Protocols Relating to the Provision of and Organisation of Postnatal Care

1BACKGROUND

2COMMUNICATION AND DOCUMENTATION

3handover of care

4Maintaining maternal health

4.1Within the first 24 hours after delivery...... 3

4.2Between 2 and 7 Days...... 5

4.3Weeks 2-8 post delivery...... 10

5postnatal care for women with specific needs

5.1HIV / Hepatitis B Positive

5.2Care of women following epidural anaesthesia

6Community Based Postnatal Care

6.1Homebirths

6.2First Contact Visit (community)......

6.3Follow up community visits

6.4Discharge of care to the Health Visitor

7EVIDENCE BASE

8MONITORING COMPLIANCE

1BACKGROUND

“Postnatal care is pre-eminently about the provision of a supportive environment in which a woman, her baby and the wider family can begin their new life together. It is not the management of a condition or an acute situation” 1These guidelines are based on the conceptual framework outlined in the NICE Guidance on Postnatal Care which places the woman and her baby at the centre of care, appreciating that all postnatal care should be delivered in partnership with the woman and should be individualised to meet the needs of each mother-infant dyad.” (NICE 2006)

2COMMUNICATION AND DOCUMENTATION

Each individual woman and baby will have an individualized postnatal care plan tailored to their individual requirements completed by the midwife providing care. This is usually commenced following birth, either on the Delivery Suite or at the woman’s home (for women having a community birth) by the midwife providing care.

This postnatal care plan will take into account any issues arising in the antenatal or Intrapartum period that may impact on care. Each woman also has a coordinating health care professional responsible for her postnatal care.This will usually be the woman’s named community midwife but for women with multiagency or multidisciplinary needs this may be may be a member of the Haamla team or other health care professional. All women must havethe name of her coordinating health care professional clearly documented in her postnatal care plan.

All care given in the postnatal period should be documented in the Postnatal Care plan. This should include any relevant factors from the antenatal, intrapartum and immediate postnatal period. Any Health care professional writing in the Postnatal Care plan should clearly identify themselves in the relevant section. Any specific plans of care should also be clearly documented and updated regularly. Any changes to plans of care should also be documented clearly, outlining the reason for the change and identifying the new plan of care. Additional documentation can be made in the Hospital Medical records if appropriate. Where there are deviations from the normal these should be clearly documented and a plan of care agreed. The SBAR tool should be used in all situations when verbal communication relating to clinical care between two or more healthcare professionals is required

3handover of care

For information relating to handover of care please refer to the LTHT guideline ‘Protocols relating to the onsite handover of care within the Maternity service

4Maintaining maternal health

4.1Within the first 24 hours after delivery

4.1.1Core Information

All women should be given information about the physiological process of recovery after birth, and that some health problems are common, with advice to report any health concerns to healthcare professional, in particular:

  • Signs and symptoms of PPH: sudden and profuse blood loss or persistent increased blood loss; faintness; dizziness; palpitations/tachycardia.
  • Signs and symptoms of infection: fever; shaking; abdominal pain and/or offensive vaginal loss.
  • Signs and symptoms of thromboembolism: unilateral calf pain; redness or swelling of calves; shortness of breath or chest pain.
  • Signs and symptoms of pre-eclampsia: headaches accompanied by one or more of the symptoms of visual disturbances, nausea, vomiting, feeling faint.

Women who have had an epidural or spinal anaesthesia should be advised to report any severe headache, particularly when sitting or standing.

In addition women should be given information to enable them to assess their newborns general condition and identify any signs and symptoms of common health problems including:

  • Jaundice
  • Nappy rash
  • Thrush
  • Constipation / bowel problems

Information on potentially serious health concerns in the woman,and common health problems in newborn babies can be found in the postnatal care pan and this should be shown to the woman and discussed. Once discussed the midwife should sign the midwives checklist prior to transfer to community to show that this had been discussed.

