Section | 4 | Labour
its spine backwards, extending its pelvis causing its lower
Fig. 17.8 The baby descending in the ‘all-fours’ position.
Facilitating a vaginal breech birth in
an upright/kneeling position
Breech births can be as physiological as any other vaginal
birth and a woman who has chosen to birth vaginally, or
discovers in labour that her baby is presenting by the
breech, requires calm support from skilled and confident
midwives (Marshall 2010). The importance of not pushing
until the cervix has been confirmed as fully dilated should
be explained to the woman. In addition, the woman
should be aware that other skilled attendants may need to
be called to the birth.
At the start of the expulsive part of the second stage of
labour, the woman tends to make pelvic rocking move-
ments which facilitates the descent of the fetus and cor-
rects positioning for further progress. As the woman
commences pushing spontaneously, gradually the anterior
buttock should descend, becoming visible at the introitus
of the vagina, followed by the baby’s anus, genitalia and
posterior buttock. The bitrochanteric diameter is then
born with lateral flexion, known as ‘rumping’. While this is
occurring, the baby’s shoulders are entering the oblique
diameter of the maternal pelvis.
Descent continues, the baby’s thighs, popliteal fossa
(back of the knee) and lower legs become visible and the
pelvis is eventually born. The baby is then observed to arch
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body to curl round the maternal symphysis pubis. As a
result, the tension that this places on the baby’s legs assists
in their spontaneous release from the introitus, especially
when the woman is in an upright, kneeling position, and
the baby is born as far as the umbilicus. At this point, the
woman may spontaneously lower her body so that the
baby is sitting on the floor, further encouraging flexion of
the baby. It is no longer common practice to pull down a
loop of cord to avoid traction of the umbilicus unless there
appears to be constriction of the blood vessels as manipu-
lating the cord or stretching it can induce spasm of the
vessels.
With further descent and continued anticlockwise rota-
tion, the head enters the brim of the maternal pelvis as
the shoulders rotate in the mid-cavity assisted by the pelvic
floor muscles. Evans (2012b) emphasizes that this contin-
ued rotation of the baby’s body assists in bringing the
arms down using the pelvic floor muscles in a way that is
very similar to the Løvset manoeuvre (used when the birth
is delayed should the arms be extended). The anterior
shoulder is released under the symphysis pubis and the
posterior shoulder and arm pass over the perineum. At this
point Evans (2012a) refers to the baby flexing its legs up
towards its abdomen and its arms up towards its shoul-
ders, similar to a sit-up or tummy scrunch. Such a move-
ment, results in the baby flexing its head by bringing its
chin down onto its chest and pivoting the occiput on the
internal aspect of the symphysis pubis. This stimulates the
woman to lower her body from an upright kneeling posi-
tion to an all-fours or a knee–chest position, moving her
pelvis round the baby’s flexing head. This enables the
baby’s chin, face, sinciput and head to smoothly pass over
the perineum. The midwife is only required to support the
baby as the head is spontaneously born.
If a uterotonic is to be given to the woman as part of
the third stage of labour management, it should be
withheld until the baby’s head is completely born.
The birth of the after-coming head
To avoid any sudden change in fetal intracranial pressure
and subsequent cerebral haemorrhage it is vital the head
is born in a steady and gradual fashion and often some
assistance is given at this point. There are three methods
used.
Burns Marshall manoeuvre
This particular manoeuvre facilitates movement of the
baby’s head through the maternal pelvic outlet, but is only
possible when the woman is in a semi-recumbent, adapted
lithotomy position. The baby is allowed to ‘hang’ until the
head descends onto the perineum, when after about one
to two minutes the nape of the neck becomes visible and
the suboccipital region is born. The baby’s ankles are
grasped with forefinger between the two, maintaining suf-
ficient traction to prevent the neck from extending and
 Physiology and care during the transition and second stage phases of labour Chapter | 17 |

A B

Fig. 17.9 Burns Marshall manoeuvre for the after-coming

head. (A) Correct grasp around the fetal ankles. (B) The B
sub-occipital region pivots 180° under the pubic arch: the
mouth and nose are free of the vulva.

resulting in possible cervical spine fracture (Fig. 17.9A).

The feet are taken up through a 180o arc until the mouth
and nose are free of the vulva. This should be undertaken
slowly to prevent sudden changes in pressure to the baby’s
head and undue stretching of the perineum. The perineum
can be guarded to prevent sudden escape of the head (Fig.
17.9B). It is imperative that the midwife observes the baby
has descended sufficiently to ensure that it is the subocci­
pital region that pivots under the pubic arch and not the
neck to avoid fracture of the cervical vertebra and crushing C
of the spinal cord.
Fig. 17.10 Mauriceau–Smellie–Veit manoeuvre to assist the
Mauriceau–Smellie–Veit manoeuvre birth of the after-coming head in a breech presentation.
Whilst the baby’s head is facilitated through the same 180o (A and B) ‘All-fours’ position demonstrating how the occiput
is tipped forwards to achieve flexion, pivoting downwards
arc as in the Burns Marshall manoeuvre, the Mauriceau–
under the symphysis pubis to facilitate birth of the head.
Smellie–Veit manoeuvre provides more control with the
(C) In a semi-recumbent/sitting/adapted lithotomy position,
birth of the head and places less strain on the baby’s back. showing position of hands and downward direction of
This particular manoeuvre can be undertaken in a variety flexion whilst pivoting upwards through a 180° arc under the
of positions that the woman may adopt for the birth: semi- pubic arch.
recumbent, sitting, the adopted lithotomy position or the
all-fours position. As this manoeuvre facilitates maximum
flexion of the baby’s head, it can be used to advantage of the left hand (see Fig. 17.10A,B). It is important that
when the head is extended and descent is delayed. Further- the midwife avoids placing her finger in the baby’s mouth
more, it allows for slow birthing of the baby’s head and to prevent fracture to the jaw or trauma to the mouth and
thus reduces the risk of intracranial haemorrhage. gums, which can result in the baby having difficulties
In an ‘all-fours’ position, the midwife supports the with feeding. The vault of the baby’s head should be born
baby’s back over her right arm and flexes the baby’s head slowly and gently to facilitate gradual adaptation of the
by tipping the occiput forwards with the middle finger head to the changing pressures imposed by the birth
of the right hand and by gentle pressure on the baby’s process. This should be in a downwards direction following
malar bones (cheek bones) with the first and ring fingers the pelvic curve of Carus.

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Section | 4 | Labour

In the semi-recumbent position, the midwife should

support the baby on one of her arms, with her first and
ring fingers placed on the baby’s malar bones, pulling the
jaw down and increasing flexion. The other hand is placed
across the baby’s shoulders with the midwife’s middle
finger on the occiput to increase flexion. The outer fingers
can apply gentle traction on the baby’s shoulders. Main-
taining flexion, the head is drawn out of the vagina until
the suboccipital region appears and then the baby’s head
is slowly pivoted gently and slowly upwards around the
symphysis pubis following the curve of Carus, delivering
the chin and face first (see Fig. 17.10C).

Forceps birth
If an obstetrician is facilitating the vaginal breech birth,
forceps may be applied to the after-coming head to ensure
the birth is controlled.

Manoeuvres to assist the breech birth

If the midwife uses her professional judgement and Fig. 17.11 Assisting the birth of extended leg by applying
decides to undertake a manoeuvre to assist the breech pressure in the popliteal fossa.
birth, as this will involve making some contact with the
woman she must obtain the woman’s consent in order to
avoid the legal tort of trespass to the person (Dimond
2006; Nursing and Midwifery Council [NMC] 2008). If
the fact that the baby is presenting by the breech is known
before the onset of labour, it is recommended that the
midwife and the woman discuss the reasons for any pos-
sible manoeuvres, including their benefit and risks. The
midwife could seek consent to undertake any necessary
manoeuvres prior to the labour.
The following manoeuvres were originally developed to
facilitate a breech birth with the woman positioned on the
bed, but can be utilized when the woman is on all fours
or standing. With the benefits of gravity encouraging
descent of the fetus in the latter positions, the likelihood
of the midwife needing to adopt such measures is reduced.
Nevertheless, as noted above, unexpected breech presenta-
tions in late labour still arise, so it is important that the
midwife is both aware of, and skilled, in these manoeuvres Fig. 17.12 Correct grasp for the Løvset manoeuvre for
and maintains her competence in these areas. extended arms.

The birth of extended legs The birth of extended arms:

If the fetal legs are not born spontaneously, it is likely they
are extended, splinting the baby’s body, which impedes
lateral flexion of the spine and ultimately delays the birth.
Gentle pressure, as shown in Fig. 17.11, can be applied in
the popliteal fossa of one of the legs to encourage knee
flexion. This assists in the birth of the leg by sweeping it
to the side of the abdomen through abducting the hip.
This can be repeated for the other leg if necessary. The knee
is a hinge joint which bends in one direction only. If the
knee is pulled forwards from the abdomen, severe injury
to the joint can result.
the Løvset manoeuvre
This manoeuvre, which is a combination of rotation and
downward traction, is used when the arms fail to appear
during the birth of the baby’s trunk and chest as a result
of them being extended above the head. If the arms are
not released then the birth will be delayed with increasing
risk of hypoxia to the baby.
The baby is held at the iliac crests with thumbs over the
sacrum and downward traction is applied whilst the baby
is rotated 180° (Fig. 17.12). Care must be taken to always
keep the baby’s back towards the woman’s front, i.e. the

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 Physiology and care during the transition and second stage phases of labour
baby’s abdomen must be uppermost in an all-fours position
or the baby’s back is uppermost in a semi-recumbent posi-
tion. It is important that the baby is not grasped by the
flanks or abdomen as this may cause intra-abdominal
trauma resulting in kidney, liver or spleen injury.
To keep the baby’s abdomen uppermost should the
woman have adopted the all-fours position, if the baby’s
right arm is extended the baby should be rotated to the
right by applying downward traction on the pelvic girdle
in order to release the arm. This process is then repeated
for the left arm if necessary.
The Løvset manoeuvre creates friction of the baby’s pos-
terior arm lying in the sacral curve against the pubic bone
as the shoulder becomes anterior, sweeping the arm in
front of the face (Fig. 17.13). The movement enables the
shoulders to enter the maternal pelvis in the transverse
diameter. The anterior arm is then born and the baby can
be rotated back in the opposite direction in order for the
other arm to be born. If the arm is not born spontaneously,
it is usual to splint the humerus with two fingers, flex the
elbow and sweep the arm across the face and downwards
across the baby’s chest (‘cat-lick’ manoeuvre).
Delay in the birth of the head
If the head is trapped in an incompletely dilated cervix, an
air channel can be created to enable the baby to breathe
Box 17.4 Second stage of labour checklist for vaginal breech birth at term
• Regular fetal heart monitoring undertaken and
documented: Continuous electronic fetal heart
monitoring in hospital. Pinard or sonicaid auscultation
following every contraction in the second stage at
home (NICE 2007 recommendations).
• Check for cord prolapse if membranes rupture
and buttocks are not engaged.
• Check for full dilatation before encouraging the
woman to push: The woman may experience a
premature urge to push as the fetal body can pass
through the cervix prior to full dilatation: the fetal
head could become entrapped causing asphyxia
increasing perinatal morbidity and mortality.
• The umbilical cord may be loosened gently (rarely
required): This may be undertaken to prevent
constriction of blood vessels as the baby’s body is born.
In the all-fours position, the condition of the baby can
be easily monitored by observing the chest movements.
• Encourage a physiological birth with minimum
handling (hands off the breech): To allow the baby
to be born by gravity and propulsion and reduce
trauma to the baby once the buttocks are distending
the vulva.
• Vault of the fetal skull should be born slowly: To
avoid rapid decompression resulting in intracranial
haemorrhage.
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Chapter | 17 |
pending intervention. This is done by inserting two fingers
or a Sim’s speculum in front of the baby’s face and holding
the vaginal wall away from the nose. Any mucus is wiped
away and the airways are cleared. Attempts to release the
head from the cervix result in high perinatal morbidity
and mortality. Shushan and Younis (1992) have suggested
the McRoberts manoeuvre as a method to facilitate the
release of the fetal head. This requires the woman to lie
flat on her back, bringing her knees up to her abdomen,
and abducting the hips. More commonly this manoeuvre
is used to relieve shoulder dystocia and is described in
detail in Chapter 20.
Posterior rotation of the occiput is rare and usually results
from mismanagement. If the woman is in a semi-
recumbent position, the baby’s back should always remain
uppermost after the shoulders are born. To assist the birth
should the head be in the occipitoposterior position, the
baby’s chin and face may pass under the symphysis pubis
as far as the root of the nose and the baby is then lifted
up towards the mother’s abdomen to enable the occiput
to sweep the perineum.
When facilitating the birth of a woman presenting with
a breech at term, there are some important issues for the
midwife to consider that are pertinent to the breech sce-
nario. These have been summarized in the Second Stage
of Labour Checklist, as detailed in Box 17.4.
• Be aware and skilled in manouevres: To assist the
birth of the breech if problems arise with fetal
descent and to control the birth of the baby’s head.
• DO NOT PERFORM BREECH EXTRACTION (routine
use of manoeuvres/interventions to expedite
birth): This can cause delay and obstruction, e.g. fetal
arms pulled upwards, head extended backwards.
• Care of the baby following birth should include:
Appropriate resuscitation including suction of the
oropharynx and inspection of the vocal cords (if thick
meconium), maintaining the baby’s body temperature,
early feeding and paediatric assessment for signs of
birth trauma.
• Postnatal examination of the mother: To assess
the physical condition, including any birth trauma and
discuss the birth and its outcome whilst assessing
psychological wellbeing.
• Documentation: Is vitally important throughout the
labour and birth, to include specific details of all
discussions and referrals and the time they were
initiated. As the breech is born, the time that each
stage is reached and any manoeuvres undertaken
should also be recorded. Additionally documentation
should account for immediate condition of the baby,
including any resuscitation measures taken, and the
condition of the mother following the birth.
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1 2

3 4D

5 6

7 8

Fig. 17.13 The Løvset manoeuvre to assist the birth of extended arms.

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 Physiology and care during the transition and second stage phases of labour
Potential complications
of breech birth
It is important that midwives are fully aware of the poten-
tial complications associated specifically with vaginal
breech births at term, which are listed in Box 17.5. Many
of these can be avoided by having an experienced and
skilled attendant assisting at the birth. In the latest Centre
for Maternal and Child Enquiries (CMACE) Report on
Perinatal Mortality in 2009 there were eight intrapartum
stillbirths at term (CMACE 2011): however, the mode of
birth or place of birth were not articulated.
Professional responsibilities and
term breech birth
As an autonomous, accountable practitioner, the midwife
has responsibility to maintain skills in normal physiologi-
Box 17.5 Potential complications of breech birth
Potential fetal/neonatal complication
Congenital abnormality, e.g. hydrocephaly.
Congenital dislocation of the hip (↑ frank/extended
breech).
Fetal asphyxia.
Intracranial haemorrhage.
Superficial tissue damage/bruising and oedema of
baby’s genitalia, feet.
Fractures of the femur, humerus, clavicle and spine/
spinal cord damage.
Dislocation of the hip, shoulder, neck.
Brachial nerve paralysis (Erb’s palsy).
Soft tissue damage/rupture to baby’s liver, kidneys,
spleen and adrenal glands.
Dislocation of fetal jaw/soft tissue damage to mouth
and gums/feeding difficulties.
Cold injury/thermal shock and hypoglycaemia.
Potential maternal complication
Urethral, vaginal and perineal trauma.
Effects of anaesthesia (local, regional general), infection,
haemorrhage, thromboembolic disorders etc.
Psychological distress, affecting attachment to baby,
feeding difficulties and traumatic stress disorder.
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Chapter | 17 |
cal birth in relation to breech presentations at term in
order to offer women real choice regarding mode of birth.
This includes being familiar with the current evidence and
re-developing the skills midwives once had to facilitate
vaginal breech births at term where there are no contrain-
dications. It is therefore essential that these skills are seen
as part of the normal physiological birth process rather
than viewed as a rare maternity ‘emergency’.
RECORD-KEEPING
It is the responsibility of the midwife assisting the birth to
complete the labour record. This should include details of
any drugs administered, of the duration and progress of
labour, of the reason for performing an episiotomy, and
of perineal repair. This information is recorded on the
Associated cause
A cause for the presentation.
Mechanism of the birth itself poses risks.
Usually a complication of the presentation and not the birth
process.
Umbilical cord prolapse (↑ preterm labour/footling breech/
ill-fitting presenting part).
Cord compression.
Premature placental separation due to uterine retraction once the
baby’s body has been born.
Rapid decompression of the fetal skull causing tearing of the
dura mater lining the brain and other major blood vessels.
Pressure on the cervix / prolapsed foot that lies in the vagina or
at the vulva for some time.
Incorrect or excessive handling during the birth.
Abdominal area is roughly squeezed.
Baby’s mouth incorrectly being used to create traction rather
than the malar bones (cheekbones) in the Mauriceau–Smellie–
Veit manoeuvre.
Ambient temperature too cool and baby loses heat during
completion of the birth process.
Associated cause
Rapid birth of the baby’s head.
Risks of operative procedures.
Unexpected vaginal breech birth with lack of time to discuss
options.
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Section | 4 | Labour
Box 17.6 Dilemmas of practice
• The contrast between the current evidence base and
actual practices.
• The contrast between knowledge gained from
experience (empirical knowledge) and that gained
from evidence (authoritative knowledge).
• The problem of using guidelines and clinical risk
assessments based on population evidence for
individual women/babies.
• Balancing maternal choice, institutional demands, and
midwifery expertise.
mother’s notes (paper and/or computerized) and may be
duplicated on her domiciliary record as well as in the birth
register in some sites. Details of the baby’s condition,
including Apgar score, are also recorded. In some areas
extra charts and monitoring processes are being intro-
duced to respond to a range of imperatives. It is the profes-
sional responsibility of the midwife to remember that the
primary purpose of record keeping is to ensure effective
delivery and handover of care for each mother and baby,
not to protect staff or the organization from the risk of
litigation. As the Nursing and Midwifery Council Mid-
wives Rules and Standards state: ‘you must make sure the
needs of the woman or baby are the primary focus of your
practice’ (NMC 2012: 15). Midwives need to balance the
need for complete and accurate record-keeping with the
need to maintain a focus on the woman and her fetus and
birth companions. If demands to complete duplicate or
unnecessary records hinder this central activity, the
midwife should bring the situation to the attention of her
manager and/or supervisor of midwives. See Box 17.6 for
other current dilemmas in practice as midwives negotiate
around the various requirements of undertaking their
vocation, being a professional, being an employee and
practising competently and ethically.
New developments such as the All Wales Clinical
Pathway for Normal Labour (NHS Wales 2006), which
uses exception reporting, provide alternative approaches
to record-keeping that may be useful for practitioners in
the future. All data in the UK are subject to the Data
Protection Act 1998.
Official notification of the birth must be completed
within 36 hours. This may be undertaken by anyone
present at the birth but is usually carried out by the
midwife. The notification is sent to the Chief Medical
Officer in the health district in which the baby was born.
CONCLUSION
The processes of transition and of second stage labour are
likely to be very physically and emotionally intense,
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Box 17.7 Diane’s birth story
The birth of my first baby should have been one of the
happiest days of my life. Instead, I felt I had failed; I was
mentally and physically traumatized. Five years on, when I
was eventually pregnant again, my fears started creeping
back, and I considered having a caesarean section. I was
referred to the local caseload midwifery team. When
my midwife came to visit, I told her that my first birth
had left me traumatized, confused and scared about
everything. This was my big turn around: after talking to
her I realized I did not want a caesarean section, and I
started to feel confident about giving birth naturally.
The big day arrived. I was over the moon that I had
started my labour naturally. After a few hours my
midwife came to my house, just to check how everything
was going. Eventually, we decided it was time to go to
the hospital. When I arrived they organized an epidural
for me, which I had discussed, and which was in my
birth plan. I was getting excited, knowing I was going
to meet my baby soon. My midwife supported me and
encouraged me on everything I decided. She was there
for me all the time, keeping me focused and positive
about my birth. After about 3 hours, I started pushing
hard with contractions. The epidural wore off enough for
me to turn around on to my knees with my body upright,
and I could feel the baby drop down. I gave it my all for
two pushes, and out popped the head. I controlled my
breathing, pushing slowly, and my beautiful baby girl
came out. The midwife brought her through my legs so I
could see her and that’s when my husband cut her cord,
which was memorable and overwhelming for him. I was
the happiest person, I had the biggest smile on my face:
to me this was a beautiful birth. Thanks to the wonderful
midwives – it goes to show that with the right help and
guidance you can overcome your fears and anxieties with
positive thinking.
particularly for the woman, but also for her partner and
other birth companions. If maternal behaviour and
instinct are respected, in the context of skilled and watch-
ful waiting, the vast majority of labours will progress
physiologically. The skill of the midwife is to support the
woman effectively, to guide her when her spirits or the
labour are flagging, and to enable her to accomplish her
birth safely and in triumph. Diane’s story in Box 17.7
provides a personal account of how important this is for
women.
Clear, comprehensive, proportionate record-keeping is
essential. While much practice in this area is still not based
on formal evidence (see Box 17.8), new observations
about normal birth are beginning to be recorded, which
will form the basis for future research.
Key issues in the management of the second stage of
labour are summarized in Box 17.9.
 Physiology and care during the transition and second stage phases of labour Chapter | 17 |

Box 17.8 Examples of areas in need of research Box 17.9 Key issues in the management of the
in transition and second stage labour second stage of labour

• The areas of controversy, as set out in Box 17.1.
• The nature of physiological fetal heart patterns, and
variation and significance of variation in normal fetal
heart tones and rhythms as heard with a Pinard’s
stethoscope.
• The physiological variation in mechanisms and
patterns of labour in settings where no restrictions on
positioning or length of labour are imposed as a
matter of routine.
• Evaluation of maternal behaviours and other
non-invasive techniques to assess progress in labour.
• The short-, medium- and long-term epigenetic
consequences of physiological labour and birth for
the mother and her baby.
• The optimum approach to supporting women who
experience the early pushing urge.
• Tools and technologies (including e- and
m-technologies) to enhance personalized approaches
to tailoring maternity care provision for the specific
needs and choices of individual women.
• The transition and second stage phases of labour are
emotionally intense and physically hard.
• The majority of labours will progress physiologically.
• Maternal behaviour is usually a good indication of
progress during this time.
• The core midwifery skill is to support the woman in
the context of a sound knowledge of the physiology
and the mechanisms of this phase of labour.
• Support should be unobtrusive.
• The woman is the central player.
• Clear, comprehensive record keeping is essential.
• There are many gaps in the research evidence in this
area.

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FURTHER READING
Davis E 2012 Heart and hands: a
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birth, 5th edn. Ten Speed Press, New
York
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skills and experiences gained by lay
midwives working in America. If offers
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options? AIMS, Taunton
An informative and empowering text that
discusses the major issues surrounding
breech birth and explains the options for
women and midwives to consider that are
reinforced by the inclusion of poignant
personal birth stories.
Floyd-Davis R, Sargent C F 1997
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Press, California
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392
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pub2
knowledge, and how the knowledge and
expertise of women and of less dominant
cultures is not privileged, even in the area
of childbirth, and even in the face of the
evidence.
International Mother Baby Childbirth
Initiative. Available at www.imbci.
org/ (accessed 5 March 2013)
This international campaign is modelled on
the Baby Friendly Initiative, and is based
on 10 key steps which are believed to
promote optimal births for mother and
baby. The site includes inspirational
material, and updates from demonstration
sites across the world.
Leap N, Hunter B 1993 The midwife’s
tale: an oral history from
handywoman to professional
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experiences and responsibilities while
Waldenström U, Schytt E 2009 A
longitudinal study of women’s
memory of labour pain – from 2
months to 5 years after the birth.
BJOG: An International Journal of
Obstetrics and Gynaecology
116(4):577–83
Walsh D 2010 Labour rhythms. In:
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midwifery practice: intrapartum care.
Wiley–Blackwell, Chichester
White G 2007 You cope by breaking
down in private: fathers and
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British Journal of Midwifery
15(1):39–45
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purple line. Practising Midwife
10(1):26–7
Yildirim G, Beji N K 2008 Effects of
pushing techniques in birth on
mother and fetus: a randomized
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Consortium on Safe Labor 2010
Contemporary patterns of
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Gynecology 116(6):1281–7
attending women in labour are fascinating.
The final chapter offers some accounts of
labours from the point of view of women
themselves.
Marshall J E 2010 Facilitating vaginal
breech at term. In: Marshall J E,
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pp 89–102
This chapter considers the midwife’s
professional, legal and ethical
responsibilities in facilitating vaginal breech
births at term within both the hospital and
home environment.
Royal College of Midwives
Campaign for Normal Birth.
Online. Available at
www.rcmnormalbirth.org.uk/
(accessed 5 March 2013)
The campaign was set up by the Royal
College of Midwives to inspire and support
normal birth practice in the midwifery
 Physiology and care during the transition and second stage phases of labour Chapter | 17 |

profession. It is a web-based initiative,
using real stories and midwives’
experiences, underpinned with a sound
evidence base. The site includes top tips to
maximize physiological childbirth. There
are some excellent videos showing different
positions, and how to help women to adopt
them.
Walsh D 2007 Evidence based care for
normal labour and birth. Routledge,
London
A clearly written overview of both formal
and informal evidence that effectively
integrates narrative, evidence and
experiential learning.

USEFUL WEBSITES

Campaign for Normal Birth: The Breech Birth Network: Midwifery Matters (Association of Radical
www.rcmnormalbirth.org.uk www.breechbirth.org.uk Midwives): www.midwifery.co.uk

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 Chapter
Physiology and care during the third stage
of labour
Cecily Begley
CHAPTER CONTENTS
Physiological processes
Separation and descent of the placenta
Caring for a woman in the third stage
of labour
Expectant (or physiological) care during
the third stage of labour (EMTSL)
Active management of the third stage
of labour (AMTSL)
Is the timing of uterotonic administration,
cord clamping and/or CCT clinically
important in influencing the incidence
of PPH?
Evidence for active versus expectant
management
Asepsis
Cord blood sampling
Completion of the third stage
Blood loss estimation
Examination of placenta and membranes
Immediate care
Record-keeping
Transfer from the birth room
Complications of the third stage
Postpartum haemorrhage
Primary postpartum haemorrhage
Secondary postpartum haemorrhage
Care after a postpartum haemorrhage
Conclusion
© 2014 Elsevier Ltd
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18
References 414
Further reading 416
396 Useful website 416
396
The third stage of labour is a time of profound
398 relief for most women, following on the
exertions of labour and birth. During this stage,
398 mother, baby and father come together as a
family unit for the first time; parents explore and
become familiar with their newborn, marvel at
400
their baby’s behaviour and relax. The physical
mechanisms of birth continue almost unnoticed,
and the placenta and membranes are expelled.
Until the third stage is complete, continued
403 vigilance on the part of the midwife is essential
to ensure that postpartum haemorrhage (PPH) is
403 prevented or treated early, and that the placenta
and membranes are born intact. PPH is ranked
404 among the top four major causes of maternal
404 death globally (World Health Organization
404 [WHO] 2012). Although the majority (99%) of
deaths reported occur in developing countries,
404 the risk of PPH should not be underestimated for
404 any birth, and PPH is at present the sixth leading
405 cause of direct maternal death in the United
Kingdom (UK) (Centre for Maternal and Child
406 Enquiries [CMACE] 2011). Maternal mortality
406 rates in high resource countries are relatively low
406 when compared to low resource countries;
however, maternal morbidity is similar in
406 significance and rates of PPH are increasing
412 world-wide (Knight et al 2009). To facilitate a
413 healthy, enjoyable outcome for mother and baby,
good antenatal health plus preparation, coupled
414 with skilled, evidence-based practice of the
414 midwife are crucial.
395
Section | 4 | Labour
THE CHAPTER AIMS TO:
• describe the normal physiological mechanism of
placental separation, descent and expulsion,
including factors that facilitate haemostasis
• present evidence on the types, use and side-effects
of uterotonic drugs in active management of the
third stage
• discuss the evidence relating to timing of clamping
the umbilical cord, and controlled cord traction
• describe the risk factors most commonly associated
with PPH and discuss the current evidence-based
management strategies for prevention and
treatment
• discuss the midwife’s care of the mother and family
unit, during and immediately after separation and
expulsion of the placenta and membranes.
PHYSIOLOGICAL PROCESSES
The third stage can be defined as the period from the birth
of the baby to complete expulsion of the placenta and
membranes. It involves the development of the relation-
ship between mother, baby and father, the separation,
descent and expulsion of the placenta and membranes, the
control of haemorrhage from the placenta site, and some-
times, the initiation of breast-feeding. Although tradition-
ally labour is divided into three distinct component parts
to aid comprehension, it should be viewed as one continu-
ous process. With this in mind, it is important to under-
stand that the physiology of the third stage depends, in
part, on what has happened during pregnancy as well as
during the first and second stage of labour, and on the
woman’s basic level of health and wellbeing. The mid-
wife’s knowledge and evidence-based skills play a crucial
role in ensuring that the care received by the woman works
with, not against, physiological processes.
The placenta may shear off during the final expulsive
contractions accompanying the birth of the baby or remain
adherent for some time. The third stage usually lasts
between 5 and 15 minutes, but any period up to 1 hour
may be considered normal.
Separation and descent of the
placenta
Mechanical factors
The unique characteristic of uterine muscle lies in its
power of retraction. During the second stage of labour, the
uterine cavity progressively empties as the baby moves
down, enabling the retraction process to accelerate. Thus,
by the beginning of the third stage, the placental site has
396
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Muscle layer of uterus
Maternal blood vessels
‘Living ligature’
Plane of separation
Membranes
A Umbilical cord
Retraction causes
oblique fibres to shorten,
clamping blood vessels
Septa torn, separation
begins
Veins in spongy layer of
the decidua become
tense and burst
Villi collapsing as blood
B is released
‘Living ligatures’ retract
to seal off blood vessels
Blood vessels
collapsing
Blood tracks between
placenta and decidua
completing separation
C
Fig. 18.1 The placental site during separation. (A) Uterus
and placenta before separation. (B) Separation begins.
(C) Separation is almost complete.
already diminished in area by about 75% (Baldock and
Dixon 2006). As this occurs, the placenta becomes com-
pressed and the blood in the intervillous spaces is forced
back into the spongy layer of the decidua basalis. Retrac-
tion of the oblique uterine muscle fibres exerts pressure
on the blood vessels so that blood does not drain back
into the maternal system. The vessels during this process
become tense and congested. With the next contraction
the distended veins burst and a small amount of blood
seeps in between the thin septa of the spongy layer and
the placental surface, stripping it from its attachment (Fig.
18.1). As the surface area for placental attachment reduces,
the relatively non-elastic placenta begins to detach from
the uterine wall.
The majority of placentas are situated on the anterior or
posterior wall of the uterus, and separation usually starts
from the lower pole of the placenta and moves gradually
upwards (Herman et al 2002). Fundal placentas separate
first at both poles, followed by the fundal part. The length
of the third stage may be approximately 2 minutes shorter
 Physiology and care during the third stage of labour
A B C
Fig. 18.2 The mechanism of placental separation.
(A) Uterine wall is partially retracted, but not sufficiently to
cause placental separation. (B) Further contraction and
retraction thicken the uterine wall, reduce the placental site
and aid placental separation. (C) Complete separation and
formation of the retroplacental clot. Note: The thin lower
segment has collapsed like a concertina following the birth
of the baby.
A B
Fig. 18.3 Expulsion of the placenta. (A) Schultze method.
(B) Matthews Duncan method.
when the placenta is located at the fundus (Altay et al
2007). If separation begins centrally, a retroplacental clot
is formed (Fig. 18.2). This further aids separation by exert-
ing pressure at the midpoint of placental attachment so
that the increased weight helps to strip the adherent lateral
borders and peel the membranes off the uterine wall so
that the clot thus formed becomes enclosed in a membra-
nous bag as the placenta descends, fetal surface first. This
process of separation (first described by Schultze) is associ-
ated with more complete shearing of both placenta and
membranes and less fluid blood loss (Fig. 18.3A). If the
placenta begins to detach unevenly at one of its lateral
borders, the blood escapes so that separation is unaided
by the formation of a retroplacental clot. The placenta
descends, slipping sideways, maternal surface first. This
process (first described by Matthews Duncan in the nine-
teenth century) takes longer and is associated with ragged,
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Chapter | 18 |
Fig. 18.4 Third stage: placenta in lower uterine segment.
incomplete expulsion of the membranes and a higher
fluid blood loss (Fig. 18.3B).
Once separation has occurred the uterus contracts
strongly, forcing placenta and membranes to fall into the
lower uterine segment (Fig. 18.4), and finally, into the
vagina.
Haemostasis
The normal volume of blood flow through the placental
site is 500–800 ml/min, but this is considerably reduced
once the baby is born and the placental site on the uterine
wall has diminished (Baldock and Dixon 2006). At pla-
cental separation, blood flow has to be arrested swiftly, or
serious haemorrhage can occur. The interplay of four
factors within the normal physiological processes that
control bleeding are critical in minimizing blood loss and
preventing maternal morbidity or mortality. They are:
1. Retraction of the oblique uterine muscle fibres in the
upper uterine segment through which the tortuous
blood vessels intertwine – the resultant thickening
of the muscles exerts pressure on the torn vessels,
acting as clamps, and preventing haemorrhage (see
Fig. 18.1). It is the absence of oblique fibres in the
lower uterine segment that explains the greatly
increased blood loss usually accompanying placental
separation in placenta praevia.
2. The presence of vigorous uterine contraction
following separation – this brings the walls into
apposition so that further pressure is exerted on the
placental site.
397
Section | 4 | Labour
3. The achievement of haemostasis – there is a
transitory activation of the coagulation and
fibrinolytic systems during, and immediately
following, placental separation. It is believed that
this protective response is especially active at the
placental site so that clot formation in the torn
vessels is intensified. Following separation, the
placental site is rapidly covered by a fibrin mesh
utilizing 5–10% of circulating fibrinogen.
4. Breast-feeding – the release of oxytocin from the
posterior pituitary in response to skin-to-skin contact
between mother and baby, and the baby’s nuzzling
at the breast, causes uterine contractions.
CARING FOR A WOMAN IN THE
THIRD STAGE OF LABOUR
Two methods of care may be used during the third stage,
expectant (physiological) care or active management. It is
ultimately the woman’s decision as to how she would,
ideally, like her birth plan to be followed in the third stage.
She may have philosophical, religious or cultural beliefs
that influence her decision. The attending midwife may
also have views, based on evidence, as to the ideal method
of care for each particular woman. Midwives should
ensure that, in order to facilitate informed decision-
making by the woman, adequate time for deliberation and
questions is made available, where possible, during the
course of her routine antenatal consultations. The best
available research information on care during the third
stage of labour should be offered in an objective manner
(Begley et al 2011), supported by written information on
possible care options for the woman in keeping with the
setting in which she intends to birth. Information on types
of uterotonics, explanation of their different routes of
administration, benefits, risks and side-effects involved,
and timing and method of placental birth or delivery
should be given.
The midwife’s care of the mother should be based on
an understanding of the normal physiological processes at
work, including having access to as much information as
possible about the woman’s pregnancy and labour history.
Progress of the first and second stages of labour are likely
to impact on management of the third stage of labour and
should not be reviewed in isolation. The midwife’s actions
can make the third stage a wonderful, relaxing time of
birth and can reduce the risks of haemorrhage, infection,
retained placenta and shock, any of which may increase
maternal morbidity and even result in death. A mother’s
ability to withstand complications in the third stage
depends, to a large degree, upon her general health and
the avoidance of debilitating, predisposing problems, such
as anaemia, ketosis, exhaustion and prolonged hypotonic
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uterine action. Factors that may influence the risk of haem-
orrhage are discussed in more detail later.
Detailed, accurate, written (contemporaneous wherever
possible) documentation is extremely important in all
aspects of care, particularly in areas where evidence-based
information is relied upon to assess whether due care has
been delivered. In the case of third stage management, two
examples might be: where a woman requests expectant
(physiological) management of the third stage of labour
(EMTSL), the midwife should clarify the circumstances in
which this decision may be reversed (e.g. if severe bleeding
should occur); where a woman requests active manage-
ment (AMTSL), the midwife should clarify the circum-
stances in which this decision may be reversed (e.g., if the
baby requires attention and the placenta separates before
a uterotonic has been given). The woman’s preference for
care must be recorded in her notes antenatally, and a
record of the discussion may be signed by the woman. It
would be prudent for midwives to notify their supervisor
of midwives (SoM), clinical manager or the attending
medical practitioner if any of the woman’s requests are
contrary to local guidelines.
Expectant (or physiological) care
during the third stage of labour
(EMTSL)
In expectant management, the normal, physiological
mechanisms of labour are supported and no routine
actions (such as administration of a uterotonic drug, or
clamping of the umbilical cord) are carried out. A study
of the reported actions of 27 expert midwives (who used
EMTSL in at least 30% of births, and had recorded PPH
rates of less than 4%) identified the key actions that they
believed led to success when using EMTSL (Begley et al
2012). A synthesis of these actions, some of which are
supported by other research also, provides the following
instructions for best practice when using EMTSL:
1. Maintain a calm, quiet, warm environment. Use
warmed sheets or blankets to wrap mother and baby
together, skin-to-skin. This close contact, and the
baby’s eventual nuzzling at the breast, will stimulate
oxytocin release, which may shorten the third stage
and increase breast-feeding on discharge (Marín
Gabriel et al 2010).
2. Maintain the woman in a comfortable, semi-upright
position (at least a 45° angle) to encourage placental
separation by maintaining a gentle downward
weight.
3. Facilitate this time of parent–baby discovery and
attachment by keeping quiet, observing from a
distance and not interfering with the physiological
processes.
4. Watch and wait. Take cues from the woman’s
behaviour; if she is alert and happy, examining the
 Physiology and care during the third stage of labour
baby and talking, she is not bleeding excessively or
in need of any intervention. Reassurance can also be
obtained from discretely checking the woman’s pulse
if there is any anxiety in, for example, a prolonged
third stage.
5. Signs of placental separation:
■ The woman may fidget, make a face, or state that
she has a contraction.
■ A large ‘gush’ of blood may follow, indicating
partial or complete separation of the placenta. It
usually ceases after 10–20 seconds, especially if
the placenta has separated completely and the
uterus has contracted well. This gush is larger
than that seen when a uterotonic is given
routinely, and midwives need to develop an
understanding of this physiological blood loss
and not rush to administer oxytocic treatment
unnecessarily.
6. Signs of placental descent:
■ The woman may wriggle, change position, or
complain of pressure, or a pain, in her back or
bottom.
■ The cord may lengthen and/or the walls of the
vulva may bulge as the placenta descends.
■ The uterus becomes hard, round and mobile
(Fig. 18.5). This can be seen visually, or by the
fact that the baby, resting on the mother’s
abdomen, has moved downwards. It is
inadvisable to touch or manipulate the uterus at
this stage, as this can prevent full contraction,
disturb the fibrin mesh, and cause excessive
bleeding. If there is concern that the uterus may
be filling up with blood (a concealed
haemorrhage), a gentle hand placed on the
fundus will detect if there is a large, soft,
uncontracted uterus.
Umbilicus
15
10
5
Pubic
symphysis
A B C uterus cannot contract down fully while the bulk of
Beginning of Placenta in the End of 3rd
the 3rd stage lower segment stage
Fig. 18.5 Fundal height relative to the umbilicus and
symphysis pubis.
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Chapter | 18 |
7. Birthing the placenta:
■ Gravity should be used during the birth of the
placenta by encouraging a truly upright position:
sitting on a birthing stool, standing up in the
birthing pool or on the birthing mat, walking out
to the toilet, sitting on the toilet, kneeling upright
or squatting over a bedpan. A basin, bin bag or
disposable sheet can be placed strategically over,
or in, the pan of the toilet to receive the placenta.
It should be noted that such positions increase
visible blood loss (Gupta and Nikodem 2002).
■ Maternal effort can be used to expedite expulsion,
and most women will push the placenta out as
soon as they feel pressure, with little effort.
■ The cord should be left unclamped until
pulsation ceases (McDonald et al 2013), or until
after the birth of the placenta, unless the mother
wishes it to be cut earlier. Any mild resuscitation
of the baby can be done at the site of birth, with
the benefit of continued oxygen flow to the baby
through the umbilical cord.
■ If the placenta is definitely separated and is sitting
just inside the vagina (i.e., the insertion of the
cord can be seen at the vulva, or the cord has
lengthened and the vulval walls are bulging) the
midwife may ease gently on the cord to help lift
out the placenta. This is not controlled cord
traction as no force is used, the placenta is
separated and has left the uterus, therefore no
counter-pressure is required on the abdomen as
there is no risk of uterine inversion. Controlled
cord traction should NEVER be used in the absence
of a well contracted uterus following uterotonic
administration.
■ Trailing membranes should be teased out gently,
by turning the placenta around and twisting them
into a ‘rope’, thus stripping the ends gently from
the uterine wall.
8. At any time, a uterotonic may be administered to
control haemorrhage, or if uterine tone is poor
following placental birth. It is preferable to withhold
administration until the placenta is delivered, if
possible, to avoid the risk of a retained placenta
when the uterus contracts strongly in response to the
treatment.
This spontaneous process can take from 10 minutes to
1 hour to complete, with a median of 13 minutes (Begley
1990). If the placenta remains undelivered for a prolonged
period, the risk of bleeding becomes greater because the
the placenta is in situ. Dombrowski et al (1995) found
that the frequency of haemorrhage increased between
10 minutes and 40 minutes after the birth of the baby.
However, patience and confidence not to interfere unnec-
essarily are required on the part of the midwife to secure
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Section | 4 | Labour
a successful conclusion. Early attachment of the baby to
the breast may enhance these physiological changes by
stimulating the reflex release of oxytocin from the post­
erior lobe of the pituitary gland, which helps to secure
good uterine action.
Active management of the third
stage of labour (AMTSL)
An active management policy usually includes the routine
prophylactic administration of a uterotonic agent, either
intravenously, intramuscularly or (occasionally) orally, as
a precautionary measure aimed at reducing the risk of
postpartum haemorrhage. It is applied regardless of the
assessed obstetric risk status of the woman, and is usually
undertaken in conjunction with clamping of the umbilical
cord shortly after birth of the baby and delivery of the
placenta by the use of controlled cord traction. In situa-
tions where women may also be assessed as being at
higher risk for PPH (e.g. multiple birth), a prophylactic
infusion of larger doses of uterotonics diluted in intrave-
nous solutions may be administered over several hours
following the birth. This would also be considered to be
part of an active management policy, as would routine
uterine massage following delivery of the placenta in some
countries (Jangsten et al 2011), although there is no evi-
dence to support this practice once an oxytocic has been
given (Hofmeyer et al 2013).
Active management in the third stage is the policy of
third stage labour management most widely practised
throughout the developed world. Like all interventions
performed, skill in assisting the delivery of the placenta
and membranes is extremely important to prevent com-
plications. Whether women should routinely receive uter-
otonic drugs, have the umbilical cord clamped or be given
assistance with placental delivery has been the subject of
a great deal of debate and many research trials. These three
aspects are considered separately here.
Administration of uterotonics
Uterotonics (also known as oxytocics, or ecbolics), are
drugs (e.g. Syntometrine, Syntocinon, ergometrine and
prostaglandins) that stimulate the smooth muscle of the
uterus to contract. They may be administered with crown-
ing of the baby’s head, at the birth of the anterior shoulder
of the baby, after the birth of the baby but prior to placen-
tal expulsion, or following the birth, or delivery, of the
placenta and membranes.
In practice, one of the following uterotonic drugs is
usually used.
Intravenous ergometrine 0.25–0.5 mg
This drug acts within 45 seconds, and is particularly useful
in securing a rapid contraction where hypotonic uterine
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action results in haemorrhage. If a doctor is not present in
such an emergency, a midwife may give the injection, if it
is within his/her scope of practice. There is no evidence
for the continued routine use of intravenous ergometrine,
which is associated with an increased risk of retained pla-
centa (Prendiville et al 1988; Begley 1990), so this drug is
more often used to treat a PPH rather than as a prophy-
lactic drug. If an intravenous cannula is not already in situ,
any difficulty encountered in locating a vein or sudden
movement by the woman may result in failed venepunc-
ture or at least a delay in administration. Ergometrine can
cause headache, nausea, vomiting and an increase in
blood pressure (Begley 1990) and it is contraindicated
where there is a history of hypertensive disorder or cardiac
disease (Dyer et al 2010). To decrease the chance of nausea
and vomiting when the woman has had a caesarean
section under epidural, it is advisable not to use
ergometrine on its own (Balki and Carvalho 2005).
Combined ergometrine and oxytocin
(a commonly used brand is Syntometrine)
A 1 ml ampoule contains 5 IU of oxytocin and 0.5 mg
ergometrine and is administered by i.m. injection. The
oxytocin acts within 2 1 2 min, and the ergometrine within
6–7 min (Fig. 18.6). Their combined action results in a
rapid uterine contraction enhanced by a stronger, more
sustained contraction lasting several hours. It can be
administered as the anterior shoulder of the baby is born,
or after the birth of the baby. The use of combined
ergometrine/oxytocin or any ergometrine-based drug is
associated with side-effects such as elevation of blood
pressure, nausea and vomiting (Begley 1990). The most
recent report on maternal deaths from the Centre for
Maternal and Child Enquiries in the UK states that
‘Syntometrine should be avoided as a routine drug com-
pletely’ (CMACE 2011: 69).
CAUTION: No more than two doses of ergometrine
0.5 mg should be given, due to its side-effects.
Oxytocin
Oxytocin (a commonly used brand is Syntocinon) is a
synthetic form of the natural oxytocin produced in the
Oxytocin
acts in 21/2 min
Ergometrine
acts in 6–7 min
lasting 2–4 hours
0 1 2 3 4 5 6 7 8 9
Minutes
Fig. 18.6 The rapid action of oxytocin in comparison with
ergometrine.
 Physiology and care during the third stage of labour
posterior pituitary, and is safe to use in a wider context
than combined ergometrine/oxytocin agents. It can be
administered as an intravenous and or intramuscular
injection. However, an intravenous bolus of oxytocin can
cause profound, fatal hypotension, especially in the pres-
ence of cardiovascular compromise. The recommendation
of the Confidential Enquiry in Maternal Deaths (Lewis
and Drife 2001: 21) is that ‘when given as an intravenous
bolus the drug should be given slowly in a dose of not
more than 5 IU’.
Research evidence to date suggests that oxytocin is an
effective uterotonic choice where routine prophylactic
management of the third stage of labour is practised
(Khan et al 1995; Cotter et al 2001; Choy et al 2002),
more specifically in women who experience a blood loss
exceeding 1000 ml. Two Cochrane reviews have suggested
that it is probably better to use oxytocin rather than
ergometrine, due to the side-effects of ergot (Cotter et al
2001; Liabsuetrakul et al 2007).
Carbetocin, originally developed for veterinary use and
not widely employed for prophylactic use in management
of the third stage, is a long-acting synthetic oxytocin ana-
logue which can be administered as a single-dose 100 mg
injection. Carbetocin has been shown in some trials to be
as effective as oxytocin in preventing PPH (Reyes et al
2011; Su et al 2012); however, it does require refrigeration
for stability.
Prostaglandins
The use of prostaglandins for third stage management has
up until now been more often associated with the treat-
ment of postpartum haemorrhage than with prophylaxis.
This may be partly due to prostaglandin agents being more
expensive and associated with side-effects, such as diar-
rhoea (Anderson and Etches 2007) and cardiovascular
complications of increased stroke volume and heart rate
(van Selm et al 1995).
In more recent years, a great deal of research time and
investment has been invested in seeking alternate ways of
implementing strategies to reduce the risk of PPH. Miso-
prostol (a prostaglandin E1 analogue) was first used to
treat gastric ulcers, but when its potential as a uterotonic
agent was discovered, optimism regarding its suitability in
low resource settings was high. It is cheap, not prone to
loss of potency, does not need to be sterile or refrigerated
and can be administered vaginally, orally or rectally, negat-
ing the need for syringes. Misoprostol orally or sublin-
gually (400–600 µg) appears to be a useful drug to prevent
PPH, but is not as effective as Syntocinon (Ng et al 2007;
Tunçalp et al 2012) and has unpleasant side-effects, such
as severe shivering and higher temperature, both of which
are transient but unacceptable to some women. Its use
appears to be no more likely than Syntocinon to necessi-
tate manual removal of the placenta. Even though the
recommendation of the latest Cochrane review is that
misoprostol should not replace other uterotonics, the
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Chapter | 18 |
authors suggest that it may be useful in circumstances
where nothing else is available (Tunçalp et al 2012).
Clamping of the umbilical cord
This may, necessarily, be carried out following birth of the
baby’s head if the cord is tightly around the neck; however,
it is preferable, and usually possible, to loosen the loop
and slip it over the baby’s head, then allow the baby’s body
to slip out beside the loop. If the cord is looped several
times around the neck it will be possible to gently tighten
one, or more, of the loops of cord and then ease a looser
loop over the baby’s head. In this way, the baby’s oxygen
supply is not cut off prematurely, which could be very
detrimental to their condition. If this is not successful, the
midwife can be ready to clamp and cut the cord just as the
woman starts a contraction, so that the oxygen supply is
cut off only just before the birth.
Early clamping of the cord, as part of active manage-
ment of the third stage of labour (AMTSL), is normally
applied in the first 30 seconds to 3 minutes after birth,
regardless of whether or not cord pulsation has ceased. It
has been suggested that this practice may have the follow-
ing effects:
• It may reduce the volume of blood returning to the
fetus by an amount between 75 and 125 ml (van
Rheenen and Brabin 2004; Farrar et al 2011), which
is 30–40% of total potential blood volume (Farrar
et al 2011).
• It may prematurely interrupt the respiratory function
of the placenta in maintaining O2 levels and
combating acidosis in the early moments of life. This
may be of particular importance in a baby who is
slow to breathe.
• It may result in lower neonatal bilirubin levels,
although the effect on the incidence of clinical
jaundice is unclear (McDonald et al 2013).
• It may increase the likelihood of fetomaternal
transfusion as a larger volume of blood remains in
the placenta. Venous pressure is further increased as
retraction continues and may be sufficiently high to
rupture surface placental vessels, thus facilitating the
transfer of fetal cells into the maternal system; this
may be a critical factor where the mother’s blood
group is Rhesus negative (see Chapter 10).
• It results in the truncated umbilical vessels
containing a quantity of clotted blood, which
provides an ideal medium for bacterial growth; as
this is near to, and has a patent opening into, the
baby’s abdomen there is potential for systemic
infection (Mercer et al 2006).
• Heavier placental weight has also been associated
with early cord clamping (Newton et al 1961), which
may cause difficulty with delivery of the placenta,
particularly when the cervix has contracted following
administration of a uterotonic.
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Section | 4 | Labour
Proponents of late clamping suggest that no action be
taken until cord pulsation ceases or the placenta has been
completely delivered, thus allowing the physiological
processes to take place without intervention. Suggested
advantages of late clamping include:
• The route to the low resistance placental circulation
remains patent, which provides the newborn with a
safety valve for any raised systemic blood pressure.
This may be critical when the baby is preterm or
asphyxiated, as raised pulmonary and central venous
pressures may exacerbate the difficulties in initiating
respiration and accompanying circulatory adaptation
(Dunn 1985).
• The transfusion of the full quota of placental blood
to the newborn. This may constitute as much as
30–40% of the circulating volume (Farrar et al 2011),
depending on when the cord is clamped and at what
level the baby is held prior to clamping and may
therefore be important in maintaining haematocrit
levels.
• The neonatal effects associated with increased
placental transfusion include higher mean birth
weight by 87–116 g (Farrar et al 2011) and higher
neonatal haematocrit accompanied by an increase in
the incidence of jaundice in term (McDonald et al
2013) and preterm babies (Rabe et al 2012). There is
growing evidence that delaying cord clamping
confers improved iron status in infants up to
6 months post-birth (Chaparro et al 2006; Mercer
2006; Hutton and Hassan 2007; Rabe et al 2012;
McDonald et al 2013).
• Delayed cord clamping in preterm babies (until at
least 30–120 seconds) is associated with babies
requiring fewer transfusions, and having a lower risk
of developing necrotizing enterocolitis or
intraventricular haemorrhage (Rabe et al 2012).
• Delayed cord clamping may decrease the risk of
fetomaternal transfusion, which is important in
women with Rhesus-negative blood (Wiberg et al
2008).
Given the benefits of delayed cord clamping and the
documented harms caused by early clamping, many
centres have now stopped using early cord clamping as
part of their active management package (Afaifel and
Weeks 2012).
The actual action to take when clamping the cord early
is to place one clamp (usually a disposable plastic one)
close to the baby’s navel end. Care should be taken to
apply the clamp 3–4 cm clear of the abdominal wall, to
avoid pinching the skin or clamping a portion of gut,
which, in rare instances, may be in the cord. A greater
length of cord is left when umbilical vessels are needed for
transfusion, for example in preterm babies and cases of
Rhesus haemolytic disease. The second clamp is placed
closer to the placental end of the cord, with approximately
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2–4 cm between them. The cord between the two clamps
is then cut, while shielding personnel from blood spurts
with a gloved hand. The baby may then be placed on the
mother’s abdomen, put to the breast or be more closely
examined on a warmed cot if resuscitation is required.
There is very little evidence concerning how much, if
any, of a uterotonic agent the baby receives following
birth, through an intact cord. In five documented cases of
accidental administration of an adult dose of Syntometrine
to a newborn infant, no long-term adverse effects were
reported (Whitfield and Salfield 1980). If the cord is
clamped and cut soon after birth, the midwife should
release the second clamp and drain blood from the mater-
nal end of the cord to simulate placental–fetal transfusion,
as this may reduce maternal blood loss up to 77 ml and
shorten the third stage by up to 3 minutes (Soltani et al
2011).
Delivery of the placenta and membranes
Controlled cord traction (CCT)
Recent research has shown that this manoeuvre has no
effect on severe haemorrhage (>1000 ml) and little, if any,
effect on mild PPH (>500 ml) in both high (Deneux-
Tharaux et al 2013) and low income settings (Gülmezoglu
et al 2012). It does, however, shorten the third stage of
labour by 6 minutes (Gülmezoglu et al 2012). This means
that, in developing countries in particular, oxytocin can be
given by healthcare workers, without the need to train
them in safe utilization of CCT (Gülmezoglu et al 2012),
providing that they are taught to avoid manipulating the
uterus or pulling on the cord.
If CCT is to be used successfully, the principles of pla-
cental separation described at the beginning of this chapter
should be clearly understood. Before proceeding, the
midwife should check:
• that a uterotonic drug has been administered
• that it has been given time to act
• that the uterus is well contracted
• that counter-traction is applied
• that signs of placental separation and descent are
present.
At the beginning of the third stage, a strong uterine
contraction results in the fundus being palpable below the
umbilicus (see Fig. 18.5). It feels broad as the placenta is
still in the upper segment. As the placenta separates and
falls into the lower uterine segment there is a small fresh
blood loss, the cord lengthens, and the fundus becomes
rounder, smaller and more mobile as it rises in the
abdomen above the level of the placenta.
It is important not to manipulate the uterus in any way
as this may precipitate incoordinate action. No further
step should be taken until a strong contraction is palpable.
If tension is applied to the umbilical cord without this
contraction, uterine inversion may occur. This is an acute
 Physiology and care during the third stage of labour
Fig. 18.7 Controlled cord traction.
obstetric emergency with life-threatening implications for
the mother (see Chapter 22), and was implicated in one
maternal death in the UK in the period 2006–2008
(CMACE 2011).
Once the uterus is found to be contracted, one hand is
placed above the level of the symphysis pubis with the
palm facing towards the umbilicus, exerting pressure in an
upwards direction. This is counter-traction. The other
hand, firmly grasping the cord, applies traction in a down-
ward and backward direction following the line of the
birth canal (Fig. 18.7). Some resistance may be felt but it
is important to apply steady tension by pulling the cord
firmly and maintaining the pressure. Jerky movements
and force should be avoided. The aim is to complete the
action as one continuous, smooth, controlled movement.
However, it is only possible to exert this tension for a short
time as it may be an uncomfortable procedure for the
mother and the midwife’s hand will tire.
Downward traction on the cord must be released
before uterine counter-traction is relaxed as sudden with-
drawal of counter-traction while tension is still being
applied to the cord may also facilitate uterine inversion.
If the manoeuvre is not immediately successful there
should be a pause before the uterine contraction is again
checked and a further attempt is made. Should the uterus
relax, tension is temporarily released until a good con-
traction is again palpable. Once the placenta is visible it
may be cupped in the hands to ease pressure on the
friable membranes. A gentle upward and downward
movement or twisting action will help to coax out the
membranes and increase the chances of delivering them
intact. Artery forceps may be applied to gradually ease the
membranes out of the vagina. This process should not be
hurried; great care should be taken to avoid tearing the
membranes.
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Chapter | 18 |
Is the timing of uterotonic
administration, cord clamping
and/or CCT clinically important in
influencing the incidence of PPH?
Although active management leads to reduced risk of PPH,
it is important to establish which of the components of
this package lead(s) to this reduction. Given the difficul-
ties of adhering to an active management policy, the
absence of uterotonics in low resource countries, and the
preferences of some women for physiological manage-
ment, it is important to explore practice behaviours to
clarify whether or not the policy, as it is currently practised,
should continue.
Whether oxytocin is administered before or after the
placenta is expelled does not appear to make any signifi-
cant difference to the incidence of PPH (blood loss
>500 ml and >1000 ml), maternal hypotension, retained
placenta, length of third stage, mean blood loss, maternal
haemoglobin, need for maternal blood transfusion or
therapeutic uterotonics (Soltani et al 2010).
Similarly, CCT has no effect on severe haemorrhage
(>1000 ml) and little, if any, effect on mild PPH (>500 ml)
(Gülmezoglu et al 2012). Given the emerging evidence on
the benefits of delaying cord clamping (McDonald et al
2013), it is now reasonable to suggest an active manage-
ment package that includes cord clamping after 3 minutes,
followed by administration of oxytocin (either before or
after the birth of the placenta) and either maternal effort
or controlled cord traction to expel the placenta once
separation occurs. As AMTSL has not been implemented
in that first 3 or more minutes, the principles of care
described for expectant care during the third stage should
be followed in that period.
Evidence for active versus
expectant management
There is an increasing amount of appropriate, rigorously
conducted research evidence available that suggests that
the prophylactic administration of a uterotonic signifi-
cantly reduces the risk of PPH, results in a lower mean
blood loss, fewer blood transfusions are required and
there is a reduced need for therapeutic uterotonics (Begley
et al 2011). It has also been highlighted by the widely
ranging ‘risk status’ of women included in several studies
that it is in fact very difficult to define a group of women
who are not at risk for PPH. However, women truly at ‘low
risk’ for PPH do not appear to suffer undue harm from
EMTSL (Begley et al 2011; Dixon et al 2011), and this
should remain an option for care (NICE [National Insti-
tute for Health and Clinical Excellence] 2007). Midwifery
students should be given the opportunity to assist at births
using EMTSL, to learn and develop their skills, as ‘knowl-
edge of physiological management of the third stage of
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Section | 4 | Labour
labour is considered a basic midwifery competency’ by the
International Confederation of Midwives (ICM 2008).
It should be noted that the care pathway, whether active
or expectant, is reliant on all components of the pathway
being carried out as recommended. For example, if man-
agement is expectant, then the introduction of a utero­
tonic drug, cord clamping or pulling on the cord will
disrupt the intended sequence of the care process leading
to what is often described as a fragmented approach. Once
the sequence of the processes is altered, the clinician
should commit to completing the process. That is, if the
protocol for expectant management is interrupted the clin­
ician should proceed to completing the process with an
active management approach. This practice has been
shown to reduce the incidence of PPH significantly in a
birth centre setting (Patterson 2005).
Asepsis
The need for asepsis is even greater now than in the pre-
ceding stages of labour. Laceration and bruising of the
cervix, vagina, perineum and vulva provide a route for the
entry of microorganisms. At the placental site, a raw
surface provides an ideal medium for infection. Strict
attention to the prevention of infection is therefore
vital.
Cord blood sampling
This may be required for a variety of conditions:
• when the mother’s blood group is Rhesus negative
or as a precautionary measure if the mother’s Rhesus
type is unknown;
• when atypical maternal antibodies have been found
during an antenatal screening test;
• where a haemoglobinopathy is suspected (e.g. sickle
cell disease);
• ‘when there has been concern about the baby either
in labour or immediately following birth’ (NICE
2007:231).
The sample should be taken as soon as possible from
the fetal surface of the placenta where the blood vessels
are congested and easily visible. If the cord has not been
clamped prior to placental birth the fetal vessels will not
be congested, but a sample of sufficient volume may still
be easily obtained, or can be taken by syringe prior to birth
of the placenta. In the case of paired cord blood sampling
being required for reasons outlined by NICE (2007),
blood will be obtained from the umbilical cord. To achieve
this, an additional clamp will need to be applied resulting
in double-clamping of the cord. The appropriate contain-
ers should be used for any investigations requested. These
may include the baby’s blood group, Rhesus type, haemo-
globin estimation, serum bilirubin level, cord blood anal-
ysis for acid base status, Coombs’ test or electrophoresis.
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Maternal blood for Kleihauer testing can be taken upon
completion of the third stage.
COMPLETION OF THE THIRD STAGE
Once the placenta has spontaneously birthed, or has been
delivered, the midwife must first check that the uterus is
well contracted and fresh blood loss is minimal. Careful
inspection of the perineum and lower vagina is important.
A strong light is directed onto the perineum in order to
assess trauma accurately prior to instigating repair. This
should be carried out as gently as possible as the tissues
are often bruised and oedematous. If perineal suturing
(see Chapter 15) is required it should be carried out as
expediently as possible to prevent unnecessary blood
loss, increased risk of oedema at the site of trauma and
perhaps unnecessary re-infiltration of additional local
anaesthetics.
Blood loss estimation
Blood loss is difficult to measure and is frequently under-
estimated (Duthie et al 1990; Prastertcharoensuk et al
2000). Account must be taken of blood that has soaked
into linen and swabs as well as measurable fluid loss and
clot formation. The site of the blood loss does not neces-
sarily alter the impact in terms of potential debility for
affected women. Brandt (1966) believes that women can
withstand perhaps a 1000–1500 ml blood loss. However,
any further blood loss may not be tolerated so readily.
Women who undergo elective caesarean section will for
the most part have been adequately prepared. Women
who undergo emergency caesarean section or vaginal birth
who are dehydrated or anaemic may not withstand sudden
large volumes of blood loss.
In his study of the importance and difficulties of precise
estimation of PPH, Brandt (1967) calculated that 20% of
women lose >500 ml of blood after a vaginal birth. It was
estimated that 3940 ml of circulating blood volume were
required to maintain the central venous pressure at
10 cmH2O. Most measurement techniques are not suffi-
ciently sensitive to detect a rapid volume change in the
immediate setting when decisions need to be made.
Note: It should also be remembered that any amount of
blood loss that causes a physical deterioration such as
feeling faint, sudden onset of tachycardia, altered respira-
tions or drop in blood pressure should be immediately
investigated.
Examination of placenta and
membranes
This should be performed as soon after birth as practicable
so that, if there is doubt about their completeness, further
 Physiology and care during the third stage of labour
Cut end of cord
Placenta
Hand spread out
to aid inspection
of the membranes
Fig. 18.8 Examination of the membranes.
action may be taken before the woman leaves the birth
room or the midwife leaves the home. A thorough inspec-
tion must be carried out in order to make sure that no part
of the placenta or membranes has been retained. The
membranes are the most difficult to examine as they
become torn during the birth or delivery and may be
ragged. Every attempt should be made to piece them
together to give an overall picture of completeness. This is
easier to see if the placenta is held by the cord, allowing
the membranes to hang. The hole through which the baby
was born can then usually be identified and a hand can
be spread out inside the membranes to aid inspection (Fig.
18.8). The placenta should then be laid on a flat surface
and both placental surfaces minutely examined in a good
light. The amnion should be peeled from the chorion right
up to the umbilical cord, which allows the chorion to be
fully viewed.
Any clots on the maternal surface need to be removed
and kept for measuring. Broken fragments of cotyledon
must be carefully replaced before an accurate assessment
is possible.
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Chapter | 18 |
The lobes of a complete placenta fit neatly together
without any gaps, the edges forming a uniform circle.
Blood vessels should not radiate beyond the placental
edge. If they do, this denotes a succenturiate lobe, which
has developed separately from the main placenta (see
Chapter 6). When such a lobe is visible there is no cause
for concern, but if the tissue has been retained the vessels
will end abruptly at a hole in the membrane. If there is
any suspicion that the placenta or membranes are incom-
plete, they must be kept for inspection and a doctor
informed immediately in case a PPH occurs or there is the
possibility that a surgical intervention may be required.
Upon completion of the examination, the midwife
should return her attention to the mother. The empty
uterus should be firmly contracted and below the level of
the umbilicus. If the fundus has risen in the abdomen a
blood clot may be present. This should be expelled while
the uterus is in a state of contraction by pressing the
fundus gently in a downward and backward direction –
with due regard to the risk of inversion and acute discom-
fort to the woman. Force should never be used.
Immediate care
It is advisable for mother and baby to remain in the mid-
wife’s care for at least 1 hour after birth, regardless of the
birth setting. Much of this time will be spent in clearing
up and completion of records but careful observation of
mother and infant is very important. If an epidural cath-
eter is in situ it is usually removed and checked at this
time. Early physiological observations including ensuring
a well-contracted uterus, assessment of vaginal blood loss
and a gentle inspection of the genital tract to inspect for
trauma should be undertaken (NICE 2007).
The woman should be encouraged to pass urine because
a full bladder may impede uterine contraction. She may
not actually feel an urge to do so, especially if she has
passed urine immediately prior to giving birth or an effec-
tive epidural has been in progress, but she should be asked
to try. Uterine contraction and blood loss should be
checked on several occasions during this first hour. Once
basic procedures to ensure the woman’s and baby’s safety
and comfort have been completed, the woman may be
offered a light meal such as tea and toast.
Most women intending to breastfeed will wish to put
their babies to the breast during these early moments of
contact. This is especially advantageous, as babies are
usually very alert at this time and their sucking reflex is
particularly strong. There is also evidence to suggest that
women who breastfeed soon after birth successfully
breastfeed for a longer period of time (Salariya et al 1979).
An additional benefit lies in the reflex release of oxytocin
from the posterior lobe of the pituitary gland, which
stimulates the uterus to contract. This may result in
the mother experiencing a sudden fresh blood loss as
the uterus empties and she should be pre-warned and
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Section | 4 | Labour
reassured that it is a normal response. The desire to feed
a newborn baby is a warm, loving and instinctive response.
While breastfeeding should be actively encouraged, a
formula feed should be available for those who do not
wish to breastfeed.
Record-keeping
A complete and accurate account of the labour, including
the documentation of the administration of all medicines,
physical examination and observations, is the midwife’s
responsibility. This should also include details of examina-
tion of the placenta, membranes and cord with attention
drawn to any abnormalities. The volume of blood loss is
particularly important. This record not only provides
information that may be critical in the future care of both
mother and infant but is a legal document that may be
used as evidence of the care given. Signatures are therefore
essential, with cosignatories where necessary. In the UK,
many mothers now carry their own notes related to preg-
nancy and details of the birth. The completed records are
a vital communication link between the midwife respon-
sible for the birth and other caregivers, particularly those
who take over care and provide ongoing community
support services once the woman returns home.
It is usually the midwife who completes the birth noti-
fication form. Timely notification and referral may prevent
delay in a woman receiving appropriate assistance should
she need it.
Transfer from the birth room
The midwife is responsible for seeing that all observations
are made and recorded prior to transfer of mother and
baby to the postnatal ward, or home, or before the midwife
leaves the home following the birth.
The postnatal ward midwife should verify these details
prior to transfer of mother and baby. Following a domicili-
ary birth, the midwife should leave details of a telephone
number where she may be contacted should the parents
feel any cause for concern.
COMPLICATIONS OF THE
THIRD STAGE
Postpartum haemorrhage
Primary postpartum haemorrhage is defined as bleeding
from the genital tract in excess of 500 ml at any time fol-
lowing the baby’s birth up to 24 hours postpartum (WHO
2003). A loss of 500–999 ml in a healthy woman is con-
sidered a mild PPH, and severe haemorrhage is deemed to
be a loss of greater than 1000 ml (Bloomfield and Gordon
1990).
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Postpartum haemorrhage (PPH) is one of the most
alarming and serious emergencies a midwife may face and
can occur following both traumatic and straightforward
births. It is always a stressful experience for the woman
and any support persons present and may undermine her
confidence, influence her attitude to future childbearing
and delay her recovery. Although the maternal mortality
rate (MMR) in developed countries such as those of
Western Europe, Australasia, North America and Japan is
quoted as approximately 7, 6, 16 and 7 per 100 000 live
births respectively (Hogan et al 2010), the reported MMR
for lower resource countries is much higher; for example,
southern Asia with 323 per 100 000 live births, and sub-
Saharan Africa (west) with 629 per 100 000 live births
(Hogan et al 2010). A significant number of the deaths
recorded were due to PPH, often in the absence of a
trained health professional. The midwife is often the first,
and may be the only, professional person present when a
haemorrhage occurs, so her prompt, competent action will
be crucial in controlling blood loss and reducing the risk
of maternal morbidity or even death.
Primary postpartum haemorrhage
Fluid loss is extremely difficult to measure with any degree
of accuracy, especially when a mixture of blood and fluid
has soaked into the bed linen and spilled onto the floor.
It should also be remembered that measurable solidified
clots represent only about half the total fluid loss. With
these factors in mind, the best yardstick is that any blood
loss, however small, that adversely affects the mother’s
condition constitutes a PPH. Much will therefore depend
upon the woman’s general wellbeing. In addition, if the
measured loss reaches 500 ml, it must be treated as a PPH,
irrespective of maternal condition; however, it should be
noted that in high income countries, and in a woman who
is otherwise healthy with a high haemoglobin, a blood
loss of 500 ml is the equivalent of a routine blood dona-
tion and usually causes no ill effects.
Causes
There are several reasons why a PPH may occur, including
atonic uterus, retained placenta, trauma and blood coagu-
lation disorder.
Atonic uterus
This is a failure of the myometrium at the placental site to
contract and retract and to compress torn blood vessels
and control blood loss by a living ligature action. When
the placenta is attached, the volume of blood flow at the
placental site is approximately 500–800 ml/min. Upon
separation, the efficient contraction and retraction of
uterine muscle will staunch the flow and prevent a haem-
orrhage, which can otherwise ensue with horrifying speed
(Box 18.1).
 Physiology and care during the third stage of labour
Box 18.1 Causes of atonic uterine action
• Incomplete separation of the placenta
• Retained cotyledon, placental fragment or membranes
• Precipitate labour
• Prolonged labour resulting in uterine inertia
• Polyhydramnios or multiple pregnancy causing
overdistension of uterine muscle
• Placenta praevia
• Placental abruption
• General anaesthesia especially halothane or
cyclopropane
• Episiotomy or perineal trauma
• Induction or augmentation of labour with oxytocin
• A full bladder
• Aetiology unknown
Incomplete placental separation
If the placenta remains fully adherent to the uterine wall,
it is unlikely to cause bleeding. However, once separation
has begun, maternal vessels are torn. If placental tissue
remains partially embedded in the spongy decidua, effi-
cient contraction and retraction are interrupted.
Retained placenta, cotyledon, placental
fragment or membranes
These will similarly impede efficient uterine action (Sosa
et al 2009).
Precipitate labour
When the uterus has contracted vigorously and frequently,
resulting in a duration of labour that is less than 1 hour,
then the muscle may have insufficient opportunity to
retract.
Prolonged labour
In a labour where the active phase lasts >12 hours uterine
inertia (sluggishness) may result from muscle exhaustion
(Chapter 19).
Polyhydramnios, macrosomia or multiple
pregnancy
The myometrium becomes excessively stretched and there-
fore less efficient (Sosa et al 2009).
Placenta praevia
The placental site is partly or wholly in the lower segment
where the thinner muscle layer contains few oblique
fibres: this results in poor control of bleeding.
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Chapter | 18 |
Placental abruption
Blood may have seeped between the muscle fibres, inter-
fering with effective action. At its most severe this results
in a Couvelaire uterus (Chapter 12).
Induction or augmentation of labour
with oxytocin
In some circumstances, the use of oxytocin during labour
may result in hyperstimulation of the uterus and cause a
precipitate, expulsive birth of the baby (Sosa et al 2009;
Grotegut et al 2011). In this instance the uterus may still
be responding in a stimulated, but ineffective manner in
terms of contracting the empty uterus. In the case of induc-
tion or augmentation of labour, that continues over a
prolonged period without establishing efficient uterine
contractions, physical and emotional fatigue of the
mother, and uterine fatigue or inertia may occur. This
inertia inhibits the uterine muscle from providing
strong, sustained contraction and retraction of the empty
uterus that aids in the prevention of a postpartum
haemorrhage.
Episiotomy, and need for perineal sutures
Blood loss from perineal trauma, in addition to even a
normal blood loss from the uterus, can together equal a
mild PPH (Sosa et al 2009). Poeschmann et al (1991)
have shown that an episiotomy can cause up to 30% of
postpartum blood loss.
General anaesthesia
Anaesthetic agents may cause uterine relaxation, in par-
ticular the volatile inhalational agents, for example
halothane.
Mismanagement of the third stage of labour
‘Fundus fiddling’ or manipulation of the uterus may pre-
cipitate arrhythmic contractions so that the placenta only
partially separates and retraction is lost.
A full bladder
If the bladder is full, its proximity to the uterus in the
abdomen on completion of the second stage may interfere
with uterine action. This also constitutes mismanagement.
Aetiology unknown
A precipitating cause may never be discovered.
There are in addition a number of factors that do not
directly cause a PPH, but do increase the likelihood of
excessive bleeding (Box 18.2).
Previous history of PPH or retained placenta
There may be a risk of recurrence in subsequent pregnan-
cies, depending on the cause of the PPH in the previous
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Section | 4 | Labour
Box 18.2 Predisposing factors that might
increase the risks of postpartum haemorrhage
• Previous history of postpartum haemorrhage or
retained placenta
• Presence of fibroids
• Maternal anaemia
• Ketoacidosis
• Multiple pregnancy
• HIV/AIDS
• Caesarean section
birth. A detailed obstetric history taken at the first ante­
natal visit will ensure that optimum care can be given.
Fibroids (fibromyomata)
These are normally benign tumours consisting of muscle
and fibrous tissue, which may impede efficient uterine
action.
Anaemia
Women who enter labour with reduced haemoglobin con-
centration (below 10 g/dl) may feel a greater effect of any
subsequent blood loss, however small. Moderate to severe
anaemia (<9 g/dl) is associated with an increase in third
stage blood loss and risk of postpartum haemorrhage
(Kavle et al 2008; Soltan et al 2012).
HIV/AIDS
Women who have HIV/AIDS are often in a state of severe
immunosuppression, which lowers the platelet count to
such a degree that even a relatively minor blood loss may
cause severe morbidity or death.
Ketosis
The influence of ketosis upon uterine action is still unclear.
Foulkes and Dumoulin (1983) demonstrated that, in a
series of 3500 women, 40% had ketonuria at some time
during labour. They reported that if labour progressed
well, this did not appear to jeopardize either the fetal or
maternal condition. However, there was a significant rela-
tionship between ketosis and the need for oxytocin aug-
mentation, instrumental delivery and PPH when labour
lasted more than 12 hours. Correction of ketosis is there-
fore advisable and can be facilitated by ensuring women
have an adequate intake of fluids and light solid nourish-
ment as tolerated throughout labour. There is no evidence
to suggest restriction of food or fluids is necessary during
the normal course of labour (Singata et al 2010).
Caesarean section
It should be noted that, of the five women who died of
postpartum haemorrhage in the UK in the period
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2006–2008, four of them had had a caesarean section (the
fifth concealed her pregnancy and died alone at home)
(CMACE 2011). The report noted that in three of the four
women (75%), a lack of routine observation of vital signs
in the postoperative period, or failure on the part of staff
to notice that bleeding was occurring, were key failures in
care. Postoperative observations need to be recorded regu-
larly, using a modified early obstetric warning score
(MEOWS) chart, and abnormal findings acted upon
(CMACE 2011).
Signs of PPH
Signs may be obvious, such as:
• visible bleeding
• maternal collapse.
However, more subtle signs may present, such as:
• pallor
• rising pulse rate
• falling blood pressure
• altered level of consciousness; the mother may
become restless or drowsy
• an enlarged uterus as it fills with blood or blood
clot; it feels ‘boggy’ on palpation (i.e. soft and
distended and lacking tone); there may be little or
no visible loss of blood.
Prophylaxis
By using the above list, it is possible for the midwife to
apply some preventive screening in an attempt to identify
women who may be at greater risk and to recognize causa-
tive factors. During the antenatal period a thorough and
accurate history of previous obstetric experiences will
identify possible risk factors. Arrangements for birth can
be discussed with the woman, and the necessity for birth
to take place in a unit where facilities for dealing with
emergencies are available can be explained. The early
detection and treatment of anaemia will help ensure that
women enter labour with a haemoglobin level, ideally, in
excess of 10 g/dl. The midwife should check that blood
tests, if needed, are taken regularly and the results recorded
and explained to the woman. If necessary, action can be
taken to restore the haemoglobin level before birth.
Women more prone to anaemia should be closely moni-
tored, e.g. those with multiple pregnancies.
During labour, good management practices during the
first and second stages are important to prevent prolonged
labour and ketoacidosis. A mother should not enter the
second or third stage with a full bladder. AMTSL is recom-
mended for all women at high risk of PPH, and will reduce
blood loss for women of mixed risk (Begley et al 2011).
Two units of cross-matched blood should be kept availa-
ble for any woman known to have a placenta praevia or
other major predisposing risk factors for PPH.
 Physiology and care during the third stage of labour
Treatment of PPH
Whatever the stage of labour or crisis that may occur, the
midwife should adhere to the underlying principle of
always reassuring the woman and her support persons by
continually relaying appropriate information and involv-
ing them in decision-making.
Three basic principles of care should be applied imme-
diately upon observation of excessive bleeding, using the
mnemonic ABC:
1. Call for medical Aid.
2. Stop the Bleeding by rubbing up a contraction,
giving a uterotonic and emptying the uterus.
3. ResusCitate the mother as necessary.
Call for medical aid
This is an important initial step so that help is on the way
whatever transpires. If the bleeding is brought under
control before the doctor arrives, then no action by the
doctor will be needed. However, the woman’s condition
can deteriorate very rapidly, in which case medical assist-
ance will be required urgently. If the mother is at home or
in a midwife-led unit, the emergency department of the
closest obstetric unit should be contacted and, depending
on the policy of the region, an obstetric emergency team
summoned or ambulance transfer arranged.
Stop the bleeding
The initial action is always the same, regardless of whether
bleeding occurs with the placenta in situ or later.
Rub up a contraction
The fundus is first felt gently with the fingertips to assess
its consistency. If it is soft and relaxed, the fundus is mas-
saged with a smooth, circular motion, applying no undue
pressure. When a contraction occurs, the hand is held still.
Give a uterotonic to sustain the contraction
In many instances, oxytocin 5 units or 10 units, or com-
bined ergometrine/oxytocin 1 ml, has already been
administered and this may be repeated. Alternatively,
ergometrine 0.25–0.5 mg may be injected intravenously
(in the absence of contraindications), and will be effective
within 45 seconds; vomiting may occur immediately. No
more than two doses of ergometrine should be given
(including any dose of combined ergometrine/oxytocin),
as it may cause pulmonary hypertension. Several reports
have described the dramatic haemostatic effects of pros-
taglandins used in cases of uterine atony. Misoprostol
(Cytotec) or carboprost (Hemabate) are the most common
prostaglandin drugs used to increase uterine contractility
for the treatment of PPH. However, the side-effects
(nausea, vomiting, pyrexia, hypertension, diarrhoea) asso-
ciated with these drugs can make their use limited (Ander-
son and Etches 2007).
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Chapter | 18 |
The baby may be put to the breast to enhance the physi-
ological secretion of oxytocin from the posterior lobe of
the pituitary gland, thus stimulating a contraction.
Empty the uterus
Once the midwife is satisfied that it is well contracted, she
should ensure that the uterus is emptied. If the placenta
is still in the uterus, it should be delivered; if it has been
expelled, any clots should be expressed by firm but gentle
pressure on the fundus.
Resuscitate the mother
An intravenous infusion should be commenced while
peripheral veins are easily negotiated. This will provide a
route for an oxytocin infusion or fluid replacement. As an
emergency measure, the mother’s legs may be lifted up in
order to allow blood to drain from them into the central
circulation. However, the foot of the bed should not be
raised as this encourages pooling of blood in the uterus,
which prevents the uterus contracting.
It is usually expedient to catheterize the bladder to
ensure that a full bladder is not impeding uterine contrac-
tion and thus precipitating further bleeding, and to mini-
mize trauma should an operative procedure be
necessary.
On no account must a woman in a collapsed condition
be moved prior to resuscitation and stabilization.
The flow chart in Fig. 18.9 briefly sets out the possible
courses of action that may be taken depending on whether
or not bleeding persists. If the above measures are success-
ful in controlling any further loss, administration of oxy-
tocin, 40 units in 1 litre of intravenous solution (e.g.
Hartmann’s or saline) infused slowly over 8–12 hours, will
ensure continued uterine contraction. This will help to
minimize the risk of recurrence. Before the infusion is
connected, 10 ml of blood should be withdrawn for hae-
moglobin estimation and for cross-matching compatible
blood. If bleeding continues uncontrolled, the choice of
further action will depend largely upon whether the pla-
centa remains undelivered.
Placenta delivered
If the uterus is atonic following birth of the placenta, light
fundal pressure may be used to expel residual clots while
a contraction is present. If an effective contraction is not
maintained, 40 units of Syntocinon in 1 litre of intrave-
nous fluid should be started. The placenta and membranes
must be re-examined for completeness because retained
fragments are often responsible for uterine atony and may
need to be removed manually, under anaesthetic.
Bimanual compression
If bleeding continues, bimanual compression of the uterus
may be necessary in order to apply pressure to the placen-
tal site. It is desirable for an intravenous infusion to be in
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Section | 4 | Labour

1. Call a
doctor Lower genital tract injury Apply pressure, repair the wound

Laparotomy, repair the tear

2. Stop the
Uterus firmly
Bleeding Ruptured uterus
contracted
Hysterectomy

Clotting disorder

Rub up a contraction Put the baby to the breast

Give an oxytocic Ergometrine 0.5 mg IV

IV infusion Syntocinon 40 u/l

Uterus atonic
Bedpan
Empty the bladder
Catheter
Empty the uterus

Lift the legs

3. Resuscitate
Restore circulation Placenta Placenta Expel
the mother IV fluids
undelivered delivered clots
Blood
transfusion

Unseparated,
retained Separated

Attempt manual
removal of
placenta In lower uterine In cervix
segment or vagina

Unsuccessful
= placenta accreta Controlled Grasp and
cord traction remove

Observe and
leave to absorb; Measures fail
antibiotics to arrest bleeding

Bimanual
compression
Assess postnatal Correct as
Hb level appropriate
Hysterectomy

Fig. 18.9 Management of primary PPH.

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 Physiology and care during the third stage of labour
Fig. 18.10 Bimanual compression of the uterus.
progress. The fingers of one hand are inserted into the
vagina like a cone; the hand is formed into a fist and
placed into the anterior vaginal fornix, the elbow resting
on the bed. The other hand is placed behind the uterus
abdominally, the fingers pointing towards the cervix. The
uterus is brought forwards and compressed between the
palm of the hand positioned abdominally and the fist
in the vagina (Fig. 18.10). If bleeding persists, a clotting
disorder must be excluded before exploration of the
vagina and uterus is performed under a general anaes-
thetic. Compression balloons may also be used to provide
pressure on the placental site and if bleeding continues,
ligation of the uterine arteries or hysterectomy may be
considered.
Placenta undelivered
The placenta may be partially or wholly adherent.
Partially adherent
When the uterus is well contracted, an attempt should be
made to deliver the placenta by applying CCT. If this is
unsuccessful a doctor will be required to remove it
manually.
Wholly adherent
Bleeding does not usually occur if the placenta is com-
pletely adherent. However, the longer the placenta remains
in situ the greater is the risk of partial separation, which
may give rise to profuse haemorrhage.
Retained placenta
This diagnosis is reached when the placenta remains unde-
livered after a specified period of time (usually 1 hour
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Chapter | 18 |
following the baby’s birth). The conventional treatment is
to separate the placenta from the uterine wall digitally,
effecting a manual removal.
Breaking of the cord
This is a not unusual occurrence during completion of the
third stage of labour. Before further action, it is crucial to
check that the uterus remains firmly contracted. If the
placenta remains adherent, no further action should be
taken before a doctor is notified. It is possible that manual
removal may be indicated. If the placenta is palpable in
the vagina, it is probable that separation has occurred and
when the uterus is well contracted then maternal effort,
with a fully upright posture, may be encouraged (see
expectant management, above). If there is any doubt, the
midwife applies fresh sterile gloves before performing a
vaginal examination to ascertain whether this is so. As a
last resort, if the woman is unable to push effectively then
gentle fundal pressure may be used, following administra-
tion of a uterotonic drug. Great care is exercised to ensure
that placental separation has already occurred and the
uterus is well contracted. The woman should be relaxed as
the midwife exerts downward and backward pressure on
the firmly contracted fundus. This method can cause con-
siderable pain and distress to the woman and result in the
stretching and bruising of supportive uterine ligaments. If
it is performed without good uterine contraction, acute
inversion may ensue. This is an extremely dangerous pro-
cedure in unskilled hands and is not advocated in every-
day practice when alternative, safer methods may be
employed. It is very unlikely that this would be practised
in the UK.
Manual removal of the placenta
This should be carried out by a doctor. An intravenous
infusion must first be sited and an effective anaesthetic in
progress. The choice of anaesthesia will depend upon the
woman’s general condition. If an effective epidural anaes-
thetic is already in progress, a top-up may be given in order
to avoid the hazards of general anaesthesia. A spinal
anaesthetic offers an alternative but where time is an
urgent factor a general anaesthetic will be initiated.
Management
Manual removal is performed with full aseptic precautions
and, unless in a dire emergency situation, should not be
undertaken prior to adequate analgesia being ensured for
the woman. With the left hand, the umbilical cord is held
taut while the right hand is coned and inserted into the
vagina and uterus following the direction of the cord.
Once the placenta is located the cord is released so that
the left hand may be used to support the fundus abdomi-
nally, to prevent rupture of the lower uterine segment (Fig.
18.11). The operator will feel for a separated edge of the
placenta. The fingers of the right hand are extended and
the border of the hand is gently eased between the
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Section | 4 | Labour
Fig. 18.11 Manual removal of the placenta.
placenta and the uterine wall, with the palm facing the
placenta. The placenta is carefully detached with a side-
ways slicing movement. When it is completely separated,
the left hand rubs up a contraction and expels the right
hand with the placenta in its grasp. The placenta should
be checked immediately for completeness, so that any
further exploration of the uterus may be carried out
without delay. A uterotonic drug is given upon
completion.
In very exceptional circumstances, when no doctor is
available to be called, a midwife would be expected to
carry out a manual removal of the placenta. Once she has
diagnosed a retained placenta as the cause of PPH, the
midwife must act swiftly to reduce the risk of onset of
shock and exsanguination. It must be remembered that
the risk of inducing shock by performing a manual
removal of the placenta is greater when no anaesthetic is
given. In a developed country, the midwife is unlikely to
find herself dealing with this situation.
At home
If the placenta is retained following a home birth, emer-
gency obstetric help must be summoned. Under no cir-
cumstances should a woman be transferred to hospital
until an intravenous infusion is in progress and her condi-
tion stabilized. It is best if the placenta can be delivered
without moving the mother but if this is not possible, or
if further treatment is needed, she should be transferred
to a consultant unit, with her baby.
Morbid adherence of placenta
Very rarely, the placenta remains morbidly adherent; this
is known as placenta accreta. If it is totally adherent, then
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bleeding is unlikely to occur and it may be left in situ to
absorb during the puerperium. If, however, only part of
the placenta remains embedded then the risks of fatal
haemorrhage are high and an emergency hysterectomy
may be unavoidable.
Trauma as a cause of PPH
If bleeding occurs despite a well-contracted uterus, it is
almost certainly the consequence of trauma to the uterus,
vagina, perineum or labia, or a combination of these. As
stated previously, Poeschmann et al (1991) cautioned that
episiotomy may contribute up to 30% of total blood loss;
in their study the severity of blood loss was linked to the
length of time that elapsed between incision of the peri-
neum and the commencement of repair. Predictably, the
longer the wait the greater is the blood loss.
In order to identify the source of bleeding, the mother
is placed in the lithotomy position under a good direc-
tional light. An episiotomy wound or tears to the anterior
labia, clitoris and perineum often bleed freely. These exter-
nal injuries are easily identified and torn vessels may be
clamped with artery forceps prior to ligation. Internal
trauma to the vagina, cervix or uterus more commonly
occurs following instrumental or manipulative delivery. A
speculum is inserted to enable the cervix and vagina to be
clearly visualized and examined. Tissue or artery forceps
may be used to apply pressure prior to suturing under
general anaesthesia.
If bleeding persists when the uterus is well contracted
and no evidence of trauma can be found, uterine rupture
must be suspected. Following a laparotomy this is repaired,
but if bleeding remains uncontrolled a hysterectomy may
become inevitable.
Blood coagulation disorders causing PPH
As well as the causes already listed above, PPH may be the
result of coagulation failure (see Chapters 12 and 13). The
failure of the blood to clot is such an obvious sign that it
can be overlooked in the midst of the frantic activity that
accompanies torrential bleeding. It can occur following
severe pre-eclampsia, antepartum haemorrhage, massive
PPH, amniotic fluid embolus, intrauterine death or sepsis.
Evaluation should include coagulation status and replac-
ing appropriate blood components (Anderson and Etches
2007). Fresh blood is usually the best treatment, as this
will contain platelets and the coagulation factors V and
VIII. The expert advice of a haematologist will be needed
in assessing specific replacement products such as fresh
frozen plasma and fibrinogen.
Maternal observation
following PPH
Once bleeding is controlled, the total volume lost must
be measured and/or estimated as accurately as possible.
 Physiology and care during the third stage of labour
Large amounts appear less than they are in reality. A
MEOWS chart should be maintained postpartum and
abnormal scores should be reported and prompt action
taken (CMACE 2011). Maternal pulse and blood pressure
are recorded every 15 minutes and the temperature taken
every 4 hours. The uterus should be palpated frequently
to ensure that it remains well contracted and lochia lost
must be observed. Intravenous fluid replacement should
be carefully calculated to avoid circulatory overload.
Monitoring the central venous pressure (see Chapter 22)
will provide an accurate assessment of the volume
required, especially if blood loss has been severe. Fluid
intake and urinary output are recorded as indicators of
renal function. The output should be accurately measured
on an hourly basis by the use of a self-retaining urinary
catheter.
The woman may need high dependency care if closer
monitoring is required, until her condition is stable. All
records should be meticulously completed and signed
contemporaneously. Continued vigilance will be impor-
tant for 24–48 hours. As this woman will need a period
of recovery, she will not be suitable for early transfer
home.
Secondary postpartum
haemorrhage
Secondary postpartum haemorrhage is any abnormal or
excessive bleeding from the genital tract occurring
between 24 hours and 12 weeks postnatally. In developed
countries, 2% of postnatal women are admitted to hospi-
tal with this condition, half of them undergoing uterine
surgical evacuation (Alexander et al 2007). It is most
likely to occur between 10 and 14 days after birth. Bleed-
ing is usually due to retention of a fragment of the pla-
centa or membranes, or the presence of a large uterine
blood clot. Typically occurring during the second week,
the lochia is heavier than normal and will have changed
from a serous pink or brownish loss to a bright red blood
loss. The lochia may also be offensive if infection is a
contributory factor. Subinvolution, pyrexia and tachycar-
dia are usually present. As this is an event that is most
likely to occur at home, women should be alerted to the
possible signs of secondary PPH prior to discharge from
midwifery care.
Management
The following steps should be taken:
• call a doctor
• reassure the woman and her support person(s)
• rub up a contraction by massaging the uterus if it is
still palpable
• express any clots
• encourage the mother to empty her bladder
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Chapter | 18 |
• give a uterotonic drug either by the intravenous or
intramuscular route
• keep all pads and linen to assess the volume of
blood lost
• if bleeding persists, discuss a range of treatment
options with the woman and, if appropriate, prepare
her for theatre.
If the bleeding occurs at home and the woman has
telephoned the hospital, midwife or her GP, she should
be told to lie down flat until professional assistance
arrives (the front door should be left unlocked if the
woman is alone). On arrival, the doctor, midwife or para-
medic will assess the amount of blood loss and the
woman’s condition and attempt to arrest the haemor-
rhage. If the loss is severe or uncontrolled, the nearest
emergency obstetric unit will be called and the mother
and baby prepared for transfer to hospital. The doctor,
midwife or paramedic who attends will start an intrave-
nous infusion and ensure that the mother’s condition is
stable first.
Careful assessment is usually undertaken prior to the
uterus being explored under general anaesthetic. The use
of ultrasound as a diagnostic tool is invaluable in mini-
mizing the number of mothers who have operative inter-
vention. If retained products of conception cannot be
seen on a scan, the mother may be treated conservatively
with antibiotic therapy and oral ergometrine. The haemo-
globin should be estimated prior to discharge. If it is
below 9 g/dl, options for iron replacement should be dis-
cussed with the woman. The severity of the anaemia will
assist in determining the most appropriate care, which
may be dependent on whether or not the woman is
symptomatic (e.g. feeling faint, dizzy, short of breath).
Management may vary from increased intake of iron-rich
foods, iron supplements or, in extreme cases, blood trans-
fusion. It is also important to discuss the common symp-
toms that may be experienced as a result of anaemia
following PPH, including extreme tiredness and general
malaise. Encourage the woman to seek assistance and
stress the importance of making an appointment to see
her GP to have her general health and haemoglobin
levels checked.
Haematoma formation
PPH may also be concealed as the result of progressive
haematoma formation. This may be obvious at such sites
as the perineum or lower vagina, but it is more difficult to
diagnose if it occurs into the broad ligament or vault of
the vagina. A large volume of blood may collect insidi-
ously (up to 1 litre). Involution and lochia are usually
normal, the main symptom being increasingly severe
maternal pain. This is often so acute that the haematoma
has to be drained in theatre under a general anaesthetic.
Secondary infection is a strong possibility.
413
Section | 4 | Labour

Box 18.3 Key issues in the management of the

Care after a postpartum
third stage of labour haemorrhage
Whatever the cause of the haemorrhage, the woman will
• Difficulty of implementing well-documented research need the continued support of her midwife until she
evidence into practice (e.g. delayed cord clamping, regains her confidence. Her partner may also be fearful of
avoidance of CCT, using EMTSL for low-risk women)
a recurrence and need much reassurance. If the mother is
needs to be addressed.
breastfeeding, lactation may be impaired but this will only
• Care during the third stage of labour should not be be temporary and she should be reassured that persevering
viewed in isolation from what has occurred during the
will result in a return to normal lactation.
first and second stages of labour.
• The development of the mother–baby–father
relationship should be given priority.
• The global PPH rate has not reduced significantly in CONCLUSION
the past decade regardless of interventions applied
(see CMACE 2011 for UK). Key issues in the management of the third stage of labour
• Possible research: How does delayed childbearing are summarized in Box 18.3.
(increased age of women having a first baby), assisted
reproductive technology, high rates of oxytocin use in
the first stage, or obesity affect the risk of PPH?

