The provision of and need for postnatal care

1. The provision of and need for postnatal care

2. midwifery care and support to newly birthed mothers needs to be woman-focused and family-orientated. • Good communication to explain what is considered to be normal physical, emotional/psychological, occurrences during the postnatal period will reassure a mother that she is going through a normal physiological process • . Building a trusting, caring relationship will give a mother confidence to ask questions when she has concerns and is anxious about her health and wellbeing.

3. mothers reported that midwives were always or mostly kind and understanding (80%) and treated them with respect (83%) • Mothers who had undergone either an operative or surgical procedure to aid their birth were reported to be the least satisfied with their postnatal care.

4. A social model include aspects of observing and monitoring the health and wellbeing of the mother, father and their baby initially, in a hospital and then home setting, will support both parents to adjust to their new parenting role. • Guidance and reassurance is an important

5. involving fathers in maternity care’ ‘to provide effective support • a midwife ‘attend’ a postpartum woman on a regular basis for the first few days regardless of whether the mother is in hospital or at home • contact visits, midwifery practice include physical examination to assess the new mother's recovery from the birth

6. The postnatal care pathway is divided into three ‘time bands’ which cover the postnatal period, these are: • the first 24 hours after birth

7. the first 2–7 days • the period from day 8 to around 6–8 weeks. • During these postnatal time bands a midwife will need to advise women about some health problems that she may be at risk of developing and to discuss any symptoms or concerns she may have. • Contact numbers and how to summon help and advice need.

8. Midwifery postpartum contact and visits • postnatal care occurs either in the family or a relative's home • . Expectations of mothers about the purpose of home visits by the midwife may vary according to their cultural backgrounds and individual needs.

9. Newly birthed mothers who have experienced motherhood before may feel that they need minimal support from a midwife • In contrast, a first-time mother or a mother who has had complications will more likely need further support and contact. • The concept of postpartum care is one that aims to assist the mother, her baby and family towards attaining an optimum health status. • Where the visit from the midwife can be seen as supportive and useful to the mother and her family

10. continue midwifery support would appear to be more on social or psychological outcomes, or for breastfeeding support than overt clinical or physical morbidity

11. Physiological changes and observations • a ‘top to toe’ examination as a thorough review of someone who is generally well, • highlights that women want to be ‘checked over’ (physically)

12. Returning to non-pregnant status • In the postnatal period, all of the mother's body systems have to adjust from the pregnant state back to the pre-pregnant state • . Mothers go through a transitional period and the period of physiological adjustment and recovery following birth

13. The relationships between physiological, emotional/psychological and cultural and sociological factors are topics for postnatal care for mother & her baby .

15. Vital signs: general health and wellbeing

16. Observations of temperature, pulse, respiration (TPR) and blood pressure (BP) • During the first 6 hours postnatal care observations to record vital signs will need to be taken and these should be within a normal range before a woman returns home if she has opted for an early transfer. • An Early Warning Score has recently been introduced in some maternity units If the woman has had a home birth the midwife must not leave the new mother's home until she is satisfied that vital signs are stable.

17. It is not necessary to undertake observations of temperature routinely for women who appear to be physically well and who do not complain of any symptoms that could be associated with an infection. • where the woman complains of feeling unwell with flu-like symptoms, or there are signs of possible infection or information that might be associated with a potential environment for infection, the midwife should undertake and record the temperature.

18. Making a note of the pulse rate is probably one of the least invasive and most cost- effective observations. • While observing the pulse rate, particularly if this is done for a full minute, the midwife can also observe a number of related signs of wellbeing: the respiratory rate, the overall body temperature, any untoward body odour, skin condition and the woman's overall colour

19. Blood pressure • Following the birth of the baby, a baseline recording of the woman's blood pressure will be made. • In the absence of any previous history of morbidity associated with hypertension, it is usual for the blood pressure to return to a normal range within 24 hours after the birth.

20. Routinely undertaking observations of blood pressure without aclinical reason is therefore not required once a baseline recording has been taken. • this should be within 6 hours of the birth.