Women should be directed to the relevant information pages in the postnatal care plan and the Midwives check prior to transfer to Community re discussion of information completed by the midwife giving the information

4.1.2Core Care

  • All women should have a thromboprophylaxis risk assessment after delivery and prophylaxis arranged as required
  • The post delivery observations will be a full assessment, documented on the MOEWS chart. If the assessment is normal (no red/yellow scores), this will be the last recording on delivery suite unless the patient’s condition deteriorates. On admission to postnatal ward a full assessment of the patient must be made and the MOEWS Chart completed. If the results are normal (no red/yellow scores) no further MOEWS observations are required. If 4 hourly observations are indicated the MOEWS chart must be continued. Any patient who feels unwell must have a full MOEWS assessment performed. The MOEWS chart is part of the postnatal care plan. The MOEWS chart will be used by community midwives for assessment of any unwell patients on community
  • Blood Pressure should be recorded soon after birth and then at least once within the 6 hours following birth unless otherwise indicated.
  • Women should be encouraged to pass urine after birth and the time and volume of the first void must be documented in the Postnatal care plan
  • All women should be encouraged to mobilise as soon as appropriate following the birth.
  • All women should be given the opportunity to discuss their birth and to ask questions about the care they have received. For women who have had a traumatic birth and /or poor neonatal outcome an appointment with a Consultant Obstetrician should be offered and arranged by completing the Request for Postnatal Appointment form and sent to the relevant secretary to arrange.

4.1.3Concerns

Infection – if infection is suspected the woman’s temperature/pulse should be taken and documented in the Postnatal Care plan. If the temperature is above 38’C it should be rechecked within 4-6 hours and medical opinion sought.

Excessive or offensive vaginal loss – routine measurement of uterine involution by abdominal palpation or by other means of measurement is unnecessary1 but where there is (or the woman reports) excessive vaginal loss, offensive lochia, abdominal tenderness or fever an assessment of vaginal loss, uterine involution and position should be undertaken. Any abnormalities in the size, tone or position of the uterus should be evaluated, documented and appropriate action taken as required i.e. medical review. If no uterine abnormality is found then other causes of the symptoms should be considered and a medical review obtained.

Hypertension – if the diastolic blood pressure is greater than 90 mm Hg, and there are no other signs and symptoms or pre-eclampsia then measurement of the blood pressure should be repeated within 4 hours. If the diastolic blood pressure remains high then a medical review should be obtained.

Urinary retention – Document in the delivery suite records and the postnatal care plan the time and volume of the first void post-delivery for ALL women.

Please refer to Guidelines Relating to Bladder Care during Labour and Post Delivery

Obese women or women with special needs – any obese women (BMI over 40kg/m2) or women with other special needs i.e. a disability should have an individualised care plan in place prior to delivery. This care plan should be reviewed and updated following delivery in the postnatal period as necessary.

Immediate referral for medical review (emergency action) is required if there is:

  • Any patient who feels unwell. This patient s must have a full MOEWS assessment performed. Please refer to the Modified Obstetric early Warning Scoring System (MOEWS) including early recognition of the severely ill woman Guideline
  • Sudden or profuse blood loss accompanied by any signs or symptoms of shock, including tachycardia, hypotension, hypo perfusion and a change in consciousness
  • Diastolic BP is higher than 90 mm Hg and accompanied by another sign or symptom of pre-eclampsia, or if the diastolic BP is greater than 90 mm HG and is not reduced below 90 mm Hg within 4 hours
  • The temperature remains above 38’c on the second reading or there are other observable symptoms and measurable signs of sepsis
  • A woman complains of unilateral calf pain, redness, swelling, shortness of breath or chest pain

4.2Between 2 and 7 Days

4.2.1Women should be offered information and reassurance about:

  • Perineal pain and perineal hygiene
  • Urinary incontinence and micturition
  • Bowel function
  • Fatigue
  • Headache
  • Back pain
  • Normal patterns of emotional changes in the postnatal period and that these usually resolve within 10-14 days of giving birth (This information should be offered by the 3rd day)
  • Contraception
  • Contact details for expert contraceptive advice

All women should be offered advice on diet, exercise and planning activities, including spending time with their babies

4.2.2Core Care

Anti-D: Women who are rhesus negative should have a Kleihaur test taken shortly after delivery. If Anti-D is required, this should be given within 72 hours of the birth. If, for some reason, it is not given inside this time, the senior midwifery manger on call should be contacted and the anti-D should be given as soon as possible. If ringing the laboratory to check whether anti-D is needed or not, please ask for the baby’s blood group; Coombs results can lead to confusion.