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management of the third stage of
labour. BMJ; 345:e4546. doi:
10.1136/BMJ
A thought-provoking editorial.
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This article debates the non-uniformity of
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 Chapter 19
Prolonged pregnancy and disorders
of uterine action
Annie Rimmer

CHAPTER CONTENTS This chapter examines the evidence relating to

Prolonged pregnancy
Incidence
Possible implication for mother, fetus
and baby
Predisposing factors
Plan of care for prolonged pregnancy
The midwife’s role
Induction of labour (IOL)
Indications for induction of labour
Methods of induction
Midwife’s role when caring for the
mother where labour is being induced
Alternative approaches to initiating
labour
Failure to progress and prolonged labour
Delay in the latent phase of labour
Delay in the active phase of labour
The influence of the 3 ‘Ps’
The midwife’s role in caring for
a woman in prolonged labour
Delay in the second stage of labour
Obstructed labour
Precipitate labour
Making birth a positive experience
References
Further reading
Useful websites
prolonged pregnancy, induction of labour,
418 prolonged labour and precipitate labour. Any
decision with regards to the management of a
418
pregnancy that continues beyond term is based
on discussion between the woman and
418 obstetrician, but the midwife is in a unique
419 position to help the woman make sense of such
discussions, thereby enabling her to make an
419 informed decision based on informed choice.
420 When labour is induced, when there is failure to
420 progress in labour or when labour is prolonged,
421 with or without further complications, the
midwife remains in a key position to ensure the
422 woman is kept informed so that she is enabled
to continue to exercise her ability to be
425 autonomous in the plan of care of her own
labour and birth and the execution of that plan.
426 The role of the midwife in the care of the
woman will be discussed throughout.
426
426
427 THE CHAPTER AIMS TO:
427 • explore the issues relating to prolonged pregnancy
with reference to research and other evidence
428 • outline the indications for the induction of labour
429 and examine the methods used to induce labour in
429 contemporary practice
430 • describe the process where there is perceived failure
to progress in labour or labour is prolonged and
430
review the current evidence used to support the
431 management and care in such cases
433 • describe the serious complication that is obstructed
433 labour and discuss the importance of competent

© 2014 Elsevier Ltd 417

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Section | 4 | Labour
midwifery management and care of women during
the antenatal and intrapartum period if such
complications are to be avoided
• highlight the significant events in a precipitate
labour.
PROLONGED PREGNANCY
Much of the confusion when exploring the research and
other evidence on pregnancies that go beyond the expected
date of birth (EDB) and more specifically beyond 42 weeks
(294 days) lies in the terms used to describe such pregnan-
cies such as post-term pregnancy, prolonged pregnancy
and postdates. According to Hermus et al (2009) post-
term pregnancy is defined as a pregnancy where the gesta-
tion exceeds 42 completed weeks (294 days). This
definition is also used by others when referring to pro-
longed pregnancy (NICE [National Institute for Health
and Clinical Excellence] 2008a; Simpson and Stanley
2011). Gülmezoglu et al (2012) refer to pregnancies that
go beyond 294 days as both post-term and postdate.
What is clear is that all these terms refer to a specific
gestation of the pregnancy and not the fetus or neonate.
For the purposes of this chapter the term prolonged preg-
nancy will be used to describe a pregnancy equal to or
beyond 42 weeks. Postmaturity refers to a description of
the neonate with peeling of the epidermis, long nails,
loose skin suggestive of recent weight loss and an alert face
(Koklanaris and Tropper 2006). The relationship, if any,
between prolonged pregnancy and postmaturity will be
explored later in the chapter.
If prolonged pregnancy is defined by weeks of gesta-
tion, whether this is based on a calculation of the EDB
using Naegele’s rule or by ultrasound scan no later than
16 weeks, is to consider women as a homogenous group
and neglects, among other things, the racial variations
with shorter gestational age in South Asian and Black
women (Balchin et al 2007). If the anxiety pertaining to
prolonged pregnancy is possible adverse neonatal
outcome then perhaps we need to consider how pro-
longed pregnancy is defined for these groups of women.
Laursen et al (2004) suggest the notion of prolonged
pregnancy as ‘a normal variation of human gestation’.
According to Hovi et al (2006) only a small proportion
of prolonged pregnancies have babies that are postmature
as described above.
INCIDENCE
According to NICE (2008a), the frequency or incidence of
prolonged pregnancy is between 5% and 10%. The wide
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variation is a reflection of the disparate definitions as high-
lighted above, the number of women where EDB is uncer-
tain and different induction policies (Simpson and Stanley
2011). Based on a definition of equal to or more than 42
weeks a true incidence of prolonged pregnancy is difficult
to assess because in many cases women’s labour is induced
before reaching that time for specific complications in the
pregnancy, for maternal request or because the pregnancy
has gone beyond the EDB. According to the Department
of Health (DH 2006), prolonged pregnancy was the most
common indication given for induction of labour (IOL)
in England, accounting for approximately 46% of induc-
tions overall. Unfortunately the latest figures from the
Health and Social Care Information Centre (HSCIC 2012)
do not provide the same breakdown of statistics, only
giving an overall induction rate for England for 2011–2012
of 22.1%. It is acknowledged that in this period in England
4.2% of women gave birth at 42 weeks and over (HSCIC
2012).
The use of an early ultrasound scan to date the preg-
nancy (Chapter 11), whether or not there is uncertainty
with the last menstrual period (LMP), is thought by many
to reduce the number of pregnancies categorized as pro-
longed (Ragunath and McKewan 2007; NICE 2008a;
Simpson and Stanley 2011; Tun and Tuohy 2011; Oros et al
2012). Both accurately defining prolonged pregnancy and
the accurate dating of a pregnancy is important if the
woman is to be advised appropriately regarding the pos-
sible risks when discussing the options of expectant man-
agement or IOL where pregnancy is prolonged in order to
avoid unnecessary intervention in an otherwise ‘low-risk’
pregnancy.
Possible implications for mother,
fetus and baby
In exploring the research and other evidence, a number of
studies suggest there is an increase in perinatal mortality
and morbidity as the pregnancy goes beyond 41 weeks
(Hermus et al 2009; Simpson and Stanley 2011; Cheyne
et al 2012; Gülmezoglu et al 2012; Oros et al 2012).
Whilst many authors acknowledge that the ‘absolute risk
is small’ (NICE 2008a; McCarthy and Kenny 2010; Simpson
and Stanley 2011; Cheyne et al 2012; Gülmezoglu et al
2012), this information almost appears as an afterthought
and not worthy of further discussion. If prolonged preg-
nancy is to be perceived as a ‘complication’ the possible
‘risks’ need to be viewed from the perspectives of the
mother, fetus and neonate with regards to morbidity and
mortality.
Simpson and Stanley (2011) suggest that if a pregnancy
continues beyond 41 completed weeks the risks for the
mother are associated with a large for gestational age or
macrosomic infant such as shoulder dystocia, genital tract
 Prolonged pregnancy and disorders of uterine action
trauma, operative birth and postpartum haemorrhage
(PPH). In an otherwise low-risk pregnancy such risks must
be balanced with the risks of IOL, such as increased need
for epidural anaesthesia, uterine hyperstimulation, opera-
tive birth, PPH and failed induction (Ragunath and
McKewan 2007; Hermus et al 2009; McCarthy and Kenny
2010; Bailit et al 2010; Gülmezoglu et al 2012; Jowitt 2012;
Oros et al 2012).
According to Simpson and Stanley (2011), the possible
risks for the fetus and neonate in a prolonged pregnancy
appear to be two-fold: placental dysfunction linked to
oligohydramnios, restricted fetal growth, meconium asp­
iration, asphyxia and still birth; conversely the cases where
growth continues resulting in a macrosomic infant at risk
of bony injury, soft tissue trauma, hypoxia and cerebral
haemorrhage. The work of Fox (1997) suggests that the
changes in the placenta over the course of pregnancy are
part of a process of maturation and an increase in func-
tional efficiency as opposed to a decrease in functional
efficiency. Given that few post-term neonates exhibit signs
of postmaturity, possible changes in placental function
might be more appropriately linked to pregnancies where
the neonate displays such characteristics rather than in
prolonged pregnancies per se (Koklanaris and Tropper
2006).
Predisposing factors
Factors that might predispose a woman to a prolonged
pregnancy include: obesity, nulliparity, family history of
prolonged pregnancy, male fetus, fetal anomaly such as
anencephaly (Olesen et al 2006; Biggar et al 2010; Arrow-
smith et al 2011; Morken et al 2011; Simpson and Stanley
2011). Cardozo et al (1986) suggest there might be three
sub-groups related to a prolonged pregnancy, which
include those where the dates are incorrect, those with a
normal prolonged gestation where physiological maturity
is achieved after 42 weeks and those with correct dates and
are functionally mature but who do not go into labour at
term. Biggar et al (2010) looking at whether the spontan­
eous onset of labour is immunologically mediated found
the risk of prolonged pregnancy is higher in first pregnan-
cies and subsequently reduces with each following preg-
nancy, where the father is the same. If there is a different
father the risk of prolonged pregnancy is as if it were a first
pregnancy. Morken et al (2011) found there was a familial
factor in relation to the recurrence of prolonged pregnancy
across generations, which involves both the mother and
the father. Laursen et al (2004) demonstrate a lower peri-
natal mortality rate in prolonged pregnancies where the
mother has had a previous prolonged pregnancy, which
would seem to support a possible genetic influence with
a prolonged gestation as a normal variation on human
gestation.
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Chapter | 19 |
PLAN OF CARE FOR PROLONGED
PREGNANCY
In previous editions of this book the subheading ‘Manage-
ment of prolonged pregnancy’ has been used, which may
give the impression that the woman has little to contribute
to the pregnancy and how it should proceed once she has
reached 42 weeks. This implies compliance with the
‘choices’ given by the healthcare professional rather than
active participation in the discussion on the options and
choices available which every woman is entitled to
(Kirkham et al 2002; Cheyne et al 2012; Stevens and
Miller 2012). The concept of ‘plan of care’ for prolonged
pregnancy is perhaps less autocratic, the term implying an
approach the purpose of which is for the healthcare pro-
fessional to work with the woman to determine the most
appropriate way forward with the pregnancy in order to
ensure the optimum outcome for both mother and baby.
In a prolonged pregnancy where there are any obstetric or
medical complications the priority in the plan of care
should, with maternal consent, follow the practice for the
specific complication. If the pregnancy is otherwise low
risk, the plan of care can follow an expectant or active
approach, and the decision on which approach to take
should be based on the woman (and partner) receiving
the information on the possible benefits and risks of each
to enable her to make an informed decision based on
informed choice (NICE 2008a; Jowitt 2012).
If a woman chooses the expectant approach the recom-
mendations from NICE (2008a) are increased antenatal
surveillance which includes cardiotocography (CTG) at
least two times a week, and an ultrasound scan to estimate
the maximum amniotic fluid pool depth rather than a
more complex approach to antenatal fetal surveillance
which includes ‘computerised CTG, amniotic fluid index,
and assessment of fetal breathing, tone and gross body
movements’ (NICE 2008a: 279).
The use of a cervical membrane sweep (CMS) at 41
weeks’ gestation has been shown to increase the spontan­
eous onset of labour before 42 weeks in some nulliparous
and parous women (Mitchell et al 1977; de Miranda et al
2006). The purpose of CMS is to attempt to initiate the
onset of labour physiologically thus avoiding the interven-
tion of IOL using prostaglandin, artificial rupture of mem-
branes (ARM) and oxytocin. CMS is designed to separate
the membranes from their cervical attachment by intro-
ducing the examining fingers into the cervical os and
passing them circumferentially around the cervix. The
process of detaching the membranes from the decidua
results in an increase in the concentration of circulating
prostaglandins that may contribute to the initiation of the
onset of labour in some individuals (Mitchell et al 1977).
Massage of the cervix can be used when the cervical os
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Section | 4 | Labour
remains closed and this process may also cause release of
local prostaglandin. If after an appropriate time labour has
not started spontaneously the process can be repeated. The
practice of CMS is not associated with any increase in
maternal or neonatal infection although women report
more vaginal blood loss and painful contractions in the
24-hour period following the procedure. Simpson and
Stanley (2011) state that to avoid IOL in one woman CMS
would need to performed for seven women and suggest
the benefit is therefore small. However, when one com-
pares this to Stock et al (2012), who state that 1040
women would need to be induced to avoid one perinatal
death, whilst leading to seven additional admissions to
the special care baby unit, the ‘odds’ for CMS as a possible
means to initiate labour seem extremely favourable.
Menticoglou and Hall (2002) argue that ‘ritual induc-
tion’ at 41 weeks is based on flawed evidence and interferes
with a ‘normal physiologic situation’. Heimstad et al
(2007) compared IOL at 41 weeks’ gestation with expect-
ant management and found no difference between the two
groups with regards to neonatal morbidity or mode of
birth. A number of authors cite evidence that where there
is an active approach and IOL is undertaken beyond 41
weeks there is a reduction in perinatal mortality (NICE
2008a; Simpson and Stanley 2011; Tun and Tuohy 2011).
But as stated above, many authors acknowledge that the
‘absolute risk of perinatal death is small’ (NICE 2008a;
McCarthy and Kenny 2010; Simpson and Stanley 2011;
Cheyne et al 2012; Gülmezoglu et al 2012). Oros et al
(2012) found that IOL at 41 weeks led to an increase in
the length of hospital stay for the mother and an increase
in the caesarean section rate.
The debate on the management of prolonged pregnancy
centres on the disparate evidence with regards to fetal risk
and neonatal outcome in terms of perinatal mortality and
morbidity, and implementing a policy of ‘management’
rather than a ‘plan of care’ is designed to reduce these risks.
When looking at the evidence surrounding post dates
(40+0 weeks to 41+6 weeks) and prolonged pregnancy (42
weeks), what is clear is that nothing is clear. There is a
plethora of evidence but much of it is contradictory and
much of it is couched in emotive terms. Reference is con-
sistently made to the ‘risks of’ prolonged pregnancy or the
‘risk of’ recurrence of prolonged pregnancy, which seems
to imply that a poor outcome is inevitable. NICE (2008a)
refers to the ‘risks of’ prolonged pregnancy against the
harms and benefits of IOL to avoid prolonged pregnancy.
The mechanisms leading to the onset of labour remain
largely unknown and the possibility of a prolonged preg-
nancy being a variation on human gestation within
normal parameters should be considered.
Like many authors, NICE (2008a) seem to imply, either
implicitly or explicitly, there are no benefits to a prolonged
pregnancy. Can nature really have got it so wrong? The
emphasis appears to be that in human parturition an EDB
is calculated, and it is downhill all the way from there; and
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whilst the EDB remains the focus, the debate and contro-
versy will continue. A number of women will gladly
accept, and may even request IOL once they go beyond
their EDB and that decision must be respected, but
the decision not to have labour induced must also be
respected, rather than, as NICE (2008a: 29), suggest
‘should’ be respected.
The midwife’s role
The woman and her partner must be given clear and un-
biased information pertaining to the benefits and possible
risks of any proposed plan of care to enable the woman
to make an informed decision based on informed choice.
It is clear from the literature that this is not always the case,
and the woman is being directed towards IOL by over­
emphasizing the risks of prolonged pregnancy whilst
downplaying the risks associated with IOL (Gatward et al
2010; Cheyne et al 2012; Stevens and Miller 2012). Whilst
the obstetrician will take the lead in such cases, the
midwife has a key role in facilitating the woman’s right to
autonomy by ensuring she has been given clear and unbi-
ased information, that she fully understands the options
available to her, and in appropriate cases, acting as the
woman’s advocate (NMC [Nursing and Midwifery Council]
2012, 2008). Women are put in an unenviable situation
at an extremely vulnerable time in their lives and they
expect, quite rightly, that the experts will help them to
make sense of the choices available to them. The midwife
has a duty of care to assist women at this time. It is,
however, important to understand that whatever plan of
care is put in place in any pregnancy, it is not always pos-
sible to avoid a perinatal death.
See Box 19.1 for a summary of the key points relating
to prolonged pregnancy.
INDUCTION OF LABOUR (IOL)
Labour is the process whereby the uterine muscle contracts
and retracts leading to effacement and dilatation of the
cervix, the birth of the baby, expulsion of the placenta and
membranes, and the control of bleeding (see Chapters
16–18). It is only one part of the passage in the childbirth
experience but for the majority of women and their
partners it is the singular most important part and the
care and management they receive will always be
remembered.
IOL is an intervention to initiate the process of labour
described above by artificial means and involves the use
of prostaglandins, ARM (amniotomy), intravenous oxy-
tocin, or any combination of these (WHO [World Health
Organization] 2011). It is the term used when initiating
this process in pregnancies from 24 weeks’ gestation, the
legal definition of fetal viability in the United Kingdom
 Prolonged pregnancy and disorders of uterine action
Box 19.1 Key points in the management of
prolonged pregnancy
• Accurate EDB determined by LMP and early
ultrasound reduces the incidence of pregnancies
diagnosed as prolonged.
• The length of gestation in some racial groups must
also be considered with regards to a definition of
prolonged pregnancy in these groups of women to
improve perinatal outcomes.
• A membrane sweep can be offered from 40 weeks as
a means to initiate the onset of spontaneous labour.
• Where there is any complication in a pregnancy
approaching or beyond term the priority in
management should follow the practice for the
specific complication.
• Where the woman makes the choice for expectant
management she must be informed that any
deviations highlighted in antenatal surveillance will
necessitate a review of the plan of care and the
options available to her.
(UK) (House of Commons Select Committee 2007).
Where labour is being induced a full assessment must be
made to ensure that any intervention planned will confer
more benefit than risk for both mother and baby.
There has been a steady rise in IOL in recent years, the
most recent statistics showing an IOL rate of 22.1%
(HSCIC 2012). In the UK it is an intervention that has
become routine practice in maternity units within the
National Health Service (NHS). When comparing IOL to
a spontaneous onset of labour, evidence demonstrates
that it is more painful, that women are more likely to
require epidural anaesthesia and an assisted mode of
birth (NICE 2008a; WHO 2011). The decision therefore
to induce labour should only be made when it is clear
that a vaginal birth is the most appropriate outcome in
this pregnancy, at this time, for that particular woman
and her baby.
Indications for IOL
IOL is considered when the maternal or fetal condition
suggests that a better outcome will be achieved by inter-
vening in the pregnancy than by allowing it to continue.
This most commonly applies to cases where there are
deviations from the normal physiological processes of
childbirth as a result of hypertension, diabetes, fetal
growth restriction or macrosomia. A list of some of the
indications for IOL can be seen in Box 19.2, although this
should not be considered as a definitive list. The mother
may also request to have labour induced, although NICE
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Chapter | 19 |
Box 19.2 Indications for induction of labour
Maternal
• Prolonged pregnancy – defined as one that exceeds
42 completed weeks or 294 days. This is the
commonest reason for induction of labour in England
because of the increased risk of perinatal mortality
and morbidity when the pregnancy continues beyond
term, although the absolute risk is small (see above).
• Hypertension, including pre-eclampsia – the decision
to induce labour and expedite delivery is done in the
best interests of the woman and her baby and the
timing of induction will be influenced by the severity
of her symptoms.
• Diabetes – the type and severity of diabetes influence
the decision to induce. The risk of fetal macrosomia is
increased where diabetic control is poor. In women
with pre-existing type 1 and type 2 diabetes, the risk
of adverse perinatal outcome is significantly increased
over the national population (NICE 2008b). Where the
fetus is normally grown, elective IOL is offered after
38 weeks’ gestation.
• Prelabour rupture of membranes – the longer the
interval between membrane rupture and birth of the
baby increases the risk of infection to mother and
fetus. For the majority of women spontaneous labour
will commence within 24 hours of rupture of
membranes but women should be offered the choice
of IOL after 24 hours or expectant management (NICE
2008a).
• Maternal request – this may be for psychological or
social reasons. For some women there are compelling
reasons for requesting IOL when there is no clinical
indication. In such cases it is important the woman is
quite clear about the implications of such a decision.
IOL may be considered from 40 weeks (NICE 2008a).
Fetal
• Fetal death – if there are no complications such as
SRM, infection or bleeding the choice of immediate
IOL or expectant management should be offered.
Where there are complications IOL is recommended.
• Fetal anomaly not compatible with life.
(2008a) state this should only be agreed in exceptional
circumstances. Ultimately, the grounds on which the deci-
sion is made to induce labour must be sound enough to
support the outcome whatever that outcome might be.
There is no guarantee IOL will result in a vaginal birth or
positive outcome for mother and/or her baby.
The contraindications for IOL are situations that pre-
clude a vaginal birth in the best interests of the mother
and/or baby. These are listed in Box 19.3.
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Section | 4 | Labour
Methods of induction
The cervix must maintain its integrity during pregnancy
and then undergo remodelling prior to labour. For an
induction to be successful the cervix needs to have under-
gone the changes that will ensure the uterine contractions
are effective in the progressive dilatation and effacement
of the cervix, descent of the presenting part and the birth
of the baby.
The cervix is said to be ripe when it has undergone these
changes. The Bishop score, devised in the 1960s (Bishop
1964), is the means by which the ripeness of the cervix is
assessed using a scoring that examines four features of the
cervix and the relationship of the presenting part to the
ischial spines. Each of these five elements is scored between
0 and 3 on vaginal examination (VE). The scoring system
has been modified and it is this version that is used in
contemporary practice (see Table 19.1). Whilst a score of
≤6 is considered to be unfavourable, a score of 8 or more
suggests a greater probability of a vaginal birth, similar to
that when the onset of labour is spontaneous (NICE
2008a; Gülmezoglu et al 2012). A ripe or favourable cervix
is one that for the purpose of IOL is more compliant,
offering less resistance as the contraction and retraction of
the myometrium forces the presenting part down (NICE
2008a).
Box 19.3 Some contraindications for induction
of labour
• Placenta praevia
• Transverse lie or compound presentation
• HIV-positive women not receiving any anti-retroviral
therapy or women on any anti-retroviral therapy with
a viral load of 400 copies/ml or more (RCOG 2010;
NICE 2011)
• Active genital herpes
• Cord presentation or cord prolapse when vaginal birth
is not imminent
• Known cephalo-pelvic disproportion (CPD)
• Severe acute fetal compromise
Table 19.1 Modified Bishop’s pre-induction pelvic scoring system
Inducibility features
Dilatation of cervix in cm
Consistency of cervix
Cervical canal length in cm
Position of cervix
Station of presenting part in cm above or below ischial spine
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A VE to assess the cervix and the likelihood of successful
induction in this way is by nature a subjective examination
and as such there will be inter-observer variations. Trans-
vaginal ultrasound assessment of cervical length was
found to be superior to the Bishop’s score in predicting
the success of IOL (Elghorori et al 2006), but currently VE
remains the most common method of cervical assessment
for IOL. Whilst it is acknowledged that a VE is a subjective
means of assessment, if the same individual undertakes
the assessment each time then inter-observer variation
does not apply. This would also provide the woman with
continuity of caregiver at an extremely vulnerable and
anxious time for her, which is in the woman’s best interest
and a standard of care midwives should aim to meet.
Cervical membrane sweep
A cervical membrane sweep (CMS), as described previ-
ously, is considered by NICE (2008a) to be an addition to,
rather than a method of IOL per se. They recommend it is
offered to nulliparous women at the 40- and 41-week
antenatal examination and to parous women at the
41-week review. It is commonly undertaken by a doctor or
midwife experienced in the practice and has been shown
to reduce the need for further methods to induce labour
(Mitchell et al 1977; Boulvain et al 2005; McCarthy and
Kenny 2010). However, Rogers (2010) suggests the evi-
dence on this is inconclusive and both women and mid-
wives need to be aware of this if the woman is to be able
to make an informed choice. Some women may find the
procedure uncomfortable or painful and they may experi-
ence vaginal spotting and abdominal cramps (McCarthy
and Kenny 2010). Wong et al (2002) found that whilst the
procedure was safe in that it did not lead to prelabour
rupture of membranes, bleeding or maternal or neonatal
infection, for some women it did cause significant discom-
fort and in their study was not found to reduce the need
for IOL. Boulvain et al (2005) suggest the possible benefits
in terms of a reduction in more formal induction methods
need to be weighed against the discomfort of the VE and
other adverse effects of bleeding and irregular contractions
not leading to labour. The recommendation from NICE
(2008a) to offer CMS at 40/41 weeks is to avoid prolonged
0 1 2 3
<1 1–2 2–4 >4
Firm Firm Med Soft
>4 2–4 1–2 <1
Post Mid Ant –
−3 −2 −1, 0 +1, +2
 Prolonged pregnancy and disorders of uterine action
pregnancy and is not meant for high-risk cases. Whilst the
evidence on whether it leads to spontaneous labour is
inconclusive, if the alternative is IOL for women whose
only risk factor seems to be their EDB it is perhaps an
‘intervention’ that is worthy of consideration.
Prostaglandin E2 (PGE2) (Dinoprostone)
Prostaglandins are naturally occurring female hormones
present in tissues throughout the body. Prostaglandin E2
and F2 are known to be produced by tissues of the cervix,
uterus, decidua and the fetal membranes and to act locally
on these structures. Dinoprostone is the active ingredient
in PGE2 vaginal tablets, gel and pessaries (BNF [British
National Formulary] 2013). It replicates prostaglandin E2
produced by the uterus in early labour to ripen the cervix
and is seen as a more natural method than the use of
oxytocin. PGE2 placed high in the posterior fornix of the
vagina, taking great care to avoid inserting it into the cervi-
cal canal (see Fig. 19.1) is absorbed by the epithelium of
the vagina and cervix leading to relaxation and dilatation
of the muscle of the cervix and subsequent contraction of
uterine muscle. According to Blackburn (2013), the use of
a prostaglandin greatly increases the probability of delivery
occurring within 24 hours, and prior to the use of oxytocin
potentiates the effects of the oxytocic agent (BNF 2013).
There are a number of preparations of PGE2, which have
been found to be clinically equivalent; but not bioequiva-
lent. The current recommendation from NICE (2008a) is
Vagina
(directed posteriorly)
Posterior fornix
Fig. 19.1 Insertion of prostaglandins. The posterior fornix of
the vagina is used to insert prostaglandins for ripening or
induction of labour. The key point is that when undertaking
a vaginal examination to assess the cervix midwives should
follow the direction of the vagina, which will be directed
posteriorly if the woman is semi-recumbent. The uterus is
anteverted and anteflexed, creating the posterior fornix. The
cervix may appear ‘difficult to reach’, particularly when
unfavourable.
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Chapter | 19 |
the use of gel, tablet or controlled release pessary. In a
small study by Tomlinson et al (2001), the women receiv-
ing the slow release pessary gave a higher satisfaction score
with regards to their perception of labour. Whilst the slow
release preparation would appear to confer more benefit
from the woman’s perspective with regard to fewer vaginal
examinations, the difference in cost between the gel, tablet
and controlled release pessary, with currently the latter
being marginally more expensive, may prohibit its use in
some NHS Trusts for routine use in IOL.
Prior to the insertion of PGE2, the midwife will carry out
an abdominal examination to confirm fetal lie, presenta-
tion, descent of presenting part and fetal wellbeing by use
of electronic fetal monitoring (EFM). All findings are
clearly recorded in the woman’s maternity records and if
there is any doubt or concern in the findings the process
must be stopped and the doctor informed (NMC 2012).
Following insertion of PGE2 the woman is advised to lie
down for 30 minutes. When contractions begin continu-
ous EFM is used to assess fetal wellbeing. If the CTG is
confirmed to be normal, i.e. all four features are consid-
ered to be reassuring, the CTG can be discontinued and
intermittent auscultation used unless there are any other
clear indications for the use of continuous EFM (NICE
2007, 2008a). Currently the IOL process commonly takes
place as an inpatient, either on the antenatal ward or
labour suite depending on the reason for IOL. There is
evidence to support starting the IOL process in the
morning rather than the evening, citing increased mater-
nal satisfaction with the process (NICE 2008a). Prior to
the administration of the PGE2 the midwife must confirm
there is a bed available on the labour suite in the event
there is a need to transfer the woman as a matter of
urgency. For the safety of the woman and her baby any
decision to proceed with IOL must take cognisance of the
current situation on the labour suite because the woman’s
response to insertion of PGE2 cannot be predicted. If there
are any maternal or fetal risk factors in the pregnancy the
IOL must take place on the labour suite.
Where the membranes are intact or ruptured the recom-
mended initial dose for all women, whether it is a first or
subsequent pregnancy, is one dose of PGE2 tablet (3 mg)
or gel (1–2 mg), re-assess in 6 hours and if labour is not
established, and the woman has given consent, a second
dose of tablet or gel is inserted into the posterior fornix of
the vagina. This equates to one cycle. Alternatively one
cycle of PGE2 controlled-release pessary (10 mg) can be
given over 24 hours, which is one pessary. The maximum
recommended dose of PGE2 tablet, gel or controlled-
release pessary being one cycle (NICE 2008a). Side-effects
of PGE2 include nausea, vomiting and diarrhoea (BNF
2013). If labour is not established after one cycle of treat-
ment the IOL is classed as having failed, and having
established both mother and baby are in good health
discussion must take place between the woman and doctor
with regards to further options – these being another
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Section | 4 | Labour
attempt to induce labour or elective caesarean section
(NICE 2008a).
Vaginal PGE2 is currently the only recommended route
for the use of prostaglandins for IOL. Misoprostol (PGE1)
is not licensed for use in the UK. Whilst it is thought to
be more effective and less expensive than PGE2 and oxy-
tocin for the IOL there remain questions about safety
issues with regards to uterine hyperstimulation. Currently
in the UK PGE1 is recommended for IOL only where there
is an intrauterine fetal death (IUFD).
With a caesarean section (CS) rate in excess of 25%
(HSCIC 2012), it is inevitable that more and more women
with a uterine scar will be faced with the decision regard-
ing IOL. Whilst previously PGE2 was not recommended
where there was a scar on the uterus, women with a previ-
ous lower segment caesarean section (LSCS) may now be
offered IOL using PGE2. It is important for the midwife to
understand the significance of a scarred uterus and choices
with regards to IOL to ensure the woman is informed of
the increased risk of requiring an emergency CS and
increased risk of rupture of the uterus.
Risk associated with use of PGE2
The use of PGE2 can be unpredictable and may lead
to uterine hyperstimulation, placental abruption, fetal
hypoxia, pulmonary or amniotic fluid embolism (Kramer
et al 2006). The risk of uterine rupture is rare, occurring
in between 0.3% and 7% of labours.
Artificial rupture of membranes (ARM)
There are two layers of membrane surrounding the fetus:
the amnion is closest to the fetus, and the chorion is
nearest to the decidua. ARM is a relatively simple process
that can be used in an attempt to induce labour if the
cervix is favourable and the presenting part is fixed in the
pelvis, particularly where the woman does not want to use
drugs such as PGE2 or oxytocin, or where there is a risk of
hyperstimulation if using PGE2. Prior to the procedure an
abdominal examination is carried out and if the lie is
longitudinal, the presenting part is engaged and the fetal
heart rate is within normal limits, a VE is done to assess
the cervix, confirm the presentation and station and to
exclude possible cord presentation or vasa praevia. If these
findings are satisfactory the bag of membranes lying in
front of the presenting part (forewaters) is ruptured with
the use of an amnihook or similar device to release the
amniotic fluid. The fluid is assessed for colour and volume
and following ARM it may be possible to distinguish other
features on the presenting part to identify the position of
the fetus. After the procedure the woman is made comfort-
able, the fetal heart is auscultated and all findings are
recorded in the maternity notes. The longer the interval
between ARM and birth increases the risk of the woman
developing chorioamnionitis as a result of an ascending
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infection from the genital tract leading to an increased risk
of perinatal mortality (Bricker and Luckas 2012; Blackburn
2013). For this reason if a decision has been made to
induce labour for perceived risks it is common practice to
start an oxytocin infusion within a few hours if labour has
not been established following the ARM. In their review
of two trials Bricker and Luckas (2012) found insufficient
evidence to recommend amniotomy alone for the IOL.
Changes to ripen the cervix are thought to be in response
to prostglandin produced by the amnion and cervix. In
pregnancy the chorion provides a barrier to the amnion
and fetus from the vagina and cervix. Prostaglandin dehy-
drogenase (PGDH) is an enzyme produced by the chorion
that breaks down prostaglandin. As a result of the actions
of this enzyme the changes in the cervix do not take place
and pre-term labour is avoided (Smyth et al 2013). Mitch-
ell et al (1977) found that VE in late pregnancy rapidly
increases the concentration of circulating prostaglandins.
This change occurs both in sweeping the membranes and
with ARM. It is thought it is the disruption of the attach-
ment of the membranes to the uterine wall that facilitates
this change. In contrast, Van Meir et al (1997) found that
in labouring women the part of the chorion that was in
close contact with the cervical os released less PGDH
allowing the prostaglandin from the amnion to come
into contact with the cervix and facilitate ripening of the
cervix. The theory is that if an ARM is performed too early
the action of the amniotic prostaglandins on the cervix
is lost.
Oxytocin
Oxytocin is synthesized in the hypothalamus and then
transported to the posterior lobe of the pituitary gland
from where it is episodically released to act on smooth
muscle. The number of oxytocin receptors in the myo-
metrium significantly increases by term increasing uterine
oxytocin sensitivity (Blackburn 2013).
In its synthetic form, oxytocin (Syntocinon) is a power-
ful uterotonic agent that may be used as part of the process
for IOL following ARM. NICE (2008a) do not recommend
the use of oxytocin alone for IOL, or the use of ARM and
oxytocin as a ‘primary method’ of IOL, unless the use of
vaginal PGE2 is specifically contraindicated. Oxytocin
should be administered by slow intravenous infusion
using an infusion pump or syringe driver with non-return
valve. The infusion rate should follow NHS Trust protocol
and the maximum rate of 0.2 units/minute should not be
exceeded (BNF 2013). The dose is titrated against uterine
activity, usually increasing the dose every 30 minutes with
the aim of 3–4 contractions every 10 minutes with each
contraction lasting approximately one minute, using the
lowest possible dose. If contractions exceed this rate, or
the contractions fail to establish, the infusion must be
stopped and the case reviewed to determine the next step.
There should be an interval of at least six hours between
 Prolonged pregnancy and disorders of uterine action
administration of prostaglandins and commencement of
an oxytocin infusion.
When using an oxytocin infusion the fetal heart rate and
uterine activity should be monitored using continuous
EFM to ensure the fetus does not become compromised
by the induced uterine contractions. There is a risk of
hyperstimulation and hypertonic uterus leading to fetal
compromise (Ragunath and McEwan 2007; McCarthy and
Kenny 2010). In such cases the infusion is decreased or
discontinued and medical aid summoned. Even with the
use of the CTG the midwife still has an important role to
play in assessing the woman’s progress. The graphic repre-
sentation on the CTG provides an indication of the fre-
quency of the contractions but does not necessarily
provide an accurate representation of the length and
strength of the contractions, and for this reason it is
important that the midwife continues to palpate the
uterus to assess contractions for their length and strength.
Whatever ‘science’ is being employed to assess maternal
and fetal wellbeing the midwife has a valuable opportu-
nity to be with the woman and to use her ‘art’ to make a
more holistic assessment of the woman and how she is
responding to the process and what she wants and needs
at this time.
Risks associated with use of intravenous oxytocin
include:
• Uterine hyperstimulation or hypertonus
• Fetal hypoxia and asphyxia
• Uterine rupture
• Fluid retention as a result of the antidiuretic effect of
oxytocin
• Postpartum haemorrhage
• Amniotic fluid embolism (AFE)
Midwife’s role when caring
for the mother where labour
is being induced
The midwife’s responsibilities regarding IOL include care
during the antenatal and intrapartum period. Where a
decision has been made to induce labour it is important
the midwife ensures the woman and her partner have been
fully informed and understand the process and how it
might be undertaken. As can be seen from above there are
a number of ways that labour can be induced and the
manner the induction will take will depend on the indi-
vidual circumstances of each woman. All information
should be given in an objective manner to ensure the
woman and her partner understand the reason for the
induction, any possible consequences or risks of having/
not having the procedure as well as any alternatives to IOL
(NICE 2008a). It is important for the woman and her
partner to understand that induction may be delayed if the
labour suite is busy, that it might take some time for con-
tractions to be initiated, and the possibility the induction
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Chapter | 19 |
process will be unsuccessful. Whilst the assumption may
be that this will already have been discussed, it is incum-
bent upon the midwife to ensure the woman is fully
informed (NMC 2008, 2012). Time should be allowed for
discussion with the midwife or obstetrician and it must be
remembered that consent to a treatment can be withdrawn
at any time and this decision by the woman must be
respected (Griffith et al 2010). The midwife or doctor
should record any discussion that takes place and any
requests made in the maternity notes.
During the induction process all maternal and fetal
observations will be recorded in the maternity notes. Until
labour is established and the partogram is commenced the
observation are normally recorded in the antenatal section
of the notes. Because the layout is not as comprehensive
and logical as the partogram it is important the midwife
is clear and methodical in her documentation at this time
(NMC 2012). The frequency and type of monitoring of the
mother and fetus will depend on the reason for and
method of induction. The midwife is advised to follow the
local NHS Trust guidelines regarding IOL in each case, if
this is what the woman wishes and has consented to. It is
important when monitoring the wellbeing of the mother
and fetus during the induction process that the midwife
understands the possible risks associated with each
method of induction and is confident and competent in
recognizing and responding to any deviations from
normal.
When the onset of labour is spontaneous it is a more
insidious process and as such the woman has time to
adjust to the changes in her body and is usually better able
to cope with contractions. When labour is induced the
sudden onset of strong painful contractions occurring
every three to four minutes can be quite overwhelming
and result in an early request for pain relief. As well as this
the woman has to make a temporal shift from how she
planned to birth her baby to what is now taking place. This
can be extremely hard for the woman and her partner to
come to terms with and can have a negative impact on this
singularly important time in both their lives. Continuity
of caregiver in labour is important in developing a rapport
with the woman and her partner and in being able to
make an assessment of her progress based on physical
observations of abdominal examination and VE as well as
less tangible observations of body language and behaviour
(Lowe 2007; Laursen et al 2009; Hodnett et al 2012). In
this way the midwife may be better able to advise the
woman of her progress to help her in her decision as to
how she would like her labour to proceed. IOL does not
have to be a negative experience and the midwife is in a
key position to use her ‘art’ to enable the woman to have
a positive birthing experience, whatever the outcome.
It must be remembered that each woman’s labour,
whether it is spontaneous onset or induced, is their own
individual experience, and what they wish for their labour
may not always conform to NHS Trust guidelines. As in
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all care the midwife provides, valid consent must be
obtained before any examination or intervention, and this
requires taking time to give the woman the information
so that she is fully informed and knows and understands
what she is consenting to. When a woman is experiencing
painful contractions in labour the information about any
examinations or procedures that the midwife or doctor
may wish to perform should be given between
contractions.
Alternative approaches to
initiating labour
For some women avoidance of any surgical or pharmaco-
logical intervention in an otherwise low-risk pregnancy is
extremely important and they might seek advice from the
midwife on this matter. Alternative approaches include the
ingestion of castor oil, nipple stimulation, sexual inter-
course, acupuncture and the use of homeopathic methods.
Whilst some reviews, for example Kavanagh et al (2008)
and Smith and Crowther (2012), have found insufficient
evidence to recommend some of these as a method to
initiate labour it is important for the midwife to under-
stand how each of these are thought to work, and to be
familiar with the wider literature on these subjects to
develop a broad understanding to ensure that any advice
given on alternative therapies is in line with her sphere of
practice (NMC 2012). For the complete list of reviews on
alternative approaches to initiating labour visit the
Cochrane database online.
One alternative approach with more positive findings is
that of stimulation of the breast. The findings of Kavanagh
et al (2005) suggest stimulation of the breast either by
massage or nipple stimulation ‘appears beneficial in rela-
tion to the number of women not in labour after 72 hours,
and reduced postpartum haemorrhage rates’. It appears to
be less effective where the cervix is not ripe. Stimulation
of the breast or more specifically the nipple appears to
cause the release of endogenous oxytocin, the effect being
to initiate a uterine response, but further studies are
needed before it can be considered for use in high-risk
groups.
FAILURE TO PROGRESS AND
PROLONGED LABOUR
The physiology of labour encompasses effective uterine
contractions and cervical changes leading to progressive
effacement and dilatation of the cervix, rotation of the
fetus and descent of the presenting part, the birth of the
baby, and expulsion of the placenta and membranes and
the control of bleeding. The psychology of labour encom-
passes the need for a safe and stress-free environment, one
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in which the woman feels in control of events and has
trust in those caring for her (Laursen et al 2009) and is an
equally important part of the process of labour (see
Chapter 1).
For many, the process of labour starts spontaneously
and continues that way without the need to intercede. For
others the process may falter and the caregiver must assess
whether this is a temporary slowing down in progress as
the woman’s mind and body adjusts to what is happening,
and to what has yet to happen, or whether it is the first
signs of a delay in progress that may benefit from a change
in the status quo. Historically, terms such as ‘failure to
progress’, ‘prolonged labour’ and ‘dystocia’ have been used
when labour is perceived not to be following a pre-
determined line of progress, whether that is the rate of
cervical dilatation/hour or if the labour is considered to
have exceeded a set number of hours. NICE (2007) do not
specify these terms but refer to a change in progress in the
first or second stage of labour as ‘suspected delay’ or ‘delay’
depending on the findings.
Prolonged labour is not easily defined, primarily
because there is no consensus as to what constitutes a
normal time limit for labour either in the latent or active
part of the first stage or the passive or active part of the
second stage. When labour is slow to progress or pro-
longed there is an increased risk of chorioamnionitis if
there has been prolonged rupture of membranes, and an
increased risk of postpartum haemorrhage as a result of
an atonic uterus. Nonetheless it must also be remembered
the interventions used to correct a dystocia, such as amni-
otomy, oxytocin infusion and instrumental or operative
birth, are not risk-free and therefore any decision to inter-
vene must take account of the full clinical picture and as
importantly the wishes of the woman.
Delay in the latent phase of labour
In the first stage of labour, the latent phase is the period
when structural changes occur in the cervix and it becomes
softer and shorter (from 3 cm to less than 0.5 cm), its
position is more central in relation to the presenting part
and there are painful contractions (Chapter 16). Accord-
ing to NICE (2007), the dilatation of the cervix at this time
is up to 4 cm. During this period the woman needs
support and encouragement from those caring for her.
The perceived result of painful contractions may be disap-
pointing when hearing the cervix is 3 cm dilated after
several hours. If progress in this phase of labour is consid-
ered to be slow the emphasis is on conservative manage-
ment rather than intervention (Hayman 2004). The
midwife must ensure the woman knows to keep eating
and drinking if she feels able to as this will not only help
maintain her energy levels but can also bring a sense of
normality and comfort. It is important for the woman to
rest at this time and not to feel that if she tries to sleep the
contractions will cease. Advice on how to relieve pain
 Prolonged pregnancy and disorders of uterine action
might include simple back massage, changes of position,
a warm bath or some simple analgesia; all are an impor-
tant part of care at this time. Any intervention such as an
ARM at this stage can interfere with the action of amniotic
prostaglandin on the cervix and be counterproductive
(Smyth et al 2013).
Delay in the active first stage
of labour
NICE (2007) refers to the established first stage of labour
rather than the active phase, and define this as the period
when the uterine contractions are regular and painful and
the cervix dilates progressively from 4 cm. Neal et al
(2010) suggest that the active phase begins between 3 and
5 cm when there are regular uterine contractions.
For nulliparous women delay is suspected if their
progress, in terms of cervical dilatation, is less than 2 cm
in 4 hours. For parous women it is the same, or there is
considered to be a ‘slowing in progress’ (NICE 2007: 40).
This suggests the rate of cervical dilatation and duration
of labour is measurable and such measurements can be
applied to all nulliparous or multiparous women. It is,
however, rather more complex and needs to take account
of a wide range of variables in terms of maternal age,
maternal size, fetal position etc. Such factors may mean
labour does not conform to a pre-determined rate of pro-
gression whilst still being normal for that particular
woman. Nonetheless, when caring for women in labour
midwives do need some parameters to work within in
order to better understand what is considered acceptable
in terms of progress (Neal et al 2010). NICE (2007)
acknowledges the active phase of labour does not follow
the trajectory that Friedman (1954) put forward to suggest
a rate of 0.5 cm/h. Although they suggest that considera-
tion should also be given to the rotation, descent and
station of the presenting part, these observations do not
appear to merit the same importance as cervical dilatation.
For some women good progress will be made in terms of
rotation, descent and station of the presenting part,
although such progress is not always reflected in a corre-
sponding change in cervical dilatation. Neal et al (2010:
317) suggest that for low-risk, nulliparous women, with
spontaneous onset of labour ‘contemporary expectations
of active labour are overly stringent’.
When there is ‘suspected delay’ the midwife needs to
discuss with the woman how the situation might be best
managed from this point onwards, with appropriate con-
sideration of all the facts in the context of that particular
woman. Alleviating anxiety by ensuring there is continu-
ous support in labour, changing maternal position, allevi-
ating pain using non-pharmacological means are some of
the ways in which the midwife can help the woman at this
time. Medical interventions to correct this include ARM or
oxytocin or a combination of both, and the means to
augment labour in this way has become common practice
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Chapter | 19 |
in the UK, with as many as 50% of nulliparous women
receiving an oxytocin infusion in labour (Hayman 2004).
If these means fail, an instrumental or operative birth may
be the only course of action depending on the stage of
labour reached. The caesarean section rate in England is
currently 25% with 14.8% being emergency caesarean sec-
tions (HSCIC 2012), and many of these will be for a
diagnosis of failure to progress or prolonged labour.
The partogram or partograph is a graphical representa-
tion of the maternal and fetal condition in established
labour and the dilatation of the cervix against time. Infor-
mation on a number of findings that are important in
making an appropriate assessment of the ongoing progress
of labour are usually recorded on a single sheet. NICE
(2007) recommends the use of a partogram once the
woman is in established labour despite the only evidence
to support its use being studies from low-income coun-
tries. In a recent review by Lavender et al (2012), the
routine use of a partogram as part of the management of
labour could not be recommended, suggesting that its use
should be determined at a local level. Possibly one of the
most debated issues in the use of a partogram is the plot-
ting of cervical dilatation on a graph which has an ‘alert
line’ and an ‘action line’. The assumption is that the cervix
dilates at a given rate in established labour, with the graph
highlighting any perceived deviations from this pre-
determined trajectory. Whilst a record of observations in
labour on one sheet of paper might for example make for
easier reading for anyone taking over care of a woman in
labour, the plotting of cervical dilatation in this way
suggest progress in labour can be assessed based on cervi-
cal dilatation alone.
The influence of the 3 ‘Ps’
Dystocia can be as a result of ineffective uterine contrac-
tions, malposition of the fetus leading to a relative or
absolute CPD, malpresentation, or any combination of
these. These may result in poor progress during the active
phase or a cessation of cervical dilatation following a
period of normal dilatation (Hayman 2004). An under-
standing of the role played by the 3 ‘Ps’ – passages, pas-
senger and powers – will help in determining why there
is a delay in progress in first or second stage of labour and
what action might be taken.
In the developed world the majority of women have
grown up well nourished, fit and healthy, and the passages
the fetus must negotiate are unlikely to be seriously flawed,
excluding possible trauma to the pelvis. Nonetheless the
impact of a full rectum, full bladder and fibroids cannot
be ignored in causing a delay in the progress of labour. A
malpresentation such as shoulder, brow or face (mento-
posterior) is one of the causes of poor progress or pro-
longed labour and this may occur as a result of a problem
with the passage (Chapter 20). A brow might revert to a
face (mento-anterior) or vertex presentation and the face
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Section | 4 | Labour
in mento-posterior position may rotate to mento-anterior
at the pelvic floor and if so a vaginal birth may be possible
(Singh and Paterson-Brown 2006). The shoulder, brow or
face (mento-posterior) cannot be born vaginally but a
carefully executed abdominal and vaginal examination
will exclude or confirm this so that the necessary action
can be taken to prepare the woman for caesarean section.
When the fetus is adopting an attitude where the head
is deflexed or slightly extended and the occiput is posterior
the presenting diameters are larger and there will be a
degree of ascynclitism. This inevitably slows progress but
does not necessarily mean progress is abnormal. This
might be considered a relative CPD because with effective
uterine contractions the fetus may adopt a more flexed
attitude. On some occasions more time is needed to do
this safely. El Halta (1998) suggests that rupturing the
membranes when the fetus is an occipitoposterior posi-
tion may result in a sudden descent of the fetal skull
resulting in a deep transverse arrest whereby the occipito­
frontal diameter (11.5 cm) is caught on the bi-spinous
diameter of the outlet (10–11 cm). Epidural anaesthesia
has been found to delay the progress of labour in the first
and second stage (Lowe 2007; Cheng et al 2009), particu-
larly so where there is an occipitoposterior position
(Chapter 20). The musculature of the pelvic floor plays an
important part in assisting the rotation of the presenting
part and epidural anaesthesia causes the pelvic floor to
relax inhibiting rotation. It also has an impact on the
stretching of the birth canal that normally triggers the
neuro-hormonal reflex (Ferguson’s reflex). In some cases
the head is simply (normally) large and any decision to
intervene at this point with oxytocin may increase strength
and frequency of uterine contractions in such a way as to
unduly force this process with inevitable fetal heart rate
changes prompting further intervention.
Although the uterus has prepared itself for the meta-
bolic activity of labour, as labour continues the smooth
muscle uses up its metabolic reserves and becomes tired.
Any change to the strength, length or frequency of contrac-
tions will affect progress and is indicative of inefficient
uterine action. Whilst some ketosis is considered normal
in labour there remains a need for additional supplies of
energy if the uterus is to continue contracting effectively
and enable labour to progress without the need for
medical intervention (Lowe 2007; Blackburn 2013).
Women need to have adequate oral intake in order to cope
with the very real demands that labour puts on their body.
The midwife’s role in caring for a
woman in prolonged labour
A prolonged labour leads to increased levels of stress,
anxiety, fear and fatigue, and increases the risk of infection,
PPH and emergency caesarean section (Svärdby et al 2006;
Laursen et al 2009). The importance of effective antenatal
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education in developing a plan of care for labour should
not be underestimated. Advice on suitable food and drink
to eat in the early stages of labour to maintain energy
levels, positions and activities to encourage a forward rota-
tion where there is an occipitoposterior position are just
some of the ways that might help to assist the woman in
the normal progress of labour.
When the woman and her partner come into hospital,
continuity of caregiver helps to create a sense of trust
between the woman, partner and midwife but also allows
for more accurate assessment over time to enable the
midwife to suggest non-interventionist ways in which
progress can be maintained if appropriate. An alternative
position might help to facilitate more effective contrac-
tions or improve pelvic diameters when the position of
the baby is posterior. At this stage it is also important to
maintain hydration, to encourage voiding and to suggest
non-pharmacological ways to relieve pain. Facilitating
autonomy by keeping the woman and her partner
informed of her progress and the choices she has is impor-
tant in helping her to feel in control and to alleviate
anxiety. Raised adrenalin levels as a result of fear, anxiety
or pain can impact negatively on uterine activity and can
slow progress in labour.
Accurate observations in labour are critical in assessing
progress. Recognition and detection of abnormal progress
in labour with appropriate clinical response will improve
the outcome of labour for both mother and baby (Neilson
et al 2003). An abdominal examination deftly undertaken
can provide vital information about the labour with regard
to the lie, presentation, position and descent of presenting
part as well as the length, strength and frequency of
contractions whereby any change in the pattern of the
contractions can be picked up. If the woman consents to
VE the findings can be compared to provide a more com-
prehensive picture of the progress of labour. On VE the
midwife is assessing the presence and degree of moulding
of the fetal skull, the presence and position of caput in
relation to sutures and fontanelles, and the dilatation of
the cervix noting any thickening and its application to the
presenting part. Any changes to the colour of the liquor if
the membranes have previously ruptured, or to the fetal
heart rate will give some indication as to how the fetus is
coping with the progress of labour. Continuity of caregiver
at this time reduces the likelihood of interobserver varia-
tions whilst increasing the chance of spontaneous vaginal
birth (Hodnett et al 2012).
When the decision to augment labour has been agreed
by all parties, the woman and her partner will need addi-
tional support from the midwife, as the interventions nec-
essary for this process may be very different from the birth
they had previously imagined. Psychological as well as
physical support is important at this time, as the control
of the birth of their baby now appears to be in the hands
of a third party and this can lead to negative feelings of
the childbirth experience (Nystedt et al 2005, 2006).
 Prolonged pregnancy and disorders of uterine action
The management of prolonged labour is a collaborative
effort involving the woman and her partner, the midwife,
obstetrician and anaesthetist. The normal pattern of obser-
vations and care in labour apply and any deviations from
normal are reported to the obstetrician. When an ARM has
been performed to augment labour an appropriate period
of grace should be given for effective uterine contractions
to resume before commencing an oxytocin infusion. The
uterus responds with increased sensitivity to the oxytocin
infused as the cervix dilates and it may be necessary to
reduce the rate of the infusion as full dilatation is
approached to avoid hyperstimulation of the uterus and
the concomitant effects on mother and fetus. With the
woman’s consent, an assessment will be made 2–4 hours
after ARM or after commencing oxytocin to ascertain the
likelihood of a successful vaginal birth. If there is persist-
ent poor progress in the active phase despite optimal con-
tractions, 4 to 5 per 10 minutes lasting more than 40
seconds, and the woman is pain-free, well hydrated and
with an empty bladder, it is unlikely that continuing with
an oxytocin infusion will lead to a vaginal birth.
The decision to augment labour in parous women or in
women with prior caesarean section must be made by an
experienced obstetrician because of the very real risk of
hyperstimulation and uterine rupture.
Delay in the second stage of labour
The second stage of labour can be divided into a passive
(pelvic) phase and active (perineal) phase (Chapter 17).
Delay in this stage of labour may be due to malposition
causing failure of the vertex to descend and rotate; ineffec-
tive contractions due to a prolonged first stage; large fetus
and large vertex; or absence of the desire to push with
epidural analgesia. Assuming the woman is receiving
active support and encouragement during the second
stage, and has trust in those caring for her, some of these
situations may be rectified with a change of position
and further encouragement, or the judicious use of an
oxytocin infusion to avoid the need for an instrumental
or operative birth.
Time limits in second stage range from 30 minutes to 2
hours for parous women and 1 to 3 hours for nulliparous
women (NICE 2007), but an understanding of the differ-
ent phases as the head negotiates the birth canal can avoid
the encouragement of premature bearing down efforts,
which only serve to tire and demoralize the mother. The
variation in time limits takes into consideration the impact
of epidural analgesia on the desire to push in the second
stage. The active phase when the mother is bearing down
is the most critical time. When a diagnosis of delay in the
second stage has been made the case is referred to the
obstetrician for review and assessment. The impact on
both mother and fetus if the second stage is allowed to
exceed a pre-determined time limit must be weighed
against the risks of any interventions at this critical time
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Chapter | 19 |
in the childbirth experiences. Where there is any indica-
tion that the mother or the fetus is compromised the birth
must be expedited as soon as possible but imposing an
arbitrary time limit is felt by some to be unnecessary if
both mother and fetus are doing well (Neilson et al 2003;
Hayman 2004; Gilchrist et al 2010).
OBSTRUCTED LABOUR
Whilst obstructed labour is not uncommon in developing
countries (Neilson et al 2003), in the UK it is only likely
to be seen where a woman has laboured unattended at
home for several hours and then seeks help at a
hospital.
Obstructed labour occurs when despite good uterine
contractions there is no advance of the presenting part.
Possible causes of obstructed labour include absolute
CPD, deep transverse arrest, malpresentation, lower
segment fibroids, fetal hydrocephaly and multiple preg-
nancy with conjoined or locked twins. Because of the high
presenting part if the woman goes into labour there may
be spontaneous rupture of the membranes and cord pro-
lapse with related risk to the fetus. If the condition is not
recognized the mother’s uterus will continue to contract
to overcome the obstruction. She will become progres-
sively more dehydrated, ketotic, pyrexial and tachycardic.
The fetus will develop a bradycardia because of the relent-
less contractions. As the uterus continues to contract and
retract the upper segment becomes progressively thicker,
closely enveloping the fetus, and the lower segment
becomes increasingly thinner. In nulliparous women the
contractions may cease for a period before resuming again
with increasing strength and frequency with little interval
between contractions until the uterus assumes a state of
tonic contraction. The difference between upper and lower
segment may be seen as a ridge obliquely crossing the
abdomen (Bandl’s ring). The mother is in severe and unre-
lenting pain. If VE is possible the presenting part will be
high with excessive moulding (Fig. 19.2). The uterus is in
imminent danger of rupture and emergency measures
must be taken if the situation has been allowed to get this
far. Uterine rupture leads to maternal mortality and the
tonic contractions and uterine rupture cause the hypoxia,
asphyxia and subsequent perinatal mortality (Neilson
et al 2003).
If the woman has been discovered in this condition at
home a paramedic ambulance should be called for imme-
diate transfer to hospital. The labour suite should be
informed, which, in turn, should contact the senior obste-
trician, anaesthetist, paediatrician, theatre staff and special
care unit. Whilst waiting for the ambulance the midwife
should cannulate, take blood for urgent cross-match and
site an intravenous infusion. The woman’s General Practi-
tioner (GP) can be called if close by to provide additional
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Section | 4 | Labour
Placenta
Thick upper
segment
Thin lower
segment
Presenting part shows
moulding and a caput
succedaneum is present
Fig. 19.2 Obstructed labour. The uterus is moulded around
the fetus; the thickened upper segment is obvious on
abdominal palpation.
help and support until the ambulance arrives. Observa-
tions of mother and fetus, and any actions taken and by
whom, are recorded in the maternity notes as soon as
possible. If obstructed labour is diagnosed on admission
to hospital an emergency caesarean section is performed.
In the UK obstructed labour is not something that is
managed, in that when a woman is receiving skilled ante-
natal and intrapartum care it is not something that should
occur. During antenatal care the midwife will highlight
any predisposing maternal or fetal factors that might
impact on normal progress in labour with appropriate
referral to the obstetrician so that a full and frank discus-
sion can take place and a decision made with the woman
on the safest mode of birth. During labour, skilled obser-
vation and assessment of progress, particularly skilled
abdominal examination, will alert the midwife to any mal-
presentation or failure of the presenting part to advance
despite optimal uterine contractions. VE will confirm sus-
pected malpresentation, and where the presentation is
vertex, reveal increasing caput or moulding. With a high
presenting part in labour cervical dilatation will be
extremely slow and there will be little if any application
to the presenting part. The obstetrician is informed as
soon as possible so that the birth can be expedited. As for
all women, despite the very real threat to maternal and
perinatal wellbeing these procedures should only be
undertaken with maternal consent.
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PRECIPITATE LABOUR
Precipitate labour is defined as ‘expulsion of the fetus
within 3 hours of commencement of contractions’ (NICE
2008a: 40). In some women the uterus is over-efficient
and much or all of the first stage is not recognized because
contractions are not painful and the realization of the
birth of the head may be the first indication that labour
has actually started. In women with spontaneous onset of
labour the incidence of precipitate labour is approximately
2%, and women having a precipitate labour are at risk of
placental abruption (NICE 2008a).
Other problems that may be associated with a precipi-
tate labour include soft tissue trauma of the maternal
genital tract due to sudden stretching and distension as
the baby is born, fetal hypoxia as a result of the frequency
and strength of the contractions, intracranial haemorrhage
from the sudden compression and decompression of the
fetal skull as it passes through the birth canal with speed,
and possible injury as the head and body emerge rapidly
and fall to the floor. The unexpected nature of the event
means that the place of birth may be inappropriate and
the baby may be further compromised if the importance
of maintaining the baby’s temperature is not recognized.
The overefficient uterus may relax after the birth of the
baby, resulting in retained placenta and/or PPH. The psy-
chological impact of such a rapid birth must not be under-
estimated, and not surprisingly some women will be in a
state of shock after the event.
Whilst precipitate labour will often recur in subsequent
pregnancies there is no evidence to recommend IOL as a
preventative measure. However, a woman who has experi-
enced an unattended precipitate labour and birth may
request IOL in order to ensure an attended birth in a safe
environment (NICE 2008a)
MAKING BIRTH A POSITIVE
EXPERIENCE
For the woman who has a spontaneous onset of labour at
term, has a single fetus in a cephalic presentation and who
has no underlying medical disorders, labour should
be about the normal physiological event. The only
intervention it requires on the part of the midwife is to be
there to meet the needs of the woman and to offer con-
tinuous support and encouragement to enable her to feel
secure and confident in those caring for her at this momen-
tous time.
The views of midwives and doctors on childbirth are
often considered to be diametrically opposite, with mid-
wives looking on childbirth as normal until proved other-
wise (RCM 2008) and obstetricians viewing it as normal
retrospectively (El-Hamamay and Arulkumaran 2005).
 Prolonged pregnancy and disorders of uterine action Chapter | 19 |

Whatever the perspective taken, the primary outcome is
the safety of the mother and baby. Whilst a high-risk preg-
nancy and labour cannot be made low-risk it can still be
a positive birthing experience for the woman and her
partner. Childbearing is a time of major life transition and
each woman and partner deserve to have a positive birth
experience whether labour is spontaneous or induced and
the birth is vaginal or by caesarean section. Working
together as a team cannot but help to contribute to that
positive birth experience.

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FURTHER READING
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et al 2013 Length of human
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its natural variation. Human
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humanrep/det297. http://humrep
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Although the study appears underpowered
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USEFUL WEBSITES
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Reviews:
http://onlinelibrary.wiley.com
Health and Social Care Information
Centre: www.hscic.gov.uk/
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Chapter | 19 |
Hospital Audit. Australian and New
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Wong S F, Hui S K, Choi H et al 2002
Does sweeping of membranes
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From an international perspective this is
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 Chapter 20
Malpositions of the occiput and
malpresentations
Terri Coates

CHAPTER CONTENTS Shoulder presentation 449

Causes 449
Introduction 436 Antenatal diagnosis 450
Occipitoposterior positions 436 Intrapartum diagnosis 450
Causes 436 Possible outcome 451
Antenatal diagnosis 436 Complications 451
Antenatal preparation 437 Management 451
Intrapartum diagnosis 438 Unstable lie 451
Midwifery care 439 Causes 451
Manual rotation 439 Management 452
Mechanism of right occipitoposterior Compound presentation 452
position (long rotation) 440
References 452
Possible course and outcomes of labour 441
Further reading 453
The birth 442
Complications 442 Malposition refers to any position other than
occipitoanterior (OA) in a fetus with a vertex
Face presentation 444 presentation. In a normal physiological labour,
Causes 444 the fetal head presents with the occiput in
Antenatal diagnosis 445 lateral position in early stages of labour with
anterior rotation as labour progresses.
Intrapartum diagnosis 445
Mechanism of a left mentoanterior Malpresentations are all presentations of the
position 445 fetus other than the vertex. Malpresentations
that occur due to extension of the fetal head,
Possible course and outcomes
causing brow or face to present, are usually
of labour 446
diagnosed during active labour. Prompt and
Management of labour 447 appropriate referral must be made.
Complications 448 Both malpositions and malpresentations are
Brow presentation 448 associated with a difficult labour and an
Causes 449 increased risk of operative intervention. The
Diagnosis 449 midwife must undertake regular clinical
examinations to monitor the progress of labour
Management 449 to ensure fetal and maternal wellbeing. Effective
Complications 449 communication and record keeping is crucial to

© 2014 Elsevier Ltd 435

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Section | 4 | Labour
provide safe care. The woman and her partner
must be kept fully informed and supported
throughout. Vaginal birth is possible in many
cases, but intervention or operative birth
become necessary when the malposition or
malpresentation persist and labour fails to
progress.
THIS CHAPTER AIMS TO:
• understand the features of the malpresentations and
malpositions
• recognize the predisposing factors
• outline possible causes of these positions and
presentations
• describe the physical landmarks to aid recognition
and diagnosis
• demonstrate sound knowledge of the mechanisms
• consider the outcomes for each position
• explore the midwife’s management and the current
uncertainties.
INTRODUCTION
Malpositions and malpresentations present the midwife
with challenges of recognition and diagnosis both in the
antenatal period and during labour. The midwife must
ensure all examinations and discussions with the woman
are documented and appropriate obstetric referral is made
where a malpresentation or malposition has been found.
The midwife should take time to discuss this with the
women to ensure they understand what may happen and
the activities that may help (Munro and Jokinen 2012).
The presenting diameters do not fit well onto the cervix
and therefore do not produce optimal stimulation for
uterine contractions and labour. Labour with a fetus in a
malposition or a malpresentation can be long, tedious and
painful, requiring empathy, sustained encouragement and
support for the woman and her partner. All the usual care
in labour is provided, paying particular attention to
comfort and hydration (see Chapter 16). The woman
should be encouraged to take an active part in decision-
making and must be kept informed throughout.
In labour women should be encouraged to adopt pos-
tures and positions they find comfortable and encouraged
to remain mobile. They should be supported to use coping
methods to deal with their particular pattern of labour
(Simkin 2010). The progress of labour may be slow so
midwives should take care to avoid the use of language
that may demoralize the woman and her partner. Any sign
of fetal or maternal distress or delay in labour must be
referred promptly to an obstetrician. Practices that are
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considered unhelpful include immobility and labouring
on a bed, the setting of arbitrary time limits on the various
stages of labour and the early use of epidural analgesia
(Munro and Jokinen 2012).
OCCIPITOPOSTERIOR POSITIONS
Occipitoposterior (OP) positions are the most common
type of malposition of the occiput and occur in approxi-
mately 10–30% of labours, but only around 5% of births
(Pearl et al 1993; Ponkey et al 2003; Munro and Jokinen
2012). Women can be reassured that internal rotation to
anterior positions can be expected in the majority of cases.
A persistent OP position results from a failure of internal
rotation or malrotation prior to birth (Gardberg et al
1998; Peregrine et al 2007). The vertex is presenting, but
the occiput lies in the posterior rather than the anterior
part of the pelvis. As a consequence, the fetal head is
deflexed and larger diameters of the fetal skull present
(Fig. 20.1).
Causes
The direct cause of the occipitoposterior position is often
unknown, but it may be associated with an abnormally
shaped pelvis. In an android pelvis, the forepelvis is narrow
and the occiput tends to occupy the roomier hindpelvis.
The oval shape of the anthropoid pelvis, with its narrow
transverse diameter, favours a direct OP position.
Antenatal diagnosis
Abdominal examination
Listen to the woman, as she may complain of backache
and report feeling that her baby’s bottom is very high up
against her ribs, as well as feeling movements across both
sides of her abdomen.
On inspection
There is a saucer-shaped depression at or just below the
umbilicus. This depression is created by the ‘dip’ between
the head and the lower limbs of the fetus. The outline
created by the high, unengaged head can look like a full
bladder (Fig. 20.2).
On palpation
While the breech is easily palpated at the fundus, the back
is difficult to palpate as it is well out to the maternal
side, sometimes almost adjacent to the maternal spine.
Limbs can be felt on both sides of the midline. The head
is unusually high in an OP position which is the most
common cause of non-engagement in a primigravida at
term. This is because the large presenting diameter, the
 Malpositions of the occiput and malpresentations
A Right occipitoposterior position
B Left occipitoposterior position
Fig. 20.1 (A) Right occipitoposterior position. (B) Left
occipitoposterior position.
occipitofrontal (11.5 cm), is unlikely to enter the pelvic
brim until labour begins and flexion occurs. The occiput
and sinciput are on the same level (Figs 20.3 and 20.4).
Flexion allows the engagement of the suboccipitofrontal
diameter (10 cm).
The cause of the deflexion is a straightening of the fetal
spine against the lumbar curve of the maternal spine. This
makes the fetus straighten its neck and adopt a more erect
attitude.
On auscultation
The fetal back is not well flexed so the chest is thrust
forward, therefore the fetal heart can be heard in the
midline. However, the fetal heart may be heard more easily
at the flank on the same side as the back.
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Chapter | 20 |
Fig. 20.2 Comparison of abdominal contour in (A) posterior
and (B) anterior positions of the occiput.
OF 11.5 cm
Fig. 20.3 Engaging diameter of a deflexed head:
occipitofrontal (OF) 11.5 cm.
Antenatal preparation
There is no current evidence that suggests active changes
of maternal posture will help to achieve an optimal fetal
position before labour (Hunter et al 2007; Munro and
Jokinen 2012). Research has shown that the woman
adopting a knee–chest position several times a day may
achieve temporary rotation of the fetus to an anterior posi-
tion but has only a short-term effect upon fetal presenta-
tion (Kariminia et al 2004; Hunter et al 2007). There is
437
Section | 4 | Labour

5– 4
– 3– OF DEFLEXED
CE V ER
5 5 5 EN TE
ER X

F
UM
Occiput, Sinciput Occiput below

34
C

.2 c
sinciput rises

CIR
brim

11.4CM

m
above brim

BIPARIETAL 9.5 CM

FRONTAL
BITEMPORAL 8.2 CM

OCCIPITO-
Brim

Fig. 20.5 Presenting dimensions of a deflexed head.

Fig. 20.4 Flexion with descent of the head.

insufficient evidence to suggest that women should adopt

the hands and knees posture, unless they find it comfort-
able (Simkin 2010; Munro and Jokinen 2012). Further
research is needed to evaluate the effect of adopting a
hands and knees posture on the presenting part during
labour (Hunter et al 2007).
For customary antenatal assessment of fetal position
Leopold’s manoeuvres can be used during abdominal
examination (see Chapter 10). These traditional methods
of examination are only an assessment of the placement
of the fetal spine and cannot estimate the direction of the
fetal head. Peregrine et al (2007) used ultrasound scans to
confirm abdominal palpation and found that the fetal
head is often aligned differently within the pelvis than the
fetal spine within the uterus. In other words, the fetus may
have turned its head to the right or left and the head may
be anterior within the pelvis but the fetal back may palpate
as lateral.
A review of current techniques used to diagnose fetal
position such as Leopold’s manoeuvres, the location of
fetal heart sounds, vaginal examinations and presence of
back pain are often unreliable (Simkin 2010). Failure to
identify fetal position accurately can impact on the ability
of the midwife to offer appropriate care. Consequently it
is considered that ultrasound is the most reliable way to
accurately detect the fetal position (Munro and Jokinen
2012). More research studies are needed to examine the
efficacy of midwifery skills in diagnosing fetal malposi-
tions and non-technological approaches to improving the
birth outcome for the woman and fetus.
Intrapartum diagnosis
The large and irregularly shaped presenting circumference
(Fig. 20.5) does not fit well onto the cervix. This may
hinder cervical ripening and predispose to a prolonged
latent phase (Akmal and Paterson-Brown 2009). The
contractions may also be in-coordinate. A high head pre-
disposes to early spontaneous rupture of the membranes
at an early stage of labour, which, together with an ill-
fitting presenting part, may result in cord prolapse (see
Chapter 22).
The woman may complain of continuous and severe
backache, worsening with contractions. However, the
absence of backache does not necessarily indicate an ante-
riorly positioned fetus. Descent of the head can be slow
even with good contractions. The woman may have a
strong desire to push early in labour because the occiput
is pressing on the rectum.
Vaginal examination
The findings (Fig. 20.6) will depend upon the degree of
flexion of the head. Locating the anterior fontanelle in the
anterior part of the pelvis is diagnostic but this may be
difficult if caput succedaneum is present. The direction of
the sagittal suture and location of the posterior fontanelle
will help to confirm the diagnosis. The position of the fetal
head may be checked using ultrasound where reason for
the delay in labour requires accurate diagnosis.

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 Malpositions of the occiput and malpresentations
Anterior
R L R L
A B
R L
C characterized by significant anal dilatation some time
Fig. 20.6 Vaginal touch pictures in a right occipitoposterior
position. (A) Anterior fontanelle felt to left and anteriorly.
Sagittal suture in the right oblique diameter of the pelvis.
(B) Anterior fontanelle felt to left and laterally. Sagittal suture
in the transverse diameter of the pelvis. (C) Following
increased flexion, the posterior fontanelle is felt to the right
and anteriorly. Sagittal suture in the left oblique diameter of
the pelvis. The position is now right occipitoanterior.
Midwifery care
First stage of labour
The woman may experience severe and unremitting back-
ache, which is tiring and can be very demoralizing, espe-
cially if the progress of labour is slow. Continuous support
from the midwife will help the woman and her partner to
cope with the labour (Simkin 2010; Hodnett et al 2012)
(see Chapter 16). The midwife can help to provide physi-
cal support such as massage and other comfort measures.
Mobility should be encouraged with changes of posture
and position and where possible, the use of a bath or
birthing pool and other non-pharmacological measures
such as transcutaneous electrical nerve stimulation (TENS)
or aromatherapy. There is no evidence that the all-fours
position either during pregnancy or in labour will rotate a
malpositioned baby (Kariminia et al 2004; Munro and
Jokinen 2012) but may help reduce persistent back pain.
An exaggerated Sims position in labour may offer some
relief, and anecdotal evidence suggests that it may also aid
rotation of the fetal head.
The woman may experience a strong urge to push long
before the cervix has become fully dilated. This is because
of the pressure of the occiput on the rectum. However, if
the woman pushes at this time, the cervix may become
oedematous and this would further delay the onset of the
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Chapter | 20 |
second stage of labour. The urge to push may be eased by
a change in position and the use of breathing techniques,
inhalational analgesia or other methods to enhance relax-
ation. The woman’s partner and the midwife can assist
throughout labour with massage and physical support.
The woman may choose a range of pain control methods
(see Chapter 16) throughout her labour depending on the
level and intensity of pain she is experiencing at that time.
The midwife must ensure that any delay in labour and
fetal or maternal distress are promptly recognized and
appropriate referrals made (Nursing and Midwifery
Council [NMC] 2012).
Second stage of labour
Full dilatation of the cervix may need to be confirmed by
a vaginal examination because moulding and formation
of a caput succedaneum may be in view while an anterior
lip of cervix remains. The second stage of labour is usually
before the head is visible. The midwife can encourage the
woman to adopt upright positions that may help to
shorten the length of the second stage and reduce the need
for operative assistance (see Chapter 17). Squatting may
increase the transverse diameter of the pelvic outlet which
may increase the chance of a vaginal birth.
The length of the second stage of labour is usually
increased when the occiput is posterior, and there is an
increased likelihood of an operative birth (Pearl et al
1993; Gimovsky and Hennigan 1995). In some cases
where contractions are weak and ineffective an oxytocin
infusion may be administered to stimulate adequate con-
tractions and achieve advancement/descent of the present-
ing part.
Manual rotation
Manual rotation of the head from occipitoposterior (OP)
or occipitotransverse (OT) positions to an anterior posi-
tion has been shown to reduce the need for assisted birth
and caesarean section by correcting the fetal malposition.
This will facilitate the descent of the fetal head, to encour-
age a spontaneous vaginal birth (Shaffer et al 2011).
There are two techniques for undertaking manual rota-
tion either by an obstetrician or an experienced and
trained midwife. Both techniques require informed
consent from the woman and adequate analgesia. The
woman’s bladder must be empty and the cervix should be
fully dilated. Either, constant pressure is exerted with the
tips of the fingers against the lambdoidal suture to rotate
the fetal head into the occiput anterior position, or the
whole hand is introduced into the birth canal and fingers
and thumb positioned under the lateral posterior parietal
bone and the anterior parietal bone (Phipps et al 2011):
the head is then rotated to the anterior position. Using
either method, the rotation may take two or three
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Section | 4 | Labour
contractions to complete and then should be held for two
contractions whilst the woman bears down to reduce the
risk of the rotation reverting (Phipps et al 2011; Shaffer
et al 2011). If a midwife is practising in a setting where
operative birth is not readily available, such as in a birth-
ing centre, this intervention may reduce maternal and neo-
natal morbidity and mortality (Shaffer et al 2011).
Malpositions and malpresentations are generally associ-
ated with a higher incidence of interventions in labour,
complications and instrumental birth (Cheng et al 2006).
Immediate and subsequent postnatal care of the woman
and her baby following an instrumental birth are dis-
cussed in Chapter 21 and Chapter 31.
Mechanism of right
occipitoposterior position
(long rotation) (Figs 20.7–20.10)
• The lie is longitudinal.
• The attitude of the head is deflexed.
• The presentation is vertex.
• The position is right occipitoposterior.
• The denominator is the occiput.
• The presenting part is the middle or anterior area of
the left parietal bone.
Right Left
Fig. 20.7 Head descending with increased flexion. Sagittal
suture in right oblique diameter of the pelvis.
Right Left
Fig. 20.9 Occiput and shoulders have rotated 2 8 of a circle
forwards. Sagittal suture in the left oblique diameter of the
pelvis. The position is right occipitoanterior.
Figs 20.7–20.10 Mechanism of labour in right occipitoposterior position.
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• The occipitofrontal diameter, 11.5 cm, lies in the
right oblique diameter of the pelvic brim. The
occiput points to the right sacroiliac joint and
the sinciput to the left iliopectineal eminence.
Flexion
Descent takes place with increasing flexion. The occiput
becomes the leading part.
Internal rotation of the head
The occiput reaches the pelvic floor first and rotates for-
wards 3 8 of a circle along the right side of the pelvis to lie
under the symphysis pubis. The shoulders follow, turning
2 of a circle from the left to the right oblique diameter.
8
Crowning
The occiput escapes under the symphysis pubis and the
head is crowned.
Extension
The sinciput, face and chin sweep the perineum and the
head is born by a movement of extension.
Right Left
Fig. 20.8 Occiput and shoulders have rotated 18 of a circle
forwards. Sagittal suture in transverse diameter of the pelvis.
Right Left
Fig. 20.10 Occiput has rotated 3 8 of a circle forwards. Note
the twist in the neck. Sagittal suture in the anteroposterior
diameter of the pelvis.
 Malpositions of the occiput and malpresentations Chapter | 20 |

Restitution Possible course and outcomes

The occiput turns 1 8 of a circle to the right and the head
realigns itself with the shoulders.
Internal rotation of the shoulders
The shoulders enter the pelvis in the right oblique diam-
eter; the anterior shoulder reaches the pelvic floor first and
rotates forwards 1 8 of a circle to lie under the symphysis
pubis.
External rotation of the head
At the same time the occiput turns a further 1
8 of a circle
to the right.
Lateral flexion
The anterior shoulder escapes under the symphysis pubis,
the posterior shoulder sweeps the perineum and the body
is born by a movement of lateral flexion.
of labour
Long internal rotation
This is the commonest outcome. With good uterine con-
tractions producing flexion and descent of the head, the
occiput will rotate forward 3 8 of a circle as described
above.
Short internal rotation
The term persistent occipitoposterior position (Figs 20.11 and
20.12) indicates that the occiput fails to rotate forwards.
Instead, the sinciput reaches the pelvic floor first and
rotates forwards. As a result, the occiput goes into the
hollow of the sacrum. The baby is born facing the pubic
bone (face to pubis).
Cause
Failure of flexion: the head descends without increased
flexion and the sinciput becomes the leading part. It

RIGHT LEFT RIGHT LEFT

Fig. 20.11 Persistent occipitoposterior position before Fig. 20.12 Persistent occipitoposterior position after short
rotation of the occiput: position is right occipitoposterior. rotation: position direct occipitoposterior.

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Section | 4 | Labour
reaches the pelvic floor first and rotates forwards to lie
under the symphysis pubis.
Diagnosis
In the first stage of labour: signs are those of any posterior
position of the occiput, namely a deflexed head and a fetal
heart heard in the flank or in the midline. Descent is slow.
In the second stage of labour: delay is common. On vaginal
examination the anterior fontanelle is felt behind the sym-
physis pubis, but a large caput succedaneum may mask
this. If the pinna of the ear is felt pointing towards the
woman’s sacrum, this indicates a posterior position.
The long occipitofrontal diameter causes considerable
dilatation of the anus and gaping of the vagina while the
fetal head is barely visible, and the broad biparietal diam-
eter distends the perineum and may cause excessive
bulging. As the head advances, the anterior fontanelle can
be felt just behind the symphysis pubis. Consequently the
fetus is born facing the pubis. Characteristic upward
moulding is present with the caput succedaneum on the
anterior part of the parietal bone (Fig. 20.13).
The birth (Figs 20.14–20.17)
The sinciput will first emerge from under the symphysis
pubis as far as the root of the nose and the midwife main-
tains flexion by restraining it from escaping further than
the glabella, allowing the occiput to sweep the perineum
and be born. She then extends the head by grasping it and
bringing the face down from under the symphysis pubis.
Perineal trauma is common and the midwife should watch
for signs of rupture in the centre of the perineum (button-
hole tear). An episiotomy may be required, owing to the
larger presenting diameters.
Undiagnosed face to pubis
If the signs are not recognized at an earlier stage, the
midwife may first be aware that the occiput is posterior
OF 11.5 cm
Fig. 20.13 Upward moulding (dotted line) following
persistent occipitoposterior position. OF, occipitofrontal.
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when the hairless forehead is seen escaping beneath the
pubic arch. Any accidental extension of the fetal head
should be corrected by flexion towards the symphysis
pubis.
Deep transverse arrest
The head descends with some increase in flexion. The
occiput reaches the pelvic floor and begins to rotate for-
wards. Flexion is not maintained and the occipito-frontal
diameter becomes caught at the narrow bi-spinous diam-
eter of the outlet. Arrest may be due to weak contractions,
a straight sacrum or a narrowed pelvic outlet.
The sagittal suture is found in the transverse diameter
of the pelvis and both fontanelles are palpable. Neither
sinciput nor occiput leads. The head is deep in the pelvic
cavity at the level of the ischial spines although the caput
may be lower still. There is no advance and obstetric assist-
ance will be required. Manual rotation may be attempted
first, and then vaginal birth may follow with the woman’s
effort.
Management
The woman must be kept informed of progress and par-
ticipate in decisions. Pushing at this time may not resolve
the problem but the midwife and the woman’s partner can
help by encouraging ‘sigh out slowly’ (SOS) breathing. A
change of position may help to overcome the urge to bear
down (see Chapter 17).
Where assistance is needed for a safe birth the woman’s
informed consent is required. The procedure would be
undertaken under local, regional or more rarely general
anaesthesia (see Chapter 21) considering the choice of the
woman, her condition and that of her unborn baby. The
baby’s head will be brought into an anterior position and
the birth completed using forceps or vacuum extraction
(see Chapter 21).
Conversion to face or brow presentation
When the head is deflexed at the onset of labour, extension
occasionally occurs instead of flexion. If extension is com-
plete then a face presentation results, but if incomplete, the
head is arrested at the brim with the brow presenting. This
is a rare complication of posterior positions, and is more
commonly found in multigravidae.
Complications
Apart from prolonged labour with its attendant risks to
the woman and fetus and the increased likelihood of
instrumental birth, there are a number of complications
that may occur which the midwife should consider.
 Malpositions of the occiput and malpresentations
Fig. 20.14 Allowing the sinciput to escape as far as the
glabella.
Fig. 20.16 Grasping the head to bring the face down from
under the symphysis pubis.
Figs 20.14–20.17 Birth of head in a persistent occipitoposterior position.
Obstructed labour
This may occur when the head is deflexed or partially
extended and becomes impacted in the pelvis (see
Chapter 19).
Maternal trauma
A forceps birth will result in perineal bruising and
trauma. Birth of a baby in the persistent occipitoposterior
position, particularly if previously undiagnosed, may
cause a third or fourth degree tear (Melamed et al
2013).
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Chapter | 20 |
Fig. 20.15 The occiput sweeps the perineum, sinciput held
back to maintain flexion.
Fig. 20.17 Extension of the head.
Neonatal trauma
The unfavourable upward moulding of the fetal skull,
found in an occipitoposterior position, can cause intrac-
ranial haemorrhage, as a result of the falx cerebri being
pulled away from the tentorium cerebelli. The larger pre-
senting diameters also predispose to a greater degree of
compression. Cerebral haemorrhage (see Chapter 31) may
also result from chronic hypoxia, which may accompany
prolonged labour.
Neonatal trauma occurring following birth from an
occipitoposterior position has also been associated with
forceps or ventouse births.
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Section | 4 | Labour
FACE PRESENTATION
When the attitude of the head is one of complete exten-
sion, the occiput of the fetus will be in contact with its
spine and the face will present. The incidence is about
≤1 : 500 (Bhal et al 1998; Akmal and Paterson-Brown
2009) and the majority develop during labour from vertex
presentations with the occiput posterior; this is termed
secondary face presentation. Less commonly, the face presents
before labour; this is termed primary face presentation.
There are six positions in a face presentation; the denomi-
nator is the mentum and the presenting diameters are the
submentobregmatic (9.5 cm) and the bitemporal (8.2 cm)
(Figs 20.18–20.23).
Causes
Anterior obliquity of the uterus
The uterus of a multigravida with slack abdominal muscles
and a pendulous abdomen will lean forward and alter the
direction of the uterine axis. This causes the fetal buttocks
to lean forwards and the force of the contractions to be
directed in a line towards the chin rather than the occiput,
resulting in extension of the head.
Fig. 20.18 Right mentoposterior. Fig. 20.19 Left mentoposterior.
Fig. 20.21 Left mentolateral. Fig. 20.22 Right mentoanterior.
Figs 20.18–20.23 Six positions of face presentation.
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Contracted pelvis
In the flat pelvis, the head enters in the transverse diameter
of the brim and the parietal eminences may be held up in
the obstetrical conjugate causing the head to become
extended such that a face presentation develops. Alterna-
tively, if the head is in the posterior position with the
vertex presenting, and remains deflexed, the parietal emi-
nences may be caught in the sacrocotyloid dimension of
the maternal pelvis so that the occiput cannot descend,
and the head becomes extended resulting in a face pres-
entation. This is more likely in the presence of an android
pelvis, in which the sacrocotyloid dimension is reduced.
Hydramnios (polyhydramnios)
If the vertex is presenting and the membranes rupture
spontaneously, the resulting rush of an excess of amniotic
fluid may cause the head to extend as it sinks into the
lower uterine segment.
Congenital malformation
Anencephaly can be a fetal cause of a face presentation. In
a cephalic presentation, because the vertex is absent the
face is thrust forward and presents. More rarely, a tumour
of the fetal neck may cause extension of the head.
Fig. 20.20 Right mentolateral.
Fig. 20.23 Left mentoanterior.
 Malpositions of the occiput and malpresentations
Antenatal diagnosis
Antenatal diagnosis is rare since face presentation devel-
ops during labour in the majority of cases. A cephalic
presentation in a known anencephalic fetus may be pre-
sumed to be a face presentation.
Intrapartum diagnosis
Abdominal palpation
Face presentation may not be detected, especially if the
mentum is anterior. The occiput feels prominent, with a
groove between the head and back, but it may be mistaken
for the sinciput. The limbs may be palpated on the side
opposite to the occiput and the fetal heart is best heard
through the fetal chest on the same side as the limbs. In
a mentoposterior position the fetal heart is difficult to hear
because the fetal chest is in contact with the maternal
spine (Fig. 20.24).
Vaginal examination
The presenting part is high, soft and irregular. When the
cervix is sufficiently dilated, the orbital ridges, eyes, nose
and mouth may be felt. However, confusion between the
mouth and anus could arise. The mouth may be open, and
the hard gums are diagnostic with the possibility of the
fetus sucking the examining finger. As labour progresses
the face becomes oedematous, making it more difficult to
distinguish from a breech presentation. To determine
the position the mentum must be located. If it is posterior,
the midwife should decide whether it is lower than the
Fig. 20.24 Abdominal palpation of the head in a face
presentation. Position right mentoposterior.
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Chapter | 20 |
sinciput, and if it can advance, it will rotate forwards. In a
left mentoanterior position, the orbital ridges will be in
the left oblique diameter of the pelvis (Fig. 20.25). Care
must be taken not to injure or infect the eyes with the
examining finger.
Mechanism of a left mentoanterior
position
• The lie is longitudinal.
• The attitude is one of extension of the fetal head
and neck.
• The presentation is the face (Fig. 20.26).
• The position is left mentoanterior.
• The denominator is the mentum.
• The presenting part is the left malar bone.
Extension
Descent takes place with increasing extension. The
mentum becomes the leading part.
Internal rotation of the head
This occurs when the chin reaches the pelvic floor and
rotates forwards 1 8 of a circle. The chin escapes under the
symphysis pubis (Fig. 20.27A).
A B
Fig. 20.25 Vaginal touch pictures of left mentoanterior
position. (A) The mentum is felt to left and anteriorly. Orbital
ridges in left oblique diameter of the pelvis. (B) Following
increased extension of the head, the mouth can be felt.
(C) The face has rotated 18 of a circle forwards. Orbital
ridges in transverse diameter of the pelvis. Position direct
mentoanterior.
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Section | 4 | Labour

Flexion
This takes place and the sinciput, vertex and occiput sweep

cm
the perineum; the head is born (Fig. 20.27B).

.5
9.5 cm

11
SM
V Restitution
This occurs when the chin turns 1
8 of a circle to the
SMB

woman’s left side.

Internal rotation of the shoulders

Fig. 20.26 Diameters involved in the birth of a face
presentation. Engaging diameter, submentobregmatic (SMB)
9.5 cm. The submentovertical (SMV) diameter, 11.5 cm,
sweeps the perineum.
The shoulders enter the pelvis in the left oblique diameter
of the maternal pelvis and the anterior shoulder reaches
the pelvic floor first, rotating forwards 1 8 of a circle along
the right side of the pelvis.

External rotation of the head

This occurs simultaneously. The chin moves a further 1
8
of a circle to the left.

Lateral flexion
The anterior shoulder escapes under the symphysis pubis,
the posterior shoulder sweeps the perineum and the baby’s
body is born by a movement of lateral flexion.

Possible course and outcomes

of labour
Prolonged labour
Labour is often prolonged because the face is an ill-fitting
presenting part and does not therefore stimulate effective
uterine contractions. The woman should be kept informed
A of her progress and any proposed intervention throughout
labour.
In addition, the facial bones do not mould and, in order
to enable the mentum to reach the pelvic floor and rotate
forwards, the shoulders must enter the pelvic cavity at the
same time as the head. The fetal axis pressure is directed
to the chin and the head is extended almost at right-angles
to the spine, increasing the diameters to be accommodated
in the pelvis.

Mentoanterior positions
With good uterine contractions, descent and rotation of
the head occur (Fig. 20.27) and labour progresses to a
spontaneous birth as described below.

B Mentoposterior positions
Fig. 20.27 Birth of head in mentoanterior position. (A) The If the head is completely extended, so that the mentum
chin escapes under symphysis pubis. Submentobregmatic reaches the pelvic floor first, and the contractions are effec-
diameter at outlet. (B) The head is born by a movement of tive, the mentum will rotate forwards and the position
flexion. becomes anterior.

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 Malpositions of the occiput and malpresentations
Fig. 20.28 Persistent mentoposterior position.
Persistent mentoposterior position
In this case, the head is incompletely extended and the
sinciput reaches the pelvic floor first and rotates forwards
1 of a circle, which brings the chin into the hollow of the
8 C
sacrum (Fig. 20.28). There is no further mechanism. The
face becomes impacted because, in order to descend
further, both head and chest would have to be accommo-
dated in the pelvis. Whatever emerges anteriorly from the
vagina must pivot around the subpubic arch. When the
chin is posterior this is impossible because the head can
extend no further.
Reversal of face presentation
A face presentation in a persistent mentoposterior posi-
tion may, in some cases, be manipulated to an occipito­
anterior position using bimanual pressure (Neuman et al
1994; Gimovsky and Hennigan 1995). This method was
developed to reduce the likelihood of an operative birth
for those women who refused caesarean section. Using a
tocolytic drug, such as terbutaline, to relax the uterus, the
fetal head is disengaged using upward transvaginal pres-
sure. The fetal head is then flexed with bimanual pressure
under ultrasound guidance to achieve an occipitoanterior
position.
Management of labour
First stage of labour
Upon diagnosis of a face presentation, the midwife should
inform the doctor of this deviation from the normal.
Routine observations of maternal and fetal conditions are
made as in a normal physiological labour (see Chapter
16). A fetal scalp electrode must not be applied, and care
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Chapter | 20 |
A B
D
Fig. 20.29 Birth of face presentation. (A) The sinciput is held
back to increase extension until the chin is born. (B) The chin
is born. (C) Flexing the head to bring the occiput over the
perineum. (D) Flexion is completed; the head is born.
should be taken not to infect or injure the eyes during
vaginal examinations.
Immediately following rupture of the membranes, a
vaginal examination should be performed to exclude cord
prolapse which is more likely because the face is an ill-
fitting presenting part. Descent of the fetal head should be
assessed abdominally, and careful vaginal examination
performed every 2–4 hours to determine cervical dilata-
tion and descent of the head.
In mentoposterior positions the midwife should note
whether the mentum is lower than the sinciput, since rota-
tion and descent depend on this. If the head remains high
in spite of good contractions, caesarean section is likely.
The woman may be prescribed oral ranitidine, 150 mg
every 6 hours throughout labour if it is considered that an
anaesthetic may be necessary.
Birth of the head (Fig. 20.29)
When the face appears at the vulva, extension must be
maintained by holding back the sinciput and permitting
the mentum to escape under the symphysis pubis before
the occiput is allowed to sweep the perineum. In this
way, the submentovertical diameter (11.5 cm) instead of
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Section | 4 | Labour

the mentovertical diameter (13.5 cm) distends the vaginal
orifice. Because the perineum is also distended by the
biparietal diameter (9.5 cm), an elective episiotomy may
be performed to avoid extensive perineal lacerations.
If the head does not descend in the second stage of
labour, the doctor should be informed. In a mentoanterior
position it may be possible for the obstetrician to assist
the baby’s birth with forceps when rotation is incomplete.
If the position remains mentoposterior, the head has
become impacted, or there is any suspicion of dispropor-
tion, a caesarean section will be necessary.
Complications
Obstructed labour
week. Trauma during labour may cause tracheal and laryn-
geal oedema immediately after the birth, which can result
in neonatal respiratory distress. In addition, fetal anoma-
lies or tumours, such as fetal goiters that may have con-
tributed to fetal malpresentation, may make intubation
difficult. As a result, a clinician with expertise in neonatal
resuscitation should be present at the birth.
Cerebral haemorrhage
The lack of moulding of the facial bones can lead to intra­
cranial haemorrhage caused by excessive compression of
the fetal skull or by rearward compression, in the typical
moulding of the fetal skull found in this presentation
(Fig. 20.30).

Because the face, unlike the vertex, does not mould, a

minor degree of pelvic contraction may result in obstructed
labour (see Chapter 19). In a persistent mentoposterior
position the face becomes impacted and caesarean section
is necessary.
Cord prolapse
Maternal trauma
Extensive perineal lacerations may occur at birth owing to
the large submentovertical and biparietal diameters dis-
tending the vagina and perineum. There is an increased
incidence of operative birth by either forceps or by caesar-
ean section, both of which increase maternal morbidity.

A prolapsed cord is more common when the membranes

rupture because the face is an ill-fitting presenting part.
The midwife should always perform a vaginal examination
when the membranes rupture to rule out cord prolapse
(see Chapter 22).
Facial bruising
The baby’s face is always bruised and swollen at birth, with
oedematous eyelids and lips. The head is elongated (Fig.
20.30) and the baby will initially lie with the head
extended. The midwife should warn the parents in advance
of the baby’s battered appearance, reassuring them that this
is only temporary as the oedema will disappear within 1
or 2 days, with the bruising usually resolving within a
9.5 cm
BROW PRESENTATION
In the brow presentation the fetal head is partially extended
with the frontal bone, which is bounded by the anterior
fontanelle and the orbital ridges, lying at the pelvic brim
(Fig. 20.31). The presenting diameter of 13.5 cm is the
mentovertical (Fig. 20.32), which exceeds all diameters in
an average-sized gynaecoid pelvis. This presentation is
rare, with an incidence of approximately 1 in 1000 births
(Bhal et al 1998).

mc
.5
11
V
SM
SMB

Fig. 20.30 Moulding in a face presentation (dotted line).

SMB, submentobregmatic; SMV, submentovertical. Fig. 20.31 Brow presentation.

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 Malpositions of the occiput and malpresentations
cm
.5
13
MV
Fig. 20.32 Brow presentation. The mentovertical (MV)
diameter, 13.5 cm, lies at the pelvic brim.
Causes
These are the same as for a secondary face presentation
(see above); during the process of extension from a vertex
presentation to a face presentation, the brow will present
temporarily and in a few cases this will persist.
Diagnosis
Brow presentation is not usually detected before the onset
of labour.
Abdominal palpation
The head is high, appears unduly large and does not
descend into the pelvis despite good uterine contractions.
Vaginal examination
The presenting part is high and may be difficult to reach.
The anterior fontanelle may be felt on one side of the
maternal pelvis and the orbital ridges, and possibly the
root of the nose, at the other (Fig. 20.33). A large caput
succedaneum may mask these landmarks if the woman
has been in labour for some hours.
Management
The doctor must be informed immediately this presentation is
suspected. This is because vaginal birth is extremely rare
and obstructed labour usually results. It is possible that a
woman with a large pelvis and a small baby may give birth
vaginally. When the brow reaches the pelvic floor the
maxilla rotates forwards and the head is born by a mecha-
nism somewhat similar to that of a persistent occipitopos-
terior position. However, the midwife should never expect
such a favourable outcome. The woman should be warned
about the possible course of labour and that a vaginal
birth is unlikely.
If there is no evidence of fetal compromise, the doctor
may allow labour to continue for a short while in case
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Chapter | 20 |
cm
.5
13
MV
Fig. 20.33 Moulding in a brow presentation (dotted line).
MV, mentovertical.
further extension of the head converts the brow presenta-
tion to a face presentation. Occasionally spontaneous
flexion may occur, resulting in a vertex presentation. If the
head fails to descend and the brow presentation persists,
a caesarean section is performed, with the woman’s
consent.
Complications
These are the same as in a face presentation, except that
obstructed labour requiring caesarean section is the prob-
able rather than a possible outcome.
SHOULDER PRESENTATION
When the fetus lies with its long axis across the long axis
of the uterus (transverse lie) the shoulder is most likely to
present. Occasionally the lie is oblique but this does not
persist as the uterine contractions during labour make it
longitudinal or transverse.
Shoulder presentation occurs in approximately 1 : 300
pregnancies near term. Only 17% of these cases remain as
a transverse lie at the onset of labour of which the majority
are multigravidae (Gimovsky and Hennigan 1995; Akmal
and Paterson-Brown 2009). The head lies on one side of
the abdomen, with the breech at a slightly higher level
on the other. The fetal back may be anterior or posterior
(Figs 20.34 and 20.35).
Causes
Maternal
Before term, transverse or oblique lie may be transitory,
related to the woman’s position or displacement of the
449
Section | 4 | Labour
Fig. 20.34 Shoulder presentation, dorsoanterior.
Fig. 20.35 Shoulder presentation, dorsoposterior.
presenting part by an overextended bladder prior to ultra-
sound examination. Other causes are described below.
Lax abdominal and uterine muscles
This is the most common cause and is found in multigravi-
dae, particularly those of high parity.
Uterine malformation
A bicornuate or subseptate uterus may result in a trans-
verse lie, as, more rarely, may a cervical or low uterine
fibroid.
Contracted pelvis
Rarely, this may prevent the head from entering the
pelvic brim.
Fetal
Pre-term pregnancy
The amount of amniotic fluid in relation to the fetus is
greater, allowing the fetus more mobility than at term.
Multiple pregnancy
There is a possibility of hydramnios but the presence of
more than one fetus reduces the room for manoeuvre
when amounts of amniotic fluid are normal. It is the
second twin that more commonly adopts a transverse lie
after the birth of the first baby.
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Hydramnios
The distended uterus is globular in shape and the fetus can
move freely in the excessive amniotic fluid volume.
Macerated fetus
Lack of muscle tone causes the fetus to slump down into
the lower pole of the uterus.
Placenta praevia
This may prevent the fetal head from entering the
pelvic brim.
Antenatal diagnosis
Abdominal palpation
The uterus appears broad and the fundal height is less than
expected for the period of gestation. On pelvic and fundal
palpation, neither head nor breech is felt. The mobile
head is found on one side of the abdomen and the breech
at a slightly higher level on the other.
Antenatal management
A cause for the shoulder presentation must be sought
before deciding on a course of management and requires
a medical referral. Ultrasound examination can detect pla-
centa praevia or uterine malformations, while X-ray pel-
vimetry will demonstrate a contracted pelvis (see Chapter
3). Any of these causes requires elective caesarean section.
Once such causes have been excluded, external cephalic
version (ECV) may be attempted. If this fails, or if the lie
is transverse again at the next antenatal visit, the woman
is admitted to hospital while further investigations into
the cause are made. The woman frequently remains in
hospital until labour commences because of the risk of
cord prolapse if the membranes rupture.
Intrapartum diagnosis
The findings are as above but when the membranes have
ruptured the irregular outline of the uterus is more marked.
If the uterus is contracting strongly and becomes moulded
around the fetus, palpation is very difficult. The pelvis is
no longer empty as the shoulder is wedged into the brim.
Vaginal examination
In early labour the presenting part may not be felt. The
membranes usually rupture early because of the ill-fitting
presenting part, with a high risk of cord prolapse.
If the labour has been in progress for some time the
shoulder may be felt as a soft irregular mass. It is some-
times possible to palpate the ribs, with their characteristic
grid-iron pattern being diagnostic (Fig. 20.36). When the
 Malpositions of the occiput and malpresentations
Ribs
Scapula
Acromion process
Clavicle
Humerus
Fig. 20.36 Vaginal touch picture of shoulder presentation.
shoulder enters the pelvic brim an arm may prolapse,
which should be differentiated from a leg, i.e. the hand is
not at right-angles to the arm, the fingers are longer than
the toes and of unequal length, and the thumb can be
opposed. No os calcis can be felt and the palm is shorter
than the sole. If the arm is flexed, an elbow feels sharper
than a knee.
Possible outcome
Whenever the midwife detects a transverse lie she must
obtain medical assistance. There is no mechanism for
the birth of a shoulder presentation.
If a transverse lie is detected in early labour while the
membranes are still intact, the doctor may attempt an ECV.
If this is successful, the doctor may then undertake a con-
trolled rupture of the membranes. (This may be consid-
ered before labour in some cases [Hutton and Hofmeyr
2006]). If the membranes have already ruptured spontane-
ously, a vaginal examination must be performed immedi-
ately to detect possible cord prolapse.
If a shoulder presentation persists in labour, the birth of
the baby must be by caesarean section to avoid obstructed
labour and subsequent uterine rupture (see Chapter 22).
Immediate caesarean section must be performed:
• when ECV is unsuccessful
• when the membranes are already ruptured
• if the cord prolapses
• when labour has already been in progress for some
hours.
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Complications
Prolapsed cord
This may occur when the membranes rupture (see
Chapter 22).
Prolapsed arm
This may occur when the membranes have ruptured and
the shoulder has become impacted. Birth should be by
immediate caesarean section.
Neglected shoulder presentation
With adequate supervision both antenatally and during
labour, this should never occur.
The fetal shoulder becomes impacted, having been
forced down and wedged into the maternal pelvic brim.
The membranes have ruptured spontaneously and if the
arm has prolapsed it becomes blue and oedematous. The
uterus goes into a state of tonic contraction, the over-
stretched lower segment is tender to touch and the fetal
heartbeat may be absent. All the maternal signs of
obstructed labour are present (see Chapter 19) and the
outcome, if not treated in time, is a ruptured uterus and a
stillbirth.
Management
An immediate caesarean section is performed regardless
of whether the fetus is alive or dead, as attempts at
manipulative procedures or destructive operations can be
dangerous for the woman and may result in uterine
rupture.
UNSTABLE LIE
The lie is defined as unstable when after 36 weeks’ gesta-
tion, instead of remaining longitudinal, it varies from one
examination to another between longitudinal and oblique
or transverse.
Causes
Any condition in late pregnancy that increases the mobil-
ity of the fetus or prevents the fetal head from entering the
pelvic brim may cause this.
Maternal
These include:
• lax uterine muscles in multigravidae
• contracted pelvis.
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Section | 4 | Labour

Fetal enters the pelvis and an intravenous infusion of oxytocin

These include:
• hydramnios
• placenta praevia.
Management
Antenatal
It may be advisable for the woman to be admitted to
hospital to avoid unsupervised onset of labour with a
transverse lie. Alternatively, the woman may admit herself
to the hospital maternity unit as soon as labour com-
mences. The risk associated with the possibility of rupture
of membranes and cord prolapse should be emphasized
if the woman chooses to remain at home.
Ultrasonography is used to exclude placenta praevia.
Attempts will be made to correct the abnormal presenta-
tion by ECV. If unsuccessful, caesarean section is
considered.
Intrapartum
Obstetricians may recommend induction of labour after
38 weeks’ gestation, when the lie is unstable. Having first
ensured that the lie is longitudinal, a controlled rupture
of the membranes is performed so that the fetal head
is commenced to stimulate contractions.
The midwife should ensure that the woman has an
empty rectum and bladder before the procedure, as a
loaded rectum or full bladder can prevent the presenting
part from entering the pelvis. The abdomen should be
palpated at frequent intervals to ensure that the lie remains
longitudinal and to assess the descent of the fetal head.
Labour is regarded as a trial.
If labour commences with the lie other than longitudi-
nal, the complications are the same as for a transverse lie.
COMPOUND PRESENTATION
When a hand, or occasionally a foot, lies alongside the
head, the presentation is said to be compound. This tends
to occur with a small fetus or roomy maternal pelvis and
seldom is difficulty encountered except in cases where it
is associated with a flat pelvis. On rare occasions the head,
hand and foot are felt in the vagina – a serious situation
that may occur with a dead fetus.
If a compound presentation is diagnosed during the first
stage of labour, medical aid must be sought. If diagnosis
occurs during the second stage of labour and the midwife
sees a hand presenting alongside the vertex, she should try
to hold the hand back.

