Cases

Chapter 8 Postnatal midwifery care

Case 1: Unplanned home birth

The midwife is called to attend Carla who has delivered at home unplanned. On arrival paramedics are in attendance and confirm that Olivia was born spontaneously and quickly following their arrival. Olivia is 41 weeks; she is skin-to-skin with her mother, pink, warm and crying lustily in Carla's arms. The placenta and membranes delivered physiologically 30 minutes after the birth of Olivia; initial estimation of blood loss appears to be approximately 400 millilitres, but blood continues to trickle from Carla's vagina.

Questions

• a) What would your actions be?

  Show Answer

  Correct answer:

  • Place Carla on clean dry towels or sheets to ascertain any further blood loss, in semi-recumbent position.
  • Palpate the fundus of the uterus to check position and tone of the uterus - rub up a contraction if the uterus is not contracted (see Chapter 16).
  • If the blood loss is due to an atonic uterus administer appropriate oxytocic drugs (see Chapter 16).
  • Inspect perineum and vagina for any trauma.
  • Check completeness of placenta and membranes.
  • Encourage Carla to put Olivia to the breast to stimulate oxytocin release.
  • Catheterise the bladder. Any urine contained may interfere with strong contraction of the uterus.
  • Measure and record vital signs.
  • Depending on severity of the vaginal blood loss, paramedics can insert two wide bore IV cannulas, take venous bloods samples, and administer IV fluid.
  • Bi-manual compression of the uterus may need to be employed where bleeding persists (see Chapter 16).
  • Communicate with the labour ward at the maternity hospital with regard to transfer to hospital and summoning second midwife.
  • Follow Basic Life Support interventions if required.

Case 2: Communication

Karen is a 35-year-old woman who has recently given birth to her first child Harriet. Karen went into labour spontaneously and reached full dilatation before Harriet was born by cesarean section at 39 weeks, weighing 3.23 kg. Karen was transferred from hospital care to community midwifery care on her third postnatal day and visited by the community midwife at home on the fourth postnatal day. Her hospital notes state the reason for cesarean section was 'failure to progress'.

Questions

• a) Consider this statement and reflect on the following questions:
  1. Is this a phrase you are familiar with?
  2. What does it suggest to you?
  3. How do you think women may interpret this?
  4. What impact do you think this may have on women?
  4. What other terminology could be used which may influence a women's confidence more positively?

  Show Answer

  Correct answer:
  These are reflective questions which do not have model answers because the intention is for you to think about how you would provide the compassion, kindness and respect for women you may be caring for.

Case 3: Involution of the uterus

Kimberley had a normal birth 7 days ago of her second baby; she is breastfeeding and the midwife is visiting them at home to perform a postnatal examination. Part of the postnatal examination involves the midwife asking Kimberley about the colour, frequency and odour of the lochia and whether she has any abdominal pain. Kimberley informs the midwife that she has recently noticed the lochia has increased, has been feeling unwell and has also had to take co-codamol for the pain in her abdomen.

Questions

• a) What do you suspect this condition might be?

  Show Answer

  Correct answer:
  Subinvolution of the uterus due to possible infection.

• b) What are the signs and symptoms of infection?

  Show Answer

  Correct answer:
  The signs and symptoms of infection can include fever, abdominal tenderness and offensive and excessive vaginal blood loss. However, pyrexia is no longer favoured as a diagnostic category because it is not always present in the presence of infection (Sinha and Otify 2012).
  Sinha, P. Otify M (2012) Genital tract sepsis: early diagnosis, management and prevention. The Obstetrician and Gynaecologist 14, pp.106-114.

• c) What are the causes of incomplete involution of the uterus?

  Show Answer

  Correct answer:
  Slow, delayed or incomplete involution of the uterus can be caused by ineffective uterine contractility, retained placental products, membrane fragments and infection.

• d) What would the midwife's actions be?

  Show Answer

  Correct answer:

  • Determine clinical wellness of the woman to inform decision-making and plan care.
  • Palpate the uterus abdominally to determine position and tone of the uterus and the presence of pain experienced by the mother. Assess whether the uterus is involuting normally.
  • Measure, assess significance and record vital signs.
  • Take a full history of the characteristics of the lochia and nature of the pain.
  • Recheck the woman's records to determine the completeness of placenta and membranes after the birth.
  • Immediate medical referral and treatment is required for subinvolution of the uterus and suspected infection.