MMR: All women are offered testing for rubella immunity in the antenatal period. For women with no immunity, the MMR vaccine should be offered prior to discharge from the postnatal period. If a vaccination is given this should be documented in the postnatal care plan.

General Health and Wellbeing: Women should be asked about their general health and well being and any common health problems discussed including:

  • Micturition and urinary incontinence
  • Bowel function
  • Healing of the perineal wound
  • Headache
  • Fatigue
  • Back Pain

Self Care Techniques: All women should be encouraged to use self care techniques such as exercise, rest, having help to care for the baby, talking to someone about her feelings and that she has access to social support networks.

Emotional Changes: All women should be asked about their emotional wellbeing, their family and social support and their usual coping strategies for dealing with day to day matters. All women and their partners/family should be encouraged to tell their health care professional about any changes in mood, emotional state and behavior that are outside the woman’s normal pattern.

Women should be observed for any risk, signs and symptoms of domestic abuse and told who to contact for advice and management. Please refer to the Multi agency public protection arrangements guidelines in (Appendix B of the Protocols relating to the Provision of Antenatal Care

4.2.3Concerns

Any common health problems should be managed as appropriate. This may require advice, treatment or medical review as indicated.

Perineal pain: If perineal pain is present then the woman should be offered an assessment of the perineum.

  • Any bruising, oedema, inflammation or gaping in the wound edges should be noted.
  • Any signs and symptoms of infection, inadequate repair, wound breakdown or non-healing should be further evaluated and medical review sought if appropriate. If there is any evidence of infection a swab should be taken and sent for microscopy and a doctor / GP informed
  • If the woman complains of pain then other causes should be excluded i.e UTI, endometritis

Strategies to help in the alleviation of perineal pain include:

  • Ice packs may provide short term relief but should only be used as temporary measures as they may inhibit healing.
  • Use of gel pads i.e femepads
  • Regular analgesia (i.e. paracetamol). If paracetamol is ineffective then additional analgesia should be considered although medication that can cause constipation should be avoided. Diclofenac suppositories have been found to be effective in the short term relief of perineal pain if used prophylactically after perineal trauma.
  • Bathing may be beneficial but there is no evidence that additives will aid healing i.e salt / savalon. If the woman is prescribed analgesia postnatally then she should be given medication to take home (TTO’s)
  • The is no evidence that alternative therapies have any effect on pain relief / perineal healing although anecdotal evidence does suggest that some women will find benefit. Alternative therapies should only be used if either the midwife or woman has experience in their application.
  • There is little evidence to support the use of a rubber ring and therefore these should not be recommended
  • If a suture is too tight and requires removal, this should be done with sterile scissors and not stitch cutters.

Women who have sustained a 3rd or 4th degree tear require additional support. All these women should be referred to a physiotherapist as soon as possible and an appointment made for outpatient review in the Perineal Clinic at 3 months postnatal. Additional care should include:

  • Examining the perineum regularly to check healing and ensure adequate pain relief is been taken. If paracetamol is not strong enough then obtain prescription for stronger analgesia
  • Checking that lactulose® and antibiotics have been prescribed
  • Stressing the importance of perineal hygiene and if there are concerns about infection refer to GP
  • Assessing perineal healing and severity of pain
  • If no healing progress within 2 weeks or pain persistent refer to GP / obstetrician as above
  • Provision of a patient information leaflet

Headache: Whilst headaches are a common complaint in the postnatal period it is important to exclude other causes. An initial assessment should be undertaken on all women complaining of headache including history taking about the onset, location and duration of the headache. Other factors to consider are whether the woman had epidural / spinal analgesia, essential hypertension / pregnancy induced hypertension, or a history of migraines. Where women complain of the sudden onset of severe headache, headache associated with trauma, symptoms of pre-eclampsia, or BP ≥ 100mmHg an immediate referral to a doctor / GP should be made.