REFERENCES

Akmal S, Paterson-Brown S 2009
Malpositions and malpresentations
of the foetal head. Obstetrics and
Gynecology and Reproductive
Medicine 199:240–6
Bhal P S, Davies N J, Chung T 1998 A
population study of face and brow
presentation. Journal of Obstetrics
and Gynecology 18(3):231–5
Cheng Y W, Shaffer B L, Caughy A B
2006 The association between
persistent occiput posterior and
neonatal outcomes. Obstetrics and
Gynecology 107(4):837–44
Gardberg M, Laakkonen E, Salevaara M
1998 Intra-partum sonography and
persistent occiput posterior position:
a study of 408 deliveries. Obstetrics
and Gynecology 91(5):1746–9
Gimovsky M, Hennigan C 1995
Abnormal fetal presentations.
Current Opinion in Obstetrics and
Gynecology 7(6):482–5
Hodnett E D, Gates S, Hofmeyr G J et al
2012 Continuous support for
women during childbirth. Cochrane
Database of Systematic Reviews
2012, Issue 10. Art. No. CD003766.
doi: 10.1002/14651858.CD003766.
pub4
Hunter S, Hofmeyr G J, Kulier R 2007
Hands and knees posture in late
pregnancy or labour for fetal
malposition (lateral or posterior).
Cochrane Database of Systematic
Reviews 2007, Issue 4. Art. No.
CD001063. doi: 10.1002/14651858
.CD001063.pub3
Hutton E K, Hofmeyr G J 2006 External
cephalic version for breech
presentation before term. Cochrane
Database of Systematic Reviews 2006,
Issue 1. Art. No. CD000084. doi:
10.1002/14651858.CD000084.pub2
Kariminia A, Chamberlain M E, Keogh J
2004 Randomised controlled trial of
effect of hands and knees posturing
on incidence of occiput posterior
position at birth. British Medical
Journal 328(7438):490–3
Melamed N, Gavish O, Eisner M 2013
Third- and fourth-degree perineal
tears – incidence and risk factors.
Journal of Maternal–Fetal and
Neonatal Medicine 26(7):660–4
Munro J, Jokinen M 2012 RCM evidence-
based guidelines for midwifery-led
care in labour. Persistent lateral and
posterior fetal positions at the onset
of labour. Royal College of Midwives
Trust, London
Neuman M, Beller U, Lavie O 1994
Intrapartum bimanual tocolytic-
assisted reversal of face presentation:
preliminary report. Obstetrics and
Gynecology 84(10):146–8
NMC (Nursing and Midwifery Council)
2012 Midwives Rules and Standards.
NMC, London
Pearl M L, Roberts J M, Laros R K et al
1993 Vaginal delivery from the
persistent occiput posterior position.
Influence on maternal and neonatal
morbidity. Journal of Reproductive
Medicine 38(12):955–61

452
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 Malpositions of the occiput and malpresentations Chapter | 20 |

Peregrine E, O’Brian P, Jauniaux E 2007
Impact on delivery outcome of
ultrasonographic fetal head position
prior to induction of labor.
Obstetrics and Gynecology
109(3):618–25
Phipps H, de Vries B, Hyett J et al 2011
Prophylactic manual rotation for
fetal malposition to reduce operative
delivery (Protocol). Cochrane
Database of Systematic Reviews 2011,
Issue 10. Art. No. CD009298. doi:
10.1002/14651858.CD009298
Ponkey S E, Cohen A P, Heffner L J et al
2003 Persistent fetal occiput
posterior position: obstetric
outcomes. Obstetrics and
Gynecology 101(9):15–20
Shaffer B L, Cheng Y W, Vargas J E et al
2011 Manual rotation to reduce
caesarean delivery in occiput
posterior or transverse position.
Journal of Maternal–Fetal and
Neonatal Medicine 24(1):65–72
Simkin P 2010 The fetal occiput
position: state of the science and a
new perspective. Birth 37(1):61–71

FURTHER READING

Chapman K 2000 Aetiology and
management of the secondary brow.
Journal of Obstetrics and
Gynaecology 20:(1)39–44
Six cases of vaginal birth from a brow
presentation over a career of 39 years are
recorded in this article. Most midwives will
never see a brow presentation birth
vaginally; this is a fascinating record from
a long career.
Gardberg M, Tuppurainen M 1994
Anterior placental location
predisposes for occiput posterior
presentation near term. Acta
Obstetrica et Gynecologica
Scandinavica 73(2):151–2
In a series of 325 ultrasound examinations
the authors demonstrated an association
between an anteriorly situated placenta and
OP position after 36 weeks of pregnancy.
Reichman O, Gdansky E, Latinsky B
et al 2008 Digital rotation from
occipito-posterior to occipito-
anterior decreases the need for
caesarean section. European Journal
of Obstetrics and Gynecology and
Reproductive Biology 136:25–8
The results of a prospective study suggest
that digital rotation should be considered
when managing the labour with a fetus in
the OP position. The manoeuvre has been
shown to have a high success rate, in
experienced hands, reducing the need for
vacuum extraction and caesarean section
and so shortens the duration of hospital
stay. The intervention has the potential to
reduce maternal and neonatal morbidity
and mortality.
Shaffer B I, Cheng Y W, Vargas J E et al
2011 Manual rotation to reduce
caesarean delivery in persistent
occiput posterior or transverse
position. Journal of Maternal Fetal
and Neonatal Medicine 24(1):65–72
Compared to expectant management
manual rotation of the fetal head from OT
or OP positions was associated with a
reduction of caesarean sections and adverse
maternal outcomes and no adverse neonatal
outcomes. If a midwife is practising in a
setting where operative birth is not readily
available, this intervention may reduce
maternal and neonatal morbidity and
mortality.

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 Chapter 21

Operative births
Richard Hayman

CHAPTER CONTENTS Psychological support and the role of

the midwife 465
Assisting a vaginal birth 456 Vaginal birth after caesarean section
Indications for ventouse or forceps 456 (VBAC) 466
Fetal 456 Postoperative care 466
Maternal 456 Analgesia/anaesthesia 468
Contraindications to an instrumental Research and the incidence of caesarean
vaginal birth 457 section: tackling high and rising caesarean
Absolute 457 section rates 471
Relative contraindications (for forceps References 472
or ventouse) 457 Further reading 473
Prerequisites for any operative Useful websites 473
vaginal birth 457
This chapter describes the methods of operative
Birth by ventouse 457 birth that may be used when the mother is
Types of ventouse 457 unable to give birth without medical or surgical
The use of the ventouse 458 assistance. The role of the midwife in these
Procedure 458 procedures will be explored, as will the principles
of ‘keeping the normal, normal’.
Precautions in use 459
The midwife ventouse practitioner 460 THE CHAPTER AIMS TO:
Birth by forceps 460
Characteristics of the obstetric forceps 460
• identify the areas of midwifery care that relate to
the preparation for an assisted vaginal birth
Classification of obstetric forceps 460
(ventouse/forceps) or birth by caesarean section (CS)
Types of obstetric forceps 460 • describe the role of the midwife in relation to the
Procedure 460 issues of informed consent and the management of
Complications of instrumental vaginal complications following assisted birth
birth 462 • consider the various techniques used for assisted
Caesarean section 463 vaginal birth (ventouse/forceps) and birth by CS, plus
Clarifying the indications for caesarean the skills required by the midwife to improve the
section 463 experience for both the mother and her partner
The operative procedure 464 • discuss the changing role of the midwife in relation
Women’s request for caesarean section 465 to medical intervention.

© 2014 Elsevier Ltd 455

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Section | 4 | Labour
ASSISTING A VAGINAL BIRTH
Assisted vaginal birth is a frequently and widely practised
intervention in the provision of care to women during
childbirth. In England during 2011–12, of the 668 936
births recorded, 85 009 (13%) were assisted with forceps
or ventouse (Health and Social Care Information Centre,
Hospital Episodes Statistics 2012). However, the incidence
of instrumental intervention varies widely both between
and within countries, and may be performed as infre-
quently as 1.5% or as often as 26%. Such differences
may be linked to the alternative management strategies
employed during labour in different units (Bragg et al
2010). Various techniques have been championed to help
lower the rates of operative births. These are summarized
in Box 21.1.
It should be noted, however, that other interventions,
such as epidural analgesia, have been observed to be asso-
ciated with an increased risk of instrumental vaginal birth
and have been suggested to be linked to an increased risk
of birth by caesarean section (CS) (Anim-Somuah et al
2011). However, such ‘disadvantages’ must be balanced
against the higher rates of maternal satisfaction that this
form of analgesia provides. It is up to the woman to make
an informed choice as to which of the benefits and risks
are most important, not up to the attending medical staff
to make didactic decisions on her behalf. Indeed, whilst
it has been commented (Johanson and Menon 1999) that,
in general, maternal outcomes would be improved by low-
ering instrumental birth rates, no evidence to support such
a statement has ever been forthcoming, as it is not easy to
see what the alternatives are for a woman who, despite her
own best efforts, has not been able to secure a ‘normal
birth’.
Box 21.1 Useful techniques to help lower the
operative birth rate
• One-to-one care in labour (Hodnett et al 2011)
• Active management of the second stage with
Syntocinon (O’Driscoll et al 1993; Brown et al
2008)
• Upright birth posture/mobilization (NICE 2007; Gupta
et al 2012)
• Delaying the onset of the active second stage by 1–2
hours in women with regional analgesia/anaesthesia
(NICE 2007)
• Fetal blood sampling rather than expediting
birth when fetal heart rate abnormalities occur
(NICE 2007)
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INDICATIONS FOR VENTOUSE
OR FORCEPS
The indications for assisted vaginal birth may be simply
categorized into fetal and maternal. However, the reasons
cited for intervention are frequently imprecise as multiple
factors often interact.
Fetal
• Malposition of the fetal head (occipitolateral
and occipitoposterior). Such positions occur
more frequently in the presence of regional
anaesthesia, as alterations in the tone of the pelvic
floor may impede the spontaneous rotation to
the optimal occipitoanterior position during the
decent of the presenting part (vertex of the
fetal head).
• Fetal ‘distress’ is a commonly cited indication for
instrumental intervention; however, ‘presumed fetal
compromise’ is a more comprehensive term (unless a
fetal blood sample has been obtained showing
hypoxia and acidosis, in which case ‘fetal hypoxia’
should be used) (NICE [National Institute for Health
and Clinical Excellence] 2007).
• Elective instrumental intervention for infants of
reduced weight. In infants weighing <1.5 kg, delivery
with forceps does not confer an advantage over
spontaneous birth and may increase the incidence of
intracranial haemorrhage. Ventouse carries the same
risks, but in addition should be avoided in infants of
<34+6 weeks of gestation.
• Assisted vaginal breech birth. Forceps can be applied
to the after-coming head to control the birth of the
vertex, a situation where the ventouse is
contraindicated.
Maternal
• The commonest maternal indications are those
of maternal distress, exhaustion, or prolongation
of the second stage of labour. This has been
suggested as greater than 2 hours in a primigravida
(3 hours if an epidural is in situ), or more than
1 hour in a multipara (2 hours if an epidural is
in situ) (NICE 2007).
• Medically significant conditions such as: aortic valve
disease with significant outflow obstruction;
myasthenia gravis; significant antepartum
haemorrhage due to placental abruption or vasa
praevia; severe hypertensive disease; and previous CS
(to minimize the risk of scar rupture).

CONTRAINDICATIONS TO AN
INSTRUMENTAL VAGINAL BIRTH
Absolute
• The vertex is ≥1/5th palpable abdominally.
• The position as determined by a vaginal examination
(occipitoanterior/posterior or lateral) of the fetal
head is unknown.
• Before full dilatation of the cervix (although a
possible exception occurs with the ventouse birth of
a second twin).
• When the operator is inexperienced in instrumental
vaginal birth.
In addition the ventouse should not be used:
• In gestations of <34+6 weeks because of the increased
risk of intracranial haemorrhage in the fetus.
• With the fetus presenting by the face.
• If there is a significant degree of caput that may
either preclude correct placement of the cup or, more
sinisterly, indicate a substantial degree of
cephalopelvic disproportion CPD).
Relative contraindications
(for forceps or ventouse)
• Fetal bleeding disorders (e.g. alloimmune
thrombocytopenia) or a predisposition to fractures
(e.g. osteogenesis imperfecta) are relative
contraindications specifically to an operative birth
with the ventouse. However, the comparative risks of
a birth by a difficult second stage caesarean section
must also be considered and a discussion undertaken
antenatally about the most appropriate plan for
birth (it may be wiser to recommend that such
women have an elective CS).
• There is minimal risk of fetal haemorrhage if the
vacuum extractor is employed following fetal blood
sampling or application of a scalp electrode.
PREREQUISITES FOR ANY OPERATIVE
VAGINAL BIRTH
• Rupture of the membranes must be confirmed.
• The cervix must be fully dilated.
• Cephalic presentation with identification of the
position (occipitoanterior/posterior or lateral).
• Adequate pelvis as ascertained by clinical pelvimetry.
• The fetal head must be <1/5th palpable per abdomen,
with the presenting part at or below the ischial
spines.
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Operative births Chapter | 21 |
• Adequate analgesia/anaesthesia.
• Empty bladder/no obstruction below the fetal head
(contracted pelvis/ovarian cyst).
• A knowledgeable and experienced operator with
adequate preparation to proceed with an alternative
approach if necessary.
• An adequately informed woman (with signed
consent form detailing appropriate risks/benefits/
complications as the situation demands).
BIRTH BY VENTOUSE
The ventouse is essentially a suction cup (made from
plastic or metal) that is connected (via tubing) to a vacuum
source. Following the placement of the cup onto the fetal
head, traction can be applied to assist the birth.
There is no definitive guide as to which instrument to
use on which occasion. However the ventouse cup may
not be successful at securing birth and therefore obstetric
forceps should be chosen if there is:
• suspected fetal macrosomia
• excessive caput or moulding
• poor maternal effort due to exhaustion (which may
be compounded by epidural analgesia and poor
sensation)
• gestation <34 completed weeks.
Types of ventouse
Until recently, the most commonly used ventouse in use
in the United Kingdom (UK) was that of the ‘soft’ or sili-
cone cup design (Fig. 21.1A). Whilst these cups have the
undoubted advantages of being extremely malleable
(reducing maternal trauma by being more easy to correctly
place within the vagina) and having a reduced incidence
of fetal scalp trauma when compared to other cup designs,
soft cups have a poorer success rate than metal cups in
achieving a vaginal birth (RCOG [Royal College of Obste-
tricians and Gynaecologists] 2011).
Metal cup ventouse designs are of the Bird or Malstrom
types, which have a centrally placed traction chain with a
laterally located vacuum conduit. They come in diameters
of 4, 5 and 6 cm.
Both the standard soft and metal cup designs require
the generation of an operating vacuum from an external
source – and as such these pieces of equipment require
two operators for their successful use (one to control the
placement of the ventouse and assist the birth, the other
(most commonly the attending midwife) to control the
degree of vacuum that is generated.
More recent advances in design have removed the need
for the external suction generators by incorporating the
vacuum mechanism into ‘hand-held’ pumps (e.g. Kiwi
OmniCupTM) as illustrated in Fig. 21.1(B). Such devices are
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Section | 4 | Labour
safe and may be useful for rotational births because they
are low profile and are easily manoeuvered into the correct
position. However, they have a significantly higher failure
rate than the conventional metal cup ventouse, with cup
detachments occurring more frequently.
The use of the ventouse
The ventouse is more frequently employed by obstetri-
cians than the obstetric forceps due to its apparent ease of
use and comparative safety. However, repeated meta-
analyses have demonstrated that the ventouse is less likely
to achieve a successful vaginal birth than forceps, although
both types of instruments are associated with a lowering
of the overall CS rate (Johanson and Menon 1999).
Although the ventouse is associated with an increased risk
of neonatal complications such as cephalohaematoma
B Fig. 21.1 (A) The soft cup ventouse. (B) The Kiwi OmniCupTM.
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(Chapter 31), other facial (nerve palsies) and significant
cranial injuries (fractures) are more common with forceps.
Procedure
• The rationale for the birth is discussed with the
woman and her partner. The procedure is explained
and consent obtained (written consent should be
obtained if time allows).
• The woman’s legs should be placed into the
lithotomy position.
• Whilst inhalational analgesia may be sufficient
(entonox – N2O), more commonly a pudendal nerve
block with perineal infiltration may be administered,
or an epidural, if already in situ, may be topped up.
• Once adequate analgesia is assured, the maternal
bladder is emptied.

(1)
(3)
C
Fig. 21.1 Continued (C) Birth by ventouse.
• The fetal heart rate (FHR) must be continuously
monitored (with a cardiotocograph – CTG).
• For the successful use of the ventouse, it is essential
to determine the flexion point, which is located, in
an average term infant, along the sagittal suture 3 cm
anterior to the posterior fontanelle (and thus 6 cm
posterior to the anterior fontanelle). The centre of
the cup should be placed directly over this, as failure
to adequately position the cup can lead to a
progressive deflexion of the fetal head during
traction.
The operating vacuum pressure for nearly all ventouse
is between 0.6 and 0.8 kg/cm2 (60–80 kPa/500–800
cmH2O). No evidence exists that a stepwise reduction in
pressure improves the rate of successful birth when com-
pared with a linear reduction. Using the latter technique
with a silastic cup, a caput succedaneum (Chapter 31) is
formed instantly, and with the metal cup or OmniCupTM,
an adequate chignon is produced in <2 minutes. It is
important to note that a cup of 5 cm diameter is suitable
for nearly all births, even with larger babies.
When the vacuum is achieved, traction must be applied
to coincide with a contraction and thus maternal expulsive
efforts. Without both of these contributing factors, birth
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Operative births Chapter | 21 |
(2)
(4)
with a ventouse will fail. Traction is provided along a track
defined by the curve of Carus (Chapter 3): initially in a
downwards and backwards direction, then in a forward
and upward manner. Once the fetal head has crowned, the
vacuum is released, the cup removed and with further
maternal efforts the baby will be born. In addition to the
relative ease of use and low risk of complications, it is
undoubtedly this sense of contribution to the birth that
makes the ventouse a more satisfactory birthing experi-
ence for the mother and her partner than an operative
birth with obstetric forceps.
Precautions in use
With the ventouse, the operator should allow ≤2 episodes
of breaking the suction in any vacuum assisted birth, and
the maximum time from application to birth should
ideally be ≤15 minutes. If there is no evidence of descent
with the first pull, the woman should be reassessed to
ascertain the reason for failure to progress. In addition,
care should be taken to ensure that no vaginal skin is
trapped in the edges of the cup as this can result in
complex degrees of perineal trauma that can be extremely
difficult to repair in a satisfactory fashion.
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The midwife ventouse practitioner
Some midwives feel that women will be better served by
a midwife ventouse practitioner rather than an obstetri-
cian and embrace such innovations (Tinsley 2010).
However, others see it as exceeding the limits of normal
midwifery practice (Charles 1999). The fact is that mid-
wifery care is changing and developing, specifically with
the advancement of care within stand-alone midwife-led
units.
Whilst the idea of reducing the psychological trauma to
a woman during a birth by limiting the number of carers
in attendance at this crucial and critical time is to be com-
mended, it would be foolhardy to assume that the midwife
ventouse practitioner would be the primary carer for every
pregnant women on every occasion that required an
assisted vaginal birth. As such it is likely that a midwife
previously unknown to the labouring woman would be
asked to assist at the moment when help is required, an
event that would therefore be no less ‘traumatic’ for a
woman or her partner than asking an obstetrician to
attend. All accoucheurs, including midwife ventouse prac-
titioners, must be well educated and trained before carry-
ing out a ventouse birth – although it is highly unlikely
that the more complex surgical skills required of a birth
by forceps or CS would be mastered in addition. It should
be remembered that as a ventouse will fail in up to 20%
of cases, even in the most skilled hands, having no ability
to change instruments or resort to birth by CS will place
those midwives who work as ventouse practitioners in
isolation in a most unenviable position.
BIRTH BY FORCEPS
Characteristics of the obstetric
forceps
All obstetric forceps are composed of two separate blades
(determined as right and left by reference to their insertion
around the fetal head within the maternal vagina), two
shanks (shafts) of varying length and two handles. Forceps
are often described as non-rotational or rotational. Non-
rotational forceps are ‘held’ together by either an English
(non-sliding) lock on the shank or, in the case of rota-
tional forceps, by a sliding lock on the shank. The blades
have a cephalic curve to accommodate the form of the
baby’s head and are fenestrated (and not solid) to mini-
mize the trauma to the baby’s head during both placement
and birth. They also have a pelvic curve to reduce the
risks of trauma to the maternal tissues during the birth
process.
When the blades are correctly positioned around the
fetal skull, the handles will be neatly aligned in the hands
of the doctor who applies them and will be noted to ‘lock
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with ease’. Forceps that do not lock are most commonly
incorrectly placed.
Classification of obstetric forceps
Forceps operations fall into two categories: mid- and low-
cavity. Mid-cavity forceps are used when the leading part
of the fetal head has reached below the level of the ischial
spines; low-cavity forceps are used when the head has
descended to the level of the pelvic floor. High-cavity
forceps (with the leading part of the fetal head above the
level of the ischial spines) are now considered unsafe and
a CS will be the preferred method of birth in nearly all
cases.
Types of obstetric forceps
Wrigley’s forceps
These are designed for use in outlet lift-out when the head
is on the perineum or to assist the birth of the fetal head
at caesarean section. They have a short shank, fenestrated
blades with both pelvic and cephalic curves, and an
English lock (Fig. 21.2).
Neville–Barnes or Simpson’s forceps
These are generally used for a low- or mid-cavity forceps
birth when the sagittal suture is in the anteroposterior
diameter of the cavity of the pelvis. Whilst they have
cephalic and pelvic curves to the fenestrated blades, the
handles are longer and heavier (Fig. 21.2) than those of
the Wrigley’s. Anderson’s and Haig–Ferguson’s forceps are
also similar in shape and size.
Kielland’s forceps
These were originally designed to deliver the fetal head at
a station at, or above, the pelvic brim. They are now more
commonly used for the rotation and extraction of a baby
whose head is in the deep transverse or occipitoposterior
malpositions. By comparison to the non-rotational
forceps, the Kielland’s forceps blades have fenestrated
blades with a much-reduced pelvic curve (in order to allow
for the safe rotation of the fetus), longer shanks (to enable
rotation within the mid-cavity of the pelvis) and a sliding
lock to allow for correction of any degree of asynclitism
of the fetal head. These forceps (Fig. 21.2) should be used
only by an obstetrician skilled in their application and
use, and indeed in many units their use has been
abandoned.
Procedure
In addition to the key points outlined for ventouse
on page 458, i.e. rationale, consent, urinary bladder
 Operative births Chapter | 21 |

Fig. 21.2 Types of forceps. From above: Kielland’s, Neville–Barnes and Simpson’s. Note the difference in cephalic curve. The
rotational forceps (Kielland’s) have a long shaft and little pelvic curve. Wrigley’s forceps have a shorter shank.

catheterization, FHR monitoring and position of the

woman’s legs, specific issues to consider are:
• Consideration should be given as to the location
of the birth – in the birthing room (lift-out or
low-cavity – non rotational deliveries) or in the
obstetric theatre (all other forceps births).
• Unlike the ventouse, inhalational analgesia or a
pudendal nerve block with perineal infiltration
is unlikely to be sufficient for a forceps birth. In
the majority of instances an epidural, if already in
situ, may be topped up, or a spinal anaesthetic
should be administered. These are mandatory
before consideration is given to using Kielland’s
forceps.
• The forceps should be held discretely in front of the
woman (to visualize how they will be inserted per
vaginum) and placed around the fetal head. The left
blade is inserted before the right blade, with the
accoucheur’s hand protecting the vaginal wall from
direct trauma.
• The forceps blades come to lie parallel to the axis of
the fetal head, and between the fetal head and the
pelvic wall. The operator then articulates and locks Fig. 21.3 Left blade being inserted. The fingers of the right
the blades, checking their application before hand guard the vaginal tissue.
applying traction. The blades must be repositioned
or the procedure abandoned if the application is • As with the ventouse, the axis of traction changes
incorrect. during the birth and is guided along the curve of
• Traction should be applied in concert with uterine Carus, the blades being directed to the vertical as the
contractions and maternal expulsive efforts. head crowns (see Figs 21.3–21.6).

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Section | 4 | Labour

Fig. 21.6 As the head crowns it is lifted upwards.

Fig. 21.4 Right blade being inserted.

without the concurrent use of an episiotomy), vaginal

trauma, use of general anaesthesia, flatal, faecal and
urinary continence (Chapter 15).

Maternal complications
Complications may include:
• Trauma or soft tissue damage – occurring to the
cervix, vagina or perineum.
• Dysuria or urinary retention, which may result from
bruising or oedema to the tissues around the
urethra.
• Perineal discomfort.
• Haemorrhage (both from tissue trauma and also
uterine atony – the risk of which is always increased
following an assisted vaginal birth).

Fig. 21.5 Traction of the head is downwards until this point;
when the head is low, the direction of pull is outward,
towards the operator.
Complications of instrumental
vaginal birth
Although forceps are less likely than the ventouse to fail
to achieve a vaginal birth, they are significantly more likely
to be associated with third- or fourth-degree tears (with or
Neonatal complications
Complications may include:
• Marks on the baby’s face and bruising (commonly
caused by the pressure from the forceps blades and
around the caput succedaneum/chignon from the
ventouse – nearly all of which resolve within 48–72
hours after birth; see Chapter 31).
• Facial palsy, which may result from pressure from a
blade compressing a facial nerve (a transient
problem in most instances).

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■ Prolonged traction during a birth with a ventouse
will increase the likelihood of scalp abrasions,
cephalohaematoma or sub-aponeurotic bleeding
(Chapter 31).
Some authors suggest that failure rates of <1% should
be achieved using the correct technique and with well-
maintained equipment. Many authors feel that this is an
unrealistic target. Failure of the ventouse realistically arises
in up to 20% of cases and indeed Johanson and Menon
(1999) achieved vaginal birth with the first instrument in
only 86% of assisted births.
The following as factors will often be found to have
contributed to failure:
With the ventouse
• Failure to select the correct cup type – inappropriate
use of the silastic cup – especially in the presence of
deflexion of the fetal head, excess caput, ‘dense’
epidural block or fetal macrosomia (true CPD).
• Failure of the equipment to provide adequate traction
as a consequence of a leakage of the vacuum.
• Incorrect cup placement – too anterior or lateral,
with or without inclusion of maternal soft tissues
within the cup.
With any instrument
• Inadequate initial case assessment – high head,
misdiagnosis of the position and attitude of
the head.
• Traction along the wrong plane (often too anteriorly
and not along the curve of Carus).
• Poor maternal effort with inadequate use of
syntocinon to maximize the contribution from
coordinated uterine activity.
Whatever the outcome, the midwife in attendance is
vital to the success of any manoeuvres undertaken, encour-
aging the mother to be an active participant in her birth,
supporting the mother and her partner through what may
be perceived to be a ‘deviation from normal’ and impor-
tantly, to support the clinician undertaking the assisted
birth.
CAESAREAN SECTION
Caesarean section is an operative procedure, which is
carried out under anaesthesia (regional or general),
whereby the fetus, placenta and membranes are delivered
through an incision made in the abdominal wall and
uterus.
The RCOG (2001) National Sentinel Caesarean Section
Audit reported that the overall CS rate was 21.5% (England
and Wales), accounting for approximately 120 000 births
per year. Whilst the CS rates for maternity units ranged
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Operative births Chapter | 21 |
from 10% to 65%, 10% of women had CS before labour
(range between maternity units 4% to 59%), and 12% of
women who went into labour had a CS (range between
maternity units 2% to 22%).
It is believed that some of the differences in CS rates
observed may be explained by differences in the demo-
graphic and clinical characteristics of the population, such
as maternal age, ethnicity, previous CS, breech presenta-
tion, prematurity and induction of labour. However the
exact reasons for these differences remains unclear.
Although there has been an increase in CS rates over the
past 20 years, the four major clinical determinants of the
CS rate have not changed. Common primary indications
reported for women having a primary CS were: failure to
progress in labour (25%), presumed fetal compromise
(28%) and breech presentation (14%). The most common
indications for women having a repeat CS were: previous
CS (44%), maternal request as reported by clinicians
(12%), failure to progress (10%), presumed fetal compro-
mise (9%) and breech presentation (3%).
Currently in the UK, slightly more than one in seven
women experience complications during labour that
provide an indication for CS. These problems can be life-
threatening for the mother and/or baby (e.g. eclampsia,
abruptio placenta) and, in approximately 40% of such
cases, a CS provides the safest route for birth. In all cases the
principal aims must be to ensure that those women and
babies who need birth by CS are so delivered, and that those
who do not are saved from an unnecessary intervention.
In 1985, concern regarding the increasing frequency of
caesarean section led the World Health Organization
(WHO) to hold a Consensus Conference (Stephenson
1992). This conference concluded that there were no health
benefits above a CS rate of 10–15%. The Scandinavian
countries managed to hold CS rates at this level during the
1990s, with outcomes comparable to or better than those
of countries with higher CS rates. However, this is no longer
the case and CS rates in these countries have now increased
towards those in the other developed nations.
Although many factors have been associated with an
increase in the CS rate, not all have been to the detriment
of the mother or baby. Interestingly, whilst the CS rate has
risen over the two preceding decades, the instrumental
vaginal birth rate has remained relatively constant.
Clarifying the indications for
caesarean section
NICE (2011) recommends that the urgency of CS should
be documented using the following standardized scheme
in order to aid clear communication between healthcare
professionals about the urgency of a CS:
1. Immediate threat to the life of the woman or fetus.
2. Maternal or fetal compromise which is not
immediately life-threatening.
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Section | 4 | Labour
3. No maternal or fetal compromise but needs early
delivery.
4. Delivery timed to suit woman or staff.
The need for birth by a category 1 (‘crash’) CS is fortu-
nately a rare event as it can be a psychologically traumatic
event for the woman and her partner. It is also extremely
stressful for the clinical staff in attendance. Resources may
have to be obtained from other areas of clinical care to
facilitate such a birth and care standards risk being com-
promised in the rush to secure a ‘safe’ outcome. Care
should therefore be exercised before making this decision,
and in utero fetal resuscitation (fluids, tocolytics and
oxygen) may give enough time for a more considered and
careful approach.
Indications for which elective caesarean
section would be the strongly recommended
mode of birth:
• Past obstetric history
■ previous classical caesarean section
■ interval pelvic floor or anal sphincter repair
■ previous severe shoulder dystocia with significant
neonatal injury.
• Current pregnancy events
■ significant fetal disease likely to lead to poor
tolerance of labour
■ monoamniotic twins or higher-order multiple
pregnancy
■ placenta praevia
■ obstructing pelvic mass
■ active primary herpes at onset of labour.
• Intrapartum events
■ presumed fetal compromise in the first stage
■ maternal disease for which delay in delivery may
compromise the safety of the mother
■ absolute cephalopelvic disproportion (brow
presentations etc).
These lists are not comprehensive and factors or other
indicators may co-exist to influence the decision-making
process.
The operative procedure
• The rationale for the intervention is discussed with
the woman and her partner. The procedure is
explained and consent obtained (written consent
must be obtained in all cases other than a category
1 or ‘crash section’). For elective procedures
consent may be taken in a dedicated preoperative
assessment (the decision having been previously
discussed and agreed in the antenatal clinic by a
senior clinician in consultation with the woman
and her partner).
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• A preoperative assessment includes: weight and
observations of blood pressure, pulse and
temperature. The woman is gowned, make-up, the
presence of any nail varnish and jewellery removed
(rings/ear-rings taped).
• The woman is visited by the anaesthetist and the
operating department practitioner preoperatively,
and assessed. An anaesthetic chart will be
commenced.
• Results of any blood tests that have been requested
are obtained (full blood count, group and save and
cross match, if required).
• The woman will have fasted and have taken the
prescribed antacid therapy.
• Many women prefer to have urinary catheterization
in the theatre once the regional or general
anaesthetic has been administered. However some
women will prefer to have this procedure undertaken
in the privacy of their room before entering the
operating theatre.
• As the woman will need to lie flat, it is essential that
a wedge or cushion is used, or the table is tilted, to
direct the gravid uterus away from the inferior vena
cava. The risks of supine hypotension syndrome will
thus be reduced.
• The regional or general anaesthetics will be
administered.
• A surgical ‘time out’ should be carried out on every
woman entering the operating theatre prior to the
preparation of the skin. In competent hands this
takes a matter of seconds dramatically improving
safety whilst not delaying the birth to any
perceptible degree.
• The skin is prepared in accordance with local and
national guidelines. Currently, it remains unclear
what kind of skin preparation might be the most
efficacious in the prevention of post CS surgical
wound infection (Hadiati et al 2012).
• Intravenous antibiotics should be administered as
surgical prophylaxis before the skin is incised. This
reduces the risk of maternal infection more than
prophylactic antibiotics given after skin incision, and
no effect on the baby has been demonstrated.
The anatomical layers that need to be breached in order
to reach the fetus are: skin, subcutaneous fat, rectus sheath,
muscle (rectus abdominis), abdominal peritoneum, pelvic
peritoneum and uterine muscle.
A transverse lower abdominal incision (bikini line inci-
sion) is usually performed with the skin and subcutaneous
tissues incised using a transverse curvilinear incision at a
level of two fingerbreadths above the symphysis pubis. The
subcutaneous tissues are subsequently separated by blunt
dissection and the rectus sheath incised transversely for
2 cm either side of the midline. This incision is then

extended with scissors or blunt dissection before the facial
sheath is separated from the underlying muscle. The recti
are separated from each other, the peritoneum incised and
the abdominal cavity entered.
The fold of the peritoneum over the anterior aspect of
the lower uterine segment and above the bladder is incised
and the bladder mobilized and reflected down. The uterus
is incised transversely taking care not to cause surgical
trauma to the fetus (a significant risk in the presence of
low levels of amniotic fluid). The surgeon, with help from
the surgical assistant (who must apply fundal pressure),
will then secure the safe delivery of the baby.
The main reason for preferring the lower uterine segment
technique is the reduced incidence of dehiscence of the
uterine scar in any subsequent pregnancy and/or birth
when compared to a classical or vertical incision (which
may be the only surgical approach that is suitable in situ-
ations such as anterior wall placenta praevia, in extreme
prematurity (where no lower uterine segment may be
formed) or in the presence of dense adhesions from previ-
ous surgery.
Oxytocics (a bolus of 5 IU of Syntocinon) should be
given by the anaesthetist after birth of the baby and clamp-
ing of the umbilical cord. When the baby and placenta
have been delivered, the uterus is closed in two layers and
the rectus sheath and skin sutured. Most surgeons use a
braided polyglactin suture (Vicryl) for all layers. The
wound is then dressed and the vagina swabbed to remove
any clots. This also allows a final intraoperative assessment
of any ongoing bleeding from within the uterus.
Women having a CS should be offered thromboprophy-
laxis because they are at increased risk of venous throm-
boembolism (Lewis 2007; CMACE [Centre for Maternal
and Child Enquiries] 2011). The choice of method of
prophylaxis (for example, graduated stockings, hydration,
early mobilization, low molecular weight heparin) should
take into account risk of thromboembolic disease,
although in most cases it is simplest, and safest, to admin-
ister low molecular weight heparin to all women until they
are fully mobile. Those with an increased risk (e.g. mater-
nal obesity or concurrent maternal morbidity) should
have a more formal assessment of risk and an individual-
ized care plan put in place.
Early skin-to-skin contact between the woman and her
baby should be encouraged and facilitated as it improves
maternal perceptions of the infant, mothering skills,
maternal behaviour, breastfeeding outcomes and reduces
infant crying (Chapter 34). In addition, women who have
had a CS should be offered additional support to help
them to start breastfeeding as soon as possible after the
birth of their baby. This is because women who have had
a caesarean section are less likely to start breastfeeding in
the first few hours after the birth, but, when breastfeeding
is established, they are as likely to continue as women who
have had a vaginal birth.
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Operative births Chapter | 21 |
Women’s request for caesarean
section
The reasons behind the ‘demands’ for birth by CS are
frequently complex. Despite the focus of attention in the
media, evidence suggests that very few women actually
request CS in the absence of medical indications and the
‘too posh to push cohort’ are in an extreme minority
(Chaffer and Royle 2000; Weaver et al 2007). However,
the accounts of women who have had difficult experiences
of childbirth describe ‘knowing something was wrong
but believe that they were not listened to’ are all too
familiarly encountered. Such women frequently publicize
their problems via Facebook or other social media net-
works, fuelling the idea of ‘them against us’, and the joys
of any future pregnancy risk being overwhelmed by the
focus for a birth by CS whatever the rationale behind their
beliefs.
Psychological support and the role
of the midwife
Choice is an important element in understanding this
sequence. Women expect to be actively involved in their
care and all staff involved must ensure that recent, valid
and relevant information is provided in a comprehensible
manner. This will help women to decide what is best for
them, in relation to their own specific circumstances. The
midwife, as an informed, confident and competent prac-
titioner, will have a pivotal role in this process and be able
to provide women with clear and unbiased information
concerning the choices available (McAleese 2000). This
will often relieve the stress of the situation and help
women make a competent decision, supporting them in
the midst of any misgivings.
One-to-one care from a support person during labour
can influence the rate of birth by CS as a continual, sup-
portive presence in labour is undoubtedly of considerable
benefit, both to the woman and to her family (Walker and
Golois 2001; Hodnett et al 2011). It is important that mid-
wives recognize the positive impact on outcomes of their
continuous presence during established labour (NICE
2007; Hodnett et al 2011).
Psychological support mechanisms may also help these
women to overcome their fears and, as such, it may be
appropriate to develop links with trained counsellors to
enable women to explore their anxieties and reach a more
informed and rational decision prior to electing to undergo
major abdominal surgery. However, NICE (2011) recom-
mends for women requesting a CS that if, after discussion
and offer of support (including perinatal mental health
support for women with anxiety about childbirth, see
Chapter 25), a vaginal birth is still not an acceptable
option, a planned caesarean section should be offered.
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Vaginal birth after caesarean
section (VBAC)
Ziadeh and Sunna (1995) reported that the widespread
adoption of a policy whereby 80% of women with a prior
CS should have a VBAC would potentially eliminate up to
one-third of births by CS. This is still the target towards
which those providing care to women in pregnancy strive.
When advising about the mode of birth after a previous
CS it is important to consider the maternal preferences
and priorities, the risks and benefits of repeat CS and the
risks and benefits of planned VBAC, including the risk of
unplanned (i.e. emergency) CS.
NICE (2011) recommends that women who have had
up to and including four caesarean sections should be
informed that the risks of fever, bladder injuries and surgi-
cal injuries do not vary with the planned mode of birth
and that the risk of uterine rupture, although higher
for planned vaginal birth, is rare. However it is a ‘brave’
clinician who would choose to recommend vaginal birth
as a safe option in those women who have had two
previous CS.
It is also important to remember that pregnant women
with both a previous CS and a previous vaginal birth
should be informed that they have an increased likelihood
of achieving a vaginal birth than women who have had a
previous CS but no previous vaginal birth.
Pare et al (2006) argued that the concerns around the
safety of VBAC ignored the potential downstream conse-
quences of a strategy whereby multiple elective repeat cae-
sarean sections are considered to be the safer option. These
include an increased length of stay in hospital and
increased risks of placenta praevia and accreta in future
pregnancies. They confirmed that for women who desire
two or more additional children, the risks of multiple
caesarean sections outweigh the risks of a VBAC attempt.
Criteria for a successful VBAC:
• Adequate supervision including continuous
electronic fetal monitoring with CTG.
• All the facilities for assisted birth are readily
available.
• Progress of the labour is sufficient, observed both in
the descent of the presenting part and by the
dilatation of the cervix.
• The woman and her partner are fully informed about
the risks and benefits.
Postoperative care
After birth by CS women should be observed on a one-to-
one basis by a properly trained member of staff until they
have regained airway control, have observed cardiorespira-
tory stability and are able to communicate effectively. After
recovery from anaesthesia, observations (respiratory rate,
heart rate, blood pressure, pain and sedation) should be
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recorded every 15 minutes in the immediate recovery
period (for the first 30 minutes) and thereafter every half-
hour for 2 hours, and hourly thereafter provided that the
observations are stable or satisfactory. If these observations
are not stable, more frequent observations and medical
review are recommended. In addition the wound and
lochia must be inspected every 30 minutes to detect
any ongoing blood loss. If the mother intends to breast-
feed, the baby should be put to the breast as soon as
possible, a process that can usually be achieved with
minimal disturbance to the undertaking of these routine
observations.
For women who have had intrathecal opioids, there
should be a minimum hourly observation of respiratory
rate, sedation and pain scores for at least 12 hours if
diamorphine has been administered and for 24 hours in
the case of morphine. For women who have had epidural
opioids or patient-controlled analgesia (PCA) with
opioids, there should be routine hourly monitoring of
respiratory rate, sedation and pain scores throughout treat-
ment and for at least 2 hours after discontinuation of
treatment.
Postoperative analgesia
Postoperative analgesia should be given on a regular basis
and may be given in a variety of ways:
• Ongoing epidural anaesthesia/analgesia. Women
should have diamorphine (3 mg) or fentanyl
(100 µg) administered into the epidural space for
intra- and postoperative analgesia as it reduces the
need for supplemental analgesia after a caesarean
section. Intravenous or intramuscular administration
of diamorphine (2.5–5 mg) is a suitable alternative.
However, intramuscular or intravenous analgesia
should never be given in conjunction with epidural
opioids for at least the first 4 hours after
administration of the epidural dose because of the
cumulative effects and risks of respiratory depression.
• PCA using opioid analgesics may be offered after
caesarean section as an alternative pain relief
regimen.
• Antiemetics (e.g. cyclizine; prochlorperazine) are
usually prescribed when opioids are required.
• Analgesia, such as diclofenac (oral or rectal) or
paracetamol (oral, intravenous or rectal) are the
mainstays of postoperative analgesia.
• Oral drugs (e.g. dihydrocodeine, codydramol,
ibuprofen or paracetamol).
Providing there are no contraindications (history of kidney
disease, sensitivity to nonsteroidal anti-inflammatory
drugs [NSAIDs], peptic ulcer, severe brittle asthma),
NSAIDs should be offered post-caesarean section as an
adjunct to other analgesics, as they reduce the need for the
administration of opioids.

Care following regional block
Following birth under epidural or spinal anaesthesia, the
woman may sit up as soon as she wishes, provided her
blood pressure is not low. All observations must be
recorded as described above.
Women who are recovering well after CS and who do
not have complications can eat and drink when they feel
hungry or thirsty, at which point the intravenous fluid
infusion can be discontinued.
The baby should remain with the mother unless there
is a medical reason for care being provided elsewhere (e.g.
on a special care or neonatal intensive care unit) and
indeed they should be transferred to the postnatal ward
together once it is safe to do so. Such care is undoubtedly
of benefit to a woman’s psychological health and long-
term wellbeing.
Care in the postnatal ward
Once care is transferred to the postnatal ward, the blood
pressure, temperature, respirations and pulse must be
checked every 4 hours and recorded using a modified
obstetric early warning score chart (MOEWS) (Lewis
2007). In addition, the wound and lochia should be
inspected at the same time. Removal of the urinary bladder
catheter should be carried out once a woman is mobile
after a regional anaesthetic and not sooner than 12 hours
after the last epidural ‘top up’ dose. Healthcare profession-
als caring for women who have had a CS and who have
urinary symptoms should consider the possible diagnosis
of: urinary tract infection, stress incontinence (which
occurs in about 4% of women after CS) or urinary tract
injury (which occurs in about 1 per 1000 women after
birth by CS).
The mother should be encouraged to move her legs and
to perform leg and breathing exercises, however routine
respiratory physiotherapy does not need to be offered to
women after a caesarean section under general or regional
anaesthesia, as it does not improve respiratory outcomes
such as coughing, phlegm, body temperature, chest palpa-
tion and auscultatory changes.
The woman should be helped to get out of bed as soon
as possible following a CS, and should also be encouraged
to become fully mobile. Prophylactic low molecular
weight heparin and antiembolic or thromboembolic
deterrent (‘TED’) stockings should be prescribed. However,
the first dose of low molecular weight heparin should be
delayed until 4 hours after the intrathecal injection or
removal of the epidural catheter.
Women who have had a general anaesthetic for CS may
feel very tired and drowsy for some hours. A woman may
complain of a feeling of detachment and unreality and
may feel that she does not relate well to the baby. The
woman who is concerned should be reassured and be
given the opportunity to talk freely.
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Operative births Chapter | 21 |
Fig. 21.7 Baby in clip-on cot, adjacent to and within easy
reach of mother when in bed.
The mother must be encouraged to rest as much as pos-
sible and tactful advice may need to be given to her visi-
tors. If the mother becomes too tired, help is needed with
care for the baby. This should, preferably, take place at the
mother’s bedside and should include support with breast-
feeding. The clip-on cots, which may be attached to the
mother’s bed, are invaluable in promoting good care
(Fig. 21.7).
Caesarean section wound care should include: remov-
ing the dressing 24 hours after the delivery, assessing the
wound for signs of infection (such as increasing pain,
redness or discharge) separation or dehiscence, encourag-
ing the woman to wear loose comfortable clothes and
cotton underwear, gently cleaning and drying the wound
daily if needed and planning the removal of sutures or
clips if required.
Some women may have a lingering feeling of failure or
disappointment at having had an emergency CS and may
value the opportunity to talk this over with the midwife
or other clinicians involved in her care. Indeed it is con-
sidered to be good practice for the obstetrician who under-
took the CS to review the woman postpartum, not only in
order to discuss the problems that necessitated the surgical
intervention, but also to counsel about the options for any
future pregnancy.
Healthcare professionals caring for women who have
heavy and/or irregular vaginal bleeding following CS
should be aware that this is more likely to be due to
endometritis than retained products of conception. As a
consequence, should this complication be suspected, first
line treatment with broad spectrum antibiotics should be
implemented rather than referral for ultrasound assess-
ment. However, if there are any concerns about the com-
pleteness of the placental tissue or membranes, referral for
senior review at an early stage should be the preferred
course of action.
Whilst the length of hospital stay is likely to be longer
after a caesarean section (an average of 3–4 days) than
after a vaginal birth (average 1–2 days), women who are
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Section | 4 | Labour
Fig. 21.8 Locating the pudendal nerve.
recovering well, are apyrexial and do not have complica-
tions following CS should be offered early transfer home
(after 24 hours) from hospital and follow-up at home, as
this is not associated with more infant or maternal
readmissions compared with later transfer.
Analgesia/anaesthesia
Pudendal block
This is the procedure where local anaesthetic is infiltrated
into the tissue around the pudendal nerve within the pelvis
(Fig. 21.8). The pudendal nerve emerges from the spine at
the level of the S2–S4 vertebrae and ‘descends’ into the
pelvis crossing behind the ischial spine as it does so. The
pudendal nerve supplies the levator ani muscles, the deep
and superficial perineal muscles and the sensory nerves
(pain/stretch and temperature) of the lower vagina and
perineum. A pudendal needle (a specifically designed
needle incorporating a sheath guard) is employed with up
to 20 ml of local anaesthetic, usually 1% lidocaine (ligno-
caine), being injected into the region around and below
the ischial spine. As both motor and sensory nerves are
affected with this technique it may be used to provide
analgesia for the lower vagina and perineum, and is there-
fore used during forceps and ventouse instrumental births.
Perineal infiltration
See Chapter 15 for infiltration and repair of episiotomy,
as well as third- and fourth-degree perineal trauma.
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Pudendal artery
Pudendal nerve
Sacrospinous ligament
Regional anaesthesia
The two most commonly employed regional anaesthetic
techniques are those of epidural and intrathecal (spinal)
anaesthetic.
The epidural space is the space located within the bony
spinal canal just outside the dura mater. In contact with
the inner surface of the dura is another membrane called
the arachnoid mater. The cerebrospinal fluid (CSF) is con-
tained between the arachnoid mater and the pia mater,
another membrane that lies directly in contact with
the spinal cord. In adults, the spinal cord terminates at
the level of the lower border of the L2 vertebra below
which lies a bundle of nerves known as the cauda equina
(‘horse’s tail’).
Insertion of an epidural needle involves threading a
needle between the spinal vertebrae, through the liga-
ments and into the epidural potential space taking great
care not to puncture the dura mater immediately below,
which contains the CSF.
Techniques
Procedures involving injection of any substance into the
epidural space require the operator to be technically pro-
ficient in order to avoid complications.
The subject is most commonly placed in the seated or
lateral positions. Intravenous access is mandatory.
Following a standard aseptic technique protocol, the
level of the spine at which the catheter/spinal needle is to
be placed is identified.
 Operative births Chapter | 21 |

Epidural technique has some similarity to epidural anaesthesia.

However, important differences include:
The iliac crest is a commonly used anatomical landmark
for lumbar epidural injections, as this level roughly cor- • Intrathecal anaesthesia requires a lower dose of drug
responds with the fourth lumbar vertebra, which is usually and has a faster onset than epidural anaesthesia.
below the termination of the spinal cord. Following the • The block achieved with spinal anaesthesia is
infiltration of local anaesthetic, a Tuohy needle is usually typically described as being more dense.
inserted in the midline, between the spinous processes, • A spinal anaesthetic block typically lasts for 2 hours,
passing below the vertebral lamina until reaching the liga- however it cannot be topped up, as no catheter is
mentum flavum and the epidural space. A slight clicking inserted.
sensation may be felt by the operator as the tip of the • Intrathecal injections are performed below the
needle breaches the ligamentum flavum and enters the second lumbar vertebral body to avoid damaging the
epidural space. spinal cord.
A syringe containing saline is attached to the Tuohy
needle – most practitioners using the loss of resistance to Complications
pressure to identify that the needle is correctly placed. According to the Association of Anaesthetists of Great
A catheter is then threaded through the needle (typically Britain and Ireland (AAGBI) (2002), these include:
3–5 cm into the epidural space), the needle withdrawn
and the catheter secured to the skin with adhesive tape or
• Failure to achieve analgesia or anaesthesia occurs in
about 5% of cases, while another 15% experience
dressings to prevent it becoming dislodged.
only partial analgesia or anaesthesia. If analgesia is
The catheter is a fine plastic tube, through which anaes-
inadequate, another epidural may be attempted.
thetic drugs may be injected into the epidural space. Many
epidural catheters have three or more orifices along the
• The following factors are associated with failure to
achieve epidural analgesia/anaesthesia: obesity,
shaft at the distal tip (far end) of the catheter to allow
history of a previous failure of epidural anaesthesia,
rapid and even dispersal of the injected agents more
history of substance abuse (with opiates), advanced
widely around the catheter and reduce the incidence of
labour (cervical dilatation of more than 7 cm at
catheter blockage.
insertion) and previous history of spinal surgery.
A person receiving an epidural for pain relief may receive
local anaesthetic (most commonly levo-bupivacaine), with
• Accidental dural puncture with headache (common,
about 1 in 100 insertions). The epidural space in the
or without an opioid (most commonly fentanyl). These
adult lumbar spine is only 3–5 mm deep. It is
are injected in relatively small doses, compared to when
therefore comparatively easy to accidentally puncture
they are injected intravenously or intramuscularly.
the dura (and arachnoid) with the needle, causing
For a short procedure, the anaesthetist may introduce a
cerebrospinal fluid (CSF) to leak out into the
single dose of medication (the ‘bolus’ technique), although
epidural space. This may, in turn, cause a post-dural
the effects of this will eventually wear off. Thereafter, the
puncture headache (PDPH). This can be severe and
anaesthetist or midwife may repeat the bolus provided the
last several days, and in some rare cases weeks or
catheter remains undisturbed. For a prolonged effect, a
months. It is caused by a reduction in CSF pressure
continuous infusion of drugs may be employed. However
and is characterized by postural exacerbation when
there is evidence that patient controlled epidural analgesia
the subject raises his/her head above the lying
(PCEA), whereby the administration of the boluses is con-
position. If severe it may be successfully treated with
trolled by the patient (up to a predetermined maximum
an epidural blood patch, however most cases resolve
dose) provides better analgesia than a continuous infusion
spontaneously with time.
technique, although the total doses received by the indi-
vidual are often identical.
• Bloody tap (about 1 in 30–50). It is easy to injure an
epidural vein with the needle. In people who have
Typically, the effects of the epidural block are noted
normal blood clotting, it is extremely rare for
below a specific level on the body – a block at or below
significant complications to develop. However,
the T10 sensory level is ideal for women in labour or
people who have a coagulopathy may be at
during birth. Nonetheless, giving very large volumes into
increased risk.
the epidural space may spread the block higher.
The epidural catheter is usually removed prior to trans-
• Catheter misplaced into the subarachnoid space
(rare, less than 1 in 1000). If the catheter is
fer to the postnatal ward.
accidentally misplaced into the subarachnoid space
(e.g. after an unrecognized accidental dural
Spinal anaesthesia puncture), normally cerebrospinal fluid can be freely
Intrathecal (spinal) anaesthesia is a technique whereby a aspirated from the catheter (which would usually
local anaesthetic drug is injected into the cerebrospinal prompt the anaesthetist to withdraw the catheter and
fluid through a fine (24–26 gauge) spinal needle. The re-site it elsewhere). If, however, this is not

469
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Section | 4 | Labour
recognized, large doses of anaesthetic may be
delivered directly into the cerebrospinal fluid. This
may result in a high block, or, more rarely, a total
spinal, where anaesthetic is delivered directly to the
brain stem, causing unconsciousness and sometimes
seizures.
• Neurological injury lasting less than 1 year (rare,
about 1 in 6700).
• Death (very rare, less than 1 in 100 000).
• Epidural haematoma formation (very rare, about 1
in 168 000)
• Neurological injury lasting longer than 1 year
(extremely rare, about 1 in 240 000).
• Paraplegia (extremely rare, 1 in 250 000).
General anaesthesia
Despite the increasing use of regional anaesthesia, general
anaesthesia is required in up to 5% of women requiring
anaesthesia during birth. General anaesthesia can usually
be more rapidly administered than a regional block, and
is therefore of value when speed is important (such as
when the fetus is in serious jeopardy). Women are pre-
oxygenated (they are given oxygen to breathe for several
minutes) prior to the ‘rapid sequence’ induction of anaes-
thesia with the intravenous administration of anaesthetic
(e.g. thiopentone or propofol) followed by a muscle
relaxant (e.g. suxamethonium) and cricoid pressure is
applied (essential to reduce the risks of aspiration of
stomach contents). Maternal unconsciousness ensues
within seconds and orotracheal intubation is secured with
a cuffed tube. There are minimal side-effects and relatively
little negative fetal consequence at the time of birth pro-
vided meticulous practices are in place.
Anaesthesia is sustained by inhalational anaesthetic
means (commonly enflurane or sevoflurane) with an
opioid administered intravenously after clamping the
cord.
Difficult or failed intubation
This condition is more likely to occur in pregnant women,
particularly with those who have pregnancy-induced
hypertension or who are obese. Access to the larynx may
be obstructed or difficult to view in these women and
therefore anticipation of the disorder is the key to its
management. Should difficulties be anticipated, anaes-
thetists should carry out the intubation using a well-
lubricated stylet or bougie to aid the endotracheal
intubation.
The management of a failed intubation is primarily to
maintain adequate oxygenation via assisted ventilation of
the woman until the effects of suxamethonium and thio-
pentone have worn off and the woman has regained con-
sciousness. This is done through the continued application
of cricoid pressure and ventilation via a face mask.
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It is therefore imperative that surgery is not commenced
until the anaesthetist has secured the airway and con-
firmed that the woman is adequately ventilated.
Complications
Although surgical and anaesthetic techniques have
improved, women are still more liable to suffer from
complications and to have increased morbidity following
caesarean section under general anaesthetic when com-
pared to regional blockade.
Mendelson’s syndrome
This condition was described by Mendelson in 1946. It is
a chemical pneumonitis caused by the reflux of gastric
contents into the maternal lungs during a general anaes-
thetic. The acidic gastric contents damage the alveoli,
impairing gaseous exchange. It may become impossible to
oxygenate the woman and death may result. The predis-
posing factors are: the pressure from the gravid uterus
when the woman is lying down, and the effect of the
progesterone relaxing smooth muscle and the cardiac
sphincter of the stomach. Analgesics administered during
labour (e.g. pethidine) can cause significant delay in
gastric emptying and will thereby exacerbate these risks.
Prevention of Mendelson’s syndrome
Antacid therapy. Prophylactic treatment should be
administered to all women in whom a caesarean is
planned or anticipated. A usual regimen is for women
having an elective operation to be given two doses of oral
ranitidine 150 mg approximately 8 hours apart. If a
general anaesthetic is anticipated, 30 ml of sodium citrate
should be orally administered immediately before
induction.
Cricoid pressure. This is a technique whereby pressure
is exerted on the cartilaginous ring below the larynx, the
cricoid, to occlude the oesophagus and prevent reflux (Fig.
21.9). This is the most important measure in preventing
pulmonary aspiration. Cricoid pressure is administered
during the induction of a general anaesthetic (most com-
monly by an operating department practitioner) and is
maintained until the tracheal tube is confirmed as being
correctly positioned and the seal of the cuff inflated.
In the UK the most recent review into anaesthetic compli-
cations during pregnancy and childbirth, for the 2006–
2008 triennium, reviewed 127 cases in which anaesthetic
services were involved in the care of women who died from
either a direct or indirect cause of maternal death. This
comprised 49% (127 of 261) of all the maternal deaths
during that period. From these deaths the assessors identi-
fied seven (3%) women who died from problems directly
associated with anaesthesia a rate of 0.31 deaths per
100 000 women who gave birth. However, in a further
18 deaths, anaesthetic management contributed to the
outcome or there were lessons to be learned. There

Oesophagus
Trachea
Fig. 21.9 Cricoid pressure showing occlusion of the oesophagus by pressure applied to the cricoid cartilage.
were also 12 women with severe pregnancy-induced
hypertension or sepsis for whom obstetricians or gynae-
cologists failed to consult with anaesthetic or critical-care
services sufficiently early, which the assessors considered
may have contributed to the deaths.
It was concluded that:
• The effective management of failed tracheal
intubation is a core anaesthetic skill that should be
rehearsed and assessed regularly.
• The recognition and management of severe, acute
illness in a pregnant woman requires
multidisciplinary teamwork. An anaesthetist and/or
critical-care specialist should be involved early.
• Obstetric and gynaecology services, particularly those
without an on-site critical-care unit, must have a
defined local guideline to obtain rapid access to, and
help from, critical-care specialists (CMACE 2011).
Research and the incidence of
caesarean section: tackling high and
rising caesarean section rates
Low CS rates are associated with low levels of intervention
and high levels of psychological support. It is difficult to
decipher whether caesarean section rates have been affected
by interventions, such as proactive management of
labour – that is, artificial rupture of membranes and use
of oxytocin – or whether other factors have influenced
these.
NICE (2011) guidelines recommend that the clinical
interventions proven to reduce the rates of birth by CS
include all the key points highlighted in Box 21.2.
While there is no accepted optimal rate for CS in the
UK, some units manage to keep their CS rate below 20%.
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Operative births Chapter | 21 |
Adam's apple
Cricoid cartilage
Trachea
Box 21.2 Cinical interventions proven to reduce
the rates of birth by CS
• External cephalic version (ECV) at 36 weeks
• Continuous support in labour
• Induction of labour for pregnancies beyond 41 weeks
• Use of a partogram with a 4 hour action line in
labour
• Fetal blood sampling before caesarean section for
abnormal cardiotocograph in labour
• Support for women who choose vaginal birth after
caesarean section
Source: NICE 2011
If reductions in the rate are to be achieved, efforts should
focus on where there is the most potential for reduction:
reducing primary CS, particularly in first-time mothers,
and increasing rates of VBAC.
To provide more meaningful information to women
when they are choosing their mode of birth, NICE has
recommended that there is a pressing need to document
the medium- to long-term outcomes in women and their
babies after a planned CS or a planned vaginal birth. They
note that it should be possible to gather data using stand-
ardized questions (traditional paper-based questionnaires,
face-to-face interviews and Internet-based questionnaires)
about maternal septic morbidities and emotional well­
being up to 1 year after a planned CS in a population of
women who have consented for follow-up.
NICE (2011) also comment that it would be important
to collect high-quality data on infant morbidities after a
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Section | 4 | Labour
planned CS compared with a planned vaginal birth. A
long-term morbidity evaluation (between 5 and 10 years
after the CS) could use similar methodology to assess
additional symptoms related to urinary and gastrointes­
tinal function.
REFERENCES
Anim-Somuah M, Smyth R M D, Jones
L 2011 Epidural versus non-epidural
or no analgesia in labour. Cochrane
Database of Systematic Reviews,
Issue 12. Art. No. CD000331. doi:
10.1002/14651858.CD000331.pub3
Association of Anaesthetists of Great
Britain and Ireland (AAGBI) 2002
Immediate: Post anaesthetic recovery.
AAGBI, London
Bragg F, Cromwell D A, Edozien L C
et al 2010 Variation in rates of
caesarean section among English
NHS trusts after accounting for
maternal and clinical risk: cross
sectional study. British Medical
Journal 341:c5065 (correction
c65749).
Brown H C, Paranjothy S, Dowswell T
et al 2008 Package of care for active
management in labour for reducing
caesarean section rates in low-risk
women. Cochrane Database of
Systematic Reviews, Issue 4. Art No.
CD004907. doi:10.1002/14651858.
CD004907.pub2
Chaffer D, Royle L 2000 The use of
audit to explain the rise in caesarean
section. British Journal of Midwifery
8(11):677–84
Charles C 1999 How it feels to be a
midwife practitioner. British Journal
of Midwifery 7(6):380–2
CMACE (Centre for Maternal and Child
Enquiries) 2011 Saving mothers’
lives: reviewing maternal deaths to
make motherhood safer: 2006–08.
The Eighth Report on Confidential
Enquiries into Maternal Deaths in
the United Kingdom. BJOG: An
International Journal of Obstetrics
and Gynaecology 118(Suppl
1):1–203
Gupta J K, Hofmeyr G J, Shehnmar M
2012 Position in the second stage of
labour for women without epidural
472
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ACKNOWLEDGEMENT
The author would like to acknowledge the contribution of
Adela Hamilton to this chapter.
anaesthesia. The Cochrane Database
of Systematic Reviews, Issue 5. Art
No. CD002006. doi:
10.1002/14651858.CD002006.pub3
Hadiati D R, Hakimi M, Nurdiati D S
2012 Skin preparation for preventing
infection following caesarean
section. Cochrane Database of
Systematic Reviews, Issue 9. Art. No.
CD007462. doi: 10.1002/14651858.
CD007462.pub2
Health and Social Care Information
Centre, Hospital Episodes Statistics
2012 NHS maternity statistics
2011–2012 summary report.
(Accessed online at www.data.gov.uk
14 May 2013)
Hodnett E D, Gates S, Hofmeyr G J et al
2011 Continuous support for women
during childbirth. Cochrane
Database of Systematic Reviews,
Issue 2. Art No. CD003766. doi:
10.1002/1465/858.pub3
Johanson R B, Menon V 1999 Vacuum
extraction versus forceps for assisted
vaginal delivery. Cochrane Database
of Systematic Reviews, Issue 2. Art.
No. CD000224. doi:
10.1002/14651858.CD00022
Lewis G (ed) 2007 The Confidential
Enquiry into Maternal and Child
Health (CEMACH) Saving mothers’
lives: reviewing maternal deaths to
make motherhood safer – 2003–
2005. The Seventh Report on
Confidential Enquiries into Maternal
Deaths in the United Kingdom.
CEMACH, London
McAleese S 2000 Caesarean section for
maternal choice? Midwifery Matters
84:1–7
NICE (National Institute for Health and
Clinical Excellence) 2007
Intrapartum care. Care of healthy
women and their babies during
childbirth. CG 55. NICE, London
NICE (National Institute for Health and
Clinical Excellence) 2011 Caesarean
section. CG 132. NICE, London
O’Driscoll K, Meagher D, Boylan P
1993 Active management of labour,
3rd edn. Mosby, London
Pare E, Quiñones J, Macones G 2006
Vaginal birth after caesarean section
versus elective repeat caesarean
section: assessment of maternal
downstream health outcomes. BJOG:
An International Journal of
Obstetrics and Gynaecology
113:75–85
RCOG (Royal College of Obstetricians
and Gynaecologists) 2001 Clinical
Effectiveness Support Unit. The
National Sentinel Caesarean Section
audit report. RCOG, London
RCOG (Royal College of Obstetricians
and Gynaecologists) 2011 Operative
vaginal delivery. Green-top Guideline
No. 26. RCOG, London
Stephenson P A 1992 International
differences in the use of obstetrical
interventions. World Health
Organization, Copenhagen, WHO
EUR/ICP of MCH 112
Tinsley V 2010 Midwives undertaking
ventouse births. In Marshall J E,
Raynor M D (eds) Advancing skills
in midwifery practice. Churchill
Livingstone, Edinburgh, p 67–75
Walker R, Golois E 2001 Why choose
caesarean section? Lancet 357:636–7
Weaver J, Stratham H, Richards M 2007
Are there ‘unnecessary’ cesarean
sections? Perceptions of women and
obstetricians about cesarean sections
for nonclinical indications. Birth
34(1):32–41
Ziadeh S M, Sunna E I 1995 Decreased
cesarean birth rates and improved
perinatal outcome: a seven year
study. Birth 22(3):144–7

FURTHER READING
CMACE 2011 (Centre for Maternal and
Child Enquiries) Perinatal mortality
2009: United Kingdom. CMACE,
London
A useful audit report on perinatal deaths in
the UK.
James D K, Steer P J, Weiner C P et al
2010 High risk pregnancy:
management options. Elsevier
Health Sciences, London
This book examines the full range of
challenges in general obstetrics, medical
complications of pregnancy, prenatal
diagnosis, fetal disease and management of
USEFUL WEBSITES
Mothers and Babies: Reducing Risk
Through Audits and Confidential
Enquiries Across the UK:
www.mbrrace.ox.ac.uk
National Confidential Enquiry into
Patient Outcome and Death:
www.ncepod.org.uk
mebooksfree.com
Operative births
labour and delivery. This comprehensive
work features the fully searchable text
online at www.expertconsult.com, as well as
more than 100 videos of imaging and
monitoring giving easy access to the
resources needed to manage high-risk
pregnancies. It is a reference book, but a
thoroughly readable one.
Luesley D M, Baker P N (eds) 2010
Obstetrics and gynaecology: an
evidence-based text for MRCOG, 2nd
edn. Hodder/Arnold, London
This book, written by obstetricians
approaching their Part 2 MRCOG
National Institute for Health and Care
[formerly Clinical] Excellence:
www.nice.org.uk
National Patient Safety Agency:
www.npsa.nhs.uk
Royal College of Obstetricians and
Gynaecologists: www.rcog.org.uk
Chapter | 21 |
examination, is a useful handbook for
students of midwifery and midwives alike.
The perspective is evidence-based and very
woman-centred. Sections D and E focus on
the first and second stages of labour, their
complications and management. It contains
useful references at the end of each chapter.
Simms R, Hayman R 2011 Instrumental
vaginal delivery. Obstetrics,
Gynaecology and Reproductive
Medicine 21(1): 7–14
A general reference that informs the text of
this chapter.
Scottish Intercollegiate Guideline
Network: www.sign.ac.uk
World Health Organization:
www.who.net
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 Chapter 22

Midwifery and obstetric emergencies

Terri Coates

CHAPTER CONTENTS Effect of amniotic fluid embolism on

the fetus 486
Introduction 476 Acute inversion of the uterus 486
Communication 476 Classification of inversion 486
Use of the SBAR Tool 476 Causes 487
Vasa praevia 476 Warning signs and diagnosis 487
Diagnosis 477 Management 487
Management 477 Basic life support measures 487
Presentation and prolapse of the Shock 489
umbilical cord 477 Hypovolaemic shock 489
Predisposing factors 477 Central venous pressure 491
Cord presentation 478 Septic shock 492
Cord prolapse 478 Drug toxicity/overdose 492
Shoulder dystocia 479 References 492
Incidence 479 Further reading 494
Risk factors 479 Useful websites 495
Warning signs and diagnosis 480
Management and manoeuvres 480 The emergency situations covered in this chapter
are rare, but the communication and actions of
Outcomes following shoulder dystocia 483
the midwife are fundamental to the wellbeing
Rupture of the uterus 484 of the woman, her baby and also her partner
Causes 484 and family. Early detection of severe illness in
Signs of intrapartum rupture of childbearing women remains a challenge to all
the uterus 484 health professionals involved in their care.
Awareness of local emergency procedures and
Management 484 knowledge of correct use of any supportive
Amniotic fluid embolism 485 equipment are essential, and midwives in all
Predisposing factors 485 practice settings must maintain skills that enable
them to act appropriately in an emergency. The
Clinical signs and symptoms 485
use of multiprofessional workshops to rehearse
Emergency action 485 simulated situations can ensure that all members
Complications of amniotic fluid of the care team know exactly what is required
embolism 486 when needed. Midwives need also to engage in

© 2014 Elsevier Ltd 475

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Section | 4 | Labour
reviews of practice to ensure that policies and
protocols are regularly reviewed to incorporate
best practice and current evidence.
THE CHAPTER AIMS TO:
• recognize the importance of effective
communication between members of the
multiprofessional team in critical clinical situations
• heighten awareness of sudden changes in maternal
condition
• identify symptoms suggestive of serious illness
• discuss emergency situations with discussion of
possible causes and the action to be taken
• consider the rare obstetric conditions of uterine
rupture, acute inversion of the uterus and vasa
praevia
• discuss amniotic fluid embolism and the prompt
action required to preserve the woman’s life
• review the treatment of hypovolaemic shock and
septic shock in midwifery practice
• outline the drills for basic resuscitation.
INTRODUCTION
The immediate management of the emergencies discussed
in this chapter is dependent on the prompt action of the
midwife. Recognition of the problem and the instigation
of emergency measures may determine the outcome for
the mother or the fetus. The midwife should remain calm
and attempt to keep the woman and her partner fully
informed to obtain her consent and cooperation for pro-
cedures that may be needed.
It is recognized that pregnancy and labour are normal
physiological events, however regular routine observations
of vital signs must be an integral part of midwifery care.
There is potential for pregnant women and those who
have recently given birth to be at risk of physiological
deterioration that is not always predicted or recognized
(Centre for Maternal and Child Enquiries [CMACE] 2011).
To improve recognition of women who are unwell before
they become critically ill the modified early obstetric
warning score (MEOWS) chart should now be used
(CMACE 2011).
All midwifery and medical staff must be updated on the
signs and symptoms of critical illness from both obstetric
and non-obstetric causes. Regular drills should be held to
maintain and improve these skills. All staff should be
trained in basic life support to a nationally recognized level
and emergency drills for maternal resuscitation should be
regularly practised in all maternity units (CMACE 2011;
National Health Service Litigation Authority [NHSLA]
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2011). Furthermore, effective communication between
members of the multiprofessional team is essential to
ensure the optimum outcome for the childbearing woman
who becomes unwell and her baby (National Health
Service [NHS] Institute for Innovation and Improvement
2008).
COMMUNICATION
Health services are often criticized for poor communica-
tion among their staff, especially when the outcome does
not go according to expectations. However, there are very
few instruments that specifically focus on how to improve
verbal communication. The SBAR: Situation, Background,
Assessment and Recommendations tool developed by the
NHS Institute for Innovations and Improvements (2008)
is a framework that midwives can use to develop critical
clinical conversations that require immediate attention
and action.
Use of the SBAR tool
The tool consists of standardized prompt questions about
the condition of an individual in four stages:
• Situation
• Background
• Assessment
• Recommendation.
These prompts can assist the midwife to assertively and
effectively share concise and focused information about a
woman’s condition, reducing repetition. The SBAR tool
can be used in all clinical conversations: face-to face, by
telephone or through collaborative multiprofessional
team meetings.
In each of the following midwifery and obstetric emer-
gencies, the use of the SBAR tool should be paramount in
facilitating appropriate action that is always in the best
interest of the woman and her baby.
VASA PRAEVIA
The term vasa praevia is used when a fetal blood vessel lies
over the cervical os, in front of the presenting part. This
occurs when fetal vessels from a velamentous insertion of
the cord or to a succenturiate lobe (Chapter 6) cross the
area of the internal os to the placenta. The fetal life is at
risk owing to the possibility of rupture of the vessels
leading to exsanguination unless birth occurs within
minutes. Good outcome depends on antenatal diagnosis
and birth by caesarean section before the membranes
rupture (Oyelese and Smulian 2006).
 Midwifery and obstetric emergencies
Diagnosis
Vasa praevia may be diagnosed antenatally using ultra-
sound scan. Sometimes vasa praevia will be palpated on
vaginal examination when the membranes are still intact.
If it is suspected, a speculum examination should be made.
Fresh vaginal bleeding, particularly if it commences at the
same time as rupture of the membranes, may be due to
ruptured vasa praevia. Fetal distress disproportionate to
blood loss may be suggestive of vasa praevia.
Management
The midwife should call for urgent medical assistance.
The fetal heart rate should be monitored via cardiotoco-
graph (CTG). If the woman is in the first stage of labour
and the fetus is still alive, an emergency caesarean section
is carried out. If she is in the second stage of labour, the
birth should be expedited such that the baby may be
born vaginally. Caesarean section may be carried out but
the mode of birth will be dependent on parity and fetal
condition.
There is a high fetal mortality associated with this emer-
gency and a paediatrician should therefore be present for
the birth. If the baby is born in poor condition, resuscita-
tion, urgent haemoglobin estimation and a blood transfu-
sion with O-negative blood may be necessary.
PRESENTATION AND PROLAPSE
OF THE UMBILICAL CORD
Predisposing factors
These are the same for both presentation and prolapse of
the cord (for definitions see Box 22.1). Any situation
where the presenting part is neither well applied to the
cervix nor well down in the pelvis may make it possible
Box 22.1 Definitions
Cord presentation
This occurs when the umbilical cord lies in front of the
presenting part, with the fetal membranes still intact.
Cord prolapse
The cord lies in front of the presenting part and the fetal
membranes are ruptured (see Fig. 22.1).
Occult cord prolapse
This is said to occur when the cord lies alongside, but not
in front of, the presenting part.
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Chapter | 22 |
for a loop of cord to slip down in front of the presenting
part. Such situations include:
• high or ill-fitting presenting part
• high parity
• prematurity
• malpresentation
• multiple pregnancy
• hydramnios.
(Lin 2006; Holbrook and Phelan 2013)
High head
If the membranes rupture spontaneously when the fetal
head is high, a loop of cord is able to pass between the
uterine wall and the fetus resulting in its lying in front of
the presenting part. As the presenting part descends, the
cord becomes trapped and occluded.
Multiparity
The presenting part may not be engaged when the mem-
branes rupture and malpresentation is more common.
Prematurity
The smaller size of the fetus in relation to the pelvis and
the uterus allows the cord to prolapse. Babies of very low
birth weight (<1500 g) are particularly vulnerable (Lin
2006; Holbrook and Phelan 2013).
Malpresentation
Cord prolapse is associated with breech presentation,
especially complete or footling breech. This relates to the
ill-fitting nature of the presenting parts and also the prox-
imity of the umbilicus to the buttocks. In this situation,
the degree of compression may be less than with a cephalic
presentation, but there is still a danger of asphyxia.
Shoulder and compound presentation and transverse
lie (Chapter 20) carry a high risk of prolapse of the
cord, occurring with spontaneous rupture of the
membranes.
Multiple pregnancy
Malpresentation, particularly of the second twin, is more
common in multiple pregnancy with the consequences of
possible cord prolapse.
Hydramnios
The cord is liable to be swept down in a gush of liquor if
the membranes rupture spontaneously. Controlled release
of liquor during artificial rupture of the membranes is
sometimes performed to try to prevent this.
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Cord presentation
This is diagnosed on vaginal examination when the cord
is felt behind intact membranes. It may be associated
with aberrations found during fetal heart monitoring such
as decelerations, which occur if the cord becomes
compressed.
Management
Under no circumstances should the membranes be rup-
tured. The midwife should discontinue the vaginal exami-
nation, in order to reduce the risk of rupturing the
membranes. Medical aid should be summoned. To assess
fetal wellbeing, continuous electronic fetal monitoring
should be commenced or the fetal heart should be aus-
cultated as frequently as possible. The woman should be
assisted into a position that will reduce the likelihood of
cord compression. Unless birth is imminent, caesarean
section is the most likely outcome.
Cord prolapse
Diagnosis
Whenever there are factors present that predispose to cord
prolapse (Fig. 22.1), a vaginal examination should be
Fig. 22.1 Cord prolapse.
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performed immediately on spontaneous rupture of the
membranes.
Bradycardia and variable or prolonged decelerations of
the fetal heart are associated with cord compression,
which may be caused by cord prolapse. The diagnosis of
cord prolapse is made when the cord is felt below or
beside the presenting part on vaginal examination. The
cord may be felt in the vagina or in the cervical os or a
loop of cord may be visible at the vulva (Lin 2006).
Immediate action
Where the diagnosis of cord prolapse is made, the time
should be noted and the midwife must call for urgent
assistance. The midwife should explain to the woman and
her birth partner her findings and any emergency meas-
ures that may be needed. If an oxytocin infusion is in
progress this should be discontinued. If the cord lies
outside the vagina, then it should be gently replaced to
prevent spasm, to maintain temperature and prevent
drying. Administering oxygen to the woman by face mask
at 4 l/min may improve fetal oxygenation.
Relieving pressure on the cord
The risks to the fetus are hypoxia and death as a result of
cord compression. The risks are greatest with prematurity
and low birth weight (Holbrook and Phelan 2013). The
midwife may need to keep her fingers in the vagina and
hold the presenting part off the umbilical cord, especially
during a contraction. The woman can be supported to
change position and further reduce pressure on the cord.
If the woman raises her pelvis and buttocks or adopts the
knee–chest position, the fetus will be encouraged to grav-
itate towards the diaphragm (Fig. 22.2). The foot of the
bed may also be raised (Trendelenburg position) to
relieve compression on the cord. Alternatively, the woman
can be helped to lie on her left side, with a wedge or
pillow elevating her hips (exaggerated Sims’ position)
(Fig. 22.3). There is some evidence to suggest that bladder
filling may also be an effective technique for managing
Fig. 22.2 Knee–chest position. Pressure on the umbilical
cord is relieved as the fetus gravitates towards the fundus.
 Midwifery and obstetric emergencies
Fig. 22.3 Exaggerated Sims’ position. Pillows or wedges are
used to elevate the woman’s buttocks to relieve pressure on
the umbilical cord.
cord prolapse (Houghton 2006; Bord et al 2011). A self-
retaining 16G Foley catheter is used to instill approxi-
mately 500–700 ml of sterile saline into the bladder. The
full bladder can relieve compression of the cord by elevat-
ing the presenting part about 2 cm above the ischial
spines until birth by caesarean section. The bladder
would be drained in theatre immediately before the caes­
arean section commences.
Birth must be expedited with the greatest possible speed
to reduce the mortality and morbidity associated with this
emergency. Caesarean section is the treatment of choice in
those instances where the fetus is still alive and vaginal
birth is not imminent.
If a cord prolapse is diagnosed in the second stage of
labour, with a multigravida, the midwife may perform an
episiotomy to expedite the birth. Where the presentation
is cephalic, assisted birth may be achieved through ven-
touse or forceps (Chapter 21).
If a cord prolapse occurs in the community setting, emer-
gency transfer to a consultant-led maternity unit is essen-
tial. The midwife should carry out the same procedures to
relieve the compression on the cord. Senior obstetric and
anaesthetic staff should be informed and be prepared to
perform an emergency caesarean section. An experienced
paediatrician should be available to resuscitate the baby,
should it be born alive.
SHOULDER DYSTOCIA
The term shoulder dystocia describes failure of the shoul-
ders to traverse the pelvis spontaneously requiring
additional manoeuvres after the birth of the head (Royal
College of Obstetricians and Gynaecologists [RCOG]
2012). However, a universally accepted definition of
shoulder dystocia has yet to be produced (RCOG 2012).
The anterior shoulder becomes trapped behind or on
the symphysis pubis, while the posterior shoulder may be
in the hollow of the sacrum or high above the sacral
promontory (Fig. 22.4). This is, therefore, a bony dysto-
cia, and traction at this point will further impact the ante-
rior shoulder, impeding attempts to assist the baby’s
birth.
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Chapter | 22 |
Fig. 22.4 Shoulder dystocia.
Incidence
Shoulder dystocia is not a common emergency: the inci-
dence is reported as varying between 0.58% and 0.7% in
collected data (RCOG 2012).
Risk factors
Although it would be useful to identify those women at
risk from a birth complicated by shoulder dystocia, most
risk factors can give only a high index of suspicion
(Al-Najashi et al 1989). Antenatal risk factors include dia-
betes, post-term pregnancy, high parity, maternal age over
35 and maternal obesity (weight over 90 kg).
Fetal macrosomia (birth weight over 4000 g) has been
associated with an increased risk of shoulder dystocia, the
incidence increasing as birth weight increases (Delpapa
and Mueller-Heubach 1991; Hall 1996). Ultrasound scan-
ning for prediction of macrosomia to prevent shoulder
dystocia still has a poor record of success though it is
anticipated that ultrasound detection of macrosomia can
be improved (Hall 1996; Siggelkow et al 2011). If a large
baby is suspected then this fact must be communicated
clearly to the team caring for the woman in labour (Con-
fidential Enquiries into Stillbirths and Deaths in Infancy
[CESDI] 1999).
Maternal diabetes and gestational diabetes have been
identified as important risk factors (Athukorala et al
2007). In diabetic women, a previous birth complicated
by shoulder dystocia increases the risk of recurrence to
9.8%; this compares with a risk of recurrence of 0.58% in
the general population (Smith et al 1994; Ouzounian et al
2012). The National Institute for Health and Clinical
Excellence (NICE) diabetes guideline currently recom-
mends elective birth is offered at 38 weeks’ gestation
(NICE 2008).
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Section | 4 | Labour

Box 22.2 HELPERR mnemonic

Help
Episiotomy need assessed
Legs in McRoberts position
Pressure suprapubically
Enter vagina (internal rotation)
Remove posterior arm
Roll the woman over and try again
Adapted from the American Academy of Family Physicians (2004)
Advanced Life Support in Obstetrics (ALSO®)
In labour, risk factors that have been consistently linked
with shoulder dystocia include oxytocin augmentation,
prolonged labour, prolonged second stage of labour and
operative births (Benedetti and Gabbe 1978; Al-Najashi
et al 1989; Keller et al 1991; Bahar 1996; Gupta et al
2010). For a clinically suspected large baby, the multipro-
fessional team must be alert for the possibility of shoulder
dystocia (CESDI 1999).
Warning signs and diagnosis
The birth may have been uncomplicated initially, but the
head may have advanced slowly, with the chin having diffi-
culty in sweeping over the perineum. Once the head is born,
it may look as if it is trying to return into the vagina (the
turtle sign). Shoulder dystocia is diagnosed when manoeu-
vres such as gentle downward axial traction* on the head,
that may normally be used by the midwife, fail to complete
the birth (RCOG 2012). The woman should be discouraged
from pushing and any further traction must be avoided.
Management and manoeuvres
The HELPERR Mnemonic (Box 22.2) devised to provide a
systematic approach to the management of shoulder dys-
tocia is limited and unhelpful as demonstrated by recent
evidence. A study by Jan et al (2014) reported a poor cor-
relation between healthcare professionals’ knowledge of
manoeuvres and their eponyms. They therefore concluded
that any teaching of practical skills should not rely on
mnemonics but should primarily be concerned with com-
prehension, learning and regular opportunities to practise
skills and use clinical judgement e.g. mandatory ‘skills and
drills’ training.
Upon diagnosing shoulder dystocia, the midwife must
summon help immediately: the midwife coordinator, an
experienced obstetrician, an anaesthetist and a person pro-
ficient in neonatal resuscitation. Stating the problem early
*Axial traction is traction in line with the fetal spine, i.e. no lateral
deviation.
Fig. 22.5 The McRoberts manoeuvre position.
to the team has been associated with improvements in
outcomes in shoulder dystocia (RCOG 2012).
Shoulder dystocia is a frightening experience for the
woman, for her partner and for the midwife. The midwife
should keep calm and explain as much as possible to the
woman to ensure her full cooperation for the manoeuvres
that may be needed to complete the birth.
The purpose of all these manoeuvres is to disimpact the
shoulders. The principle of using the simplest manoeuvres
first should be applied. The midwife will need to make an
accurate and detailed record of the time help was sum-
moned and those who attended, the type of manoeuvre(s)
used and the time taken, the amount of force used and
the outcome of each manoeuvre attempted (Nursing and
Midwifery Council [NMC] 2012). It is also important to
record which of the fetal shoulders was anterior.
Non-invasive procedures
Change in maternal position
Any change in the maternal position may be useful to help
release the fetal shoulders as shoulder dystocia is a bony,
mechanical obstruction. However, certain manoeuvres
have proved useful and are described below. It is antici-
pated that following the use of one or more of these
manoeuvres, the birth is likely to proceed.
The McRoberts manoeuvre
This manoeuvre involves assisting the woman to lie com-
pletely flat (pillows removed) with her buttocks at the
edge of the bed and hyperflexing her hips to bring her
knees up to her chest as far as possible (Fig. 22.5).
This manoeuvre will rotate the angle of the symphysis
pubis superiorly and use the weight of the woman’s legs
to create gentle pressure on her abdomen, releasing the
impaction of the anterior shoulder (Gonik et al 1983,
1989). The McRoberts manoeuvre is associated with the
lowest level of morbidity and requires the least force to
assist the birth (Bahar 1996; RCOG 2012).
Suprapubic pressure
Pressure should be exerted on the side of the fetal back
and towards the fetal chest. This manoeuvre may help to

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 Midwifery and obstetric emergencies
Fig. 22.6 Correct application of suprapubic pressure for
shoulder dystocia.
After Pauerstein C (ed), Clinical obstetrics. Churchill Livingstone, New
York, 1987, with permission.
adduct the shoulders and push the anterior shoulder away
from the symphysis pubis into the larger oblique or trans-
verse diameter (Fig. 22.6). Suprapubic pressure can be
employed together with the McRoberts manoeuvre to
improve success rates (RCOG 2012).
All-fours position
The all-fours position (or Gaskin manoeuvre) is achieved by
assisting the woman onto her hands and knees. The act of
the woman turning may be the most useful aspect of this
manoeuvre (Bruner et al 1998). In shoulder dystocia, the
impaction is at the pelvic inlet and the force of gravity will
keep the fetus against the anterior aspect of the mother’s
uterus and pelvis. However, this manoeuvre may be espe-
cially helpful if the posterior shoulder is impacted behind
the sacral promontory as this position optimizes space
available in the sacral curve and may allow the posterior
arm/shoulder to be born first. Manipulative manoeuvres
can be performed while the woman is on all fours but clear
verbal communication is needed as eye contact is difficult.
Where non-invasive procedures have not been success-
ful, direct manipulation of the fetus must be attempted,
requiring the midwife to insert a whole hand into the
vagina. The McRoberts position as detailed above can be
used, or the woman could be placed in the lithotomy
position with her buttocks well over the end of the bed so
that there is no restriction on the sacrum.
Episiotomy
The problem facing the midwife is an obstruction at the
pelvic inlet which is a bony dystocia, not an obstruction
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Chapter | 22 |
Fig. 22.7 The Rubin manoeuvre.
caused by soft tissue. Although episiotomy (Chapters 15
and 17) will not help to release the shoulders per se, the
midwife should consider the need to perform one to gain
access to the fetus without tearing the perineum and
vaginal walls.
Rotational manoeuvres
The Rubin manoeuvre
Rubin (1964) advocated using suprapubic rocking to dis-
lodge the anterior shoulder. If rocking alone proved unsuc-
cessful, vaginal examination (inserting the whole hand)
was suggested to identify the most accessible shoulder
(usually the posterior shoulder), and push that shoulder
in the direction of the fetal chest. This process adducts the
shoulders and allows rotation away from the symphysis
pubis. The manoeuvre reduces the 12 cm bisacromial
diameter (Fig. 22.7).
The Woods manoeuvre
Woods’ (1943) manoeuvre requires the midwife to insert
a whole hand into the vagina and identify the fetal chest.
Then, by exerting pressure on to the posterior fetal shoul-
der, rotation is achieved. Although this manoeuvre does
abduct the shoulders, it will rotate the shoulders into a
more favourable diameter and enable the midwife to com-
plete the birth (Fig. 22.8).
Birth of the posterior arm
The midwife has to insert a hand into the vagina, making
use of the space created by the hollow of the sacrum, as
shown in Figs 22.9A,B. Then two fingers grasp the wrist of
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Section | 4 | Labour

the posterior arm (see Fig. 22.9C), to flex the elbow and
sweep the forearm over the chest for the hand to be born,
as shown in Fig. 22.9D (O’Leary 2009). If the rest of the
birth is not then accomplished, the birth of the second
arm is assisted following rotation of the shoulder using
either the Woods or Rubin manoeuvre or by reversing the
Løvset manoeuvre (Chapter 17).

Zavanelli manoeuvre
If the manoeuvres described above have been unsuccess-
ful, the obstetrician may consider the Zavanelli manoeu-
vre (Sandberg 1985, 1999) as a last hope for birth of a live
baby. The Zavanelli manoeuvre requires the reversal of the
mechanisms of birth so far achieved and reinsertion of the
fetal head into the vagina. The birth is then completed by
Fig. 22.8 The Woods manoeuvre. caesarean section.
After Sweet B R, Tiran D, Mayes’ midwifery. Baillière Tindall, London,
Method: The head is returned to its pre-restitution
1996: p 664, with permission.
position (Fig. 22.10A). Pressure is then exerted onto the

A B

C D

Fig. 22.9 Birth of the posterior arm. (A) Location of the posterior arm. (B) Directing the arm into the hollow of the sacrum.
(C) Grasping and splinting the wrist and forearm. (D) Sweeping the arm over the chest and delivering the hand.

