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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

Oxford Handbook of Midwifery (110 page)

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Observe and monitor the woman for signs and symptoms of pulmonary embolism.
Document all observations and treatment in her notes.
Pulmonary embolism
Pulmonary embolism remains a major cause of maternal death worldwide and is the most common cause in the UK.
¹
Early ambulation for all women is the most effective form of prevention.
Women most at risk are those with:
- Previous history of DVT or pulmonary embolism
- Pre-existing or pregnancy-induced medical or obstetric complications resulting in prolonged immobility
- Epidural anaesthesia
- Operative birth
- Prolonged labour
- Anaemia.
  Signs and symptoms
Severe chest pain
Breathlessness
Gasping for breath
Fear
Tachycardia
Shallow, gasping respirations
Sweating, pallor
Cyanosis, particularly at the peripheries and around the mouth.
Treatment
Ensure a safe environment.
Summon emergency medical aid and help from other midwives in the vicinity.
Ask for emergency trolley and defibrillator.
Lay her down flat.
Commence basic emergency care:
- A
  irway—ensure it is patent
- B
  reathing—ensure she is breathing. Monitor respiratory rate and depth of respirations
- C
  irculation—check pulse rate.
If trained and able, ask a colleague to insert an IV cannula and commence IV fluids, e.g. Hartmann’s solution, 1L. This is best done as soon as possible, before her veins collapse as her blood pressure falls.
If collapse is total and she has stopped breathing, and her pulse is weak or absent, initiate emergency resuscitation procedure drill until help arrives.
Practice points
2 Pulmonary embolism is the highest major cause of direct maternal death in the UK.
¹
2 It is essential that all midwives know and practise the emergency drills regularly, in order that, should an emergency occur, the emergency procedure works well and all know what to do.
1
Lewis, G (ed.) (2007).
The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Live; Reviewing Maternal Deaths to Make Motherhood Safer
—
2003–2005.
The 7th Report on Confidential Enquires into Maternal Deaths in the United Kingdom. London: CEMACH.
CHAPTER 21
Disorders of the postnatal period
504‌‌
Postnatal pain
- ‘After pains’
  : the most common cause of postnatal pain, is experienced as the uterine involution and pelvic musculature return to normal.
  All women experience them to some degree, from mild discomfort to pain equivalent to moderate labour pains. It is caused by the release of oxytocin to cause uterine contraction and retraction and is exacerbated in a breastfeeding mother, in response to suckling and the ‘let down’ response. An appropriate analgesic, taken prior to breastfeeding, will usually help. The pain is intermittent in nature.
- Abdominal or pelvic pain
  may also be associated with a full bladder, constipation, flatus, intrauterine infection or, in rare cases, a pelvic vein thrombosis.
- Pain in the uterus
  , which is constant or present on abdominal palpation, is most likely due to infection. Other signs, such as a raised temperature and pulse rate, and heavy, offensive vaginal blood loss,
  may be present.
- Symphysis pubis pain
  occurs 8–60h after birth and may inhibit mobility.
Whenever possible, the midwife should seek the support of the obstetric physiotherapist. Bed rest with hips adducted and analgesia may be supplemented by a pelvic binder, an elasticated support bandage, or trochanteric belt. Lying on her side in bed helps reduce symphysis pubis separation. Elbow crutches or a walking frame may be needed to support weight-bearing for several weeks. She will also need considerable help with the baby’s care.
HEADACHE
505‌‌
Headache
General headache
As with the general population, there are many causes of postnatal head- ache. The duration, severity, and frequency are important in the postnatal period.
Tiredness, lack of sleep, the hot, dry environment of the postnatal ward, dehydration, worrying about her baby, her ability as a mother, infant feeding, particularly establishing breastfeeding, may all cause tension and anxiety leading to headache.
Simple analgesia, such as paracetamol or ibuprofen, should be effective in these situations.
Ensure that she drinks sufficient fluid, particularly water.
2 A walk in the fresh air, in the cooler part of the day, will also often help, as will support and encouragement with baby care.
Epidural anaesthesia
Headache arising from a dural tap once the mother is mobile again, and
is worse when she is standing. The headache may be accompanied by neck stiffness, vomiting, and visual disturbances.
The anaesthetist must be informed, to manage the leakage of CSF.
She may already have returned home and will require readmission to hospital with her baby.
High blood pressure
It is most important to monitor the blood pressure if there has been a pre-existing raised blood pressure.
2 An untreated raised blood pressure will cause increasing headache and may lead to fits or a cerebrovascular accident.
Psychological stress
It is important that issues pertinent to birth are explored sensitively in privacy, also other issues that may be worrying her.
Take time to explore her feelings and ascertain whether there are problems at home; for example, domestic abuse.
Deal sensitively and confidentially with any issues that arise, with the mother’s permission; this may mean referral to other members of the multidisciplinary team.
CHAPTER 21
Disorders of the postnatal period
506‌‌
Urinary tract disorders
The physiological changes that occurred in pregnancy and labour may take up to 6 weeks to resolve after birth, hence the potential for urinary prob- lems and infection is considerable.
Problems are relatively common in the immediate postnatal period and usually resolve as the pelvic floor regains its muscle tone and the pelvic structures return to the pre-pregnant state. However, for a small number of women, the problem persists for weeks or months.
Common disorders
- Difficulty in voiding urine
- Frequency of micturition
- Acute retention of urine
- Cystitis
- Urinary tract infection. Most at risk are those with:
  •
  Antenatal asymptomatic bacteriuria
- Antenatal urinary tract infection or pyelonephritis
- Catheterization in labour
- Epidural or spinal anaesthetic
- Long second stage with slow progress
- Vaginal delivery of a large baby
- Instrumental delivery, particularly forceps, causing trauma to the bladder and urethra
- Perineal trauma, particularly vulval grazes and tears
- Lax abdominal wall.
  Management
- Determine the cause.
- Catheterize if retention of urine is present.
- Reassure the mother.
- Give analgesia if required.
- Exclude urinary tract infection through laboratory culture of an MSU.
- Postnatal pelvic floor exercises.
  Acute retention of urine
- Usually caused by trauma to the bladder and urethra during labour.
- Bladder feels hard and distended abdominally.
- Lower abdominal severe discomfort and pain, if sensation is present.
- After an epidural or spinal anaesthetic, the sensation to pass urine may be lost for a number of hours.
- The uterus is higher in the abdomen than it should be and is displaced to one side.
  Management
- Catheterize to remove the urine, and withdraw the catheter.
- Advise the mother to drink plenty of fluid, and keep an accurate fluid balance chart until you are sure the crisis period is over.
- An indwelling catheter must not be left in at this stage.
  URINARY TRACT DISORDERS
  507