Postpartum ‘simple’ headache

Women should be reassured that this type of headache is common following delivery and is no cause for concern. Women should be advised on relaxation techniques and issues related to childcare / rest as appropriate. Mild analgesia can be recommended (i.e. paracetamol) but if this is insufficient then referral to a doctor / GP should be undertaken.

Post Dural Puncture Headache (PDPH)

If a post dural puncture headache does occur then referral to an anaesthetist should occur. Bed rest may help to alleviate the symptoms but measures should be taken to prevent thromboembolic disease. Various options for treatment should be discussed with the woman including a blood patch into the epidural space if the clinical condition indicates this. Support with childcare should be offered as required.

Headache associated with Hypertension

Any woman complaining of headache with a history of pregnancy induced hypertension or symptoms of pre-eclampsia should undergo a blood pressure assessment. If the BP is ≥ 100mmHg the woman should be reviewed by an obstetrician or GP urgently.

Backpain: All women should be reassured that backache is common after childbirth. This will normally improve with simple analgesia and normal activity. Women should be given a copy of the leaflet “Fit for Motherhood” by the Association of Chartered Physiotherapists when this is available. Further information can be given on the correct posture when handling, lifting and feeding the baby.

Simple postpartum backache

  • Advise on the use of simple analgesia i.e. paracetamol
  • If paracetamol is not strong enough then refer to obstetrician / GP
  • Advise to continue normal activity and not take bed rest
  • If no significant improvement, refer to doctor / GP

Nerve Root Pain (Sciatica)

  • Initial management as for simple backache, but diagnosis and treatment by doctor / GP is required

Pelvic Girdle Pain

  • Refer to doctor / GP as stronger analgesia may be required
  • Refer for physiotherapy
  • Bed rest may be necessary in acute phase
  • Give explanations and advice as appropriate

Urinary Symptoms:

Urinary Incontinence

Some women may experience leakage of small amounts of urine postnatally and advice about pelvic floor exercises may be beneficial. Information of pelvic floor exercises is included in the ‘Fit for Motherhood’ leaflet. However the midwife needs to be alert to signs of infection or retention of urine. If a urinary tract infection (UIT) or retention is suspected, a a medical review should be sought. If appropriate a referral for physiotherapy can be made e.g. if the woman continues to require protective pads, or finds the condition interferes with routine tasks

Women with urinary catheters in situ

Women may be discharged with a catheter in situ providing that a plan of care is agreed and recorded in the postnatal care plan prior to discharge. A catheter specimen of urine or a mid-stream specimen of urine should be sent for culture and sensitivity when the catheter is removed so that the appropriate antibiotics can be prescribed if necessary.

Urinary Tract Infection (UTI)

If the woman complains of frequency / incontinence / voiding difficulties / haematuria or pain on micturition, a sample of urine should be obtained for testing. If a reagent strip for urinalysis is positive for nitrates then the woman should be treated as a UTI. If the reagent strip for urinalysis is negative then an MSU should be sent before treatment is commenced. Women with a suspected UTI should be encouraged to increase their fluid base i.e. at least 2 litres a day 1

Bowel symptoms: Women may experience various bowel problems in the postnatal period. Constipation and haemorrhoids are the most common but anal fissures and faecal incontinence have also been identified as problems. Women should be advised that it is common not to have a bowel motion for a few days after delivery and advice should be given on a high fibre diet with an adequate fluid intake. If women are anxious about passing a motion for the first time after delivery, reassure that it is highly unlikely to result in further perineal damage. It may be more comfortable if a clean maternity pad is held against the perineum when passing a motion.