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 Midwifery and obstetric emergencies
A cia in 5.7–9.7% of cases and the attending paediatrician
B (Crofts et al 2006; RCOG 2012). Record keeping following
Fig. 22.10 The Zavanelli manoeuvre. (A) Head being
returned to direct anteroposterior (pre-restitution) position.
(B) Head being returned to the vagina.
After Sandberg 1985, with permission.
occiput and the head is returned to the vagina (Fig.
22.10B). Prompt birth of the baby by caesarean section is
then required.
Symphysiotomy
Symphysiotomy is the surgical separation of the symphysis
pubis and is used to enlarge the pelvis to enable the
birth. It is usually performed in cases of cephalopelvic
disproportion (CPD) and is used more routinely in the
developing world. There are a few recorded cases where
symphysiotomy has been used successfully to relieve
shoulder dystocia (Wykes et al 2003), but the procedure
has usually been associated with a high level of maternal
morbidity. The rarity of reported cases makes it difficult
to assess the technique for the relief of shoulder
dystocia.
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Chapter | 22 |
Outcomes following shoulder
dystocia
Maternal
Approximately two-thirds of women will have a blood loss
of >1000 ml from injury associated with the birth (O’Leary
2009). Maternal death from uterine rupture has been
reported following the use of fundal pressure and from
haemorrhage during and following the birth (O’Leary
2009).
Fetal
Neonatal asphyxia may occur following shoulder dysto-
must be experienced in neonatal resuscitation (CESDI
1999; RCOG 2012). Brachial plexus injury is commonly
associated with shoulder dystocia (Gurewitsch et al
2006; Sandmire and DeMott 2009). Damage to cervical
nerve roots 5 and 6 may result in an Erb’s palsy
(Chapter 31).
Neonatal morbidity may be as high as 42% following
shoulder dystocia and remains a cause of intrapartum
fetal death (CESDI 1999). Fetal damage may occur even
with excellent management using appropriate obstetric
manoeuvres. Following shoulder dystocia, examination of
the newborn should be carried out by a senior neonatal
clinician (RCOG 2012).
The midwife must ensure that simulation training and
practice drills are attended annually to maintain skills
shoulder dystocia should include identification of the
anterior shoulder and the direction of the fetal head as
shown in Box 22.3 (NMC 2012; RCOG 2012).
Box 22.3 Key points for record keeping
following shoulder dystocia
• Time of birth of the head and time of birth of
the body
• Anterior shoulder at the time of the dystocia
• Manoeuvres performed, their timing and sequence
• Maternal perineal and vaginal examination
• Estimated blood loss
• Staff in attendance and the time they arrived
• General condition of the baby (Apgar score)
• Umbilical cord blood acid–base measurements
• Neonatal assessment of the baby
• Time of completion of records
Adapted from RCOG (2012)
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Section | 4 | Labour
RUPTURE OF THE UTERUS
Rupture of the uterus is one of the most serious complica-
tions in midwifery and obstetrics. It is often fatal for the
fetus and may also be responsible for the death of the
mother. In the 2006–2008 triennial report, there were 111
cases of uterine rupture reported as causing morbidity in
women, however, of the nine maternal deaths from haem-
orrhage, only one was associated with uterine rupture
(Norman 2011). Nevertheless, uterine rupture remains a
significant problem worldwide. With effective antenatal
and intrapartum care, some cases of uterine rupture may
be avoided.
Rupture of the uterus is defined as being complete or
incomplete:
• complete rupture involves a tear in the wall of the
uterus with or without expulsion of the fetus
• incomplete rupture involves tearing of the uterine wall
but not the perimetrium.
Dehiscence of an existing uterine scar may also occur.
This involves rupture of the uterine wall but the fetal
membranes remain intact. The fetus is retained within
the uterus and not expelled into the peritoneal cavity
(Cunningham et al 2010; Landon 2010). The risk of uterine
rupture is increased for those women who have a uterine
scar. Studies cite figures of between 0.4 and 4% of labours
following a previous caesarean section (Landon 2010).
Causes
Cases of spontaneous rupture of an unscarred uterus in
primigravidae are reported in the literature (Roberts and
Trew 1991; Uccella et al 2011), but are very rare in the
developed world (Hofmeyr et al 2005).
Rupture of the uterus can be precipitated in the follow-
ing circumstances:
• antenatal rupture of the uterus, where there has been
a history of previous uterine surgery
• neglected labour, where there is previous history of
caesarean section
• high parity
• use of oxytocin, particularly where the woman is of
high parity
• use of prostaglandins to induce labour, in the
presence of an existing scar (Lydon-Rochelle et al
2001; Landon 2010)
• obstructed labour: the uterus ruptures owing to
excessive thinning of the lower segment (Bandl’s
ring)
• extension of severe cervical laceration upwards into
the lower uterine segment – the result of trauma
during an assisted birth
• trauma, as a result of a blast injury or an accident
(Michiels et al 2007)
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• perforation of the non-pregnant uterus can result in
rupture of the uterus in a subsequent pregnancy
(Usta et al 2007; Landon 2010).
Signs of intrapartum rupture
of the uterus
Complete rupture of a previously non-scarred uterus may be
accompanied by sudden collapse of the woman, who
complains of severe abdominal pain. The maternal pulse
rate increases and, simultaneously, alterations of the fetal
heart may occur, including the presence of variable decel-
erations (Landon 2010). In the UK during the triennium
2003–2005 there were three intrapartum fetal deaths asso-
ciated with ruptured uterus (Acolet 2007). There may be
evidence of fresh vaginal bleeding. The uterine contrac-
tions may stop and the contour of the abdomen alters. The
fetus becomes palpable in the abdomen as the presenting
part regresses. The degree and speed of the woman’s col-
lapse and shock depend on the extent of the rupture and
the blood loss (see Box 22.4).
Incomplete rupture may have an insidious onset found
only after birth or during a caesarean section. This type is
more commonly associated with previous caesarean
section. Blood loss associated with dehiscence, or incom-
plete rupture, can be scanty, as the rupture occurs along
the fibrous scar tissue, which is avascular (Landon 2010).
Whenever shock during the third stage of labour is more
severe than the type of birth or blood loss would indicate,
or the woman fails to respond to the treatment given, the
possibility of incomplete rupture should be considered.
Incomplete rupture may also be manifest as a cause of
abdominal pain and/or postpartum haemorrhage follow-
ing vaginal birth.
Management
All maternity units should have a protocol for dealing with
uterine rupture. An immediate caesarean section is per-
formed in the hope of procuring a live baby. Following the
birth of the baby and placenta, the extent of the rupture
can be assessed. Choice between the options to perform a
hysterectomy or to repair the rupture depends on the
Box 22.4 Key signs of rupture of uterus
• Abdominal pain or pain over previous caesarean
section scar
• Abnormalities of the fetal heart rate and pattern
• Vaginal bleeding
• Maternal tachycardia
• Poor progress in labour
 Midwifery and obstetric emergencies
extent of the trauma and the woman’s condition. Further
clinical assessment will include evaluation of the need for
blood replacement and management of any shock.
The woman will be unprepared for the events that have
occurred and therefore may be totally opposed to hyster-
ectomy. Few reports of successful pregnancy following
repair of uterine rupture are available (Landon 2010).
AMNIOTIC FLUID EMBOLISM
Amniotic fluid embolism (AFE) is rare, unpredictable and
unpreventable. In the triennium 2006–2008, there were a
total of 13 maternal deaths (0.57/100 000 maternities)
resulting from AFE with the diagnosis having been
confirmed clinically and by post-mortem examination
(Dawson 2011). Although AFE has now fallen to fourth
place among the leading causes of direct maternal deaths
(Dawson 2011) and continues to be a significant factor in
maternal mortality, it is no longer considered universally
fatal through improvements in resuscitation.
Amniotic fluid embolism occurs when amniotic fluid
enters the maternal circulation via the uterus or placental
site such that maternal collapse can progress rapidly. The
body responds to AFE in two phases. The initial phase is
one of pulmonary vasospasm causing hypoxia, hypoten-
sion, pulmonary oedema and cardiovascular collapse. The
second phase sees the development of left ventricular
failure, with haemorrhage and coagulation disorder and
further uncontrollable haemorrhage. Mortality and mor-
bidity are high (Dawson 2011) though early diagnosis may
lead to a better outcome (Knight et al 2010) and early
transfer to an intensive care unit is associated with
decreased morbidity (Dawson 2011).
When AFE occurs in a well-equipped unit, it should be
considered a treatable and survivable event in the majority
of cases (Knight et al 2010). Emergency drills for maternal
resuscitation and peri-mortem caesarean section should
be regularly practised in clinical areas in all maternity
units (Dawson 2011).
Predisposing factors
Amniotic fluid embolism can occur at any gestation.
Chance entry of amniotic fluid into the circulation under
pressure may occur through the uterine sinuses of the
placental bed. It is mostly associated with labour and
its immediate aftermath, but cases in early pregnancy
and postpartum have been documented (Knight et al
2010).
The barrier between the maternal circulation and the
amniotic sac may be breached during periods of raised
intra-amniotic pressure, such as termination of pregnancy
or during placental abruption. Procedures such as artificial
rupture of the membranes (ARM) and insertion of an
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Chapter | 22 |
Box 22.5 Key signs and symptoms of amniotic
fluid embolism
• Respiratory
– Cyanosis
– Dyspnoea
– Respiratory arrest
• Cardiovascular
– Tachycardia
– Hypotension
– Pale clammy skin/shivering
– Cardiac arrest
• Haematological
– Haemorrhage from placental site
– Coagulation disorders, DIC
• Neurological
– Restlessness, panic
– Convulsions
• Fetal compromise
intrauterine catheter, have been associated with AFE.
Amniotic fluid embolism can also occur during an intrau-
terine manipulation, such as internal podalic version or
during a caesarean section.
Clinical signs and symptoms
Premonitory signs and symptoms (restlessness, abnormal
behaviour, respiratory distress and cyanosis) may occur
before collapse (Knight et al 2010). There is maternal
hypotension and uterine hypertonus. The latter will induce
fetal compromise and is in response to uterine hypoxia.
Cardiopulmonary arrest follows quickly. Only minutes
may elapse before cardiac arrest. Blood coagulopathy
develops following the initial collapse (Dawson 2011). The
key signs and symptoms are summarized in Box 22.5.
Emergency action
Any one of the above symptoms is indicative of an acute
emergency. As the woman is likely to be in a state of col-
lapse, effective resuscitation needs to be commenced at
once. An emergency team should be called since the
midwife responsible for the care of the woman will require
immediate assistance. If collapse occurs in a community
setting, basic life support should be commenced prior to
the arrival of emergency services.
Despite improvements in intensive care, the outcome of
this condition is poor if AFE occurs outside a hospital
setting. Specific management for the condition is life
support, with high levels of oxygen being required.
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Complications of amniotic fluid

embolism
Disseminated intravascular coagulation (DIC) is likely to
occur within 30 minutes of the initial collapse. In some
cases the woman bleeds heavily prior to developing amni-
otic fluid embolism, which contributes to the severity of
her condition. It has also been reported that the amniotic
fluid has the ability to suppress the myometrium, resulting
in uterine atony.
Acute renal failure is a complication of the excessive
blood loss and the prolonged hypovolaemic hypotension.
Prompt transfer to a critical care unit for specialized care
improves the outcome in AFE (Knight et al 2010; Dawson
2011).
Midwifery support and advice should be continued for
the family. The woman should be given the opportunity
to talk about emergency treatment when she has recovered
sufficiently (Mapp 2005; Mapp and Hudson 2005).
Effect of amniotic fluid embolism
on the fetus
Perinatal mortality and morbidity are high where amni-
otic fluid embolism occurs before the birth of the baby.
Delay in the time from initial maternal collapse to the
baby’s birth needs to be minimal if fetal compromise or
death is to be avoided. However, maternal resuscitation
may, at that time, be a priority. Box 22.6 summarizes the
key points relating to amniotic fluid embolism.
All cases of suspected or proven amniotic fluid embo-
lism, whether fatal or not, should be reported to the
National Amniotic Fluid Embolism Register at the follow-
ing address:
United Kingdom Obstetric Surveillance System
[UKOSS]
National Perinatal Epidemiology Unit [NPEU]
University of Oxford (Old Road Campus)
Old Road
Headington
Oxford
OX3 7LF
ACUTE INVERSION OF THE UTERUS
This is a rare but potentially life-threatening complication
of the third stage of labour. It occurs in approximately 1
in 20 000 births (Witteveen et al 2013). A midwife’s aware-
ness of the precipitating factors enables her to take preven-
tive measures to avoid this emergency.
Classification of inversion
Inversion can be classified according to severity as follows:
• first-degree: the fundus reaches the internal os
• second-degree: the body or corpus of the uterus is
inverted to the internal os (Fig. 22.11)
• third-degree: the fundus protrudes to or beyond the
introitus and is visible
• fourth degree: this is total uterine and vaginal
inversion where both the uterus and vagina are
inverted beyond the introitus.
Inversion is also classified according to the timing of the
event:
• acute inversion: occurs within the first 24 hours
• subacute inversion: occurs after the first 24 hours, and
within 4 weeks
• chronic inversion: occurs after 4 weeks and is rare
(Bhalia et al 2009).
It is the first of these, acute inversion, that the remainder
of this section considers.

Box 22.6 Key points for amniotic fluid

embolism

• Major cause of maternal death worldwide

• Universal features: maternal shock, dyspnoea and
cardiovascular collapse
• Fetal compromise
• Can occur at any time: most commonly immediately
after labour
• Suspected in cases of sudden collapse or
uncontrollable bleeding
Fig. 22.11 Second-degree inversion of the uterus.

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 Midwifery and obstetric emergencies
Causes
Causes of acute inversion are associated with uterine atony
and cervical dilatation, and include:
• mismanagement in the third stage of labour,
involving excessive cord traction to manage the birth
of the placenta
• combining fundal pressure and cord traction to expel
the placenta
• use of fundal pressure to expel the placenta while
the uterus is atonic
• pathologically adherent placenta
• spontaneous occurrence, of unknown cause
• primiparity
• fetal macrosomia
• short umbilical cord
• sudden emptying of a distended uterus.
(Momin 2009; Witteveen et al 2013)
Careful management of the third stage of labour is
needed to prevent inversion of the uterus. In active man-
agement of the third stage of labour, palpation of the
fundus is essential to confirm that contraction has taken
place, prior to undertaking controlled cord traction.
Warning signs and diagnosis
The major sign of acute inversion of the uterus is profound
shock and usually haemorrhage. The blood loss is within
a range of 800–1800 ml. Inversion of the uterus will cause
the woman severe abdominal pain. On palpation of the
uterus, the midwife may feel an indentation of the fundus.
Where there is a major degree of inversion the uterus may
not be palpable abdominally but may be felt upon vaginal
examination or, in a severe case, the uterus may be seen at
the vulva.
The pain is thought to be caused by the stretching of the
peritoneal nerves and the ovaries being pulled as the
fundus inverts. Bleeding may or may not be present,
depending on the degree of placental adherence to the
uterine wall. The cause of the symptoms may not be
readily apparent and diagnosis may be missed if inversion
is incomplete.
Management
Immediate action
A swift response is needed to reduce the risks to the
woman. Throughout the events the woman and her
partner should be kept informed of what is happening.
Assessment of vital signs, including level of consciousness,
is of utmost importance.
1. Urgent medical help is summoned.
2. The midwife in attendance should immediately
attempt to replace the uterus. If replacement is
delayed the uterus can become oedematous and
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Chapter | 22 |
replacement will become increasingly difficult.
Replacement may be achieved by pushing the fundus
with the palm of the hand, along the direction of
the vagina, towards the posterior fornix. The uterus
is then lifted towards the umbilicus and returned to
position with a steady pressure known as Johnson’s
manoeuvre. If replacement cannot be achieved
immediately the foot of the bed can be raised to
reduce traction on the uterine ligaments and ovaries
(Cunningham et al 2010; Witteveen et al 2013).
3. An intravenous cannula should be inserted and
blood taken for cross-matching prior to commencing
an infusion.
4. Analgesia such as morphine may be given to the
woman.
5. If the placenta is still attached, it should be left in
situ as attempts to remove it at this stage may result
in uncontrollable haemorrhage.
6. Once the uterus is repositioned, the midwife or
obstetrician should keep their hand in situ until a
firm contraction is palpated. Oxytocics should be
given to maintain the contraction (Cunningham et al
2010; Witteveen et al 2013).
Medical management
The hydrostatic method of replacement involves the instil-
lation of several litres of warm saline infused through a
giving set into the vagina. The pressure of the fluid builds
up in the vagina and restores the uterus to the normal
position, while the midwife or obstetrician seals off the
introitus by hand or using a soft ventouse cup.
If the inversion cannot be replaced manually, a cervical
constriction ring may have developed. Drugs can be given
to relax the constriction and facilitate the return of the
uterus to its normal position. Surgical correction via a
laparotomy may be needed to correct inversion. Full
support and explanation of the emergency should be
offered to the woman in the postnatal period (Mapp 2005;
Mapp and Hudson 2005; Witteveen et al 2013).
BASIC LIFE SUPPORT MEASURES
Cardiac arrests are rare in maternity units but they can
occur and their management is sometimes suboptimal
(CMACE 2011). The midwife must undertake, record and
act on basic observations using the Modified Early Obstet-
ric Warning Scoring (MEOWS) system that contain triggers
to identify symptoms and recognize any deterioration in
the woman’s condition in order to prompt medical referral
(CMACE 2011). All medical and midwifery staff should be
trained to a nationally recognized level: Basic Life Support
(BLS), Immediate Life Support (ILS) or Advanced Life
Support (ALS), as appropriate (National Patient Safety
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Section | 4 | Labour

Agency 2007; Resuscitation Council UK [RCUK] 2010;

CMACE 2011; RCOG 2011).
Emergency drills for maternal resuscitation should be
regularly practised in clinical areas in all maternity units
(NHSLA 2011). These drills should include the identifica-
tion of the equipment required and appropriate methods
for ensuring that cardiac arrest teams know the location
of the maternity unit and theatres in order to arrive
promptly. Specialized courses such as Advanced Life
Support in Obstetrics (ALSO®) and Managing Obstetric
Emergencies and Trauma (MOET) provide additional
training for obstetric, midwifery and other staff employed
in the area of midwifery and obstetric care.
Standards of basic life support have been agreed inter-
nationally for health professionals and lay people (RCUK
2010). Basic life support refers to the maintenance of an
airway and support for breathing, without any specialist Fig. 22.12 The airway is opened by tilting the head
equipment other than possibly a pharyngeal airway. backwards and lifting the chin upwards.
Recent guidelines place greater emphasis on high quality
cardiopulmonary resuscitation (CPR) with minimal inter-
ruptions in chest compressions. The basic principles are as
follows:
A Airway
B Breathing
C Circulation
D Disability: assess consciousness
E Environment: keep safe
(RCUK 2010)

1. Check the surroundings to establish it is safe to

proceed.
2. Establish the level of consciousness by shaking the
woman’s shoulders and enquiring whether she
can hear.
3. Summon urgent assistance by the most appropriate
means if there is no response.
4. If the woman is already lying flat on her back,
remove any pillows. A pregnant woman should be
further positioned with a left lateral tilt to prevent
aortocaval compression.
5. Tilt the woman’s head back, lifting the chin upwards
to open the airway (Fig. 22.12). Any obstruction,
such as mucus or vomit, should be cleared away.
6. Observe for chest movements, listen and feel for
breath.
7. Commence chest compressions, if the pulse is Fig. 22.13 Chest compression. The midwife leans well over
absent or the breathing is absent or abnormal. the patient, with arms straight. Hands are one on top of the
8. Place the hands palm downwards one on top of the other with fingers interlinked. The heel of the hand is used
other with the fingers interlinked, with the heel of to compress the chest.
the lower hand positioned over the lower part of the
sternum. With arms straight, compress the chest to carry out resuscitation (Fig. 22.13). The surface
100–120 times/min to a depth of 5 cm, releasing at under the woman must be firm for compressions to
the same rate as compression. The chest should succeed.
recoil completely after each compression. 10. Give two rescue breaths after 30 chest compressions,
9. Consider kneeling over the woman or find preferably by bag and mask but mouth-to-mouth if
something to stand on to ensure a suitable position necessary. Each breath should last for only 1 second.

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 Midwifery and obstetric emergencies
Box 22.7 Key points for basic life support
• Check safety of surroundings
• Gently shake the woman and shout
• Call for help
• Check the woman’s breathing
• Check the woman’s pulse
• Use 30 chest compressions to 2 breaths
• Continue resuscitative measures until help arrives
Adapted from RCUK (2010)
Ensure that the woman’s chest rises with each breath
and is seen to fall again. If unhappy to perform
mouth-to-mouth breathing, continue chest
compressions only.
11. Minimize any interruptions to chest compressions.
12. A change in rescuers should occur every 2 minutes
where possible.
(RCUK 2010)
Chest compression and rescue breathing should be con-
tinued until help arrives when those experienced in resus-
citation are able to take over (Grady et al 2007; RCUK
2010). The exact sequences of resuscitation will depend on
the training of staff and their experience in assessment of
breathing and circulation. These measures are summa-
rized in Box 22.7.
SHOCK
Shock is a complex syndrome involving a reduction in
blood flow to the tissues that may result in irreversible
organ damage and progressive collapse of the circulatory
system (Mulryan 2011; Chandraharan and Arulkumaran
2013). If left untreated it will result in death. Shock can
be acute but prompt treatment results in recovery, with
little detrimental effect on the woman. However, failure to
initiate effective treatment, or inadequate treatment, can
result in a chronic condition ending in multisystem organ
failure, which may be fatal (NICE 2007).
Shock can be classified as follows:
• hypovolaemic: the result of a reduction in
intravascular volume such as in severe haemorrhage
during childbirth
• septic or toxic: occurs with a severe generalized infection
• cardiogenic: impaired ability of the heart to pump
blood; in midwifery it may be apparent following a
pulmonary embolism or in women with cardiac
defects
• neurogenic: results from an insult to the nervous
system as in uterine inversion
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• anaphylactic: may occur as the result of a severe
allergy or drug reaction.
This section deals with the principles of hypovolaemic shock
and septic shock, either of which may develop as a conse-
quence of childbirth.
Hypovolaemic shock
This is caused by any loss of circulating fluid volume as in
haemorrhage, but may also occur when there is severe
vomiting. The body reacts to the loss of circulating fluid
in stages as follows.
Initial stage
The reduction in fluid or blood decreases the venous
return to the heart. The ventricles of the heart are inade-
quately filled, causing a reduction in stroke volume and
cardiac output. As cardiac output and venous return fall,
the blood pressure is reduced. The fall in blood pressure
decreases the supply of oxygen to the tissues and cell func-
tion is affected.
Compensatory stage
The fall in cardiac output produces a response from the
sympathetic nervous system through the activation of
receptors in the aorta and carotid arteries. Blood is redis-
tributed to the vital organs. Vessels in the gastrointestinal
tract, kidneys, skin and lungs constrict. This response is
seen by the skin becoming pale and cool. Peristalsis slows
down, urinary output is reduced and exchange of gas in
the lungs is impaired as blood flow diminishes. The heart
rate increases in an attempt to improve cardiac output and
blood pressure. The pupils of the eyes dilate. The sweat
glands are stimulated and the skin becomes moist and
clammy. Adrenaline (epinephrine) is released from the
adrenal medulla and aldosterone from the adrenal cortex.
Antidiuretic hormone (ADH) is secreted from the poste-
rior lobe of the pituitary. Their combined effect is to cause
vasoconstriction, increased cardiac output and a decrease
in urinary output. Venous return to the heart will increase
but, unless the fluid loss is replaced, this will not be
sustained.
Progressive stage
This stage leads to multisystem organ failure. Compensa-
tory mechanisms begin to fail, with vital organs lacking
adequate perfusion. Volume depletion causes a further fall
in blood pressure and cardiac output. The coronary arter-
ies suffer lack of supply and peripheral circulation is poor,
with weak or absent pulses.
Final, irreversible stage of shock
Multisystem organ failure and cell destruction are irrepa-
rable and death ensues.
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Section | 4 | Labour
Effect of shock on organs and systems
The human body is able to compensate for loss of up to
10% of blood volume, principally by vasoconstriction.
When that loss reaches 20–25%, however, the compensa-
tory mechanisms begin to decline and fail. In pregnancy
the plasma volume increases, as does the red cell mass.
The increase is not proportionate, but allows a healthy
pregnant woman to sustain significant blood loss at birth
as the plasma volume is reduced with little disturbance to
normal haemodynamics. In cases where the increase in
plasma volume is reduced or there has been an antepar-
tum haemorrhage, the woman is more susceptible to
experience a pathological effect on the body and its
systems following a much lower blood loss during child-
birth. Individual organs are affected as below.
Brain
The level of consciousness deteriorates as cerebral blood
flow is compromised. The woman will become increasingly
unresponsive to verbal stimuli and there is a gradual reduc-
tion in the response elicited from painful stimulation.
Lungs
Gas exchange is impaired as the physiological dead space
increases within the lungs. Levels of carbon dioxide rise
and arterial oxygen levels fall. Ischaemia within the lungs
alters the production of surfactant and, as a result of this,
the alveoli collapse. Oedema in the lungs, due to increased
permeability, exacerbates the existing problem of diffusion
of oxygen. Atelectasis, oedema and reduced compliance
impair ventilation and gaseous exchange, leading ulti-
mately to respiratory failure. This is known as adult respira-
tory distress syndrome (ARDS).
Kidneys
The renal tubules become ischaemic owing to the reduc-
tion in blood supply. As the kidneys fail, urine output falls
to less than 20 ml/hour. The body does not excrete waste
products such as urea and creatinine, so levels of these in
the blood rise.
Gastrointestinal tract
The gut becomes ischaemic and its ability to function as
a barrier against infection wanes. Gram-negative bacteria
are able to enter the circulation.
Liver
Drug and hormone metabolism ceases, as does the conju-
gation of bilirubin. Unconjugated bilirubin builds up and
jaundice develops. Protection from infection is further
reduced as the liver fails to act as a filter. Metabolism of
waste products does not occur, so there is a build-up of
lactic acid and ammonia in the blood. Death of hepatic
cells releases liver enzymes into the circulation.
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Management
Urgent resuscitation is needed to prevent the woman’s
condition deteriorating and causing irreversible damage
(Chandraharan and Arulkumaran 2013). Women who
decline blood products must have their wishes respected
and a treatment plan in case of haemorrhage should be
discussed with them before labour (CMACE 2011).
The priorities are to:
1. Call for help: shock is a progressive condition and
delay in correcting hypovolaemia can lead ultimately
to maternal death.
2. Maintain the airway: if the woman is severely
collapsed she should be turned on to her side and
40% oxygen administered at a rate of 4–6 l/min. If
she is unconscious, an airway should be inserted.
3. Replace fluids: two wide-bore intravenous cannulae
should be inserted to enable fluids and drugs to be
administered swiftly. Blood should be taken for
cross-matching prior to commencing intravenous
fluids. A crystalloid solution such as normal saline,
Hartmann’s, or Ringer’s lactate is given until the
woman’s condition has improved. A systematic
review of the evidence found that colloids were not
associated with any difference in survival and were
more expensive than crystalloids (Perel et al 2013).
Crystalloids are, however, associated with loss of
fluid to the tissues, and therefore to maintain the
intravascular volume colloids are recommended after
2 l of crystalloid have been infused. No more than
1000–1500 ml of colloid such as Gelofusine or
Haemocel should be given in a 24 hours period.
Packed red cells and fresh frozen plasma are infused
when the condition of the woman is stable and
these are available.
4. Arrest haemorrhage: the source of the bleeding needs
to be identified and stopped. Any underlying
condition should be managed promptly and
appropriately.
5. Warmth: it is important to keep the woman warm,
but not over warmed or warmed too quickly, as this
will cause peripheral vasodilatation and result in
hypotension.
Assessment of clinical condition
An interprofessional team approach to management
should be adopted to ensure that the correct level of exper-
tise is available. A clear protocol for the management of
shock should be used, with the midwife fully aware of key
personnel required. Once the woman’s immediate condi-
tion is stable, the midwife should continue to assess and
record the woman’s condition or liaise with staff on the
critical care unit if the woman has been transferred there
for subsequent care (Chandraharan and Arulkumaran
2013).
 Midwifery and obstetric emergencies
Hypovolaemic shock in pregnancy will reduce placental
perfusion and oxygenation to the fetus, resulting in fetal
distress and possibly death. Where maternal shock is
caused by antepartum factors, the midwife should deter-
mine whether the fetal heart is present, but as swift and
aggressive treatment may be required to save the woman’s
life, this should be the first priority.
Detailed MEOWS observation charts including fluid
balance should be accurately maintained. The extent of the
woman’s condition may require her to be transferred to a
critical care unit.
Observations and clinical signs of deterioration
in hypovolaemic shock
1. Assess level of consciousness in association with the
Glasgow Coma Score (GCS). This is a reliable,
objective tool for measuring coma, using eye
opening, motor response and verbal response. A
total of 15 points can be achieved, and one of <12 is
cause for concern. Any signs of restlessness or
confusion should be noted (Dougherty and Lister
2011).
2. Assess respiratory status using respiratory rate,
depth and pattern, pulse oximetry and blood
gases. Humidified oxygen should be used if
oxygen therapy is to be administered for any length
of time.
3. Monitor blood pressure continuously, or at least
every 30 minutes, with note taken of any fall in
blood pressure.
4. Monitor cardiac rhythm continuously.
5. Measure urine output hourly, using an indwelling
catheter and urometer.
6. Assess skin colour including core and peripheral
temperature hourly.
7. If a central venous pressure (CVP) line has been
sited, haemodynamic measures of pressure in the
right atrium are taken to monitor infusion rate and
quantities. The fluid balance should be maintained
and recorded accurately.
8. Observe for further bleeding, including lochia, or
oozing from a wound or puncture site.
9. Undertake venepuncture for haemoglobin and
haematocrit estimation to assess the degree of
blood loss.
10. The woman is likely to be nursed flat in the acute
stages of shock. Clinical assessment will also include
review and recording of pressure areas, with
positional changes made as necessary to prevent
deterioration. A lateral tilt should be maintained to
prevent aortocaval compression if a gravid uterus is
likely to compress the major vessels.
Box 22.8 summarizes the key points relating to the man-
agement of hypovolaemic shock.
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Chapter | 22 |
Drip stand with manometer attached
Adhesive manometer tape
Level of right atrium
Three-way
tap
Fig. 22.14 Monitoring central venous pressure.
Box 22.8 Key points for managing
hypovolaemic shock
• Call for help
• Identify the source of bleeding and control temporarily
if able
• Gain venous access using two wide-bore cannulae
• Rapidly infuse intravenous fluid to correct loss
• Assess for coagulopathy and correct
• Manage the underlying condition
Central venous pressure
It is unlikely that a midwife will experience central venous
pressure (CVP) being measured outside of an intensive
care unit (Fig. 22.14). CVP is the pressure in the right
atrium or superior vena cava and is an indicator of the
volume of blood returning to the heart, reflecting the com-
petence of the heart as a pump and the peripheral vascular
resistance. Normal CVP values will change with gestation,
and can vary between +5 and +10 cmH2O. Values within
this range indicate that the vascular space is well filled and
red cell transfusion would not be necessary. However, in
the presence of acute peripheral circulatory failure, which
accompanies severe shock, the monitoring of CVP aids
assessment of blood loss with a negative value indicating
the necessity for fluid replacement (Scales 2010). An iso-
lated CVP recording is of little clinical value. Trends in CVP
results are more useful clinically and are interpreted in
conjunction with fluid balance and peripheral perfusion.
It is extremely dangerous to base an intravenous regimen
on guesswork, as hypervolaemia or hypovolaemia, cardiac
and renal failure may result.
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Septic shock all observations should be recorded on a MEOWS chart to

determine any further deterioration in the woman’s condi-
Death and serious illness from pregnancy-related sepsis tion and subsequent prompt action.
are rare. This means that many midwives will not have
seen a case, and it is surprising and shocking when it does
happen. The last Confidential Enquiry (CMACE 2011) Management
reported a total of 26 women died over the triennium
The advice of an anaesthetist and the critical care team
2006–8 as a result of genital tract sepsis. Women and their
should be sought at an early stage.
families should be made aware of the importance of dis-
Treatment is based on preventing further deterioration
closing significant symptoms to enable earlier interven-
in the woman’s condition by restoring circulatory volume
tions in treatment of any underlying infection (Chapters
and then eradication of the infection. Rigorous treatment
12 and 13).
with intravenous antibiotics is essential to halt the illness.
Septic shock is a distributive form of shock, where an
Replacement of fluid volume will restore perfusion of the
overwhelming infection develops. Certain organisms
vital organs. Fluid balance is essential but difficult to
produce toxins that cause fluid to be lost from the circula-
manage in septic shock (especially when hourly urine
tion into the tissues. The commonest form of sepsis
output is low), as fluid overload may lead to fatal pulmo-
causing death in childbearing in the UK is reported to be
nary or cerebral oedema. The midwife must maintain
that caused by beta-haemolytic Streptococcus pyrogenes
careful monitoring and clear, accurate documentation of
(Lancefield Group A) (CMACE 2011). This is a Gram-
the woman’s condition throughout (NMC 2012).
positive organism, responding to intravenous antibiotics,
Measures are needed to identify the source of infection
specifically those that are penicillin-based. Gram-negative
and to protect the woman against re-infection by main-
organisms such as Escherichia coli, Proteus or Pseudomonas
taining high standards of care in clinical procedures. A full
pyocyaneus are common pathogens in the female genital
infection screening should be undertaken, including a
tract.
high vaginal swab, throat swab, midstream specimen of
The placental site and perineal wounds are the main
urine and blood cultures. Retained products of conception
points of entry for an infection associated with pregnancy
can be detected on ultrasound, and these can then be
and childbirth. This may occur following prolonged
removed if they are apparent.
rupture of fetal membranes, birth trauma, septic abortion
In all situations where the woman requires to be trans-
or in the presence of retained placental tissue.
ferred to a critical care unit, relatives should be kept
informed of her progress. The midwife may be the person
Clinical signs with whom the relatives have formed a relationship and
Sepsis is often insidious in onset but requires prompt therefore is relied upon to give them information on the
recognition and immediate medical referral. Recognition woman’s condition and progress.
is a particular challenge to the community midwife. The
woman may present with tachypnoea, tachycardia, pyrexia
or extremely low temperature, or rigors. However, a tem-
perature recording may appear normal if the woman has DRUG TOXICITY/OVERDOSE
taken paracetamol as this will reduce pyrexia. The woman
may seem confused or anxious, exhibiting a change in her Drug toxicity and illicit drug overdose should be consid-
mental state. Abdominal pain and gastrointestinal symp- ered as a cause in all cases of maternal collapse in any type
toms are common in pelvic sepsis. Other symptoms, of setting. The principals of observation and resuscitation
including hypotension, develop in septic shock as the con- already discussed in this chapter apply to such a scenario.
dition progresses. Haemorrhage may be apparent, which Common sources of drug toxicity in midwifery and obstet-
could be a direct result of events due to childbearing, ric practice are local anaesthetic agents injected intra­
however, it occurs in septic shock due to disseminated venously by accident and magnesium sulphate given in
intravascular coagulation (DIC) (Chapter 12). In hospital the presence of renal impairment (RCOG 2011).

REFERENCES

Acolet D (ed) 2007 Confidential Enquiry
into Maternal and Child Health
(CEMACH) Perinatal Mortality 2005:
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Grady K, Howell C, Cox C 2007
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Gupta M, Hockley C, Quigley M A et al
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Gurewitsch G T, Johnson E,
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2005 World Health Organization
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maternal mortality and morbidity:
Chapter | 22 |
the prevalence of uterine rupture.
British Journal Obstetrics and
Gynaecology 112(9):1221–8
Holbrook B D, Phelan S T 2013
Umbilical cord prolapse. Obstetrics
and Gynecology Clinics of North
America 40(1):1–14
Houghton G 2006 Bladder filling: an
effective technique for managing
cord prolapse. British Journal of
Midwifery 14(2):88–9
Jan H, Guimicheva B, Gosh S, et al 2014
Evaluation of healthcare
professionals’n understanding of
eponymous maneuvers and
mnemonics in emergency obstetric
care. International Journal of
Gynaecology and Obstetrics
125(3):228–31
Keller J D, Lopez J A, Dooley S L et al
1991 Shoulder dystocia and birth
trauma in gestational diabetes: a five
year experience. American Journal
of Obstetrics and Gynecology
165:928–30
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et al 2010 Incidence and risk factors
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115(5):910–17
Landon M B 2010 Predicting uterine
rupture in women undergoing trial
of labor after prior cesarean delivery.
Seminars in Perinatology
34(4):267–71
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Obstetrical and Gynecological Survey
61(4):269–77
Lydon-Rochelle M, Holt V L, Easterling
T R et al 2001 Risk of uterine rupture
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delivery. New England Journal of
Medicine 345(1):3–8
Mapp T 2005 Feelings and fears during
obstetric emergencies 2. British
Journal of Midwifery 13(1):36–40
Mapp T, Hudson K 2005 Feelings and
fears during obstetric emergencies 1.
British Journal of Midwifery
13(1):30–5
Michiels I, De Valck C, De Loor J et al
2007 Spontaneous uterine rupture
during pregnancy, related to a horse
fall 8 weeks earlier. Acta Obstetrica
et Gynecologica Scandinavica
86(3):380–1
Momin A A, Saifi S G A, Pethani N R
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chronic stage. Journal of Clinical
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Mulryan C 2011 Acute illness
management. Sage, London
National Health Service Institute for
Innovation and Improvement 2008
SBAR: Situation, Background,
Assessment and Recommendation
Tool. Available at www
.improvement.nhs.uk (accessed 22
July 2013)
National Health Service Litigation
Authority (NHSLA) 2011 Clinical
Negligence Scheme for Trusts:
Maternity Clinical Risk Management
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NHSLA, London
NICE (National Institute for Health and
Clinical Excellence) 2007 Acutely ill
patients in hospital: recognition of
and response to acute illness in
adults in hospital. Clinical Guideline
50. NICE, London. Available at:
www.nice.org.uk/cg50 (accessed 1
July 2013)
NICE (National Institute for Health and
Clinical Excellence) 2008 Diabetes in
pregnancy. Management of diabetes
and its complications from pre-
conception to the postnatal period.
Clinical Guideline 63. NICE,
London. Available at: www.nice.org
.uk/cg63 (accessed 1 July 2013)
National Patient Safety Agency (NPSA)
2007 Safer care for the acutely ill
patient: learning from serious
incidents. NPSA, London
Norman J 2011 Haemorrhage. In: Centre
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reviewing maternal deaths to make
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Eighth Report on Confidential
Enquiries into Maternal Deaths in
the United Kingdom. BJOG: An
International Journal of Obstetrics
and Gynaecology 118(Suppl 1):71–6
NMC (Nursing and Midwifery Council)
2012 Midwives Rules and Standards.
NMC, London
FURTHER READING
Draycott T, Winter C, Crofts J et al (eds)
2008 PROMPT PRactical Obstetric
Multi-Professional Training Course
Manual Vol. 1. RCOG Press,
London
494
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O’Leary J A 2009 Shoulder dystocia and
birth injury: prevention and
treatment, 3rd edn. Humana Press,
Totowa, NJ
Ouzounian J G, Gherman R B, Chauhan
S et al 2012 Recurrent shoulder
dystocia: analysis of incidence and
risk factors. American Journal of
Perinatology 29(7):515–18
Oyelese Y, Smulian J C 2006 Placenta
previa, placenta accreta, and vasa
previa. Obstetrics and Gynecology
107(4):927–41
Perel P, Roberts I, Ker K 2013 Colloids
versus crystalloids for fluid
resuscitation in critically ill patients.
Cochrane Database of Systematic
Reviews 2013, Issue 2. Art. No.
CD000567. doi: 10.1002/14651858.
CD000567.pub6
RCUK (Resuscitation Council UK) 2010
Resuscitation guidelines. RCUK,
London. www.resus.org.uk/pages/
guide.htm (accessed 30 June 2013)
Roberts L, Trew G 1991 Uterine rupture
in a primigravida. Journal of
Obstetrics and Gynaecology
11(4):261–2
RCOG (Royal College of Obstetricians
and Gynaecologists) 2011 Maternal
collapse in pregnancy and the
puerperium. Green-Top Guideline
No. 56. RCOG, London
Royal College of Obstetricians and
Gynaecologists (RCOG) 2012
Shoulder dystocia. Green-Top
Guideline No. 42, 2nd edn. RCOG,
London. www.rcog.org.uk/files/
rcog-corp/GTG%2042_Shoulder%20
dystocia%202nd%20edition%20
2012.pdf (accessed 30 June 2013)
Rubin A 1964 Management of shoulder
dystocia. Journal of the American
Medical Association 189:835
Sandberg E C 1985 The Zavanelli
maneuver: a potentially
revolutionary method for the
resolution of shoulder dystocia.
American Journal of Obstetrics and
Gynecology 152:479–87
Recommended training course for childbirth
emergencies presenting current best practice.
Draycott T J, Crofts J F, Ash J P et al
2008 Improving neonatal outcome
through practical shoulder dystocia
Sandberg E C 1999 The Zavanelli
maneuver: 12 years of recorded
experience. Obstetrics and
Gynecology 93(2):312–17
Sandmire H F, DeMott R K 2009
Controversies surrounding the causes
of brachial plexus injury.
International Journal of Gynecology
and Obstetrics 104(1):9–13
Scales K (2010) Central venous pressure
monitoring in clinical practice.
Nursing Standard 24(29):49–55
Siggelkow W, Schmidt M, Skala C et al
2011 A new algorithm for improving
fetal weight estimation from
ultrasound data at term. Archives of
Gynecology and Obstetrics
283(3):469–74
Smith R B, Lane C, Pearson J F 1994
Shoulder dystocia: what happens at
the next delivery? British Journal of
Obstetrics and Gynaecology
101:713–15
Uccella S, Cromi A, Bogani G et al 2011
Spontaneous prelabor uterine
rupture in a primigravida: a case
report and review of the literature.
American Journal of Obstetrics and
Gynecology 205(5):e6–8
Usta I M, Hamdi M A, Abu Musa A A
et al 2007 Pregnancy outcome in
patients with previous uterine
rupture. Acta Obstetrica et
Gynecologica Scandinavica,
86(2):172–6
Witteveen T, van Stralen G, Zwart J et al
2013 Puerperal uterine inversion in
The Netherlands: a nationwide
cohort study. Acta Obstetricia et
Gynecologica Scandinavica
92(3):334–7
Woods C E 1943 A principle of physics
as applied to shoulder delivery.
American Journal of Obstetrics and
Gynecology 45:796–805
Wykes C B, Johnston T A, Paterson-
Brown S et al 2003 Symphysiotomy:
a lifesaving procedure. British
Journal Obstetrics Gynaecology
110(2):19–21
training. Obstetrics and Gynecology
112(1):14–20
The introduction of shoulder dystocia
training for all maternity staff was
associated with improved management and

neonatal outcomes of births complicated by
shoulder dystocia.
James A, Endacott R, Stenhouse E 2011
Identifying women requiring
maternity high dependency care.
Midwifery 27(1):60–6
Key issues in the management of women
who become critically ill during pregnancy,
labour and the postpartum period are
discussed, with identification of recognition
of signs of clinical deterioration with
subsequent referral for appropriate
care.
National Institute for Health and
Clinical Excellence 2007 Acutely ill
patients in hospital: recognition of
and response to acute illness in
adults in hospital. Clinical Guideline
50. NICE, London. http://
publications.nice.org.uk/acutely-ill
-patients-in-hospital-cg50
Provides guidance on the care and
management of the acutely ill patient.
USEFUL WEBSITES
Erb’s Palsy Group, for parents and
health professionals:
www.erbspalsygroup.co.uk
National Amniotic Fluid Embolism
Register: www.npeu.ox.ac.uk/ukoss/
current-surveillance/amf
mebooksfree.com
Midwifery and obstetric emergencies
Raynor M D, Marshall J E, Jackson K
2012 Midwifery practice: critical
illness, complications and
emergencies case book. Open
University Press, Maidenhead
This text provides a case study approach to
several critical conditions and emergencies
that can prove a challenge to all healthcare
professionals working in midwifery practice,
with particular importance being placed on
multiprofessional team working. Each case
explores and explains the pathology,
pharmacology and care principles and uses
test questions and answers to assist learning.
Resuscitation Council UK 2010
Resuscitation guidelines. RCUK,
London. www.resus.org.uk
Internationally agreed information and
guidance on resuscitation and emergency
life support. The website contains a range
of publications, information and posters
that can be downloaded to support clinical
practice.
National Institute for Health and Care
(formerly Clinical) Excellence:
www.nice.org.uk
NHS Improving Quality (formerly NHS
Institute for Innovation and
Improvement): www.nhsiq.nhs.uk/
Chapter | 22 |
Robson S E, Waugh J J S (eds) 2013
Medical disorders in pregnancy: a
manual for midwives, 2nd edn. John
Wiley and Sons, London
The need for joint medical and midwifery
care is stressed in the latest CMACE report,
with a recommendation that contemporary
midwifery education prepares midwives for
problems in pregnancy and adverse
pregnancy outcome.
Royal College of Obstetricians and
Gynaecologists 2011 Maternal
collapse in pregnancy and the
puerperium. Green-Top Guideline
No. 56. Royal College of
Obstetricians and Gynaecologists,
London. www.rcog.org.uk/files/
rcog-corp/GTG56.pdf
Provides up-to-date information and
excellent reference material on
maternal collapse in pregnancy and
the puerperium.
Resuscitation Council UK:
www.resus.org.uk
Royal College of Obstetricians and
Gynaecologists: www.rcog.org.uk
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 Section 5
Puerperium

23 Physiology and care during the 25 Perinatal mental health 531

puerperium 499 26 Bereavement and loss in maternity care   555
24 Physical health problems and complications 27 Contraception and sexual health in a global
in the puerperium 515 society 569

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 Chapter 23

Physiology and care during the puerperium

Mary Steen, Julie Wray

CHAPTER CONTENTS and voluntary services can work together to

support the mother, father, baby and other
The postnatal period 499 family members to cope and adjust following the
Historical background 500 birth of a new baby (Department of Health [DH]
2005; National Institute for Health and Clinical
Framework and regulation for postnatal Excellence [NICE] 2006; Nursing and Midwifery
care 501 Council [NMC] 2012). This approach to postnatal
Midwives and postpartum care 501 care differs from that offered to women in most
Public health care 501 other developed countries where the provision
for regular contact with midwives as the main
The provision of and need for postnatal healthcare professional responsible for postnatal
care 502 care is less well defined. (Potential postnatal
Midwifery postpartum contact and visits 503 morbidity and in some cases mortality for the
Physiological changes and observations 504 mother is discussed in Chapter 24.)
Returning to non-pregnant status 504
Future health, future fertility 509 THE CHAPTER AIMS TO:
Record-keeping and documentation 509 • review the historical background of postnatal care
Evidence and best practice 509 • explore the role of the midwife in the assessment
Transition to parenthood 509 and care of women’s postpartum health and
References 510 wellbeing
Further reading 514 • review the current evidence for women’s general
Useful websites 514 health and wellbeing after childbirth
• discuss the contemporary challenges for the
There is current evidence that postnatal care is
provision of maternity care during the postnatal
often undervalued and under-resourced even
period
though it is an important and challenging time
for a mother who has recently given birth, her • explore women’s and their partners views and
partner and family (Wray and Bick 2012). Current experiences of postnatal care.
postnatal care in the United Kingdom (UK) can
involve several healthcare practitioners.
Midwives are the lead health professional,
with support from maternity support workers,
THE POSTNATAL PERIOD
general practitioners, health visitors and other
practitioners depending on the mother’s Following the birth of a baby, placenta and membranes,
individual needs and circumstances. Both public the newly birthed mother enters a period of physical and

© 2014 Elsevier Ltd 499

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Section | 5 | Puerperium
emotional/psychological recuperation (Buckley 2006;
Wray 2012). Skin-to-skin contact is advocated immedi-
ately following birth and during the postnatal period as
there is clear evidence of benefit to the mother and father
(Moore et al 2012). The puerperium starts immediately
after birth of the placenta and membranes and continues
for 6 weeks. In many cultures around the world 40 days
for recuperation is a time-honoured practice (Hundt et al
2000; Waugh 2011). A general expectation is that by 6
weeks after birth a woman’s body will have recovered suf-
ficiently from the effects of pregnancy and the process of
parturition. However, there has now been a recognition
that the return to a non-pregnant state of health and well-
being can take much longer (World Health Organization
[WHO], 2010; Bick et al 2011). Some women continue
to experience health problems related to childbirth that
extend well beyond the 6-week period defined as the puer-
perium (WHO 2010). In some cases, healing and recovery
can take up to a year following birth (Bedwell 2006; Wray
and Bick 2012).
It has been customary to refer to the first weeks after the
birth as the postnatal period, defined in the UK by the
NMC as ‘a period after the end of labour during which
the attendance of a midwife upon a woman and baby is
required, being not less than 10 days and for such
longer period as the midwife considers necessary’ (NMC
2012: 6).
By no longer stating an endpoint in time until which
midwifery care can still be made available to women, it is
envisaged that offering more flexibility to the provision of
midwifery care will make a positive impact on the health
and wellbeing of women (Cattrell et al 2005; Redshaw and
Heikkila 2010).
The National Childbirth Trust (NCT) makes clear on its
website that it is the quality of postnatal care provided to
women and families in the first days and weeks after
birth that can have a huge impact and affect mothers’ and
families’ experiences of the transition to parenthood (NCT
2012).
However, in this present climate, when there is an ever-
increasing birth rate, a shortage of midwives and ongoing
financial constraints, this is an extremely challenging task
for maternity service providers.
HISTORICAL BACKGROUND
Postnatal care in the UK has been an integral part of the
midwife’s role since the beginning of the last century
following the introduction of the Midwives Act in 1902.
This was instigated by the high maternal mortality rates.
Despite a decline in death rates among all age groups in
the general population, maternal mortality rates remained
high. The majority of maternal deaths were caused by
puerperal infection (interestingly, the latest triennial
500
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report on the Confidential Enquiries into Maternal Deaths
in the UK cites sepsis as currently the leading cause of
maternal mortality [CMACE 2011]).
This had a marked effect on what constituted important
aspects of postnatal care. Routine observations, such as
temperature, pulse, respirations, blood pressure, breast
examination, uterine involution and observation of
lochia, were introduced as well as a set pattern of postnatal
visits.
Midwives were expected to visit twice a day for the first
three days and then daily until day 10, commonly referred
to as the ‘lying in period’ (Leap and Hunter 1993). Two
further Midwives Acts extended the regulatory maximum
duration of postnatal care from 10 to 14 days in 1936 and
then this was increased to 28 days in 1962. This approach
to postnatal care was considered appropriate to meet the
needs of women at that time. However, a considerable
decline in maternal mortality rates began in the 1930s and
has continued up to the present day. A traditional pattern
and content of postnatal care continued until the 1980s.
Then, two major changes happened that affected the
pattern of postnatal care, those being the woman returning
home much earlier following childbirth and the introduc-
tion of ‘selective visiting’ rather than specified days in 1986
by the former midwifery governing body, the United
Kingdom Central Council (UKCC 1986). A postal survey
undertaken in England in 1991 reported that most mater-
nity services had changed from the daily home visits up
to the tenth postnatal day to selective home visits, but
there was wide variation in patterns of selective visiting
(Garcia et al 1994). This may be due to the fact that little
guidance was given on how to plan and implement this
change and there was no evaluation with regard to the
implications for women. A House of Commons Health
Committee report (Winterton 1992) highlighted, among
other things, that postnatal care was neglected and there
was a lack of research in this area. This was followed by
the establishment of the Expert Maternity Committee,
whose remit was to examine policy and make recommen-
dations for the maternity services in England and Wales.
Their report ‘Changing Childbirth’ (DH 1993) recom-
mended that the maternity services should offer women
more choice, greater continuity of care, more involvement
in the planning of their care and should be midwifery-led,
and more recently the ‘Maternity Matters’ report (DH
2007a) reiterated these recommendations.
Today, a partnership approach, where the woman is
encouraged to explore how she is feeling physically
and emotionally and to seek the advice and support of
the midwife, is advocated (Wray and Bick 2012). The
importance of all newly birthed mothers having access to
postnatal care that will meet their individual needs is
underpinned by the NMC (2012) Midwives Rules and
Standards and by a national guideline defining core care,
and what should be provided for the mother and baby in
the days and weeks following birth (NICE 2006).
 Physiology and care during the puerperium
FRAMEWORK AND REGULATION FOR
POSTNATAL CARE
The initial framework for hospital postnatal care in the
early 20th century involved a regimented approach, with
the newly birthed mother being viewed as a patient; a
period of prescribed bed rest, compliance with hospital
regimens such as vulval swabbing, binding of legs and
separation from her baby were thus routine procedures. A
gradual shift in this ‘sickness’ framework of care as
described by Parsons (1951) started to occur during the
20th century. Renfrew (2010) describes how mothers in
the late 1970s and early 1980s were still kept in postnatal
wards for a week or more after birth and their babies were
kept in nurseries with their feeds timed and measured,
regardless of whether they were being breastfed or formula-
fed. In the 1990s the provision of postpartum care was
reviewed with regard to its content, purpose or effective-
ness (Marsh and Sargent 1991; Garcia and Marchant 1993;
Twaddle et al 1993); this led to research that investigated
and challenged regimented and ritual patterns of postpar-
tum care (Bick et al 2002; Shaw et al 2006; Wray 2006).
Nowadays, mothers have the choice to return home in
a few hours after the birth, as it is considered both safe
and acceptable by society at large. The newly birthed
mother can recuperate in her own familiar surroundings
with the support of her family and friends.
The recent Health and Social Care Act 2012 will con-
tinue to support mothers to make their own choices about
who and what services/care best meet their individual
needs. Independent sector providers as well as National
Health Service (NHS) maternity service providers will be
free to innovate to deliver quality services.
MIDWIVES AND POSTPARTUM CARE
It is vitally important that midwives have the knowledge
and skills to determine when to be proactive and under-
take specific observations when there are indications to do
so. Therefore, the midwife needs to be able to acknowl-
edge and recognize what are normal expected outcomes
following birth and also be able to identify signs of what
is not normal and when to instigate care that will involve
further investigation, tests and the support of other health
professionals. It is the midwife’s responsibility to ensure
she is competent and to undertake any further necessary
education and training if required to provide extended
care (see Box 23.1).
Public health care
It has long been recognized that poverty and being socially
disadvantaged is society leads to increased risk of poor
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Chapter | 23 |
Box 23.1 The midwife’s skills and knowledge
The UK’s Nursing and Midwifery Council states in The
Code: Standards of Conduct, Performance and Ethics for
Nurses and Midwives:
Keep your skills and knowledge up to date:
■ You must have the knowledge and skills for safe
and effective practice when working without
direct supervision.
■ You must recognise and work within the limits of
your competence.
■ You must keep your knowledge and skills up to
date throughout your working life.
■ You must take part in appropriate learning and
practice activities that maintain and develop your
competence and performance.
Source: NMC 2008: 38–41
health and wellbeing (Hart 1971; Acheson 1998). In
England, the Department of Health has acknowledged
that ‘Healthy mothers are key for giving healthy babies a
healthy start in life’ (DH 2004). It is important that
mothers and their family receive information and advice
about healthy lifestyles. Midwives have a vital role to
address public health targets and are ideally situated to
promote healthy lifestyles to the mother, her partner and
extended family during the postnatal period. However,
midwives cannot address public health issues alone and
working collaboratively with other professionals and local
communities and signposting to other services needs to
occur. Models of care to give more intense care and support
to disadvantaged groups have been developed. Sure Start
centres were set up to provide accessible community-based
services that would enable families with young children to
improve their health and wellbeing (DH 1999). Targets
were linked to public health issues such as smoking ces-
sation, breastfeeding rates and reaching disadvantaged
groups (National Evaluation of Sure Start [NESS] 2004).
The government’s Every Child Matters: Change for Children
agenda (DfES 2004) supported the Sure Start goals and
aimed to increase the support for children and young
people up to the age of 19. These centres became Sure Start
Children’s Centres, where family healthcare and parenting
skills from midwives and health visitors were delivered
with support from other professionals (DCSF 2009).
Positive benefits for mothers and their families who live
within the designated postcode for Children’s Centre serv-
ices have been reported (Tanner et al 2012). However, a
sustained commitment to service provision and funding
is essential for this to benefit mothers and their families.
In 2009, Children’s Centres became a statutory require-
ment under the Apprenticeships, Skills, Children and
501
Section | 5 | Puerperium
Learning Act (HM Government 2009; DfE 2010). In 2010,
the Coalition government offered protection from spend-
ing cuts to enable Children’s Centres to continue to
provide a range of services to local communities but at the
time of writing there are concerns in the present economic
climate with budget reductions; the government is inter-
ested in developing community management models such
as cooperatives and social enterprises (DfE 2012).
Working in tandem with Children’s Centres is the
Family Nurse Partnership (FNP) Programme as developed
in the USA and recently piloted in selected areas of high
deprivation in England. It has been reported that teenage
first-time mothers, their partners and family find this
approach acceptable (Barnes et al 2011). Further work is
being undertaken to see if a group approach is of any
benefit to families who are not eligible for the FNP pro-
gramme (Barnes and Henderson 2012). Early indications
show that there are some benefits and peer support is
valuable. An holistic maternal health and wellbeing pro-
gramme, specifically designed to raise awareness of the
general health and wellbeing of mothers, their babies and
families also reported how beneficial group and peer
support is to postnatal mothers (Steen 2007b) (see
Box 23.2).
Recently, the Health and Social Care Act 2012 gives
a new focus to public health (HM Government 2012).
This Act provides the underpinnings for Public Health
England, a new body to drive improvements in public
health.
Box 23.2 Examples of postnatal women’s views
Postnatal workshops:
‘I needed to talk about my birth as I was disappointed
I had been induced, but I can understand why now.’
‘I didn’t know that most breast cancer is detected by
the woman herself, I will start checking now.’
‘I feel guilty about smoking and now I have my
daughter to think about I will seriously think about
stopping.’
‘I’m finding being a mum hard. I’m always tired and
feeling weepy but I feel a lot better once I have come to
the class.’
Postnatal exercise classes:
‘I couldn’t do my pelvic floor exercises properly before. I
can now.’
‘I did some of the exercises in early labour and used the
positions I was shown, it really helped.’
‘I had a section in the end but I wasn’t too
disappointed as I coped really well during labour and used
the Pilates and relaxation techniques.’
Source: Steen 2007b: 119
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The provision of and need for
postnatal care
The provision of midwifery care and support to newly
birthed mothers needs to be woman-focused and family-
orientated. Good communication to explain what is con-
sidered to be normal physical, emotional/psychological,
occurrences during the postnatal period will reassure a
mother that she is going through a normal physiological
process. Building a trusting, caring relationship will give a
mother confidence to ask questions when she has con-
cerns and is anxious about her health and wellbeing.
A recent survey undertaken on behalf of the National
Childbirth Trust (NCT 2010) involving 1260 first-time
mothers reported that these mothers felt that midwives
were always or mostly kind and understanding (80%) and
treated them with respect (83%) . However, there were still
gaps in the provision and satisfaction with regards to post-
natal care reported. Only 4% of mothers reported being
involved in the development of a postnatal care plan to
meet their individual needs as recommended by NICE
(2006). Mothers who had undergone either an operative
or surgical procedure to aid their birth were reported to be
the least satisfied with their postnatal care. Although this
survey does not represent the whole of the UK maternal
population and socially disadvantaged mothers’ voices
were not represented, it does give an insight into areas
where improvements in postnatal care provision should
be targeted.
‘I have a bit of weight to lose and this will help me get
back into shape.’
‘I’m steadily getting my figure back. The exercises
appear to be helping.’
‘I really enjoyed the exercises and intend to continue to
do Pilates.’
Postnatal general comments:
‘I always go home feeling good about myself and fit and
healthy.’
‘I love the company as well as being able to exercise.’
‘It’s great that you can bring your baby with you. I love
being able to exercise with him on a mat next to me.’
‘I bring my mum as well. We both have enjoyed it.’
‘I’m going to come to the gym and get my boyfriend to
come as well.’
‘It will be difficult for me to attend classes when I go
back to work but I intend to walk more and exercise on a
weekend.’
‘I have enjoyed coming to the sessions and I’ve loved
being able to meet other mums.’
 Physiology and care during the puerperium
A social model of care that encompasses aspects of
observing and monitoring the health and wellbeing of the
mother, father and their baby initially, in a hospital and
then home setting, will support both parents to adjust to
their new parenting role. Guidance and reassurance is an
important aspect of midwifery care. Working in partner-
ship with the mother and father will assist them to develop
confidence in their ability to be parents and care for their
baby. There is growing evidence that when fathers are
included this is beneficial to both the mother’s and the
baby’s health and wellbeing (Flouri and Buchanan 2003;
Bottorff et al 2006; Tohotoa et al 2009). For example,
fathers can play an important role in breastfeeding support
(Wolfberg et al 2004; Piscane et al 2005). Therefore, it is
vital that they are included in discussions and pathways
of care. Yet, there is also evidence that many fathers feel
excluded unsure and fearful (Steen et al 2012). A recent
publication entitled ‘Reaching out: involving fathers in
maternity care’ (Royal College of Midwives [RCM] 2011:
3) has highlighted that ‘to provide effective support
fathers themselves need to be supported, involved and
prepared’.
In the UK, it is still usual for a midwife to ‘attend’ a
postpartum woman on a regular basis for the first few days
regardless of whether the mother is in hospital or at home
(NMC 2012). During the course of contact visits, mid-
wifery practice has been to undertake a routine physical
examination to assess the new mother’s recovery from the
birth (Rowan and Bick 2006; Bick 2012; Wray and Bick
2012). From an international perspective this practice is
unusual; it is only comparatively recently that postpartum
home visits, and postpartum support programmes, have
been initiated in America, Canada and Australia (Boulvain
et al 2004; Peterson et al 2005; Vernon 2007) and that
women in these countries have recognized a need for and
their satisfaction with current services (De Clerc 2006). In
the UK, the role of maternity support worker (MSW) has
been introduced to support midwives to provide care to
mothers and their families. However, the development of
MSWs can be inconsistent (Kings Fund 2011). The RCM
(2010) Position Statement on maternity support workers
reports that there should be a clear framework which
defines their role, responsibility and arrangements for
supervision. A study reviewed the involvement of mater-
nity support workers in the community over an extended
postnatal period and found no differences in health out-
comes but reported that mothers found benefit in the extra
support (Morrell et al 2000).
A common reference to postnatal services being the
‘Cinderella’ of the maternity service provision as a whole
has led to repeated reports from women of poor support,
disappointment in the services and in some cases evidence
of negligence as a result of sub-standard care (Wray 2006;
Lewis 2007; Redshaw and Heikkila 2010; WHO 2010).
The framework for assessing resources released from the
NHS costs would appear to be based on a measurement
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Chapter | 23 |
of clinical need resulting in the main providers of health
services having to make comparisons between postpartum
women’s needs and other members of the population who
are suffering from acute or chronic illnesses (O’Sullivan
and Tyler 2007). The birth of a baby does not attract the
same level of funding as the needs of those with long-term
conditions or terminal diseases. However, there has been
an increasing awareness that there are important aspects
around promoting good health and wellbeing of the
newly birthed mother and baby as this has implications
for the nation’s healthcare costs (NICE 2006; NCT 2010).
The postnatal care pathway recommended by NICE (2006)
is divided into three ‘time bands’ which cover the post­
natal period, these are:
• the first 24 hours after birth
• the first 2–7 days
• the period from day 8 to around 6–8 weeks.
During these postnatal time bands a midwife will need to
advise women about some health problems that she may
be at risk of developing and to discuss any symptoms or
concerns she may have. Contact numbers and how to
summon help and advice need to be made readily avail-
able and issuing regular reminders to encourage and
enable a mother to do this if she has any concerns is
paramount.
Midwifery postpartum contact
and visits
The majority of postnatal care in the UK now occurs either
in the family or a relative’s home. Expectations of mothers
about the purpose of home visits by the midwife may vary
according to their cultural backgrounds and individual
needs. Some faiths hold important ceremonies for the
newborn baby and a home visit from a midwife will need
to be mutually arranged to fit around these. Newly birthed
mothers who have experienced motherhood before may
feel that they need minimal support from a midwife and
this can also be mutually arranged. In contrast, a first-time
mother or a mother who has had complications will more
likely need further support and contact. The concept of
postpartum care is one that aims to assist the mother, her
baby and family towards attaining an optimum health
status. Where the visit from the midwife can be seen as
supportive and useful to the mother and her family, this
purpose is more likely to be achieved. Research that has
explored the experiences of women from different ethnic
backgrounds has demonstrated marked inequalities in
both the provision of services as well as the actual direct
contact with caregivers (Hirst and Hewison 2002). In con-
trast, where the timing of midwifery postpartum care is
extended beyond 28 days, there is greater opportunity for
midwives to continue midwifery support where this might
be appropriate, and this has been welcomed as progress
although the focus would appear to be more on social or
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psychological outcomes, or for breastfeeding support than
overt clinical or physical morbidity (Winter et al 2001;
Bick et al 2002). In the United States a woman can choose
to employ a doula to help her during her transition to
motherhood. A doula can provide physical, emotional
and social support (Simkin 2008). This option is becom-
ing more readily available in the UK (Gibbon and Steen
2012).
PHYSIOLOGICAL CHANGES AND
OBSERVATIONS
Regardless of place of birth, the midwife is primarily con-
cerned with the observation of the health of the postpar-
tum mother and the new baby. As such, it has been
common practice to have an overall framework upon
which to base the assessment of the mother’s state of
health and for the observations contained within the
examination to link with pre-stated categories in the post-
natal midwifery records. This formalized approach to the
postpartum review might be an appropriate tool to use if
there is concern about a woman who is feeling unwell and
there is a need for a comprehensive picture of the woman’s
state of health (see Chapters 13 and 24). Where this is not
the case such an approach might be less useful from the
viewpoint of the needs of a healthy woman who has
recently given birth (Redshaw and Heikkila 2010). The
concern focuses on whether in the time taken to complete
a ‘top to toe’ examination as a thorough review of someone
who is generally well, the midwife might ignore or give
less attention to what the mother really wants to talk
about (Ridgers 2007). However, Wray (2011: 158 ) high-
lights that women want to be ‘checked over’ (physically)
as a means to obtain contact and feedback from the
midwife about their bodies and recovery separate from
their baby. As one new mother pointed out: ‘it was only
when she [the midwife] checked me over that you could
think about yourself and talk about how you were healing
and getting sorted’.
The skill of the midwife’s care is to achieve a balance
when deciding which observations are appropriate so that
she does not fail to detect potential aspects of morbidity.
The next part of this chapter identifies areas of physiology
that are likely either to cause women the most anxiety or
to have the greatest outcome with regard to morbidity.
These descriptions relate to observations undertaken for
women who have had vaginal births and uncomplicated
pregnancies.
Returning to non-pregnant status
In the postnatal period, all of the mother’s body systems
have to adjust from the pregnant state back to the pre-
pregnant state. Mothers go through a transitional period
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and the period of physiological adjustment and recovery
following birth is closely related to the overall health
status of the mother. The intricate relationships between
physiological, emotional/psychological and cultural and
sociological factors are all encompassed in the remit of
caring for the postnatal woman and her newborn (MaGuire
2000; Wiggins 2000; Bick 2012).
Vital signs: general health and wellbeing
The following information is based on the premise that
the midwife is exploring the health of the postpartum
woman from a viewpoint of confirming normality.
‘Common sense’, although a concept that is very difficult
to define, is probably a well-understood paradigm and
taking such an approach is an important part of midwifery
care with regard to addressing the issues that are visible
before seeking out the less obvious. In this instance, an
overall assessment of the woman’s physical appearance
will add considerably to the management of what will be
undertaken prior to continuing any further investigation
for either the woman or her baby.
Observations of temperature, pulse, respiration
(TPR) and blood pressure (BP)
During the first 6 hours postnatal care observations to
record vital signs will need to be taken and these should
be within a normal range before a woman returns home
if she has opted for an early transfer. An Early Warning
Score has recently been introduced in some maternity
units (Lewis 2007). If the woman has had a home birth
the midwife must not leave the new mother’s home until
she is satisfied that vital signs are stable.
It is not necessary to undertake observations of tempera-
ture routinely for women who appear to be physically well
and who do not complain of any symptoms that could be
associated with an infection. However, where the woman
complains of feeling unwell with flu-like symptoms, or
there are signs of possible infection or information that
might be associated with a potential environment for
infection, the midwife should undertake and record the
temperature. This will enhance the amount of clinical
information available where further decisions about
potential morbidity may need to be made.
Making a note of the pulse rate is probably one of the
least invasive and most cost-effective observations a
midwife can undertake. If undertaken when seated along-
side or at the same level as the woman, it can create posi-
tive feelings of care while also obtaining valuable clinical
information. While observing the pulse rate, particularly
if this is done for a full minute, the midwife can also
observe a number of related signs of wellbeing: the respira-
tory rate, the overall body temperature, any untoward
body odour, skin condition and the woman’s overall
colour and complexion, as well as just listening to what
the woman is saying.
 Physiology and care during the puerperium
Blood pressure
Following the birth of the baby, a baseline recording of
the woman’s blood pressure will be made. In the absence
of any previous history of morbidity associated with
hypertension, it is usual for the blood pressure to return
to a normal range within 24 hours after the birth. Rout­
inely undertaking observations of blood pressure without
a clinical reason is therefore not required once a baseline
recording has been taken. NICE (2006) suggest this should
be within 6 hours of the birth.
Circulation
The body has to reabsorb a quantity of excess fluid follow-
ing the birth and for the majority of women this results in
passing large quantities of urine, particularly in the first day,
as diuresis is increased (Cunningham et al 2005). Women
may also experience oedema of their ankles and feet and
this swelling may be greater than that experienced in preg-
nancy. These are variations of normal physiological proc-
esses and should resolve within the puerperal time scale as
the woman’s activity levels also increase. Advice should be
related to taking reasonable exercise, avoiding long periods
of standing, and elevating the feet and legs when sitting
where possible. Swollen ankles should be bilateral and not
accompanied by pain; the midwife should note particularly
if this is present in one calf only as it could indicate pathol-
ogy associated with a deep vein thrombosis.
Skin and nutrition
Women who have suffered from urticaria of pregnancy or
cholestasis of the liver should experience relief once the
pregnancy is over. The pace of life once the baby is born
might lead to women having a reduced fluid intake or
eating a different diet than they had formerly (Tuffery and
Scriven 2005). This in turn might affect their skin and
overall physiological state. Women should be encouraged
to maintain a balanced fluid intake and a diet that has a
greater proportion of fresh food in it (Tuffery and Scriven
2005; DH 2007b). This will improve gastrointestinal activ-
ity and the absorption of iron and minerals, and reduce
the potential for constipation and feelings of fatigue.
Breast care
It is essential that midwives offer support and advice on
common breast and breastfeeding problems. With a
woman’s permission a midwife needs to check for any
physical problems such as engorgement, cracked or bleed-
ing nipples, mastitis, or signs of thrush. Engorgement on
postnatal day 3 and 4 is a common problem for most
mothers regardless of whether they have chosen to breast-
or formula-feed. It is important that mothers are aware of
this and this needs to be discussed antenatally so it does
not come as a complete surprise. If breastfeeding and
engorged, advise the mother to feed on demand, perform
breast massage from under her axilla and towards the
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Chapter | 23 |
nipple, to hand express, take analgesia if necessary, and to
wear a well-fitting bra. For further content on complica-
tions see Chapters 24 and 34.
The uterus
After the birth, oxytocin is secreted from the posterior lobe
of the pituitary gland to act upon the uterine muscle and
assist separation of the placenta. Following the birth of the
placenta and membranes, the uterine cavity collapses
inwards; the now opposed walls of the uterus compress
the newly exposed placental site and effectively seal the
exposed ends of the major blood vessels. The muscle layers
of the myometrium act like ligatures that compress the
large sinuses of the blood vessels exposed by placental
separation. These occlude the exposed ends of the large
blood vessels and contribute further to reducing blood
loss. In addition, vasoconstriction in the overall blood
supply to the uterus results in the tissues receiving a
reduced blood supply; therefore, de-oxygenation and a
state of ischaemia arise. Through the process of autolysis,
autodigestion of the ischaemic muscle fibres by proteolytic
enzymes occurs resulting in an overall reduction in their
size. There is phagocytic action of polymorphs and macro­
phages in the blood and lymphatic systems upon the
waste products of autolysis, which are then excreted via
the renal system in the urine. Coagulation takes place
through platelet aggregation and the release of thrombo-
plastin and fibrin (Cunningham et al 2005).
What remains of the inner surface of the uterine lining
apart from the placental site, regenerates rapidly to
produce a covering of epithelium. Partial coverage occurs
within 7–10 days after the birth; total coverage is complete
by the 21st day (Cunningham et al 2005).
Once the placenta has separated, the circulating levels
of oestrogen, progesterone, human chorionic gonado-
trophin and human placental lactogen are reduced. This
leads to further physiological changes in muscle and con-
nective tissues as well as having a major influence on the
secretion of prolactin from the anterior lobe of the pitu­
itary gland.
Abdominal palpation of the uterus is usually performed
soon after placental expulsion to ensure that the physio-
logical processes are beginning to take place (Chapter 18).
On abdominal palpation, the fundus of the uterus should
be located centrally, its position being at the same level or
slightly below the umbilicus, and should be in a state of
contraction, feeling firm under the palpating hand. The
woman may experience some uterine or abdominal
discomfort, especially where uterotonic drugs have
been administered to augment the physiological process
(Anderson et al 1998).
Uterine involution
The process of involution is essential background knowledge
for midwives monitoring the physiological process of the
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Section | 5 | Puerperium
return of the uterus to its non-pregnant state. Involution
involves the gradual return and reduction in size of the
uterus to a pelvic organ until it is no longer palpable
above the symphysis pubis (Stables and Rankin 2011). This
process is usually assessed by measuring the symphysio-
fundal height (S-FD). This is the distance from the top of
the uterine fundus to the symphysis pubis and is com-
monly assessed by anthropometry (abdominal palpation)
(Bick et al 2009). NICE (2006) has concluded that there
is insufficient evidence to recommend the routine meas-
urement of fundal height and how often this should take
place as the process of involution is highly variable
between individual women. Therefore, involution of the
uterus should be placed into context alongside the colour,
amount and duration of the woman’s vaginal fluid loss
and her general state of health at that time. Uterine involu-
tion in combination with other observations such as a
raised or lowered temperature abdominal tenderness and
offensive lochia can be helpful to detect any maternal
morbidity, e.g. sepsis (CMACE 2011).
Assessment of postpartum uterine involution
There are several aspects to the abdominal palpation of
the postpartum uterus that contribute to the observation
as a whole. The first is to identify height and location of
the fundus (the upper parameter of the uterus). Assess-
ment should then be made of the condition of the uterus
with regard to uterine muscle contraction and finally
whether palpation of the uterus causes the woman any
pain. When all these dimensions are combined, this pro-
vides an overall assessment of the state of the uterus and
the progress of uterine involution can be described. Find-
ings from such an assessment should clearly record the
position of the uterus in relation to the umbilicus or the
symphysis pubis, the state of uterine contraction and
the presence of any pain during palpation. A suggested
approach to how this is undertaken in clinical practice can
be found in Box 23.3.
‘Afterpains’
‘Afterpains’ are caused by involutionary contractions and
usually last for two to three days after childbirth. These
cramping type of pains are more commonly associated
with multiparity and breastfeeding. The production of the
oxytocin in relation to the let-down response that initiates
the contraction in the uterus and causes pain. Women
have described the pain as equal to the severity of moder-
ate labour pains and women require analgesia (Marchant
et al 2002). A recent systematic analysis has concluded
that non-steroidal anti-inflammatory drugs (NSAIDs)
were better than placebo at relieving ‘afterpains’ and
NSAIDs were better than paracetamol, but there were
insufficient data to make conclusions regarding the
effectiveness of opioids at relieving ‘afterpains’ (Deussen
et al 2011).
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Box 23.3 Suggested approach to undertaking
postpartum assessment of uterine involution
• Discuss the need for uterine assessment with the
woman and obtain her agreement to proceed. She
should have emptied her bladder within the previous
30 min.
• Ensure privacy and an environment where the woman
can lie down on her back with her head supported.
Locate a covering to put over her lower body.
• The midwife should have clean, warm hands and
should help the woman to expose her abdomen; the
assessment should not be done through clothing.
• The midwife places the lower edge of her hand at the
umbilical area and gently palpates inwards towards
the spine until the uterine fundus is located.
• The fundus is palpated to assess its location and the
degree of uterine contraction. Any pain or tenderness
should be noted.
• Once the midwife has completed the assessment she
should help the woman to dress and to sit up.
• The midwife should then ask the woman about the
colour and amount of her vaginal loss and whether
she has passed any clots or is concerned about the
loss in any way.
• Following the assessment, the woman should be
informed about what has been found and any further
action that is required, and then a record of the
assessment is made in the midwifery notes.
It is helpful to explain the cause of ‘afterpains’ to women
and that they might experience a heavier loss at this time,
even to the extent of passing clots. Pain in the uterus that
is constant or present on abdominal palpation is unlikely
to be associated with ‘afterpains’ and further enquiry
should be made about this. Women might also confuse
‘afterpains’ with flatus pain, especially after an operative
birth or where they are constipated. Identifying and treat-
ing the cause is likely to relieve the symptoms or raise
concern about a more complex condition that needs
further attention.
Postpartum vaginal blood loss
Blood products constitute the major part of the vaginal
loss immediately after the birth of the baby and expulsion
of the placenta and membranes. As involution progresses
the vaginal loss reflects this and changes from a predomi-
nantly fresh blood loss to one that contains stale blood
products, lanugo, vernix and other debris from the
unwanted products of the conception. This loss varies
from woman to woman, being a lighter or darker colour,
but for any woman the shade and density tends to be
consistent (Marchant et al 2002).
 Physiology and care during the puerperium
Lochia is a Latin word traditionally used to describe the
vaginal loss following the birth (Cunningham et al
2005). Medical and midwifery textbooks have described
three phases of lochia and have given the duration over
which these phases persist. Research has explored the rel-
evance of these descriptions for women and raised ques-
tions about the use of these descriptions in clinical
practice. Marchant et al (2002) reported that not all
women are aware they will have a vaginal blood loss after
the birth and that women experience a wide variation in
the colour, amount and duration of vaginal loss in the
first 12 weeks’ postpartum. This suggests that, overall,
descriptions of normality ascribed to the traditional
descriptions of lochia are outdated and unhelpful to
women and midwives in accurately describing a clinical
observation.
Most women can clearly identify colour and consistency
of vaginal loss if asked and will be able to describe any
changes. It is important for a midwife to ask direct ques-
tions about the woman’s vaginal loss: whether this is more
or less, lighter or darker than previously and whether the
woman has any concerns. It is of particular importance to
record any clots passed and when these occurred. Clots
can be associated with future episodes of excessive or pro-
longed postpartum bleeding (see Chapters 18, 24).
Assessment that attempts to quantify the amount of
loss or the size of clot is problematic. However, the use
of descriptions that are common to both woman and
midwife can improve accuracy in these assessments – for
example, asking the mother how often she has to change
her maternity pad and describing her blood loss in her
own words.
Continence after birth
The majority of women will revert back to their non-
pregnant status during the puerperium without any major
urinary or bowel problems. Any minor changes to women’s
urinary and bowel habits should resolve within the first
few days of giving birth. Women suffering from perineal
injury may need extra reassurance that having their bowels
open may be uncomfortable but will not disrupt and dis-
lodge any stitches in the perineal region (Chapter 15). A
systematic review has reported that there is sufficient evi-
dence to suggest that pelvic floor exercise training during
pregnancy and after birth can prevent and treat urinary
incontinence (Mørkved and Bø 2013). NICE (2006) rec-
ommends that pelvic floor muscle exercises should be
taught as first line treatment for urinary incontinence.
It is important that women are given opportunities to
discuss any urinary or bowel problems as it is often a
taboo subject. Some women may find it embarrassing and
will not seek help and advice whilst others may put up
with urinary and bowel problems believing that it is
an accepted outcome following childbirth. Therefore, it
is essential that a midwife build a trusting, caring
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Chapter | 23 |
relationship to encourage a woman to disclose any urinary
or bowel problems.
Usually, urinary and bowel symptoms resolve within the
first two weeks following birth but some problems do
persist. If a woman continues to notice a change to her
pre-pregnant urinary and bowel pattern by the end of the
puerperal period, she should be advised to have this
reviewed (Steen 2013). Initially, conservative management
is advocated and then if the symptoms are persistent a
referral to a specialist may be required (RCM/CSP 2013)
(see Chapter 24).
Perineal trauma
Perineal and vaginal injury during childbirth continues to
affect the majority of women (Albers et al 2006; East et al
2012b). Morbidity associated with perineal injury and
repair is a major health problem for women throughout
the world. The Royal College of Obstetricians and Gynae-
cologists (RCOG) (2004) reported that perineal trauma
can have long-term social, psychological and physical
health consequences for women. Perineal pain and dis-
comfort associated with trauma may disrupt breastfeed-
ing, family life and sexual relationships.
In the UK, it is estimated that 1000 women per day will
require perineal repair (Kettle and Fenner, 2007). It is
therefore important that midwives are firstly educated and
trained to recognize the extent of perineal and vaginal
trauma, and secondly, have gained the confidence and
clinical skills to suture competently as failure to do so can
contribute to negative consequences for women in both
the short and long term (Steen 2010). In addition, it is
important to consider how to alleviate the associated pain
and discomfort attributed to perineal injuries following
birth.
Up-to-date knowledge and an understanding of the
negative consequences for women will help midwives to
advise women on how to alleviate perineal pain, prevent
further trauma and promote healing (Steen 2012).
Perineal pain
Regardless of whether the birth resulted in actual perineal
trauma, women are likely to feel swollen and bruised
around the vaginal and perineal tissues for the first few
days after a vaginal birth. Women who have undergone
any degree of actual perineal injury will experience pain
for several days until healing takes place (East et al 2012b).
It is essential that women are offered adequate pain relief
initially following birth and then for them to be advised
on how to alleviate the inflammation associated with peri-
neal injuries and any pain felt during the postnatal period.
In the first few days after the birth all women should be
asked if they have any pain or discomfort in the perineal
area regardless of whether there is a record of actual peri-
neal trauma (Bick and Bassett 2013).
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Section | 5 | Puerperium
Where women appear to have no discomfort or anxieties
about their perineum, it is not essential for the midwife
to examine this area and arguably it is an intrusion on the
woman’s privacy to do so. The basic principles of morbid-
ity or infection (Cunningham et al 2005) indicate that it
is unusual for morbidity to occur without inflammation
and pain although these factors are also integral to the
healing process (Steen 2007a); therefore, although the area
might be causing discomfort from the original trauma,
where this is unchanged or absent a pathological condi-
tion should not be developing. There may be occasions,
however, where the midwife might consider that the
woman is declining this observation because she is embar-
rassed or anxious. In such cases, the midwife should use
her skills of communication to explore whether there is a
clinical need for this observation to be undertaken and, if
so, to advise the woman accordingly. Examining the peri-
neal area is undertaken to assess healing after birth. Stand-
ardized scales to assist the midwife are not readily available
and formal evaluation appears to be an ongoing neglected
area of women’s health care (Steen 2010). Fortunately, for
the majority of women, the perineal wound gradually
becomes less painful and initial healing should occur by
10–14 days after the birth (Steen 2007a).
Alleviating perineal pain and discomfort
Evidence suggests that a combination of systemic and
localized treatments may be necessary to achieve adequate
pain relief which will meet individual women’s needs
(Steen and Roberts 2011).
There is some evidence that oral analgesia, bathing,
diclofenac suppositories, lidocaine gel and localized
cooling treatment can alleviate perineal pain. No adverse
effects on healing have been reported when localized
cooling is applied (East et al 2012a).
The treatments that appear to achieve pain relief are
summarized in Box 23.4.
Box 23.4 Summary of evidence to alleviate
perineal pain and discomfort
• Oral analgesia, self-administered, effective for mild
to severe pain (Moffat et al 2006; Steen and
Marchant 2007; Chou et al 2010).
• Bathing (Sleep and Grant 1988; Greenshields and
Hulme 1993; Steen and Marchant 2007).
• Voltarol suppositories – effective in first 24–48 hr,
some relief (Yoong et al 1997; Searles and Pring
1998; Hedayati et al 2005).
• Lignocaine gel – effective in first 48 hr (Harrison and
Brennan 1987a, 1987b; Corkill et al 2001).
• Localized cooling (Steen et al 2000; Steen 2002;
Steen and Marchant 2007; Navviba et al 2009; East
et al 2012a)
508
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Tiredness and fatigue
Most women will complain of tiredness and fatigue during
the first few weeks following birth, and lack of sleep at the
end of pregnancy, giving birth and establishing feeding can
take its toll. It is therefore vitally important that a newly
birthed mother is advised to consciously make time to rest
and sleep during the postpartum period. For example, she
should be advised to take the opportunity to have a ‘nap’
during the day when her baby is sleeping and not to feel
guilty about doing this. A midwife may need to reassure a
mother that household chores can wait and it takes time to
adjust to caring for a newborn. Tiredness and fatigue can
have an adverse effect on a mother’s health and wellbeing
status. Being tired and fatigued will inevitably have a nega-
tive effect on a woman’s ability to care for her newborn
(Troy and Dalgas-Pelish, 2003). Tiredness and fatigue
can lead to maternal exhaustion and has been associated
with maternal depression (Taylor and Johnson 2010) (see
Chapter 25). However, it has been reported that the
meaning of tiredness and fatigue are subjective and difficult
to define and ‘there is a lack of authoritative research on
postnatal tiredness and fatigue’ (McQueen and Mander
2003: 464). Nevertheless, midwives can play a vital role in
supporting a woman to have realistic expectations about
life after birth and advising her to nurture herself and on
the importance of finding time to rest and recuperate.
Expectations of health
It is reasonable for women to look forward to regaining
their body for themselves once the baby is born (MaGuire
2000; Steen 2007b). However, this is not the immediate
outcome for many women and, once again, individual
women will have their own expectations about the nature
and speed at which they would like this recovery to occur.
The role of the midwife at this point is to assist the woman
to identify actual symptoms of disorder from the gradual
process of reorder and advise what action the woman can
do for herself in the way of progressive recovery. Advice
for new parents in the matter of recovery from the birth is
limited and often superficial; also women may feel they
should know what to do, or have unrealistic expectations
of motherhood and their ability to cope with these new
experiences (Bartell 2004). This is one area where taking
the time to talk about what might seem to the midwife a
range of peripheral or even superficial issues that might be
worrying the otherwise healthy new mother could be of
more benefit that day than a range of routine clinical
observations (Redshaw et al 2007).
Balancing exercise and healthy activity
with rest and relaxation
Increasing the understanding in the general population
about the value of different forms of exercise and health
has been shown to be of psychological as well as physical
 Physiology and care during the puerperium
benefit (Armstrong and Edwards 2004). There is substan-
tial evidence that suggests exercising during the postnatal
period has many positive effects (Goodwin et al 2000;
Berk 2004; Steen 2007b). For example, women who exer-
cise regularly are more likely to recover more quickly after
the birth (Clapp 2001) (see Box 23.3).
Exploring each person’s level of activity will encourage
advice in relation to appropriate exercise and, by associa-
tion, nutritional intake and rest or relaxation and sleep.
Undertaking regular pelvic floor exercises is of benefit to
women’s long-term health (Mørkved and Bø 2013).
Future health, future fertility
Advice on managing fertility is within the sphere of prac-
tice of the midwife and it is an important aspect of post-
partum care (see Chapter 27). Midwives need to be aware
of a range of different needs with regard to women’s sexu-
ality and should be able to offer sensitive and appropriate
advice on contraception where this is needed.
Record-keeping and documentation
A midwife has to provide high standards of practice and
care at all times (NMC 2008). Clear and accurate records
of any observations and discussions that have taken place
during the postnatal period are a key tool in safeguarding
the health and wellbeing of the mother and her baby. In
its Code, the Nursing and Midwifery Council (NMC 2008)
clearly states that a midwife must keep clear and accurate
records (Box 23.5).
Box 23.5 The midwife’s record-keeping
The UK’s Nursing and Midwifery Council states in The
Code: Standards of Conduct, Performance and Ethics for
Nurses and Midwives:
Keep clear and accurate records:
■ You must keep clear and accurate records of the
discussions you have, the assessments you make,
the treatment and medicines you give and how
effective these have been.
■ You must complete records as soon as possible
after an event has occurred.
■ You must not tamper with original records in any way.
■ You must ensure any entries you make in
someone’s paper records are clearly and legibly
signed, dated and timed.
■ You must ensure any entries you make in
someone’s electronic records are clearly
attributable to you.
■ You must ensure all records are kept securely.
Source: NMC 2008: 42–7
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Chapter | 23 |
Evidence and best practice
The midwife should gain a considerable amount of infor-
mation during her contact with the mother and baby.
The wide range for normality and the individuality
within this can make it difficult for the midwife to decide
whether an observation is related to morbidity. It is more
likely to be the relationship between several observations
that raises cause for concern and, where these appear to
be more related to abnormality than normality, the
midwife has a responsibility to make appropriate referral
to a medical practitioner or other appropriate healthcare
professional. In the UK the midwife’s statutory frame-
work (NMC 2012) is different from the overall guidance
and frameworks for care provision developed under the
auspices of various Departments of Health. This is an
important distinction with regard to the professional
accountability of the midwife and her obligation as an
employee (NMC 2008).
TRANSITION TO PARENTHOOD
The transition to parenthood involves major adjustments
within a family and some mothers will welcome and
actively seek help and support from a midwife during the
postnatal period, but some women, for a range of reasons,
may not. Women from different cultural backgrounds may
have traditions that conflict with the current management
of postpartum care (Ockleford et al 2004), or consider
that they already have sufficient skills and experience. Not
being able to speak or understand English may also
prevent a woman from seeking help.
Although a visit to the home might have been planned,
there will also be times when women are not at home
when the midwife visits. It is important to keep in mind
individual circumstances and whether these might have
any bearing on a no-access visit. For example, parents with
a disability such as hearing loss or poor mobility might
not hear a doorbell. It is, therefore, important to make
arrangements for contact to be made by alternative means
(e.g. using a visual alarm or telephone to alert the woman
of the visit beforehand) (Disability Pregnancy and Parent-
hood International 2007).
The midwife needs to recognize situations where the
mother perceives she has different priorities from those
routinely provided by the healthcare services. The option
of attending a postnatal clinic/drop-in centre has been
introduced in some areas of the UK to meet maternity
services local needs and offers some flexibility around
postnatal follow-up care (Gibbon and Steen 2012).
A recent meta-synthesis has reported that fathers cannot
support their partner effectively in achieving a positive
parenthood experience unless they are themselves sup-
ported, included and prepared for parenthood (Steen et al
509
Section | 5 | Puerperium

2012). A study has reported that inadequate preparation
remains a concern to both women and their partners and
concluded that there is an urgent need for an improve-
ment in parents’ preparation for parenthood (Deave and
Johnson 2008). Becoming a parent is often a stressful
event and can contribute to relationship difficulties
and attachments within the family. Both parents have
reported in studies that they would have benefited from
some early warning and education (Deave and Johnson
2008; Steen et al 2011). The midwife has an important role
in supporting both parents during the transition to parent-
hood as there are clear health and wellbeing benefits for
the mother and baby (DfE 2010). In addition, the midwife
may have an important role with regard to referral and
support for women who are in abusive relationships
(Steen and Keeling 2012).
Where there are concerns about the safety or protection
of the newborn infant, the supervisor of midwives should
be informed and advice sought from the local social serv-
ices (the Safeguarding Children Board). Children’s Centres
offer a range of services to assist disadvantaged groups and
local communities during the transition to parenthood.
Family nurse practitioners (FNPs) can also offer further
support. In addition, there is good evidence that new
parents benefit from the support that their families, friends
and other parents can offer.

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Steen M, Cooper K, Marchant P et al
2000 A randomised controlled trial
to compare the effectiveness of
icepacks and Epifoam with cooling
maternity gel pads at alleviating
perineal trauma. Midwifery
16(1):48–55
Steen M, Downe S, Bamford N et al
2012 ‘Not-patient’ and ‘not-visitor’:
a metasynthesis of fathers’
encounters with pregnancy, birth
and maternity care. Midwifery
28(4):362–71
Steen M, Downe S, Graham-Kevan N
2011 Development of antenatal
education to raise awareness of the
risk of relationship conflict.
Evidence-Based Midwifery 8(2):53–7
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Steen M, Keeling J 2012 STOP! Silent
screams. The Practising Midwife
15(2):28–30
Steen M, Marchant P 2007 Ice packs
and cooling gel pads versus no
localised treatment for relief of
perineal pain: a randomised
controlled trial. Evidence-Based
Midwifery Journal 5(1):16–22
Steen M, Roberts T 2011 The
consequences of pregnancy and birth
for the pelvic floor. British Journal of
Midwifery 19(11):692–8
Tanner E, Agur M, Hussey D et al 2012
Evaluation of Children’s Centres in
England. Research Report DFE-
RR230. DfE, London
Taylor J, Johnson M 2010 How women
manage fatigue after childbirth.
Midwifery 26(3):367–75
Tohotoa J, Maycock B, Hauck Y L et al
2009 Dads make a difference: an
exploratory study of paternal support
for breastfeeding in Perth, Western
Australia. International Breastfeeding
Journal 29(4):15
Troy N A, Dalgas-Pelish P 2003 The
effectiveness of a self care
intervention for the management of
postpartum fatigue. Applied Nursing
Research 16(1):38–45
Tuffery O, Scriven A 2005 Factors
influencing antenatal and postnatal
diets of primigravid women. Journal
of the Royal Society of Health
125(5):227–31
Twaddle S, Liao X H, Fyvie H 1993 An
evaluation of postnatal care
individualised to the needs of the
woman. Midwifery 9(3):154–60
UKCC (United Kingdom Central
Council for Nursing, Midwifery and
Health Visiting) 1986 A midwife’s
code of practice. UKCC, London
Vernon D (ed) 2007 With women:
midwives’ experiences: from
shiftwork to continuity of care.
Australian College of Midwives,
Canberra
Waugh L J 2011 Beliefs associated with
Mexican immigrant families’ practice
of la cuarentena during postpartum
recovery. Journal of Obstetric,
Gynecologic and Neonatal Nursing
40(6):732–41
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WHO (World Health Organization)
2010 WHO Technical Consultation
on Postpartum and Postnatal Care.
WHO Document Production
Services, Geneva, Switzerland. http://
whqlibdoc.who.int/hq/2010/
WHO_MPS_10.03_eng.pdf (accessed
17 July 2013)
Wiggins M 2000 Psychosocial needs
after childbirth. Life after birth:
reflections on postnatal care, report
of a multi-disciplinary seminar, 3rd
July. RCM, Cardiff
Winter H R, MacArthur C, Bick D E et al
2001 Postnatal care and its role in
maternal health and well-being.
MIDIRS Midwifery Digest 11
(Suppl 1):S3–S7
Winterton N 1992 House of Commons
Health Committee Second Report:
Maternity services, vol 1. HMSO,
London
Wolfberg A J, Michels K B, Shields W
et al 2004 Dads as breastfeeding
advocates: results of a randomized
controlled trial of an educational
intervention. American Journal of
Obstetrics and Gynecology
191:708–12
Wray J 2006 Seeking to explore what
matters to women about postnatal
care. British Journal of Midwifery
14(5):246–54
Wray J 2011 Bouncing back? An
ethnographic study exploring the
context of care and recovery after
birth through the experiences and
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Wray J 2012 Impact of place upon
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MIDIRS Midwifery Digest
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Wray J, Bick D 2012 Is there a future for
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the UK? MIDIRS Midwifery Digest
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Yoong W C, Biervliet F, Nagrani R 1997
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513
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FURTHER READING
Ball J 1994 Reactions to motherhood:
the role of postnatal care. Books for
Midwives Press, Hale, Cheshire
Baston H, Hall J 2009 Midwifery
essentials: postnatal. Churchill
Livingstone/Elsevier, Edinburgh
Brown S, Lumley J, Small R et al 1994
Missing voices: the experiences of
motherhood. Oxford University
Press, Melbourne
Byrom S, Edwards G, Bick D (eds) 2009
Essential midwifery practice:
postnatal care. Wiley–Blackwell,
Oxford
USEFUL WEBSITES
Made for Mums: www.madeformums
.com/breast-and-bottlefeeding/
how-to-breastfeed-your-baby/
19342.html
Maternity Action:
www.maternityaction.org.uk/
514
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Choi P, Henshaw C, Baker S et al
2005 Supermum, superwife,
supereverything: performing
femininity in the transition to
motherhood. Journal of
Reproductive and Infant Psychology
23:167–80
Dykes F 2005 A critical ethnographic
study of encounters between
midwives and breast-feeding women
in postnatal wards in England.
Midwifery 21:241–52
Gibbon K, Steen M 2012 Postnatal care.
Caring for women during a
Mums net: www.mumsnet.com/
National Childbirth Trust:
www.nct.org.uk/professional/
research/pregnancy-birth
-and-postnatal-care/postnatal
-care
homebirth. In: Steen M (ed)
Supporting women to give birth at
home. A practical guide for
midwives. Routledge, London,
p 148–54
Lunt K 2013 How to undertake a
postnatal examination. RCM
Magazine, 4:32–3
Miller T 2005 Making sense of
motherhood: a narrative approach.
Cambridge University Press,
Cambridge
National Institute for Health and Care
[formerly Clinical] Excellence: http://
pathways.nice.org.uk/pathways/
postnatal-care
Royal College of Midwives: http://
www.rcm.org.uk/midwives/
by-subject/postnatal-care/
 Chapter 24

Physical health problems and complications

in the puerperium
Julie Wray, Mary Steen

CHAPTER CONTENTS Talking and listening after childbirth 526

References 527
The need for women-focused and Further reading 529
family-centred postpartum care 516
Useful websites 529
Potentially life-threatening conditions
and morbidity after the birth 516
Immediate untoward events for the mother This chapter reviews the care of women
following the birth of the baby 516 who either entered the postpartum period
Maternal collapse within 24 hours of having experienced obstetric or medical
the birth without overt bleeding 517 complications, including those who did not
Postpartum complications and identifying undergo a vaginal birth, or whose postpartum
deviations from the normal 517 recovery, regardless of the mode of birth, did
not follow a normal pattern. It includes the
The uterus and vaginal loss following care for women with signs and symptoms of
vaginal birth 518 life-threatening conditions and those with
The uterus and vaginal loss following obvious risks for increased postpartum
operative delivery 519 physical morbidity. (The effects of morbidity
Wound problems 520 related to psychological trauma are covered in
Circulation 522 Chapter 25.)
Headache 523
Backache 523 THE CHAPTER AIMS TO:
Urinary problems 523
• discuss the role of midwifery care in the detection
Bowel problems 524 and management of life-threatening conditions and
Anaemia 524 postpartum morbidity
Breast problems 525 • review best practice in the management of problems
Practical skills for postpartum midwifery associated with trauma and pathology arising from
care after an operative birth 525 pregnancy and childbirth
Emotional wellbeing: psychological • review the role of the midwife (and family) where
deviation from normal 526 postpartum health is complicated by an instrumental
Self care and recovery 526 or operative birth.

