C H A P T E R



C H A P T E R 2 4

Physical health problems and complications in the puerperium

The chapter aim s to:

• discuss the role of midwifery care in the detection and management of life-threatening conditions and postpartum morbidity

• review best practice in the management of problems associated with trauma and pathology arising from pregnancy and childbirth

• review the role of the midwife (and family) where postpartum health is complicated by an instrumental or operative birth.

The need for women-focused and family-centred postpartum care

A women-focused approach to care in the postpartum period alongside individualized care planning developed with the woman and her family will assist physical and psychological recovery (NICE [National Institute for Health and Clinical Excellence] 2006a). What is important is to focus upon the needs of women as individuals rather than fifing women into a routine care package ( DH [Department of Health] 2004; Bick et al 2009; Wray and Bick 2012). The midwife needs to be familiar with the woman's background and antenatal and labour history irrespective of the care sefing (NICE 2006a) when assessing whether or not the woman's progress is following the expected postpartum recovery pattern (Garcia et al 1998; DH 2004; Redshaw and Heikkila 2010).

All women should be offered appropriate and timely information with regard to their own health and wellbeing (and their babies) including recognition of, and responding to, problems (NICE 2006a; Bick et al 2011). The effects of obstetric or medical complications will be assessed for and reviewed within the context of the immediate and ongoing care by the midwife of the woman's health over the postnatal period. The role of the midwife in these cases is first to identify whether a potentially life-threatening condition exists and, if so, to refer the woman for appropriate emergency investigations and care (NMC (NICE 2006a, CMACE [Centre for Maternal and Child Enquiries] 2011; NMC [Nursing and Midwifery Council] 2012). Where the birth involves obstetric or medical

complications, a woman's postpartum care is likely to differ from those women whose pregnancy and labour are considered straightforward. However, it must also be considered that some women have a perception of the whole birth experience as traumatic, although to the obstetric or midwifery staff no untoward events occurred (Singh and Newburn 2000; Marchant 2004).

Potentially life-threatening conditions and morbidity after the birth

Despite the apparent advances in medication and practice, women still die postpartum. The discovery of penicillin and the provision of a blood transfusion were major contributions to saving women's lives over the past century (Loudon 1986, 1987), and maternal death aher childbirth where there has been no preceding antenatal complication is now a rare occurrence in the United Kingdom (UK) (Lewis 2007; CMACE 2011). Thrombosis or thromboembolism and haemorrhage were major causes of direct maternal deaths in the UK but these have declined (Lewis 2007). Cardiac disease is the most common cause of indirect death; the indirect maternal mortality rate has not changed significantly since 2003–2005 (CMACE 2011). However, sepsis is now the most common cause of direct maternal death in the triennium 2006–2008 associated with genital tract infection, particularly from community-acquired Group A streptococcal (GAS) infection (CMACE 2011). The mortality rate related to sepsis increased from 0.85 deaths per 100 000 maternities in 2003–2005 to 1.13 deaths in 2006–2008 (CMACE 2011).

Being aware of this information is vital for all those involved in giving postnatal care as good quality care can contribute to the prevention as well as the detection and management of potentially fatal outcomes (Wray and Bick 2012).

From research, it became clear that maternal morbidity aher childbirth was typically under-reported by women (Bick and MacArthur 1995; Marchant et al 1999). The extent of postnatal morbidity was remarkable in the extensive nature of the problems and the duration of time over which such problems continued to be experienced by women (MacArthur et al 1991; Garcia and Marchant 1993; Glazener et al 1995; Brown and Lumley 1998; Glazener and MacArthur 2001; Waterstone et al 2003; Bick et al 2009).

The midwife has a duty to undertake midwifery care for at least the first 28 days, and according to NICE (2006a) all women should receive essential core routine care in the first 6–8 weeks aher birth. The activities of the midwife are to support the new mother and her family unit by monitoring her recovery aher the birth and to offer her appropriate information and advice as part of the statutory duties of the midwife (NMC 2012).

