P2010/0304-001 3.

1/09WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Care of the Postnatal Woman Following an Uncomplicated Pregnancy and Birth Care of the Postnatal Woman following an Uncomplicated Pregnancy and Birth WACSClinProc3.1/06 Postnatal care Midwives and medical officers Postnatal care P2010/0303-001 Administration of MMR vaccine to Postnatal Woman P2010/0305-001Administration of Rh Immunoglobulin P2010/0299-003 Breastfeeding Protocol P2010/0294-001 Administration of Drugs by Midwives/Registered Nurse under Standing Orders according to section 63b of the Poisons Regulations P2010/0306-001 Extended Midwifery Service P2010/0307-001 Postnatal Thromboprophylaxis Purpose: To promote recovery from labour and birth To promote emotional/psychological and physical wellbeing To give educational support and advice to women which will promote sound infant care, successful adaptation to motherhood and effective mother-infant interaction To monitor the progress of the postpartum woman To detect complications in a timely manner and make appropriate referrals when required To provide health education Recommended Practice: Perform a postpartum assessment within four hours of birth and then daily thereafter if within normal limits. The postnatal assessment is to be documented on the vaginal pathway with variances noted and documented in the womans medical record. 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 the midwife. Women should be advised of the signs and symptoms of potentially life-threatening conditions and advised to notify their midwife immediately or call for emergency help if any signs or symptoms occur.
Care of the postnatal woman following uncomplicated pregnancy and birth May-11 1 WACSClinProc3.1/09

Signs and Symptoms Sudden and profuse blood loss or persistent increased blood loss Faintness, dizziness or palpitations/tachycardia Fever, shivering, abdominal pain and/or offensive vaginal loss Headaches accompanied by one or more of the following symptoms within the first 72 hours after birth: visual disturbances nausea, vomiting Unilateral calf pain, redness or swelling Shortness of breath or chest pain

Condition Postpartum haemorrhage

Infection Pre-eclampsia/eclampsia

Thromboembolism

Procedure: Maternal Observations Measure and document BP once within 6 hours after transfer to the postnatal ward. If diastolic blood pressure is greater than 90mmHg, and there are no other signs and symptoms of pre-eclampsia, blood pressure should be repeated within 4 hours. In the absence of any signs and symptoms of infection, routine assessment of temperature is unnecessary.

Uterine Involution and Lochia In the absence of abnormal vaginal loss, assessment of the uterus by abdominal palpation or measurement as a routine observation is unnecessary. Assessment of vaginal loss and uterine involution and position should be undertaken in women with excessive or offensive vaginal loss, abdominal tenderness or fever. Regular hot packs and/or paracetamol 1g QID (in accordance with the Standing Orders) may be given for afterbirth pain.

Urinary Elimination If a woman has not voided within 6 hours postpartum and measures to encourage micturition, such as taking a warm bath or shower, are not immediately successful, bladder volume should be assessed and catheterisation considered. If the woman is experiencing dysuria due to perineal grazes or trauma suggest increasing oral fluids to decrease urine acidity or 1 to 2 Ural sachets maybe given 4 times per day (in accordance with the Standing Orders).

Perineum and vulva If the woman has any discomfort or concerns inspect the perineum and vulva for healing. Signs and symptoms of infection, inadequate repair, wound breakdown or non-healing should be referred to the medical officer. Ensure adequate analgesia; consider ice packs prn or paracetamol 1g QID (in accordance with the Standing Orders).

Care of the postnatal woman following uncomplicated pregnancy and birth May-11 2

WACSClinProc3.1/09

Bowel Elimination Ask the woman if she is experiencing any discomfort or difficulty with defecation. Encourage high fibre diet and increased fluid intake. If bowel function has not resumed by day three offer a mild aperient such as Coloxyl 240mg nocte, Nulax 10g daily or Fybogel 1 Sachet BD (in accordance with the Standing Orders). If bowel function has not resumed by day 4 to 5 and the women does not have an anal fissure or haemorrhoids, offer a glycerine suppository (in accordance with the Standing Orders). Woman with haemorrhoids should be advised to avoid constipation. Consider topical application Proctosedyl ointment three times daily for 1 week (in accordance with the Standing Orders). If complaining of pain or bleeding then referral to the medical officer is warranted.

Haemorrhoids

Breast Care If the woman has any discomfort or concerns inspect breasts for areas of redness, inspect condition of the nipples and areola, palpate the breasts for areas of heat, lumps or pain.

Legs Inspect legs for any areas of redness, heat, tenderness or swelling.

Psychosocial Assessment Emotional status birthing experience, perceptions and expectations Fatigue Social supports Consider referral to social worker and or other relevant allied health professionals.

Postnatal Education Guide on pathway

Anti D Administer Anti-d to non immune Rh negative women who have had an Rh positive baby. (Refer to Administration of Rh D Immunoglobulin Policy 3.2)

MMR Administer MMR vaccine to women who are non-immune or have low immunity. (Refer to Administration of MMR Policy 3.7)

Anaemia Women with a history of anaemia during pregnancy (Hb > 115g/L) and/or a history of significant blood loss at birth should continue to take oral elemental iron (dose 80mg) during the postnatal period ie: Ferrous sulphate 325mg daily and ascorbic acid 500mg daily (to aid absorption) (in accordance with the Standing Orders).
WACSClinProc3.1/09

Care of the postnatal woman following uncomplicated pregnancy and birth May-11 3

These women should be instructed to continue taking oral elemental iron supplements for at least six weeks. Discharge Discharge planning should commence at booking in to ensure optimal follow-up and well being of postnatal women. The expected length of stay for uncomplicated women following a vaginal birth is 24 to 48 hours. o Extended Midwifery Service may be available after discharge. Refer to the Extended Midwifery Service guideline WACSClinProc3.4/09 for referral criteria and process. All women who have had an uncomplicated delivery should make an appointment to see their GP for their six weeks post natal check. Appointments should be made for women or babies who require specialist follow-up. Women with gestational diabetes should make an appointment with the diabetic clinic for a 6 week postnatal GTT. Written referral to the Child and Family Health Nurse should be completed for all women. Consider telephone or fax contact with CFHN service if additional support or assistance is required. Ensure discharge medications obtained. Fax discharge or transfer to DEM between 1600 and 0700.

o o

Attachments
Attachment 1

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: 3 August 2009

Care of the postnatal woman following uncomplicated pregnancy and birth May-11 4

WACSClinProc3.1/09

REFERENCES Joanna Briggs Institute 2005 Mother: Subsequent care Online: http://www.jbiconnect.org/connect/ebhc/embed/practice-manuals.php Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia The National Collaborating Centre for Primary Care 2006 Postnatal care: Routine postnatal care of women and their babies. Online: http://www.nice.org.uk/nicemedia/live/10988/30144/30144.pdf

Care of the postnatal woman following uncomplicated pregnancy and birth May-11 5

WACSClinProc3.1/09