© 2014 Elsevier Ltd 515

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Section | 5 | Puerperium
THE NEED FOR WOMEN-FOCUSED
AND FAMILY-CENTRED POSTPARTUM
CARE
A women-focused approach to care in the postpartum
period alongside individualized care planning developed
with the woman and her family will assist physical and
psychological recovery (NICE [National Institute for
Health and Clinical Excellence] 2006a). What is important
is to focus upon the needs of women as individuals
rather than fitting women into a routine care package (DH
[Department of Health] 2004; Bick et al 2009; Wray and
Bick 2012). The midwife needs to be familiar with the
woman’s background and antenatal and labour history
irrespective of the care setting (NICE 2006a) when assess-
ing whether or not the woman’s progress is following the
expected postpartum recovery pattern (Garcia et al 1998;
DH 2004; Redshaw and Heikkila 2010).
All women should be offered appropriate and timely
information with regard to their own health and wellbeing
(and their babies) including recognition of, and respond-
ing to, problems (NICE 2006a; Bick et al 2011). The effects
of obstetric or medical complications will be assessed for
and reviewed within the context of the immediate and
ongoing care by the midwife of the woman’s health over
the postnatal period. The role of the midwife in these cases
is first to identify whether a potentially life-threatening
condition exists and, if so, to refer the woman for appro-
priate emergency investigations and care (NMC (NICE
2006a, CMACE [Centre for Maternal and Child Enquiries]
2011; NMC [Nursing and Midwifery Council] 2012).
Where the birth involves obstetric or medical complica-
tions, a woman’s postpartum care is likely to differ from
those women whose pregnancy and labour are considered
straightforward. However, it must also be considered that
some women have a perception of the whole birth experi-
ence as traumatic, although to the obstetric or midwifery
staff no untoward events occurred (Singh and Newburn
2000; Marchant 2004).
POTENTIALLY LIFE-THREATENING
CONDITIONS AND MORBIDITY
AFTER THE BIRTH
Despite the apparent advances in medication and practice,
women still die postpartum. The discovery of penicillin
and the provision of a blood transfusion were major
contributions to saving women’s lives over the past
century (Loudon 1986, 1987), and maternal death after
childbirth where there has been no preceding antenatal
complication is now a rare occurrence in the United
Kingdom (UK) (Lewis 2007; CMACE 2011). Thrombosis
516
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or thromboembolism and haemorrhage were major causes
of direct maternal deaths in the UK but these have declined
(Lewis 2007). Cardiac disease is the most common cause
of indirect death; the indirect maternal mortality rate
has not changed significantly since 2003–2005 (CMACE
2011). However, sepsis is now the most common cause
of direct maternal death in the triennium 2006–2008
associated with genital tract infection, particularly from
community-acquired Group A streptococcal (GAS) infec-
tion (CMACE 2011). The mortality rate related to sepsis
increased from 0.85 deaths per 100 000 maternities in
2003–2005 to 1.13 deaths in 2006–2008 (CMACE 2011).
Being aware of this information is vital for all those
involved in giving postnatal care as good quality care can
contribute to the prevention as well as the detection and
management of potentially fatal outcomes (Wray and Bick
2012).
From research, it became clear that maternal morbidity
after childbirth was typically under-reported by women
(Bick and MacArthur 1995; Marchant et al 1999). The
extent of postnatal morbidity was remarkable in the exten-
sive nature of the problems and the duration of time over
which such problems continued to be experienced by
women (MacArthur et al 1991; Garcia and Marchant 1993;
Glazener et al 1995; Brown and Lumley 1998; Glazener
and MacArthur 2001; Waterstone et al 2003; Bick et al
2009).
The midwife has a duty to undertake midwifery care for
at least the first 28 days, and according to NICE (2006a)
all women should receive essential core routine care in the
first 6–8 weeks after birth. The activities of the midwife are
to support the new mother and her family unit by moni-
toring her recovery after the birth and to offer her appro-
priate information and advice as part of the statutory
duties of the midwife (NMC 2012).
IMMEDIATE UNTOWARD EVENTS
FOR THE MOTHER FOLLOWING THE
BIRTH OF THE BABY
Immediate (primary) postpartum haemorrhage (PPH) is
a potentially life-threatening event which occurs at the
point of or within 24 hours of expulsion of the placenta
and membranes and presents as a sudden, and excessive
vaginal blood loss (see Chapter 18). Secondary, or delayed
PPH is where there is excessive or prolonged vaginal loss
from 24 hours after birth and for up to 6 weeks’ postpar-
tum (Cunningham et al 2005a). Unlike primary PPH,
which includes a defined volume of blood loss (>500 ml)
as part of its definition, there is no volume of blood speci-
fied for a secondary PPH and management differs accord-
ing to apparent clinical need (Alexander et al 2002; Bick
et al 2009).
 Physical health problems and complications in the puerperium
Regardless of the timing of any haemorrhage, it is most
frequently the placental site that is the source. Alterna-
tively, a cervical or deep vaginal wall tear or trauma to the
perineum might be the cause in women who have recently
given birth. Retained placental fragments or other prod-
ucts of conception are likely to inhibit the process of
involution, or reopen the placental wound. The diagnosis
is likely to be determined more by the woman’s condition
and pattern of events (Hoveyda and MacKenzie 2001;
Jansen et al 2005) and is also often complicated by the
presence of infection (Cunningham et al 2005b; see
Chapter 18). The recent CMACE (2011: 13) report states
that, ‘there remains an urgent need for the routine use
of a national modified early obstetric warning score
(MEOWS) chart in all pregnant or postpartum women
who become unwell and require either obstetric or gynae-
cology services’. Usage of this score will help in providing
timely recognition, treatment and referral of women who
have or are developing a critical illness after birth and
postnatal.
Maternal collapse within
24 hours of the birth without
overt bleeding
Where no signs of haemorrhage are apparent other causes
need to be considered (see Chapter 13). Management of
all these conditions requires ensuring the woman is in a
safe environment until appropriate treatment can be
administered by the most appropriate health profession-
als, and meanwhile maintaining the woman’s airway, basic
circulatory support as needed and providing oxygen. It is
important to remember that, regardless of the apparent
state of collapse, the woman may still be able to hear and
so verbally reassuring the woman (and her partner or rela-
tives if present) is an important aspect of the immediate
emergency and ongoing care.
POSTPARTUM COMPLICATIONS AND
IDENTIFYING DEVIATIONS FROM
THE NORMAL
Following the birth of their baby, women recount feelings
that are, at one level, elation that they have experienced
the birth and survived, and at another, the reality of pain
or discomfort from a number of unwelcome changes as
their bodies recover from pregnancy and labour (Gready
et al 1997; Wray 2011a). Women may experience symp-
toms that might be early signs of pathological events.
These might be presented by the woman as ‘minor’ con-
cerns, or not actually be in a form that is recognized as
abnormal by the woman herself. Where the postpartum
visit is undertaken as a form of review of the woman’s
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Chapter | 24 |
physical and psychological health, led by the woman’s
needs, the midwife is likely to obtain a random collection
of information that lacks a specific structure. Women will
probably give information about events or symptoms that
are the most worrying or most painful to them at that
time. At this point the midwife needs to establish whether
there are any other signs of possible morbidity and deter-
mine whether these might indicate the need for referral.
Figure 24.1 suggests a model for linking together key
observations that suggest potential risk of, or actual,
morbidity.
The central point, as with any personal contact, is the
midwife’s initial review of the woman’s appearance and
psychological state. This is underpinned by an assessment
of the woman’s vital signs, where any general state of
illness is evident, including signs of infection. It is sug-
gested that a pragmatic approach be taken with regard to
evidence of pyrexia as a mildly raised temperature may
be related to normal physiological hormonal responses,
for example the increasing production of breastmilk.
However, infection and sepsis are important factors in
postpartum maternal morbidity and mortality and the
midwife should not make an assumption that a mildly
raised temperature is part of the normal health parame-
ters (Lewis 2007; CMACE 2011; Bick 2012). The accumu-
lation of a number of clinical signs will assist the midwife
in making decisions about the presence or potential for
morbidity. Where there is a rise in temperature above
38 °C it is usual for this to be considered a deviation
from normal and of clinical significance. If puerperal
infection is suspected, the woman must be referred back
to the obstetric services as soon as possible (CMACE
2011). Adherence to local infection control policies and
awareness of the signs and symptoms of sepsis in post­
natal women is important for all practitioners caring for
women. This is particularly the case for community mid-
wives, who may be the first to pick up any potentially
abnormal signs during their routine postnatal observa-
tions for all women, not just those who have had a cae-
sarean section (CS) (CMACE 2011).
The pulse rate and respirations are also significant
observations when accumulating clinical evidence.
Although there may be no evidence of vaginal haemor-
rhage, for example, a weak and rapid pulse rate (>100 bpm)
in conjunction with a woman who is in a state of collapse
with signs of shock and a low blood pressure (systolic
<90 mmHg) may indicate the formation of a haematoma,
where there is an excessive leakage of blood from damaged
blood vessels into the surrounding tissues. A rapid pulse
rate in an otherwise well woman might suggest that she is
anaemic but could also indicate increased thyroid or other
dysfunctional hormonal activity.
The midwife needs to be alert to any possible relation-
ship between the observations overall and their potential
cause with regard to common illnesses, e.g. that the
woman has a common cold, and that the morbidity is
517
Section | 5 | Puerperium

Uterus
On palpation feels poorly contracted
Wide, ‘boggy’, spongy
Fundus may be deviated to one side
Not progressively reducing in size
Tenderness felt on palpation
Vaginal loss heavier and fresher than
previously or scant but offensive
Passing clots

Breasts Wounds
Feel tight and tender General condition Inflammation and tenderness around wound area
One segment is flushed or reddened Poor healing or gaping at the skin edge
Feeling unwell
One or both nipples have sore, broken Pain felt deeper in the wound site
Flu-like symptoms
or discoloured/flaky skin Virulent clear or purulent exudate
Pyrexia >38°C
If breast-feeding, obtain a history of Remove sutures where these are tight and pulling
Tachycardia >100 bpm
feeding patterns and observe a feed Obtain a swab for culture
Pale, listless
Obtain swab for infection Review the wound environment and method of
cleansing the wound

Circulation
Respiratory collapse or severe breathlessness requires emergency assistance
Review for: Previous history of pulmonary embolism, DVT
Current history of epidural, prolonged labour, operative birth, varicose
veins, anaemia, obesity
Severe maternal illness requiring prolonged inactivity
Check use of preventative measures:
TED stockings, prophylactic heparin, degree of mobility attained
Look for signs of localized inflammation of varicose veins, pain in calf, mild pyrexia

Fig. 24.1 Diagrammatic demonstration of the relationship between deviation from normal physiology and potential morbidity.

associated with or affected by having recently given birth.
Where the midwife is in conversation with the woman as
part of the postpartum assessment, if she receives infor-
mation that suggests the woman has signs deviating from
what is expected to be normal, it is important that a
range of clinical observations are undertaken to refute
or confirm this, followed by timely and appropriate
referral.
Following an innovative research study into extended
midwifery care of women beyond the conventional 10–14-
day period, a set of guidelines were compiled to assist
midwives make decisions about the need for referral (Bick
et al 2009). As part of the NICE (2006a) process compil-
ing guidelines for core care, it was recognized that mid-
wives develop skills and processes from their experience
to accumulate evidence from their observations and con-
versations about the overall wellbeing of the mother and
the baby. However, this process was mainly covert and
difficult to adapt in any formal way to help less experi-
enced midwives or even explain the course of action to the
women themselves (Marchant et al 2003; Marchant 2006).
To clarify the actions necessary, when the NICE guidelines
were published, a quick guide was also produced provid-
ing a table of the action required for possible signs/
symptoms of complications and common health prob-
lems in women (NICE 2006a).
The uterus and vaginal loss
following vaginal birth
It is expected that the midwife will undertake assessment
of uterine involution at intervals throughout the period of
midwifery care (see Chapter 23). It is recommended that
this should always be undertaken where the woman is
feeling generally unwell, has abdominal pain, a vaginal
loss that is markedly brighter red or heavier than previ-
ously, is passing clots or reports her vaginal loss to be
offensive (Hoveyda and MacKenzie 2001; Marchant et al
2006; Bick et al 2009; CMACE 2011).
Where the palpation of the uterus identifies that it is
deviated to one side, this might be as a result of a full
bladder. Where the midwife has ensured that the woman
had emptied her bladder prior to the palpation, the pres-
ence of urinary retention must be considered. Catheteriz­
ation of the bladder in these circumstances is indicated for
two reasons: to remove any obstacle that is preventing the
process of involution taking place and to provide relief to
the bladder itself. If the deviation is not as a result of a
full bladder, further investigations need to be undertaken
to determine the cause.
Morbidity might be suspected where the uterus fails to
follow the expected progressive reduction in size, feels
wide or ‘boggy’ on palpation and is less well contracted

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 Physical health problems and complications in the puerperium
than expected. This might be described as subinvolution
of the uterus, which can indicate postpartum infection, or
the presence of retained products of the placenta or mem-
branes, or both (Khong and Khong 1993; Howie 1995).
Treatment is by antibiotics, oxytocic drugs that act
on the uterine muscle, hormonal preparations or evacua-
tion of the uterus (ERPC), usually under a general
anaesthetic.
Vulnerability to infection, potential
causes and prevention
Infection is the invasion of tissues by pathogenic microor-
ganisms; the degree to which this results in ill-health
relates to their virulence and number. Vulnerability is
increased where conditions exist that enable the organism
to thrive and reproduce and where there is access to and
from entry points in the body. Organisms are transferred
between sources and a potential host by hands, air cur-
rents and fomites (i.e. agents such as bed linen). Hosts
are more vulnerable where they are in a condition of
susceptibility because of poor immunity or a preexisting
resistance to the invading organism. The body responds
to the invading organisms by forming antibodies,
which in turn produce inflammation initiating other
physiological changes such as pain and an increase in
body temperature.
Acquisition of an infective organism can be endogenous,
where the organisms are already present in or on the body
– e.g. Streptococcus faecalis (Lancefield group B), Clostridium
welchii (both present in the vagina) or Escherichia coli
(present in the bowel) – or organisms in a dormant state
are reactivated, notably tuberculosis bacteria. Other routes
are exogenous, where the organisms are transferred from
other people (or animal) body surfaces or the environ-
ment. Other transfer mechanisms include droplets – inha-
lations of respiratory pathogens on liquid particles (e.g.
β-haemolytic streptococcus and Chlamydia trachomatis),
cross-infection and nosocomial (hospital-acquired) transfer
from an infected person or place to an uninfected one (e.g.
Staphylococcus aureus).
The bacteria responsible for the majority of puerperal
infection arise from the streptococcal or staphylococcal
species, with community acquired GAS infection causing
most serious problems (CMACE 2011). The Streptococcus
bacterium has a chain-like formation and may be haemo-
lytic or non-haemolytic, and aerobic or anaerobic; the
most common species associated with puerperal sepsis is
the β-haemolytic S. pyogenes (Lancefield group A) although
other strains of the streptococcal bacteria have also been
identified as the source of serious morbidity (Muller et al
2006). The Staphylococcus bacterium has a grape-like struc-
ture, of which the most important species is S. aureus or
pyogenes. Staphylococci are the most frequent cause of
wound infections; where these bacteria are coagulase-
positive they form clots on the plasma which can lead to
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Chapter | 24 |
more widely spread systemic morbidity. There is addi-
tional concern about their resistance to antibiotics and
subsequent management to control spread of the infec-
tion. Regardless of the location of care, postpartum women
and healthcare professionals should be aware of how
infection can be acquired and should pay particular atten-
tion to effective hand-washing techniques. They should
adhere to the accepted practice for aseptic technique such
as local infection control policies when in contact with
wound care, including the use of gloves for this, and where
there is direct contact with areas in the body where bac­
teria of potential morbidity are prevalent. Avoiding the
spread of infection is especially necessary when the woman
or her family or close contacts have a sore throat or upper
respiratory tract infection (CMACE 2011). Educating
women and their family about the basic principles of good
hand hygiene is a key public health role of the midwife in
staving off infection.
The uterus and vaginal loss
following operative birth
A lower segment caesarean section (CS) will have involved
cutting of the major abdominal muscles and damage to
other soft tissues. Palpation of the abdomen is therefore
likely to be very painful for the woman in the first few days
after the operation. The woman who has undergone a CS
will have a very different level of physical activity from the
woman who has had a vaginal birth. It may be some hours
after the operation until the woman feels able to sit up or
move about. Blood and debris will have been slowly
released from the uterus during this time and, when the
woman begins to move, this will be expelled through the
vagina and may appear as a substantial fresh-looking red
loss. Following this initial loss, it is usual for the amount
of vaginal loss to lessen and for further fresh loss to be
minimal. All this can be observed without actually
palpating the uterus. For women who have undergone an
operative birth, once 3 or 4 days have elapsed, abdominal
palpation to assess uterine involution can be undertaken
by the midwife where this appears to be clinically appro-
priate. By this time, the uterus or area around the uterus
should not be overly painful on palpation.
Where clinically indicated, e.g. where the vaginal bleed-
ing is heavier than expected, the uterine fundus can be
gently palpated. If the uterus is not well contracted then
medical intervention is needed. Uterine stimulants (utero-
tonics) are usually prescribed in the form of an intrave-
nous infusion of oxytocin or an intramuscular injection of
syntometrine/ergometrine, if not contraindicated (Chapter
18). If the bleeding continues where such treatment has
been commenced, further investigations might include
obtaining blood for clotting factors, or the woman might
need to return to theatre for further exploration of the
uterine cavity. The emergence of ultrasound scans (USS)
in the postpartum period has led to some conflicting
519
Section | 5 | Puerperium
Injury: Death of epithelial cells
Break in continuity of
tissue structure
Bleeding
Easy entry for micro-organism
Emergency response
Initiate healing response
Cellular and matrix
components work together
Escaping blood from
leaky new blood vessels
Bruising
Absorption
of bruising
Fig. 24.2 The phases of wound healing.
Reproduced with permission from Steen 2007.
reports of the state of the normal postpartum uterus and
the value of USS in distinguishing potentially pathological
conditions (Hertzberg and Bowie 1991). More recent
studies appear to support greater use of USS to assist diag-
nosis and clinical management of problems of uterine
sub-involution (Shalev et al 2002; Deans and Dietz 2006).
Wound problems
Perineal problems
It is important that the midwife has an understanding of
the effect of trauma as a physiological process and the
520
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Phases: Overlapping/interdependent
Haemostasis
Inflammation
Proliferation
Remodelling
Haemostasis
Va s o c o n s t r i c t i o n
Fi b r i n c l o t (p l a t e l e t s + f i b r i n )
Co n t r o l o f b l e e d i n g
B a r rie r a ga in s t in f e c t io n
Inflammation
Vasodilatation
‡ ‡ ‡ ‡ Fibrin clot Chemical
‡ ‡‡
Capillary permeability Micro-organisms mediators
Extracellular fluid Tissue debris Histamine
Neutrophils, macrophages Serotonin
and lymphocytes Kinins
Proliferation
Growth factors enhance
‡
fibroplasia cell division
Contractile protein (actin)
Collagen + elastic mesh formed
Granulation tissue
Remodelling
Continued synthesis and
degradation of collagen
Regeneration: re-established normal tissue
Repair: replacement of original tissue with
functionally inferior scar tisue
normal pattern for wound healing (Steen 2007). Know­
ledge and an understanding of the physiological process
and the nutrients that are necessary to promote healing
will assist a midwife to recognize when there is a delay in
healing and also enable her to advise a woman on her
dietary requirements. (See Fig. 24.2 and Table 24.1.)
Perineal pain is a result of perineal injury, which can be
surgically or naturally induced. Women complain of
varying degrees of severity of perineal pain. There is some
evidence to suggest that the severity of the perineal injury
is linked to the severity of perineal pain (Kenyon and
Ford 2004). Perineal injury that requires suturing predis-
poses women to an increased risk of severe perineal pain
 Physical health problems and complications in the puerperium
Table 24.1 Nutrients and their contribution
to healing
Nutrient Contribution
Carbohydrates Energy for leucocyte, macrophage and
fibroblast function
Proteins Immune response, phagocytosis,
angiogenesis, fibroblast proliferation,
collagen synthesis, wound maturation
Fats Provision of energy, formation of new
cells
Vitamins
Vitamin A Collagen synthesis and cross-linking,
tensile strength
Vitamin B Immune response, collagen cross-
(complex) linking, tensile strength
Vitamin C Collagen synthesis tensile strength,
neutrophil function, macrophage
migration, immune response
Vitamin E Reduce tissue damage from free radical
formation
Minerals
Copper Collagen synthesis, leucocyte formation
Iron Collagen synthesis, oxygen delivery
Zinc Increases cell proliferation,
epithelialization, collagen strength
(Chapter 15). This might be as a result of the analgesia no
longer being effective, the presence of inflammation in the
surrounding tissues or, more seriously, the formation of a
haematoma. Haematoma usually develops deep in the
perineal fascia tissues and may not be easily visible if the
perineal tissues are already inflamed. Inadequate perineal
repair or a traumatic vaginal birth can increase the risk of
a haematoma. The blood contained within a haematoma
can exceed 1000 ml and may significantly affect the overall
state of the woman, who can present with signs of acute
shock. Treatment is by evacuation of the haematoma and
resuturing of the perineal wound, usually under a general
anaesthetic.
Perineal pain that is severe and is not caused by a haem­
atoma might arise as a result of inflammation causing the
stitches to feel excessively tight. Local application of cold
packs can bring relief as they reduce the immediate
oedema and continue to provide relief over the first few
days following the birth (Steen et al 2006). The use of oral
analgesia as well as complementary therapies such as
arnica and lavender oil is said to be beneficial, although
the effectiveness of such therapies has to date not
been confirmed by research findings (Bick et al 2009).
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Chapter | 24 |
Midwives should undertake appropriate training in com-
plementary therapies before advocating their use.
Factors that are associated with poor healing include
poor diet, obesity, preexisting medical disorders and nega-
tive social conditions such as poor housing, increased
stress and smoking (Steen 2007). Where pain in the peri-
neal area occurs at a later stage, or re-occurs, this might be
associated with an infection. The skin edges are likely to
have a moist, puffy and dull appearance; there may also
be an offensive odour and evidence of pus in the wound.
A swab should be obtained for microorganism culture and
referral made to a General Practitioner (GP). Antibiotics
might be commenced immediately when there is specific
information about any infective agent. Where the perineal
tissues appear to be infected, it is important to discuss with
the woman about cleaning the area and making an attempt
to reduce constant moisture and heat. Women might be
advised about using cotton underwear, avoiding tights
and trousers and frequently changing sanitary pads. They
should also be advised to avoid using perfumed bath addi-
tives or talcum powder.
If the perineal area fails to heal, or continues to cause
pain, a referral should be made and resuturing or refash-
ioning might be advised (a Cochrane Systematic Review
on this topic is currently being undertaken to influence
best practice guidelines). There is evidence to suggest that
a substantial proportion of women continue to have prob-
lems during the first 12 months following birth and do
not report these to healthcare professionals (Bedwell
2006). Therefore, it is important to advise women to seek
help and encourage them to discuss any problems with
their GP. Most women should be pain-free and be able to
resume sexual intercourse within a few weeks after the
birth; this will vary in individual women. Some women
may still complain of discomfort, depending on the sever-
ity of trauma experienced and the healing process. Dys-
pareunia (painful sexual intercourse) can be related to
perineal trauma (Chapter 15) and this can in the long-
term affect the woman’s relationship with her partner.
In the first 3 months post-birth, approximately, 23% of
women report dyspareunia (RCOG 2004). Although high
levels of sexual morbidity after childbirth have been iden-
tified, the approach to discussion and management of this
area appears to be problematic (Barrett et al 2000). When
giving health advice and support, healthcare professionals
are advised to identify an appropriate time, not to make
assumptions with regard to sexual activity after childbirth
and to be conversant with support agencies relevant to a
range of cultural and sexual diversities and associated indi-
vidual women’s needs (Barrett et al 2000; NICE 2006a).
Caesarean section wounds
It is now common practice for women undergoing an
operative birth to have prophylactic antibiotics at the time
of the surgery (Smaill and Hofmeyr 2002). This has been
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Section | 5 | Puerperium
demonstrated to significantly reduce the incidence of sub-
sequent wound infection and endometritis. In addition, it
is now usual for the wound dressing to be removed after
the first 24 hours, as this also aids healing and reduces
infection. Advice needs to be offered to the woman about
care of her wound and adequate drying when taking a
bath or shower, or for more obese women where abdomi-
nal skin folds are present and are likely to create an
environment that is constantly warm and moist. For
these women, a dry dressing over the suture line might be
appropriate.
A wound that is hot, tender and inflamed and is accom-
panied by a pyrexia is highly suggestive of an infection.
Where this is observed, a swab should be obtained for
microorganism culture and medical advice should be
sought. Haematoma and abscesses can also form under-
neath the wound and women may identify increased pain
around the wound where these are present. Rarely a
wound may need to be probed to reduce the pressure and
allow infected material to drain, reducing the likelihood
of the formation of an abscess. With the hospital stay
now being much shorter than previously, these problems
increasingly occur after the woman has left hospital.
Circulation
Pulmonary embolism remains a major cause of maternal
deaths in the UK and midwives and GPs need to be more
alert to identify high-risk women and the possibility of
thromboembolism in puerperal women with leg pain and
breathlessness (Lewis 2007; CMACE 2011). Women who
have a previous history of pulmonary embolism, a deep
vein thrombosis (DVT), are obese or who have varicose
veins have a higher risk of postpartum problems. Postpar-
tum care of women who have preexisting or pregnancy-
related medical complications relies on prophylactic
precautions and should be undertaken for women who
undergo surgery and have these preexisting factors.
Thromboembolitic D (TED) stockings should be provided
during, or as soon as possible after, the birth and prophy-
lactic heparin prescribed until women attain normal
mobility. All women who undergo an epidural anaes-
thetic, are anaemic, or have a prolonged labour or an
operative birth are slightly more at risk of developing com-
plications linked to blood clots. Women with preexisting
problems are at higher risk because of their overall health
status and environment of care postpartum. For example,
women who undergo a CS as a result of maternal illness
are more likely to spend longer in bed, thereby reducing
their mobility and increasing their risk of morbidity.
Clinical signs that women might report include the fol-
lowing (from the most common to the most serious). The
signs of circulatory problems related to varicose veins are
usually localized inflammation or tenderness around the
varicose vein, sometimes accompanied by a mild pyrexia.
This is superficial thrombophlebitis, which is usually
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resolved by applying support to the affected area and
administering anti-inflammatory drugs, where these are
not in conflict with other medication being taken or
with breastfeeding. Unilateral oedema of an ankle or calf
accompanied by stiffness or pain and a positive Homan’s
sign might indicate a DVT that has the potential to cause
a pulmonary embolism. Urgent medical referral must be
made to confirm the diagnosis and commence anticoagu-
lant or other appropriate therapy. The most serious
outcome is the development of a pulmonary embolism.
The first sign might be the sudden onset of breathlessness,
which may not be associated with any obvious clinical
sign of a blood clot. Women with this condition are likely
to become seriously ill and could suffer a respiratory col-
lapse with very little prior warning.
Some degree of oedema of the lower legs and ankles and
feet can be viewed as being within normal limits where it
is not accompanied by calf pain (especially unilaterally),
pyrexia or a raised blood pressure.
Hypertension
Women who have had previous episodes of hypertension
in pregnancy may continue to demonstrate this post­
partum for several weeks after the birth (Tan and De Swiet
2002). There is still a risk that women who have clinical
signs of pregnancy-induced hypertension can develop
eclampsia in the hours and days following the birth
although this is a relatively rare outcome in the normal
population (Atterbury et al 1998; Tan and De Swiet 2002).
In addition, some women appear to develop eclampsia
postpartum where there has been no previous history of
raised blood pressure or proteinuria (Chames et al 2002;
Matthys et al 2004). Some degree of monitoring of the
blood pressure should be continued for women who were
hypertensive antenatally, and postpartum management
should proceed on an individual basis (Tan and De Swiet
2002). For these women, the medical advice should deter-
mine optimal systolic and diastolic levels, with instruc-
tions for treatment with antihypertensive medication if the
blood pressure exceeds these levels. As women can develop
postnatal pre-eclampsia without having antenatal prob-
lems associated with this, because the symptoms can be
fairly non-specific, such as a headache or epigastric pain
or vomiting, the woman may delay or fail to contact a
healthcare professional for advice. Where they do seek
advice, the healthcare professional may not be alert to the
possibility of the development of postpartum eclampsia
(Chames et al 2002). Failure to detect symptoms at this
initial stage may lead to more serious outcomes as the
disease develops untreated (Chames et al 2002; Tan and
De Swiet 2002; Matthys et al 2004). Therefore, if a post-
partum woman presents with signs associated with pre-
eclampsia, the midwife should be alert to this possibility
and undertake observations of the blood pressure and
urine and obtain medical advice.
 Physical health problems and complications in the puerperium
For women with essential hypertension, the manage-
ment of their overall medical condition will be reviewed
postpartum by their usual caregivers. Undertaking clinical
observation of blood pressure for a period after the birth
is advisable so that information is available upon which
to base the management of this for the woman in the
future (Tan and De Sweit 2002).
Headache
This is a common ailment in the general population;
concern in relation to postpartum morbidity should there-
fore centre around the history of the severity, duration and
frequency of the headaches, the medication being taken
to alleviate them and how effective this is. As this is also
associated with hypertension, a recording of the blood
pressure should be undertaken to exclude this as a primary
factor. In taking the history, if an epidural analgesic was
administered, medical advice should be sought. Head-
aches from a dural tap typically arise once the woman has
become mobile after the birth and they are at their most
severe when standing, lessening when the woman lies
down. They are often accompanied by neck stiffness, vom-
iting and visual disturbances. These headaches are very
debilitating and are best managed by stopping the leakage
of cerebral spinal fluid by the insertion of 10–20 ml of
blood into the epidural space; this should resolve the clini-
cal symptoms. Where women have returned home after
the birth, they would need to return to the hospital to have
this procedure.
Headaches might also be precursors of psychological
distress and it is important that other issues related to the
birth event are explored, taking the time and opportunity
to do this in a sensitive manner. Factors that might be
overlooked include dehydration, sleep loss and a greater
than usual stressful environment (see Chapter 25).
However, the midwife should take time to discuss the
woman’s feelings and offer advice or reassurance about
these where possible.
Backache
Many women experience pain or discomfort from back-
ache in pregnancy as a result of separation or diastasis
of the abdominal muscles (rectus abdominis diastasis
[RAD]). Where backache is causing pain that affects the
woman’s activities of daily living, referral can be made to
local physiotherapy services. Pelvic girdle pain experienced
in pregnancy should resolve in the weeks after the baby is
born but it may continue for a much longer period (Aslan
and Fynes 2007).
Urinary problems
Urinary problems can have short- and long-term social,
psychological and physical health consequences for
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Chapter | 24 |
women (WHO [World Health Organization] 2010).
Approximately 19% of women will have urinary problems
following birth (Laperriere 2000). Stress incontinence
appears to be the most common form of urinary inconti-
nence reported following birth but some women may also
suffer from frequency, urgency and urge incontinence
(Birch et al 2009). Some women who have had a compli-
cated birth may be susceptible to the risk of urinary infec-
tions, which may lead to cystitis and in some severe cases
pyelonephritis (Stables and Rankin 2010). Where a woman
has undergone an epidural or spinal anaesthetic, this can
have an effect on the neurological sensors that control
urine release and flow, which may cause acute retention.
The main complication of any form of urine retention is
that the uterus might be prevented from effective contrac-
tion, which leads to increased vaginal blood loss. There is
also increased potential for the woman to contract a urine
infection with possible kidney involvement and long-term
effects on bladder function.
In addition, women who have sustained pelvic floor
damage during birth may suffer from continence prob-
lems in the short and long term. Stress and urge inconti-
nence of urine, utero-vaginal prolapse, cystocele, rectocele
and dyspareunia are associated with pelvic floor damage
(Stables and Rankin 2010). Very rarely, urinary inconti-
nence might be a result of a urethral fistula following
complications from the labour or birth.
Management of urine output has been shown to lack
consistency and recognition of its potential importance
(Zaki et al 2004). A midwife will need to be alert to any
urinary problems a woman may have as sometimes these
can be missed. Being alert to the risks and being able to
recognize ongoing urinary problems is an essential com-
ponent of care (Steen 2013). Abdominal tenderness in
association with other urinary symptoms, for example a
poor output, dysuria or offensive urine and a raised tem-
perature or general flu-like symptoms, might indicate a
urinary tract infection (UTI). A mid-stream urine sample
will be required to confirm a UTI and the infection can be
treated with antibiotics (NICE 2006b).
Women might feel embarrassed about having urinary
problems and midwives may need to consider appropriate
ways of encouraging women to talk about any problems
so that they can inform them about their future manage-
ment. Specific enquiry about these issues should be made
when women attend for their 6–8-week postnatal exami-
nation; further investigations should be made for women
who are encountering these problems. Keeping a bladder
diary can be a useful aid. NICE (2006b) have suggested
that women should complete a bladder diary for three
consecutive days to allow for variation in day-to-day
activities to be captured.
Recently it has been reported that women with ongoing
urinary incontinence following birth are nearly twice as
likely to develop postnatal depression (Sword et al 2011).
Therefore, it is essential that midwives have knowledge
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Section | 5 | Puerperium
and an understanding of the risks and symptoms of
urinary problems and are able to ask sensitive questions
to identify women at risk as failure to do so can lead to
poor mental health. These women will need additional
social and psychological support (Steen 2013).
Bowel problems
Bowel problems can have short- and long-term social,
psychological and physical health consequences for
women (WHO 2010). It is estimated that about 3–10% of
women will suffer from faecal incontinence (RCOG 2004;
Van Brummen et al 2006). Faecal incontinence is associ-
ated with primiparity, instrumental birth and severe peri-
neal injury (Thornton and Lubowski 2006; Guise et al
2007). Constipation and haemorrhoids can be a problem
for some women. It is estimated that about 44% of women
will suffer from constipation and 20–25% of women
will suffer from haemorrhoids following birth. Symptoms
such as flatus incontinence, passive leakage, urge and
faecal incontinence can be caused by a neurological or
muscular dysfunction or both (Pollack et al 2004) (see
Chapter 15). The prevalence of bowel problems maybe
higher as many women may suffer in silence and be too
embarrassed to ask for help (Steen 2013).
Therefore, a midwife will need to be alert to any bowel
problems and to ask a woman sensitively about her bowel
habits. Being alert to the risks and being able to recognize
ongoing bowel problems is an essential component of
care. Enquiring about the pattern and frequency of bowel
movements and comparing this to the woman’s previous
experience is likely to assist a midwife in identifying
whether or not there is a problem. Factors such as dietary
intake, a degree of dehydration during labour and concern
about further pain from any perineal trauma can contrib-
ute to bowel problems. A diet that includes soft fibre,
increased fluids and the use of prophylactic aperients that
are non-irritant to the bowel can be prescribed to alleviate
constipation, the most common and apparently effective
of these being lactulose (Eogan et al 2007). Women need
advice that any disruption to their normal bowel pattern
should resolve within days of the birth, taking into con-
sideration the recovery required by the presence of peri-
neal trauma. They should also be reassured about the
effect of a bowel movement on the area that has been
sutured as many women may be unnecessarily anxious
about the possibility of tearing their perineal stitches.
Where women have prolonged difficulty with constipa-
tion, anal fissures can result (Corby et al 1997). These are
painful and difficult to resolve and therefore advice about
bowel management is important in avoiding this situa-
tion. Women who have haemorrhoids should also be
given advice on following a diet high in fibre and fluids,
preferably water and the use of appropriate aperients to
soften the stools as well as topical applications to reduce
the oedema and pain.
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It is also of concern where women might experience loss
of bowel control and whether this is faecal incontinence.
It is important to determine the nature of the incontinence
and distinguish it from an episode of diarrhoea. It might
be helpful to ask whether the woman has taken any laxa-
tives in the previous 24 hours and explore what food was
eaten. Where the problems do not seem to be associated
with other factors the woman should first be advised to
see her GP.
The role of the midwife is to encourage women to talk
about these problems by being proactive in asking women
about any bowel problems. Where women identify any
change to their pre-pregnant bowel pattern by the end of
the puerperal period, they should be advised to have this
reviewed further, whether it is constipation or loss of
bowel control.
Anaemia
Iron-deficiency during pregnancy is extremely common
even among well-nourished women and this can be a
predisposing risk factor for anaemia in the postnatal
period. The main cause of anaemia is iron deficiency and
severe anaemia can have serious health and functional
consequences (Goddard et al 2011). Whilst severe anaemia
(haemoglobin <7 g/dl) is rare in resource-rich countries,
it is a serious problem for many women in resource-poor
countries. The impact, however, of the events of the labour
and birth may leave many women looking pale and tired
for a day or so afterwards. Where it is evident that a larger
than normal blood loss has occurred, it can be valuable
to obtain an overall blood profile within which the red
blood cell volume, haemoglobin and ferritin levels can be
assessed so as to provide appropriate treatment to reduce
the effects of the anaemia; these include blood transfu-
sions and iron supplements (Dodd et al 2004; Bhandal
and Russell 2006). The degree to which the haemoglobin
level has fallen should determine the appropriate manage-
ment and this is particularly important in the presence
of preexisting haemoglobinopathies, sickle cell and
thalassaemia.
Where the haemoglobin level is <9 g/dl and women are
symptomatic, a blood transfusion might be appropriate.
Blood transfusions should be considered if a woman is at
risk of cardiovascular instability because of their degree of
anaemia (Goddard et al 2011). Body-store iron deficiency
is diagnosed by a low serum ferritin level and this can
indicate that the woman has a longstanding problem of
iron deficiency. A cut-off ferritin level varies between 12
and 15 µg/l to confirm iron deficiency (Todd and Caroe
2007). However, ferritin levels can be raised if infection
or inflammation is present, even if iron stores are low
(Goddard et al 2011). Oral iron and appropriate dietary
advice are advocated where the level is <11 g/dl. Usually,
ferrous sulphate 200 mg twice daily is recommended;
however, a lower dose may be effective and better
 Physical health problems and complications in the puerperium
tolerated. Alternatively, ferrous fumarate, ferrous gluco-
nate or iron suspensions may be better tolerated and oral
iron should be continued for 3 months after the iron
deficiency is corrected to replenish the woman’s stores of
iron. Ascorbic acid (250–500 mg) twice daily may be pre-
scribed to enhance iron absorption but to date there are
no data to support its effectiveness (Goddard et al 2011).
Women should be advised not to have milk (including hot
beverages with milk added) at the time of having iron as
it can interfere with its absorption.
Where the woman has returned home soon after the
birth, the postpartum woman’s haemoglobin values might
not have been undertaken where there was no history of
anaemia prior to labour and the blood loss at birth was
not assessed as excessive. If there is no clinical information
to hand, the midwife needs to rely on the woman’s clinical
symptoms; if these include lethargy, tachycardia and
breathlessness as well as a clinical picture of pale mucous
membranes, it would be prudent to arrange for the blood
profile to be reviewed. Some researchers have questioned
blood loss estimation after childbirth as well as the timing
of blood tests taken to assess the physiological impact of
this (Jansen et al 2007). Thus the postnatal day when the
haemoglobin test is taken might have a clinically signifi-
cant bearing on the subsequent management.
Breast problems
Regardless of whether women are breastfeeding, they may
experience tightening and enlargement of their breasts
towards the 3rd or 4th day as hormonal influences encour-
age the breasts to produce milk (see Chapter 34). For
women who are breastfeeding the general advice is to feed
the baby and avoid excessive handling of the breasts.
Simple analgesics may be required to reduce discomfort.
For women who are not breastfeeding, the advice is to
ensure that the breasts are well supported but that this is
not too constrictive and, again, that taking regular anal­
gesia for 24–48 hours should reduce the discomfort. Heat
and cold applied to the breasts via a shower or a soaking
in the bath may temporarily relieve acute discomfort as
well as the use of chilled cabbage leaves (Nikodem et al
1993; Roberts 1995).
PRACTICAL SKILLS FOR
POSTPARTUM MIDWIFERY CARE
AFTER AN OPERATIVE BIRTH
In the immediate period after an operative birth the
attendant will be closely monitoring recovery from the
anaesthetic used for CS (see Chapter 21). Regular observa-
tion of vaginal loss, leakage on to wound dressings and
fluid loss in any ‘redivac’ drain system should also be
undertaken.
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Chapter | 24 |
Once the woman has fully recovered from the operation
she should be transferred to a ward environment. Mid-
wifery care involves the overall framework of core care (see
Chapter 23). Appropriate care is to assess the needs of the
individual woman and to formalize this within a docu-
mented postnatal care plan so that she and caregivers
have a clear framework by which to promote recovery (DH
2004; NICE 2006a). Women who have undergone an
operative birth need time to recover from a major physical
shock to the systems of the body, for optimal conditions
to allow tissue repair to take place as well as psychological
adjustment to the events of the birth (Mander 2007).
Women who have undergone an operative birth will
require assistance with a number of activities they would
otherwise have done themselves. During their hospital
stay, they will need help to maintain their personal
hygiene, to get out of bed and mobilize and to start to care
for their baby. The rate at which each woman will be able
to regain control over these areas of activity is highly indi-
vidual. It is strongly suggested that caregivers should not
expect all women to have reached a certain level of recov-
ery in line with their ‘postnatal day’. Using such a frame-
work to assess the degree to which a woman is recovering
from a major operation leads to a tendency to become
judgemental and unrealistic (Wray 2011a). Women may
view undergoing a caesarean section or any complication
in the birth in different ways depending on their social
and cultural background and this might have associations
to their ongoing psychological health and wellbeing
(Chien et al 2006; McCourt 2006).
It is now common for women to have a much shorter
period in hospital after birth; some women might return
home 48–72 hours after a major operation with very
minimal support (Wray and Bick 2012). Practical advice
about the management of their recovery and self-care at
home is also within the remit of midwifery postpartum
care. For example; the midwife might suggest that the
woman identifies the ways in which she could reduce the
need to go upstairs. Alongside this, women can be encour-
aged to go out with their baby when someone is available
to help with all the baby transportation equipment; this
will encourage venous return and cardiac output at a level
that is beneficial rather than exhausting. At the same time,
getting ‘out and about’ can provide a sense of feeling good
and improved wellbeing (Wray 2011b: 2).
The benefits of mobility after surgery are well known
and although women may be supplied with thromboem-
bolitic stockings prior to the operation and be prescribed
an anticoagulant regimen such as heparin, women need
to be encouraged to mobilize as soon as practicable after
the operation to reduce the risk of circulatory problems.
Women need an explanation that mobility is of benefit
soon after the birth, but it is also an important part of care
to recognize when the woman has reached her limit with
regard to physical activity and may need to rest (Wray
2011a). Regular use of appropriate analgesia should be
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Section | 5 | Puerperium
made available to women where this is required (Mander
2007). Good information about self-care and recovery is
important to every woman and the midwife has a key role
to play in this process. Each woman is an individual and
unique so her recovery from surgery alongside her adap­
tation to motherhood needs to be borne in mind and
tailored to meet her own needs (Wray 2011a, 2011b).
EMOTIONAL WELLBEING:
PSYCHOLOGICAL DEVIATION FROM
NORMAL
Psychological distress and psychiatric illness in relation to
childbirth are covered in depth in Chapter 25. However, it
is relevant to reflect here on the possible importance of
the relationship that develops between the woman and the
midwife during their contact postpartum (Hunter 2004).
Clearly, such relationships are enriched where there has
been antenatal contact or a degree of continuity postpar-
tum, or both, and women have commented positively
where such continuity has been achieved (Singh and
Newburn 2000; Bhavnani and Newburn 2010). This prior
knowledge can mean that the midwife might detect or be
concerned about a change in the woman’s behaviour that
has not been noticed by her family. Any initial concerns
of the mother or the family should be explored by the
midwife making use of open questions and listening skills
during the postnatal contact either in the home or in the
hospital setting (NICE 2007; Bick et al 2011). Behavioural
changes may be very subtle, but, however small, they
might be of importance in the woman’s overall psycho-
logical state; it is the balance between the woman’s physi-
cal condition and her psychological state that might
influence an eventual decision to refer for expert advice.
Although the woman and her partner are likely to have
an expectation of reduced sleep once the baby is born, the
actual experience of this can have very varied effects on
individual women (Wray 2012). The cause of the lack of
sleep or tiredness is what is important – is the being
unable to get to sleep a result of anxiety about the future
and what is, as yet, unknown? This might include fears
about the possibility of a cot death, or a lack of confidence
in coping as a mother, financial or relationship worries.
The opportunity to sleep might be reduced because the
feeding is not yet established or the baby is not in a settled
environment and so the mother is constantly disturbed
when she tries to sleep. In addition, other people may not
be allowing the mother to sleep when the baby does not
need her attention. Tiredness and fatigue can adversely
affect women’s health and interfere with their adaptation
to motherhood (Troy and Dalgas-Pelish 2003), however
the terms fatigue and tiredness are subjective and difficult
to define postnatally. Seeking to unravel the issues can
help the midwife and the women to determine what is the
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underlying cause and whether simple interventions could
improve the situation. As a result of this enquiry, women
who come into the category where chronic fatigue or
anxiety prevents them from sleeping when the opportu-
nity arises may benefit from interagency referral and
support. Alternatively, where there is a physiological
reason for the tiredness, as a result of anaemia for example,
the situation can be managed clinically (Jansen et al
2007). The midwife is an important member of the
primary health care team and should practise within an
interagency context (see Chapter 25). Enabling women to
plan and set realistic goals as part of their own recovery
from childbirth is ongoing and extends beyond 28 days
and 6 weeks (Bick et al 2011; Wray 2012).
SELF-CARE AND RECOVERY
Self-care and managing one’s own health following child-
birth requires women to take some ownership of their
own health and wellbeing (Wray 2011a). The pace at
which women recover is highly variable, and notions of a
set time period (6 weeks) do not apply to all women
(NICE 2006a). Women need guidance and sound infor-
mation to enable them to recover so that they are clear
about what they can expect and what to do when they are
concerned. Good rapport and positive feedback from mid-
wives are known to help women in their recovery as well
as support from partners, family and friends (Beake et al
2010; Wray 2011a). Central to self-care is robust informa-
tion from the midwife from the outset, so that women can
feel confident in their own assessments of themselves.
TALKING AND LISTENING AFTER
CHILDBIRTH
The essence of the contact between the woman and the
midwife after the birth event is to strive to maintain a
therapeutic relationship – one of support and advice that
builds on the relationship formed ideally antenatally.
Within the current provision of care, it is not always pos-
sible to achieve the objective of continuity of carer post-
natally, and some women will have postnatal home visits
from several different midwives, possibly previously
unknown to them. Indeed other healthcare workers such
as maternity support workers (MSWs) may form part of
the postnatal care-giving process under the supervision of
midwives.
Once the birth is over and the woman has returned to
her home environment there may be aspects of the birth
that she does not understand or that even distress her to
think about. Where appropriate, a midwife undertaking
postnatal care in the woman’s home might be able to help
 Physical health problems and complications in the puerperium Chapter | 24 |

the woman review and reflect on the birth by talking about
it and listening to her concerns. Where necessary, the
midwife can facilitate referral to the key people involved
in order that the woman can discuss the birth or see the
records of the birth and clarify any outstanding issues
(Charles and Curtis 1994; Allen 1999; NICE 2006a).
Other forms of support, for instance specific counselling
for those with traumatic emotional experiences, might
also be appropriate under professional guidance (NICE
2007) (see Chapter 25).

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FURTHER READING
Bhavnani V, Newburn M 2010 Left to
your own devices: the postnatal care
experiences of 1260 first-time
mothers. NCT, London
A useful read to help inform postnatal care.
USEFUL WEBSITES
National Childbirth Trust: www.nct
.org.uk/parenting/you-after-birth
National Institute for Health and Care
[formerly Clinical] Excellence:
www.nice.org.uk
A new Quality Standard for postnatal care
was introduced in July 2013 – see http://
publications.nice.org.uk/postnatal-care-qs37
Postnatal Care HEAT module – Lab
space, Open University: http://
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associated with postpartum
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International Journal of Obstetrics
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Pol G et al 2006 Defecatory
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Urogynaecology Journal and Pelvic
Floor Dysfunction 17:224–30
Waterstone M, Wolfe C, Hooper R et al
2003 Postnatal morbidity after
National Childbirth Trust 2010
Postnatal care – still a Cinderella
story? NCT, London
An important insight into why postnatal
care is still a neglected issue.
labspace.open.ac.uk/file.php/6632/
HEAT_PNC_Final_Print_Output
_cropped.pdf
Health Education and Training (HEAT) is
an online educational series of modules
launched in 2011 by the Open University
with the aim to educate and train
approximately 250 000 frontline healthcare
workers across sub-Saharan Africa by
2016.
Chapter | 24 |
childbirth and severe obstetric
morbidity. BJOG: An International
Journal of Obstetrics and
Gynaecology 110(2):128–33
WHO (World Health Organization)
2010 WHO technical consultation on
postpartum and postnatal care.
WHO Document Production
Services, Geneva. Available at http://
whqlibdoc.who.int/hq/2010/
WHO_MPS_10.03_eng.pdf (accessed
17 May 2013)
Wray J 2011a Bouncing back? An
ethnographic study exploring the
context of care and recovery after
birth through the experiences and
voices of mothers. Unpublished PhD
thesis, University of Salford
Wray J 2011b Feeling cooped up after
childbirth – the need to go out and
about. The Practising Midwife 14:2
Wray J 2012 Impact of place upon
celebration of birth – experiences of
new mothers on a postnatal ward.
MIDIRS Midwifery Digest
23(3):357–61
Wray J, Bick D 2012 Is there a future for
universal midwifery postnatal care in
the UK? MIDIRS Midwifery Digest
22(44):495–8
Zaki M M, Pandit M, Jackson S 2004
National survey for intrapartum and
postpartum bladder care: assessing
the need for guidelines. BJOG: An
International Journal of Obstetrics
and Gynaecology 111(8):874–6
Romano M, Cacciatore A, Giordano R et
al 2010 Postpartum period: three
distinct but continuous phases.
Journal of Prenatal Medicine
4(2):22–5. Available at www.ncbi
.nlm.nih.gov/pmc/articles/
PMC3279173/
Royal College of Midwives (RCM):
www.rcm.org.uk/midwives/
by-subject/postnatal-care/
World Health Organization:
www.who.int/maternal_child
_adolescent/topics/newborn/
postnatal_care/en/
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 Chapter 25

Perinatal mental health

Maureen D Raynor, Margaret R Oates

CHAPTER CONTENTS Treatment of perinatal psychiatric

disorders 545
Part A: Pregnancy, childbirth, puerperium: The role of the midwife 545
the psychological context 532 Psychological treatments 545
Stress/anxiety 532
Social support 545
Fear of giving birth (tocophobia) 533
Pharmacological treatment 546
Tocophobia 533
Service provision 548
Transition to parenthood 534
Prevention and prophylaxis 549
Role change/role conflict 534
Prevention 549
Communication 534
Prophylaxis 549
The ideology of motherhood 534
The Confidential Enquiries into Maternal Deaths:
Social support 535
psychiatric causes of maternal death 550
Normative emotional changes during
pregnancy, labour and the puerperium 535 Conclusion 550
Pregnancy 535 References 551
Labour 535 Further reading 553
The puerperium 536 Useful websites 553
Postnatal ‘blues’ 536
Distress or depression? 537 In psychological terms, pregnancy, childbirth and
the puerperium are major life events or life
Emotional distress associated with traumatic crises. Having children is associated with an
birth events 537 immense increase in individual life changes that
Conclusion 537 may lead to anxiety and chronic stressors, for
Part B: Perinatal psychiatric disorder 537 example a new baby may result in a change of
Introduction 537 housing and brings increased financial demands.
Pregnant women in employment will inevitably
Types of psychiatric disorder 538 take maternity leave and may return to work in
Psychiatric disorder in pregnancy 539 a different capacity or even on a part-time basis.
Mild–moderate conditions 539 A new baby may cause disruption to the family
Serious conditions 540 unit. Roles and responsibilities alter with changes
to the dynamics of family relationships. Having a
Psychiatric disorder after birth 541
child may place strains on relationships and there
Puerperal (postpartum) psychosis 541 is a higher rate of relationship discord and
Postnatal depressive illness 542 breakdown around this time. Many women find

© 2014 Elsevier Ltd 531

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Section | 4 | Labour
coping with the physiological adaptation to
pregnancy, the plethora of antenatal screening
tests and advice, issues around choice, control
and communication emotionally draining.
Therefore, while many women and their partners
experience pregnancy and childbirth as a joyous,
exciting and life-affirming event, the transition
to parenthood is an emotionally charged time
bringing common anxieties, a certain degree of
loss and periods of self-doubt. This can culminate
in pregnancy and postpartum being a fragile
time of physical, psychological and social
upheavals. Like other stressful life events
childbirth can be associated with depression and
anxiety. However, it is also known to be
associated with an increased risk of serious
psychiatric illness. Pregnancy provides a wealth
of opportunities for promoting emotional
health while predicting and preventing mental
illness. It is important for midwives to be able
to identify normal adjustment reactions to
motherhood and distinguish them from the
early warning signs of emotional distress or
indeed mental illness.
This chapter is formed of two distinct but
inter-related parts:
THE AIM OF PART A IS TO:
• explore the psychological context of pregnancy,
childbirth and the puerperium by examining the full
range of human emotions that may affect women as
they adjust to change and make the transition to
motherhood
• emphasize that awareness of the multiplicity of
psychosocial factors and what constitutes normal
emotions and behaviours are key components in
enhancing understanding of perinatal mental
health.
THE AIM OF PART B IS TO:
• explore the range of perinatal disorders, i.e.
psychiatric conditions, that pre-exist or co-exist with
pregnancy as well as those conditions presenting
with the puerperium
• emphasize, by using a defined nomenclature, their
recognition and management (including relevant
pharmacology and the implications for breastfeeding
and mother–baby relationship)
• highlight key recommendations from NICE and
relevant triennial reports on the Confidential
Enquiries into Maternal Deaths in the United
Kingdom
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Part A: Pregnancy, childbirth,
puerperium: the psychological
context
Maureen D Raynor
STRESS/ANXIETY
Pregnancy, labour and the puerperium are normal life
events, yet they are periods in a woman’s life when her
vulnerability exposes her to a significant amount of stress
and anxiety. Stress and anxiety are the psychopathology of
humans’ existence and a part of normal human emotion.
A degree of stress during pregnancy is both essential and
normal for the psychological adjustment of pregnant
women. The ‘worry work’ that women encounter assists in
their psychological adaptation to the emotional demands
and changes of pregnancy. Conversely, elevated levels of
stress hormones and unnecessary anxiety will stretch
coping reserves, and could prove disabling. Stress is the
body’s psychophysical response to any type of demand or
threat, whether good or bad. Anxiety on the other hand is
a state of angst, worry or unease, often triggered by an
element of perceived threat or an event where there is an
uncertain outcome, such as a written examination or when
important decisions have to be made. The brain plays a
key role in how an individual responds and processes the
perception of a threat. This is realized via a neurohormo-
nal response by both the neocortex and limbic system. The
‘fight or flight’ reflex is produced when there is a threat to
the self. Anxiety and fear causes the individual to become
stressed, releasing stress response hormones namely cate-
cholamines (adrenaline/noradrenaline) and cortisol. A
host of psycho-physical symptoms can manifest, such as
hyperalertness, tension, sense of unease, restlessness,
insomnia, fear and forgetfulness. Gastrointestinal upset
and marked changes in the cardiovascular system, e.g.
sweating, palpitations, tachycardia, shortness of breath,
dizziness, dry mouth and nausea, can also feature. Stress
and anxiety therefore have a cognitive, somatic, emo-
tional, physiological and behavioural component.
Anxiety disorders, on the other hand, are a group of
mental illness that cause such marked distress that they
disrupt normal function, overwhelm or impair the indi-
vidual’s ability to lead a normal life. Examples of anxiety
disorders such as obsessional–compulsive and phobic
anxiety states are discussed in more detail in Part B of the
chapter.
Although many studies have raised the profile of ele-
vated levels of stress hormones during the antenatal period
having the potential to lead to deleterious effects on the
fetus (Teixeira et al 1999; Evans et al 2001; Miller et al
2005; Glover and O’Connor 2006; Talge et al 2007;
 Perinatal mental health Chapter | 25 |

Lack of social
support/lone
parenthood

Language barrier / Poverty / poor

non-English socio-economic
speaking status

Asylum / seeker Domestic abuse

or refugee staus

Other major life

events such as
Poor housing
death of a
loved one

Parenting
and caring
responsibilities

Fig. 25.1 Vulnerability factors and mental health.

O’Donnell et al 2009) or persistent antenatal anxiety
acting as a possible precursor to maternal mental illness
postpartum, this is still an emerging field. The mechanism
by which raised levels of stress hormones may affect fetal
development is not yet fully understood. Furthermore, the
research studies have provided very little data to help
guide midwifery practice on how antenatal stress can be
alleviated in pregnant women.
Thus it can be concluded that there are many factors in
women’s lives that can impact on their happiness (Fig.
25.1) and affect their emotional health and wellbeing.
Understanding the root cause and expression of anxiety,
stress and mental distress in women is complex, as the
social circumstances in which women live and into which
children are born play a major role in their health and
wellbeing.
FEAR OF GIVING BIRTH
(TOCOPHOBIA)
The fear of childbirth has grown in prominence over
recent years, as demonstrated by the emergent studies
mainly from Scandinavian countries. The exact incidence
of this psychological condition is unknown but it is esti-
mated that approximately 5–20% of pregnant women
within Western society are fearful of childbirth

533
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Section | 4 | Labour
(Waldenstrom et al 2006; Rouhe et al 2009; Adams et al
2012). The picture within developing and more resource-
poor countries is unreported. Understanding tocophobia
is challenging as there is an array of complex social factors
attributed to the roots of its expression, such as domestic
abuse, communication difficulties, previous traumatic
birth experience, poor socioeconomic status, lack of social
support, nulliparity and pre-existing mental illness (Rouhe
et al 2009, 2011). A study by Adams et al (2012) suggests
that tocophobia might result in longer duration of labour
and therefore more risk of obstetric intervention during
childbirth. It is postulated that the fear and anxiety gener-
ated in the presence of tocophobia increases catecho-
lamine levels, which can affect the frequency, strength and
duration of uterine contractions. This can affect women’s
satisfaction with their birth experience and lead to mater-
nal distress.
TRANSITION TO PARENTHOOD
Postnatally, parents may find coping with the demands of
a new baby, e.g. infant feeding, financial constraints, the
whole process of lifestyle adjustments and role changes, a
real strain. For new mothers, this will involve diverse emo-
tional responses ranging from joy and elation to sadness
and utter exhaustion. Fatigue, pain and discomfort com-
monly result once the elation that follows the safe arrival
of the baby wears off. Disturbed sleep is inevitable with a
new baby. Mothers who are trying to establish breastfeed-
ing, older women, women who are recovering from a
caesarean section or those who have had a long and dif-
ficult labour/birth, twins or higher multiples, may feel
wretched and constantly weary for months following
childbirth. Soreness and pain being experienced from peri-
neal trauma will affect libido, so too will feelings of
exhaustion, despair and unhappiness that may be associ-
ated with the round-the-clock demands of caring for a new
baby. Women may be left feeling bereft and quite miser-
able after giving birth.
Role change/role conflict
Having a baby, and particularly the transition to parent-
hood that accompanies the first child, leads to a significant
shift in a couple’s relationship; social networks are dis-
rupted, especially those of the mother, and the quality and
quantity of social support such networks can and do
provide. There is a strong possibility that old relationships,
particularly with those who are childless or single, may be
weakened, leading to a sense of social isolation. However,
some relationships are strengthened or even replaced
gradually by new contacts established with other parents.
The dynamics of relationships with family members are
also altered during this process of transition and change.
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The relationship with the woman’s parents for example
alters as the daughter becomes a mother herself and her
parents develop new roles as grandparents. The competing
demands on time of caring for a new baby may lead to
role conflict and confusion for parents. Mothers may find
that there is little time for them to pursue other activities,
which can diminish any opportunity for contact with and
support from others (Raynor and England 2010). Partners,
especially young fathers, can also experience a sense of
isolation as the dynamic within the couple’s relation
alters, becoming more baby-centred. Postnatal care is
therefore essential to women’s emotional wellbeing and
should be a continuation of the care given during preg-
nancy. Its contribution plays a significant part in the
positive adjustment to parenthood, as it assists in the
acquisition of confident and well-informed parenting
skills (DH [Department of Health] 2004; Barlow et al
2011).
Communication
Effective communication during pregnancy and the puer-
perium is essential. Yet poor communication is still the
single most common factor that is associated with women’s
dissatisfaction with their care. A survey by the National
Perinatal Epidemiology Unit (NPEU) reports that com-
munication remains a matter of concern within the mater-
nity service (Redshaw and Heikkila 2010). Being provided
with adequate information will serve to:
• diminish women’s anxiety levels and allay emotional
distress
• facilitate choice
• enable women to maintain control over
decision-making.
The ideology of motherhood
Motherhood, it is thought, ensures that a woman has
fulfilled her biological destiny, confirms a woman’s femi-
ninity and raises her status in society, but without financial
gain (Crittenden 2001; Winson 2009). Instead of feeling
elated by motherhood some women experience displeas-
ure, harbour feelings of unhappiness and feel dismayed or
even disappointed in their role as new mothers (Grabowska
2009). Many may be afraid to speak out about their feel-
ings in case they are judged a ‘bad’ or not a ‘good enough’
mother. Painful emotions may be internalized, magnify-
ing difficulties with coping and sleeping, leading many
women to suffer in silence. Distress may then manifest as
mothers rage against their impossible situation. Some
women may even grieve for the loss of their former life-
style, career or status. Nicholson (1998) contends that
healthcare professionals have defined women’s postnatal
experience through proposing that well-adjusted, ‘normal’
and therefore ‘good’ mothers are those who are happy and

fulfilled, but those who are unfulfilled, anxious or dis-
tressed are ‘ill’ and may be perceived as ‘bad’ mothers. This
may lead to feelings of isolation, inadequacy and confu-
sion. The ideology of motherhood is therefore an assump-
tion and a paradox with inherent dichotomies as the
woman strives to be ‘super mum, super wife, super every-
thing’ (Choi et al 2005). Midwives have a pivotal role to
play in assisting women and their partners to prepare for
the physical, social, emotional and psychological demands
of pregnancy, labour, the puerperium and, perhaps more
importantly, parenthood (Barlow et al 2011; DH 2011).
Social support
During periods of stress, supportive and holistic care from
midwives will not only assist in promoting emotional
wellbeing of women, but will also help to ameliorate
threatened psychological morbidity in the postnatal
period (Oakley et al 1996; Webster et al 2000; Wessely
et al 2000; Hodnett et al 2010). Women who are socially
isolated or who have poor socioeconomic circumstances
are particularly vulnerable to mental health problems and
need additional help and support. This includes women
from minority ethnic groups who do not speak English,
and often have problems accessing health care (CMACE
2011). Bick et al (2009) provide evidence regarding the
psychosocial benefits of midwifery care well beyond the
historical boundaries of the traditionally defined postnatal
period. The restructuring of postnatal care means there is
now a social expectation that midwives will respond flex-
ibly and responsively to women’s emotional needs on an
individual basis (Brown et al 2002; DH 2004, 2007a,
2007b; NICE [National Institute for Health and Clinical
Excellence] 2006). This calls for skilled multidisciplinary
and multi-agency collaboration as well as effective team-
work, taking into account the diversity within teams, for
example the Department of Health (DH 2003a, 2003b)
acknowledges the contribution of the maternity support
worker in maternity care. Social support is further explored
in Part B.
NORMAL EMOTIONAL CHANGES
DURING PREGNANCY, LABOUR AND
THE PUERPERIUM
Pregnancy
Since many decisions have to be made it is perfectly
normal for women to have periods of self-doubt and crises
of confidence. Box 25.1 outlines the many and varied
emotions women may experience during the different tri-
mesters of pregnancy. The reality for many women will
encompass fluctuations between ambivalence to positive
and negative emotions.
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Box 25.1 Normal emotional changes during
pregnancy
First trimester
• pleasure, excitement, elation
• dismay, disappointment
• ambivalence emotional lability (e.g. episodes of
weepiness exacerbated by physiological events such
as nausea, vomiting and tiredness)
• increased femininity
Second trimester
• a feeling of wellbeing, especially as physiological
effects of tiredness, nausea and vomiting start to
abate
• a sense of increased attachment to the fetus; the
impact of ultrasound scanning generating images for
the prospective parents may intensify the experience
• stress and anxiety about antenatal screening and
diagnostic tests
• increased demand for knowledge and information as
preparations are now on the way for the birth
• feelings of the need for increasing detachment from
work commitments
Third trimester
• loss of or increased libido
• altered body image
• psychological effects from physiological discomforts
such as backache and heartburn
• anxiety about labour (e.g. pain)
• anxiety about fetal abnormality, which may disturb
sleep or cause nightmares
• increased vulnerability to major life events such as
financial status, moving house, or lack of a supportive
partner
Labour
During labour, midwives must facilitate choice to help
women maintain control. Factors that induce stress should
be prevented, or at least minimized, as the woman’s long-
term emotional health may be severely compromised by
an adverse birth experience (Lyons 1998; Redshaw and
Heikkila 2010). Choice and control are important psycho-
logical concepts to mental health and wellbeing. Evidence
from Green et al’s (1998) prospective study of women’s
expectations and experiences of childbirth suggests that
having choice in pregnancy and childbirth, and a sense of
being in control, lead to a more satisfying birth experience.
In England, the publication of ‘Maternity Matters’ (DH
2007a) epitomizes a real philosophical shift in maternity
care in terms of the guaranteed choices for women.
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Section | 4 | Labour
Box 25.2 Emotional changes during labour
• Ranging from great excitement and anticipation, to
utter dread
• Fear of the unknown
• Fear of technology, intervention and hospitalization
• Tension, fear and anxiety about pain and the ability to
exercise control during labour
• Concerns about the wellbeing of the baby and ability
of the partner to cope
• Fear of death: hospitals may be construed as places
of illness, death and dying; the magnitude of such
feelings may intensify if the woman experiences
life-threatening complications or even an emergency
caesarean section
• The process of birth thrusts a lot of private data into
the realms of the public, so there could be a fear of
lack of privacy or utter embarrassment
Redshaw and Heikkila (2010) identify key factors related
to women’s perception of control during labour, these are:
• continuity of care with carer
• one-to-one care in labour
• not being left for long periods
• being involved in decision-making.
Ongoing research to determine the relationship between
women’s perception of control during childbirth and post-
natal outcomes is needed in order to measure factors such
as postnatal depression, positive parenting relationships
and self-esteem. Common emotional responses during
labour are detailed in Box 25.2.
The puerperium
The puerperium is hailed as the ‘fourth trimester’ – an
emotionally complex transitional phase. By definition, it
is the period from birth to 6–8 weeks postpartum, when
the woman is readjusting physiologically, socially and psy-
chologically to motherhood. Emotional responses may be
just as intense and powerful for experienced as well as for
new mothers. The major psychological changes are there-
fore emotional. The woman’s mood appears to be a
barometer, reflecting the baby’s needs of feeding, sleeping
and crying patterns. New mothers tend to be easily upset
and oversensitive. A sense of proportion is easily lost, as
women may feel overwhelmed and agitated by minor
mishaps. The woman might start to regain a sense of pro-
portion and ‘normality’ between 6 and 12 weeks. Exhaus-
tion is also a major factor of women’s emotional state.
Perhaps the most important factor in regaining any sem-
blance of normality is the mother’s ability to sleep
throughout the night. A woman’s sexual urges, emotional
stability and intellectual acuity may take months, if not
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Box 25.3 Normal emotional changes during
the puerperium
• Immediately following birth, the woman might
experience relief. The woman might convey a cool
detachment from events, especially if labour was
protracted, complicated and difficult
• Contradictory and conflicting feelings ranging
from satisfaction, joy and elation to exhaustion,
helplessness, discontentment and disappointment as
the early weeks seem to be dominated by the novelty
and unpredictability of the new baby
• A feeling of closeness to partner or baby; equally the
woman may feel disinterested in the baby
• Early skin-to-skin contact and breastfeeding will help
to nurture the early stages of relationship building
between mother and baby
• Being very attentive towards the baby; equally the
woman may show disinterest in the baby
• Fear of the unknown and sudden realization of
overwhelming responsibility
• Exhaustion and increased emotionality
• Pain (e.g. perineal, in nipples)
• Increased vulnerability, indecisiveness (e.g. in feeding),
loss of libido, disturbed sleep and anxiety
longer, to return. Normal emotional changes in the puer-
perium are summarized in Box 25.3.
POSTNATAL ‘BLUES’
Childbirth is an emotionally intense experience. Mood
changes in the early days postpartum are particularly
common. The postnatal ‘blues’ is a transitory state, exper­
ienced by 50–80% of women depending on parity (Harris
et al 1994). It has been identified as an antecedent to
depression following childbirth (Gregoire 1995; Cooper
and Murray 1997). The onset typically occurs between day
3 and 5 postpartum, but may last up to 1 week or more,
though rarely persisting longer than 48 hours. The main
features are mild and may include:
• a state whereby the woman experiences labile
emotions (e.g. tearfulness, despair, irritability to
euphoria and laughter)
• a state whereby the woman feels overwhelmed by
the sudden realization of the relentless responsibility
of the baby’s 24-hour dependency and vulnerability.
The actual aetiology is unclear but hormonal influences
(e.g. changes in oestrogen, progesterone and prolactin
levels) seem to be implicated as the period of increased
emotionality appears to coincide with the production of
milk in the breasts. This state of heightened emotionality

is self-limiting and will resolve spontaneously, assisted by
support from loved ones. The midwife should be vigilant
during this time as persistent features could be indicative
of depressive illness.
DISTRESS OR DEPRESSION?
Repeated contact with women during pregnancy and puer-
perium afford a wealth of opportunity to explore feelings,
experience and emotions, and for midwives to provide
clear explanations to women about the differences between
distress – a normal reaction to major life events – and
depressive illness. However, midwives should be mindful
of over-reliance on the medical model to describe women’s
moods as such an approach may serve to pathologize or
medicalize normal emotional changes (Nicholson 1998).
Emotional distress associated with
traumatic birth events
Understanding the root cause and expression of mental
distress associated with pregnancy and childbirth is
complex. It is important to recognize the inter-relationship
between traumatic life events and women’s mental health.
Vulnerability factors such as a history of childhood sexual
abuse or a morbid fear of childbirth can negate a woman’s
experience of childbirth. What is intended to be one of the
happiest days in a woman’s life can quickly turn into
anguish and distress. Furthermore, environmental factors
may lead to a sense of loss of control, for example effects
of intense pain, use of technological interventions, insen-
sitive and disrespectful care or an emergency caesarean
section (CS) may prove very distressing and frightening.Post-
traumatic stress disorder (PTSD), a term most commonly
associated with individuals who have suffered the
onslaught of war, has emerged in the literature around
maternity care (Lyons 1998). Obstetric PTSD occurs when
women feared they or their baby were in danger of dying.
Not surprisingly it is commonest after emergency CS or
obstetric emergencies, particularly involving intensive
care. It is estimated 6% of emergency CS are followed by
obstetric PTSD (Beck 2009). Box 25.4 highlights some of
the reported symptoms of obstretric PTSD.
Unlike mild to moderate depression in the postpartum
period, which seems to have its roots in the biophysical
and psychosocial domains, obstetric distress after child-
birth appears to be directly linked to the stress, fear and
trauma of birth, yet its prevalence is unrecognized (Lyons
1998). Psychological interventions such as ‘debriefing’
have been suggested to manage immediate symptomatol-
ogy but there is no reliable evidence that it is a useful
intervention in reducing psychological morbidity (Alexan-
dra 1998; Wessely et al 2000; Bick et al 2009). Moreover,
clinical guidelines from NICE (2007) have stated that fol-
lowing a traumatic birth, women should not routinely be
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Box 25.4 Reported symptoms of obstretric
PTSD
Features of obstetric PTSD – applies where symptoms are
present for more than 1 month (Lyons 1998; Beck 2009)
• Intrusive thoughts or images resulting in nightmares,
panic attacks or ‘flashbacks’ about the birth
• Detachment from loved ones and difficulty with
mother–baby relationship (attachment)
• Avoidance especially of issues relating to pregnancy/
birth
• Hypervigilance/increased arousal – having a sense of
imminent disaster
• Sleep disturbances
• Irritability or angry outbursts
• Anxiety/depression
Other features are not dissimilar to those previously
discussed in the text relating to stress and anxiety.
Box 25.5 Summary of key points
• In the UK pregnancy and the postnatal period are
unparalleled periods when women engage with
health care and have repeated contact with healthcare
professionals
• Women during pregnancy, labour and puerperium are
in a state of transition punctuated by heightened
emotions and anxiety. Family life and daily routines
become disrupted by the arrival of a new baby
• Vulnerability factors such as domestic abuse, poverty
and social isolation, can impact on the mother–baby
relationship with consequences for child development
• Risk identification of vulnerable groups of women
antenatally presents a unique opportunity for
multidisciplinary and multi-agency collaboration in
promoting mental health and wellbeing
offered ‘single-session formal debriefing focused on the
birth’. Instead midwives and other healthcare profession-
als should support women who wish to talk about their
experience and draw on the love and support of family
and friends. Neither should midwives overlook the impact
of birth on the partner.
CONCLUSION
A plethora of significant social and health policies and
clinical guidelines have resulted in wider consideration
being given to the social and psychological context of
pregnancy and the puerperium. Midwives need to have
knowledge and understanding of how they influence care
provision. Box 25.5 provides a summary of key points.
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Section | 4 | Labour
Part B: Perinatal psychiatric
conditions
Margaret R Oates
INTRODUCTION
Perinatal psychiatric disorder is now an accepted term
used both nationally and internationally. It emphasizes
the importance of psychiatric disorder in pregnancy as
well as following childbirth and the variety of psychiatric
disorders that can occur at this time, not just the ubiqui-
tously known postnatal depression (PND). It also places
emphasis on the significance of psychiatric disorders that
were present before conception as well as those that arise
during the perinatal period (Box 25.6).
The emotional wellbeing of women is of primary
importance to midwives. Not only can mental illness
affect obstetric outcomes but also the transition to parent-
hood and emotional wellbeing and health problems in
the infant. Over the last 15 years psychiatric disorder in
pregnancy and the postpartum period has been a leading
cause of maternal mortality, as highlighted in the ‘Why
Mothers Die in the UK’ (Oates 2001, 2004) and ‘Saving
Mothers’ Lives’ (Oates 2007; Oates and Cantwell 2011)
reports. These reports of the Confidential Enquiry into
Maternal Deaths recommend that midwives routinely ask
at early pregnancy assessment about previous mental
health problems, their severity and care. These recommen-
dations have also been made by the Royal College of
Psychiatrists (RCPC 2000), the Women’s Mental Health
Strategy (part of the Mental Health National Service
Framework; DH 1999), Maternity Standard 11 of the Chil-
dren, Young Peoples and Maternity National Service
Framework (DH 2004), the NICE Guidelines (2007) on
Box 25.6 What is perinatal psychiatric disorder?
• Psychiatric disorders that complicate pregnancy,
childbirth and the postnatal period
• Includes not only those illnesses that develop at this
time but also pre-existing disorders such as
schizophrenia, bipolar illness and depression
• Care involves consideration of the effects of the illness
itself and of its treatment on the developing fetus and
infant
• Care involves multidisciplinary and multi-agency
working, especially close relationships with Maternity
Mental Health and Children’s Services
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the management of antenatal and postnatal mental health
and the Clinical Negligence Standards for Trusts (NHSLA
[National Health Service Litigation Authority] 2011). In
addition, NICE (2007) recommends that midwives should
ask questions (the Whooley questions) on at least two
occasions – antenatally and following birth – about
women’s current mental health. Systems should be in
place locally to ensure that women with mental health
problems and those at risk of developing them receive the
appropriate care.
It is therefore essential that all midwives have education
and training to be familiar with normal emotional
changes, commonplace distress and adjustment reactions
as well as the signs and symptoms of more serious psychi-
atric illnesses.
TYPES OF PSYCHIATRIC DISORDER
The term ‘mental health problem’ is commonly used to
describe all types of emotional difficulties from transient
and temporary states of distress, often understandable, to
severe and uncommon mental illness. It is also used fre-
quently to describe learning difficulties, substance misuse
problems and difficulties coping with the stresses and
strains of life. It is therefore too general and too non-
specific to be of use to the midwife. The term does not
discriminate between severity and need and does not help
the midwife distinguish between those conditions that she
can manage and those that require specialist attention. For
this reason, in this chapter, the term ‘psychiatric disorder’
is preferred as it can be further categorized and the differ-
ent types can be described aiding recognition and the
planning of care.
Psychiatric disorders are conventionally categorized
into:
Serious mental illnesses
These include schizophrenia, other psychotic conditions,
bipolar illness and severe depressive illness. Previously,
these conditions were called psychotic disorders.
Mild to moderate psychiatric disorders
These were previously known as ‘neurotic disorders’. These
include non-psychotic mild to moderate depressive illness,
mixed anxiety and depression, anxiety disorders including
phobic anxiety states, panic disorder, obsessive–compulsive
disorder and post-traumatic stress disorder.
Adjustment reactions
These would include distressing reactions to life events,
including death and adversity.

Substance misuse
This includes those who misuse or who are dependent
upon alcohol and other drugs of dependency, including
both prescription and legal/illegal drugs.
Personality disorders
This is a term that should be used only to describe people
who have persistent severe problems throughout their
adult life in dealing with the stresses and strains of normal
life, maintaining satisfactory relationships, controlling
their behaviour, foreseeing the consequences of their own
actions and which persistently cause distress to themselves
and other people.
Learning disability
This is a term used to describe people who have a lifetime
evidence of intellectual and cognitive impairment, devel-
opmental delay and consequent learning disabilities. This
is usually graded as mild, moderate or severe.
Overall psychiatric disorders are very common in the
general population. The General Household Survey 2000,
as reported by the Office of National Statistics (ONS
2002), reveals a prevalence of over 20% of these disorders.
Recent figures from ONS (2012) have shown little change
in this trend in the adult population in the UK, reporting
that in 2007, approximately 1 : 6 adults had a common
mental disorder such as anxiety or depression.
They are commoner in women than in men with the
exception of substance misuse problems. However, the
majority of psychiatric disorders in the community are
mild to moderate conditions, particularly general anxiety
and depression. Mild to moderate depressive illness and
anxiety disorders are at least twice as common in women
than in men, and are particularly common in young
women with children under the age of 5. The majority
of these disorders are managed in primary care and do
not require the attention of specialist psychiatric services.
Mild to moderate depressive illness and anxiety states
respond to psychological treatments. Despite this, perhaps
because of shortage of such treatments, prescription of
antidepressants is widespread in the community, particu-
larly among women.
Serious mental illnesses are less common. Both schizo-
phrenia and bipolar illness affect approximately 1% of the
population. Bipolar illness affects men and women
equally. However, schizophrenia, particularly the more
severe chronic forms, is commoner among men. These
conditions require the attention of specialist psychiatric
services and require medical treatments as well as psycho-
logical care.
In the UK psychiatric services are usually organized
separately for adult mental health (serious mental ill-
nesses), substance misuse (drug and alcohol treatment
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Perinatal mental health Chapter | 25 |
services) and learning disability. There are also, but not
relevant to this chapter, separate services for psychiatric
disorders in the elderly.
PSYCHIATRIC DISORDER IN
PREGNANCY
In general, psychiatric disorder is not associated with a
decrease in fertility. Therefore all the previously described
psychiatric disorders can and do complicate pregnancy
and the postpartum period. The prevalence of psychiatric
disorder in young women means that at least 20% of
women will have current or previous psychiatric disorder
in early pregnancy, many of whom will be taking psychi-
atric medication at the time of conception. However, it
can be seen that only a small number will have a past
history of a serious mental illness and an even smaller
number will be currently suffering from such an illness.
Pregnancy is not protective against a recurrence or relapse
of a previous psychiatric disorder, particularly if the medi-
cation for these disorders is stopped when pregnancy is
diagnosed. Women with a previous history of serious
illness are at increased risk of a recurrence of that illness
following birth. It is for these reasons that it is so impor-
tant for midwives to enquire into women’s current and
previous mental health at early pregnancy assessment.
Table 25.1 highlights the incidence of perinatal psychi­
atric disorders.
Mild–moderate conditions
The incidence (new onset) of psychiatric disorder in preg-
nancy is mostly accounted for by mild depressive illness,
mixed anxiety and depression or anxiety states. These dis-
orders present most commonly in the early weeks of preg-
nancy, becoming less common as the pregnancy progresses.
Table 25.1 Incidence of perinatal psychiatric
disorders
Psychiatric disorder (%)
’Depression’ 15–30
PND (postnatal depression) 10
Moderate/severe depressive illness 3–5
Referred psychiatry 2
Admitted to hospital 0.4
Admitted psychosis 0.2
Births to schizophrenic mothers 0.2
539
Section | 4 | Labour
They are probably predominantly of psychosocial aetiol-
ogy, and for some women they will represent a recurrence
of a previous episode, of depression, anxiety, panic or
obsessional disorders particularly if they have suddenly
stopped their antidepressant medication. Women may
also be vulnerable at this time because of:
• previous fertility problems
• previous obstetric loss
• anxieties about the viability of their pregnancy
• social and relationship problems
• ambivalence towards the pregnancy
• other reasons for personal unhappiness.
In the past, it was often assumed that hyperemesis
gravidarum (severe vomiting) was a psychosomatic mani-
festation of personal unhappiness and psychological dis-
turbance. This condition is less common than in the past
and usually resolves by 16 weeks of pregnancy. Psychologi-
cal factors, anxiety and cognitive misattribution remain a
significant factor in some women.
Prognosis and management
Most of the conditions are likely to improve as the preg-
nancy progresses. Psychological treatments and psycho­
social interventions are effective for these conditions and
caution needs to be exercised before pharmacological
interventions are initiated during pregnancy, although
medication may be necessary for the more severe
illnesses.
For others, particularly those who develop a psychiatric
illness in the later stages of pregnancy, their condition
is likely to continue and worsen in the postpartum
period.
Serious conditions
This term refers to schizophrenia, other psychoses,
bipolar illness (manic depressive illness) and severe
depressive illness.
Incidence
Women are at a lower risk of developing a serious mental
illness for the first time during pregnancy than at other
times in their lives. This is in marked contrast to the ele-
vated risk of suffering from such a condition in the first
few months following childbirth (Kendell et al 1987).
While these conditions are uncommon, they require
urgent and expert treatment, particularly as an acute psy-
chosis in pregnancy can pose a risk to the mother and
developing fetus, both directly because of the disturbed
behaviour and indirectly because of the treatments. There
is a possibility that such an illness can interfere with
proper antenatal care.
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Prevalence
While new onset psychosis in pregnancy is relatively rare,
the prevalence of these illnesses (pre-existing) at the begin-
ning of pregnancy will be the same as at other times.
Women suffering from schizophrenia or bipolar illness are
as likely to become pregnant as the rest of the general
population. This means that approximately 2% of women
in pregnancy will either have had such an illness in the
past or be currently suffering from one. It is important to
realize that these women may range from women who are
well and stable, leading normal lives through to those who
are disabled, chronically symptomatic and on medication.
The management of these women in pregnancy therefore
has to be individualized and plans made on a case-by-case
basis. Nonetheless, there are three broad groups of women.
Group 1
The first group includes women who have had a previous
episode of bipolar illness or a psychotic episode earlier in
their lives. They are usually well, stable not on medication
and may not be in contact with psychiatric services. These
women, if their last episode of illness was more than 2
years ago, may not be at an increased risk of a recurrence
of their condition during pregnancy but face at least a 50%
risk of becoming psychotic in the early weeks postpartum.
The most important aspect of their management is there-
fore a proactive management plan for the first few weeks
following birth.
Group 2
The second broad group of women are those who have
had a previous and/or recent episode of a serious mental
illness, who are relatively well and stable but whose health
is being maintained by taking medication. This may be
antipsychotic medication or in the case of bipolar illness,
a mood stabilizer (lithium or an anticonvulsant). These
women are at risk of a relapse of their condition during
pregnancy. This risk is particularly high if they stop their
medication at the diagnosis of pregnancy. As some of these
medications may have an adverse effect on the develop-
ment of the fetus and yet an acute relapse of the illness
also is hazardous, it is important that these women have
access to expert advice on the risks and benefits of continu-
ing the treatment or changing it as early as possible in
pregnancy.
Group 3
The third broad category includes women who are chroni-
cally mentally ill with complex social needs, persisting
symptoms and on medication. These women will usually
be in contact with psychiatric services. Midwifery and
obstetric care needs to be closely integrated into the case
management of these women and there needs to be a close
working relationship between maternity, psychiatric and
social services.

Ideally, all women who have a current or previous
history of serious mental illness should have advice and
counselling before embarking upon a pregnancy. They
should be able to discuss the risk to their mental health
of becoming pregnant and becoming a parent as well as
the risks to the developing fetus of continuing with their
usual medication and perhaps the need to change it.
However, in the general population, at least 50% of all
pregnancies are unplanned at the point of conception.
Midwives should therefore enquire at early pregnancy
assessment about the women’s previous and current psy-
chiatric history and alert psychiatric services as soon as
possible about the pregnancy so that relapses of the psy-
chiatric illness during pregnancy and recurrences postpar-
tum can be avoided wherever possible.
PSYCHIATRIC DISORDER
AFTER BIRTH
The majority of postpartum onset psychiatric disorders are
affective (mood) disorders. However, symptoms other
than those due to a disorder of mood are frequently
present. Conventionally three postpartum disorders are
described:
• the ‘blues’
• puerperal (postpartum) psychosis
• postnatal depression.
The ‘blues’ is a common dysphoric, self-limiting state,
occurring in the first week postpartum (see Part A).
Puerperal (postpartum) psychosis
Globally, puerperal psychosis, the most severe form of
postpartum affective (mood) disorder has been recog-
nized and described since antiquity. It leads to 2 in 1000
women being admitted to a psychiatric hospital following
childbirth, mostly in the first few weeks postpartum.
Although a relatively rare condition, there is a marked
increase in the risk of suffering from a psychotic illness
following childbirth (Kendell et al 1987; Munk-Olsen
et al 2012). It is also remarkably constant across nations
and cultures.
Risk factors
Most women who suffer from this condition will have
been previously well, without obvious risk factors, and the
illness comes as a shock to them and their families.
However, some women will have suffered from a similar
illness following the birth of a previous child, some may
have suffered from a non-postpartum bipolar affective dis-
order from which they have long recovered or they may
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Perinatal mental health Chapter | 25 |
have a family history of bipolar illness. For others there
may be marked psychosocial adversity. It is generally
accepted that biological factors (neuroendocrine and
genetic) are the most important aetiological factors for this
condition. This implies that puerperal psychosis can and
does strike without warning, women from all social and
occupational backgrounds – those in stable marriages
with much-wanted babies as well as those living in less
fortunate circumstances.
Clinical features
Puerperal psychosis is an acute, early onset condition. The
overwhelming majority of cases present in the first 14 days
postpartum. They most commonly develop suddenly
between day 3 and day 7, at a time when most women
will be experiencing the ‘blues’. Differential diagnosis
between the earliest phase of a developing psychosis and
the ‘blues’ can be difficult. However, puerperal psychosis
steadily deteriorates over the following 48 hours while the
‘blues’ tends to resolve spontaneously.
During the first 2–3 days of a developing puerperal
psychosis there is a fluctuating rapidly changing, undif-
ferentiated psychotic state. The earliest signs are com-
monly of perplexity, fear – even terror – and restless
agitation associated with insomnia. Other signs include:
purposeless activity, uncharacteristic behaviour, disinhibi-
tion, irritation and fleeting anger, and resistive behaviour
and sometimes incontinence.
A woman may have fears for her own and her baby’s
health and safety, or even about its identity. Even at this
early stage, there may be, variably throughout the day,
elation and grandiosity, suspiciousness, depression or
unspeakable ideas of horror.
Women suffering from puerperal psychosis are among
the most profoundly disturbed and distressed found in
psychiatric practice (Dean and Kendell 1981). In addition
to the familiar symptoms and signs of a manic or depres-
sive psychosis, symptoms of schizophrenia (delusions and
hallucinations) may occur. Depressive delusions about
maternal and infant health are common. The behaviour
and motives of others are frequently misinterpreted in a
delusional fashion. A mood of perplexity and terror is
often found, as are delusions about the passage of time
and other bizarre delusions. Women can believe that they
are still pregnant or that more than one child has been
born or that the baby is older than it is.
Women often seem confused and disorientated. In the
very common mixed affective psychosis, along with the
familiar pressure of speech and flight of ideas, there is
often a mixture of grandiosity, elation and certain convic-
tion alternating with states of fearful tearfulness, guilt and
a sense of foreboding. The sufferers are usually restless and
agitated, resistive, seeking senselessly to escape and diffi-
cult to reassure. However, they are usually calmer in the
presence of familiar relatives.
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Section | 4 | Labour
The woman may be unable to attend to her own per-
sonal hygiene and nutrition and unable to care for her
baby. Her concentration is usually grossly impaired and
she is distractible and unable to initiate and complete
tasks. Over the next few days her condition deteriorates
and the symptoms usually become more clearly those of
an acute affective psychosis. Most women will have symp-
toms and signs suggestive of a depressive psychosis, a
significant minority a manic psychosis and very com-
monly a mixture of both – a mixed affective psychosis.
Relationship with the baby
Some women are so disturbed, distractible and their con-
centration so impaired that they do not seem to be aware
of their recently born baby. Others are preoccupied with
the baby, reluctant to let it out of their sight and forever
checking on its presence and condition. Although delu-
sional ideas frequently involve the baby and there may be
delusional ideas of infant ill health or changed identity, it
is rare for women with puerperal psychosis to be overtly
hostile to their baby and for their behaviour to be aggres-
sive or punitive. The risk to their baby lies more from an
inability to organize and complete tasks, and to inappro-
priate handling and tasks being impaired by their mental
state. These problems, directly attributable to the maternal
psychosis, tend to resolve as the mother recovers.
Management
Most women with psychotic illness following childbirth
will require admission to hospital, which should be to a
specialist mother and baby unit, the only setting in which
the physical needs of the mother who has recently given
birth can be met and where specialist psychiatric nursing
is available. This ensures that the physical and emotional
needs of both mother and baby are met and the develop-
ing relationship with the baby promoted.
Prognosis
In spite of the severity of puerperal psychoses, they fre-
quently resolve relatively quickly over 2–4 weeks. However,
initial recovery is often fragile and relapses are common
in the first few weeks. As the psychosis resolves, it is
common for women to pass through a phase of depres-
sion and anxiety and preoccupation with their past experi-
ences and the implications of these memories for their
future mental health and their role as a mother. Sensitive
and expert help is required to assist women through this
phase, to help them understand what has happened and
to acquire a ‘working model’ of their illness. The over-
whelming majority of women will have completely recov-
ered by 3–6 months postpartum. However, they face at
least a 50% risk of a recurrence should they have another
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child and some may go on to have bipolar illness at other
times in their lives (Robertson et al 2005).
Postnatal depressive illness
Approximately 10% of all postnatal women will develop
a depressive illness. The studies, from which this figure is
derived, are usually community studies using the Edin-
burgh Postnatal Depression Scale (EPDS) either as a diag-
nostic tool or as a screen prior to the use of other research
tools. Studies using a cut-off point of 14 usually give an
incidence of 10%; those using lower scores will give a
higher incidence. A score on a screening instrument is not
the same as a clinical diagnosis. Nonetheless a score of 14
is said to correlate with a clinical diagnosis of major
depression and the lower scores with that of major and
minor depression (Elliot 1994). The incidence of women
who would meet the diagnostic criteria for moderate to
severe depressive illness is lower, probably between 3%
and 5% (Cox et al 1993). Depression following childbirth
has the same range of severity and subtypes as depression
at other times. According to the symptomatology, duration
and severity, they may be graded as mild to moderate or
severe, and subtypes may have prominent anxiety and
obsessional phenomena.
Postnatal depressive illness of all types and severities is
therefore relatively common and represents a considerable
burden of disability and distress in these women. Although
postnatal depressive illness is popularly accepted, with the
exception of the most severe forms, it is no more common
than during pregnancy or in non-childbearing women of
the same age (O’Hara and Swain 1996). However, this
does not detract from its importance. Depressive illness of
any severity occurring at a time when the expectation is of
happiness and fulfillment and when major psychological
and social adjustments are being made together with
caring for an infant, creates difficulties not found at other
times in the human lifespan.
The term ‘postnatal depression’ is often used as a generic
term for all forms of psychiatric disorder presenting fol-
lowing birth. While in the past this has undoubtedly been
helpful in raising the profile of postpartum psychiatric
disorders, improving their recognition and reducing
stigma, it has also become problematic. Use of the term
in this way can diminish the perceived seriousness of other
illnesses, and has led to a ‘one size fits all’ view of diag­
nosis and treatments (Oates 2001). The term postnatal
depression should only be used for a non-psychotic
depressive illness of mild to moderate severity which arises
within 3 months of childbirth.
Severe depressive illness
Severe depressive illness affects at least 3% of all women
who have given birth, with a seven-fold increase in risk in
the first 3 months (Cox et al 1993). Again, the majority of

women who suffer from this condition will have been
previously well. However, women with a previous history
of severe postnatal depressive illness or severe depression
at other times or a family history of severe depressive
illness or postnatal depression are at increased risk. Psy-
chosocial factors are more important in the aetiology of
this condition than in puerperal psychosis, although bio-
logical factors play an important role in the most severe
illnesses. Nonetheless, severe postnatal depression can
affect women from all backgrounds not just those facing
social adversity.
Like puerperal psychosis, severe depressive illness is an
early onset condition in which the woman commonly
does not regain her normal emotional state following
birth. However, unlike puerperal psychosis, the onset
tends not to be abrupt; rather, the illness develops over the
next 2–4 weeks. The more severe illnesses tend to present
early, by 4–6 weeks postpartum, but the majority present
later, between 8 and 12 weeks postpartum. These later
presentations may be missed. This is partly because some
of the symptoms may be misattributed to the adjustment
to a new baby and partly because the mother may ‘put on
a brave face’, concealing how she feels from others.
Risk factors
A variety of risk factors for postnatal depressive illness
have been identified and include those associated with
depressive illness at other times. To these can be added
ambivalence about the pregnancy, high levels of anxiety
during pregnancy and adverse birth experiences, previous
perinatal death to name but a few. Many of these risk
factors, though statistically significant are so common as
to have little positive predictive value. However a cluster-
ing of these risk factors might lead to those caring for the
woman to be extra vigilant. Of more use are those risk
factors that have a higher positive predictive value. These
include a family history of severe affective disorder, a
family history of severe postnatal depressive illness, devel-
oping a depressive illness in the last trimester of pregnancy
and the loss of the previous infant (including stillbirth).
There may also be an increased risk in those women who
have conceived through IVF.
Clinical features
The familiar symptoms of severe depressive illness are
often modified by the context of early maternity and the
relative youth of those suffering from the condition:
The ‘somatic syndrome’ (biological features) of broken
sleep and early morning wakening, diurnal variation of
mood, loss of appetite and weight, slowing of mental
functioning, impaired concentration, extreme tiredness
and lack of vitality can easily be misattributed to a crying
baby, understandable tiredness and the adjustment to new
routines.
The all-pervasive anhedonia or loss of pleasure in ordinary
everyday tasks, the lack of joy and fearfulness for the future
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Perinatal mental health Chapter | 25 |
may be misattributed by the woman herself to ‘not loving
the baby’ or ‘not being a proper mother’ and all too easily
described as ‘bonding problems’ by professionals. Anhe-
donia is a particularly painful symptom at a time when
most women would expect to feel overwhelmed with joy
and happiness and in turn contributes to feelings of guilt,
incompetence and unworthiness that are very prominent in
postnatal depressive illness. These overvalued ideas can
verge on the delusional.
It is also common to find overvalued morbid beliefs and
fears for the woman’s own health and mortality and that
of her baby. She may misattribute normal infant behav-
iour to mean that the baby is suffering or does not like
her. A baby that settles in the arms of more experienced
people may confirm the mother’s belief that she is
incompetent. Commonplace problems with establishing
breastfeeding may become the subject of morbid
rumination.
Some women with severe postnatal depressive illness
may be slowed, withdrawn and retreat easily in the face of
offers of help, avoid the tasks of motherhood and their
relationship with the baby. Others may be agitated, restless
and fiercely protective of their infant, resenting the contri-
bution of others.
Anxiety and obsessive–compulsive symptoms
Although women with pre-existing anxiety and panic dis-
order or obsessional–compulsive disorder (OCD) fre-
quently experience relapses or recurrences postpartum, it
is not known whether there is an increase in incidence
(new onset) of these conditions following birth. Nonethe-
less, severe anxiety, panic attacks and obsessional phe-
nomena are common following birth. These symptoms
may dominate the clinical picture or accompany a post­
natal depressive illness. They frequently underpin mental
health crises, calls for emergency attention and maternal
fears for the infant. Repetitive intrusive, and often deeply
repugnant, thoughts of harm coming to loved ones, par-
ticularly the infant, are commonplace, often leading to
repetitive doubting and checking. The woman may doubt
that she is safe as a mother and believe that she is capable
of harming her infant. Crescendos of anxiety and panic
attacks may result from the baby’s crying or being difficult
to settle and may lead the mother to be frightened to be
alone with her child. This is easily misinterpreted by pro-
fessionals who may fear that the child is at risk.
Obsessional, vacillating indecisiveness is also common
and contributes to an overwhelming sense of being unable
to cope with everyday tasks in marked contrast to premor-
bid levels of competence. While complex obsessive–
compulsive behavioural rituals are relatively rare, obsessive
cleaning, housework and checking are common. Intrusive
obsessional thoughts and the typical catastrophic cogni-
tions associated with panic attacks frequently lead to a fear
of insanity and loss of control.
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Relationship with the baby
Severe depressive symptomatology, particularly when
combined with panic and obsessional phenomena, can
have a profound effect on the relationship with the baby,
in many, but by no means all women. Most women who
suffer from severe postnatal depressive illness maintain
high standards of physical care for their infants. However,
many are frightened of their own feelings and thoughts
and few gain any pleasure or joy from their infant. They
may find smiling and talking to their babies difficult. Most
affected women feel a deep sense of guilt and incompe-
tence and doubt whether they are caring for their infant
properly. Normal infant behaviour is frequently misinter-
preted as confirming their poor views of their own abili-
ties. While a fear of harming the baby is commonplace,
overt hostility and aggressive behaviour towards the infant
is extremely uncommon. It should be remembered that
the majority of mothers who harm small babies are not
suffering from a serious mental illness. The speedy resolu-
tion of maternal illness usually results in a normal
mother–infant relationship. However, prolonged chronic
depressive illness can interfere with attachment, social and
cognitive development in the longer term, particularly
when combined with social and mental problems (Cooper
and Murray 1997).
Management
These conditions need to be speedily identified and
treated, preferably by a specialist perinatal mental health
team. The value of early contact with professionals who
recognize and validate the symptoms and distress, and
can re-attribute the overvalued ideas of the mother and
instill hope for the future cannot be underestimated.
The treatment of the depressive illness is the same as the
treatment of depressive illness at other times. The use of
antidepressants together with good psychological care
should result in an improvement of symptoms within
2 weeks and the resolution of the illness between 6 and
8 weeks.
Prognosis
With treatment, these women should fully recover.
Without, spontaneous resolution may take many months
and up to one-third of women can still be ill when their
child is 1 year old.
Women who have had a severe depressive illness face a
1 : 2 to 1 : 3 risk of a recurrence of the illness following the
birth of subsequent children (Cooper and Murray 1995).
They are also at elevated risk from suffering from a depres-
sive illness at other times in their lives. However, the long-
term prognosis would appear to be better than when the
first episode is in non-childbearing women, both in terms
of the frequency of further episodes and in their overall
functioning (Robling et al 2000).
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Mild postnatal depressive illness
This is the commonest condition following childbirth,
affecting up to 10% of all women postpartum. It is in fact
no commoner after childbirth than among other non-
childbearing women of the same age.
Risk factors
Some women who suffer from this condition will be vul-
nerable by virtue of previous mental health problems or
psychosocial adversity, unsatisfactory marital or other rela-
tionships or inadequate social support. Others may be
older, educated and married for a long time, perhaps with
problems conceiving, previous obstetric loss or high levels
of anxiety during pregnancy. Unrealistically high expecta-
tions of themselves and motherhood and consequent dis-
appointment are commonplace. Also common are stressful
life events such as moving house, family bereavement, a
sick baby, experience of special care baby units and other
such events that detract from the expected pleasure and
harmony of this stage of life.
Clinical features
The condition has an insidious onset in the days and
weeks following childbirth but usually presents after the
first 3 months postpartum. The symptoms are variable, but
the mother is usually tearful, feels that she has difficulty
coping and complains of irritability and a lack of satisfac-
tion and pleasure with motherhood. Symptoms of anxiety,
a sense of loneliness and isolation as well as dissatisfaction
with the quality of important relationships are common.
Affected mothers frequently have good days and bad days
and are often better in company and anxious when alone.
The full biological (somatic subtype) syndrome of the
more severe depressive illness is usually absent. However,
difficulty getting to sleep and appetite difficulties, both
over-eating and under-eating, are common.
Relationship with the baby
Dissatisfaction with motherhood and a sense of the baby
being problematic are often central to this condition, par-
ticularly when compounded by difficulty in meeting the
needs of older children. Lack of pleasure in the baby,
combined with anxiety and irritability, can lead to a
vicious circle of a fractious and unsettled baby, misinter-
preted by its mother as critical and resentful of her and
thus a deteriorating relationship between them. However,
it should also be remembered that the direction of causal-
ity is not always mother to infant. Some infants are very
unsettled in the first few months of their life. A baby who
is difficult to feed and cries constantly during the day or
is difficult to settle at night can just as often be the cause
of a mild postnatal depressive illness as the result of it.
Even mild illnesses, particularly when combined with
socioeconomic deprivation and high levels of social adver-
sity, can lead to longer-term problems with mother–infant