21. Circulation • The body has to reabsorb a quantity of excess fluid following the birth and for the majority of women this results in passing large quantities of urine, particularly in the first day, as diuresis is increased ,Women may also experience oedema of their ankles and feet and this swelling may be greater than that experienced in pregnancy.

22. These are variations of normal physiological processes and should resolve within the puerperal time scale as the woman's activity levels also increase. • Advice should be related to: • taking reasonable exercise • avoiding long periods of standing • elevating the feet and legs when sitting where possible. • Swollen ankles should be bilateral and not accompanied by pain the midwife should note particularly if this is present in one calf only as it could indicate pathology associated with a deep vein thrombosis.

23. Skin and nutrition • Women who have suffered from urticaria of pregnancy or cholestasis of the liver should experience relief once the pregnancy is over. • once the baby is born might lead to women having a reduced fluid intake or eating a different diet than they had formerly ,This in turn might affect their skin and overall physiological state.

24. Women should be encouraged to maintain a balanced fluid intake and a diet that has a greater proportion of fresh food in it • This will improve gastrointestinal activity and the absorption of iron and minerals, and reduce the potential for constipation and feelings of fatigue.

25. Breast care • It is essential that midwives offer support and advice on common breast and breastfeeding problems. • With a woman's permission a midwife needs to check for any physical problems such as engorgement, cracked or bleeding nipples, mastitis, or signs of thrush. • Engorgement on postnatal day 3 and 4 is a common problem for most mothers regardless of whether they have chosen to breast- or formula-feed

26. It is important that mothers are aware of this and this needs to be discussed antenatally so it does not come as a complete surprise. • If breastfeeding and engorged, advise the mother to: • feed on demand • perform breast massage from under her axilla and towards the nipple, to hand express • take analgesia if necessary • to wear a well-fitting bra.

27. The uterus • After the birth, oxytocin is secreted from the posterior lobe of the pituitary gland to act upon the uterine muscle and assist separation of the placenta. • Following the birth of the placenta and membranes, the uterine cavity collapses inwards; the now opposed walls of the uterus compress the newly exposed placental site and effectively seal the exposed ends of the major blood vessels.

28. The muscle layers of the myometrium act like ligatures that compress the large sinuses of the blood vessels exposed by placental separation. • These occlude the exposed ends of the large blood vessels and contribute further to reducing blood loss. • vasoconstriction in the overall blood supply to the uterus results in the tissues receiving a reduced blood supply; therefore, de-oxygenation and a state of ischaemia arise. Through the process of autolysis, autodigestion of the ischaemic muscle fibres by proteolytic enzymes occurs resulting in an overall reduction in their size.

29. There is phagocytic action of polymorphs and macrophages in the blood and lymphatic systems upon the waste products of autolysis, which are then excreted via the renal system in the urine. • Coagulation takes place through platelet aggregation and the release of thromboplastin and fibrin • What remains of the inner surface of the uterine lining apart from the placental site, regenerates rapidly to produce a covering of epithelium.

30. Partial coverage occurs within 7–10 days after the birth; total coverage is complete by the 21st day • Once the placenta has separated, the circulating levels of oestrogen, progesterone, human chorionic gonadotrophin and human placental lactogen are reduced. • This leads to further physiological changes in muscle and connective tissues as well as having a major influence on the secretion of prolactin from the anterior lobe of the pituitary gland.

31. Abdominal palpation of the uterus is usually performed soon after placental expulsion to ensure that the physiological processes are beginning to take place ,On abdominal palpation, the fundus of the uterus should be located centrally, its position being at the same level or slightly below the umbilicus, and should be in a state of contraction, feeling firm under the palpating hand.

32. The woman may experience some uterine or abdominal discomfort, especially where uterotonic drugs have been administered to augment the physiological process

33. Uterine involution • The process of involution is monitoring the physiological process of the return of the uterus to its non-pregnant state. • Involution involves the gradual return and reduction in size of the uterus to a pelvic organ until it is no longer palpable above the symphysis pubis • This process is usually assessed by measuring the symphysio-fundal height (S-FD).

34. the distance from the top of the uterine fundus to the symphysis pubis and is commonly assessed by anthropometry (abdominal palpation) • No evidence of routine measurement of fundal height because the process of involution is highly variable between individual women.

