal action arise from the fact that parents want someone to listen to them, to give them a clear explanation, and to say ‘sorry’, where appropriate.
- Increasingly, maternity units are identifying and training specialist midwives to lead this service, provide specialist discussion and counselling for the parents, and advise midwifery managers on professional development and risk management issues that may arise.
  POSTNATAL AFTERTHOUGHTS FOR MIDWIVES
  511‌‌
  Postnatal afterthoughts for midwives
Midwives also need the opportunity to reflect and discuss events after caring for a woman who has experienced traumatic complications during childbirth.
Reflection with senior midwifery colleagues or a supervisor of midwives can put the events in perspective and help the midwife learn from the experience.
It is also important to reflect on the midwife’s actions and records and, where appropriate, praise their actions and assure them that they have done nothing wrong.
All those present at the birth must be given the opportunity to work through their feelings and obtain support.
In the UK, the supervisor of midwives should provide the confidential support required, identify any professional development required for the midwife, and draw up an action plan to meet any identified need.
CHAPTER 21
Disorders of the postnatal period
512‌‌
Psychological and mental health disorders
- Mental health disorders in the antenatal and postnatal period can have serious consequences for the mother, her baby and other family members. They may be pre-existing or occur for the first time in pregnancy or the postnatal period.
  ¹
- There should be clearly specified care pathways in each NHS trust, to enable the midwife to make an appropriate referral.
  ¹
- Women who require inpatient care for a mental disorder within 12 months of childbirth should be admitted to a specialist mother and baby unit, wherever possible.
  ¹
  Postnatal psychosis
  This condition is at the other end of the spectrum to baby blues and is the most severe form of psychiatric morbidity. It is the least common of
  the postnatal psychological conditions but different studies report varying
  levels of incidence from 1:500 to 1:1500.
  ^2,3It is usually sudden and dra- matic in onset and usually occurs very early, within the first week, the majority presenting before the 16th day postnatally.
  Symptoms
  These may be variable but can include:
- Changes in mood state
- Irrational behaviour
- Restlessness and agitation
- Fear
- Perplexity, as the woman loses touch with reality
- Suspicion
- Insomnia
- Episodes of mania, where the mother becomes hyperactive
- Neglect of basic needs
- Hallucinations and morbid delusional thoughts
- Profound depression.
  Twenty five per cent of women admitted for postnatal psychosis within 3 months of birth will have consulted for psychological symptoms in preg- nancy; 50% will have had symptoms of anxiety or depression in pregnancy; 50% will have non-puerperal episodes of psychosis and/or a family history of mental illness.
  ²
  PSYCHOLOGICAL AND MENTAL HEALTH DISORDERS
  513
  3 There should be immediate referral to the mental health team, as the condition will usually warrant admission to hospital. Prognosis is good, but there is a high risk of recurrence in subsequent pregnancy.
  The psychotropic drugs often used in the treatment of postnatal psychosis and for other long-term mental health conditions make it imperative that the woman understands the need for effective contraception and the risks of severe damage to the fetus in a subsequent unplanned pregnancy. The midwife should encourage her to attend the contraception and sexual health clinic for effective contraceptive management.
  1. National Institute for Health and Clinical Excellence (2007).
    Antenatal and Postnatal Mental Health
    . Clinical guideline 45. London: NICE.
  2. Kendell RE, Chalmers L, Platz C (1984). The epidemiology of postnatal psychosis.
    British Journal Psychiatry
    150
    , 662–73.
  3. Cox J (1986).
    Postnatal Depression: A Guide for Health Professionals
    . Edinburgh: Churchill Livingstone.
    CHAPTER 21
    Disorders of the postnatal period
    514‌‌
    Postnatal depression
    Postnatal depression refers to depression with its onset during the first postnatal year. It is a non-psychotic depressive disorder that varies in severity and is not fundamentally different from depression occurring at other points in a woman’s life. The incidence varies according to different reports, but is thought that around 10–15% of women suffer postnatal depression following childbirth.
    ¹However, this may only be the tip of the iceberg, as many incidences go unreported and untreated.
    Symptoms
    There is a wide range of symptoms that the mother may exhibit, including:
    - Anxiety
    - Panic attacks
    - Tension and irritability
    - Feelings of despair and emptiness
      •
      Exhaustion
    - Lack of concentration
    - Rejection of partner or baby
    - Inappropriate or obsessional thoughts
    - Loss of libido
    - Physical symptoms
    - Desire for sleep
    - Feels better in the morning
    - Guilt and anxiety about the baby
    - Preoccupied with baby’s health.
      Aetiology
      There has been wide research into the causes of postnatal depression, but no one single cause is apparent. It has been linked with both physiological and psychosocial factors.
      Physiological factors
    - Genetic background
    - Hormonal changes
    - Oestrogen is seen as being more significant than progesterone
    - Thyroid dysfunction.
      Psychosocial factors
    - Events surrounding the birth
    - Difficult to care for baby
    - Previous history of depression
    - Age of the mother
    - Prior experience with babies
    - Stressful life events
    - Marital stress
    - Inadequate postnatal sexual relations
    - Mother’s own childhood experiences
    - Social condition
    - Personality
    - Linked with parenthood rather than pregnancy or birth experiences.
  POSTNATAL DEPRESSION
  515
  Effects of postnatal depression on the family
  A review of research
  ²revealed that postnatal depression had profound and long-lasting effects on both the children and the families of women. It can have adverse effects on the children’s emotional and intellectual development, and boys appear to be affected more than girls.
  Detection
  Early diagnosis and treatment is important not only for the woman but also her family. The midwife has an important role in recognizing women at high risk of postnatal depression, and the early signs of postnatal depression.