relationships and subsequent social and cognitive devel-
opment of the child (Cooper and Murray 1997). A very
small minority of sufferers from this condition may exper­
ience such marked irritability and even overt hostility
towards their baby that the infant is at risk of being
harmed.
Management
Early detection and treatment is essential for both mother
and baby. For the milder cases, a combination of psycho-
logical and social support and active listening from a
health visitor will suffice. For others, specific psychological
treatments, such as cognitive behavioural psychotherapy
and interpersonal psychotherapy, are as effective, if not
more than, antidepressants as outlined in Antenatal and
Postnatal Mental Health guidelines (NICE 2007).
Prognosis
With appropriate management, postnatal depression
should improve within weeks and recover by the time the
infant is 6 months old. However, untreated there may be
prolonged morbidity. This, particularly in the presence of
continuing social adversity, has been demonstrated to
have an adverse effect not only on the mother–infant rela-
tionship but also on the later social, emotional and cogni-
tive development of the child.
Breastfeeding
There is no evidence that breastfeeding increases the risk
of developing significant depressive illness, nor that its
cessation improves depressive illness. Continuing breast-
feeding may protect the infant from the effects of maternal
depression and improve maternal self-esteem.
TREATMENT OF PERINATAL
PSYCHIATRIC DISORDERS
The role of the midwife
Midwives need knowledge and understanding of the dif-
ferent management strategies for perinatal psychiatric dis-
order and of the use of psychiatric drugs in pregnancy and
lactation. This knowledge is required because the women
themselves may wish for advice, because the midwife may
have to alert other professionals, for example general prac-
titioners and psychiatrists, to ask for a review of the
woman’s medication and because in case of serious mental
illness, the midwife will be part of a multiprofessional
team caring for the women.
Midwives should routinely ask all women at antenatal
booking clinic whether they have had an episode of
serious mental illness in the past and whether they are
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Perinatal mental health Chapter | 25 |
currently in contact with psychiatric services. Those women
who have a previous episode of serious mental illness
(schizophrenia, other psychoses, bipolar illness and severe
depressive illness) should be referred to a psychiatric team
during pregnancy even if they have been well for many
years. This is because they face at least a 50% risk of
becoming ill following birth. The midwife should also
urgently inform the psychiatric team if the woman is cur-
rently in contact with psychiatric services. The psychiatric
team may not be aware of the pregnant woman who is
taking psychiatric medication at the time when the
midwife first sees her should be advised not to abruptly
stop her medication. The midwife should urgently seek a
review of the woman’s medication from the general prac-
titioner, obstetrician or psychiatrist as appropriate. This
may result in the woman being advised to reduce, change
or undertake a supervised withdrawal of her medication.
There are three components to the management of peri-
natal psychiatric disorder: psychological treatments and
social interventions, pharmacological treatments and the
skills, resources and services needed.
Those who are seriously mentally ill will require all
three. Those with the mildest illnesses may require only
psychological and social interventions, which can be
carried out in primary care (NICE 2007).
Psychological treatments
All illnesses of all severities and indeed those who are not
ill but experiencing commonplace episodes of distress and
adjustment need good psychological care. This can only
be based upon an understanding of the normal emotional
and cognitive changes and common concerns of preg-
nancy and the puerperium. It also requires a familiarity
with the symptoms and clinical features of postpartum
illnesses.
For most women with mild depressive illness or emo-
tional distress and difficulties adjusting, extra time given
by the midwife or health visitor, ‘the listening visit’, will
be effective. For others, particularly those with more per-
sistent states associated with high levels of anxiety, brief
cognitive therapy treatments and brief interpersonal psy-
chotherapy are as effective as antidepressants and may
confer additional benefits in terms of improving the
mother–infant relationships and satisfaction. Similar
claims have been made for infant massage and other thera-
pies that focus the mother’s attention on enjoying her
baby. It is particularly important during pregnancy to use
psychological treatments wherever possible and avoid the
unnecessary prescription of antidepressants.
Social support
Lack of social support, particularly when combined with
adversity and life events, has long been implicated in the
aetiology of mild to moderate depressive illness in young
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Section | 4 | Labour
women. Social support not only includes practical assist-
ance and advice but also having an emotional confidante,
female friends and people who improve self-esteem. There
is evidence that organizations that are underpinned by
social support theory, such as Home Start and Sure Start,
can have a beneficial effect on maternal and infant well­
being and perhaps on mild postnatal depression (Oakley
et al 1996; Barlow et al 2007).
Pharmacological treatment
In general, psychiatric illnesses occurring during the peri-
natal period respond to the same treatments as at other
times. There are no specific treatments for perinatal psy-
chiatric disorder. Moderate to severe depressive illnesses
respond to antidepressants, psychotic illnesses to antipsy-
chotics and mood stabilizers may be needed for those with
bipolar illnesses. However, the possibility of adverse con-
sequences on the embryo and developing fetus and via
breastmilk on the infant makes the choice and dose of the
drug important.
The evidence base for the safety or adverse consequences
of psychotropic medication is constantly changing both in
the direction of increased concern and of reassurance. Any
text detailing specific advice is in danger of being quickly
out of date and the reader is directed to the regularly
updated information published by the National Teratol-
ogy Information Service (NTIS) – via Toxbase website:
www.toxbase.org/ – and to NICE (2007) Guidelines on
Antenatal and Postnatal Mental Health or Drugs and
Lactation Database (LactMed).
No matter what the changing evidence is, some general
principles apply:
• The absence of evidence of harm is not the same as
evidence of safety.
• It may take 20–30 years after the introduction of a
drug for its adverse consequences to be fully realized.
An example of this is sodium valproate in pregnancy.
• In general there is more evidence on older than on
newer drugs although this does not necessarily mean
they are safer.
• All psychotropic medication passes across the
placenta and into the breastmilk.
• Both the architecture and function of the fetal
central nervous system continues to develop
throughout pregnancy and in early infancy. Concern
should not be confined to the adverse effects in the
first 3 months of pregnancy.
• The threshold for initiating medication in pregnancy
and breastfeeding should be high. If there is an
alternative, non-pharmacological treatment, of equal
efficacy then that should be the treatment of choice.
• Serious mental illness requires robust treatment. In
all cases of illness, occurring in a pregnant or
breastfeeding mother, the clinician must endeavour
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to balance the risk of not treating the mother on
both mother and baby against the risk to the fetus or
infant of treating the mother. The more serious the
illness is, the more likely it is that the risks of not
treating outweigh the risks of treating.
• The risks to both mother and baby of a serious
maternal mental illness are greater than the risks of
medication.
• The fetus and baby is no less likely to suffer from the
side-effects of psychotropic medication than an
adult. Fetal and infant elimination of psychotropic
medication is slower and less than adults and their
central nervous systems more sensitive to the effects
of these drugs.
• Adverse consequences of medication on the fetus
and infant are dose-related. If medication is used it
should be used in the lowest effective dose and given
in divided dosage throughout the day.
• The exposure of the baby to psychotropic medication
in breastmilk will depend on the volume of milk,
the frequency of feeding, weight and age. A totally
breastfed baby under 6 weeks old will receive
relatively more psychotropic medication than an
older baby who is partially weaned.
Antidepressants
Tricyclic antidepressants
Pregnancy
Tricyclic antidepressants (e.g. imipramine, lofepramine,
amitriptyline and dosulepin) have been in use for 40
years. Tricyclic antidepressants are not associated with an
increased risk of fetal abnormality, early pregnancy loss or
growth restriction when used in later pregnancy. However
clomipramine (Anaframil) has been linked to cardiac
abnormalities. Newborn babies of mothers who were
receiving a therapeutic dose of tricyclic antidepressants at
the point of birth are at risk of suffering from withdrawal
effects (jitteriness, poor feeding and on occasion fits).
Consideration should therefore be given to a gradual
tapering and reduction of the dose prior to birth.
Breastfeeding
The excretion of tricyclic antidepressants in breastmilk is
very low. However doxepin should not be used because it
has been reported to cause sedation in babies. Any adverse
effects in the fully breastfed newborn baby can be mini-
mized by dividing the dose, e.g. 50 mg of imipramine
t.d.s.
Selective serotonin reuptake inhibitors
Pregnancy
Selective serotonin reuptake inhibitors (SSRIs) (e.g. fluox-
etine, paroxetine, citalopram) have been in use for

approximately 15 years and are now the antidepressants
most used in the treatment of depressive illness at
other times.
There has been some concern about the possible
adverse effects of certain SSRIs in early pregnancy. The
evidence continues to emerge and the risks are therefore
difficult to quantify. There may be an increased risk of
miscarriage associated with the use of all SSRIs. It is likely
that there is an increased risk of cardiac abnormalities
related to first trimester exposure to SSRIs, particularly
ventricular septal defects (VSD) with paroxetine (Seroxat).
This has led to both the manufacturer and the drug regu-
lation authorities in the USA and the UK advising against
the use of paroxetine in pregnancy. At the moment, this
restriction does not apply to fluoxetine (Prozac) and ser-
traline (Lustral) but it remains to be seen whether this
adverse effect is related to all SSRI medications. The NICE
(2007) guidelines recommend that either tricyclic antide-
pressants or sertraline should be the treatment of choice
if antidepressants are required during pregnancy. They
also recommend that antidepressants should not be used
for mild to moderate illness and that psychological treat-
ments should be used wherever possible. However, the
withdrawal of SSRI antidepressants in early pregnancy,
particularly if the woman has been receiving them for
some time, is often associated with a withdrawal syn-
drome or the recurrence of her condition. In such circum-
stances, consideration should be given to changing the
woman to a ‘safer’ alternative or reducing the dose and
supervised withdrawal.
Continued use of SSRI medication during pregnancy
has been associated with pre-term birth, reduced crown–
rump measurement and lower birth weight. Babies born
to mothers receiving SSRI medication at the point of birth
are likely to experience withdrawal effects, particularly
those babies who are preterm. SSRIs, such as citalopram
and fluoxetine that have a long half-life, are also associated
with a serotonergic syndrome in the newborn (jitteriness,
poor feeding, hypoglycaemia and sleeplessness). Consid-
eration should therefore be given to reducing and with-
drawing this medication before birth.
Breastfeeding
The excretion of SSRIs in breastmilk is higher than that
of tricyclic antidepressants. The fully breastfed newborn
may be vulnerable to serotonergic side-effects. Those
SSRIs with a long half-life (fluoxetine and citalopram)
should be avoided when breastfeeding the newborn. Ven-
lafaxine and paroxetine are not recommended for use in
breastfeeding mothers. However, in older and larger-
weight infants, particularly those who are partially
weaned, other SSRIs, particularly sertraline, may be less
problematic.
Tricyclic antidepressants or sertraline should be the anti-
depressants of choice in breastfeeding.
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Antipsychotics
There are two groups of antipsychotic medications, the
older ‘typical’ antipsychotics (e.g. trifluoperazine, haloperi-
dol, chlorpromazine) and the newer atypical antipsychotics
(e.g. risperidone, olanzapine, clozapine).
Typical antipsychotics
Pregnancy
Typical antipsychotics have been in use for 40 years. There
is no evidence that their use in early pregnancy is associ-
ated with an increased risk of fetal abnormality nor that
their continuing use in pregnancy is associated with
growth restriction or pre-term birth. However, antipsy-
chotic medication freely passes to the developing fetus and
its brain and the dose should be reduced to that which is
the minimum for clinical effectiveness. Babies born to
mothers receiving relatively high doses of typical antipsy-
chotics may experience a withdrawal syndrome and
extrapyramidal symptoms (muscle stiffness, rigidity, jit-
teriness and poor feeding). Consideration therefore
should be given to a reduction of the dose before birth
and a possibility of induction at term. Withdrawal of
medication at any stage in pregnancy may be associated
with a risk of a relapse of the maternal condition.
Breastfeeding
Typical antipsychotics are present in breastmilk, although
the amount to which the infant is exposed is likely to be
very small. The added benefits of breastfeeding to the
infant probably justify the continuation of breastfeeding
providing that the dose required is small and divided.
Drugs such as procyclidine, given to prevent extrapyrami-
dal side-effects, are not recommended.
Atypical antipsychotics
The manufacturers advise against the use of atypical anti­
psychotics in pregnancy and breastfeeding but this reflects
lack of data rather than evidence of harm. The use of olan-
zapine in pregnancy has been associated with an increased
risk of gestational diabetes. Women who become pregnant
while taking these newer antipsychotics should be urgently
reviewed. In some cases, it may be possible to change their
medication to the older type of antipsychotic. In others,
because of the substantial risk of relapse of their condition,
it may be necessary to continue with their medication.
Again this should be reduced to the lowest possible dose
and consideration given to a further reduction immediately
prior to birth and, if necessary, a managed delivery. Cloza-
pine should not be used in pregnancy and breastfeeding
because of the risk of blood dyscrasias in the infant.
Mood stabilizers
This is a group of drugs used to treat the manic component
of bipolar illness and, long term, to prevent relapses of the
547
Section | 4 | Labour
condition. The drugs used as mood stabilizers are lithium
carbonate (Priadel) and various anti-epileptic drugs, com-
monly sodium valproate and carbamazepine but also on
occasion lamotrigine.
Pregnancy
Lithium carbonate in pregnancy is associated with a risk of
developing a rare, serious cardiac condition, Ebstein’s
anomaly. Although the relative risk is large, the absolute
risk is low, being 2 in 1000 exposed pregnancies. However,
there is also an increased risk of a range of cardiac abnor-
malities, including milder and less serious conditions. The
absolute risk of all types of cardiac abnormality is 10 per
100 exposed pregnancies. Lithium in early pregnancy is
not associated with an increased risk of neural tube
abnormalities.
The continued use of lithium throughout pregnancy is
associated with an increased risk of fetal hypothyroidism,
diabetes insipidus, fetal macrosomia and the ‘floppy baby’
syndrome (neonatal cyanosis and hypotonia). These risks
are difficult to quantify. An additional problem is that the
woman will require increasing doses of lithium in later
pregnancy to maintain a therapeutic serum level because
of the increased maternal clearance of lithium. However,
the fetal clearance does not increase. Women receiving
lithium in pregnancy therefore require frequent estima-
tions of their serum lithium and close monitoring of their
condition. During labour and immediately following
birth, physiological diuresis can result in toxic levels of
maternal lithium. The woman therefore requires frequent
estimations of her serum lithium throughout labour and
in the early postpartum days.
Women who are taking lithium carbonate should be
advised to carefully plan their pregnancies and to seek
medical advice. Abrupt cessation of lithium is associated
with a substantial risk of a recurrence of their condition.
These women will usually be advised to either slowly with-
draw their lithium prior to conception or consider chang-
ing to another medication. However, there will be rare
occasions when it is necessary to continue lithium
throughout pregnancy. Such a pregnancy will need to be
managed by an obstetrician working closely with psychi-
atric services and a fully compliant, well-informed woman.
Breastfeeding
Lithium should not be used in breastfeeding as it is present
in substantial quantities in breastmilk and can result in
infant lithium toxicity, hypothyroidism and ‘floppy baby’
syndrome.
Anticonvulsants
Anticonvulsants have been used as mood stabilizers for 30
years. Carbamazepine was first used in this way, sodium
valproate is now increasingly the mood stabilizer of choice
and recently the newer anticonvulsants such as lamotri­
gine and topiramate are being used.
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Pregnancy
All anticonvulsants are associated with a doubling of the
base-line risk of fetal abnormality if used in the first tri-
mester of pregnancy. A total of 4 in 100 infants exposed
to carbamazepine will have a major congenital malforma-
tion. The risk of cleft lip and palate is further increased
with exposure to lamotrigine. The risks are highest with
sodium valproate: 8 per 100 exposed pregnancies. The use
of folic acid reduces but does not eliminate the risk of
neural tube abnormalities. Continued use of anticonvul-
sants throughout pregnancy is associated with an increased
risk of neurodevelopmental problems in the child. This is
particularly high with sodium valproate. For this reason,
NICE (2007) guidelines advise against the use of sodium
valproate in pregnancy. Women receiving these medica-
tions should carefully plan their pregnancies with expert
advice. They should, wherever possible, either have a
supervised withdrawal of their medication or change to
a ‘safer’ alternative. They should also take folic acid. If a
woman becomes pregnant while still taking these medica-
tions, she should be urgently referred for expert advice and
for an early fetal anomaly scan. As all harm is dose-related,
the woman should be advised wherever possible to reduce
her sodium valproate to below 1000 mg daily.
Breastfeeding
The advantages of breastfeeding probably outweigh the
risks of taking carbamazepine or sodium valproate during
breastfeeding. However, the infant should be monitored
for excessive drowsiness and, in the case of sodium val-
proate, rashes. Lamotrigine should not be used in breast-
feeding because of the increased risk of severe skin
reactions in the infant.
Service provision
There are a number of national recommendations for the
needs of women with perinatal psychiatric disorders Box
25.7. The distinctive clinical features of the conditions,
their physical needs and the professional liaison with
maternity services all require specialist skills and know­
ledge (Oates 1996). The frequency of the serious condi-
tions at locality level makes it difficult for general adult
psychiatric services to manage the critical mass of patients
required to develop and maintain their experience and
skills. It is difficult for maternity services to relate to
multiple psychiatric teams. However, at supra-locality
(regional) level, the frequency of serious perinatal psychi-
atric disorder is sufficient to justify the joint commission-
ing and provision of specialist services. Mothers, who
require admission to a psychiatric hospital in the early
months postpartum should, unless it is positively con-
traindicated, be admitted to a mother and baby unit. This
is not only humane but also in the best interests of the
infant and cost-effective as it shortens inpatient stay and

Box 25.7 Perinatal mental health: national
documents (regularly updated)
Royal College of Psychiatrists CR88
SIGN Guidelines – postnatal and puerperal psychosis
CNST 2004
National Screening Committee
NICE guidelines on antenatal care: routine care for the
healthy pregnant woman
NICE guidelines on antenatal and postnatal mental health
NICE guidelines on postnatal care: routine postnatal care
of women and their babies
Department of Health Reports:
Children’s, young person and maternity NSF. Maternity
Standard 11
Women’s mental health into the mainstream
Responding to domestic abuse
CEMACH/CMACE ‘Why mothers die’ triennial reports
prevents re-admission. There should be specialist perinatal
community outreach services available to every maternity
service, to deal with psychiatric problems that arise post-
partum but also to see women in pregnancy who are at
high risk of developing a postnatal illness.
The majority of women suffering from postnatal mental
illness will not require to be seen by specialist psychiatric
services. However, there is a need for integrated care path-
ways to ensure that women are effectively identified and
managed in primary care and, if necessary, referred on to
specialist services. There is a need to enhance the skills and
competencies of health visitors, midwives, obstetricians
and GPs to deal with the less severe illnesses themselves.
PREVENTION AND PROPHYLAXIS
Prevention
The National Screening Committee (2001) and NICE
(2007) guidelines do not recommend routine screening
using the EPDS and other ‘paper and pen’ scales in the
antenatal period for those at risk of postnatal depression.
They also find that there is a lack of evidence to support
antenatal interventions to reduce the risk of non-psychotic
postnatal illness. In contrast, these and other bodies (DH
2004; NICE 2008; CMACE 2011) all recommend that
women should be screened at early pregnancy assessment
for a previous or family history of serious mental illness,
particularly bipolar illness, because they face at least a
50% risk of recurrence of that condition following birth.
Those who undertake early pregnancy assessment will
need training to refresh their knowledge of psychiatric
disorder.
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Perinatal mental health Chapter | 25 |
There is little point in screening for women at high risk
of developing severe postnatal illness if systems for the
pro-active peripartum management of these conditions
are not in place and if appropriate resources are not avail-
able. It is recommended that all women who are at high
risk of developing a severe postpartum illness by virtue of
a previous history are seen by a specialist psychiatric team
during the pregnancy and a written management plan
placed in the maternity records in late pregnancy and
shared with the woman, her partner, her GP, midwife,
obstetrician and psychiatrist.
Prophylaxis
If a woman has a previous history of bipolar illness or
puerperal psychosis, consideration should be given to
starting medication on day one postnatally. For bipolar
illness the use of lithium carbonate has been shown to
reduce the risk of a recurrence. It is plausible that the use
of antipsychotic medication may also reduce the risk of
recurrence. However, lithium is not compatible with
breastfeeding. Some women will not wish to take medica-
tion when they perceive there is a 50% chance of them
remaining well. They may also place a priority on con­
tinuing to breastfeed. Breastfeeding mothers at risk of
developing a bipolar or mixed affective illness may take
carbamazepine or sodium valproate. The evidence that
antidepressants taken prophylactically may prevent the
onset of a depressive psychosis is lacking. Antidepressants
should be used with great caution in any woman who has
bipolar disorder in her personal or family history because
of the propensity of antidepressants to trigger a manic
illness.
Hormones
There is no evidence that progesterone, natural or syn-
thetic, prevents or treats postnatal depression or puerperal
psychosis. Indeed there is evidence to suggest they may
cause depression. While there is some evidence that
transdermal oestrogens are effective in treating postnatal
depression, the potential adverse physical effects (Dennis
et al 1999) and the known efficacy of antidepressants
mean this should not be the treatment of choice.
The most important aspect of preventative manage-
ment and one that will promote early identification and
the avoidance of a life-threatening emergency is close sur-
veillance, contact and support in the early weeks, the
period of maximum risk. A specialist community peri­
natal psychiatric nurse together with the midwife should
visit on a daily basis for the first two weeks and remain in
close contact for the first six. The local mother and baby
unit should be aware of the woman’s expected date of
birth and systems put in place for direct admission if
necessary.
549
Section | 4 | Labour

The Confidential Enquiries into

Maternal Deaths: psychiatric causes
of maternal death
Confidential Enquiries into Maternal Deaths (Oates 2001,
2004, 2007, 2011) have found that suicide and other psy-
chiatric causes of death are a leading cause (indirect) of
maternal death in the UK, between 1997 and 2008, con-
tributing to over 15% of maternal deaths.
Maternal suicide is more common than previously
thought. Overall, the maternal suicide rate appears to be
equivalent to that of the general rate in the female popula-
tion. Suicide in pregnancy is less common. The majority
of suicides took place in the year following birth, most in
the first 3 months. Not only is the assumption of the
‘protective effect of maternity’ called into question but also
the relative risk of suicide for seriously mentally ill women
following childbirth is elevated. An elevated standardized
mortality ratio (SMR) of 70 for women with serious
mental illness in the postpartum year has previously been
reported (Appleby et al 1998) and further confirmed
by evidence from the Enquiries with improved case
ascertainment.
In contrast to other causes of maternal death, suicide
was not associated with socioeconomic deprivation. The
majority of suicides were older, married and relatively
socially advantaged and seriously ill. A worrying number
were health professionals. This underlines the error of
merging issues of maternal mental health with those of
socioeconomic deprivation.
The majority of the suicides occurred violently by
jumping from a height or by hanging. This stands in con-
trast to the commonest method of suicide among women
in general (self-poisoning), and underlines the seriousness
of the illness from which the women died.
Half of the suicides had a previous history of admission
to a psychiatric hospital. In few cases had this risk been
identified at booking and in even fewer had any proactive
management been put into place. Had these women’s ill-
nesses been anticipated, a substantial number of these
deaths might have been avoided.
Women also died from other consequences of psychiat-
ric disorder. Some of these were due to accidental over-
doses of illicit drugs. However, deaths also occurred from
physical illness that would not have occurred in the
absence of a psychiatric disorder. Some of these were the
physical consequences of alcohol or illicit drug misuse,
others from side-effects of psychotropic medication.
However, a worrying number of deaths, some of which
took place in a psychiatric unit, were due to physical
illness being missed because of the psychiatric disorder or
mistakenly attributed to a psychiatric disorder. These find-
ings underline the importance of remembering that physi-
cal illness can present as or complicate psychiatric disorder.
Suicide is not the only risk associated with perinatal psy-
chiatric disorder. Box 25.8 identifies the four main
Box 25.8 The four main categories of
psychiatric deaths emerging from ‘Saving
Mothers’ Lives’ (Oates 2007; Oates and
Cantwell 2011)
• Suicide
• Overdose of drugs abuse
• Medical conditions caused by or mistaken for
psychiatric disorder
• Violence and accidents related to psychiatric disorders
Note: New themes are included, concerning child protection and
termination of pregnancy.
categories of psychiatric deaths emerging from ‘Saving
Mothers’ Lives’ (Oates and Cantwell 2011).
These findings have major implications for psychiatric
and obstetric practice. If psychiatrists discussed with
women plans for parenthood prior to conception; if obste-
tricians and midwives detected those at risk of serious
mental illness; if psychiatric and maternity professionals
communicated freely with each other and worked together;
if specialist perinatal mental health services were available
for those women who needed them; and if all had a
greater understanding of perinatal mental illness, then not
only would a substantial number of maternal deaths be
avoided but also the care and outcome of other mentally
ill women would be greatly improved.
CONCLUSION
The full range of psychiatric disorders can complicate
pregnancy and the postpartum year. The incidence of
affective disorder, particularly at the most severe end of
the spectrum, increases following birth. The familiar
signs and symptoms of psychiatric disorder are all
present in postpartum disorders as well, but the early
maternity context and the dominance of infant care and
mother–infant relationships exert a powerful effect on
the content, if not the form, of the symptomatology.
Early maternity is a time when there is an expectation of
joy, pleasure and fulfillment. The presence of psychiatric
disorder at this time, however mild, is disproportionately
distressing. No matter how ill the woman feels, there is
still a baby and often other children to be cared for.
She cannot rest and is reminded on a daily basis of
her symptoms and disability. Compassionate care and
understanding and skilled care aimed at speedy symptom
relief and re-establishing maternal confidence are thus
essential.

550
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FURTHER READING
DiPietro J A (2012) Maternal stress in
pregnancy: considerations for fetal
development. Journal of Adolescent
Health 51:S3–S8
Considers a number of methodological
issues in strengthening understanding of the
effects of stress/anxiety on fetal neuro-
behaviour and possible consequences for the
developing nervous system.
USEFUL WEBSITES
Department of Health: www.dh.gov.uk
Fathers Institute:
www.fatherhoodinstitute.org/
Midwifery 2020:
www.midwifery2020.org
Mothers and Babies: Reducing Risk
Through Audits and Confidential
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Perinatal mental health
National Institute for Health and
Clinical Excellence 2010 Pregnancy
and complex social factors (CG 110).
NICE, London
Addressing a variety of social complexities
that may affect a woman’s emotional
wellbeing such as poverty, homelessness,
domestic abuse, communication difficulties,
refugee or asylum status, young teenage
mother, substance misuse etc.
Enquiries across the UK:
www.mbrrace.ox.ac.uk
National Institute for Health and Care
[formerly Clinical] Excellence:
www.nice.org.uk
Perinatal Illness UK: www.chimat.org.uk
(from April 2013 this charity has
Chapter | 25 |
Shaw R L, Giles D C 2009 Motherhood
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older mothers in the UK news.
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24(2):221–36
An interesting discourse about how older
mothers are portrayed in the popular
media.
become part of Public Health
England and the URL address is
likely to change in the near future).
Scottish Intercollegiate Guideline
Network: www.sign.ac.uk
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 Chapter 26

Bereavement and loss in maternity care

Rosemary Mander

CHAPTER CONTENTS This chapter introduces the reader to issues

relating to bereavement and loss in the
Introduction 555 maternity area. The intention is to facilitate
Grief and loss 556 better coping among staff and, thus, care for
those affected. Throughout the chapter,
Attachment 556 particular attention is paid to the knowledge
Grief 556 on which practice is based, such as research,
Significance 557 evidence or personal experience.
Culture 557
Forms of Loss 557
THE CHAPTER AIMS TO:
Perinatal loss 557
Infertility 558 • consider the meaning of bereavement and loss in
maternity and childbearing
Relinquishment for adoption 558
Termination of pregnancy (TOP) 558
• contemplate the significance of bereavement and
loss in maternity and childbearing
The baby with a disability 558
• discuss forms of loss
Loss in healthy childbearing 559
• draw on research evidence and other knowledge to
The ‘inside baby’ 559 review the care of those affected by loss.
The mother’s birth experience 559
The midwife’s experience 559
Care 560
The baby 560 INTRODUCTION
The mother 561
The family 563 In 21st-century Western society, bereavement is closely
linked with loss through death. In this chapter, to increase
The formal carers 563 the relevance of these concepts, the focus is broadened to
Other aspects of care 564 include other sources of grief that are likely to affect mid-
The death of a mother 564 wifery care. In widening the topic, the original meaning of
Conclusion 565 ‘bereavement’ is reflected, which implies plundering,
robbing, snatching or otherwise removing traumatically
References 565
and, crucially, without consent. This meaning may conflict
Further reading 566 with the other part of the title – ‘loss’ – which is also
Useful addresses and websites 567 widely used in this context. But any inconsistency is

© 2014 Elsevier Ltd 555

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Section | 5 | Puerperium
fallacious because, although bereavement involves ‘taking’
in various ways, the unspoken hopes and expectations
invested in that which is lost remain irretrievable.
In many ways, loss in childbearing is unique, which is
due to the awful contrast between the sorrow of death
and the mystical joy of a new life. Additionally, the cruel
paradox of the ‘juxtaposition’ of birth and death aggra-
vates responses (Howarth 2001: 435). We tend to assume
that birth and death are separated by a lifetime; this
means that the experience becomes incomprehensible
when they are unified (Bourne 1968). Although any
childbearing loss is unique, the uniqueness of both the
individual’s experience and the phenomenon itself must
be contrasted with the frequency with which ‘lesser’
childbearing losses happen. Such lesser losses include the
reduction of the parents’ independence, the woman’s loss
of her special relationship with her fetus at birth, or the
family loss of the expected idealized baby when they rec-
ognize that the actual baby is all too real (Atkinson
2006). Central to this chapter is the woman losing a
baby and her care by the midwife. The midwife draws on
theory which, as in any care, is grounded in firm knowl-
edge, such as research evidence. Such knowledge is util­
ized in skilled care to facilitate adjustment to these
greater and lesser losses. Thus, as well as loss through
death, other forms of childbearing-related loss are also
considered.
GRIEF AND LOSS
Grief, like death and other fundamentally important
matters, is a fact of life. All human beings invariably face
grief in some form, possibly when young. Despite its uni-
versality, a woman in a higher income country experienc-
ing childbearing loss may be too young to have previously
encountered the grief of death. This is a further reason for
the uniqueness of childbearing loss.
Attachment
Limited understanding of mother–baby attachment, or
‘bonding’, long prevented our recognition of the signifi-
cance of perinatal loss. The strength of the growing rela-
tionship between the woman and her fetus emerged in a
research project involving bereaved mothers (Kennell et al
1970). This relationship develops with feeling movement
and experiencing pregnancy, including investigations such
as ultrasound scans. Ordinarily, attachment continues
to develop beyond the birth (Bowlby 1997). Attachment
during pregnancy means that, should the relationship not
continue, it must be ended as with any parting. Thus, the
reality of the mother–baby relationship needs to be recog-
nized before the loss can be accepted. These processes are
crucial for the initiation of healthy grieving.
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Grief
Through grieving we adjust to more serious, and lesser,
losses throughout life. Healthy grief means that we can
move forward, although probably not directly, from the
initial distraught hopelessness. We eventually achieve
some degree of resolution, or perhaps integration, which
permits ordinary functioning much of the time. Through
grief we learn something about both ourselves and our
resources (Vera 2003).
Grief has been viewed historically as apathetic passivity,
but it is really a time when the bereaved person actively
struggles with the emotional tasks facing her; the term
‘grief work’ summarizes this struggle (Engel 1961). The
stages of grief through which the person works have been
described in various ways, but Kübler-Ross’s (1970)
account is memorable. These stages (Box 26.1) are not
necessarily negotiated in sequence; individual variations
cause the person to move back and forth between them
before reaching a degree of resolution.
The initial response to loss comprises a defence mecha-
nism protecting the individual from the full impact of the
news or realization. This reaction comprises shock or
denial, which insulates the bereaved person from the
unbearably unthinkable reality. Facilitating coping with
impending realization, this initial response allows some
‘breathing space’, during which the person marshals their
emotional resources.
Denial soon becomes ineffective and awareness of the
reality of loss dawns. Awareness brings powerful emo-
tional reactions, together with physical manifestations.
Sorrowful feelings emerge but, less acceptably, other emo-
tions simultaneously overwhelm the bereaved person.
These include guilt and dissatisfaction, as well as compul-
sive searching and, disconcertingly, anger. Realization
dawns in waves as the bereaved person tries coping
strategies to ‘bargain’ with herself to delay accepting the
grim reality.
Box 26.1 Stages of grief
• Shock and denial
• Increasing awareness
– Emotions: sorrow – guilt – anger
– Searching
– Bargaining
• Realization
– Depression
– Apathy
– Bodily changes
• Resolution
– Equanimity
– Anniversary reactions.
 Bereavement and loss in maternity care
When such fruitless strategies are exhausted, the despair
of full realization materializes, bringing apathy and poor
concentration, together with bodily changes. At this point,
the bereaved person may show anxiety and physical symp-
toms, like depression.
When the loss is eventually accepted, it starts to become
integrated into the person’s life (Walter 1999). As men-
tioned already, this is not straightforward and may involve
slow progress and many setbacks, with oscillation and
hesitation. Although the person may never ‘get over’ the
loss, it should eventually be integrated. This ultimate
degree of ‘resolution’ is recognizable in the bereaved per-
son’s contemplation with equanimity of the strengths, and
weaknesses, of the lost person and relationship.
Significance
Healthy grieving matters because it contributes to balance
or homeostasis in the bereaved person’s life. Grief helps
people deal with the wounds inflicted by the greater and
lesser losses of life. The hazards of being unable to grieve
healthily have long been recognized in emotional terms,
but there may be an association between perinatal loss
and physical illness (Boyce et al 2002). This research sug-
gested the woman’s need for support regardless of the
nature of the loss or the extent to which it is recognized,
or her grief sanctioned, by society.
Culture
A general picture of healthy grieving, and individual vari-
ation, common to people of different ethnic back-
grounds, has been described (Katbamna 2000). The
manifestations of grief, and accompanying mourning
rituals, vary hugely. These variations are influenced by
many factors. Cecil (1996) shows the massive differences
between ethnic groups in attitudes towards childbearing
loss. A midwife may encounter difficulty understanding
the different attitudes to loss in cultures other than her
own (Mander 2006). Whether the midwife is able to
work through such feelings, to support the woman with
different attitudes, is uncertain. Closely bound up with
culture, and influencing mourning, are the grieving per-
son’s religious beliefs, or lack thereof. These aspects,
however, are difficult to separate from social class and
prevalent societal attitudes.
Despite huge variations in its manifestation, mourning
has a universal underlying purpose. It establishes support
for those closely affected, by strengthening links between
the people who remain. In perinatal loss the midwife
initially provides this support. The midwife’s role is to be
with the woman when she begins to realize the extent of
her loss and to prevent interference in the woman’s healthy
initiation of grieving.
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Chapter | 26 |
FORMS OF LOSS
The terms ‘loss’ and ‘bereavement’ apply to a range of
experiences, varying hugely in severity and effects
(Despelder and Strickland 2001). We must be careful,
however, to avoid assumptions about the meaning of loss
to a particular person. It is difficult, even impossible, for
anybody to understand the significance of a pregnancy or
a baby to someone else. This is because childbearing
carries a vast range of profound feelings, including unspo-
ken hopes and expectations based on personal and cul-
tural values. We should accept that grief in childbearing,
like pain, is what the person who is going through it says
it is (McCaffery 1979).
Some situations in which we encounter grief are men-
tioned. Some situations of childbearing grief are not
included here, while some situations listed here may not
engender grief.
Perinatal loss
When loss in childbearing is mentioned, loss in the peri-
natal period comes quickly to mind, which includes the
stillborn baby and the baby dying in the first week.
Attempts have been made to compare the severity of grief
of loss at different stages, perhaps to demonstrate that
certain women deserve more sympathy. A classic study
investigating severity, however, showed no significant dif-
ferences in the grief response between mothers losing a
baby by miscarriage, stillbirth or neonatal death (Peppers
and Knapp 1980). This study emphasized the crucial role
of the developing mother–baby relationship – the under-
standing of which has facilitated changes in care.
Stillbirth
A retrospective Swedish study focused on the mother’s
long-term recovery from stillbirth. Rådestad and col-
leagues (1996a) compared the recovery of 380 women
who had given birth to a stillborn baby with 379 women
who birthed a healthy child. The 84% response rate shows
the mothers’ perception of the importance of this study.
These researchers found that the mother recovered better
if she could decide how long to keep her baby with her
after the birth and if she could keep birth mementoes. The
mother whose recovery was more difficult was the one
where the birth of the baby was delayed after realization
of fetal demise. Clearly, these findings have important
implications for midwifery care (see section on The
Mother, below). Additionally, the researchers discuss the
‘known’ stillbirth, when the mother knows before labour
that her baby has died, previously termed ‘intrauterine
death’ or ‘IUD’. Alternatively, the loss is unexpected. While
avoiding comparisons, it is understandable that the
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Section | 5 | Puerperium
mother aware of carrying a dead baby bears particular
emotional burdens. These burdens, compounded by the
baby’s changing appearance, may impede her grieving.
Early neonatal death
Grieving a liveborn baby who dies may be facilitated by
three factors. First, the mother has seen and held her real
live baby; giving her genuine memories. Second, United
Kingdom (UK) legislation requires the registration of both
the birth and death of a baby dying neonatally, providing
written evidence of the baby’s life. Third, staff investment
in the care of this dying baby increases the likelihood of
effective parental support (Singg 2003). Even for the
mother whose preterm baby survives, though, there may
still be elements of grief (Shah et al 2011).
Accidental loss in early pregnancy:
miscarriage
Early pregnancy loss may be due to various pathological
processes, such as ectopic pregnancy or spontaneous abor-
tion. The word ‘abortion’ is better avoided in this context,
because it carries connotations of deliberate interference,
which are unacceptable to a grieving mother. The term
‘miscarriage’ is preferable, to include all accidental losses.
The grief of miscarriage has long been ignored, because of
its frequency. This has been estimated to be about one-
third of pregnancies, although the figure may be higher
(Oakley et al 1990).
Understanding the woman’s experience of miscarriage
has been sought through qualitative research, which
shows miscarriage to be far from an insignificant event,
with some mothers so ill that they fear for their lives.
Although mothers find reassurance in the conception of
the pregnancy that was lost, some come to doubt their
fertility. As in other forms of loss, the mother finds diffi-
culty in locating support and encounters comments deni-
grating her loss (Simmons et al 2006). It may be necessary
to seek the cause of a woman’s miscarriage, especially if it
happens repeatedly (Hyer et al 2004). Although miscar-
riage has been linked with stressful life events, Nelson et al
(2003) found no link between psychosocial stress and
miscarriage. Limited recognition of miscarriage is now
being addressed, and women are encouraged to create
their own rituals to assist grieving. Brin (2004) showed the
helpful nature of a religious service, of photographs or of
communicating sorrow through writing a poem or letter.
Infertility
Grief associated with involuntary infertility is less focused
than when grieving for a particular person (Lau 2011). In
this situation the couple grieve for the hopes and expecta-
tions integral to the conception of a baby. Realization of
their infertility, and the associated grief, is aggravated by
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the widespread assumption that conception is easy, which
is sufficiently prevalent for the emphasis, in society gener-
ally and healthcare particularly, to be on preventing con-
ception. Complex investigations and prolonged infertility
treatment result in a ‘roller-coaster’ of hope and despair.
As with any grief, the couple in an infertile relationship
grieve differently from each other, engendering tensions.
Being told the diagnosis or cause of their infertility resolves
some uncertainty, but raises other difficulties. These
include one partner being ‘labelled’ infertile and, hence,
‘blamed’ for the couple’s difficulty. A complex spiral of
blame and recrimination may escalate to damage an
already vulnerable relationship (Allen 2009). Clearly,
counselling an infertile couple differs markedly from
counselling those bereaved through death.
Relinquishment for adoption
Although long accepted that relinquishment is followed
by grief (Sorosky et al 1984), the view persists that,
because relinquishment is voluntary, grief is unlikely. Each
mother in the study conducted by Mander (1995) was
clear that her relinquishment was definitely involuntary
and she had no alternative to relinquishment. These
mothers really were ‘bereaved’ in the original sense (see
Introduction, above).
The grief of relinquishment differs crucially from grief
following death. First, after relinquishment grief is delayed.
This is partly because of the woman’s lifestyle and partly
because of the secrecy imposed on the woman who does
not mother her baby as is usual. Secondly, the grief of
relinquishment is not resolved in the short or medium
term. This is because, ordinarily, acceptance of loss is
crucial to resolving grief. After relinquishment, such
acceptance is impossible due to the likelihood that the one
who was relinquished will make contact when legally able.
Being reunited with the relinquished one was fundamen-
tally important to the mothers interviewed. ‘Rosa’s’ words
reflect many mothers’ hopes: ‘I’d be delighted if she would
turn up on the doorstep’ (Mander 1995).
Termination of pregnancy (TOP)
Grief associated with termination of an uncomplicated
pregnancy is problematic and for this reason it tends not
to be included in the literature on grief. The experience of
grief following TOP for fetal abnormality and of guilt fol-
lowing TOP do, however, tend to be recognized and
accepted. In view of the frequency of TOP and the grief
engendered, this deserves more attention.
TOP for fetal abnormality (TFA)
The package of investigations known as ‘prenatal diagno-
sis’ (see Chapter 11) may ultimately lead to the decision
to undergo TFA. Although it may be assumed that the
 Bereavement and loss in maternity care
mother’s reaction is solely one of relief at avoiding giving
birth to a baby with a disability, Iles (1989) suggests
reasons for a mother in this situation experiencing con-
flicting emotions that impede grieving:
• the pregnancy was probably wanted;
• the TFA is a serious event in both physiological and
social terms;
• the reason for TFA may arouse guilty feelings;
• the recurrence risk may constitute a future threat;
• the woman’s biological clock is ticking away;
• her failure to achieve a ‘normal’ outcome may
engender guilt.
Interventions have been introduced to facilitate the
grieving of the mother who has undergone TFA, which
involve counselling and the creation of memories, as in
other forms of child-bearing loss (see section on The Baby,
below). A randomized controlled trial to study the effec-
tiveness of psychotherapeutic counselling in such mothers
with no other risk factors was undertaken by Lilford et al
(1994). This study suggested that bereavement counselling
makes no difference to the difficulty or duration of griev-
ing. Additionally, the researchers concluded that mothers
attending for counselling would probably have resolved
their grief more satisfactorily than the control group
anyway.
TOP for other reasons
The non-recognition of grief associated with TOP may be
because the mother whose pregnancy is ended may be
considered ‘undeserving’ of the luxury of grief. Further,
this may be aggravated by her being blamed for her situ-
ation. Research on the psychological sequelae of TOP has
focused on the guilt of having decided to end the preg-
nancy, as opposed to grief reactions; it may be that this
focus is associated with the acrimonious abortion debate
that continues in some countries. Thus, the grief and
depression, presenting as tearfulness, were thought normal
after termination of pregnancy (Wahlberg 2006). Perhaps
these reactions could be prevented by counselling before,
as well as after, the TOP.
The baby with a disability
For various reasons a baby may be born with a disability,
which may or may not be anticipated. Disabilities vary
hugely in severity and their implications for the baby. The
mother may have to adjust to the possibility of her baby
dying, but many conditions permit the continuation of a
healthy life.
The mother’s reaction to a baby with a disability will
involve some grief. This is particularly true if the condition
was unexpected, as the mother must grieve for her expected
baby before relating to her real baby. The mother may be
shocked to find herself thinking that her baby might be
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Chapter | 26 |
better off not surviving (Lewis and Bourne 1989). Although
the mother may be reassured that such thoughts are not
unique, she may still find it difficult to begin her
grieving.
If a baby is born with an unexpected disability, the
problem of breaking the news emerges. There are no easy
answers to how this can be done to reduce the trauma, but
clear, effective and honest communication is crucial
(Farrell et al 2001).
The midwife’s experience
The emotional reaction that may sometimes be experi-
enced by the midwife may come as a surprise to her.
Considering herself to be a professional person, she may
be taken aback by the strength and complexity of her feel-
ings when caring for a bereaved mother. This aspect
has now begun to be addressed by research and to be
opened up to debate (Kenworthy and Kirkham 2011; see
Box 26.2).
LOSS IN HEALTHY CHILDBEARING
It may be hard to understand that, even in uncomplicated,
healthy childbearing, grief may still present as a feature.
The ‘inside baby’
The woman’s grief may be because, despite obstetric tech-
nology, the mother is unable to view her baby before birth.
Inevitably the real baby differs from the one whom she
came to love during pregnancy. These differences may be
minor, such as the amount of hair or crying behaviour.
Lewis (1979) coined the term ‘inside baby’ to denote the
one whom she came to love during pregnancy and who
was perfect. The ‘outside baby’ is the real one, for whom
she will care and who may have some imperfections, such
as the wrong colour of hair. Clearly the mother may have
moments of regret, during which she grieves the loss of
her fantasy ‘inside’ baby, before being able to begin her
relationship with her real baby.
The mother’s birth experience
A further form of loss, over which the mother may need
to grieve, is her loss of her anticipated birth experience. If
she hoped for an uncomplicated birth, even some of the
more common interventions may leave her feeling like a
failure (Green and Baston 2003). Thus, in the same way
as the woman may need to grieve her ‘inside baby’, even
though all appears satisfactory, this disappointed mother
has some grief work to complete.
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Section | 5 | Puerperium
Box 26.2 That sad day
This is a summary of feelings and thoughts when I
discovered an intrauterine death at 41 weeks’ gestation.
The woman involved had been admitted for induction of
labour and neither of us was prepared for this.
My heart sank when on initial palpation her abdomen
felt cold and then the electronic fetal monitor did not
detect the heart beat (I had just used the machine earlier).
I knew, although it would be difficult, that I had to try and
prepare her. I stayed later to try and give some continuity
of care and support for her and her husband. After the
scan confirmed the death I hugged her and her husband
and cried with them. After this happened, I had a day off
work with a severe migraine caused by stress. I felt very
nervous and sick about going back to work, this was
compounded when I discovered that the woman had been
admitted to Intensive Care and was very ill. However, I did
go back to work, visited the woman and sat holding her
hand. We talked about her sadness and she said she had
been worried about me leaving work late and wondered
how I had coped getting home and facing my two
children. I couldn’t believe that she was concerned about
me! She remembered every word I had said to her and
praised my honesty. I had told her before the scan that I
was sure that the baby had not survived. Two weeks later I
attended the funeral in order to seek closure and to
demonstrate my sympathy and sadness for the parents.
I have been a midwife for over 12 years and this has
NEVER happened to me before. The whole event was very
traumatic and upsetting for me. Some colleagues told me
not to be upset, cry and/or get involved, but this was
ineffective advice. I was so determined that my experience
should not be in vain that I wrote this reflective piece. In
total I have experienced the loss of over nine friends and
relatives including my parents when I was fairly young.
However, nothing can prepare someone (even a
professional) for discovering that a baby has died and
Source: Reproduced with the kind permission of The Practising Midwife
CARE
In considering the care that midwives provide in the
event of loss, there are difficulties in deciding where to
begin. Thus, I have organized this section by focusing
first on those who are involved or affected and then on
other crucial issues. From this material will emerge the
principles of midwifery care. While recognizing the artifi-
ciality of distinguishing care for the individuals involved
in this complex situation, this approach helps us to con-
sider the different needs among the people affected by
the loss.
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having to prepare the parents for this. Without the love
and support of my family, friends and colleagues I would
not have coped. As healthcare professionals we should be
empathic and display understanding towards our
colleagues in similar situations.
As Rosemary Mander [2004b] writes in ‘When the
professional gets personal’:
for professional staff who provide effective care,
there is likely to be a personal cost. These are the
‘costs of caring’, which may be regarded as the
negative side of engaging with patients and clients
and with one’s work.
The whole experience will have a huge effect on my
practice in various ways. I will encourage midwives to be
honest with the clients. This will ensure that words are
carefully chosen and also sensitively put, because they will
be clearly remembered in years to come. I will not try to
smooth over colleagues’ feelings when they are involved in
issues like this.
I am also going to liaise with the Local Supervising
Authority to look at guidance for other midwives in
situations like this. The success of the ‘Birth Afterthoughts
Service’ within the Trust has led me to identify the need
for a service for midwives dealing with bereavement and
perhaps morbidity as well. Therefore, as a Supervisor of
Midwives I aim to promote separate sessions for midwives
– even if the midwife says she is unaffected. This will not
be blame-based but will simply allow the members of staff
to come to terms with their emotions and feelings by
helping them to move on in a positive way.
To summarize, writing about this episode has been a
catharsis for me and hopefully my experience will have a
positive outcome for other staff who find themselves in the
same sad and extremely difficult situation, and therefore
benefit the parents as well.
The baby
It is particularly hard to separate the care of the baby from
the care of those who are grieving, because much of our
care comprises the creation of memories of the baby,
which will facilitate their grieving (Box 26.3). Midwives
may think of the care of the baby before the birth by con-
sidering the cot in the labour room (Mander 2006).
Although the cot’s presence may cause the staff some dis-
comfort, it reminds everybody of the baby’s reality. If pos-
sible, that is if the baby’s demise is known in advance, the
midwife discusses with the parents prior to the birth their
contact with the baby. This contact takes any of a number
 Bereavement and loss in maternity care
Box 26.3 Creating memories
• Midwifery activities
– Information-giving
– Arranging for/taking photographs*
– Cutting a lock of hair*
– Taking a footprint*
– Giving a cot card and/or name-band
• Parental activities
– Naming baby
– Seeing baby
– Holding baby
– Caring for baby: bathing – dressing
– Taking photographs
• Other activities
Writing in a book of remembrance
Service/funeral/burial/cremation
Tree planting
Writing a letter and/or poem
*Parents’ informed consent will be needed.
of forms, beginning with just a sight of the wrapped baby.
Contact with the baby has been said to resolve some of
the confusion surrounding the birth; but the benefits of
such care have also been called into question (Hughes
et al 1999).
The midwife faces the quandary of whether, and how
much, she will encourage the mother to make contact with
her baby, drawing on her understanding of its beneficial
effect on grief (Mander 2006). This quandary is difficult,
but midwives tend to be overcautious in encouraging the
mother to have contact. This was an important finding
from a study of 380 mothers who had experienced peri-
natal loss (Rådestad et al 1996b). These researchers found
that one-third of the mothers would have appreciated
more encouragement to have contact with their babies.
The mother may choose to have considerable contact
with her baby, perhaps keeping the baby with her for some
time. During this time, the mother may wish to have her
baby baptized which, as well as its religious significance,
emphasizes the baby’s reality. This simple act, possibly
undertaken by the midwife, additionally presents an
opportunity to name the baby. The mother may also
during this time have other opportunities to create memo-
ries of her experience; these include doing some of the
things a mother ordinarily does for a baby, such as bathing
and dressing him or her.
Irrespective of whether the mother chooses to have
contact with her baby immediately, it is usual to collect
certain mementoes at the time of the birth, such as a lock
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Chapter | 26 |
of hair, a footprint or photographs. If the mother chooses
to have no contact at the birth she may later ask for these
mementoes. Taking photographs of a suitable quality may
present a challenge to the midwife who is not skilled in
using a camera, causing dissatisfaction (Rådestad et al
1996b). Figure 26.1 shows the sensitive way in which a
photograph may be used to help create memories of the
birth.
In the hope of preventing a future loss, the parents may
be advised that the baby should have a post mortem exam-
ination. This raises difficult issues for parents who con-
sider that their baby has already suffered enough. In the
UK there are guidelines providing information for the
parents prior to seeking their consent for the post mortem.
These guidelines aim to prevent certain abuses, which have
previously caused anguish to bereaved parents (Dimond
2001; Royal College of Pathologists [RCP] 2000).
The funeral serves a multiplicity of purposes, including
a demonstration of general support as well as establishing
the reality of the loss. A young woman with no experience
of death may have difficulty imagining how such a ritual
could ever be beneficial. She may be helped, though, by
being reminded how cemetery and crematorium staff are
sensitive to the need to provide a suitable ceremony and
a congenial environment in which the child may subse-
quently be remembered. In some situations, such as early
miscarriage, a funeral is inappropriate. The mother may
find that an impromptu service is helpful near the time of
her loss or, later, she may create her own memorial by
writing a letter to her lost baby or planting a tree. The care
of this mother is particularly important if and when she
decides to embark on another pregnancy (Reid 2007; Arm-
strong et al 2009).
The mother
Much of the midwife’s care of the grieving mother com-
prises helping her to make sense of her mystifying experi-
ence. As mentioned already, the mother needs help to
recognize that she has given birth, even though she no
longer has her baby. Integral to this is assisting her realiza-
tion that she is a mother, through midwifery care.
The mother may start to make sense of her loss by talking
about it. Although this sounds simple enough, ‘opening up’
presents the mother with certain challenges. For example,
she may be inexperienced and uncomfortable in talking
about profound feelings. Further, she may have difficulty
finding a suitable and willing listener precisely when she
feels ready. The problem of her finding a listener was identi-
fied in a research project showing that senior hospital staff
appear too busy, and other staff insufficiently experienced,
for her to unburden herself. Family members, who might
listen, have their own difficulties to face, making them less
receptive to the mother’s needs (Rajan 1994).
In a situation of loss, any of us may feel that our control
over our lives is slipping away. Such feelings of losing
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Section | 5 | Puerperium
Fig. 26.1 Photograph showing a grieving mother cradling her baby, who has been named Baby Shane.
control are exacerbated when the loss involves a physio-
logical process such as childbearing, which many people
achieve successfully and effortlessly. Midwives should be
able to help the mother to retain some degree of control.
They can do this is by giving her accurate information
about the choices open to her and on which she is able to
base decisions. In this way, the midwife may be able to
empower the woman and the two may form a partnership
together.
The reality of the grieving mother’s control over her care
was the subject of research by Gohlish (1985). She inter-
viewed 15 mothers of stillborn babies and asked them to
identify the ‘nursing’ behaviours they considered most
helpful. This study showed the importance to the grieving
mother of assuming control over her environment. While
the midwife may be keen to share many aspects of control
in the form of decision-making with the grieving mother,
there are some decisions that midwives consider unsuita-
ble for the mother to make (Mander 1993). The suitable
decisions include the contact that the mother has with
her baby; whereas the unsuitable decisions may include
the environment in which she is cared for during her
hospital stay.
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The support offered to the woman was the subject of a
systematic review, which found that there is little evidence
to indicate the effectiveness of psychological support at
this time (Flenady and Wilson 2008). A randomized con-
trolled trial by Forrest et al (1982) investigated the effects
of support following perinatal loss. The experimental
group, comprising 25 bereaved mothers, received ideal
supportive midwifery care together with counselling; the
control group comprised another 25 bereaved mothers
who received standard care. Unlike the more psychothera-
peutically oriented study by Lilford et al (1994), Forrest
et al (1982) found that the well-supported and counselled
group recovered from their grief more quickly than the
control group. Unfortunately, both studies had difficulty
retaining contact with the grieving mothers.
The mother may find helpful support in a number of
people, who provide support on a more or less formal
basis (Forrest et al 1982). Although we may assume that
identifying support is easy, research by Rådestad et al
(1996b) has shown that, like finding a suitable listener,
locating support may be problematic for the mother.
These researchers found that for just over one-quarter of
bereaved mothers the support lasted for under 1 month;
 Bereavement and loss in maternity care
while for just over another quarter the support was
non-existent.
Of particular significance to midwives is the contribu-
tion of the lay support and self-help groups. Research by
Mander (2006) showed that midwives are happy to rec-
ommend that a mother may find a support group, such as
the Stillbirth and Neonatal Death Society (SANDS),
helpful. Unfortunately, little is known about their effec-
tiveness or the experiences of those who attend.
If the loss occurs while the woman is in hospital, her
transfer home is crucially important, due to the likelihood
of other agencies becoming involved. At this point good
inter-agency communication ensures that the woman’s
healthy grieving is not jeopardized. In her large study,
Moulder (1998) identified the quality of the help provided
for the grieving mother by community agencies. She found
that women experience very different standards of care
from the various professionals, such as health visitors,
general practitioners, community midwives and counsel-
ling personnel. Similarly, the 6-week follow-up presents
an opportunity, not only to check the woman’s physical
recovery, but also to discuss important outstanding issues.
These include the couple’s emotional recovery from their
loss, the post mortem results (if relevant), any questions
arising or remaining, as well as plans for the future. The
research by Moulder (1998) found that this follow-up visit
is often handled appropriately sensitively, in a suitable
environment, with appropriate personnel present and
adequate time to address matters of concern. Unfortu-
nately, though, some women’s appointments were delayed
and staff were condescending.
The family
The mother is clearly most intimately involved with, and
affected by, a perinatal loss. To a greater or lesser extent,
those close by will share her grief. In this context, the
chapter includes, as well as conventional family members,
a range of non-blood and non-marital relationships.
The father
The effect of the loss on the father may previously have
been underestimated (Mander 2004a). This is partly
because men tend to show their grief differently from
women and partly because they are socialized into sup-
porting their womenfolk, possibly at the cost of their own
emotional well-being. Further, men are stereotypically
unlikely to avail themselves of the therapeutic effects of
crying and articulating sorrow. Men’s coping mechanisms
also involve less healthy grieving strategies, including
returning early to work and using potentially harmful sub-
stances such as nicotine or alcohol.
Possibly in association with their different patterns of
grieving (Samuelsson et al 2001), the parental relation-
ship is likely to change following perinatal loss. Whether
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Chapter | 26 |
the couple find their relationship strengthened or threat-
ened is unpredictable.
Other family members
Perhaps because they are less closely involved, grandpar-
ents may be disproportionately adversely affected by the
loss, possibly due to their inability to protect their children
(the bereaved parents) from painful loss. Inevitably and
additionally they experience their own sense of loss at the
threat to the continuity of their family and what that
means to them.
The effects of perinatal loss on a sibling may be prob-
lematic because of uncertainty about the child’s under-
standing of the event (Hayslip and Hansson 2003;
Dyregrov 2008). This difficulty is compounded by the
parents’ difficulty in articulating their pain in a suitable
form. The parents may seek to ‘solve’ these problems by
‘protecting’ their other child(ren) from the truth. They
little know that ‘protection’ creates a pattern of unhealthy
grieving, leaving a family legacy of dysfunctional relation-
ships (Dyregrov 2008).
Whilst midwives often assume that family are best at
supporting a grieving mother (Mander 1996), family
responses may not always be healthy or helpful (Kissane
and Bloch 1994).
The formal carers
The difficulty that staff face in caring for a grieving mother
has been linked with their personal reactions to the loss
of a baby (Bourne 1968). This may be the reason for the
historical neglect of such mothers in particular and this
topic in general. Furthermore, loss of a baby represents all
too clearly the failure of the healthcare system, and those
who work in it, to ensure a successful outcome to the
pregnancy. The fear of failure in turn engenders a cycle of
avoidance, which perpetuates neglect of the mother.
This vicious cycle has been interrupted so that as the
care of the mother has been changed, it is necessary to
question whether the care of staff has kept pace (Clarke
and Mander 2006). The emotional costs of providing care
are now being recognized (Kenworthy and Kirkham 2011).
The devaluation of the emotional component of care is
associated with increasing use of the medical model and
contributes to the increasing recognition of ‘burnout’. The
need for extra support is particularly important for less
experienced staff when providing care for grieving families
(Mander 2000). The education of staff for their counsel-
ling role is another solution, which is enhanced by super-
vision for the counsellors. The role of the midwife manager
in creating a supportive environment for staff in stressful
situations should not be underestimated. The midwife
may also be able to locate support in others alongside
whom she works, such as the hospital minister or chaplain
or her named Supervisor of Midwives. Additionally, there
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Section | 5 | Puerperium
are helpful agencies which may be located within or
outwith the healthcare system (see Useful Websites,
below).
The involvement of staff in the mother’s grief raises
some difficult questions. First there is the helpfulness or
otherwise of the midwife sharing the bereaved mother’s
tears. Although some midwives are prepared to cry along-
side the mother, others feel that crying is ‘unprofessional’
and would not be comfortable shedding even a few tears.
The midwives in Mander’s (2006, 2009) research said that,
generally, crying was not a problem; but any loss of control
that impeded their ability to provide care must be avoided
at all costs. Another difficult decision is whether staff
should attend the baby’s funeral. Some of the midwives
interviewed found this helpful and they had not been
uncomfortable attending. In some circumstances, however,
this might not apply.
Other aspects of care
Not least because of their effect on grieving, other aspects
of care assume greater importance.
Record-keeping and documentation
Record-keeping in this context becomes even more signifi-
cant. This is because communication is vital in ensuring
consistent care, which will facilitate the mother’s grieving.
Although not ideal, it may be difficult to avoid this care
being provided by different personnel. Thus, each midwife
must be able to learn from the mother’s records about
decisions and actions already taken (Horsfall 2001).
The cremation or burial
The documents required for the ‘disposal’ of the baby
differ according to whether the baby was born before or
after 24 weeks’ gestation (the current legal limit of viability
in the UK), according to whether the baby was born alive
or not, and according to where the baby was born. If the
baby was pre-viable, there is no legal requirement for the
baby to be buried or cremated. It is, however, essential to
ensure that the baby’s remains are removed according to
the mother’s wishes. If she decides not to participate in the
removal of the baby’s remains, they should still be removed
sensitively (Royal College of Obstetricians and Gynaecolo-
gists [RCOG] 2006). A book of remembrance in the mater-
nity unit is available to parents to record their names, their
baby’s details and thoughts about the baby.
For a baby born after 24 weeks, burial or cremation
may be arranged by the hospital, with the parents’ per-
mission, or by the parents. Cemeteries and churchyards
are subject to individual regulation, but the local ceme-
tery is likely to have a special plot for babies to be buried
individually and a religious or other service may be avail-
able. There is also the possibility that the parents may
564
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erect a headstone, although the design may be subject to
approval.
The statutory documentation is specific to each of the
countries of the UK. Details of the registration require-
ments in each of the four countries of the UK are provided
on the websites listed at the end of this chapter.
The mother’s choices
If she loses her baby, as well as her grief work, the mother
has certain choices. In terms of how the baby’s body
should be buried or cremated, the mother decides whether
to arrange this privately or allow the hospital to organize
it. The mother also needs to decide the extent to which
she would like to be involved in planning the funeral, the
blessing or the memorial ceremony. In some hospitals,
services of remembrance are held on a regular basis, and
bereaved parents choose whether to attend. As mentioned
above, the mother needs appropriate information to
decide about the funeral and post mortem.
THE DEATH OF A MOTHER
A form of loss that happens even less frequently than the
death of a baby is when the mother dies; this is usually
known as maternal death. In the UK, the rate of maternal
death is approximately 1 in 10,000 births (Lewis 2011: 48).
This means that in a medium-sized maternity unit a
mother is likely to die about once every 3 years.
Although the obstetric and epidemiological aspects of
maternal death have been well addressed (Maclean and
Neilson 2002; Edwards 2004; Lewis 2011), the more per-
sonal aspects tend to be avoided (Mander 2001a). There
is, however, little understanding of the family’s experience,
or the life of the motherless child. Palliative care principles
may be appropriately applied to the care of the childbear-
ing woman with or dying from an incurable condition
(Mander 2011). The care of this woman and the implica-
tions for her baby and the other family members are likely
to become increasingly important as women choose to
delay child-bearing into their mature years. This childbear-
ing woman’s care has yet to be subjected to serious research
attention.
However, the experience of the midwife providing care
around the time of the death of a mother has begun to
be addressed (Mander 2001b, 2004b). This research
shows the dire implications for the midwife of attending
a mother who dies, to the extent that the experience
assumes the proportions of a disaster. The midwife’s des-
perate need for support may be met by midwifery col-
leagues who either shared her experience or have been
through a similar one. The midwife’s family also plays a
fundamentally important role in supporting her (Mander
1999).
 Bereavement and loss in maternity care Chapter | 26 |

which they deserve and need. In this way, the midwife

CONCLUSION
This chapter has shown that, for the midwife’s care of the
mother grieving a loss in childbearing to be of a suitably
high standard, there needs to be a suitably strong knowl-
edge base. Although obtaining such knowledge is not easy,
it is only by obtaining and using it that midwives are able
to give this mother and family the high standard of care
facilitates healthy grieving in the mother, having avoided
the impediments that interfere with or complicate her grief
and prevent its resolution. In this most human of situa-
tions, midwives must remember that ‘being nice’ is not
enough; they need to ensure that midwifery care is based
on a firm knowledge base if the woman is to come to terms
with her loss. Other, less widely recognized or discussed
forms of loss in childbearing have also been addressed.

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FURTHER READING
Dickenson D, Johnson M, Samson Katz Field D, Hockey J, Small N 1997 Death,
J 2000 Death, dying and bereavement,
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An easily readable examination of a wide
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Mander R 2001a Death of a mother:
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Mander R 2001b The midwife’s ultimate
paradox: a UK-based study of the
death of a mother. Midwifery
17(4):248–59
Mander R 2004a Men and maternity.
Routledge, London
Mander R 2004b When the professional
gets personal – the midwife’s
experience of the death of a mother.
Evidence Based Midwifery 2(2):
40–5
Mander R 2006 Loss and bereavement
in childbearing, 2nd edn. Routledge,
London
Mander R 2009 Good grief: staff
responses to childbearing loss. Nurse
Education Today 29(1):117–23
Mander R 2011 ‘Being with woman’: the
care of the childbearing woman with
cancer. In: Fawcett T F and McQueen
A (eds) Perspectives on cancer care.
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2003 Does stress influence early
pregnancy loss? Annals of
Epidemiology 13(4):223–9
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1990 Miscarriage. Penguin,
Harmondsworth
Peppers L, Knapp R 1980 Maternal
reactions to involuntary fetal/infant
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Rådestad I, Steineck G, Nordin C et al
1996a Psychological complications
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Journal 312:1505–8
Rådestad I, Nordin C, Steineck G et al
1996b Stillbirth is no longer
managed as a non-event: a
gender and ethnicity. Routledge,
London
nationwide study in Sweden. Birth
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Rajan L 1994 Social isolation and
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RCOG (Royal College of Obstetricians
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RCP (Royal College of Pathologists)
2000 Guidelines for the retention of
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Reid M 2007 The loss of a baby and the
birth of the next infant: the mother’s
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Samuelsson M, Rådestad I, Segesten K
2001 A waste of life: fathers’
experience of losing a child before
birth. Birth 28(2):124–30
Shah, P E, Clements M, Poehlmann J
(2011) Resolution of grief following
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Simmons R K, Singh G, Maconochie N
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Sorosky A D, Baran A, Pannor R 1984
The adoption triangle. Anchor
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Vera M 2003 Social dimensions of grief,
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Walter T 1999 On bereavement: the
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Midwifery 4(5):239–43
An in-depth exploration of relevant
psychoanalytical issues.

Kenworthy D, Kirkham M 2011
Midwives coping with loss and grief.
Radcliffe, London
A thought-provoking, yet accessible, analysis
of the midwife’s experience of caring for a
grieving woman.
Mander R 2006 Loss and bereavement
in childbearing, 2nd edn. Routledge,
London
A wide-ranging exploration of issues
relating to childbearing loss, using research
and other knowledges.
USEFUL WEBSITES
Registration and other statutory
documentation of a stillborn
baby
England & Wales: www.gro.gov.uk/
gro/content/certificates/default
.asp
Scotland: www.gro-scotland.gov.uk/
regscot/registering-a-stillbirth
.html
Northern Ireland: www.belfastcity.gov
.uk/deaths/stillbirths.asp?menuitem
=registering-a-stilldeath
Support groups
The Miscarriage Association:
www.miscarriageassociation.org.uk/
SANDS (Stillbirth and Neonatal Death
Society): http://uk-sands.org/
mebooksfree.com
Bereavement and loss in maternity care
Schott J, Henley A 1996 Childbearing
losses. British Journal of Midwifery
4(10):522–6
The implications of cultural and religious
variations in the context of childbearing
loss.
Thompson N 2002 Loss and grief: a
guide for human services
practitioners. Palgrave Macmillan,
Basingstoke
Very relevant for midwives.
CRUSE Bereavement Care:
www.crusebereavementcare.org.uk/
BLISS – The Premature Baby Charity:
www.bliss.org.uk/
TCF – The Compassionate Friends (UK):
www.tcf.org.uk/
Support for bereaved parents and their
families.
Born with Wings:
www.bornwithwings.co.uk/
Support for parents from parents.
EPT Ectopic Pregnancy Trust:
www.ectopic.org.uk/
NORCAP: www.norcap.org.uk/
Support for adults affected by adoption.
Infertility Network UK:
www.infertilitynetworkuk.com/
Advice, support and understanding.
Chapter | 26 |
Walter T 1999 On bereavement: the
culture of grief. Open University
Press, London
A scientific examination of the social
aspects of bereavement in general.
Wimpenny P, Costello J (eds) 2012
Grief, loss and bereavement:
evidence and practice for health and
social care practitioners. Routledge,
London
Some up-to-date ideas and recent
developments.
SOFT UK: www.soft.org.uk/
Support organization for trisomy 13/18 and
related disorders.
ARC Antenatal Results & Choices:
www.arc-uk.org/
Incorporating SATFA (Support Around
Termination for Abnormality).
Support for the Midwife
AIMS – Association for Improvements
in Maternity Services:
www.aims.org.uk/
Midwifery Supervisor and Local
Supervising Authority
RCM – Royal College of Midwives:
www.rcm.org.uk/
The Local Steward or Regional Officer can
be contacted via the website.
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 Chapter 27
Contraception and sexual health in
a global society
Karen Jackson

CHAPTER CONTENTS Fertility monitoring device 584

Lactational amenorrhoea method (LAM) 584
The role of the midwife 570 Male and female sterilization 585
Hormonal contraceptive methods 570 Female sterilization 585
The combined hormonal contraceptive pill 570 Male sterilization (vasectomy) 586
The combined hormone injectable The future of contraception and sexual
(Lunelle) 574 health services 586
The combined hormone patch 574 Ongoing developments 586
The combined hormone vaginal ring 574 References 587
The progestogen-only pills 574 Further reading 588
Long acting reversible contraception Useful websites/contacts 588
(LARC) 575
Progestogen injections 575 Contraception and sexual health are important
Subdermal contraceptive implants 576 considerations for women of childbearing age.
Intrauterine contraceptive device (IUCD) 577 There are numerous ways in which women
can control their fertility, but the choice of
Progestogen-releasing intrauterine system contraception will depend on a multitude of
(IUS) 578 factors, including: method of infant feeding, age,
Barrier methods of contraception (male culture, religion, access to contraception and
and female methods) 578 previous experience. Women with additional
Male condom 578 challenges such as physical, sensory or cognitive
needs, or those who do not speak or read
Female condom 578
English, may need extra support and information
Diaphragm 578 to enable them to make informed decisions
Cervical and vault caps 581 about postpartum contraception.
Spermicidal products 581
Emergency contraception 581 THE CHAPTER AIMS TO:
Coitus interruptus 582
• provide up-to-date knowledge of all forms of
Fertility awareness (Natural Family contraception
Planning) 582
• emphasize the role of the midwife in providing
Fertility awareness methods 583 contraceptive information and advice for women in
Symptothermal methods 584 their care.

© 2014 Elsevier Ltd 569

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Section | 5 | Puerperium
THE ROLE OF THE MIDWIFE
The midwife has a unique and pivotal role in discussing
contraception and sexual health. The Nursing and Mid-
wifery Council (NMC) in the United Kingdom (UK) states
that one of the activities of a midwife is to provide sound
family planning information and advice (NMC 2012).
Midwives are encouraged to take on a wider public health
role and are in a key position to create and use opportuni-
ties to enable women to express their needs in respect of
choice of contraception.
The most appropriate time to discuss sexual health,
resumption of sexual activity and contraception will, in
some respect, be dependent on the individual woman.
Some midwives may feel that any encounter with post­
natal women, even soon after giving birth, will capitalize
on contraceptive and sexual health education opportuni-
ties. The National Institute for Health and Clinical Excel-
lence (NICE) (2006) recommends that contraception
advice should be imparted within a week of the birth.
Issues such as loss of libido, adjustment to motherhood,
breastfeeding, discomfort of the perineum, vaginal dryness
and body image may also influence choice and use of a
particular method of contraception (Faculty of Sexual and
Reproductive Healthcare Clinical Effectiveness Unit
[FSRH] 2009a). The use of a leaflet from the Family Plan-
ning Association (FPA) can be helpful as such leaflets are
clear to understand in both text and illustration, and are
in a variety of languages. The midwife should be familiar
with the contraception and sexual health services available
in the area in which she practises and know the system of
referral to these specialist services.
For contraceptive methods discussed in this chapter,
the efficacy rate is given as a percentage. This rate does
not reflect the fact that fertility decreases with age and
may be suppressed during lactation, or that the success
of a method is partially dependent on motivation, experi­
ence of using the method and the teaching received on
its use. It is recognized that if 100 sexually active women
do not use any contraception, 80–90 of them will
become pregnant within a year (FPA 2012). Sexual inter-
course following childbirth is a hitherto seldom dis-
cussed issue. McDonald and Brown (2013) found in their
study of 1507 primigravidae that almost 60% of the
women had not resumed intercourse six weeks following
the birth. Discussions need to take place well before this
time to ensure no unintended pregnancies occur. Some
women may even appreciate information on contracep-
tion in the antenatal period, to give them plenty of time
to decide which contraceptive method would be right for
them. Partnership working between the new mother and
midwife is essential and conversations regarding contra-
ception should take place in a quiet, relaxed setting, with
the midwife having up-to-date knowledge on all methods
available.
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In the UK, all contraception is available free of charge
from the National Health Service (NHS). This is different
in other parts of the world, with a range of charges for
certain methods of contraception.
HORMONAL CONTRACEPTIVE
METHODS
The combined hormonal
contraceptive pill
The combined oral contraceptive pill (COC or ‘the pill’)
(Fig. 27.1) came as a breakthrough, in 1960, in terms of
women being in a better position to control their fertility.
This method has subsequently proven to be both effective
and safe. The overall use varies greatly between countries
but it is estimated to be used by approximately 1% of
Japanese women who are married or in a union, 53% in
Germany, 28% in the UK and 50% of women in Western
Europe (Guillebaud and MacGregor 2013). In the UK,
approximately 95% of women under the age of 30 have
used oral contraceptives at some time. Around 100 million
women rely on the pill worldwide (Guillebaud and
MacGregor 2013).
The combined pill contains the synthetic steroid hor-
mones oestrogen and progestogen. All COCs available in the
UK contain ethinyl oestradiol, with the exception of
Norinyl-l, which contains mestranol and Qlaira which
contains estradiol valerate. There are a variety of COCs
available containing different progestogens. This accounts
for subtle differences in their biological effects and pro-
vides women with a wide choice. The most commonly
used pills in the UK are monophasic pills, which deliver a
constant dose of steroids throughout the packet. ‘Everyday’
pills contain 28 pills in each packet, 21 of which are active
monophasic pills while the seven remaining pills contain
no hormones (FPA 2012).
Also available are biphasic and triphasic pills, in which
the dose of steroids administered varies in two or three
phases throughout the packet to mimic the natural fluc-
tuations of the hormones during the menstrual cycle.
These pills are less commonly used in the UK. A relatively
new pill, called Qlaira, is licensed in the UK; it is a complex
quadraphasic pill designed to give optimal cycle control. It
is taken every day but has two placebo tablets.
The first generation COC pills contained large doses of
oestrogen and were associated with a high risk of deep vein
thrombosis. They were replaced in the late 1960s with pills
that had lower doses of oestrogen and progestogen. They
were equally as effective as the earlier pills, being much
safer and better tolerated. The progestogens in these second
generation pills were norethisterone and levonorgestrel.
The third generation pills, which came along in the mid-
1980s, contained a variety of new synthetic progestogens,
 Contraception and sexual health in a global society Chapter | 27 |

Oestrogen dominance Progesterone dominance

Intermediate

• Ovysmen • Microgynon* = Rigevidon • Eugynon†

OVRAN 50 • Brevinor • Loestrin 20
• Marvelon = Gedarel 30/150 • Mercilon
• Cilest • Loestrin 30
NORINYL • Femodene • Femodette †
• Norimin Now off the UK market
• Katya 30/75 • Sunya 20/75
• Synphase • Triphasics (Trinovum, Logynon,
Trinordiol)
Progestogenic side-effects
• Biphasics (Binovum)
Oestrogenic side-effects • Dianette
• Yasmin
• Mood swings
(Evra patch)
• Reduced libido
• Menorrhagia (Nuva ring)
• Amenorrhoea
• Cyclical weight gain (Lunelle injection)
• Bloating
• > BP (Cyclofem injection)
• Weight gain
• Headaches / Migraine * Most commonly prescribed for • Poor cycle control
• Nausea / Vomiting the first time (R/O Missed pills
• Chloasma Infection
• Excessive vaginal secretion / Drug interaction
Leucorrhoea (R/O infection) Vegetarian)
• Acne
• Breast tenderness

Fig. 27.1 The combined hormonal contraceptive choices.

that appeared to have better effects on serum lipid profiles.
Among these were desogestrel and norgestimate, which
were also less androgenic; gestodene, which was the most
potent, achieving the best cycle control; and cyproterone
acetate, which was anti-androgenic but licensed only as a
treatment for acne. Drospirenone has been available from
the late 1990s, with mild antimineralocorticoid activity to
counteract oestrogen-induced water retention. It is also
anti-androgenic.
Mode of action
Combined oral contraceptives work primarily by prevent-
ing ovulation. The first seven active pills in a packet inhibit
ovulation and the remaining pills maintain anovulation
(FSRH 2011a).
Oestrogen and progestogen suppress follicle stimulating
hormone (FSH) and luteinizing hormone (LH) produc-
tion causing the ovaries to go into a resting state; the
ovarian follicles do not mature and ovulation does not
normally take place. Progestogen also causes the cervical
mucus to thicken, making penetration by spermatozoa
difficult. The pill renders the endometrium unreceptive to
implantation by the blastocyst. These actions provide
additional contraception in the event of breakthrough
ovulation occurring.
Efficacy
Provided that the pill is taken correctly and consistently,
and that it is absorbed normally and interaction with
other medication does not affect its metabolism, its
reliability with consistent perfect use is almost 100%
(Guillebaud and MacGregor 2013).
Important considerations
The combined oral contraceptive pill is a reliable contra-
ceptive, which is independent of sexual intercourse and

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Section | 5 | Puerperium
has many advantages. Healthcare providers should manage
consultations for contraceptive pills with due regard
for the woman’s personal context and contraception
experience.
Additional benefits of taking the COC pill, in the short
term, are regular, lighter, less painful periods, possible
reduction in premenstrual symptoms, reduction in acne,
protection against pelvic inflammatory disease (PID)
(because of the thickened cervical mucus), decreased inci-
dence of ectopic pregnancy and reduced risk of benign
breast disease. Taken long term, COC pills offer protection
against ovarian and endometrial cancers and reduction in
the incidence of ovarian cysts and benign ovarian tumours
(FSRH 2011a).
Use of the COC pill may lead to side-effects such as
irregular bleeding, headaches, nausea and breast tender-
ness; there is little evidence to support the association of
weight increase, depression and COC use (FSRH 2011a).
These effects often diminish with continued use or may
improve with a change of pill. A basic knowledge of the
side-effects attributable to the components of the COC pill
is helpful when making decisions about changing pills.
Oestrogen dominance in a pill may cause water reten-
tion, resulting in breast tenderness, mild headaches, ele-
vated blood pressure and cyclical weight gain. It may also
be responsible for nausea and vomiting, excessive vaginal
secretion (leucorrhoea) and skin pigmentation similar to
chloasma. The progestogens may lower mood and libido,
provoke acne and seborrhoea and cause mastalgia.
The vast majority of women experience no adverse
effects. Every woman is unique in their biological response
and also in their perception and tolerance of side-effects.
The metabolic effects of the COC pill can occasionally
result in major side-effects. The risks of venous throm-
boembolism (VTE) with the COC pill, in absolute terms,
show a rarity of VTE in women of reproductive age (see
Table 27.1). The risk of VTE is higher in women with a
Body Mass Index (BMI) over 30, heavy smokers, those
with a previous history of deep vein thrombosis or a
family history of venous thrombosis and those who are
immobile.
Table 27.1 Risks of venous thromboembolism
Risk of VTE per
10 000 woman years
Not using COC 4–5
COC users (risk depends on 9–10
type of COC)
In pregnancy 29
Immediate postpartum 300–400
Adapted from FSRH 2011a
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Allan and Koppula (2012) concluded that the risks of
VTE when comparing all COCs appear to be unclear, but
if there are differences they are likely to be very small and
similar, therefore, any of the COCs may be considered
for prescription if this method has been chosen for
contraception.
Some women may develop a significantly high blood
pressure, which could increase the potential for haemor-
rhagic stroke and myocardial infarction. Hypertension
with a blood pressure (BP) between 141/91 mmHg and
159/94 mmHg is considered to be at a level of risk that
outweighs the benefits of using the COC. Hypertension
with BP of 160/95 mmHg or higher poses an unacceptable
health risk with COC use (FSRH 2011a).
Cigarette smoking is known to potentiate most of the
risks associated with COC pill use such as ischaemic and
haemorrhagic stroke and myocardial infarction (FSRH
2011a).
The research surrounding the risk of developing breast
cancer for COC users is largely contradictory, but it is
widely acknowledged that there is a small increase in this
risk (FPA 2012). Any excess risk of breast cancer associated
with COC use declines in the first ten years after discon-
tinuing the pill.
Studies show a small increase in the relative risk of cervi-
cal cancer, which is associated with a long duration of use
(Guillebaud and MacGregor 2013). However, the effects of
confounding factors such as sexually transmitted infec-
tions (STI), non-use of barrier methods and a high number
of sexual partners may distort an accurate understanding
of the influence of the COC pill.
Contraindications to COC pill use are pregnancy, undi-
agnosed abnormal vaginal bleeding, history of arterial or
venous thrombosis (or predisposing factors such as immo-
bility), hypertension, focal migraines, current liver disease,
trophoblastic disease (until serum human chorionic gona-
dotrophin [hCG] is no longer detectable), smoking (if the
woman’s age is over 35 years) and a BMI over 39. This is
not an exhaustive list. As the pill is not suitable for every-
one, women wishing to consider using this form of con-
traception should have a full history recorded and be fully
informed and counselled regarding possible side-effects.
Using the COC pill
When initially commencing the pill, the very first pill is
usually taken on the first day of the menstrual period (for
postpartum use, see later). Starting on any day up to the fifth
day is just as effective, provided the first seven pills are
taken correctly. If a 21-day pill has been prescribed, the
contraceptive effect is immediate, provided that the
remainder of pills in the packet are taken correctly. If
the pill is initially commenced on any day beyond the
fifth day of the cycle, additional contraception (such as a
condom) should be used in conjunction with the pill for
the first seven days. It is recommended that Qlaira is taken
 Contraception and sexual health in a global society
on the first day of the menstrual cycle, and if taken on any
other day, additional contraception should be used for
nine days. One pill is taken every day for 21 days, then no
pills for the next seven days. Vaginal bleeding usually
occurs within the seven day break, before the next packet
of pills is commenced (FPA 2012).
When commencing the ‘Everyday’ (ED) COC pill, the
active pills are taken first. One pill is taken daily, with
care to take the pills in the correct order. Vaginal bleed-
ing will usually occur when the inactive pills are taken,
which are usually denoted by a different coloured section
on the pill packet. If two or more pills have been missed,
or the next pack of pills is two or more days late, the
advice given in Fig. 27.2 should be followed. If a pill is
forgotten from the beginning or end of a packet, the pill-
free interval is lengthened and ovulation may be more
likely to occur (FSRH 2011a). If a woman is concerned
about a missed or late pill, she can contact the local con-
traception clinic or General Practitioner (GP) for reassur-
ance or advice, as emergency contraception may be
indicated (see later).
Other factors that may render the pill less effective
include interaction with other medication, vomiting
within 2 hours of taking a pill and severe diarrhoea.
Medications that may hinder the effectiveness of the pill
include liver-enzyme-inducing drugs such as rifampicin,
some anticonvulsants and some herbal remedies, for
example St John’s wort. After absorption, synthetic oes-
trogen and progestogen are transported to the liver via
the portal vein. Liver-enzyme-inducing drugs reduce the
efficacy of the pill by increasing the metabolism, and
If one pill has been missed
Take the missed pill as soon as possible.
Continue taking the pills as normal.
No need for emergency contraception.
If other pills have been missed in the packet or missed at the end of the
previous package, emergency contraception may be required.
Fig. 27.2 Missed pill rule (FSRH 2011b).
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Chapter | 27 |
subsequent elimination of oestrogen and progestogen in
the bile. Some newer antiepileptics are not enzyme
inducers but the COC pill may reduce seizure control
with lamotrigine.
Please note that additional precautions are no longer
required when taking antibiotics (non-enzyme induc-
ing) (FSRH 2011a).
The advice to be given in cases of an illness with severe
vomiting and diarrhoea is to follow the missed pill rules.
It is important that women are made aware of possible
drug interactions and inform their medical practitioner/
GP that the COC pill is being taken whenever other medi-
cations are prescribed.
Preconception considerations
It is useful to wait for one natural period after discontinu-
ing the pill before trying to conceive as dating the preg-
nancy can be more accurate and pre-pregnancy care can
begin.
Postpartum considerations
The combined oral contraceptive pill reduces milk supply,
particularly if lactation is not well established, and is there-
fore not recommended for use in the early months in
lactating women. If the mother is bottle-feeding her baby,
the COC pill may be commenced 21 days postpartum. This
allows the high oestrogen levels of pregnancy to decrease
before introducing the pill (Guillebaud and MacGregor
2013), thus reducing the risk of thromboembolism, but
If two or more pills have been missed
Take the most recent missed pill as soon as possible.
Continue taking the pills as normal.
Condoms should be used or sexual intercourse avoided until seven active
pills have been taken.
Emergency contraception may be required depending on where in the
packet pills have been missed and if unprotected intercourse has occurred.
Woman should seek advice from GP, contraception clinic etc.
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Section | 5 | Puerperium
allowing the contraceptive effect to be initiated before
ovulation resumes. Women who have experienced
pregnancy-induced hypertension should be assessed on an
individual basis with regard to recommencing COC use
(Guillebaud and MacGregor 2013).
The COC pill can be commenced immediately follow-
ing spontaneous miscarriage or therapeutic termination of
pregnancy. Due to the risk of thromboembolism, the COC
pill should be discontinued 4 weeks before major surgery
and a progestogen-only method of contraception used. If
this is not possible, then thromboprophylaxis and com-
pression hosiery are advised. Women who have minor
surgery do not need to discontinue taking the pill.
Further postpartum considerations for discussion with
the mother may include whether remembering to take the
pill will fit into her current lifestyle and if she can easily
access a clinic or doctor’s surgery. Appropriate follow-up,
including blood pressure assessments, should be con-
ducted. Following the first prescription, follow-up is
usually at 3 months postpartum and thereafter it may be
annually.
The combined hormone
injectable (Lunelle)
Lunelle contains 25 mg medroxyprogesterone acetate and
5 mg estradiol cypionate. It is not yet licensed in the UK
due to its poor uptake and subsequent withdrawal from
the market in the United States of America (USA), but it
is popular in South America and Asia (Guillebaud and
MacGregor 2013). Lunelle is commenced on the first day
or within five days of a menstrual period, and given every
28–33 days. It is both effective and reversible. Side-effects
include breakthrough bleeding and weight gain. The effi-
cacy is comparable with perfect use of the COC pill.
Cyclofem and Mesigyna are similar monthly injections
also available to women in many countries outside of the
USA, mainly in South America and Asia.
The combined hormone patch
The combined hormone patch (EVRA) was licensed in the
UK in 2003. One patch is used weekly for three weeks
followed by one week patch-free. It is particularly suitable
for women who are unable to tolerate oral medications
and those with malabsorption syndrome. It releases 20 mg
of ethinyl oestradiol and 150 mg of norelgestromin every
24 hours. Compliance and cycle control may be improved.
The efficacy of the combined hormone patch is compara-
ble with the COC pill. The patch may be worn on most
places on the body except the breasts. It is extremely sticky
and should stay on during showering or swimming.
The FPA (2011a) suggest it may be used from day 21 in
the postnatal period. However, if the mother is breastfeed-
ing her baby, the patch should not be recommended as it
will reduce breast milk production.
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The combined hormone
vaginal ring
The combined hormone vaginal ring (NuvaRing) is
inserted into the vagina on the first day of the menstrual
cycle. If inserted at any other time additional contracep-
tion such as condoms should be used for seven days. It is
then used continuously for three weeks followed by one
week free of its use. It releases 15 mg of ethinyl oestradiol
and 120 µg of etonogestrel per 24 hours. The NuvaRing
appears to be acceptable to many women and well toler-
ated, with studies finding that compliance and cycle
control are also remarkably good (Roumen et al 2006;
Brucker et al 2008). The efficacy of the NuvaRing is com-
parable with the COC pill.
The progestogen-only pills
Progestogen-only pills (POP) were introduced partly to
avoid the side-effects of oestrogen in the combined pill, as
discussed earlier. They also offer increased choice for
women. Currently available in the UK are the older prepa-
rations, which contain norethisterone (Noriday, Micro-
nor), etynodiol diacetate (Femulen) and levonorgestrel
(Norgeston) and the new anovulant progestogen-only
pills containing desogestrel (Cerazette). All have lower
doses of progestogen compared with the COC pill.
Mode of action
The POP exerts its contraceptive effects at different levels.
The cervical mucus is viscid, making it impenetrable to
spermatozoa and the endometrium is modified to prevent
implantation. The older POPs have been shown to sup-
press ovulation in up to 60% of women. The new POP
Cerazette is anovulant and also suppresses FSH and LH
consistently such that it is effective in about 97% of
women (FSRH 2008a).
Limitations to POP use include menstrual disturbances,
encompassing unpredictable and quite often prolonged
bleeding, oligomenorrhoea or amenorrhoea. Little is
understood about the mechanism of erratic uterine bleed-
ing, which most women experience to some degree. The
menstrual disruption is the most common reason for dis-
continuation of progestogen-only methods. This indicates
the need for careful explanation of the limitations to
potential users.
An increased prevalence of functional ovarian cysts has
been demonstrated in women using progestogen-only
pills. These may settle with continuation of use and will
resolve if the POP is discontinued.
Contraindications to the use of progestogen-only-pills
are pregnancy, undiagnosed abnormal vaginal bleeding,
severe arterial disease and hydatidiform mole (until serum
hCG is no longer detectable). The rate of ectopic preg-
nancy in women using the progestogen-only pill is no
 Contraception and sexual health in a global society
higher than in women using no contraception; however,
the POP prevents uterine pregnancy more effectively than
tubal pregnancy. This is not a problem with the anovulant
POP Cerazette.
Antibiotics do not adversely affect progestogen-only
methods of contraception but women should be advised
to consult the doctor/GP regarding possible interactions if
any other medications (especially enzyme inducers such
as rifampicin) are prescribed.
Preconception considerations
There is no evidence of a teratogenic effect with
the POP.
Postpartum considerations
Progestogen-only-pills may be commenced 21 days post-
partum for contraception. These pills have no adverse
effect on lactation. Secretion of the hormone in breast
milk and absorption by the neonate is minimal and does
not affect the short-term growth and development
of infants. The POP can be used immediately following
spontaneous miscarriage or therapeutic termination of
pregnancy.
Using the POP
The POP is taken every day as there are no pill-free days
and thus tablets are taken throughout the menstrual
period. If the first tablet is taken on the first to fifth day of
the menstrual cycle, the contraceptive effect is immediate.
If the POP is started on any other day of the cycle then
additional contraception, such as a condom, should be
used for the first two days (FSRH 2008a).
If a pill is forgotten, the woman has only 3 hours in
which to remember to take it. If the woman is over 3 hours
late in taking a pill, she should continue taking her pills
and use additional contraception for the next two days.
However, with the anovulant POP Cerazette, the woman
has up to 12 hours in which to remember to take the
forgotten pill.
Following vomiting or severe diarrhoea, additional con-
traception should be used until two days after the illness
ceases. Women concerned about missed or late pills
should be advised to contact their contraception and
sexual health clinic or GP, as emergency contraception
may be indicated (see later). The effects of broad-spectrum
antibiotics on the gut flora do not affect the action of the
POP.
Efficacy
The effectiveness of the older POP is dependent upon
meticulous compliance. With perfect use, the POP is more
than 99% effective (FSRH 2008a).
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Chapter | 27 |
LONG ACTING REVERSIBLE
CONTRACEPTION (LARC)
Contraceptives that are used daily or weekly sometimes
fail because of non-adherence or incorrect use. A LARC is
defined by NICE (2005) as contraceptive methods that
require administration less than once per menstrual cycle
or month. These guidelines recommend giving women
wider access to long acting reversible contraceptive (LARC)
methods, as a feasible way to reduce unintended preg-
nancy (NICE 2005). Long acting reversible contraceptive
methods are considered to be more reliable and cost-
effective than other methods.
Long acting reversible contraceptive methods include
injectable progestogen contraceptives, intrauterine contra-
ceptive devices (IUCD), intrauterine hormonal systems
and subdermal contraceptive implants. These are all avail-
able in the UK but usage remains low due to inadequate
awareness of their availability and access as most GPs and
practice nurses do not fit implants and intrauterine
methods of contraception.
For a long acting method to be initiated, informed
choice is crucial because only women who have realistic
expectations may tolerate protracted side-effects. The
implants and intrauterine systems are expensive, therefore
a reasonable continuation rate is pertinent.
Progestogen injections
The two contraceptive progestogen injections currently
available in the UK are Depo-Provera, or depot medroxy-
progesterone acetate (DMPA), and Noristerat (norethister-
one enanthate). Both methods are given by deep
intramuscular injection.
DMPA is the method of choice for many women, not
simply those for whom other methods are contraindi-
cated. Over 6 million women use this method in 130
countries worldwide, and in some countries, for example
South Africa, it is the most commonly used reversible
method. In the UK, less than 2% of women attending
contraception clinics use injectables. The progestogen
injections prevent ovulation, thicken cervical mucus and
cause atrophy of the endometrium.
Depot medroxyprogesterone acetate
This is the most commonly used injectable and is given in
a 150 mg dose at 12 week intervals. It is released slowly
from the injection site into the circulation. DMPA is more
than 99% effective. Prolonged spotting, however, is a
common side-effect in the first year but amenorrhoea
often prevails in long-term use. Some DMPA users experi-
ence other side-effects such as breast discomfort, nausea,
vomiting, weight gain, seborrhoea, acne and mood swings.
It is now recognized that amenorrhoea for more than two
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Section | 5 | Puerperium

years with DMPA is associated with chronic low serum
oestrogen and reduced bone density. All women choosing
DMPA should be aware of this information. Teenagers,
who will not have attained peak bone mass, should be
advised to use other methods. The peak bone mass is
attained around the age of 30 years. Women who have
been amenorrhoeic for more than three years receiving
DMPA should have their bone density assessed with dual
X-ray absorptiometry (DEXA) scan. It may be reassuring
to learn that reduced bone mineral density (BMD) when
using DMPA does not progress indefinitely but usually
stabilizes after about five years. The BMD returns to normal
after discontinuation (Scholes et al 2005).
Depot medroxyprogesterone acetate can offer addi-
tional health benefits for women with homozygous sickle
cell haemoglobinopathy by reducing haemolytic and bone
pain crises (Guillebaud and MacGregor 2013).
After discontinuation of DMPA, there may be a delay in
the return of fertility for up to 18 months.
Norethisterone enanthate (NET-EN)
Marketed as Noristerat, this injectable contraceptive is
given intramuscularly in a 200 mg dose at 8 week inter-
vals. It is used more commonly in Germany and many
developing countries. Noristerat is more than 99% effec-
tive and its side-effects are similar to DMPA.
Using injectable progestogens
If the initial injection is given within the first five days of
the menstrual period (preferably days 1 to 3), the contra-
ceptive effect is immediate. If given at any other time, the
practitioner must ensure that there is no likelihood of
pregnancy already and advise that additional contracep-
tive cover is required for the next seven days (Guillebaud
and MacGregor 2013).
ensure lactation is well established and reduce bleeding
problems.
Subdermal contraceptive implants
Contraceptive implants have been used internationally for
several years. Norplant was used in the UK from 1993 and
replaced by Implanon from 1999. Nexplanon, however,
replaced Implanon in 2010. The differences in the more
recent implant are that the rod is radio-opaque, containing
barium in order to locate it on X-ray if necessary, and it
has a pre-loaded applicator which has been designed to
reduce insertion errors.
Using implants
Implants are capsules containing progestogen, which are
inserted under local anaesthetic into the inner aspect of
the non-dominant upper arm (Fig. 27.3). The steroid is
released into the circulation, producing a change in the
cervical mucus which prevents spermatozoa penetration,
disturbance of the maturation of the endometrium and
suppression of ovulation.
Norplant, which had six capsules containing levonor­
gestrel, has been replaced by Norplant 2 (also marketed
as Jadelle), which has two capsules. Jadelle is effective for
5 years and still available in many developing countries.
Nexplanon and Implanon are single contraceptive rods
containing 68 mg of etonogestrel. These single contracep-
tive rod devices should be inserted during the first five days
of the menstrual cycle and no additional contraceptive
cover is required. Ovulation is suppressed within 24
hours. They are effective for 3 years but can be removed at
any time if the woman wishes. After removal, the serum

Specific considerations
This method is irreversible from the time of action, there-
fore any side-effects may be present until the injection
wears off. The efficacy of DMPA and NET-EN is not affected Actual size
by concurrent use of liver enzyme-inducing medications.

Preconception considerations
Injectable progestogen is not recommended as contracep-
tion for women who plan to conceive soon.