35. involution of the uterus considerd with the color, amount and duration of the woman's vaginal fluid loss and her general state of health at the same time • Uterine involution in combination with other observations such as a raised or lowered temperature abdominal tenderness and offensive lochia can be helpful to detect any maternal morbidity, e.g. sepsis

36. Assessment of postpartum uterine involution • abdominal palpation of the postpartum uterus used to identify height and location of the fundus (the upper parameter of the uterus). • Assessment should then be made of the condition of the uterus with regard to uterine muscle contraction and finally whether palpation of the uterus causes the woman any pain.

37. Record: • the position of the uterus in relation to the umbilicus or the symphysis pubis • the state of uterine contraction • the presence of any pain during palpation.

38. Suggested a pproach to under taking post partum assessment of uterine involution • Discuss the need for uterine assessment with the woman • obtain her agreement • emptied her bladder within the previous 30 min. • Ensure privacy • lie down on her back with her head supported. • Locate a covering to put over her lower body.

39. The midwife should have clean, warm hands and should help the woman to expose her abdomen; the assessment should not be done through clothing. • The midwife places the lower edge of her hand at the umbilical area and gently palpates inwards towards the spine until the uterine fundus is located. • The fundus is palpated to assess its location and the degree of uterine contraction. • Any pain or tenderness should be noted. • Once the midwife has completed the assessment she should help the woman to dress and to sit up.

40. The midwife should then ask the woman about the color and amount of her vaginal loss and whether she has passed any clots • Following the assessment, the woman should be informed about what has been found and any further action that is required • a record of the assessment in the midwifery notes.

41. ‘After pains’ • ‘After pains’ are caused by : • involutionary contractions and usually last for two to three days after childbirth. • These cramping type of pains are more commonly associated with multiparity and breastfeeding • The production of the oxytocin in relation to the let-down response that initiates the contraction in the uterus and causes pain. • Women have described the pain as equal to the severity of moderate labor pains and women require analgesia

42. non- steroidal anti-inflammatory drugs (NSAIDs) were before than placebo at relieving ‘after pains’ and NSAIDs were before than paracetamol, no evidence of using opioids • It is helpful to explain the cause of ‘after pains’ to women

43. If pain is constant or present on abdominal palpation it has no relation with ‘after pains’ and further enquiry should be made about this. • Women might also confuse ‘after pains’ with flatus pain, especially after an operative birth or where they are constipated. • Identifying and treating the cause is likely to relieve the symptoms

44. Postpartum vaginal blood loss • Blood products constitute the major part of the vaginal loss immediately after the birth of the baby and expulsion of the placenta and membranes. • the vaginal loss from fresh blood ,staleقديم blood products, lanugo, vernix and other debris from the unwanted products of the conception.

45. This loss varies from woman to woman, being a lighter or darker color, but for any woman the shade and density tends to be consistent -Lochia is a Latin word traditionally used to describe the vaginal loss following the birth • Medical and midwifery textbooks have described three phases of lochia and have given the duration over which these phases persist.

46. not all women are aware they will have a vaginal blood loss after the birth and that women experience a wide variation in the color, amount and duration of vaginal loss in the first 12 weeks' postpartum.

47. It is important for a midwife to ask direct questions about the woman's vaginal loss: this is more or less, lighter or darker than previously and whether the woman has any concerns. • record any clots passed and when these occurred. • Clots can be associated with future episodes of excessive or prolonged postpartum bleeding

48. Assessment that attempts to quantify the amount of loss or the size of clot is problematic. • asking the mother how often she has to change her maternity pad and describing her blood loss in her own words.

49. Continence after birth • The majority of women will return back to their non-pregnant status during the puerperium without any major urinary or bowel problems. • Any minor changes to women's urinary and bowel habits should resolve within the first few days of giving birth.

50. Any woman suffering from perineal injury may need extra reassurance • pelvic floor exercise training during pregnancy and after birth can prevent and treat urinary incontinence ,pelvic floor muscle exercises should be taught as first line treatment for urinary incontinence