Oxford Handbook of Midwifery (42 page)

support non-suturing of larger tears or of second-degree tears.
¹

1
Kettle C, Tohill S (2008). Perineal care: non-suturing of muscle and skin in first- and second- degree tears.
British Medical Journal Clinical Evidence
(online). 2008 Sep 24: pii: 1401. Available at: M
http://ukpmc.ac.uk/backend/ptpmcrender.cgi?accid=pmc2907946&blobtype=pdf (accessed 18.2.11).

CHAPTER 8
The need for social support

154‌‌

Preparation for infant feeding

All pregnant women should be informed about the benefits and manage- ment of breastfeeding.
¹

Recording a woman’s feeding intention at booking is questionable because:

• She may feel that she cannot change this decision at a later date
  
• Subsequent discussion may be more difficult if she has stated an intention to bottle feed
  
• Discussing breastfeeding when a woman has stated an intention to bottle feed may seem unnecessary.
  

  Preparation for breastfeeding
  

  No special care of the breasts is required in preparation for breastfeeding, but the following may be helpful:
  

• Bathing in the normal way is all that is necessary to keep the breasts and nipples clean
  
• Using soap may cause irritation as it removes the natural antiseptic lubricants (sebum) secreted from Montgomery’s tubercles
  
• It is useful to learn the skill of hand expression in the last month of pregnancy
  
• All women and their partners should have the opportunity to discuss breastfeeding during the antenatal period
  
• All women and their partners should have the opportunity to attend antenatal education classes/workshops related to breastfeeding.
  

  Preparation for artificial feeding, i.e. with infant formulas
  

  If a mother has chosen to artificially feed her infant, the midwife should support her, but it is important to ensure that the mother has made an informed choice and is aware of the benefits of breastfeeding both for the baby and for herself.
  

  Women should not receive instruction on how to make up bottles of infant formula as part of their antenatal group sessions; however, they should:
  

• Have the opportunity to discuss infant feeding individually with a health professional
  ²
  
• Receive information and instruction on how to make up bottles,
  ²
  if required, on a one-to-one basis or one-to-two basis with an appropriately trained health professional
  
• Receive information and instruction on how to sterilize equipment used in the preparation of infant feeds
  
• Receive information on artificially feeding, for example, the different types of formulas.
  
  1. Unicef (1998).
     Implementing the Ten Steps to Successful Breastfeeding.
     London: Unicef UK Baby Friendly Initiative.
     
  2. National Institute for Health and Clinical Excellence (2006). Routine postnatal care of women and their babies. Clinical guideline 37. London: NICE. Available at:
     www.nice.org.uk/cg37.
     

  Chapter 9
  ‌‌
  

  Recognizing and managing pregnancy complications
  

  155
  

  Bleeding in early pregnancy
  156
  

  Antepartum haemorrhage
  158
  

  Breech presentation
  160
  

  Hyperemesis
  162
  

  Infections
  164
  

  Intrauterine growth restriction
  168
  

  Multiple pregnancy
  170
  

  Obstetric cholestasis
  172
  

  Pregnancy-induced hypertension
  174
  

  

  The impact of obesity during pregnancy and beyond
  176
  

  CHAPTER 9
  Pregnancy complications
  

  156‌‌
  

  Bleeding in early pregnancy
  

  Once a pregnancy has been confirmed, any vaginal bleeding should be reported as it could signal a potential complication. Around 15% of women experience bleeding early in pregnancy. This could be related to events such as:
  

• Implantation bleed
  —a small amount of blood escapes as the fertilized ovum embeds in the lining of the uterus.
  
• Decidual bleed
  —bleeding from the decidual lining at the time a menstrual period would be expected, before the enlarging gestation sac completely fills the uterine cavity.
  

  There may be other causes of bleeding not related to the uterus, such as:
  

• Cervical erosion that bleeds on contact
  
• Vaginitis
  
• Cervical polyp
  
• Ectopic pregnancy—a pregnancy implanted outside the cavity of the uterus, commonly in the fallopian tubes
  
• Hydatidiform mole
  
• Cervical erosion that bleeds on contact—post-coital bleed.
  

  The most significant cause of bleeding is spontaneous miscarriage, 80% of which occur in the first trimester. Spontaneous miscarriage can be classified as follows.
  

• Threatened:
  bleeding with no uterine contraction or pain and the cervix does not dilate.
  
• Inevitable:
  when the cervix dilates or the membranes rupture.
  
• Complete:
  the cervix closes and bleeding stops after the expulsion of the gestation sac.
  
• Incomplete:
  retained placental tissue causes persistent bleeding and uterine contractions; requires evacuation of the uterus under anaesthetic to prevent the development of infection.
  
• Missed:
  the retention of a dead pregnancy; chorionic tissue may survive and
  produce hCG which enables the pregnancy to be retained in the uterus.
  
• Miscarriage with infection:
  infection following expulsion of the gestation sac, commonly after incomplete abortion.
  
• Recurrent:
  loss of three or more early pregnancies.
  
• Induced:
  surgical or medical method.
  

  The woman does not require any specific treatment if bleeding is minimal and resolves spontaneously; although she may wish to confirm that the pregnancy is still viable.
  

  The National Service Framework
  ²
  recommends provision of early pregnancy assessment units (EPAUs) where woman may be referred for a further pregnancy test and ultrasound scan to confirm whether or not the pregnancy is continuing.
  

  Persistent bleeding with pain requires admission to hospital for assessment and management. Post-miscarriage bleeding may require further treatment. Occasionally, if no infection is present and the uterus is empty, bleeding will settle after administration of ergometrine.
  

  1. Royal College of Obstetrics and Gynaecologists (2006).
     Management of Early Pregnancy Loss.
     

     Green-Top Guideline 25. London: RCOG Press.
     

  2. Department of Health (2004).
     National Service Framework for Children, Young People and Maternity Services
     . Maternity Standard. London: DH, p. 25.
     

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  CHAPTER 9
  Pregnancy complications
  

  158‌‌
  

  Antepartum haemorrhage
  

• Definition
  : bleeding from the genital tract after the 24th week of pregnancy and before the onset of labour.
  
• Antepartum haemorrhage (APH) complicates 2–5% of all pregnancies and is responsible for significant maternal mortality and morbidity.
  
• In the latest CEMACH report
  ¹
  five women died from APH.
  
• The most common causes are placenta praevia with an incidence of 31% and placental abruption with an incidence of 22%.
  ²
  

  Placenta praevia
  

  As the placenta encroaches on the lower uterine segment, bleeding occurs as the uterus stretches and grows. The lower uterine segment forms from 28 weeks.
  

• Bleeding is painless and presents as a fresh loss.
  
• There is often persistent malpresentation of the fetal presenting part.
  
• There is a further risk of postpartum haemorrhage (PPH) as the retractive power of the lower segment is poor.
  

  There are four grades of placenta praevia:
  

• Grade 1.
  The placental edge encroaches on the lower uterine segment, but does not reach the internal cervical os. Blood loss is usually minimal so the mother and fetus remain in good condition and vaginal delivery is possible.
  
• Grade 2.
  The placenta is partially in the lower uterine segment and reaches but does not cover the internal cervical os. Blood loss is moderate and fetal hypoxia is more likely to be present than maternal shock. Vaginal delivery is possible if the placenta is anterior.