Postpartum considerations
Injectable progestogen contraceptives can be given prior
to the 21st day postpartum, thus preventing the earliest
ovulation; however, the woman must be warned about
the increased risk of bleeding. It can be used by women
who are breastfeeding their baby but delaying com-
mencement until 6 weeks postpartum is often advised to Fig. 27.3 Subdermal implant.

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 Contraception and sexual health in a global society
is cleared of etonogestrel within 1 week and fertility is
promptly regained.
Efficacy
Norplant is more than 99% effective. Nexplanon and
Implanon have practically zero failure rates if instructions
are carefully followed (Guillebaud and MacGregor 2013).
Reported implant failures are often due to interaction with
enzyme-inducing medications used concurrently, failing
to recognize that the implant has been incorrectly inserted
and failing to recognize the woman is pregnant before the
fitting.
Specific considerations
Irregular bleeding is the most common problem for
women using subdermal contraceptive implants. Only
20–30% of users become amenorrhoeic, however head-
ache, seborrhoea, acne and mood swings have also been
reported as side-effects. Insertion and removal require a
minor surgical procedure, with accompanying risks of
bleeding and infection. These aspects should be discussed
prior to the woman making her decision. Counselling
before fitting and during use appears to be the only
way to reduce premature discontinuation due to the
side-effects.
Preconception considerations
The action of the implant is quickly reversible and ovula-
tion can return within 21 days of removal in 94% of
women (FSRH 2008b). This makes it suitable also for
women wishing to ‘space’ pregnancies.
A B
Fig. 27.4 Intrauterine contraceptive devices (IUDs). After insertion through the cervix, the framed devices assume the
shape shown; the threads attached to it protrude into the vagina. (A) Copper-carrying device. (B) Frameless copper device.
(C) Levonorgestrel-releasing system.
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Chapter | 27 |
Postpartum considerations
If the implant is inserted up to or at 21 days postpartum
it is effective immediately; however, if it is inserted after
the 21st day postpartum, additional contraception, such
as a condom, should be used. The implant is safe for
women who are breastfeeding their babies. The implant
can also be inserted immediately after miscarriages or
induced terminations of pregnancy. No extra contraceptive
precautions need to be taken.
Intrauterine contraceptive
device (IUCD)
These devices are inserted into the uterus, as illustrated in
Fig. 27.4. They contain copper, which increases contracep-
tive efficacy. There seems to be an aversion for the use of
IUCDs and progestogen-releasing intrauterine systems
(IUS) in the UK, where only 6% of women use them
(Guillebaud and MacGregor 2013). The IUCD is the most
popular method in some countries and 150 million
women worldwide use IUCDs, of which 60 million are in
China.
Mode of action
The IUCD creates an inflammatory response in the
endometrium. Leucocytes are capable of destroying sper-
matozoa and ova. Gamete viability is also impaired by
alteration of uterine and tubal fluids. Copper affects
endometrial enzymes, glycogen metabolism and oestro-
gen uptake, thus rendering the endometrium hostile to
implantation, consequently IUCDs are more than 99%
effective (see Fig. 27.4A).
C
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Section | 5 | Puerperium
Using the IUCD
A copper IUCD can be inserted any time during the men-
strual cycle if it is certain that the woman is not pregnant,
or up to 5 days following the earliest estimated date of
ovulation: that is, day 19 in a 28-day cycle, when it will
be effective immediately. The woman may experience
some discomfort during the procedure, which should be
performed using aseptic techniques. Depending upon the
type of IUCD used, it may be left in place from 5–10 years
and longer in some instances; e.g. if a woman aged 40
years or over has an IUCD fitted, it may remain in place
until one year after the menopause, if this occurs after the
age of 50. Once in situ, the device requires no action of
the user and it does not interfere with sexual intercourse.
Women are usually taught to feel the threads attached to
the IUCD on a regular basis as reassurance that it remains
in place. A follow-up appointment in 3–6 weeks following
insertion is recommended to assess for any infection,
translocation or expulsion. Subsequently the woman
requires further follow-up appointments only if she has
any concerns. The traditional routine annual review is no
longer recommended (NICE 2005).
Side-effects of using the IUCD include menorrhagia,
dysmenorrhoea, bacterial vaginosis and colonization by
Actinomycetes-like organisms. When the latter is reported in
a routine cervical smear, the woman should be counselled
about the options of either changing the IUCD or retaining
it and being reviewed periodically to ensure there is no
pelvic infection. Removal of the IUCD whenever desired is
easy and painless, and fertility is promptly restored.
The suggestion that IUCDs promote pelvic inflam­
matory disease (PID) has been refuted. Clinical risk
assessment for sexually transmitted infection (STI) is rec-
ommended (Guillebaud and MacGregor 2013). Routine
or selective screening for chlamydia and gonorrhoea may
be appropriate in some cases, where prompt treatment
and contact tracing will be offered. Intrauterine contracep-
tive devices are associated with a decreased risk of ectopic
pregnancies because of their effectiveness. However, in the
unlikely event that a pregnancy should occur, the ratio
of ectopic to intrauterine pregnancies is greater among
women using IUCDs, as in general the device prevents
more intrauterine pregnancies than ectopic pregnancies.
Thus a woman who has an IUCD fitted should be advised
to seek early medical advice, should she suspect that she
is pregnant.
If uterine pregnancy occurs, there is an increased risk of
spontaneous miscarriage, therefore gentle removal of the
device is preferred, to prevent infection and premature
labour. If removal is not possible, it is reassuring to know
there is no evidence of teratogenicity in the fetus.
A newer frameless device, GyneFix, as shown in Fig.
27.4(B), comprising six copper sleeves crimped onto a
polypropylene monofilament thread, is fitted with one
end embedded into the fundal myometrium of the uterus.
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This device is associated with lower expulsion rates and
less dysmenorrhoea.
Progestogen-releasing intrauterine
system (IUS)
The intrauterine system was developed to overcome some
of the problems associated with conventional IUCDs and
heavy menstrual bleeding. The progestogen-releasing
intrauterine system in current use consists of a small
plastic T-shaped frame carrying a Silastic sleeve loaded
with 52 mg of levonorgestrel (see Fig. 27.4C). It is inserted
into the uterus and the steroid hormone is released stead-
ily at 20 µg/day. The hormone prevents endometrial pro-
liferation, thickens the cervical mucus and may suppress
ovulation in some cycles. The frame, by inducing a sterile
inflammatory reaction, may also contribute to the contra-
ceptive effect. The system is fitted within the first seven
days of the menstrual period, when the contraceptive
effect is immediate. It is licensed for 5 years of use and is
more than 99% effective. A new frameless device contain-
ing progestogen has already been developed (Fibroplant-
LNG) and has been trialled in several countries, including
Belgium. In addition, a lower dose T-frame IUS called
Femilis (Femilis Slim for nulliparae) have been developed
with trials also being undertaken in Belgium regarding
its use and efficacy. It is not known, however, if these
products will be introduced into the UK market in the
near future.
Specific considerations
Irregular vaginal bleeding is common initially with the
IUS, and then it gradually ceases. The uterine bleeding
associated with the IUS is lighter than the menstrual
period experienced when using a copper IUCD, with pos-
sible amenorrhoea in the long term. The failure rates of
both intrauterine methods compare favourably with
female sterilization.
Postpartum considerations
The IUS and copper IUCD have no adverse effect on lacta-
tion. They can be inserted 4 weeks after vaginal birth or
Caesarean section (FSRH 2009b). Following miscarriage
or induced termination of pregnancy, immediate insertion
is safe.
BARRIER METHODS OF
CONTRACEPTION (MALE AND
FEMALE METHODS)
Barrier methods of contraception prevent the sperm
coming into contact with the oocyte. These methods
 Contraception and sexual health in a global society
include male and female condoms, caps and diaphragms
which can be used in conjunction with spermicidal prepa-
rations to further increase their efficacy.
Some of the advantages of using condoms are that they
are easily available at many outlets in the UK and using
them does not require medical intervention. They offer
some protection against STIs (FPA 2011b) and cervical
cancer and can be used with another method of contracep-
tion. This is often called ‘double Dutch method’. One of the
main disadvantages of using barrier methods of contracep-
tion is the possible interruption to sexual intercourse,
which may be off-putting for some couples.
It is good practice to ensure that anyone choosing a
barrier method is also aware of emergency contraception
and how to access it, should it be required.
Male condom
Some 4.4 billion couples worldwide use the male condom
(Fig. 27.5) for contraception, with 6 billion couples using
it for Human Immunodeficiency Virus (HIV) prevention.
However, there are striking geographical differences. Japan
accounts for more than one-quarter of all condom users
in the world, being used by 75% of the contraception-
using population. By contrast, and despite the substantial
Fig. 27.5 Male condom.
Photograph K Jackson.
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Chapter | 27 |
problem of HIV, the use of this method of contraception
remains remarkably low in Africa, the Middle East and
Latin America (Guillebaud and MacGregor 2013).
Guillebaud and MacGregor (2013) state that recent
studies show approximately 25% of all couples in the UK
use condoms but this may be occasional use or in addition
to other methods. There are many varieties of condoms on
the market, including latex, hypoallergenic and poly-
urethane. Polyurethane condoms are less sensitive to heat
and humidity and not affected by oil-based lubricants
(FPA 2011b).
Correct use of condoms is essential. Only condoms
with a CE (European standard) mark should be used and
the expiry date should be checked on the condom’s
package. Condoms should be stored away from extremes
of heat, light and damp and care should be taken when
handling the condom to prevent it from tearing. The
condom is rolled on to the erect penis before any genital
contact is made, as it is possible for some sperm to be
present in the pre-ejaculate (Guillebaud and MacGregor
2013). About 1 cm of air-free space must be left at the tip
of the condom for the ejaculate, otherwise the condom
may burst. Some condoms are designed with a teat end
for this purpose. The penis should be withdrawn very
soon after ejaculation before it reduces in size and the
condom becomes loose. The condom should be held in
place during withdrawal of the erect penis so that it does
not slip off. The condom should only be used once, and
then disposed of in a waste bin: it should not be flushed
down the toilet.
Oil-based lubricants can damage rubber condoms but
not polyurethane types. Water-based lubricants are not
known to cause damage and are therefore recommended.
The efficacy of the condom if used correctly is 98% but
is dependent on experience and age of the user.
Female condom
The female condom consists of a polyurethane sheath that
is inserted into the vagina (Fig. 27.6). The closed inner end
is anchored in place by a polyurethane ring, while the
outer edge lies flat against the vulva. It is available free
from contraception clinics and may be purchased from
selected chemists. Great care has to be taken to ensure that
the penis is inserted inside the polyurethane sheath and
not incorrectly positioned between the condom and the
vaginal wall.
The efficacy depends on age and experience of the user,
as with the male condom; however, the FPA (2011b) states
that if it is used correctly it is 95% effective.
Diaphragm
A diaphragm consists of a thin rubber dome with a metal
circumference to help maintain its shape (Fig. 27.7). A
range of types and sizes are available and, in the UK,
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Section | 5 | Puerperium

Fig. 27.8 The diaphragm in place.

diaphragms are individually fitted at contraception clinics

Fig. 27.6 Female condom.
Image reproduced courtesy of Sciencephoto, with permission.
and some GP practices. Less than 1% of women use this
method of contraception in the UK (Guillebaud and Mac-
Gregor 2013). It is not used widely in developing countries
and Guillebaud and MacGregor (2013) believe this may
be due to the fact that the device requires medical fitting.
When in place, the rim of the diaphragm should lie
closely against the vaginal walls and rest between the pos-
terior fornix and the symphysis pubis. Before insertion, a
spermicide should be applied. After insertion, the woman
has to check that her cervix is covered by the diaphragm
(see Fig. 27.8). In order to preserve spontaneity during
sexual intercourse, the diaphragm can be inserted every
evening as a matter of routine.
If sexual intercourse occurs more than 3 hours after
insertion of the diaphragm, then additional spermicide is
required. The diaphragm must be left in place for at least
6 hours after the last intercourse, to ensure any sperm
cannot reach the cervix. Once removed, the diaphragm
should be washed with a mild soap, dried and inspected
for any damage. A new diaphragm should be fitted
annually or following a loss or gain in weight of more
than 3 kg.
Efficacy depends on the age and experience of the user
and the FPA (2010a) quote that it is between 92% and
96% effective if used according to their guidance.
Cultural beliefs may affect use of this method, for
example in Judaism, where it is viewed as unacceptable to
use any method of contraception that prevents the sperm
from reaching its intended goal (Jogee 2004).

Postnatal considerations
The size of diaphragm should be reassessed at the
Fig. 27.7 The diaphragm. 6th week postpartum, when the vagina and pelvic
Image reproduced courtesy of Sciencephoto, with permission. floor muscles will have regained some of their tone and

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 Contraception and sexual health in a global society
Fig. 27.9 The cervical/vault cap.
Image reproduced courtesy of Sciencephoto, with permission.
any tissue injury sustained from the birth will have
healed.
Cervical and vault caps
Cervical and vault caps cover only the cervix, adhering to
it by suction. They are made of rubber and look smaller
in diameter than the diaphragm (Fig. 27.9). They require
fitting at a contraception clinic. Only one cervical cap, the
FemCap, is now available in the UK (Guillebaud and
MacGregor 2013).
Spermicidal products
Spermicidal agents have not been shown to increase effi-
cacy of condoms and because they can cause irritation to
genitalia, may in fact increase the risk of HIV transmission.
Use of Nonoxinol-9 lubricated condoms is no longer gener-
ally recommended. However, current advice is still to use
this spermicide with the female barrier methods – dia-
phragms and caps – as this has been shown to be beneficial
(Guillebaud and MacGregor 2013). Up until recently, a
range of spermicidal products were available for use in the
UK. However, the only product now available is Gygel, a
clear gel containing Nonoxinol-9. Spermicidal pessaries are
no longer available in the UK. Foams and aerosols are yet
to be introduced into the UK market, but may well be avail-
able in other countries (Guillebaud and MacGregor 2013).
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Chapter | 27 |
Efficacy
General teaching in the UK is that spermicidal products
are not effective when used alone.
EMERGENCY CONTRACEPTION
Emergency contraception is required when contraception
has not been used before, or during sexual intercourse,
used incorrectly or when there is perceived to have been a
failure in the contraception used, e.g. a condom mishap
such as breaking, tearing or coming off. There are three
types of emergency contraception:
• emergency hormonal contraception (EHC)
• selective progesterone receptor modulator (SPRM)
• copper intra-uterine contraceptive device (IUCD).
Emergency hormonal
contraception (EHC)
EHC is a progestogen preparation with the brand name
Levonelle which consists of one pill containing 1.5 mg of
levonorgestrel and is available in many countries through-
out the world. In the UK it is free from sexual health
clinics, walk-in centres, some accident and emergency
departments and GP practices. Many health centres and
clinics provide EHC free of charge through selected phar-
macies in an effort to reduce unwanted pregnancies. It can
also be purchased over the counter from pharmacies.
This method works by delaying ovulation or preventing
implantation of the fertilized oocyte, depending on the
stage of ovulation. This method may be contraindicated if
there has been more than one episode of unprotected
sexual intercourse (UPSI) during the cycle, as the earlier
sexual intercourse may already have resulted in a preg-
nancy. Very careful questioning by the practitioner needs
to take place prior to supplying EHC to prevent an unfa-
vourable outcome.
Nausea is uncommon with the progestogen-based pill
but an additional pill may be required if the woman
vomits within 2 hours of taking the medication. The next
menstrual period may begin earlier or later than expected
and it should be stressed that contraception must be used
until the next period commences. If the woman receives
the EHC in a contraception clinic in the UK, she is always
given an appointment to return to the clinic if menstrua-
tion does not commence on time, or is shorter or lighter
than usual. If menstruation is more than 7 days late, a
pregnancy test will be offered. Any unusual lower abdomi-
nal pain must be investigated as this could be a sign of an
ectopic pregnancy.
The efficacy of EHC depends on how quickly the emer-
gency contraception is commenced. If taken within 24
hours of unprotected sexual intercourse, it will prevent
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Section | 5 | Puerperium

95% of pregnancies. This gradually decreases to 58% by example, in a regular 28-day cycle, the IUCD can be fitted
72 hours (FPA 2011c). There are very few contraindications up to day 19 of the cycle. It can then be left in place for
to using this method but those health professionals use as a regular method of contraception, or removed
administering Levonelle need to know about any other during the next menstrual period.
medication being used by the woman. Emergency hormo-
nal contraception can be used more than once in each
menstrual cycle, but it may disrupt the menstrual period
pattern.
COITUS INTERRUPTUS

Technically coitus interruptus should not be considered a

Selective progesterone receptor form of contraception as it potentially has a high failure
modulator (SPRM) rate. It involves withdrawal of the penis from the vagina
prior to ejaculation, and couples should be made aware
Ulipristal acetate with the brand name ellaOne is an emer-
of emergency contraception. Many euphemisms are used
gency contraception that has been in use since 2009. In
when referring to this, such as ‘being careful’ or the ‘with-
the UK ellaOne is free from sexual health clinics, walk-in
drawal method’. Andrews (2005) gives a rate of 90% effec-
centres, some accident and emergency departments and
tiveness as a contraceptive. Failure is due to the small
GP practices. It is given as a 30 mg oral dose which should
amount of semen that may leak from the penis prior to
be taken as soon as possible after UPSI or failed contra­
ejaculation with the potential of penetrating the ovum.
ception. The action of SPRM is thought to be due to
The success of this method depends on the man exercising
inhibition or delay in ovulation and alteration of the
a great amount of self-control and is based on trust and
endometrium (Brache et al 2010). EllaOne is licensed for
honesty. This method is used widely throughout the world
up to 120 hours following an exposure of risk to preg-
by different cultures and is the oldest form of contracep-
nancy. Only one dose of ellaOne can be taken per men-
tion, being referred to in the Old Testament of the Bible.
strual cycle. As with EHC, careful questioning within a
consultation is required to ensure that there has been no
previous risk of pregnancy either within a previous or the
current menstrual cycle. FERTILITY AWARENESS (NATURAL
Randomized controlled trials (RCTs) have shown that FAMILY PLANNING)
ellaOne is at least as effective at preventing pregnancy as
Levonelle, and pooled data demonstrate that ellaOne is
The study of fertility awareness, previously (and some-
more effective than EHC up to 120 hours following UPSI
times still) referred to as natural family planning, is a
or failed contraception (FSRH 2011b).
fascinating observation of the way in which the female
Side-effects include abdominal pain, menstrual disor-
body works to produce the optimum conditions for
ders such as irregular vaginal bleeding, disruption to the
conception.
menstrual cycle with most women reporting lengthening
According to UK Medical Eligibility Criteria for Contra-
of their cycle by 3 days; however, some women report a
ceptive Use (FSRH 2009b), Natural Family Planning
shortening of their cycle. Drug interactions can occur with
includes all the methods of contraception based on the
liver enzyme-inducers such as carbemazepine and drugs
identification of the fertile time in the menstrual cycle. The
that increase gastric pH, such as antacids. Ulipristal binds
effectiveness of these methods depends on accurately
to progesterone receptors and therefore may reduce the
identifying the fertile time and modifying sexual behav-
efficacy of progesterone-containing contraceptives (FSRH
iour. To avoid pregnancy, the couple can either abstain
2011b).
from sexual intercourse or use a barrier method of contra-
Women may be asked to return to the clinic in 3-4 weeks
ception during the fertile time. Natural methods are attrac-
to have a pregnancy test, or if menstruation is more that
tive to couples who do not wish to use hormonal or
7 days late.
mechanical methods of contraception. The midwife can
provide the appropriate FPA leaflet, signpost the couple to
The copper intrauterine the local contraception clinic or find local information on
fertility awareness teachers and available education from
device (IUCD)
the website: www.fertilityuk.com.
The IUCD is the most effective method of emergency con- The method can also be used as a guide to women
traception, with a failure rate of less than 1%. Implanta- wishing to become pregnant, by concentrating sexual
tion of the fertilized oocyte is avoided if the IUCD is intercourse on the days they are most fertile. The fertile
inserted within 5 days of UPSI or earliest estimated date time lasts around 8–9 days of each menstrual cycle. The
of ovulation. This provides the clinician a much longer oocyte survives for up to 24 hours, however the FPA
time range in which to offer emergency contraception. For (2010b) suggest that a second oocyte could, occasionally,

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 Contraception and sexual health in a global society
be released within 24 hours of the first. In addition, the
FPA (2010b) state that as a sperm can live inside a female
body for up to 7 days, this means that should sexual inter-
course occur 7 days before ovulation, a pregnancy could
result.
Fertility awareness methods
Physiological signs of fertility are:
• cervical secretions (Billings or ovulation method)
• basal body (waking) temperature
• cervical palpation
• calendar calculation.
Cervical secretions
Following menstruation the vagina will become dry. As
oestrogen levels rise, the fluid and nutrient content of the
secretions increases to facilitate sperm motility, conse-
quently a sticky white, creamy or opaque secretion is
noticed. As ovulation approaches the secretions become
wetter, more transparent and slippery with the appearance
of raw egg white that are capable of considerable stretch-
ing between the finger and thumb. The last day of the
transparent slippery secretions is called the peak day, which
coincides closely with ovulation. Following ovulation, the
hormone progesterone causes the secretions to thicken
forming a plug of mucus in the cervical canal, acting as a
barrier to sperm. The secretions will then appear sticky and
dry until the next menstrual period.
When practising this method of contraception, the cer-
vical secretions are observed daily. The fertile time starts
when secretions are first noticed following menstruation
and ends on the third morning after the peak day. If the
secretions are used as a single indicator of fertility, the
presence of seminal fluid can make observation difficult.
Changes in secretions will be affected by seminal fluid,
menstrual blood, spermicidal products, vaginal infections
and some medications (Guillebaud and MacGregor 2013).
Postpartum considerations
In the first 6 months following childbirth, the majority of
women who are fully breastfeeding will be able to rely on
the lactational amenorrhoea method (LAM) for contracep-
tion. Women who wish to continue using natural methods
of contraception should begin observing cervical secre-
tions for the last two weeks before the LAM criteria will
no longer apply (i.e. 5 months and 2 weeks postpartum),
in order to establish their basic infertile pattern.
Basal body temperature
A woman can calculate her ovulation by recording her
temperature immediately on waking each day. Should the
woman have arisen during the night, she must take at least
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Chapter | 27 |
3 hours rest before recording her temperature. After ovula-
tion, the hormone progesterone produced by the corpus
luteum causes the temperature to rise by about 0.2 °C. The
temperature remains at this higher level until the next
menstrual period. The infertile phase of the menstrual
cycle will begin on the third day after the temperature rise
has been observed. Andrews (2005) points out that the
temperature can be affected by infection, therefore care
needs to be taken when interpreting temperature charts.
Postpartum considerations
A mother with the demands of a new baby may find dif-
ficulty in recording her temperature at the same time every
day. Consequently many women prefer to rely on examin-
ing cervical secretions, or combine noting secretions with
cervical changes at this time.
Cervical palpation
Changes in the cervix throughout the menstrual cycle can
be detected by daily palpation of the cervix by the woman
or her partner. After menstruation the cervix is low, easy
to reach, feels firm and dry and the os is closed. As ovula-
tion approaches, the cervix shortens, softens, sits higher in
the vagina and the os dilates slightly under the influence
of oestrogen.
Postpartum considerations
Hormonal changes in pregnancy take around 12 weeks to
settle postpartum. The cervix will not revert completely to
its pre-pregnant state as the os will remain slightly dilated
even in the infertile time.
Calendar calculation
The calendar method (see Fig. 27.10) is based on observa-
tion of the woman’s past menstrual cycles. When com-
mencing to use this method, the specialist practitioner and
the woman should examine the previous six menstrual
cycles (Andrews 2005). The shortest and longest cycles
1 10 14 18 28
‘Safe period’ ‘Fertile period’ as expected ‘Safer period’
follicular phase day of ovulation (day 14) luteal phase
+/- 4 days
Fig. 27.10 Natural family planning: The fertility awareness
(rhythm) method. Diagram to illustrate rhythm method of
contraception in a 28-day menstrual cycle.
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Section | 5 | Puerperium
over the previous six months are used to identify the likely
fertile time. The first fertile day is calculated by subtracting
21 days from the end of the shortest menstrual cycle. In a
28-day cycle, this would be day 7. The last fertile day is
calculated by subtracting 11 days from the end of the
longest menstrual cycle. In a 28-day cycle, this would be
day 17. Cycle length is constantly reassessed and appropri-
ate calculations made. Guillebaud and MacGregor (2013)
indicate that the calendar method is not sufficiently reli-
able to be recommended as a single indicator of fertility,
but is useful when combined with other indicators of
fertility. Ovulation usually takes place 14 days before the
first day of the next menstrual period. Therefore a woman
who has a 28-day cycle would ovulate on approximately
day 14 of her cycle and a woman who has a 30-day cycle
would ovulate on approximately day 16 of her cycle.
Postpartum considerations
Calendar calculations must be recalculated once normal
menstruation has recommenced.
Symptothermal method
This is a combination of temperature charting, observing
cervical secretions and calendar calculation, with the
option of observing cervical palpation in order to identify
the most fertile time. Andrews (2005) also includes in this
method the observation of ovulation pain or ‘mittelschmerz’
and cyclic changes such as breast tenderness. Use of more
than one indicator increases the accuracy in identification
of the fertile time. When combining indicators, a couple
should avoid sexual intercourse from the first fertile day
by calculation, or the first change in the cervix until the
third day of elevated temperature, provided all elevated
temperatures occur after the peak day.
Fertility monitoring device
These hand-held computerized devices monitor luteiniz-
ing hormone (LH) and oestrone-3-gluronide (a metabo-
lite of oestradiol) through testing the urine. The most well
known in the UK is the ‘Persona’ monitoring device which
is about 94% effective and will detect from the urine test
when a woman is fertile, indicating this through a series
of lights. A green light indicates the infertile phase and a
red light indicates the fertile phase, therefore barrier
methods must be used should sexual intercourse be con-
templated. A yellow light indicates that the database
requires more information and a further urine test is
required.
Postnatal considerations
The fertility monitor is not recommended as a method of
contraception during lactation. The manufacturers of the
Persona recommend that a woman has had two normal
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menstruations with cycle lengths from 23 to 35 days
before using the monitor at the beginning of the third
period (Guillebaud and MacGregor 2013).
Lactational amenorrhoea
method (LAM)
It is thought that the action of the infant suckling at the
breast causes neural inputs to the hypothalamus. This
results in the inhibition of gonadotrophin release from the
anterior pituitary gland, leading to suppression of ovarian
activity. The delay in return of postnatal fertility in lactat-
ing mothers varies greatly as it depends on patterns of
breastfeeding, which are influenced by local culture
and socioeconomic status. The time taken for the return
of ovulation is directly related to sucking frequency and
duration. The maintenance of night-feeds and the intro-
duction of supplementary feeds also affects the return of
ovulation.
The lactational amenorrhoea method (LAM) is a very
effective method of contraception when used according to
the Bellagio consensus statement (Guillebaud and Mac-
Gregor 2013). Research data concludes that there is over
98% protection against pregnancy during the first 6
months following birth if a woman is still amenorrhoeic
and fully or almost fully breastfeeding her baby (FPA
2010b). In order to confirm that LAM remains effective
as a contraceptive method, the woman should be asked
if three questions (as indicated in Fig. 27.11) still
apply. Mothers who work outside the home can still be
considered to be nearly fully breastfeeding, provided they
stimulate their breasts by expressing breastmilk several
times a day.
The LAM is not recommended for use after 6 months
following birth, because of the increased likelihood of
ovulation. Studies throughout the world have been con-
ducted on the effectiveness of LAM as a contraceptive,
Since your last delivery,
are you still
amenorrhoeic?
If the answers to all are
positive, then
Are you fully you have a reliable
breast-feeding? natural contraception
Is baby less than
6 months old?
Fig. 27.11 Natural contraception: lactational amenorrhoea
method (LAM).
 Contraception and sexual health in a global society Chapter | 27 |

confirming a rate of over 98% protection against preg-

nancy (Labbok 2012), suggesting it is a viable option for
some postnatal breastfeeding women.

MALE AND FEMALE STERILIZATION

This is the choice of contraception for many couples once

they have decided their family is complete. Sterilization
should be viewed as permanent, although in a few cases
reversal of the operation is requested. Couples requesting
sterilization need thorough counselling to ensure that
they have considered all eventualities, including possible A
changes in family circumstances. Although consent of a
partner is not necessary, joint counselling of both partners
is desirable. The procedure is available on the NHS for
both sexes but waiting times can vary. There are no altera-
tions to hormone production following sterilization in
males or females and some couples find the freedom from
fear of pregnancy very liberating.

Female sterilization
An estimated 600 million women worldwide have under-
gone female sterilization (Guillebaud and MacGregor
2013). During the procedure (Fig. 27.12), the uterine tube
is occluded using division and ligation, application of B
clips or rings, diathermy or laser treatment.
The operation is performed under local or general
anaesthetic. The procedure can be performed via a laparot-
omy, minilaparotomy or laparoscopy. It can also be
performed vaginally using a hysteroscope. The procedure
usually requires a day in hospital.
Women are advised to continue to use contraception for
four weeks following the procedure, or in the case of hys-
teroscopic sterilization (Essure) contraception should con-
tinue for 3 months, after which successful tubal blockage
is confirmed by hysterosalpingography (FPA 2010c). The
couple should be advised to seek medical help urgently if
they suspect pregnancy following sterilization because of
the increased risk of ectopic pregnancy if the procedure is
unsuccessful.

Postpartum considerations
Should sterilization occur around the time of birth, it is
vital that the woman receives thorough counselling prior
to the procedure to avoid any regret later on. Women are
often advised to wait 6 weeks after the birth before under-
going the procedure. The FRSH (2009a) suggest that if
sterilization is going to be undertaken at the same time as
an elective caesarean operation, then one week or more
should be provided for counselling and decision-making
before the procedure finally takes place.
C
Fig. 27.12 Female sterilization.
Guillebaud and MacGregor (2013) suggest that a waiting
period of 12 weeks is desirable to ensure that the couple
will have no regrets over the sterilization.
The failure rate for female sterilization is 1 in 200 (FPA
2010c). Reversal of the sterilization is not usually available
though the NHS in the UK and can be difficult and expen-
sive to obtain privately. Women considering sterilization

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Section | 5 | Puerperium
Fig. 27.13 Male sterilization (vasectomy).
should be made aware of the availability of LARC methods,
which are highly effective but reversible.
Male sterilization (vasectomy)
The procedure of male sterilization involves excision or
removal of part of the vas deferens, which is the tube that
carries sperm from the testes to the penis (Fig. 27.13). A
small cut or puncture to the skin of the scrotum is made to
gain easier access to the vas deferens. The tubes are cut and
the ends closed by tying them or sealing them with dia-
thermy. The wound on the scrotum will be very small and
stitches are not usually required. In the UK the operation
is carried out in an outpatients department or clinic setting.
It is usually completed under local anaesthetic and takes
around 10–15 minutes. Men are advised to refrain from
excessive physical activity for about one week and to avoid
heavy lifting following the procedure (Andrews 2005).
It may take some time for sperm to be cleared from the
vas deferens; it can take approximately 12 weeks after the
operation for this to occur. Consequently, the semen must
be tested to confirm that it no longer contains sperm and
sometimes further tests are necessary to confirm the
absence of sperm. Sexual intercourse can take place during
this period but contraception must be used until a nega-
tive sperm result is confirmed.
The failure rate of male sterilization is 1 in 2000 (FPA
2010c). Careful counselling needs to take place before the
procedure is carried out. Reversal of vasectomy is not
usually available through the NHS and Andrews (2005)
quotes around a 50% success rate in achieving a pregnancy
following successful reversal within 10 years of the proce-
dure being undertaken.
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THE FUTURE OF CONTRACEPTION
AND SEXUAL HEALTH SERVICES
In the UK the government remains committed to develop-
ing confidential, non-judgemental, integrated sexual
health services, including STI screening and treatment,
contraception, termination of pregnancy, health promo-
tion and prevention (HM Government 2010). A recent
Department of Health (DH) publication, ‘A framework for
sexual health improvement in England’ (DH 2013), sets
out a clear strategy for tackling sexual health issues such
as STIs and teenage pregnancy. However, current financial
challenges mean that the FSRH (2012) are concerned that
budget cuts and changes to commissioning processes may
compromise access to and quality of contraceptive and
sexual health services for the forseeable future.
In response to the Social Exclusion Unit Report (DH
1999), many NHS Trusts now provide clinics and projects
for young people, and improved access to contraceptive
and sexual health services has led to a decrease in the
conception rate of the under-18s. One of the specific
targets of this report was to reduce the teenage pregnancy
rate by 50% by 2010. The actual statistics showed a 13.3%
decline in conceptions to the under-18s and 25% reduc-
tion in births in this same age group. Plans to decrease
teenage conceptions further continue (DH 2010). With
strict adherence to the Fraser guidelines (Guillebaud and
MacGregor 2013), teenagers under the age of 16 can
receive advice and treatment from a contraceptive and
sexual health practitioner.
The NICE guidelines (2005) have emphasized the need
to promote long acting reversible contraception (LARC).
This recommendation will encourage more women to use
a form of contraception that does not have to be remem-
bered on a daily basis.
There is a trend in the UK for many women to have their
children later in life and to have much smaller families.
Throughout the world, couples will seek to find new ways
to limit their family size as the need to reduce population
growth continues (Guillebaud and MacGregor 2013).
ONGOING DEVELOPMENTS
An extended regimen of combined contraceptive pills for
84 days, e.g. Seasonale, has been confirmed to be safe.
Seasonale is a COC pill that has the equivalent of Micro­
gynon 30 but is packaged in four packets to be taken
consecutively followed by a pre-determined pill-free inter-
val (Guillebaud and MacGregor 2013). It is currently
licensed in many countries, including the USA, and may
be available in the UK soon. Other similar products include
Seasonique. Alternative delivery systems reducing the need
for daily pill-taking are being explored. Subcutaneous
 Contraception and sexual health in a global society Chapter | 27 |

injections (depo-subQ) and chewable tablets are being
developed for progestogens. Research into biodegradable
implants (which would be particularly useful in low
income countries) and the use of transdermal spray for the
delivery of a potent progestogen is ongoing. The Popula-
tion Council is considering research into proteomics and
an immunological approach to contraception. Effective
methods for men are still problematic and the long-
awaited male pill is still not imminent (Guillebaud and
MacGregor 2013). Gene blockers (reducing sperm mobil-
ity), the male patch and heat-based methods are amongst
those being developed. Long acting testosterone injections
with implanted progestogens or semen blocking methods
may be available in the future (Dorman and Bishai 2012).

REFERENCES

Allan M, Koppula S 2012 Risk of venous
thromboembolism with various
hormonal contraceptives. Canadian
Family Physician 58(10):1097
Andrews G (ed) 2005 Women’s sexual
health, 3rd edn. Elsevier, Edinburgh
Brache V, Cochon L, Jesam C et al
2010 Immediate pre-ovulatory
administration of 30 mg ulipristal
acetate significantly delays follicular
rupture. Human Reproduction
25:2256–63
Brucker C, Karck U, Merkle E 2008
Cycle control, tolerability, efficacy
and acceptability of the vaginal
contraceptive ring, NuvaRing: results
of clinical experience in Germany.
European Journal of Contraception
and Reproductive Health Care
13(1):31–8
DH (Department of Health) 1999
Teenage pregnancy. Report by the
Social Exclusion Unit. TSO, London
DH (Department of Health) 2010
Teenage pregnancy strategy beyond
2010. DH, London
DH (Department of Health) 2013 A
framework for sexual health
improvement in England. DH,
London
Dorman E, Bishai D 2012 Demand for
male contraception. Expert Reviews
in Pharmacoeconomics and
Outcomes Research 12(5):605–13
FPA (Family Planning Association)
2010a Leaflet: Your guide to
diaphragms and caps. FPA, London
FPA (Family Planning Association)
2010b Leaflet: Your guide to natural
family planning. FPA, London
FPA (Family Planning Association)
2010c Leaflet: Your guide to male and
female sterilization. FPA, London
FPA (Family Planning Association)
2011a Leaflet: Your guide to the
contraceptive patch. FPA, London
FPA (Family Planning Association)
2011b Leaflet: Your guide to
male and female condoms. FPA,
London
FPA (Family Planning Association)
2011c Leaflet: Your guide to
emergency contraception. FPA,
London
FPA (Family Planning Association) 2012
Leaflet: Your guide to the combined
pill. FPA, London
FSRH (Faculty of Sexual and
Reproductive Healthcare) Clinical
Effectiveness Unit 2008a (updated
2009) Progestogen-only pills. RCOG,
London
FSRH (Faculty of Sexual and
Reproductive Healthcare) Clinical
Effectiveness Unit 2008b (updated
2009) Progestogen-only implants.
RCOG, London
FSRH (Faculty of Sexual and
Reproductive Healthcare) Clinical
Effectiveness Unit 2009a Postnatal
sexual and reproductive health.
RCOG, London
FSRH (Faculty of Sexual and
Reproductive Healthcare) Clinical
Effectiveness Unit 2009b UK medical
eligibility criteria for contraceptive
use. RCOG, London
FSRH (Faculty of Sexual and
Reproductive Healthcare) Clinical
Effectiveness Unit 2011a (updated
2012) Combined hormonal
contraception. RCOG, London
FSRH (Faculty of Sexual and
Reproductive Healthcare) Clinical
Effectiveness Unit 2011b (updated
2012) Emergency contraception.
RCOG, London
FSRH (Faculty of Sexual and
Reproductive Healthcare) 2012 FSRH
response to the APPG SRH inquiry
into restrictions in access to
contraceptive services. RCOG,
London
Guillebaud J, MacGregor A 2013
Contraception: your questions
answered, 6th edn. Churchill
Livingstone, Edinburgh
HM Government 2010 Healthy lives
healthy people: our strategy for public
health in England. TSO, London
Jogee, M 2004 Religions and cultures, 6th
edn. R & C Publications, Edinburgh
Labbok M 2012 The lactational
amenorrhoea method (LAM) for
postnatal contraception. Australian
Breastfeeding Association, Malvern
East, VIC
McDonald E, Brown S 2013 Does
method of birth make a difference to
when women resume sex after
childbirth? BJOG: An International
Journal of Obstetrics and
Gynaecology 120(7):823–30
NICE (National Institute for Health and
Clinical Excellence) 2005 (modified
2013) Long acting reversible
contraception. Department of
Health, London
NICE (National Institute for Health and
Clinical Excellence) 2006 Routine
postnatal care for women and their
babies. Department of Health,
London
NMC (Nursing and Midwifery Council)
2012 Midwives rules and standards.
NMC, London
Roumen F, op ten Berg M, Hoomans E
2006 The combined contraceptive
vaginal ring (NuvaRing): first
experience in daily clinical practice
in The Netherlands. European
Journal of Contraception and
Reproductive Health Care 11:14–22
Scholes D, LaCroix A Z, Ichikawa L E
et al 2005 Change in bone mineral
density among adolescent women
using and discontinuing depot
medroxyprogesterone acetate
contraception. Archives of Paediatric
and Adolescent Medicine 159:139–44

587
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Section | 5 | Puerperium
FURTHER READING
Gebbie A, O’Connell White K 2009 Fast
facts contraception. Health Press,
Abingdon
This textbook covers the wide spectrum of
contraception, in an easy to read and
accessible format.
Guillebaud J, MacGregor A 2013
Contraception: your questions
answered, 6th edn. Churchill
Livingstone, Edinburgh
The latest edition of this book is extremely
comprehensive and up-to-date, covering
USEFUL WEBSITES/CONTACTS
Brook: www.brook.org.uk. UK tel: 0808
802 1234
Free and confidential information for
under 25s
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all available contraceptive methods not
just available in the UK but worldwide.
It is in a question and answer style
regarding each particular contraceptive
method and provides the best available
evidence to guide and support clinical
practice.
National Institute for Health and
Clinical Excellence 2005 (modified
2013) Long acting reversible
contraception. Department of
Health, London
Faculty of Sexual and Reproductive
Healthcare: www.fsrh.org.uk
Family Planning Association UK:
www.fpa.org.uk. Northern Ireland:
This document has been recently modified
to reflect the replacement of Implanon
with Nexplanon, and also includes
guidance on the management of
unscheduled bleeding in women with
implants in situ. It is therefore still
applicable to current contraceptive
services, as it recognizes the value of
encouraging the use of long acting
reversible contraception in reducing
unwanted pregnancies.
tel: 0845 122 8687. England tel:
0845 122 8690
Fertility UK: www.fertilityuk.org
 Section 6
The neonate

28 Recognizing the healthy baby at term
through examination of the newborn
screening 591
29 Resuscitation of the healthy baby at birth:
the importance of drying, airway
management and establishment of
breathing 611
30 The healthy low birth weight baby 617
31 Trauma during birth, haemorrhages and
convulsions 629
32 Congenital malformations 645
33 Significant problems in the newborn
baby 667
34 Infant feeding 703

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 Chapter 28
Recognizing the healthy baby at term through
examination of the newborn screening
Carole England

CHAPTER CONTENTS Examination of the genitalia 607

Neurological examination 607
The first examination after birth 592 References 608
Assessment of the neonatal skin 592 Further reading 609
The head 593 Useful websites 609
The face 594
This chapter will focus upon the characteristics of
The neck 595
the healthy term baby. The midwife performs a
The chest and abdomen 596 systematic screening assessment of a baby’s
The anus 596 health and wellbeing on a regular basis. These
The genitalia 596 include the first examination after birth, the
ongoing daily examination and for those who
Limbs, hands and feet 597 have received specialist education and training,
The spine 598 the Newborn and Infant Physical Examination
Communication and documentation 598 (NIPE), performed within three days (72 hours) of
birth. Each examination assesses the whole baby
The daily examination screen 598
and builds on previous findings related to the
Breathing 598 pregnancy, birth and neonatal assessments. The
Thermoregulation-the importance midwife’s role is not to diagnose but to examine
of keeping warm 598 and distinguish the healthy baby from the one
Skin care 599 that requires referral to a medical practitioner.
To do this effectively the midwife must have a
Cardiovascular system and blood sound knowledge of abnormality to be able to
physiology 600 make appropriate and timely referral, especially
Renal system 600 if the condition is immediately life-threatening.
Gastrointestinal system 600
Immunity 601 THE CHAPTER AIMS TO:
Reproductive system: genitalia and breasts 601
• highlight the features of a healthy baby and know
Skeleto-muscular system 601 which baby needs referral to a medical practitioner
The Neonatal and Infant Physical • emphasize the importance of reading the woman’s
Examination (NIPE) 601 records before any physical assessment of her baby is
Examination of the heart 602 attempted
Examination of the eye 605 • recognize the vital importance of appropriate
Examination of the hips 606 communication with the parents, especially when

© 2014 Elsevier Ltd 591

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Section | 6 | The Neonate
obtaining consent, listening to the mother on her
opinion of her baby’s health and in reporting the
findings of the examination
• provide the details of a top-to-toe examination of
the newborn performed in the first 24 hours of life
• explore the assessment provided in the daily
examination of the baby
• critically discuss the NIPE assessment
• discuss how each screening examination is an
opportunity for health education/promotion and
psychological empowerment of both parents in how
to recognize health and wellbeing in their baby
• stress the importance of writing (and drawing if
indicated) a clear detailed record of findings and
communications that have taken place.
THE FIRST EXAMINATION
AFTER BIRTH
The aim of the first examination performed within 24
hours of birth is to detect any observable congenital mal-
formations and to assess initial adaptation to extrauterine
life that could compromise health and wellbeing (Resus-
citation Council 2011). The examination should be per-
formed in the presence of the mother and partner (as
appropriate). The ideal time is after the baby has had skin-
to-skin contact and had its first feed, during which it main-
tained a body temperature within normal parameters. The
midwife present at the birth often performs this examina-
tion and should ensure that the environment is warm and
draught-free, with equipment ready for use. Diligent hand-
washing is essential. The baby should be at rest on a flat
surface. The skills of observation, palpation and ausculta-
tion should be utilized. See Box 28.1 for screening princi-
ples that should be communicated when screening is
undertaken.
Assessment of the neonatal skin
According to Baston and Durward (2010), the colour of
the skin is generally considered a reflection of good health,
but is most difficult to assess accurately in the first few
hours of extrauterine life and the midwife needs to distin-
guish between different types and degrees of blue skin to
know if the baby is well or whether to refer to the neonatal
registrar.
A blue skin as a result of central cyanosis
To assess blueness due to accumulation of carbon dioxide
and deprivation of oxygen is a difficult task in white ethnic
groups and even more so in babies from black ethnic
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Box 28.1 The principles of screening
The midwife should:
• inform the mother exactly why the examination is
being conducted
• obtain informed consent from the mother to perform
the examination on her baby
• ensure the baby is wearing identification bracelets
that correspond with the mother’s identity and
documentation
• perform a thorough examination of the baby
• provide full details of the findings of the
examination
• offer an action plan of care as required
• document detailed findings and evidence of
communication that arose between the midwife and
mother/parents before, during and after the
examination
Source: UK National Screening Committee (2008)
groups who have a pigmented skin. The baby’s oral mucus
membranes and tongue are not pigmented and will
provide the midwife with reliable evidence of central cya-
nosis. A dull blue skin may indicate poor perfusion and
can be assessed by measuring capillary refill time (CRT)
by blanching the baby’s chest skin with a finger and, on
release, seeing how long it takes for the capillaries to refill.
Any time over 2 seconds indicates poor peripheral per-
fusion. Pallor of the skin is a result of peripheral shutdown
and is always a serious sign as this could also indicate
acute blood loss, anaemia, the processes involved in
cooling or/and the presence of infection. Jaundice that
develops from birth in the first 24 hours is considered
pathological, is usually as a result of haemolysis (excessive
breakdown of red blood cells) and should also be reported
immediately (England 2010b) (see Chapter 33).
A blue skin as a result of other factors
Most babies will have peripheral shutdown (acrocyanosis)
in hands and feet as blood is diverted to major organs.
Occasionally babies will present with a blue face as a result
of petechiae, which are pinpoint haemorrhagic spots on
the skin, usually as a result of a tightening cord around
the neck which constricts the jugular veins during fetal
descent in the second stage of labour. The venous blood
is trapped in the sinuses of the brain and will find an exit
point into the skin, thus the facial tissues become bruised.
The use of a pulse oximeter will indicate the amount of
haemoglobin saturated with oxygen in the baby’s blood
and should be about 95% or above in the first 24 hours
of life.
 Recognizing the healthy baby at term through examination of the newborn screening Chapter | 28 |

Common skin lesions found at birth

Skin lesions, as they are discovered either by the parents
or midwife, need addressing immediately. There is no
room for guesswork and the prudent midwife will ask for
a second opinion should there be any doubt.

Cuts, abrasions and bruises

These are carefully assessed as they may serve as portals of
entry for infection. Create a line drawing in documenta-
tion to illustrate size and complexity to avoid disputes
regarding origin (iatrogenic lesions caused by treatment,
e.g. use of forceps or ventouse; see Chapter 31, Figs 31.1,
31.2) or as a result of non-accidental injury. Extensive
bruising may lead to clinical jaundice. Fig. 28.1 Large pigmented naevus.
With thanks to Carl Kuschel 2007.

Vascular birth marks found at birth

Vascular proliferations (increase in growth) in the skin will
resolve and involute in time:
• Salmon patch haemangioma or ‘stork marks’: occur
in 50% of babies, are superficial capillaries that
blanche on pressure, resolve spontaneously,
commonly found on the nape of the neck, eyelids
and glabella.
• Strawberry haemangioma: not always present at
birth; occurs in 10% of babies by the age of one
year; bright red in colour. Benign but can develop
over orifices, e.g. anus, to cause obstruction and can
leave scar tissue. Laser treatment is available but
natural resolution offers a better cosmetic outcome.
• Cavernous haemangioma: similar to the strawberry
haemangioma but invades deeper into the vascular
tissues; leaves a blue discoloration to the skin and Fig. 28.2 Milia.
grows with the child.
Vasculature malformations that do not involute are perma-
nent and always present at birth: useful to distinguish from future non-accidental
injury (Griffith 2009).
• Port wine stain: red, purple markings present in 0.3
• Pigmented naevi affect 3% of babies, present at birth
% of neonates (Gordon and Lomax 2011) can be an
as a dark brown patch on the lower back or buttocks
isolated mark or associated with syndromes. Some
with speckles around the edge of the lesion, usually
lesions (Sturge–Weber syndrome) follow the
as a solitary patch (Fig. 28.1). Major concern is the
trigeminal nerve (fifth cranial nerve); have a midline
development of malignancy over time and must be
cut off and can infiltrate into the meninges and
monitored closely for changes in size and shape
cerebral cortex on the affected side resulting in
(Gordon and Lomax 2011).
seizures and eye abnormalities. This condition can
• Milia are small white follicular cysts commonly
devastate parents and the midwife needs to provide
known as milk spots (Fig. 28.2). They normally
empathic informed support.
appear on the cheeks forehead and nose and are
Pigmented birthmarks thought to be retention of keratin and sebaceous
• Mongolian blue spots are produced by clusters of secretions. They clear within 4 weeks of birth.
melanocytes in the dermis, are benign and have no
clinical significance. Present in 90% African, 81%
The head
Asian and 9.6% white caucasian babies, they have a
slate-grey to blue-black discoloration usually found According to Noonan et al (2011), the shape, size and
over the buttocks, back and legs and fade by 7 years symmetry of the head in relation to the face and rest of
of age. They resemble bruising so a line drawing is the body should be assessed. The head circumference

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Section | 6 | The Neonate
measurement of the occipitofrontal diameter should be in
the range of 32–36 cm for a term baby. Lumsden (2010)
asserts that macrocephaly (greater than the 97th centile) or
microcephaly (below the 2nd centile) can be plotted on a
head circumference growth chart in the Child Health
Record. A head that is disproportionate to body size
may indicate asymmetrical intrauterine growth restriction
where the head has been spared disruption to its growth
(see Chapter 30). Be aware that a stand-alone head meas-
urement may appear perfectly normal but its relationship
with the body may render it large. A large head is also
associated with hydrocephaly and congenital syndromes.
A small head is associated with poor brain development.
Fetal alcohol spectrum disorders (FASD) and transplacen-
tal infections will deleteriously affect fetal brain growth.
Observation and palpation of the scalp will indicate the
presence and degree of caput succedaneum which will
resolve in 2–3 days. The direction and degree of moulding
can indicate the engaging diameter of the fetal skull
involved in the process of labour. The bones, sutures and
fontanelles can then be examined. The anterior fontanelle
(bregma) closes at 18 months of age and if tense or
bulging can indicate congenital hydrocephaly, intercranial
haemorrhage or meningitis. A sunken bregma is associ-
ated with dehydration because as an extracellular fluid,
cerebrospinal fluid is derived from venous blood. The pos-
terior fontanelle (lambda) closes around 6 weeks. More
than one lambda along the lamboidal suture lines often
alongside a flat occiput can indicate trisomy 21, as can
abnormal patterns of hair growth (low hair line, extra
crowns) which are featured in a variety of syndromes (see
Chapter 32).
The face
The midwife should endeavour to see both parents before
expressing concern on an unusual-looking face, however
an assumption should not be made that the male partner
is the biological father of the baby. The face should be
analysed as a whole. Individual features in isolation do
not necessarily indicate a syndrome but in combination
with other features they make a syndrome more likely. The
baby’s facial expression could indicate an underlying con-
dition, e.g. pain, irritability, distress and is worthy of note.
The symmetry of the face should be observed as this could
indicate birth trauma in the form of facial paralysis where
one side of the face appears to droop, especially around
the eye and mouth on one side, when the baby is crying
(Fig. 28.3). This is a result of damage to the seventh cranial
nerve (facial), known as Bell’s palsy, during the application
of forceps or from head compression against the sacral
promontory during birth. Any degree of recovery will
depend upon the amount of damage to the myelin sheath
that covers and feeds the nerve.
The ear position should be similar on both sides. The
upper margin of the ear pinna should be on the level of
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Fig. 28.3 Right-sided facial palsy. Note that the eye is open
on the paralysed side and the mouth is drawn over to the
non-paralysed side.
Reproduced from Thomas R, Harvey D 1997 Colour guide: neonatology,
2nd edn, Churchill Livingstone, Edinburgh, with permission of Elsevier.
the eyes. However, a finding of low set ears alone may be
a normal variation. Malformed and/or low set ears are
associated with chromosomal abnormalities or urogenital
malformations and warrant referral. Roth et al (2008)
argue that peri-auricular skin tags can indicate hearing
impairment. The incidence of significant permanent con-
genital hearing impairment (PCHI) is 1 : 1000 births in
developed countries. The NHS Newborn Hearing Screen-
ing Programme (UK National Screening Committee 2012)
offers hearing screening in the first week of life and aims
to provide high-quality detection care and support for
babies and their families. A pre-auricular sinus may be
blind-ending or connected to the inner ear. The latter
condition will need referral to the Ear Nose and Throat
(ENT) surgeon.
The nose shape will vary, but the two nares should be
centrally placed and be patent. Most babies are obligatory
nose-breathers and patency can be observed when the
baby is breathing normally at rest. Nasal flaring may be
indicative of respiratory distress. Choanal atresia is a con-
dition in which one or both posterior nasal passages are
blocked by either bone or soft tissue. In the bilateral con-
dition the baby will be centrally cyanosed at rest but will
become better perfused when crying. Urgent referral to an
ENT surgeon will be required.
When a cleft lip is detected by antenatal screening,
automatic referral is made to the local cleft lip and palate
team (plastic surgeon, ENT surgeon, audiologist, ortho-
dontic surgeon and speech therapist) before the baby is
born. For those babies who have their condition detected
after birth, the midwife should refer to the registrar who
will make referral to the cleft lip and palate team. Cleft lip
can be either unilateral or bilateral and can extend into
the hard and soft palate. A cleft palate is not always
obvious and requires thorough assessment in order to
confirm its presence. A gloved finger should be inserted
 Recognizing the healthy baby at term through examination of the newborn screening Chapter | 28 |

The orbit of the eye. Interpupillary distance Fig. 28.4 Features of the baby’s eyes in relation to
The intraorbital distance is between each pupil the face.
(hypertelorism in very wide
set eyes or hypotelorism
in very close set eyes)
Outer canthal
distance

Epicanthic fold

Normal ear
position

Palpebral fissure length Inner canthal distance

(the width of an eye) (large enough to fit in
the width of an eye)

into the mouth, eliciting a suck reflex. By palpating the
hard palate it should be possible to feel if a cleft is present.
Detection of clefts in the soft palate should involve visual
inspection using a pen torch and tongue depressor. The
palate should be high arched, intact with a central uvula.
Cleft lip and/or palate may be familial or may be as a
result of maternal medication (e.g. phenytoin) or chro-
mosomal abnormality (e.g. Down and Patau’s syndrome).
Lumsden (2010) reports that clefting of the lip and palate
affects 1 : 700 babies in the United Kingdom (UK), with
50% lip and palate together, 25% lip alone and 25%
palate alone, so is a relatively common condition. A small
jaw (micrognathia) may be familial or part of a syndrome
like Pierre Robin, which comprises a midline cleft palate
and protruding tongue (glossoptosis). The midwife must
be aware that the main problem is of the tongue falling
back and obstructing the oropharynx. The baby may also
experience problems with feeding. Referral to the ENT and
orthodontic surgeons will be made alongside the speech
therapist.
Epstein’s pearls are a cluster of several white spots in the
mouth at the junction of the soft and hard palate in the
midline. They are the same as milia, are of no significance
and disappear spontaneously. Natal teeth are lower inci-
sors that have small crowns with no roots and pose the
risk of tongue ulceration and, if they become loose, inha-
lation into the trachea. Referral to the orthodontic team
for elective removal is required. The tongue should also be
examined for cysts and dimples. A tight frenulum that is
attached too far forward to the floor of the mouth restricts
mobility of the tongue to different degrees and will give
the appearance of tongue-tie (ankyloglossia). Treatment
for severe tongue-tie is frenulotomy (surgical division of
the frenulum), especially when breastfeeding is being
adversely affected.
The eyes should be symmetrically positioned on the face
in relation to the other facial features such as eyelids,
eyebrows and the slant of the palpebral fissures (see Fig.
28.4). The outer canthal distance can be divided equally
into thirds, with one eye width fitting into the inner
canthal space. Extremely wide (hypertelorism) or narrowly
spaced eyes are abnormal and may indicate a syndrome,
as may epicanthic folds, however the latter finding is a
normal feature in some ethnic groups, so some caution is
warranted. The sclera is normally white in colour; a yellow
discoloration occurs with jaundice. Conjunctival haemor-
rhages may occur as a result of the birth, are insignificant
and will take a few days to resolve but are, according to
Griffith (2009), associated with non-accidental injury, so
documentation of their appearance and size is vital. The
iris of a baby is navy blue with fibres radiating from the
centre. It should be perfectly circular with a round pupil
in the centre. White specks on the iris called Bushfield
spots are associated with Down syndrome. Opacity of the
lens could indicate congenital cataract. Clouding of the
cornea could be a sign of congenital glaucoma. Small eyes
occur as a result of transplacental infection, e.g. rubella,
cytomegalovirus. Any profuse or purulent discharge from
the eyes (Fig. 28.5) should be swabbed and sent for culture
and sensitivity. Eye drops/ointments to treat gonococcal
infection, staphylococci and chlamydial conjunctivitis
should be started while awaiting the results. Absence of
one or both eyes may have an environmental or chromo-
somal cause and such a finding requires referral to the
ophthalmologist.
The neck
This may be shortened or webbed with extra skin and
is a sign of Turner’s syndrome. The clavicles should be

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Section | 6 | The Neonate
Fig. 28.5 Ophthalmia neonatorum.
Reproduced from Mitchell H 2004 Sexually transmitted infections in
pregnancy. In: Adler M W, Cowen F, French P et al (eds) ABC of
sexually transmitted infections, 5th edn, p 35, with permission from
Blackwell Publishing.
examined for fractures, especially if there is any history of
shoulder dystocia or any suggestions of Erb’s palsy (see
Chapter 31 and Fig. 31.5).
The chest and abdomen
Bedford and Lomax (2011) assert that the heart rate will
vary in range from 100 to 160 beats per minute (bpm).
The respiratory rate will be 30–40 breaths per minute
(bpm), but not exceed 60 bpm and will vary in rhythm
with small periods of apnoea (absence of breathing for 20
seconds or more). There should be no sternal or costal
recession. The nipples should be lateral to the mid-
clavicular line and should be normal in shape and form.
The presence of abnormal or supernumerary (extra)
nipples should be recorded as a line drawing on a body
map with referral to the registrar.
Observation of respiratory movement should reveal that
chest and abdominal movements are synchronous as the
diaphragm is the major muscle of respiration. Asymmetri-
cal chest movement may be caused by either unilateral
pneumothorax or phrenic nerve damage on the side that
isn’t moving. Also consider the presence of a diaphragm­
atic hernia noted when the chest looks relatively big in
comparison to a scaphoid (sunken) abdomen. Ausculta-
tion of ectopic bowel sounds in the chest may support this
supposition (see Chapter 33).
The abdomen should look and feel soft and rounded.
The cord should be checked for bleeding. The cord vessels
should have two arteries and one vein. A single umbilical
artery increases the chances of congenital abnormalities
but further investigations are not justified on this finding
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alone. Exomphalos is where the bowel, covered by a trans-
parent sac composed of amnion and peritoneum, pro-
trudes through the umbilical cord and is associated with
Beckwith–Wiedemann syndrome (exomphalos, large for
gestational age, abnormal glucose metabolism, character-
istic skin creases to the ears). By comparison, gastroschisis
is caused by a defect in the abdominal wall, which allows
bowel to protrude through it. No sack covers the loops of
bowel, so before birth the bowel has been in contact with
the irritant properties of amniotic fluid, but there are no
associations with other congenital abnormalities. Both
conditions may be found on antenatal screening and at
birth the protruding bowel is covered with film wrap to
prevent fluid and heat loss in readiness for surgical repair.
The anus
Inspection for the presence and appearance of the anus is
vital. The presence of meconium does not always exclude imper-
forate anus (anal atresia). In a perforate anus, the rectum
and anal sphincter connect so that substantial amounts of
meconium can be passed at any one time. If there is an
underlying defect referred to as a high imperforate obstruc-
tion, there could be a rectal–vaginal fistula or a rectal–
urethral fistula that may allow passage of small amounts
of meconuim. A ‘low’ anomaly may merely consist of a
membrane covering the anal sphincter, which, while in
place, will impede the passage of all meconium. England
(2010a) contends that anal abnormalities can indicate that
other gastrointestinal malformations may be present, so
caution with feeding is recommended. The passage of a
nasogastric tube and withdrawal of hydrochloric acid can
exclude oesophageal atresia but does not necessarily rule
out tracheo-oesophageal fistula.
The genitalia
Male genitalia
The penis should be about 3 cm in length, straight, with
no chordee (a bend in the shaft). According to Fox et al
(2010), an apparently short penis is more common,
usually buried in supra-pubic fat, but remains a finding
that can cause real consternation to parents. True micro-
penis is rare and associated with hypopituitarism and
referral to the paediatric endocrinologist may occasionally
be warranted. The midwife should never attempt to with-
draw the foreskin.
Observing the baby pass urine may help to detect a
hypospadius where the urethral meatus opens on the
ventral (under) side of the penis and an epispadius where
the urethral meatus opens on the dorsal (upper) side.
Parents should be advised not to have their baby circum-
cised for religious or cultural reasons, as the foreskin will
be used to surgically repair the defect.
 Recognizing the healthy baby at term through examination of the newborn screening
According to Gordon (2011), the scrotum should be
examined to ensure symmetry on both sides as asymmetry
may indicate a persistent connection between the abdomi-
nal cavity and scrotum, so that fluid (hydrocele) or loops
of bowel (inguinal hernia) can escape and occupy the
scrotal sac on the affected side. A dark discoloration of the
scrotum, with or without swelling, is abnormal and may
indicate testicular torsion. The testicle twists on itself,
limits its own blood supply and the testicle dies from
ischaemia. Torsion can occur at any age and requires
immediate surgical review. The testicles should descend
into the scrotal sac by term. Each testicle is 1–1.5 cm in
size, palpable along the route from the posterior abdomen
to the scrotal sac, often found in the groin. Undescended
testicles (cryptorchidism) occurs in 2–4% of term babies.
If not descended by one year, orchidopexy is performed to
surgically place the testicle in the scrotal sac to prevent
infertility and malignancy in later life.
Female genitalia
The examination will confirm that the general anatomy
appears appropriate, with the labia majora covering the
labia minora.
Disorders of sex development
(ambiguous genitalia)
The midwife’s communication skills will be of utmost
importance as the parents ask ‘What have we got and is it
alright?’ The stark but not recommended answer to these
questions is, ‘I don’t know and no’. Honesty is the only
way to effectively manage this situation, however, and the
midwife’s choice of words should be tactful but truthful,
with an immediate response to the parents’ queries. Recent
practice of placing the newborn onto the mother’s
abdomen has enabled the parents to examine their baby
and make their own discoveries, often before the midwife
has had chance to see for her/himself. It is helpful to
suggest to the parents that they initially give their baby a
cross-gender name like Sam or Jo so that pronouns like he
and she are avoided. This may also help as a temporary
measure when informing family members of the birth and
the baby’s name.
According to Wassner and Spack (2012), there are many
different causes of ambiguous genitalia: the most common
is congenital adrenal hyperplasia, with an incidence of
1 : 15 000 babies. An XX female baby has an enlarged clit­
oris that appears like a penis and labia that may look more
like a scrotum. This is an autosomal recessive condition
where lack of an enzyme called 21 hydroxylase interferes
with the cholesterol pathway in the production of proges-
terone (from which cortisol and aldosterone are formed),
testosterone and oestradiol. In the absence of serum cor-
tisol and aldosterone, the anterior pituitary hormone
adrencorticotrophin (ACTH) stimulates the pathway but
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Chapter | 28 |
only testosterone is produced, which results in masculi-
nized genitalia and life-threatening imbalances in sodium
and cortisol levels. Referral to an endocrinologist and a
paediatric surgeon will follow (see Chapters 32 and 33).
The genitalia of male XY babies look within normal limits
but these babies may present later with failure to thrive,
vomiting and dehydration related to abnormal aldoster-
one and steroid physiology. The midwife should warn the
parents of the likelihood that their baby may be trans-
ferred to the neonatal intensive care unit (NICU) for extra
monitoring.
Limbs, hands and feet
The term baby will lie in a flexed position with the head
in the midline or turned slightly to one side. The hands
are flexed, with the thumb lying beneath the fingers in a
fist. In addition to noting length and movement of the
limbs and joints, it is essential that the digits are counted
and separated to ensure that webbing (syndactyly) is not
present on hands and feet. The hands should be opened
fully as any extra digits (polydactyly) may be concealed in
the clenched fist. X-ray assessment will determine whether
the defect needs referral to either the plastic surgeon (skin
only) or orthopaedic surgeon (bone and skin). A single
palmar (Simian) crease is associated with Down syn-
drome, however 10% of the normal population have a
single palmar crease on one hand and 5% have one on
both hands.
Davis (2011) uses the word structural clubfoot to refer
to the most common foot deformity (1 : 1000 births in the
UK), known as congenital talipes equinovarus. The word
talipes means ankle and foot. In this condition the foot is
plantar-flexed (turned downwards like a horse’s foot and
inwards towards the midline of the baby). The ratio of
boys to girls is 3 : 1 and in 50 % of cases, both feet are
affected. The cause is unknown but is associated with
Down syndrome and spina bifida. Referral to an orthopae-
dic surgeon is required. First line treatment is the Porseti
method of gentle manipulation and serial casting in
plaster of Paris at weekly intervals, which allows the foot
to be gradually corrected over a period of 6 weeks.
Positional conditions of the foot are caused by intra­
uterine overcrowding. These are:
• positional clubfoot/talipes equinovarus, which
when gently manipulated will easily correct.
Davis (2011) argues that a normal baby’s foot can
be turned outwards by 50–70° and upwards by
20°. If this can be achieved, a physiotherapist can
advise the parents on gentle massage. Davis further
argues that it is not uncommon for a child to have
a structural clubfoot on one side and a positional one
on the other, with no clear view if they are of the
same entity. This notion does call for the midwife
to check each foot individually and not
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Section | 6 | The Neonate
automatically assume that both feet are affected in
the same way.
• talipes calcaneo-valgus, which is characterized by
dorsiflexion where the foot is turned upwards and
outwards and associated with the breech position
and developmental dysplasia of the hip (DDH).
Referral to an orthopaedic surgeon is required. Often
gentle manipulation conducted by parents will bring
about correct alignment, with occasional need for a
plaster cast.
The spine
The best way to examine the spine is by holding the baby
per chest/abdomen on one hand, and running the fingers
of the other hand down the spinal processes. Any curva-
ture of the spine can be noted. Spina bifida occulta (char-
acterized by a missing vertebral process) may lie beneath
a fat pad, swelling, dimple, tuft of hair or birthmark. For
spina bifida cystica (mylomeningocele and meningocele),
see Chapter 32. A sacral dimple should be carefully exam-
ined to make sure it is skin-lined with no sinus to the CSF
pathway. If CSF is leaking it represents a portal for infec-
tion, so referral to both the plastic surgeon and neurosur-
gical teams will be made. In the interim, X-ray of the
lumbosacral spine and an ultrasound scan of the lower
spinal cord, kidneys and bladder will be arranged.
Communication and documentation
As soon as the examination is completed, the baby should
be handed back to the mother and skin-to-skin contact
re-established. This first examination after birth is extremely
important and needs to be done thoroughly. According to
England and Morgan (2012), parents are often taken aback
by the course of events that unfolds if a malformation or
problem is identified. This is often because they are not
correctly prepared for the screening intervention. The
words used to obtain consent from the mother set
the scene on how she will perceive the importance of the
examination. For example, if the midwife says ‘I need to
take a quick look over your baby to see if everything is
alright’, this could imply that the examination is being
done quickly because it is not really necessary but is
routine and has to be done. If the midwife says ‘Will you
please allow me to examine your baby in detail, so that if
I find anything that I think will affect your baby’s health,
I can tell you about it and then, with your permission, ask
for a second opinion?’, this question offers a detailed
explanation of the midwife’s intention in gaining consent.
What the midwife says should be documented alongside
details of examination findings, parental reaction, referral
details and support provided. The midwife should not be
influenced by the limited space provided in the record
being completed (England and Morgan 2012).
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THE DAILY EXAMINATION SCREEN
This examination is usually performed daily while the
baby remains in hospital and continues on a more inter-
mittent basis once the baby is in community until dis-
charge to the care of the health visitor. Health education
stems from how the baby is behaving and its general
appearance. A healthy term baby weighs approximately
3.5 kg, has a clear skin, good muscle tone, cries lustily,
feeds well, keeps warm and sleeps. The midwife will con-
tinue the health screening process by always asking the
mother how her baby is. Carefully listening to her answer
is a crucial part of the examination and her response will
often dictate in what order the midwife performs the
examination, starting with any areas of concern. Recording
what the mother has said (and how she said it) is helpful
for other health care practitioners who will see the baby
at a future time (England 2010c).
Breathing
The midwife should observe the baby’s respiratory rate
that involves the diaphragm, chest and abdomen rising
and falling synchronously. It should be explained to the
parents that babies have a periodic breathing pattern that
is erratic, with respirations being shallow and irregular,
interspersed with brief 10–15 second periods of apnoea.
Given that babies are either obligatory (required) or pref-
erential nose-breathers, it is important to check that their
nostrils are clear of dried secretions. Tickling the edge of
the nostrils with cotton wool can induce sneezing, which
aids some clearance. An irritable baby with excessive snuf-
fles and sneezing could indicate opiate withdrawal. In an
assessment of health, the midwife must consider that res-
piratory difficulties can occur because of neurological,
metabolic, circulatory or thermoregulatory dysfunction as
well as infection, airway obstruction or abnormalities of
the respiratory tract itself.
Thermoregulation – the importance
of keeping warm
One of the midwife’s priorities is to make sure the baby is
maintaining a body temperature within normal param­
eters. According to Brown and Landers (2011), a neutral
thermal environment is one that is neither too hot nor too
cold and enables the baby to use the minimal amount of
energy to stay warm. Babies are individuals, with each
one having their own metabolic rate, so the clinical accept-
able temperature range of 36.5–37.5 °C is wide. In the
first week of life core temperature can be unstable as
the heat-regulating centre in the hypothalamus and
medulla oblongata is attempting to adapt from a hot water
intrauterine environment to an cooler extrauterine air
 Recognizing the healthy baby at term through examination of the newborn screening
Air current convection
Conduction to cold surface
Evaporation from wet skin
Radiation to cold
structures/items
in vicinity
Fig. 28.6 Modes of heat loss in the neonate.
environment with concurrent threats of heat loss via radia-
tion, conduction, evaporation and convection (Fig. 28.6).
Cooling babies are unable to shiver and instead attempt
to maintain body heat by a means of non-shivering thermo-
genesis whereby they utilize brown fat and simultaneously
increase their metabolic rate by increasing glucose and
oxygen consumption to make more energy, carbon dioxide
and heat. For this process of aerobic glycolysis to function
effectively, the baby needs available oxygen and glucose.
As oxygen is consumed, energy can be made in the absence
of, or with minimal amounts of oxygen, which is referred
to as anaerobic glycolysis, however the amounts of glucose
to maintain this form of energy production is more than
20 times greater to make the same amount of energy as in
aerobic glycolysis. Hence the baby becomes hypoxic and
may begin to show signs of respiratory distress. England
(2010a) argues that a transient expiratory grunt may be one
of the first respiratory signs of cooling. Nasal flaring, tachy­
pnoea, sternal or subcostal recession, are all signs of res-
piratory distress that may follow. Hence the importance of
listening to how the mother or father describes the baby. The
baby will not grunt like a pig; one father described how
his son made ‘a strange noise on each breathe’. Subtle
colour changes may accompany these fleeting episodes.
The first step is to observe the baby overall and feel the
head and chest to gather a general sense of how warm the
baby is. Follow this by the use of a thermometer via the
axilla, tympanic membrane (ear), or in the groin. A
clothed term baby should maintain its body temperature
satisfactorily provided the environmental temperature is
draught-free, sustained between 18 °C and 21 °C, nutri-
tion is adequate and movements are not restricted by tight
swaddling. Inadequate clothing or/and being inadvert-
ently left exposed is a common cause of heat loss. If the
baby is cooling, skin-to-skin contact with the mother
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Chapter | 28 |
should be initiated immediately. The baby’s temperature
and general condition should be reviewed after 30 minutes.
Blackburn (2007) argues that pyrexia (37.7 °C and
above) in a term baby may indicate infection; however,
hyperthermia can occur if the baby is exposed to an inap-
propriate heat source (placed in a sunny window) or
dressed inappropriately for the ambient temperature. Feet-
to-foot placing of the baby in the cot in the supine posi-
tion has contributed to the reduction in overheating and
associated sudden infant death syndrome (Foundation for
Sudden Infant Death 2013). Over-heating increases meta-
bolic rate and can draw upon supplies of glucose and
oxygen to maintain the required energy level. Respiratory
distress may follow unless the baby is allowed to cool
slowly.
Skin care
Although sterile at birth, the skin, when exposed to air is
quickly colonized by microorganisms, which produce a
pH of 4.9, creating an acid mantle that protects the skin
from infection. Vernix caseosa should be allowed to absorb
into the skin because it is a highly sophisticated mixture
of proteins and fatty acids that produce an antibacterial
and antifungal skin barrier. Gordon and Lomax (2011)
assert that the midwife should not be tempted to apply
anything to a post-term skin that is dry and cracked,
because within a few days of peeling, perfect skin will
be revealed beneath. Skin-to-skin contact just after birth
and during subsequent feeding (to include formula-fed
babies too) is an excellent way to colonize the baby’s skin
with friendly bacteria. Great care must be provided to
maintain the integrity of the lipids (fats) that seal each
skin cell. Chemicals used in manufactured baby skin prod-
ucts can irrevocably damage epidermal lipids and lead to
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Section | 6 | The Neonate
trans-epidermal water loss. It is recommended by Trotter
(2010) that for the first month of life it is safer to bath
all babies in plain water once or twice a week only. Cotton
wool balls should be used for baby cleansing (top
and tail).
According to Gordon and Lomax (2011), the midwife
should inspect the skin for rashes, septic spots, excoriation
or abrasions. Seborrhoeic dermatitis (cradle cap) is com-
monly seen on the scalp of the newborn, but can occur in
the axillae, groins and nappy area. It presents with scaly
lesions that are greasy to the touch and thought to be as
a response to irritants. Skin rashes such as erythema
toxicum that occur within 72 hours of birth as a red
blotchy rash, usually over the face and trunk, may be a
sign of over-heating. Removing some of the baby’s
clothing/bedding will usually resolve it. This is in com-
parison to septic spots that will need swabbing for culture
and sensitivity followed by topical or systemic antibiotic
therapy as necessary. Similarly, paronychia, which is infec-
tion of the nail cuticle caused by ragged nails, will be
treated in the same way. Parents should be advised to file
their baby’s nails and not use scissors or bite them off to keep
them short. The umbilical stump is rapidly colonized,
necroses and separates by a process of dry gangrene, which
usually takes between 7 and 15 days. The cord represents
a portal of entry for infection (especially Escherichia coli as
a result of contamination from stools) and must be
observed for any signs of redness in the surrounding
abdominal skin, referred to as an umbilical flare. If the
flare begins to spread and extend up the abdomen, this
must be reported immediately as antibiotic therapy will
be required.
Cardiovascular system and
blood physiology
The Resuscitation Council (2011) recommends that the
umbilical cord is not clamped for at least the first minute
after birth, to allow oxygenated blood to be transferred
from the placenta to the baby. As a result, the total circulat-
ing blood volume at birth may exceed 80–90 ml/kg and
ward off neonatal iron-deficiency anaemia. The haemo-
globin level may also be in excess of 18–22 g/l. The red
cell count (5–7 ×1012/l) may contribute to the develop-
ment of physiological jaundice (see Chapter 33). Black-
burn (2007) believes that conversion from fetal to adult
haemoglobin, which commences at 36 weeks gestation, is
completed in the first 1–2 years of life. The white cell count
is high initially (18.0 ×109/l) but decreases rapidly.
According to Lwaleed and Kazmi (2009), the blood clot-
ting system is immature because there is no transplacental
passage of coagulation proteins from the mother, so all
levels of blood clotting reflect fetal synthesis which is com-
pleted before the 30th gestational week. Vitamin K is
poorly transferred across the placenta, and due to the low
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amount in breast milk the incidence of classic haemor-
rhagic disease of the newborn (HDN) occurring within the
first week of life is enhanced in babies who are exclusively
breastfed, until the bowel becomes colonized by E. coli
and the Vitamin K-dependent clotting factors II (pro-
thrombin), VII, IX and X can be synthesized in the pres-
ence of bile salts. Vitamin K (intramuscular or oral
suspension) is available to all babies in the UK as a pro-
phylactic precaution against HDN. Early onset HDN
(within first 24 hours) is exclusively caused by transplacen-
tal passage of anticoagulant medicines that inhibit Vitamin
K activity. In this situation the baby will be prescribed a
therapeutic dose of Vitamin K via intramuscular injection
(Lwaleed and Kazmi 2009).
Renal system
About 20% of babies will pass urine in the birthing room
and this should be noted. Ninety per cent will void by 24
hours of age and 99% by 48 hours. The rate of urine
formation varies from 0.05 to 5.0 ml/kg/hour at all gesta-
tional ages with a range of 25–300 ml/kg/day. The com-
monest cause of initial delay or decreased urine production
is inadequate perfusion of the kidney. Added to this, the
kidneys are immature and the glomerular filtration rate is
low, but mature within the first month of life. Tubular
reabsorption capabilities are also limited, which renders
the baby unable neither to concentrate or dilute urine
adequately, nor to compensate for high or low levels of
sodium, potassium and chloride in the blood. This results
in a narrow margin between under- and over-hydration
and, as Blackburn (2007) argues, the ability to excrete
medicines is also restricted. The urine is dilute, straw-
coloured and odourless. Urate crystals may cause red brick
staining in the nappy, which is usually a sign of under-
hydration but is largely insignificant. It is the midwife’s
responsibility to assess whether the urine output falls
within acceptable parameters by asking the mother about
the character of the baby’s wet nappies given that delay in
urine production/passage may be due to physiological
stress, intrinsic renal abnormalities or obstruction of the
urinary tract. The midwife should check the records for
antenatal scan findings that may identify abnormality
such as the presence of oligohydramnios, which may indi-
cate problems with passing urine as a fetus. Many syn-
dromes involve kidney function, especially those babies
with low set ears, abnormal genitalia, anal atresia and
lower spine anomalies. Fox et al (2010) argue that the baby
should be assessed for signs of dehydration, infection and
a palpable abdominal bladder with referral to the registrar
for further investigations as necessary.
Gastrointestinal system
The gastrointestinal (GI) tract of the neonate is structurally
complete, although functionally immature in comparison
 Recognizing the healthy baby at term through examination of the newborn screening
with that of the adult (Blackburn 2007). The mucous
membrane of the mouth is pink and moist. The teeth are
buried in the gums and ptyalin secretion is low. Sucking
and swallowing reflexes are coordinated. The tongue may
be coated with milk plaques, which should be distin-
guished from the fungus Candida albicans, which will need
treatment. The stomach has a small capacity (15–30 ml),
which increases rapidly in the first weeks of life. The
cardiac sphincter is weak, predisposing to regurgitation of
milk or posseting. Gastric acidity, equal to that of the adult
within a few hours after birth, diminishes rapidly within
the first few days and by the 10th day the baby is virtually
achlorhydric (without acid), which increases the risk of
infection from the mouth. Gastric emptying time is nor-
mally 2–3 hours. Enzymes are present, although there is
a deficiency of amylase and lipase, which diminishes the
baby’s ability to digest compound carbohydrates and fat,
therefore no sandwiches are allowed! When milk enters
the stomach, a gastrocolic reflex results in the opening
of the ileocaecal valve. The contents of the ileum pass into
the large intestine and rapid peristalsis means that feeding
is often accompanied by reflex emptying of the bowel.
Bowel sounds can be heard on auscultation within one
hour of birth. Sterile meconium present in the large intes-
tine from 16 weeks’ gestation, is passed within the first 24
hours of life and should be totally excreted within 48–72
hours. As a result of air entering the gastrointestinal (GI)
tract, E. coli colonizes the bowel and the stools become
brownish-yellow in colour and odorous. Once feeding is
established the faeces become yellow. The consistency and
frequency of stools reflect the type of feeding. Digested
breast milk produces loose, bright yellow and inoffensive
acid stools. The baby may pass 8–10 stools a day. The
stools of the formula-fed baby are paler in colour, semi-
formed, less acidic and have a more offensive odour. A
melaena stool contains digested blood from high in the
GI tract, has a tar-like appearance and may be caused by
blood swallowed at birth, bleeding maternal nipples or
damage to the baby’s GI tract itself. Low GI bleeding may
result in frank blood, which is blood that can be seen in
the stools with the naked eye and may be related to HDN
(Lwaleed and Kazmi 2009).
Glycogen stores are rapidly depleted so early feeding is
required to maintain normal blood glucose levels (2.6–
4.4 mmol/l). Weight loss is normal in the first few days
but more than 10% body weight loss is abnormal and
requires investigation. Most babies regain their birth
weight in 7–10 days, thereafter gaining weight at a rate of
150–200 g per week.
Immunity
According to Paterson (2010), neonates demonstrate a
marked susceptibility to infections, particularly those
gaining entry through the mucosa of the respiratory and
gastrointestinal systems. Localization of infection is poor,
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Chapter | 28 |
with minor infections having the potential to become gen-
eralized very easily. The baby has some immunoglobulins
at birth but the sheltered intrauterine existence limits the
need for learned immune responses to specific antigens.
There are three main immunoglobulins: IgG, IgA and IgM.
Immunoglobulin G is small enough to cross the placen-
tal barrier. It affords immunity to specific viral infections
and at birth the baby’s level of IgG is equal to or slightly
higher than those of the mother. This provides passive
immunity during the first few months of life and by
2 months the baby is able to produce a good response
to protein vaccines hence the timing for the commence-
ment of routine childhood immunization programmes
(Paterson 2010).
Immunoglobulin M (IgM) and A (IgA) can be manufac-
tured by the fetus and raised blood levels of IgM at birth
are suggestive of intrauterine infection. This relatively low
level of IgM is thought to render the baby more susceptible
to gastroenteritis. Levels of IgA are also low and increase
slowly. Secretory salivary levels attain adult values within 2
months and protect against infection of the respiratory tract,
gastrointestinal tract and eyes. Colostrum and breastmilk
provide the baby with passive immunity in the form of
Lactobacillus bifidus, lactoferrin, lysozyme and secretory IgA.
Reproductive system: genitalia
and breasts
In both sexes, withdrawal of maternal oestrogens results
in transient breast engorgement, sometimes accompanied
by a milky secretion around the 5th day. Girls may develop
pseudo-menstruation, a blood-stained discharge in the
nappy, for the same reason. Both findings are insignificant
but can be concerning for parents and an appropriate
explanation should dispel any anxieties.
Skeleto-muscular system
The muscles are complete, subsequent growth occurring
by hypertrophy rather than by hyperplasia. Palpation
around the sternomastoid muscle can identify a develop-
ing haematoma that feels hard to the touch and is referred
to as a tumour (congenital torticollis). The head may be
held to one side and is the result of traction and tearing
of the muscle. Physiotherapy referral will be made once
diagnosed. The long bones are incompletely ossified to
facilitate growth at the epiphyses.
THE NEONATAL AND INFANT
PHYSICAL EXAMINATION (NIPE)
Performed within the first 72 hours of birth, this examina-
tion specifically screens for congenital heart disease
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Section | 6 | The Neonate
(CHD), congenital cataract, developmental dysplasia of
the hip (DDH) and undescended testes, usually in that
order. This is not a top-to-toe examination but more of an
opportunistic approach when the baby is quiet enough to
support auscultation of the chest and awake sufficiently to
open its eyes.
Examination of the heart
The incidence of CHD is 8/1000 live births and is the most
common group of structural anomalies, accounting for
30% of all congenital malformations (Horrox 2002).
Sinha et al (2012) argue that the best time for the heart
examination to be conducted is when the baby’s major
physiological adaptations are complete, so 48 hours post
birth is ideal. Half of the known cases of congenital heart
disease are detected by antenatal ultrasound scan so the
postnatal physical examination is the only other means of
early detection. Less than 50% of heart defects are actually
detected because many heart conditions are asymptomatic
and trivial. Blake (2008) recommends that reading the
case notes for details of the present pregnancy, perinatal
events and neonatal examinations already performed, is a
necessary prerequisite.
Park (2008) reports that maternal congenital heart
disease offers 15% prevalence to the woman’s children
compared to 1% in the general population. When one
child is affected the sibling recurrence risk is 3%, especially
for a high prevalence condition like Ventricular Septal
Defect (VSD), which is the most common variety of CHD
and accounts for one-third of all cases. Fox et al (2010)
assert that maternal rubella infection in the first trimester
commonly results in patent ductus arteriosus (PDA) and
pulmonary artery stenosis. Other viral infections in late
pregnancy may cause myocarditis. Maternal medications
such as anticonvulsants (phenytoin) and amphetamines
are highly suspected teratogens. Excessive maternal alcohol
intake may cause fetal alcohol syndrome in which VSD,
PDA and the tetralogy of Fallot are commonly seen. Mater-
nal diabetes increases the prevalence of transposition of
the great arteries (TGA), VSD, PDA and cardiomyopathy.
Sinha et al (2012) report that heart defects are common
in chromosomal disorders, to include trisomy 13,18, 21
and Turner’s syndrome (XO).
The cardiovascular examination
Gill and O’Brien (2007) recommend that the heart
itself should technically be left until last with ausculta-
tion as the final step, however auscultation is ineffectual
if the baby starts to cry, so many examiners listen to the
heart earlier in the examination. The mother’s view is
invaluable and is treated as significant unless proven oth-
erwise. Using words to describe her baby as happy,
cranky, responsive, sleepy, floppy can provide useful
information on the baby’s neurological and homeostatic
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state, especially how her baby responds physically to
taking a feed.
Inspection
England (2010c) believes that inspection is the most
important skill because it yields more information about
the baby’s cardiovascular behaviour and therefore should
not be rushed. The examiner should look at the sleeping/
resting baby’s general appearance and compare gestational
age with weight and size, as smallness could indicate
growth disruption at the time when major organs were
evolving. The examiner should question whether the baby
has any dysmorphic features indicative of chromosomal
abnormalities that are associated with heart defects. Once
the baby’s chest is undressed, breathing can be assessed.
The rate should be counted for over a minute as breathing
tends to be irregular. Central cyanosis needs urgent man-
agement. Pallor may precede respiratory distress, but again
is difficult to assess, and as Bedford (2011) argues, an
oxygen saturation of haemoglobin <95% is abnormal and
merits cardiologist assessment. It is wise to always check
saturation levels pre and post ductal so if the baby has a
PDA, proximal (hand) saturations may be within normal
limits and post-ductal levels (foot) will be much lower.
England (2010a) believes that respiratory distress may be
a sign of cardiac compensation so it is important to inspect
for asymmetrical chest wall movements, a tachypnoea > 60
breaths per minute, nasal flaring, sternal or costal reces-
sion, the use of respiratory accessory muscles, head
bobbing and the presence of an expiratory grunt. Capillary
refill greater than 2 seconds is abnormal but oxygen
therapy should always be considered cautiously as it may
close a PDA, which could be is acting as a life-saving
conduit in certain heart conditions (Horrox 2002; Bedford
2011).
Palpation
Palpation of the peripheral pulses for rhythm, strength,
volume and character then follows. The easiest pulse to
feel is the brachial at the antecubital fossa. The rate should
be counted over a period of 10 seconds. Palpation of the
femoral pulses is a difficult task. Many examiners apply
too much pressure to the artery and in effect they eradicate
the pulse wave. Strong arm pulses and weak leg pulses
suggests coarctation of the aorta (COA). If the right bra-
chial artery pulse is stronger than the left brachial artery
pulse, this could suggest a COA where the constriction is
proximal to the left subclavian artery. Equal but bounding
brachial pulses are found in PDA with a wide but dimin-
ishing pulse pressure in the lower limbs. A weak thready
pulse is found in congestive heart failure (CHF) and in
circulatory shock.
Rhythms originating in the sino-atrial node are called
sinus rhythms. In a regular sinus rhythm, the rhythm and
 Recognizing the healthy baby at term through examination of the newborn screening
rate of the heartbeat are normal for the age of the baby. In
sinus tachycardia, with beats above 160 per minute, first
consider pyrexia. Gill and O’Brien (2007) contend that the
pulse rate will accelerate approximately 10 beats per
minute for every 1°C rise in temperature. Hypoxia, circula-
tory shock, CHF and thyrotoxicosis are other possible
causes. Sinus bradycardia is defined as beats below 80 per
minute. Hypothermia, hypoxia, increased intercranial
pressure and hypothyroidism may be causative factors.
The midwife can place their open hand onto the precor-
dium, which is the area over the sternum and ribs to the
left side of the chest. A palpable precordium murmur is
referred to as a thrill, which can sometimes be seen with
the naked eye, is characteristic of heart disease with a high
volume overload such as a left-to-right shunt through the
ductus arteriosus and is always of diagnostic value. Right
ventricular enlargement is best sought with one’s fingertips
placed between the 2nd, 3rd and 4th ribs along the left
sternal edge. The apex beat is found in the 4th intercostal
space along the mid-clavicular or nipple line. A diffuse,
forceful and displaced apex beat, usually caused by hyper-
trophied heart muscle is relatively rare and described as a
heave. Palpation of the upper abdomen that reveals an
enlarged liver (greater than 1 cm below the costal margin)
may indicate heart failure as the liver acts as a reservoir of
blood because the heart cannot cope with the required
workload. An enlarged spleen, palpable in the left upper
quadrant of the abdomen, complements this clinical
picture.
Auscultation
By the time inspection and palpation have been per-
formed much of the information the baby can supply
has been obtained and auscultation is the last step. It is
recommended that a paediatric stethoscope should be
used and its diaphragm (the flat side) utilized at all aus-
cultation sites to hear the high-pitched sounds of a sys­
tolic murmur.
The sternum, clavicles and ribs, to include the costal and
intercostal spaces, are important landmarks as well as the
heart structures. There are two upper landmarks each side
of the upper sternum. The right sternal, 2nd intercostal
space is the aortic area. This is referred to as the upper right
sternal border (URSB). The left sternal 2nd intercostal
space is the pulmonary area and is known as the upper
left sternal border (ULSB). A further two landmarks are
both located to the left of the lower sternum. The left
sternal 5th intercostal space is the tricuspid area and may
be called the lower left sternal border (LLSB) and the apex
is found below the nipple on the mid-clavicular line,
in the 4th or 5th intercostal spaces. This is the mitral
area. The baby should then be turned onto its right side
and the heart should be examined for murmurs along the
route of the aorta on the left side of the spine from the
scapular area to below the ribs. The examiner is listening
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Chapter | 28 |
for turbulence of blood in the newly developed collateral
circulation caused by COA.
Each cardiac cycle has two heart sounds that can be
heard through a stethoscope when applied to the chest
wall. The first heart sound (S1) is known as ‘lub’ and is
described as long and booming and occurs when the atriv-
entricular (AV) valves, the tricuspid and bicuspid (mitral)
valves are closing at the beginning of ventricular contrac-
tion (systole). The second heart sound is ‘dub’; it is short
and sharp, and reflects closure of the semi lunar valves of
the aorta and pulmonary artery, at the beginning of ven-
tricular relaxation (diastole). The best place to hear the
first heart sound (S1) is at the apex or the LLSB. Splitting
of the heart sound where the tricuspid and mitral valves
close slightly out of synchrony, is not usually heard in a
normal baby.
The second heart sound (S2) is heard in the ULSB. Split-
ting of closure of the aortic and pulmonary artery valves
is easily heard with the stethoscope and the degree of
splitting normally varies with respiration, increasing on
inspiration and decreasing or becoming a single sound on
expiration. The third and fourth heart sounds are not nor-
mally heard but can be best auscultated at the apex or
LLSB. The third heart sound (S3) represents ventricular
filling that starts as soon as the mitral and tricuspid valves
open, and the fourth heart sound represents ventricular
filling that occurs in response to contraction of the atria.
The fourth heart sound (S4) if heard at the apex is patho-
logical and is seen in conditions with decreased ventricular
compliance (flexibility) or CHF. Where there is a combina-
tion of a loud S3 or S4 with a tachycardia, common in
CHF, this is referred to as a gallop rhythm. This informa-
tion can only complement a clinical picture of a deterior­
ating neonate that has a respiratory distress and is not
feeding.
A heart murmur is an additional noise heard during the
cardiac cycle. Absence of a murmur does not exclude congenital
heart disease. The location, timing in the cycle, grade, dura-
tion or rhythm, quality and radiation of the murmur
should be assessed. It is usual to listen to the chest wall in
four specific areas. A systolic murmur occurs between S1
and S2 and is classified as one of two types, either an ejec-
tion or regurgitant murmur. The examiner should pay par-
ticular attention to the timing of the onset of the murmur
because the onset in relation to S1 is far more important
than the duration of the murmur. In ejection systolic
murmurs there is always an interval between S1 and the
onset of the murmur. They are referred to as crescendo–
decrescendo murmurs as the murmur is at its maximum,
half-way between S1 and S2. A murmur may be short or
long in duration and can be caused either by a large
volume of blood passing through the semi-lunar valves or
a normal flow of blood passing through stenosed or
deformed semi-lunar valves.
By comparison, regurgitant systolic murmurs begin
with S1 and usually last through systole (and even into
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Section | 6 | The Neonate
diastole) and are referred to as pansystolic, meaning
from start to finish. Park (2008) argues that these
murmurs are always pathological and are associated with
VSD and feature regurgitation of the mitral and tricuspid
valves. Bedford (2011) believes that examiners should
only be concerned with systolic murmurs in the neonate
as the heart is beating too fast to pick up a diastolic
murmur, which occurs when the heart is at rest between
S2 and S1.
The intensity of the murmur is customarily graded from
1 to 6. Innocent murmurs are no louder than 2. Grade 3
murmurs are moderately loud. Palpable murmurs (thrill)
are graded as 4, are loud and regarded as pathological.
Grades 5 murmurs are very loud and audible with the
stethoscope barely on the chest wall, whilst grade 6 is
audible when standing at the end of the baby’s cot.
Quality refers to how the examiner describes the sounds
heard, e.g. systolic murmurs of VSD have a uniform
Box 28.2 Case vignette: Baby Joe
This vignette is to illustrate that significant cardiovascular
disease may not be clinically apparent at the time of the
NIPE and that consent information should highlight this
fact to the parents.
Consider the case of baby Joe, born at term in good
condition with no history of scan anomalies. His 36-hour
NIPE reports him as a healthy baby in all aspects. At 52
hours of age he deteriorates quickly and presents with
central cyanosis, poor perfusion and respiratory distress. His
tone is poor. The precordium and pulses are normal. On
auscultation there are no heart murmurs or extra sounds.
Joe is extremely sick.
The care provided:
• emergency referral and admission to the NICU
• prostaglandin E prescribed to open the ductus arteriosus
• transposition of the great arteries diagnosed on
echocardiograph
• transfer to cardiac surgical unit arranged.
The care provided to Joe’s parents:
A NIPE midwife may be called upon to provide/contribute
to information given to the parents about their sick baby.
The parents will usually be upset, fearful, possibly angry
and, as a result, not able to listen effectively (England and
Morgan 2012). In this situation the most asked questions
are:
• why didn’t the anomaly scan and NIPE examination
reveal the condition?
• what is the condition?
• what is happening to Joe now?
• will Joe die … when can we see him?
Using language that will have to be personalized for
both parents to understand, the following information may
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high-pitched quality often described as blowing whereas
an ejection systolic murmur where stenosis is featured, has
a harsh grating quality. If a murmur radiates from one area
to another it is usually pathological (Park 2008). The things
that matter most are the presence of central cyanosis, poor
perfusion, tachycardia, an abnormal precordium, a heart
murmur with a gallop rhythm and hepatosplenomegaly.
Thorough documentation should reflect inspection, pal-
pation and auscultation findings. A cardiac murmur if
present should include details of location, timing in the
cycle, grade, character and be illustrated. If the baby looks
and feels healthy but the midwife can hear extra heart
sounds that warrant a second opinion, referral should be
made to the registrar, with the parent’s informed consent.
As a result of the registrar’s opinion, the parents should be
informed that at this moment in time their baby’s heart
appears healthy or, alternatively, needs further investiga-
tion (see Box 28.2).
be given. Short explanations that answer parents’ direct
questions are required. Line drawings that are created
alongside the verbal explanations may be helpful:
‘Joe has a rare condition called transposition of the
great arteries. This is where the aorta which
transports blood to the body and the pulmonary
artery which takes it to the lungs are in the wrong
position. On a 20-week anomaly scan the four
chambers of the heart can be seen but it is not always
possible to see which major blood vessel arises from
which ventricle. In Joe’s case his pulmonary artery was
coming from his left ventricle, blood was going to his
lungs and then returning to the left side of his heart
creating a mini circulation. On the right side, blood
was returning to his heart but instead of going to his
lungs, the blood was directed into the misplaced
aorta, which took the blood back to his body. From
birth, Joe appeared well because an extra vessel
called the ductus arteriosus was open and able to
shunt oxygen to Joe’s body tissues, but as this vessel
started to close (which is a normal occurrence), Joe
started to deteriorate. This is why the midwife
examiner emphasized to you at the end of Joe’s
examination “at this point in time … on this occasion,
Joe appears well”, because at that time, he did
appear well.’
England (2010c) believes there is an accepted given that
thorough examiners will send home a baby that will be
readmitted with a serious heart defect. This emphasizes the
importance of ensuring that parents really understand that
the assessment can only reflect the status of the baby at
the time of the examination.
 Recognizing the healthy baby at term through examination of the newborn screening
Examination of the eye
The neonatal eye is 75% of the adult size but the visual
system is immature and neural connections from eye to
brain are incomplete. Babies have no depth perception
because this relies on both eyes working together and
neonatal eyes resemble those of chameleons where one
eye appears to be functioning independently from the
other. During the first three months of life there is a need
for both eyes to function well because reduced light stimu-
lation to the eye causes the condition amblyopia where the
brain fails to pay enough attention to the messages coming
from each eye and as a result, the neural connections for
each eye are not created. By 6 months of age, the eyes and
brain become ‘locked on’ to each other and this then sets
the stage for the baby’s future visual acuity. Amblyopia can
occur in one or both eyes and is usually caused by disrup-
tion of the light pathways to the retina when there is corneal
clouding or scarring, congenital cataract or clouding of the vitre-
ous humour. It is vital to screen for these media opacities
within 72 hours of birth and later at 6 weeks of age.
The skills of examination start with inspection. Oedema
of the eyelids is common and bruising may be present.
The examiner should confirm that any trauma and bruis-
ing is commensurate with the birth history and ensure the
bruising is not a birth mark. The ocular landmarks are the
structures that surround the eye and how they appear as
part of the face as a whole. With the ophthalmoscope
ready for use, the examiner should be prepared to inspect
the eyes should the baby open them. Prising eyelids open
may add to any oedema and a ptosis (drooping of the
eyelid) may go unnoticed. Reducing the room lighting,
sitting the baby up or asking the mother to hold the baby
over her shoulder with the examiner approaching from
behind the mother, works well for some.
The red reflex should be elicited first. The retina is the
nervous tissue of the eye, which is stimulated by light.
Anteriorly, it is in contact with the vitreous humour and
is avascular. Posteriorly it is supported by a vascular and
lymphatic supply from the underlying choroid. When a
light is shone into the eyes, the vascular retina shines back
and is known on photographs as ‘red eye’. If the red reflex
can be seen, this should indicate to the examiner that there are
no media opacities present. However the redness of the red
reflex may be affected by the pigmentation of the baby’s
skin, and particularly in Asian, Afro-Caribbean, Chinese
and Japanese babies they offer different hues of redness
from brown to grey to purple, which is a reflection of their
pigmented choroid and is a normal finding.
The ophthalmoscope dial should be turned to 0 and
with the right hand the scope should be held to the exam-
iner’s right eye (or vice versa if left handed). Holding the
scope close to the examiner’s eye is important if one uses
the analogy of a hole in a fence. To look through a hole
in a fence, one needs to get up close to the hole to see
through to the other side. Each eye of the baby is initially
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Chapter | 28 |
examined separately. Thus the examiner should shine a
white light from the ophthalmoscope at the baby’s eye
from a distance of 5–10 cm and focus on the pupil margin.
A red glow from the pupil will be silhouetted against the
edge of the iris. To examine both eyes together, the exam-
iner now holds the ophthalmoscope at a distance of 20 cm
from the baby’s eyes to simultaneously elicit the red reflex
from each eye. If there is any asymmetry (inequality) of
the colour and intensity of the red reflex, or a white papil-
lary reflex (leucocuria) is seen, the possibility of a media
opacity in one or both eyes should be considered and
documented. A congenital cataract (2–3 per 10 000 births)
is, according to Noonan et al (2011), the commonest cause
of blindness and should be uppermost in the examiner’s
differential diagnosis, but retinoblastoma, a malignant
tumour (44 per million births in Europe), represents the
most common intraocular tumour of childhood. Con-
genital infection from toxoplasmosis and retinopathy of
prematurity are less common causes.
The ophthalmoscope should then be set to +9 dioptres
to conduct a detailed examination of the front of the eye
to detect any abnormalities that are not available to the
naked eye. The conjunctiva and sclera should be white.
Sub-conjunctival haemorrhages are of no clinical signifi-
cance (but their presence and size should be documented,
as non-accidental injury cannot be ruled out). A blue
sclera is worthy of note as it is indicative of collagen
disease. The sclera looks blue because it is thin and not
supported by collagen and is associated with the collagen
disease osteogenesis imperfecta (brittle bone disease),
which warrants referral.
The cornea should be clear and any lacerations or scar-
ring should be noted. Clouding and/or bulging of the
cornea could indicate congenital glaucoma, which needs
urgent referral. Both pupils should equally respond to
light. A coloboma is where the iris does not form a com-
plete circle and may be associated with abnormalities that
extend to include the ciliary body and choroid. Complete
absence of the iris known as aniridia will also need refer-
ral. Different-coloured irises at this stage in life is also
suspicious (Gill and O’Brien 2007).
Assessing whether the eye is infected should be no casual
task and the examiner should always consider the gravity
of ophthalmia neonatorum. According to Noonan et al
(2011), a sticky eye demands microbiological investigation
to rule out gonococcal and/or chlamydial infection, which
if untreated can rapidly lead to corneal ulceration and
blindness. Gonococcal conjunctivitis can present from 1 to
3 days with a profuse purulent discharge with swelling of
the conjunctiva and lids. A swab must be taken for micro-
scopy and culture followed by saline irrigation, topical and
systemic antibiotics, usually penicillin. The mother and
sexual contact(s) need referral to the genitourinary clinic.
Likewise chlamydial conjunctivitis presents later, at 5–14
days, but is associated with neonatal pneumonia if the
initial systemic antibiotic treatment has been inadequate.
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Section | 6 | The Neonate
Fox et al (2010) assert that specific chlamydial swabs
should be used with erythromycin the choice of antibiotic.
Noonan et al (2011) further contend that herpes virus type
II and bacterial infections such as Staphylococcus aureus,
Streptococci and E. coli need immediate treatment. Full
documentation of what has been found should be detailed
for each eye and the parents informed that on this occasion,
the eyes appear healthy (or otherwise).
Examination of the hips
Developmental dysplasia of the hip (DDH) represents a
spectrum of defects where the femoral head is not totally
in the acetabulum, but possibly on its border and can only
be diagnosed on ultrasound scan (Kasser 2012). Disloca-
tion is when the femoral head is outside of the acetabulum.
The femoral head continues to grow but if the femoral
head is not in the acetabulum, the acetabulum fails to grow.
Secondary adaptive changes occur so that ligaments and
muscles shorten and tighten and the acetabulum fills with
scar-like tissue. The incidence is 1 in 400 live births and
there are two factors that relate to the natural history of
DDH which makes screening difficult. Jones (1998) asserts
that as many as 20 babies in every 1000 births have unsta-
ble hips but 90% of these will stabilize spontaneously. It
is not possible to predict which 10% of these hips will
remain unstable. Stable hips at birth may later develop DDH.
The hip is at its most unstable at the time of term birth. In
early gestation there is nearly total spherical enclosure of
the femoral head by the acetabulum, but by term when the
tightness of the uterus and the lack of leg and hip freedom
is at its peak the femur is shallow, then deepens again in
the postnatal period. The low incidence of DDH in preterm
babies supports this notion. Paton (2011) argues that pre-
dominantly it is a disease of girls, with a 6 : 1 ratio with
boys, and is more common on the left side (2 : 1). The ideal
time for screening the newborn hip is 7 days. The NIPE
screen is technically too early, is a compromise but should
be followed by an examination at 4–8 weeks by the general
practitioner or the health visitor.
The baby must be warm and comfortable, be on a firm
flat surface and one of the parents must be present. The
midwife must have enough room to gain access to the baby
and be physically able and comfortable to perform the
manoeuvres (Jones 1998). A general inspection followed
by a detailed skeletal examination of the baby may reveal
additional risk factors (see Box 28.3) that the history has
not elicited. Oligohydramnios, postural foot deformities,
plagiocephaly, scoliosis and a prominent sacral dimple are
all associated with hip abnormalities. Babies that show the
effects of intrauterine growth restriction (IUGR) and those
with dysmorphic features are particularly at risk.
With the baby lying on its back and legs bent at the knee
with feet on the surface, an initial inspection should look
for any asymmetry in the appearance of the legs and groin
skin folds. Examination of the knees may show uneven
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Box 28.3 Predisposing factors to developmental
dysplasia of the hip (DDH)
1. Squashed hips in utero. The emphasis is breech birth
to include vaginal and caesarean section and to
include those babies when external cephalic version
has been performed near to and at term for breech
presentation. When oligohydramnios is featured, look
for structural or positional talipes (equino-varus/
calcaneo-valgus) or a combination of these two
presentations
2. Genetic predisposition. There is a higher proportion
of identical twins with DDH compared to non-
identical twins
3. Family history of dislocation of the hip/DDH
4. Ligament hyperlaxity can lead to full abduction in the
presence of a dislocated hip
5. Geographical variation where abduction of the child’s
hips is a strong cultural feature, with an incidence of
0.25 per 1000 live births; however, where swaddling
the legs together (usually for warmth) is the cultural
norm, the incidence rises to 10/1000.
Source: Dove et al 2011
knee height. On the affected side, the knee is lower because
the head of the femur has dropped into the soft tissues
because it is not being held by the bony acetabulum.
However, equal knee height could indicate either normal-
ity of both hips or bilateral dislocation of both hips.
Pulling the legs straight to measure leg length, should be
done after the hip examination as this manoeuvre stimu-
lates flexor tone resistance, which is enough to upset a
settled baby and render the examination less valid.
The modified Ortolani and Barlow manoeuvres are
referred to as the combined stress test and are performed to
diagnose the subluxatable (dislocatable) or dislocated hip
and make it possible to notice the presence or absence of
knee and hip clicks. The range of abduction in flexion is
also a useful sign to indicate the degree (if any) of
abnormality.
The Ortolani manoeuvre is described for examination
of the left hip, using the examiner’s right hand. The exam-
iner steadies the pelvis between the thumb of the left hand
on the baby’s symphasis pubis and fingers under the
sacrum. With the baby’s left leg flexed in the palm of
the right hand, the head of the femur is held between the
examiner’s right thumb on the inner side of the thigh
opposite the lesser trochanter and the middle longest
finger over the greater trochanter. In an attempt to relocate
a posteriorly displaced head of the femur forwards into
the acetabulum, the middle finger applies gentle pressure
upon the greater trochanter. The baby’s thighs are flexed
forward (to the head of the baby) onto the abdomen and
rotated and abducted through an angle of 70–90° towards
 Recognizing the healthy baby at term through examination of the newborn screening
the examining surface. If the hip is dislocated, a clunk
will be felt (and sometimes heard) as the head of the
femur slips into the acetabulum. A high-pitched click is
probably a product of soft tissue structures moving
over bony prominences. Remember Ortolani – Out to In
(Baston and Durward 2010).
The Barlow manoeuvre is described for examination of
the left hip and the examiner’s right hand. From a position
of abduction, the hip is adducted to 70° and gentle pres-
sure is exerted by the examiner’s right thumb on the lesser
trochanter in a backward and lateral direction. If the
thumb is felt to move backwards over the labrum (the
fibro-cartilaginous rim of the acetabulum) onto the pos-
terior aspect of the joint capsule, a clunk may be heard as
the head of the femur dislocates out of the acetabulum.
England (2010c) describes the noise as a deeper clunk with
significant movement. The dislocatable hip can feel
strangely soft with little or no resistance. The Ortolani
manoeuvre will then be performed to return the head of
femur to the acetabulum. To examine the right hip the role
of the examiner’s hands is reversed. Dove et al (2011)
support the view that it is acceptable for the experienced
examiner to undertake the Ortolani and Barlow manoeu-
vres sequentially on both hips simultaneously.
The Barlow and Ortolani tests involve gentle manoeu-
vres. The softer the touch, the more information is secured;
indeed very little pressure is needed to dislocate the head
of femur because the acetabulum is so shallow. A heavy-
handed approach will often make the baby stiffen and
resist being touched. In this circumstance the examiner
needs to abandon the examination, talk to the baby (and
parents) in an attempt to relax him (and them) and then
attempt a further examination. A useful analogy is a gear
stick in a car. Gentle manipulation of the baby’s legs in a
circular rotation helps to reduce muscle and nerve tension.
Likewise, the lightest of touch can help guide that gear
stick home.
Documentation of findings in the Personal Child Health
record should offer details and be explained to the parents.
Dove et al (2011) assert that it is not enough to place a
tick against the word hips. When an abnormality is found
an example of the record may be written thus: ‘The right
hip abducted fully in flexion; is stable and the combined
stress test Ortolani/Barlow manoeuvre was negative with
no shortening on knee height inspection. The left hip
shows shortening on knee height inspection with resist-
ance to abduction, which resulted in an Ortolani clunk as
the head of femur returned to the acetabulum. The find-
ings were confirmed by Dr Smith (neonatal registrar).
Double nappies were applied. Referral arranged for a 2
week follow-up for ultrasound scan and appointment with
orthopaedic consultant. Both parents were present at the
examinations and have been informed of the clinical find-
ings and referral arrangements.’ An entry that communi-
cates health must reflect that both hips abduct fully in
flexion and there is no apparent shortening on knee height
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Chapter | 28 |
inspection. It should be clear that both hips are stable and
the combined stress test comprising the Ortolani and
Barlow manoeuvres is negative for both hips. The parents
should be told that on this examination/occasion, their
baby’s hips appear healthy.
Examination of the genitalia
This examination will repeat the previous examinations
reported in this chapter and review any new
developments.
Neurological examination
The neurological examination will be performed continu-
ously throughout the examination, noting how the baby
handles and behaviourly tolerates the examination. The
healthy term baby will make eye-to-eye contact, fix and
follow a face when held 30 centimetres from the examiner.
There should be natural facial movements with blinking
of the eyes. When lying supine the baby will be flexed at
the knees with hips abducted; the head turned to one side.
Movements are smooth, symmetric and varied. The baby
should be able to demonstrate a rooting reflex. Coordi-
nated movements of lip, tongue, palate and pharynx are
required to suck and swallow successfully. Failure to suck
when the stomach is empty is indicative of abnormal func-
tion and an important sign of brain stem damage.
Primary (primitive) reflexes (see Box 28.4) are best per-
formed at the end of the NIPE screen as they will usually
unsettle, even distress the baby. They provide information
about lower motor neuron activity and muscle tone. Per-
sistence beyond the normal age suggests that higher cortical
centres are not gaining control of tone and movement as
expected and can be an early sign of cerebral palsy. Extremes
of tone (rag doll floppiness) or persistent extension of the
back (opisthotonus) are both abnormal. Flexed arms and
extended legs is also an abnormal posture. Jitteriness is a
feature of the healthy baby and can be stopped by touching
the affected area. Irritability in the form of repetitive move-
ments, for example an eyelid or finger, could represent a
convulsion in a baby and warrants referral.
At present NIPE training is largely regarded as an
expanded role of the registered midwife. However the Mid-
wifery 2020 report (Department of Health 2010) recom-
mends that overall care of the neonate needs to be
improved, and according to Lumsden (2012), NIPE train-
ing is now becoming part of pre-registration midwifery
education. There is a requirement for all midwives to
further develop their neonatal knowledge in recognizing
health, by knowing and understanding the abnormal. This
will involve enhancing their communication and examin-
ing skills in being able to conduct all three screening
examinations discussed in this chapter, in order to provide
truly holistic, individualized care that will place the
midwife as the lead practitioner for the healthy baby.
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Section | 6 | The Neonate

