Routine postnatal care for women and babies

Patient-centred care is the driving force behind the recommendations in the NICE guideline. By Dr Chris Barry

The NICE guideline on postnatal care 1 aims to place mothers and babies at the centre of their care. It establishes the principle of enabling women to make informed choices in a supportive environment and is not concerned with the management of a condition or an acute situation.

The guidance, which is based on the concept of healthcare professionals working in partnership with mothers and their infants, states that postnatal care should be individualised to meet the needs of each mother and baby. It aims to identify the essential ‘core care’ that every mother and baby should receive, as needed, during the first six to eight weeks after birth.

Multidisciplinary approach
The multidisciplinary approach required by the guideline was reflected in the composition of the guideline group, which included an obstetrician, a community paediatrician, midwives, a GP, health visitors and three lay representatives. The aim was to provide practical guidance based on a combination of clinical evidence and common sense.

The Quick Reference Guide is structured largely on what should happen at the various stages from the point of view of both mother and baby, outlining the basic requirements at every contact, in the first two hours, the first week and then two to eight weeks after the birth.

It defines signs and symptoms of serious or life-threatening conditions in both mother and baby, such as postpartum haemorrhage, infection, pre-eclampsia and DVT, advising that women should be informed about these.

The guidance is specific on such things as recording the woman’s BP and urine voiding within the first six hours. It also deals with a range of common problems, such as backache, constipation, haemorrhoids, faecal incontinence, urinary retention and incontinence, perineal hygiene, dyspareunia and resumption of contraception. Emotional well-being and signs of postnatal depression are discussed.

The baby should be examined within 72 hours of birth and again at six to eight weeks; the guideline specifies what these examinations should cover. It addresses the vitamin K question, recommending IM administration, because that has the best evidence of efficacy, but stating that if the parents are not happy with this, oral vitamin K may be given in two doses. Routine immunisations are also considered.
Information is provided on sudden infant death syndrome and how parents can minimise the risk to their baby; this includes advice about bed-sharing if the parents smoke or have recently drunk any alcohol.

BOX 1: BREASTFEEDING AND EMOTIONAL WELL-BEING
  • Do not separate the woman and her baby within the first hour. Routine weighing, measuring and bathing should be carried out later, unless the mother requests differently
  • Encourage skin-to-skin contact
  • Do not ask about feeding method before skin-to-skin contact has been made
  • Encourage initiation of breastfeeding within the first hour
  • Offer skilled breastfeeding support from the first feed
  • Do not give formula milk to breastfed babies unless this is medically indicated
  • Do not distribute commercial packs that contain or advertise formula milk
  • Give culturally appropriate information on the benefits of colostrum, breastfeeding and timing of the first breastfeed
  • Promote parent- and mother-baby attachment
  • Offer support and information to fathers
  • Encourage social networks
  • Offer group-based parenting programmes as required

The promotion of emotional well-being and breastfeeding are thoroughly addressed (see box 1). Apart from an entire section on breastfeeding, offering a great deal of detailed advice, there are specific policy recommendations for healthcare providers; these have financial consequences, but are in the guideline for good reason (see box 2).

BOX 2: IMPLEMENTING THE GUIDANCE
  • Establish local protocols about communication, transfer of care between clinical sectors and healthcare professionals
  • Ensure the Baby Friendly Initiative (or a similar externally evaluated breastfeeding programme) is implemented
  • Draw up a written breastfeeding policy that is communicated to all healthcare professionals and fully implemented
  • Ensure breastfeeding support is available in all care locations
  • Hospitals should make available 24-hour rooming-in, privacy, adequate rest and ready access to food and drink

Implementing the guidance
Implementing the guidance may be a tall order for some trusts, but the evidence shows that doing so is effective in increasing the incidence and duration of breastfeeding, with its lifelong benefits to mother and baby. However, formula feeding is not ignored in the guideline.

Birth may occur in all sorts of settings, so the wording of the guideline is of necessity rather generic. There was also extensive discussion about the concept of ‘lead professional’. It is recognised that this will usually be a midwife, but may be the GP or others, depending on circumstances. The important point is that this person (and their contact details) should be clearly identified at all times to the woman.

The guideline also specifies the competencies required of healthcare professionals, not by professional group, but by function. A newborn physical examination may be undertaken by a doctor, a midwife or another professional; what is important is that they have undergone the appropriate training and validation for the task.

Here, I have only been able to provide a summary of some of the key points in the guideline. For those who wish to find out more, I can highly recommend the Quick Reference Guide, which is clearly laid out and easy to read and which covers the essential points that most healthcare professionals will need to know about. Best of all, it is also common sense.

- Dr Chris Barry is a locum GP in Swindon and a member of the NICE Postnatal Care Guideline Development Group

Reference
1. NICE. Routine postnatal care of women and their babies. Clinical guideline 37 . NICE, London, July 2006

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