Immediate untoward events for the mother following the birth of the baby

Immediate (primary) postpartum haemorrhage (PPH) is a potentially life-threatening

event which occurs at the point of or within 24 hours of expulsion of the placenta and membranes and presents as a sudden, and excessive vaginal blood loss (see Chapter 18). Secondary, or delayed PPH is where there is excessive or prolonged vaginal loss from 24 hours aher birth and for up to 6 weeks' postpartum (Cunningham et al 2005a). Unlike primary PPH, which includes a defined volume of blood loss (>500 ml) as part of its definition, there is no volume of blood specified for a secondary PPH and management differs according to apparent clinical need (Alexander et al 2002; Bick et al 2009).

Regardless of the timing of any haemorrhage, it is most frequently the placental site that is the source. Alternatively, a cervical or deep vaginal wall tear or trauma to the perineum might be the cause in women who have recently given birth. Retained placental fragments or other products of conception are likely to inhibit the process of involution, or reopen the placental wound. The diagnosis is likely to be determined more by the woman's condition and pafern of events (Hoveyda and MacKenzie 2001; Jansen et al 2005) and is also ohen complicated by the presence of infection (Cunningham et al 2005b; see Chapter 18). The recent CMACE (2011: 13) report states that, ‘there remains an urgent need for the routine use of a national modified early obstetric warning score (MEOWS) chart in all pregnant or postpartum women who become unwell and require either obstetric or gynaecology services’. Usage of this score will help in providing timely recognition, treatment and referral of women who have or are developing a critical illness after birth and postnatal.

Maternal collapse within 24 hours of the birth without overt bleeding

Where no signs of haemorrhage are apparent other causes need to be considered (see Chapter 13). Management of all these conditions requires ensuring the woman is in a safe environment until appropriate treatment can be administered by the most appropriate health professionals, and meanwhile maintaining the woman's airway, basic circulatory support as needed and providing oxygen. It is important to remember that, regardless of the apparent state of collapse, the woman may still be able to hear and so verbally reassuring the woman (and her partner or relatives if present) is an important aspect of the immediate emergency and ongoing care.

Postpartum complications and identifying deviations from the normal

Following the birth of their baby, women recount feelings that are, at one level, elation that they have experienced the birth and survived, and at another, the reality of pain or discomfort from a number of unwelcome changes as their bodies recover from pregnancy and labour (Gready et al 1997; Wray 2011a). Women may experience symptoms that might be early signs of pathological events. These might be presented by the woman as ‘minor’ concerns, or not actually be in a form that is recognized as

abnormal by the woman herself. Where the postpartum visit is undertaken as a form of review of the woman's physical and psychological health, led by the woman's needs, the midwife is likely to obtain a random collection of information that lacks a specific structure. Women will probably give information about events or symptoms that are the most worrying or most painful to them at that time. At this point the midwife needs to establish whether there are any other signs of possible morbidity and determine whether these might indicate the need for referral. Figure 24.1 suggests a model for linking together key observations that suggest potential risk of, or actual, morbidity.

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FIG. 24.1 Diagrammatic demonstration of the relationship between deviation from normal physiology and potential morbidity.

The central point, as with any personal contact, is the midwife's initial review of the woman's appearance and psychological state. This is underpinned by an assessment of the woman's vital signs, where any general state of illness is evident, including signs of infection. It is suggested that a pragmatic approach be taken with regard to evidence of pyrexia as a mildly raised temperature may be related to normal physiological hormonal responses, for example the increasing production of breastmilk. However, infection and sepsis are important factors in postpartum maternal morbidity and mortality and the midwife should not make an assumption that a mildly raised temperature is part of the normal health parameters (Lewis 2007; CMACE 2011; Bick 2012). The accumulation of a number of clinical signs will assist the midwife in making decisions about the presence or potential for morbidity. Where there is a rise in temperature above 38 °C it is usual for this to be considered a deviation from normal and of clinical significance. If puerperal infection is suspected, the woman must be referred back to the obstetric services as soon

as possible (CMACE 2011). Adherence to local infection control policies and awareness of the signs and symptoms of sepsis in postnatal women is important for all practitioners caring for women. This is particularly the case for community midwives, who may be the first to pick up any potentially abnormal signs during their routine postnatal observations for all women, not just those who have had a caesarean section (CS) (CMACE 2011).

The pulse rate and respirations are also significant observations when accumulating clinical evidence. Although there may be no evidence of vaginal haemorrhage, for example, a weak and rapid pulse rate (>100 bpm) in conjunction with a woman who is in a state of collapse with signs of shock and a low blood pressure (systolic ................
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