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Postnatal care
Introduction
The puerperium is defined as being from delivery of the placenta to the end of the 6th postnatal week. This arbitrary definition, however, has no true physiological basis, as some pregnancy changes revert to the pre-pregnancy state within a few minutes, whereas others never revert.
The uterus contracts within a few minutes of delivery from a cavity capable of containing 4 or 5 litres to a space barely able to contain an adult’s fingers. It involutes over the next 4 weeks, its weight reducing from 1000 g to just 50–100 g, with the lochial discharge changing from red to brownish pink and finally cream/white. Maternal weight reduces, plasma volume, red cell mass and haemostasis revert to normal, and the other systemic, endocrine and metabolic adaptations return to the pre-pregnancy state. Lactation, instigated by the falling progesterone levels and maintained by oxytocin, can inhibit the return of menstruation and fertility until weaning.
Routine postnatal assessment is useful to help provide the mother with support as she cares for her baby, and to identify complications at an early stage.
Normal puerperium
For those giving birth in hospital, the postnatal stay should be tailored to each individual mother. The length of this stay depends largely on maternal wishes and on her clinical condition, and may be anything from an immediate discharge to several days or longer. Difficulties with establishing breastfeeding or bonding, the development of medical problems, poor social circumstances or lack of home support, may all warrant additional inpatient stay and support.
If the woman is rhesus-negative, a Kleihauer test should be performed and the baby’s blood group determined to establish whether anti-D prophylaxis is required and, if so, the appropriate dose. The mother should also be offered rubella vaccination if she was identified as not being immune from routine antenatal serological testing.
Early postnatal checks
In the UK, the midwife sees the woman regularly after birth, based on individual needs, and checks on:
general emotional and physical well-being
infant feeding and care – breastfeeding should be encouraged where possible
urinary and bowel function (see below)
lochia – this may continue for up to 4–8 weeks
contraceptive plans.
In the early postnatal days, all women should be given the opportunity to discuss their birth with the appropriate healthcare professional.
On examination, the following should be undertaken as a matter of routine:
pulse, blood pressure and temperature, looking for signs of haemorrhage, anaemia or sepsis
abdominal examination should be carried out if there are any concerns to ensure that the uterus is involuting and non-tender. On the first day after birth, the uterine fundus should be palpable at the umbilicus and it gradually reduces in size until, by the 10–14th day, it is no longer palpable above the symphysis pubis
perineum examination, looking particularly for evidence of wound breakdown in those who have experienced perineal trauma and/or received sutures. Cool gel packs may be applied intermittently, although ice packs are not advocated. Simple analgesia can be prescribed and local anaesthetic gels or sprays may sometimes alleviate discomfort.
A midwife will see a woman for a minimum of 10 days and up to 28 days. In some regions, the duration of postnatal visits has been extended to 6 weeks, to incorporate the 6-week examination.
Late postnatal check
This usually takes place around 6 weeks after birth and is an opportunity to review the birth, address any questions and place these in context for future births. It is important to assess the baby and how well the mother is coping, looking particularly for tiredness or depression.