Box 28.4 Neurological reflexes in the newborn

• Placing reflex. Whilst the baby is being held upright,
the top of the foot is touched by the edge of a
surface and the baby will lift and place its foot on the
surface. Presents from 36 weeks’ gestation and
disappears at 3 months of age.
• Palmar and plantar grasps. Flexion of fingers/toes
when an object is placed in the palm of the hand/on
the ball of the foot. Presents at 28 weeks’ gestation
and disappears by 2–3 months.
• Asymmetric tonic neck reflex (the fencing sign).
When the head is turned to one side, the arm and leg
on that side extend, while the arm and leg on the
other side remain flexed. Established from 36 weeks’
gestation and disappears at 6 months.
• Moro (startle) reflex. On sudden head extension,
symmetrical abduction and extension followed by
flexion and adduction of the arms, with
accompanying cry. Present at 37 weeks’ gestation and
disappears around 4 months of age. Absent in heavy
sedation or hypoxic, ischaemic encephalopathy.
Unilateral presentation implies fractured clavicle,
hemiplegia, brachial plexus palsy.
• Rooting reflex. Stroking the baby’s cheek with a
finger causes the head to turn towards the
stimulation and the mouth will open. Established at
34 weeks’ gestation and disappears at 4 months of
age, when visual cues take over.
• Sucking reflex. Elicited to assess the strength and
coordination of the sucking reflex by placing a clean
finger in the mouth. Disappears by age of 12 months.
For visual display of reflexes go to www.youtube.com/
watch?v=Sv5SsLH70mY

REFERENCES

Baston H, Durward H 2010 Examination
of the newborn. A practical guide.
Routledge, London
Bedford C D 2011 Cardiovascular and
respiratory assessment of the baby.
In: Lomax A (ed) Examination of the
newborn. An evidence-based guide.
Wiley–Blackwell, Chichester
Bedford C D, Lomax A 2011
Development of the heart and lungs
and transition to extrauterine life. In:
Lomax A (ed) Examination of the
newborn. An evidence-based guide.
Wiley–Blackwell, Chichester
Blackburn S T 2007 Maternal fetal and
neonatal physiology. Saunders
Elsevier, Philadelphia
Blake D 2008 Assessment of the
neonate: involving the mother.
British Journal of Midwifery
16(4):224–6
Brown V D, Landers S 2011 Heat
balance. In: Gardner S L, Carter B S,
Enzman-Hines M et al (eds)
Neonatal intensive care. Mosby, St
Louis
Davies N 2011 Abnormalities of the
foot. In: Lomax A (ed) Examination
of the newborn. An evidence-based
guide. Wiley–Blackwell, Chichester
Department of Health 2010 Midwifery
2020: delivering expectations.
www.midwifery2020.org.uk
(accessed 4 March 2013)
Dove R, Hunter J, Wardle S 2011
Nottingham neonatal service clinical
guidelines. Screening for
developmental dysplasia of the hip.
Nottingham University Hospital
NHS Trust
England C 2010a Neonatal respiratory
problems. In: Lumsden H,
Holmes D (eds) Care of the
newborn by ten teachers. Hodder
Arnold, London
England C 2010b Care of the jaundiced
baby. In: Lumsden H, Holmes D
(eds) Care of the newborn by ten
teachers. Hodder Arnold, London
England C 2010c Physical examination
of the neonate. In: Marshall J E,
Raynor M D (eds) Advancing skills
in midwifery practice. Churchill
Livingstone, London
England C, Morgan R 2012
Communication skills for midwives.
Challenges in everyday practice.
Open University Press/McGraw-Hill
Education, Maidenhead
Foundation for Sudden Infant Death
2013 http://fsid.org.uk (accessed 2
April 2013)
Fox G, Hoque N, Watts T 2010 Oxford
handbook of neonatology. Oxford
University Press, Oxford
Gill D, O’Brien N 2007 Paediatric
clinical examination made easy.
Churchill Livingstone, London
Gordon M 2011 Examination of the
newborn abdomen and genitalia. In:
Lomax A (ed) Examination of the
newborn. Wiley–Blackwell, Oxford
Gordon M, Lomax A 2011 The neonatal
skin: examination of the jaundiced
newborn and gestational age
assessment. In: Lomax A (ed)
Examination of the newborn.
Wiley–Blackwell, Oxford
Griffith R (2009) Safeguarding children
from significant harm. British
Journal of Midwifery 17(1):58–9
Horrox F 2002 Manual of neonatal and
paediatric heart disease. Whurr
Publishers, London
Jones, A J 1998 Hip screening in the
newborn. A practical guide.
Butterworth–Heinemann, Oxford
Kasser J R 2012 Orthopaedic problems
In: Cloherty J P, Eichenwald E C,
Hansen A R et al (eds) Manual of
neonatal care. Lippincott, Williams
and Wilkins, Philadelphia
Lumsden H 2010 Examination of the
newborn. In: Lumsden H, Holmes D
(eds) Care of the newborn by ten
teachers. Hodder Arnold, London
Lumsden H 2012 Embedding NIPE into
the pre-registration midwifery
programme. Midwives (1):42–3
Lwaleed B A, Kazmi R 2009 An overview
of haemostasis. In: Hall M, Noble A,

608
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 Recognizing the healthy baby at term through examination of the newborn screening
Smith S (eds) A foundation for
neonatal care. A multidisciplinary
guide. Radcliffe, Oxford
Noonan C, Rowe F J, Lomax A 2011
Examination of the head, neck and
eyes. In: Lomax A (ed) Examination
of the newborn. Wiley–Blackwell,
Oxford
Park M K 2008 Pediatric cardiology for
practitioners. Mosby, Philadelphia
Paterson L 2010 Infections in the
newborn period. In: Lumsden H,
Holmes D (eds) Care of the
newborn by ten teachers. Hodder
Arnold, London
Paton R W 2011 Developmental
dysplasia of the hip. In: Lomax A
FURTHER READING
Bedford C D, Lomax A 2011
Development of the heart and lungs
and transition to extrauterine life. In:
Lomax A (ed) Examination of the
newborn. An evidence-based guide.
Wiley–Blackwell, Chichester
This chapter provides a detailed exploration
of the fetal circulation and the adaptations
that occur with the first breath at birth. It
also integrates the impact of hypoglycaemia,
hypoxia and hypothermia on these
transitional events and offers a useful
discussion on the energy triangle.
USEFUL WEBSITES
Resuscitation Council (UK):
www.resus.org.uk
The Resuscitation Council in the definitive
resource for keeping up to date on
mebooksfree.com
(ed) Examination of the newborn.
Wiley–Blackwell, Oxford
Resuscitation Council UK 2011
Newborn life support, 3rd edn.
London
Roth D A, Hildesheimer M, Bardenstein
S et al 2008 Periauricular skin tags UK National Screening Committee 2012
and ear pits are associated with
permanent hearing impairment in
newborns. Paediatrics 122:884–90
Sinha S, Miall L, Jardine L 2012
Essential neonatal medicine.
Wiley–Blackwell, Chichester/Oxford
Trotter S 2010 Neonatal skincare. In:
Lumsden H, Holmes D (eds) Care of
the newborn by ten teachers. Hodder
Arnold, London
McCallum L 2010 www.slideshare.net/
Prezi22/physical-examination-of
-the-newborndoc
This text offers useful information on
examination of the newborn and could be
used as a revision script.
Quarrell C 2011 Examining the
neonate in the hospital and
community: child protection
issues. In: Lomax A (ed)
Examination of the newborn:
an evidence-based guide. Wiley–
Blackwell, Chichester
techniques and information about neonatal
resuscitation.
The Auscultation Assistant:
www.wilkes.med.uncla.edu/inex.htm
Chapter | 28 |
UK National Screening Committee 2008
Newborn and infant physical
examination: standards and
competencies NHS. http://
newbornphysical.screening.nhs.uk
(accessed 3 February 2013)
NSC policy database. Hearing
(newborn). www.screening.nhs.uk/
hearing-newborn (accessed 28
October 2012)
Wassner A J, Spack N P 2012 Disorders
of sex development. In: Cloherty J P,
Eichenwald E C, Hansen A R (eds)
Manual of neonatal care. Lippincott,
Williams and Wilkins, Philadelphia,
p 791–807
This chapter asserts that the midwife is
the baby’s advocate and safeguarding
considerations should be integral to the
examination of the newborn by ensuring
that the baby remains the focus of the
examination. Does the evidence
observed fit with the parent’s account?
Who is the midwife’s designated referral
professional in safeguarding situations?
These questions are well addressed.
A good site to listen to and differentiate the
different heart sounds and murmurs.
609
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 Chapter
Resuscitation of the healthy baby at birth:
the importance of drying, airway management
and establishment of breathing
Carole England
CHAPTER CONTENTS
Drying the baby 611
Airway management and breathing 612
Difficulties in establishing an open airway 613
Parental support through effective
communication 614
References 614
Further reading 615
Midwives are the lead practitioners in normal
birth and attend most births in the hospital and
home setting. It is therefore important that
they have applicable knowledge and skills of
resuscitation to enable them to care for the
newborn baby (and parents) in a competent
supportive manner. The aim of this chapter is to
uphold the principles of care offered by the
Resuscitation Council United Kingdom [RCUK]
(2011) and explore the specific role of the
midwife in drying the baby and airway
management. Noting the time of birth and
starting the clock on the resuscitaire (if
applicable) is always the starting point for care
and documentation requirements. Requesting
assistance from the multiprofessional team at
any stage of the process is recognized as an
essential component.
© 2014 Elsevier Ltd
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29
THE CHAPTER AIMS TO:
• emphasize the importance of thoroughly drying the
baby to prevent heat loss
• support the principle of enabling the baby to
resuscitate itself by placing its head in the neutral
position
• detail how to open the airway by giving inflation
breaths in order to clear the lung fluid
• reiterate the importance of starting and
maintaining a record of the events of the
resuscitation process
• highlight the need to ask for help from the
multiprofessional team at any stage of the process.
DRYING THE BABY
Thoroughly drying of the baby is always the first step to
management of resuscitation at birth. Taking the time to
dry the baby’s head, to include the face alongside the arm
and leg creases, is sometimes not performed as thoroughly
as it should be. According to Connolly (2010), heat loss
and cooling of the baby is inevitable but failure to spend
time doing this task meticulously can result in the baby
using oxygen and glucose to maintain or raise its meta-
bolic rate. Also, in order to place a baby in skin-to-skin
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Section | 6 | The Neonate

contact with its mother, the baby needs to be thoroughly dry;
furthermore, the mother needs to be dry so that the baby
can benefit from conductive heat gains.
During this time of drying, which can take up to a
minute, the midwife should assess the baby for its colour
and muscle tone. The Apgar score is used as a communica-
tion tool to inform other team members should it be
necessary. A score at 1, 5 and 10 minutes is entered into
the record (Nursing and Midwifery Council [NMC] 2009).
Most babies will be blue at birth, which indicates that there
is accumulation of carbon dioxide (CO2) in the blood and
tissues. It is important to remember that CO2 is a stimu-
lant to the respiratory centre in the medulla oblongata, so
blue skin is a normal physiological sign and most babies will
not require resuscitating. However, too much CO2 will
depress respiration and this may account for why the baby
may be showing little or no respiratory effort. White or
mottled grey skin is an indication of peripheral shut down
as the baby is responding to low oxygen levels and is
conserving the available oxygen for the heart and brain by
diverting blood away from the skin and other non-essential
organs (Leone and Finer 2012). This is the baby that needs
to be thoroughly dried as their reserves of oxygen cannot
be wasted on attempting to keep warm. So, the rule of
thumb must be the poorer the colour, the more thorough the
drying process should be. The midwife should not let their
own anxiety or that of others hurry them in this drying
process. All wet towels should be discarded and the baby
covered in warmed dry ones. Identification name bands
should also be placed on the baby in the hospital setting,
should there be need to separate the baby from the mother
at any time.
According to Rennie and Kendall (2013), the assessment
of muscle tone indicates to what degree the nerves are
stimulating the skeletal muscles. When a baby is well
toned for its gestational age, this signals that the baby is
generally in good condition even though they may not be
breathing. A baby that is both white and floppy reflects the
possibility of long-term hypoxia as a result of the labour
process or some other co-existing factor, for example,
infection. The midwife should simultaneously assess
whether the baby is breathing by assessing the presence or
absence of chest movement and any other signs, such as
gasping. If the baby is crying, the baby has an open airway.
This assessment is followed by auscultation of the chest to
assess the heart rate. Dawson et al (2010) argue that the
midwife needs to establish whether there is a heart rate
and, if so, if it is above or below 60 beats per minute
(bpm). In the first minute, the average heart rate of a
healthy term baby is below 100 bpm, however by the
second minute it has usually risen to around 140 bpm and
by 5 minutes to 160 bpm. Dawson et al (2010) consider
that the heart rate is the most important indicator of
health in newborn babies and this is why it is so important
to make a regular assessment, hence the 1 and 5 minutes
time-frame of the Apgar score (Apgar 1952). During this
time of assessment, the umbilical cord can remain uncut
so that extra red blood cells can be transported to the baby
and enhance the baby’s oxygen-carrying capacity. Even if
the heart rate is really slow, opening the airway must be
the first task to achieve. Without an open airway, the baby
has no way of being oxygenated, as this is the only means
of assisting the heart to function. Hence the midwife
should note the Airway, Breathing and Circulation of
resuscitation when C must follow B and B must follow A:
there is no room for any short cuts.
AIRWAY MANAGEMENT
AND BREATHING
If the baby is not breathing, opening the airway is always the
first step. A flat surface is needed so the umbilical cord can
be cut and secured. In the home setting, the floor is a
tempting location to place the baby, especially if the room
is cluttered. However, the floor is not ideal, as even in the
summer it is often cold and draughty and therefore likely
to cool the baby. Furthermore, in any resuscitation situation,
the first consideration is practitioner safety. The midwife must
always make sure the environment is safe for her to func-
tion, and bad posture in particular can contribute to poor
performance and awkward communications. It is therefore
better to clear a table or use the seat of a firm chair to place
the baby on.
The prominence of the neonatal occipital protuberance
can affect the natural position of the baby’s head, when
lying on its back, with the result of either the chin falling
down to the chest in flexion or extending into the chin-up
position. Both postures consequently close the airway. The
head should be placed in the neutral position (Fig. 29.1)
with the nose uppermost, the ideal situation being when
another person can hold the baby’s head for the midwife
(Tracy et al 2011).
Fig. 29.1 Neutral position.

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 Resuscitation of the healthy baby at birth
Fig. 29.2 Small towel under the neck (sniffing position).
Fig. 29.3 Bagging demonstration.
Alternatively, a small sheet/towel or equivalent can be
placed under the neck of the baby to secure the neutral
position (sniffing position) (Fig. 29.2).
Intermittent positive pressure ventilation (IPPV) will
then be commenced using a bag and mask if available or
a T-piece, mask and resuscitaire in the hospital. The mask
must be the correct size for the baby to prevent any leaks
of air to occur on inflation of the bag. The mask should
be rolled onto the face from the chin, using the stem of
the mask (like a champagne glass) to hold it in position.
The soft part of the mask should not be touched as this
may distort its shape and lead to leakage of air (Fig. 29.3).
The bag when manually compressed will deliver posi-
tive pressure of air at 30 cmH2O. Given that the alveoli are
filled with lung fluid, this pressure should be applied for
3 seconds, which is the time it takes to steadily count
‘1–2–3’, to begin the process of forcing the lung fluid into
the lymphatic channels of the lungs. The bag should be
allowed to refill before giving the second breath, ‘2–2–3’,
the third breath, ‘3–2–3’, ‘4–2–3, and finally ‘5–2–3’. Five
inflation breaths should be sufficient to clear the lung fluid to
make room for the air. While these inflation breaths are
being given, the baby should be covered but with the chest
exposed so that any chest movement (which is the sign of
an open airway) can be seen and noted. It must be appreci-
ated that while there is an exchange of one substance with
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Chapter | 29 |
Box 29.1 Reflective question
‘If a baby is not breathing, is it acceptable
to blow oxygen onto the baby’s face
instead of using IPPV with a bag and
mask?’
This is totally inappropriate for two reasons:
1. You must first establish that the airway is open. The
only way to do this is by giving five inflation breaths
and seeing the chest rise by the fifth inflation breath.
The time you spend not giving IPPV is wasted and the
baby is not receiving any benefit from you.
2. Resuscitation gas now consists of air as standard
not oxygen. Air is a cold gas and if you blow this
onto the face of the baby, you will quickly cool the
baby.
another, i.e. lung fluid with air, there is no accumulation
of air to lift the chest until the 4th or 5th inflation breath.
This can be a nervous time for the midwife because it is
natural to think that the chest will rise on the first inflation
and it is easy for midwives to blame their own technique.
Once chest movement has been seen, the facemask should
be removed to assess if the baby is spontaneously breath-
ing. The heart rate can also be assessed at this time to
establish whether the rate has increased.
Babies that are blue with good muscle tone and a heart
rate above 60 bpm often do not need any further assist-
ance. As soon as normal respiratory effort is established
and their heart rate is over 100 bpm, they can be given to
their mother for skin-to-skin contact. However, some
babies in this category may not be breathing spontan­
eously because there remains too much CO2 in their blood
and tissues (hypercapnoea) that is depressing their respira-
tory effort. Ventilatory breaths are then commenced to
provide oxygen (21% in air) and blow off the excess CO2.
Given at a rate of 30 breaths per minute, these breaths are
therefore 2 seconds in duration. It is important to assess
the baby every 30 seconds to see if they are making spon-
taneous efforts to breathe. It is vital that the midwife does
not over-ventilate the baby and reduce their CO2 too much
and cause apnoea. Babies should be allowed to resuscitate
themselves, noting the time when the baby is breathing
spontaneously. (See Box 29.1.)
DIFFICULTIES IN ESTABLISHING
AN OPEN AIRWAY
If there is no chest movement after five inflation breaths,
this indicates that the airway is not open, so the alveoli
will remain filled with lung fluid. This is a good time to
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Section | 6 | The Neonate

consider calling for medical assistance because failure of
the following interventions may result in the need for
tracheal intubation (RCUK 2011). In the home, paramedic
support will take longer to arrive so early anticipation of
problems is considered good practice. If the baby has a
poor colour and muscle tone, this may indicate that the
position of their head has not been maintained in the
neutral position and there is a definite need for a second
person’s help both to hold the head and apply jaw thrust.
The jaw of a floppy baby can fall backwards and as the
tongue is attached to the jaw, the tongue falls back into
the airway, blocking the airway. A second person, with
their fingers on each side of the jaw, can push the jaw
forwards and hold it in that position. This is an easily
performed manoeuvre because the baby does not offer any
muscle tone resistance. Five inflation breaths should then
be given. If there is still no chest movement, suction to the
oropharynx under direct vision using the light of a laryn-
goscope may be considered should there be an obstruc-
tion. Occasionally if there is maternal bleeding at the
birth, some blood may have entered the baby’s mouth,
initially as fluid but then over time may have clotted.
(Please note: The management of meconium is not considered
in this context, as the resuscitation would be approached in a
different way: Chapters 32 and 33). After this intervention
five inflation breaths are given. If not successful, an
oropharyngeal (Guedel) airway can be inserted to open
the airway mechanically, especially in babies who may
have congenital abnormalities such as choanal atresia and/
or micrognathia. The correct sizing of the airway is vital.
When held along the line of the lower jaw with the flange
at the level of the middle of the lips, the end of the airway
should reach the angle of the jaw. The airway is slipped
over the tongue in the same attitude that it will finally lie.
The midwife should make sure that the tongue is not
pushed back into the back of the mouth. Once in situ the
mask can be placed over the airway (both the mouth and
nose) and a further five inflation breaths should be given.
If the chest fails to rise after these interventions, intubation
of the trachea will be required and an experienced neo­
natal registrar will be needed to assist.
PARENTAL SUPPORT THROUGH
EFFECTIVE COMMUNICATION
According to England and Morgan (2012) resuscitation of
the baby occurs in the presence of the parents, so a clear,
simple explanation in a calm tone should be given to
inform and support them during the process. Parental
stress and anxiety will affect how the couple are able to
receive information and respond to it. Non-verbal com-
munication is more influential in informing the parents
of the midwife’s state of mind. Documentation should
always reflect obtained consent and specific aspects of the
resuscitation, including any interactions between the
parents and multiprofessional team that have occurred
(NMC 2008, 2009, 2012). It is important to recognize that
records should always be sequentially detailed enough,
should they be required to support the midwife’s actions
at a later date and read out in court or at the NMC.

REFERENCES

Apgar V 1952 Proposal for a new
method of evaluation of newborn
infants. Anaesthesia and Analgesia
32: 260–7
Connolly G 2010 Resuscitation of the
newborn. In: Boxwell G (ed)
Neonatal intensive care nursing.
Routledge, London, p 65–86
Dawson J A, Kamlin C O F, Wong C
et al 2010 Changes in heart rate in
the first minutes after birth. Archives
of Disease in Childhood Fetal and
Neonatal Edition 95(3): F177–81
England C, Morgan R 2012
Communication skills for midwives:
challenges in everyday practice.
McGraw–Hill/Open University Press,
Maidenhead
Leone T A, Finer N N (2012)
Resuscitation in the delivery room.
In: Gleason C A, Devaskar S U
(eds) Avery’s diseases of the
newborn. Elsevier, Philadelphia,
p 328–40
NMC (Nursing and Midwifery Council)
2008 The Code: standards of
conduct, performance and ethics
for nurses and midwives. NMC,
London
NMC (Nursing and Midwifery Council)
2009 Record keeping. Guidance for
nurses and midwives. NMC, London
NMC (Nursing and Midwifery Council)
2012 Midwives rules and standards.
NMC, London
RCUK (Resuscitation Council UK) 2011
Newborn life support. RCUK,
London
Rennie J M, Kendall G S 2013 A manual
of neonatal intensive care. Taylor
and Francis, London
Tracy M B, Klimek J, Coughtrey H et al
2011 Mask leak in one-person mask
ventilation compared to two-person
in a newborn infant manikin study.
Archives of Disease in Childhood
Fetal and Neonatal Edition
96(3):F195–200

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FURTHER READING
England C, Morgan R 2012
Communication skills for midwives:
challenges in everyday practice.
McGraw–Hill/Open University Press,
Maidenhead
Chapter 7 provides details regarding
personal interactions in acute clinical
situations and explores in depth how the
midwife should communicate with parents
and members of the multiprofessional team
in the neonatal resuscitation situation.
mebooksfree.com
Resuscitation of the healthy baby at birth
Mosley C M J, Shaw B N J 2013 A
longitudinal cohort study to
investigate the retention of
knowledge and skills following
attendance on the Newborn Life
Support course. Archives of Disease
in Childhood 98(8):582–6
This article reports that practitioners
following specialist training, over time
experience deterioration in neonatal
resuscitation ability and technique,
Chapter | 29 |
especially if they are not exposed to clinical
resuscitation situations on a regular basis.
Practitioners failed on simple but essential
interventions such as not removing the wet
towel from the baby and not assessing the
baby’s heart beat. It is suggested that
practitioners should attend resuscitation
updates on a regular basis to maintain and
hone their skills, which should improve
confidence.
615
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 Chapter 30

The healthy low birth weight baby

Carole England

CHAPTER CONTENTS It is now common practice for healthy LBW

babies from 32 weeks’ gestation with a birth
Classification of babies by gestation weight of 1.7–2.5 kg to be cared for on a
and weight 617 postnatal ward with their mother. The majority
Gestational age 618 of these babies remain well, will have minimal or
no illness in the neonatal period and can be
Birth weight 618 cared for by midwives as the lead practitioner
Small for gestational age (SGA) 618 (Department of Health [DH] 2010). This chapter
Types of intrauterine growth restriction will examine the role of the midwife in
rate (IUGR) 619 supporting parents to care for their healthy LBW
baby and the specific knowledge and skills the
The preterm baby 621 midwife requires to fulfil this effectively.
Characteristics of the preterm baby 621
Care of the healthy LBW baby 622
Management at birth 622 THE CHAPTER AIMS TO:
Assessment of gestational age 622 • examine the terminology and classifications of
Thermoregulation 623 babies in relation to gestational age and birth
Hypoglycaemia 623 weight
Feeding 624 • critically discuss the importance of skin-to-skin
Optimizing the care environment for the contact and early feeding in the prevention of cold
healthy LBW baby 625 stress and hypoglycaemia
Handling and touch 625 • discuss the provision of an accommodating
Noise and light hazards 626 environment that supports the developing needs of
the LBW baby on the postnatal ward.
Sleeping position 626
References 626
Further reading 628
Useful websites 628
CLASSIFICATION OF BABIES BY
GESTATION AND WEIGHT
Between 6% and 7% of all babies born in
the United Kingdom (UK) weigh <2500 g at
birth. Preterm babies make up two-thirds of low Definitions of gestational age disregard any considerations
birth weight (LBW) babies, with the other of birth weight and likewise definitions of LBW are based
one-third being small for their gestational age upon weight alone and do not consider the gestational age
(SGA), some of which will be born at term. of the baby.

© 2014 Elsevier Ltd 617

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 Section | 6 | The Neonate

Gestational age derived from studies of local populations, because geneti-

According to Smith (2012), babies should preferably be
classified by gestational age, as this is a better physiological
measure compared to birth weight. A preterm baby is born
before completion of the 37th gestational week (259
days), which is calculated from the first day of the mother’s
last menstrual period (LMP) and has no relevance to the
baby’s weight, length, head circumference, or indeed any
other measurement of fetal or neonatal size. Smith (2012)
further asserts that gestational age estimates by first-
trimester ultrasonography are accurate within 4 days, so
that the combination of fetal crown–rump length and
menstrual history are now considered more accurate
indices for estimating gestational age.
Birth weight
The World Health Organization (WHO 1997a) recom-
mend that babies who weigh <2500 g should be called
low birth weight (LBW). As neonatal care has become
more effective and babies are surviving at earlier gesta-
tions, new LBW categories are now recognized:
• very low birth weight (VLBW) babies are those
weighing below 1500 g at birth
• extremely low birth weight (ELBW) babies are those
who weigh below 1000 g at birth.
It is the relationship between weight (for assessment of
growth) and gestational age (for assessment of maturity)
that is of great importance. This relationship can be seen
plotted on centile charts (Fig. 30.1) to visually demon-
strate that growth is appropriate, excessive or diminished
for gestational age and that the baby is either preterm,
term or post-term. Growth charts, however, should be
cally derived growth differences exist between countries,
cultures and lifestyles.
Various presentations of LBW babies can be described
as follows:
1. Babies whose rate of intrauterine growth is normal at
the moment of birth. They are small because labour
began before the end of the 37th gestational week.
These preterm babies are appropriately grown for their
gestational age (AGA). Their weight is between the
90th and 10th centiles for their gestation age.
2. Babies whose rate of intrauterine growth has slowed
down and who are born at, or later than, term.
These term or post-term babies are under-grown for
gestational age and are consequently small for their
gestational age (SGA). Their weight is below the 10th
centile for their gestational age.
3. Babies whose rate of intrauterine growth has slowed
down and who are also born before term. These
preterm babies are small by virtue of both their early
birth and impaired intrauterine growth. They are
both pre-term and SGA babies because their weight
will be below the 10th centile for their reduced
gestational age.
Babies are considered large for their gestational age
(LGA) when their weight exceeds the 90th centile. Conse-
quently, it should be recognized that both term and
preterm babies can fall into the category of AGA, SGA, or
LGA (Fig. 30.2).
SMALL FOR GESTATIONAL
AGE (SGA)

Babies that are small for their gestational age are of a size
4000
that is smaller when compared to other babies. If a baby
3750
90th is under-grown and below the 10th centile for weight,
3500 tion
sta historically there has been for some an automatic assump-
3250 ge n
or tatio 50th tion that as a fetus the baby has experienced intrauterine
3000 ef ges
arg or growth restriction (IUGR). Wilkins-Haug and Heffner
L f
2750 te
Birth weight (g)

ria (2012) define IUGR as a rate of fetal growth that is less

2500 op 10th
pr than the normal growth potential for a specific baby.
Ap ion
tat However, this does not mean that all SGA babies are small
2000 ges as a result of IUGR. Some small babies are genetically
for
all small because they have small parents or grandparents and
Sm
1500 this familial factor determines their smallness. They are
well, healthy babies who need to be treated accordingly.
1000 Centile charts can act only as guides. Trotter (2009)
states that maternal characteristics, obstetric history and
birth details in addition to the appearance and behaviour
28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 of the baby should determine what care is required.
Should a baby be born at 36 weeks’ gestation with a birth-
Gestation (weeks)
weight of 2100 g, which according to weight, is well below
Fig. 30.1 A centile chart, showing weight and gestation. the 50th centile, this baby would not fall below the 10th

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 The healthy low birth weight baby Chapter | 30 |

Low birth weight (LBW) Preterm gestation

90th 90th

50th 50th

10th 10th
Weight (g)

Weight (g)
2,500
grammes

A Gestational weeks B 37 completed weeks

The coexistence of preterm gestation

Small for gestational age (SGA) and small for gestational age (SGA)
90th (LGA) 90th

50th (AGA) 50th

10th (SGA) 10th

Weight (g)

Weight (g)

C Gestational weeks D 37 completed weeks

Fig. 30.2 Centile charts that illustrate how low birth weight babies are categorized by weight and gestation. (A) Low birth
weight. (B) Preterm gestation. (C) Small for gestational age. (D) Co-existence of preterm gestation and small for gestational age.

centile line for weight, so should not be identified as SGA To show hyperplastic and hypertrophic
but may be under-grown. Similarly it should not be cellular growth from conception to 2 years
assumed that all infants of diabetic mothers (IDM) are
macrosomic and only fall into the LGA category. Diabetes Interruption to first trimester growth IUGR - Intrauterine
and obesity are conditions that deleteriously affect mater- is more damaging than second growth restriction
and third trimester growth
nal circulation and perfusion, so some babies will suffer
from IUGR and could be small for their gestational age.
Rate of growth related to
number of cells

Hypertrophy
Types of intrauterine growth (the size of cell)
restriction (IUGR)
There are two recognized types of IUGR. The causes and Hyperplasia
predisposing factors are seen as multi-factorial (Box 30.1). (the no. of cells)

IUGR that begins early in the first trimester Conception Birth time 2 years
caused by a combination of intrinsic and postnatal age
extrinsic factors, results in symmetrical Fig. 30.3 Graph to show hyperplastic and hypertrophic
fetal growth cellular growth from conception to 2 years.
In this scenario, the fetus suffers significant interruption
to hyperplastic cell division (Fig. 30.3). As a result, the

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Section | 6 | The Neonate
Box 30.1 Causes of intrauterine growth restriction (IUGR)
Fetal growth is regulated by maternal, placental and fetal
factors and represents a mix of genetic mechanisms and
environmental influences through which growth potential
is expressed. The mechanisms that appear to limit fetal
growth are multifactorial.
Maternal factors
• Pregnancy-induced hypertension, pre-eclampsia, to
include HELLP syndrome
• Congenital and acquired heart disease, to include
chronic hypertension
• Diabetes mellitus
• Undernutrition, to include obesity. Underweight
mother/small stature. Eating disorders
• Smoking, alcohol misuse
• Drugs: therapeutic (anticancer, thyroid medication),
recreational (narcotic, prescription)
• Renal disease, collagen disorders, anaemia, thyroid
disorders and epilepsy
• Genetic diseases such as maternal phenylketonuria
and cystic fibrosis
Sources: Nodine et al 2011; Smith 2012
head circumference, length and weight are all propor-
tionately reduced for gestational age. The main causes are
referred to as intrinsic factors that operate from within the
fetus and cause symmetrical growth restriction, often as a
result of transplacental infections or chromosomal/
genetic defects. In addition, the deleterious effects of
maternal lifestyle where a poor quality diet may be in
combination with smoking, drug and/or alcohol misuse,
can impact on fetal growth and development. These
examples are referred to as extrinsic factors that can act
upon the fetal environment and contribute to congenital
malformations that culminate in conditions such as fetal
alcohol syndrome (FAS) or chronic hypoxia associated
with maternal smoking. Affected babies suffer interrup-
tion to hyperplastic (new cell) division, therefore look
small and do not have the potential for normal growth.
Remember a small head equates to a small brain. These
babies make up 10–30% of all SGA babies in Western
societies (Sinha et al 2012).
IUGR that begins in the last trimester,
caused by extrinsic factors, results in
asymmetrical fetal growth
This type of fetus has been growing normally then starts
to experience interruption to hypertrophic cell growth
(Fig. 30.3). This is influenced by extrinsic factors in its
intrauterine environment that cause disruption to placental
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• Extremes in young and elderly mothers
• Poor obstetric history that includes preterm labour
• Respiratory disorders, to include asthma
• Maternal work and ability to rest
Fetal factors
• Multiple gestation
• Chromosomal/genetic abnormality (particularly trisomy
conditions), including inborn errors of metabolism,
dwarf syndromes
• Intrauterine infection: toxoplasmosis, rubella,
cytomegalovirus, herpes simplex (ToRCH) and syphilis
Placental factors
• Abruptio placenta
• Placenta praevia
• Chorioamnionitis
• Abnormal cord insertion
• Oligohydramnios
perfusion of oxygen and nutrients. When serial ultra-
sound scans of head and abdominal circumference in
addition to Doppler measurements indicate poor and
disproportionate growth, the birth of many affected
fetuses are expedited early, usually by elective caesarean
section. For those women where an early birth is not
possible (the smaller twin or triplet; a concealed preg-
nancy or through failing to access antenatal care), their
baby will to varying degrees have a characteristic brain-
sparing appearance. The baby’s head appears relatively
large compared to the body (see Fig. 30.4); however, the
head circumference is usually within normal parameters
and brain growth is usually spared. The skull bones are
within gestational norms for length and density but the
anterior fontanelle may be larger than expected, owing
to diminished bone formation. The abdomen appears
sunken owing to shrinkage of the liver and spleen,
which surrender their stores of glycogen and red blood
cell mass respectively as the fetus adapts to the adverse
conditions of the uterus. As subcutaneous fat is used as
a source of glucose and ketones, the skin becomes
loose, giving the baby a wizened, old appearance. Vernix
caseosa is frequently reduced or absent as a result of
diminished skin perfusion. In the absence of this protec-
tive covering, the skin is continuously exposed to amni-
otic fluid and its cells will begin to desquamate (shed)
so that the skin appears pale, dry and coarse. If the baby
is of a mature gestation and has passed meconium in
 The healthy low birth weight baby
Fig. 30.4 Baby with asymmetrical growth restriction. Note
the apparently large head compared with the undergrown
body.
utero, the skin may be stained with meconium. Fetal dis-
tress in labour and hypoglycaemia are more likely to be
seen in this group of babies. Unless severely affected,
these babies appear hyperactive and hungry, with a
lusty cry.
THE PRETERM BABY
The preterm baby is born before the end of the 37th ges-
tational week, regardless of birth weight. Most of these
babies are appropriately grown, some are SGA and a small
number are LGA. The factors that play a role in the initia-
tion of preterm labour are largely unknown and mainly
overlay with factors that impair fetal growth. They are
divided into those labours that commence spontaneously
and those where a decision is made to terminate a viable
pregnancy before term: referred to as elective causes
(Box 30.2).
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Chapter | 30 |
Box 30.2 Causes of preterm labour
Spontaneous causes
• 40% unknown
• Multiple gestation – the higher the multiple the
greater the chance
• Hyperpyrexia as a result of viral or bacterial infection,
often urinary tract infections
• Premature rupture of the membranes caused by
maternal infection, especially chorioamnionitis. Also
polyhydramnios
• Maternal short stature, age (<18 or > 35years) and
parity
• Maternal uterine malformation; often bicornuate or
significant fibroids
• Poor obstetric history; history of preterm labour
• Cervical incompetence, history of cone biopsy
• Maternal substance abuse, particularly alcohol and
cigarette smoking
Elective causes
• Pregnancy-induced hypertension, pre-eclampsia,
chronic hypertension
• Maternal disease: renal, heart
• Placenta praevia, abruptio placenta
• Rhesus incompatibility
• Congenital abnormality of the baby
• IUGR
Sources: Sinha et al 2012; Smith 2012
Characteristics of the preterm baby
The appearance of the preterm baby at birth will depend
upon the gestational age. The following description will
focus upon the baby born from 32 weeks’ gestation. Preterm
babies rarely grow large enough in utero to develop mus-
cular flexion and fully adopt the fetal position. As a result
their posture appears flattened, with hips abducted, knees
and ankles flexed. Lissauer and Faranoff (2011) describe a
generally hypotonic baby with a weak and feeble cry. The
head is in proportion to the body, the skull bones are soft
with large fontanelles and wide sutures. The chest is small
and narrow and appears underdeveloped. The abdomen
is prominent because the liver and spleen are large and
abdominal muscle tone is poor (Fig. 30.5). The liver is
large because it receives a good supply of oxygenated
blood and is active in the production of red blood cells.
The umbilicus appears low in the abdomen because linear
growth is cephalo-caudal, being more apparent nearer
to the head than rump, by virtue of fetal circulation
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Section | 6 | The Neonate
Fig. 30.5 Healthy preterm baby born at 32 weeks’ gestation.
Note the presence of a nasogastric tube. The thermocouple
of the servo-mode is taped to the skin of the baby’s upper
abdomen.
oxygenation. Subcutaneous fat is laid down from 28
weeks’ gestation, therefore its presence and amount will
affect the redness and transparency of the skin. Vernix
caseosa is abundant in the last trimester and tends to
accumulate at sites of dense lanugo growth, such as the
face, ears, shoulders and sacral region, protecting the skin
from amniotic fluid maceration. The ear pinna is flat with
little curve, the eyes bulge and the orbital ridges are promi-
nent. The nipple areola is poorly developed and barely
visible. The cord is white, fleshy and glistening. The plantar
creases are absent before 36 weeks’ gestation but soon
begin to appear, as fluid loss occurs through the skin. In
girls the labia majora fail to cover the labia minora and in
boys the testes descend into the scrotal sac at about the
37th gestational week.
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CARE OF THE HEALTHY LBW BABY
Many of the care issues relevant to the LBW baby apply to
both the preterm and the SGA infant. Where differences
do exist, these will receive further consideration.
Management at birth
Given the unpredictability of the birth process on growth
and maturity, the role of the midwife in the birthing room
is to prepare the environment, staff and parents for certain
eventualities. This takes the form of informing members
of the multiprofessional team such as a second midwife,
neonatal practitioner and neonatal nurse, to be on standby
for the birth. The incidence of perinatal asphyxia and con-
genital malformation is greater in SGA babies and the
baby with a scaphoid abdomen could be physically
normal, albeit thin, but could also deteriorate quickly if
presenting with a diaphragmatic hernia. The midwife
should be fully aware of the availability of cots in the
neonatal intensive care unit (NICU), transitional care unit
or postnatal ward according to the condition of the baby
and their potential care demands following birth. The
labour room ambient temperature should ideally be
between 23 and 26 °C and the neonatal resuscitaire and
accompanying equipment should be ready for use.
It is particularly important that the midwife attaches the
correct labels to the baby at birth in case separation from
the mother should occur at any time if the baby’s condi-
tion becomes unstable. The midwife should cut the cord
and leave an extra length to allow for easy access to the
umbilical vessels in case they are needed at a later time. At
birth, the midwife should ensure that the baby is thor-
oughly dried before skin-to-skin contact is attempted, in
order to prevent evaporative heat losses. Skin-to-skin
contact for a period of up to 50 minutes is recommended
to secure the baby’s conductive heat transfer gains and
help the baby to become physically stabilized to feed. If
the mother chooses not to engage in skin-to-skin contact,
the father may wish to do so (Chin et al 2011) but if not,
the baby can be dressed, wrapped and held by the parents.
The baby’s axilla temperature should be maintained
between 36.5 °C and 37.5 °C. Early attempts at breastfeed-
ing should be encouraged (Pollard 2012).
Assessment of gestational age
With developments of more accurate dating by antenatal
ultrasound techniques, it is argued by Smith (2012) that
there is less justification for a full assessment of gestational
age in healthy LBW babies. The exception is applied when
the mother deliberately conceals her pregnancy or has
difficulty/is unable to communicate. The neonatal practi-
tioner, with the view that no harm is caused as a result of
 The healthy low birth weight baby
the process, should carefully conduct any assessments that
are carried out. Sasidharan et al (2009) considers that the
Ballard Score (Ballard et al 1991) can give an accurate
assessment of gestational age until at least 7 days of life
and continues to be the most widely used tool.
The Department of Health (DH 2009) states that WHO
has introduced growth charts based on exclusively breast-
fed babies. A chart specifically for preterm babies 32–36
weeks has also been devised that has no centile lines
between birth and the first two weeks of neonatal life and
the 50th centile has been de-emphasized to better reflect
the natural weight losses and gains of this category of
baby. It is important that midwives are educated to use
these specialized charts efficiently so that the baby’s sub-
sequent growth and development can be monitored effec-
tively (DH 2009).
Thermoregulation
Thermoregulation is the balance between heat production
and heat loss. The prevention of cold stress, which may
lead to hypothermia – which is a body temperature below
35 °C – is critical for the intact survival of the LBW baby.
Newborn babies are unable to shiver, move very much or
seek extra warmth for themselves and therefore rely upon
physical adaptations that generate heat by raising basal
metabolic rate and utilize brown fat deposits. Thus, expo-
sure to cool environments can result in multisystem
changes. As body temperature falls, tissue oxygen con-
sumption rises as the baby attempts to burn brown fat to
generate energy and heat. Diversion of blood away from
the gastrointestinal tract reduces all forms of digestion.
Attempting to warm a cold baby by feeding is ineffectual and
carries the danger of milk inhalation. Care measures should
aim to provide an environment that supports the neutral
thermal environment. This environment constitutes a range
of ambient temperatures within which the metabolic rate
is minimal, the baby is neither gaining nor losing heat,
oxygen consumption is negligible and the core-to-skin
temperature gradient is small (Blackburn 2007).
In the baby, the head accounts for at least one-fifth of
the total body surface area and brain heat production is
thought to be 55% of total metabolic heat production.
Rapid heat loss due to the large head-to-body ratio and
large surface area is exaggerated. Wide sutures and large
fontanelles add to the heat-losing tendency. Once the baby
is thoroughly dried, which includes the face, a pre-warmed
hat will minimize heat loss from the head. Asymmetric
SGA babies have increased skin maturity but often depleted
stores of subcutaneous fat, which are used for insulation.
Their raised basal metabolic rate helps them to produce
heat but their high energy demands in the presence of
poor glycogen stores and minimal fat deposition can soon
lead to hypoglycaemia (<2.6 mmol/l) followed by physio-
logical cooling (<36 °C) to reach a state of hypothermia
(<35 °C) (Bedford and Lomax 2011).
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Chapter | 30 |
All preterm babies are prone to heat loss because their
ability to produce heat is compromised by their immatu-
rity, so factors such as their large ratio of surface area to
weight, their varying amounts of subcutaneous fat and
their ability to mobilize brown fat stores will be affected
by their gestational age (Blackburn 2007). During cooling,
immaturity of the heat-regulating centres in the hypotha-
lamus and medulla oblongata causes failure to recognize the
need to act. In addition, preterm babies are unable to
increase their oxygen consumption effectively through
normal respiratory function and their calorific intake is
often inadequate to meet increasing metabolic require-
ments. Furthermore, their open resting postures increase
their surface area and, along with insensible water losses,
these factors render the preterm baby more susceptible to
evaporative heat losses. Fellows (2010) argues that when
the baby is not receiving skin-to-skin contact with either
parent and the baby is under 2 kg, the warm conditions
in an incubator can be achieved either by heating the air
to 30–32 °C (air mode) or by servo-mode: controlling the
baby’s body temperature at a desired set point (36 °C). In
servo-mode, a thermocouple is taped to the upper abdomen
and the incubator heater maintains the skin at that site at
a preset constant temperature (Fig. 30.4). Within the incu-
bator, the baby is clothed with bedding, in a room tem-
perature of 26 °C. Most preterm babies between 2.0 kg
and 2.5 kg will be cared for in a cot, in a room temperature
of 24 °C.
Hypoglycaemia
The term hypoglycaemia refers to a low blood glucose con-
centration and is usually a feature of failure to adapt from
the fetal state of continuous transplacental glucose con-
sumption to the extrauterine pattern of intermittent milk
supply (WHO 1997b). Within the first hour of life the
blood glucose levels fall, which triggers the pancreas to
stimulate the alpha cells of the Islets of Langerhans to
produce glucagon, with the consequential effect of releas-
ing glucose from glycogen stores in the liver to maintain
the blood glucose levels within safe limits. However, it is
generally questioned whether LBW babies are as effective
in this metabolism compared to appropriately grown term
babies and some caution is recommended (WHO 1997b).
Asymmetrical SGA babies may have greater brain-to-body
mass with a tendency towards polycythaemia, which
increases their energy demands, and since both the brain
and the red blood cells are obligatory glucose users, these
factors can increase glucose requirements. Glycogen
storage is initiated at the beginning of the third trimester
of pregnancy but may be incomplete as a result of preterm
birth or, in the asymmetrical SGA baby, may have been
drawn upon before birth.
Hypoglycaemia in healthy LBW babies is more likely to
occur in conditions where they become cold or where the
initiation of early feeding (within the first hour) is delayed.
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Section | 6 | The Neonate
However, hypoglycaemia is associated with mild to mod-
erate perinatal asphyxia and maternal history of beta-
blocker use (e.g. labetolol) as it causes hyperinsulinism and
interferes with glycogenolysis. The midwife should con-
sider that there may be some underlying medical condi-
tion that may call for more thorough investigation
(Chapter 33).
The signs of hypoglycaemia are varied and Wilker
(2012) acknowledges that hypoglycaemia can present with
no or few clinical signs. The clinical picture of tremor and
irritability may occasionally lead to convulsion and
decreased consciousness. A high-pitched cry, hypotonia,
unexplained apnoea and bradycardia with central cyanosis
are also recognized as serious signs of deterioration in the
baby’s health and need referral to a medical practitioner.
Jitteriness is not a sign of hypoglycaemia (United Nations
Childrens Fund [UNICEF] 2010). The aim of management
is to maintain the true blood glucose level above
2.6 mmol/l, which is considered to be the lowest level of
normal in the first few days of life (WHO 1997b; Lissauer
and Fanaroff 2011).
Healthy LBW babies who show no clinical signs of
hypoglycaemia, are demanding and taking nutritive feeds
on a regular basis and maintaining their body tempera-
ture, do not need screening for hypoglycaemia. The
emphasis of care is placed upon the concept of adequate
feeding and the cornerstone of success is the midwife’s
ability to assess whether the baby is feeding sufficiently
well to meet energy requirements. The preterm baby may
be sleepy and attempts to take the first feed may reflect its
gestational age. Midwives should be guided by the local
policies within their employing organization regarding
use of reagent strips to assess for hypoglycaemia, but prior
to the baby’s second feed is the best time to ascertain
whether the first feed was effective in maintaining the
capillary blood glucose level above 2 mmol/l. If a baby,
despite being fed, presents with clinical signs of hypogly­
caemia, a venous sample should be taken by the medical
practitioner to assess the true blood glucose level which
should be dispatched to the laboratory. A true blood
glucose level that remains <2.6 mmol/dl, despite the
baby’s further attempts to feed by breast or take colostrum
by cup, may warrant transfer to the NICU, because glucose
by intravenous bolus may be necessary to correct the meta-
bolic disturbance. Healthy mature SGA babies with an
asymmetrical growth pattern will usually breastfeed within
the first 30–60 minutes of birth and will demand feeds
every 2–3 hours thereafter. For the majority of LBW babies,
hypoglycaemia is relatively short-lived and limited to the
first 48 hours following birth.
Feeding
According to Jones and Spencer (2008) both preterm
and SGA babies benefit from human milk because it con-
tains long chain polyunsaturated omega-3 fatty acids,
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which are thought to be essential for the myelination of
neural membranes and for retinal development. Preterm
breast milk has a higher concentration of lipids, protein,
sodium, calcium and immunoglobulins, alongside lipases
and enzymes that improve digestion and absorption.
The uniqueness of the mother’s milk for her own baby
cannot be overstated but she needs to understand what
her baby may be able to achieve related to the stage of
their development, which is based upon the combined
influences of their gestational age at birth and their neo-
natal age.
For a baby to feed for nutritive purposes, the coordina-
tion of breathing with suck and swallow reflexes reflects
neurobehavioural maturation and organization, which is
thought to occur between 32 and 36 weeks’ gestation.
Blackburn (2007) argues that preterm babies are limited
in their ability to suck because they lack cheek pads, which
leads to a weaker suck, coupled with weak musculature
and flexor control, which are important for firm lip and
jaw closure.
Als and Butler (2006) believe that parents should
provide physical support for head, trunk and shoulders as
sucking is part of the flexor pattern of development and
may be enhanced by giving the baby something to grasp.
The preterm baby’s head is very heavy for the weak mus-
culature of the neck and would, if not supported, result in
considerable head lag, so correct positioning and attach-
ment to the breast can be made much more difficult to
achieve. Poor head alignment can result in airway collapse,
which may lead to apnoea and bradycardia, therefore
support from the midwife is essential when initiating
breastfeeding.
If the baby requires feeding via a nasogastric tube, it is
now common practice for parents to feed their own baby.
Tube feeding has the advantage that the tube can be left
in situ during a cup or breastfeed and has been shown to
eliminate the need to introduce bottles into a breastfeed-
ing regimen. However, babies are preferential nose breath-
ers and the presence of a nasogastric tube will inevitably
take up part of their available airway. Flint et al (2007)
argue that the prolonged use of nasogastric tubes has been
associated with delay in the development of a baby’s
sucking and swallowing reflexes simply because the mouth
is bypassed. For these reasons, cup feeding has been used
in addition or as an alternative to tube feeding, in order
to provide the baby with a positive oral experience, to
stimulate saliva and lingual lipases to aid digestion and to
accelerate the transition from naso/oro-gastric feeding to
breastfeeding. Oral gastric tubes have been associated with
vagal stimulation and have resulted in bradycardia and
apnoea.
Pollard (2012) reports that certain behaviours, such as
licking and lapping, are well established before sucking
and swallowing, and when babies are given the opportu-
nity it is not unusual to see them as early as 28 and 29
weeks licking milk that has been expressed onto the
 The healthy low birth weight baby
nipple by their mother. Thus, babies between 30 and 32
weeks’ gestation can be given expressed breastmilk (EBM)
by cup. Pollard (2012) makes a further point that tongue
movement is vital in the efficient stripping of the milk
ducts, so cup-feeding can be seen as developmental prep-
aration for breastfeeding. Between 32 and 34 weeks’ ges-
tation, cup-feeding can act as the main method of
feeding, with the baby taking occasional complete breast-
feeds. The baby uses less energy to take its feed by cup
compared to bottle, which supports their general well­
being and homeostasis.
A preterm baby of <35 weeks’ gestation can be gently
wrapped/swaddled prior to a feed and this is thought to
provide reassurance and comfort, not unlike the unique
close-fitting tactile stimulation of the uterus. McGrath
(2004) argues that this approach supports development of
flexion as well as decreasing disorganized behaviours that
could detract from feeding success. A preterm baby may
easily tire and the mother can be taught to start the flow
of milk by hand expressing, before attempting to attach
her baby to the breast. Long pauses between sucks are to
be expected. This burst–pause pattern is a signal of normal
development and seems to occur earlier with breastfeed-
ing. The baby may appear to be asleep and a change in
position may remind them of the task in hand, but it is
thought to be a mistake to force a reluctant baby to feed.
If it is obvious that the baby is more interested in sleeping,
the mother can complete the feed by nasogastric tube.
Feeding frequency can vary between 8 and 10 feeds per
day. The baby should be left to establish their own volume
requirements and feeding pattern. If necessary, the mother
should use a breast pump to maintain her lactation to
reflect her baby’s feeding style.
OPTIMIZING THE CARE
ENVIRONMENT FOR THE HEALTHY
LBW BABY
The normal sensory requirements of the developing neo-
natal brain depend upon subtle influences, first from the
uterus and then from the breast (Reid and Freer 2010).
Any disruption to this natural arrangement renders the
LBW baby vulnerable to influences in the care environ-
ment that can result in poor coordination as a result of
delays in the development of different subsystems (auto-
nomic, motor, sensory, etc.). Reid and Freer (2010)
believe maternal role development depends upon the
mother’s self-esteem and her perception of mothering. By
attempting to adapt the care environment to be more
like the intrauterine environment, the midwife can help
parents to become aware of their baby’s behavioural and
autonomic cues and utilize them in organizing care
according to their baby’s individual tolerance. The ethos
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Chapter | 30 |
of care is for them to listen and learn from their baby, to
come to know and see them as an individual, competent
for their stage of development and not merely a baby born
too early, or a dysfunctional term baby. They should be
encouraged (but not cajoled) into taking a major role in
their baby’s emerging developmental agenda, enabling
them to understand the situation in which they find
themselves, so they are further able to reset their expecta-
tions and thus provide more baby-led support (Teti et al
2005; Reid and Freer 2010).
According to McGrath (2004), the emerging task of the
term newborn baby is increasing alertness, with growing
responsiveness to the outside world. By comparison, a
preterm baby is at a stage of development that is more
concerned with their internal world. Term babies have
stable function of the autonomic and motor systems.
Preterm babies will be at different stages of this develop-
ment, depending on their gestational age and health
status. They will spend more time in rapid eye movement
(REM) sleep or drowsy states and have difficulty in achiev-
ing deep sleep. They are unable to shut out stimulation
that prevents them from sleeping and resting, and sudden
noise hazards provoke stress reactions, which can adversely
affect respiratory, cardiovascular and digestive stability.
The term baby is able to shut out such stimuli for rest and
sleep purposes. The degree to which SGA term babies have
been affected by their unique intrauterine experience is
difficult to assess in the short term, but hyperactivity is
seen as a feature of an adaptive stress reaction. These
babies, like their preterm counterparts, need an environ-
ment that supports their level of robustness. Environmen-
tal disturbances, excessive or prolonged handling and even
activities like feeding may add extra physiological burden
to an already compromised state. Social contact is consid-
ered a vital element for the development of parent–baby
interaction, yet stereotypical notions of social contact that
revolve around practical caregiving and feeding may not
be suitable for some babies and when these activities are
pooled together, may draw too heavily on the baby’s phys-
ical resources. When the baby is overstimulated and wishes
to terminate the interaction, certain cues are known as
coping signals and are recognized as fist clenching, furrowing
of the brow, gaze aversion, splayed fingers and yawning.
Should the baby wish to initiate or continue an interac-
tion, they tend to demonstrate approach signals such as
raised eyebrows, head raising and engagement in different
degrees of eye contact with their social partners. The midwife
can reassure parents that by paying attention to their
baby’s behaviour they can work with their baby’s capabili-
ties, which is crucial for maintaining the baby’s healthy
status (Als and Butler 2006).
Handling and touch
Kangaroo care (KC) is used to promote closeness between
a baby and mother and involves placing the nappy-clad
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Section | 6 | The Neonate
Fig. 30.6 Kangaroo care.
baby upright between the maternal breasts for skin-to-skin
contact (Fig. 30.6). The LBW baby can remain beneath the
mother’s clothing for varying periods of time that suit the
mother. Some mothers may have repeated contacts
throughout the day, others may prefer specific periods
around which they plan their daily activities. There are no
rules or time limitations applied, but contact should be
reviewed if there are any clinical signs of neonatal distress.
Hake-Brooks and Anderson (2008) found that preterm
babies of 32–36 weeks’ gestation who had unlimited skin-
to-skin contact, breast fed for longer compared to those
who had traditional nursery care. Conde-Agudelo and
Belizan (2009) support this view and also consider that
the baby remained more physiologically stable, with less
reported incidence of infection.
Noise and light hazards
The time spent in a postnatal ward should be a time of
rest and recuperation for both the mother and her LBW
baby. All extraneous noises should be eliminated from
clinical areas, such as musical toys and mobiles, harsh
clattering footwear, telephones, radios, intercom systems
and raised voices. Clinicians should be aware of noise
hazards, such as the closing of incubator portholes, use of
peddle bins, ward doors and general equipment. Ward
areas may be carpeted and quiet signs can be posted to
remind visitors not to disrupt the peace. In dimmed light-
ing conditions preterm babies are more able to improve
their quality of sleep and alert status. Reduced light levels
at night will help to promote the development of circadian
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rhythms and diurnal cycles. Light levels can be adjusted
during the day with curtains or blinds to shade windows
and protect the room from direct sunlight. Screens to
shield adjacent babies from phototherapy lights are also
essential.
Sleeping position
Hunter (2004) reports that preterm babies have reduced
muscle power and bulk, with flaccid muscle tone, there-
fore their movements are erratic, weak or flailing. They
exert energy to maintain their body position against the
pull of gravity. Nesting preterm babies into soft bedding,
in addition to the use of close flexible boundaries, helps
to keep their limbs in midline flexion, however it is vital
that they are nursed in a supine position to prevent
asphyxia. The supine position is also thought to be effec-
tive in promoting engagement in self-regulatory behav-
iours such as exploration of the face and mouth, hand and
foot clasping, boundary searching, flexion and extension
of the limbs. Pressure on the occiput should, over time,
ensure a more rounded head.
Placing healthy LBW babies to sleep in the prone posi-
tion has been theoretically eradicated from neonatal prac-
tice and Warwood (2010) reiterates that all babies should
be placed in the supine position, and it is incumbent upon
midwives to accustom the baby and educate the parents
in adopting this approach. Teaching resuscitation to
parents is part of routine preparation for transfer home,
although according to Younger et al (2007) this degree of
preparedness can empower some parents but frighten
others. The decision to receive training should be the
parent’s choice (Resuscitation Council United Kingdom
2011).
The importance of providing an appropriate environ-
ment for the healthy LBW baby cannot be overstressed and
the ideal environment should resemble home, which pro-
vides a cycle of day and night, regular nourishment, rest,
stimulation and loving attention. The midwife’s role is to
create such an environment, primarily for the physical
development of the baby but at the same time to provide
psychological support for the mother and her family.
According to Fleury et al (2010) the mother should be
encouraged to rely upon her own instincts and common
sense so that the rhythm of total care she adopts in
hospital will thoroughly prepare her for when she goes
home. Gambini et al (2011) make the point that often the
difference between early and late transfer home is more
dependent upon the mother’s positive attitude and skill
development than the baby’s maturity and inherent
abilities.

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Als H, Butler S 2006 Neurobehavioural
development of the pre-term infant
In: Martin R J, Fanaroff A A, Walsh
M C (eds) Faranoff and Martin’s
neonatal–perinatal medicine.
Diseases of the fetus and infant,
vol 2. Elsevier Mosby, London,
p 1051–68
Ballard J L, Khoury C, Wedig K et al
1991 New Ballard Score expanded
to include extremely premature
infants. Journal of Paediatrics
119:417–23
Bedford C D, Lomax A 2011
Development of the heart and lungs
and transition to extrauterine life. In:
Lomax A (ed) Examination of the
newborn: an evidence-based guide.
Wiley–Blackwell, Chichester, p 47–58
Blackburn S T 2007 Maternal, fetal and
neonatal physiology: a clinical
perspective. Mosby Saunders,
St Louis
Chin R, Hall P, Daiches A 2011 Father’s
experience of their transition to
fatherhood: a metasynthesis. Journal
of Reproductive and Infant
Psychology 29(1):4–18
Conde-Agudelo A, Belizan J
2009 Kangaroo mother care to
reduce morbidity and mortality
in low birthweight infants.
Cochrane Database of Systematic
Reviews 2009, Issue 2. Art No.
CD002771. doi:10:1002/14651858.
CD002771
DH (Department of Health) 2009
Using the new UK–World Health
Organization 0–4 years growth
charts. DH, London. Available at
www.dh.gov.uk/publications
(accessed 11 April 2013)
DH (Department of Health) 2010
Midwifery 2020: delivering
expectations. London, DH. Available
from www.midwifery2020.org.uk
(accessed 3 April 2013)
Fellows P 2010 Management of thermal
stability. In: Boxwell G (ed)
Neonatal intensive care nursing.
Routledge, London
Fleury C, Parpinelly M, Makuch M Y
2010 Development of the mother–
child relationship following
pre-eclampsia. Journal of
Reproductive and Infant Psychology
28(3):297–306
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The healthy low birth weight baby
Flint A, New K, Davies M 2007 Cup
feeding versus other forms of
supplemental enteral feeding for
newborn infants unable to fully
breastfeed. Cochrane Database of
Systematic Reviews 2007, Issue 2.
Art. No. CD005092. doi: 10.
1002/14651858. CD005092.pub2
Gambini I, Soldera G, Benevento B
et al 2011 Postpartum psychosocial
distress and late preterm birth.
Journal of Reproductive and Infant
Psychology 29(5):472–9
Hake-Brooks S, Anderson G 2008
Kangaroo care and breastfeeding
of mother–preterm infant dyads
0–18 months: a randomised
controlled trial. Neonatal Network
27:151–9
Hunter J (2004) Positioning. In:
Kenner C, McGrath J M (eds)
Developmental care of newborns
and infants: a guide for health care
professionals. Mosby, St Louis,
p 299–320
Jones E, Spencer A 2008 Optimising the
provision of human milk in preterm
infants. MIDIRS Midwifery Digest
18(1):118–21
Lissauer T, Fanaroff A A 2011
Neonatology at a glance.
Wiley–Blackwell, Chichester
McGrath J M 2004 Feeding. In: Kenner
C, McGrath J M (eds)
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professionals. Mosby, St Louis,
p 321–42
Nodine P M, Arrruda J, Hastings-Tolsma
M 2011 Prenatal environment: effect
on neonatal outcome. In: Gardner S
L, Carter B S, Enzman-Hines M et al
(eds) Merenstein and Gardner’s
handbook of neonatal intensive
care. Mosby Elsevier, London,
p 13–38
Pollard M 2012 Evidence-based care for
breastfeeding mothers. Routledge,
London
Reid T, Freer Y 2010 Developmentally
focused nursing care. In: Boxwell G
(ed) Neonatal intensive care nursing.
Routledge, London, p 16–39
Resuscitation Council UK (RCUK) 2011
Newborn life support, 3rd edn.
RCUK, London
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Sasidharan K, Dutta S, Narang A 2009
Validity of New Ballard Score until
7th day of postnatal life in
moderately preterm infants.
Archives of Diseases in Childhood
Fetal and Neonatal Edition 94:
39–44
Sinha S, Miall L, Jardine L 2012
Essential neonatal medicine, 5th
edn. Wiley–Blackwell, Chichester
Smith V C 2012 The high-risk newborn:
anticipation, evaluation,
management and outcome. In:
Cloherty J P, Eichenwald E C,
Hansen A R et al (eds) Manual of
neonatal care. Wolters Kluwer
Lippincott Williams and Wilkins,
London, p 74–90
Teti D M, Hess C R, O’Connell M
2005 Parental perceptions of
infant vulnerability in a preterm
sample: prediction from maternal
adaptation to parenthood during
the neonatal period. Journal of
Development and Behavioral
Paediatrics 26:283–92
Trotter C W 2009 Gestational age. In:
Tappero E P, Honeyfield M E (eds)
Physical assessment of the newborn.
NICU INK California, p 21–40
UNICEF (United Nations Children’s
Fund) 2010 Guidance on the
development of policies and
guidelines for the prevention and
management of hypoglycaemia
of the newborn. Available at
www.babyfriendly.org.uk (accessed
12 April 2013).
Warwood G 2010 Teaching resuscitation
to parents. In: Lumsden H and
Holmes D (eds) Care of the
newborn by ten teachers. Hodder
Arnold, London, p 168–77
Wilker R E 2012 Hypoglycaemia
and hyperglycaemia. In:
Cloherty J P, Eichenwald E C,
Hansen A R et al (eds) Manual of
neonatal care. Wolters Kluwer
Lippincott Williams and Wilkins,
London, p 284–96
Wilkins-Haug L E, Heffner L J 2012
Fetal assessment and prenatal
diagnosis. In: Cloherty J P,
Eichenwald E C, Hansen A R et al
(eds) Manual of neonatal care.
Wolters Kluwer Lippincott Williams
and Wilkins, London, p 1–10
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Section | 6 | The Neonate
WHO (World Health Organization)
1997a Manual of international
statistical classification of diseases,
injuries and causes of death, vol 11.
WHO, Geneva
FURTHER READING
McInnes R, Chambers J 2008
Supporting breastfeeding mothers:
qualitative synthesis. Journal of
Advanced Nursing 62(4):407–27
USEFUL WEBSITES
Ballard Score: www.ballardscore.com
The New Ballard Score assesses physical
and neuromuscular maturity to assess
gestational age.
628
WHO (World Health Organization) Younger J B, Kendell M J, Pickler R H
1997b Hypoglycaemia of the 2007 Mastery of stress in mothers of
newborn: review of the literature. preterm infants. Journal of Specialist
WHO, Geneva Paediatric Nursing 2:29–35
These authors focus upon practices that the mothers’ perspectives and can inform
support breastfeeding in neonatal and the midwife on whether the women felt
transitional care units. This article reflects supported.
Growth charts:
www.growthcharts.rcph.ac.uk
Materials for training on how to use the
charts can be downloaded on this website.
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 Chapter 31
Trauma during birth, haemorrhages
and convulsions
Claire Greig

CHAPTER CONTENTS THE CHAPTER PRESENTS INFORMATION ON:

Trauma during birth 629 • trauma during birth to skin and superficial tissues,
Trauma to skin and superficial tissues 629 muscle, nerves and bones
Muscle trauma 631 • major types of neonatal haemorrhage due to
Nerve trauma 631 trauma, disruptions in blood flow, coagulopathies
and other causes
Fractures 633
• neonatal convulsions
Haemorrhages 633
• specific interventions with parents.
Haemorrhages due to trauma 633
Haemorrhages due to disruptions in
blood flow 635
Haemorrhages related to coagulopathies 637 TRAUMA DURING BIRTH
Haemorrhages related to other causes 639
Convulsions 639 Despite skilled midwifery and obstetric care in developed,
Western societies and a reduction in the incidence, birth
Support of parents 641 trauma still occurs. Efforts continue to reduce the inci-
References 641 dence even further.
Further reading 643 Trauma during birth includes:
Useful websites 643 • trauma to skin and superficial tissues
• muscle trauma
• nerve trauma
This chapter focuses on complications occurring in • fractures.
specifically vulnerable babies; the midwife’s
awareness of this vulnerability may prevent such
complications. If a complication does occur, the Trauma to skin and
midwife must report it to the baby’s doctor and
may work with that doctor and/or a wider
superficial tissues
multiprofessional team to diagnose it and Skin
implement effective treatment. Parents may be
distressed when their baby suffers a complication Skin damage is often iatrogenic, resulting from forceps
and the midwife helps them to understand the blades (Fig. 31.1), vacuum extractor cups, scalp electrodes
complication, facilitating their discussions with and scalpels. Poorly applied forceps blades or vacuum
the multiprofessional team members, and extractor cup may result in scalp abrasions (Fig. 31.2),
assisting them to care for their baby. although less so with softer vacuum extractor cups. Forceps

© 2014 Elsevier Ltd 629

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Section | 6 | The Neonate

Fig. 31.1 Forceps abrasion on cheek. Fig. 31.2 Scalp abrasion during vacuum-assisted birth. Note
Reproduced from Thomas and Harvey 1997, with permission of Elsevier. the chignon.
Reproduced from Thomas and Harvey 1997, with permission of Elsevier.

blades may cause bruising, scalp electrodes cause puncture

wounds, as do fetal blood sampling techniques. Occasion-
ally laceration of the baby’s skin may occur during uterine Periosteum Scalp Blood and serum
incision at caesarean section. While rare, subcutaneous fat
necrosis may result from the pressure of forceps blades as
well as following severe asphyxia/hypoxaemia, meconium
aspiration syndrome and hypothermia (Pride 2012).
While superficial fat necrosis usually presents between Skull
days 1 and 28 with well-defined areas of induration (Pride
2012), all other skin injuries should be detected during
the midwife’s detailed examination of the baby immedi-
ately after birth (see Chapter 28). All trauma should be
indicated to parents and reported to the paediatrician and
General Practitioner (GP).
Abrasions and lacerations should be kept clean and dry. Fig. 31.3 Caput succedaneum.
If there are signs of infection, further medical consultation
should be sought by the midwife or parents. Antibiotics
may be required. Deeper lacerations may require closure may be subjected to pressure, a ‘girdle of contact’, with
with butterfly strips or sutures. Healing is usually rapid reduced venous return and resultant congestion and
with no residual scarring (Sorantin et al 2006). If related oedema.
causes are successfully treated, fat necrosis should sponta-
neously resolve (Pride 2012).
Caput succedaneum
With cephalic presentation, there may be a diffuse oede-
Superficial tissues matous swelling under the scalp but above the perios-
This trauma involves oedematous swellings and/or bruis- teum, called a caput succedaneum (Fig. 31.3). With an
ing. During labour the fetal part overlying the cervical os occipitoanterior position, one caput succedaneum may

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 Trauma during birth, haemorrhages and convulsions
present. With an occipitoposterior position, a caput suc-
cedaneum may form, but if the occiput rotates anteriorly
a second caput succedaneum may develop. If, during the
second stage of labour, the birth of the head is delayed,
the perineum may act as another ‘girdle of contact’ with a
second caput succedaneum forming. A ‘false’ caput suc-
cedaneum can also occur if a vacuum extractor cup is used;
because of its distinctive shape, the swelling is known as
a ‘chignon’ (see Fig. 31.2).
A caput succedaneum is present at birth, thereafter
decreasing in size. This swelling can ‘pit’ on pressure, can
cross a suture line, may be discoloured or bruised, may be
associated with increased moulding and the oedema may
move to the dependent area of the scalp (Lee 2011). The
baby may appear to experience discomfort and, although
care continues as normal, gentle handling is appropriate.
Abrasion of a chignon is possible.
The swelling is usually self-limiting, resolving within 36
hours, with no longer-term consequences (Sorantin et al
2006; Lee 2011). An abraded chignon usually heals rapidly
if the area is kept clean, dry and is not irritated.
Other injuries
The cervical os may also restrict venous return when the
fetal presentation is not cephalic. When the face presents,
it becomes congested, bruised and the eyes and lips
become oedematous. In a breech presentation bruised and
oedematous genitalia and buttocks may develop. In both
instances there may be discomfort and pain, therefore
gentle handling is essential and mild analgesia may be
required.
For babies with bruised or oedematous buttocks, main-
taining nappy area hygiene is important and must be
accomplished without inflicting further skin trauma.
Barrier ointment or cream applications may be required if
disposable nappies designed to limit the contact of urine
and faecal fluid with the skin are not available. If skin
excoriation does occur, the infection risk increases and
consultation with a wound care specialist nurse may be
required to ensure best skin care practice.
Uncomplicated oedema and bruising usually resolve
within days. However, if the baby suffers significant trauma
during a vaginal breech birth, resulting serious complica-
tions require specific treatment and take longer to resolve.
These complications may include excessive haemolysis
resulting in hyperbilirubinaemia; excessive blood loss
resulting in hypovolaemia, shock, anaemia and dissemi-
nated intravascular coagulation (DIC); and damage to
muscles resulting in difficulties with micturition and
defecation.
Muscle trauma
Injuries to muscle result from tearing or when the blood
supply is disrupted.
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Chapter | 31 |
Torticollis
Torticollis is the result of tightness and shortening of one
sternomastoid (sternocleidomastoid) muscle. The right
and left sternomastoid muscles run from the respective
side of the top of the sternum, along the right or left side
of the neck and are inserted into the mastoid process of
the right or left temporal bone. When contracted simulta-
neously, these muscles allow the head to flex. When con-
tracted separately, each turns the head to the opposite side.
The aetiology of torticollis is not fully understood. One
type may result when the muscle is torn due to excessive
traction or twisting during the birth of the anterior shoul-
der of a fetus with a cephalic presentation, or during rota-
tion of the shoulders when the fetus is being born by
vaginal breech or caesarean section.
A 1–3 cm, apparently painless, hard lump of blood and
fibrous tissue is felt on the affected sternomastoid muscle.
The muscle length is shortened, therefore the neck is
twisted to the affected side: a torticollis or wry neck. If the
techniques for assisting at the above stages of birth are
correctly applied, torticollis may be preventable (Saxena
2010).
Torticollis management involves carers and parents per-
forming passive muscle-stretching exercises initially under
the guidance of a physiotherapist, actively encouraging the
baby to move the neck. The swelling usually resolves over
several weeks to months with minimal sequelae. Surgical
intervention is required if there is no resolution by one
year. Follow-up to ensure achievement of normal move-
ment is recommended (Saxena 2010).
Nerve trauma
The nerves most commonly traumatized are the facial and
brachial plexus nerves. Spinal cord injury is very rare and
is not discussed here; an excellent explanation is given in
Brand (2006).
Facial nerve
The facial or seventh (VII) cranial nerve runs close to the
skin surface and is vulnerable to compression resulting in
unilateral facial palsy. Compression may occur in the
uterus but is more likely during birth by the maternal
sacral promontory or by a misapplied forceps blade, espe-
cially when the baby is macrosomic. On the affected side,
the baby appears to have no nasolabial fold, the eyelid
remains open and the mouth is drawn over to the unaf-
fected side (Fig. 31.4). The baby will drool excessively, may
be unable to form an effective seal on the breast or teat,
resulting in initial feeding difficulties, and may also have
difficulty swallowing (Bruns 2012).
There is no specific treatment. If the eyelid remains
open, regular instillation of eye drops lubricate the eyeball.
Feeding difficulties are usually overcome by the baby’s
631
Section | 6 | The Neonate
Fig. 31.4 Right-sided facial palsy. Note that the eye is open
on the paralysed side and the mouth is drawn over to the
non-paralysed side.
Reproduced from Thomas and Harvey 1997, with permission of Elsevier.
own adaptation, although alternative feeding positions
may help. Spontaneous resolution is usual within weeks;
this may extend to months or years if the damage is severe.
Cosmetic surgical interventions for the most severely
affected babies may be required (Bruns 2012).
Brachial plexus
Nerve roots exiting from the spine at the fifth to eighth
cervical (C5–C8) and the first thoracic (T1) vertebrae form
a matrix of nerves in the neck and shoulder: the brachial
plexus. Brachial plexus trauma was thought to result from
excessive lateral flexion, rotation or traction of the head
and neck during vaginal breech birth or when shoulder
dystocia occurred. However, the incidence of brachial
plexus injury is relatively stable despite interventions such
as elective caesarean section, less traction force and
increased skill in the manoeuvers used to manage shoul-
der dystocia. Therefore it may be that brachial plexus
trauma is related more to the force exerted by the uterus
(Benjamin 2005; Sandmire and DeMott 2009).
The possible trauma to the brachial plexus ranges from
oedema to haemorrhage to tearing of the nerves and
occurs most commonly in babies born at term (Blackburn
and Ditzenberger 2007). Foad et al (2009) explain four
types of trauma using the Narakas classification. Trauma
to C5–C6 results in Erb’s (Erb–Duchenne/Duchenne–Erb)
palsy where there is paralysis of the shoulder muscles,
biceps, elbow flexor and forearm supinator muscles. The
baby’s affected arm is limp, inwardly rotated, the elbow
extended and the wrist pronated. When C7 is also trauma-
tized, an extended Erb’s palsy presents in which the wrist
and finger extensor muscles are affected, resulting in wrist
and finger flexion – the ‘waiter’s tip position’ (Fig. 31.5).
When there is trauma to C8–T1, Klumpke’s palsy
presents. The shoulder and upper arm are unaffected but
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Fig. 31.5 Erb’s palsy.
Reproduced from Thomas and Harvey 1997, with permission of Elsevier.
the lower arm, wrist and hand are paralysed, resulting in
wrist drop, no grasp reflex and a claw-like appearance of
the hand. If there is associated trauma to the cervical sym-
pathetic nerves, Horner’s syndrome may present with no
sensation on the affected side, pupil constriction and
eyelid ptosis.
If there is trauma to C5–T1, the result is total brachial
plexus palsy (Erb–Klumpke) where there is complete
paralysis of the shoulder, arm and hand, lack of sensation
and circulatory problems. Horner’s syndrome may also
occur. If there is bilateral paralysis, spinal injury should be
suspected (Benjamin 2005; Foad et al 2009; Semel-
Concepcion 2012).
All types of brachial plexus trauma require further inves-
tigations, including X-ray and ultrasound scanning (USS)
of the clavicle, arm, chest and cervical spine, and assess-
ment of the joints. Magnetic resonance imaging (MRI) and
electromyography may assist in definitive diagnosis.
Unnecessary and extremes of movement of the affected
arm should be avoided and care taken when holding or
moving the baby to avoid the arm dangling. The baby
should not be lifted by the arms or axilla and the affected
arm should be dressed first and undressed last. After
approximately 2 weeks, when any inflammation should
have subsided, passive range of movement exercises are
initiated under the direction of a physiotherapist.
 Trauma during birth, haemorrhages and convulsions
Regular functional follow-up assessments are essential
to gauge recovery. Most babies with brachial plexus trauma
recover completely within 3 weeks. Babies with no recov-
ery of biceps’ function by 3 months and those with total
brachial plexus injury with Horner’s syndrome and no
recovery by 1 month may be referred for surgical explora-
tion and/or require microsurgical nerve repair. These
babies are more likely to have ongoing functional deficits
and may require further surgery (Benjamin 2005; Foad
et al 2009; British Medical Journal [BMJ] Evidence Centre
2012).
Fractures
Fractures are rare but the most commonly affected bones
are the clavicle, humerus, femur and those of the skull.
With all such fractures, a ‘crack’ may be heard during the
birth.
Clavicle
Clavicular fractures, the most common fractures, may
occur with shoulder dystocia, vaginal breech birth, or if
the baby is macrosomic. The affected clavicle is usually the
one that was nearest the maternal symphysis pubis. Bra-
chial plexus and phrenic nerve injuries should be excluded
in the affected baby (Laroia 2010; Mavrogenis et al 2011;
Vorvick and Kaneshiro 2011).
Humerus
Midshaft humeral fractures can occur with shoulder dys-
tocia or during a vaginal breech birth if the extended arm
is forced down and born (Laroia 2010).
Femur
Midshaft femoral fractures can occur during vaginal breech
birth if the extended legs are forced down and born (Laroia
2010).
With most fractures, distortion, deformity, swelling or
bruising are usually evident on examination; crepitus may
be felt; the baby appears to be in pain and is reluctant to
move the affected area. An X-ray examination may confirm
the diagnosis.
The baby requires gentle handling to avoid further pain
and a mild analgesic may be necessary. Fractures of the
clavicle require no specific treatment. To immobilize a
fractured humerus, place a pad in the axilla and firmly
splint the arm with the elbow bent across the chest with
a bandage, ensuring respirations are not embarrassed.
Immobilize a fractured femur using a splint and bandage.
Traction and plaster casting may be required. Stable
union of a fractured clavicle usually occurs in 7–10 days,
while the humerus and femur take 2–4 weeks (Laroia
2010).
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Chapter | 31 |
Skull
Although rare, these fractures, linear or depressed, may
occur during prolonged or difficult instrumental births.
There may be no signs but an overlying swelling, cephal-
haematoma, or signs of associated complications such as
intracranial haemorrhage or neurological disturbances,
may suggest the presence of a fracture.
X-ray examination may confirm the fracture. An ultra-
sound scan (USS) may help diagnose associated haem­
orrhage. A simple linear fracture usually requires no
treatment and heals quickly with no sequelae. Treatment
of a depressed fracture depends on the depth of the
concavity. Shallow depressions in asymptomatic babies
usually resolve spontaneously. With a deeper depression
or where there are signs of complications, the fracture
requires surgical repair. Contamination or evidence of cer-
ebrospinal fluid (CSF) leakage via the ear or nose require
antibiotic therapy. Treatment of associated complications
is necessary. Babies who have a depressed skull fracture
have an optimistic outcome except if complications occur,
when permanent neurological damage is likely (Qureshi
2012).
HAEMORRHAGES
Blood volume in the term baby is approximately
80–100 ml/kg and in the preterm baby 90–105 ml/kg,
therefore even a small haemorrhage may be potentially
fatal. In this section, haemorrhages are discussed accord-
ing to their principal cause, or in relation to other factors.
Haemorrhages may be due to:
• trauma
• disruptions in blood flow
or can be related to:
• coagulopathies
• other causes.
Haemorrhages due to trauma
Cephalhaematoma
A cephalhaematoma (cephalohaematoma) is an effusion
of blood under the periosteum that covers the skull bones
(Fig. 31.6). During a vaginal birth if there is friction
between the fetal skull and maternal pelvic bones, such as
in cephalopelvic disproportion or precipitate labour, the
periosteum may be torn from the bone, causing bleeding
underneath. Cephalhaematomas may also occur during
vacuum-assisted births. Because the fetal or newborn skull
bones are not fused, and as the periosteum is adherent to
the edges of the skull bones, a cephalhaematoma is con-
fined to one bone. However, more than one bone may
be affected; therefore multiple cephalhaematomas may
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Section | 6 | The Neonate
Periosteum Scalp Blood
Skull
Fig. 31.6 Cephalhaematoma.
Fig. 31.7 Bilateral cephalhaematoma.
develop. A double cephalhaematoma is usually bilateral
(Fig. 31.7). A caput succedaneum can co-exist with a
cephalhaematoma.
Unlike caput succedaneum, a cephalhaematoma is not
present at birth; the swelling appears after 12 hours, grows
larger over subsequent days and can persist for weeks.
The swelling is firm, does not pit on pressure, does not
cross a suture and is fixed (Blackburn and Ditzenberger
2007).
No treatment is necessary and the swelling subsides
when the blood is reabsorbed. Hyperbilirubinaemia may
complicate recovery due to haemolysis of the extravasated
blood. More rarely complications such as sepsis, osteomy-
elitis and meningitis may occur. As skull fractures may be
associated with a cephalhaematoma, they should be
excluded (Paul et al 2009; Laroia 2010).
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Subaponeurotic
or subgaleal
Epicranial
haemorrhage
aponeurosis
Skin
Bone Periosteum
Fig. 31.8 Subaponeurotic haemorrhage.
Subaponeurotic haemorrhage
Subaponeurotic (subgaleal) haemorrhage is rare. Under
the scalp, the epicranial aponeurosis, a sheet of fibrous
tissue that covers the cranial vault allowing for muscles to
attach to the bone, provides a potential space above the
periosteum through which veins travel. Excessive traction
on these veins results in haemorrhage, the epicranial
aponeurosis is pulled away from the periosteum of the
skull bones and swelling is evident (Fig. 31.8). Subapo­
neurotic haemorrhage may occur spontaneously with
any type of birth but is more often associated with forceps
and vacuum-assisted births, and severe dystocia (Reid
2007).
The swelling is present at birth, increases in size and is
a firm, fluctuant mass. The scalp is movable rather than
fixed. The swelling can cross sutures and extend into the
subcutaneous tissue of neck and eyelids. The baby may
appear pale, be hypotonic, tachycardic and tachypnoeic
and demonstrate discomfort or pain with head movement
or handling of the swelling. A caput succedaneum and/or
a cephalhaematoma may co-exist with a subaponeurotic
haemorrhage.
If the subaponeurotic haemorrhage is excessive, there is
the potential for severe shock, disseminated intravascular
coagulation (DIC) and death. This emergency situation
requires immediate medical assistance, resuscitation, sta-
bilization and full supportive care, including blood trans-
fusion (Blackburn and Ditzenberger 2007).
With a smaller haemorrhage and in the babies who
survive a larger haemorrhage, the blood is reabsorbed and
the swelling and bruising resolve over 2–3 weeks. Hyper-
bilirubinaemia complicates recovery (Reid 2007; Schi-
erholz and Walker 2010).
Subdural haemorrhage
A sickle-shaped, double fold of dura mater, the falx cerebri,
dips into the fissure between the cerebral hemispheres.
Attached at right angles to the falx cerebri, between the
cerebrum and the cerebellum, is a horseshoe-shaped fold
of dura mater – the tentorium cerebelli. In these folds of
dura run large venous sinuses draining blood from the
brain.
 Trauma during birth, haemorrhages and convulsions
Normally, moulding of the skull bones and stretching
of the underlying structures during birth are well tolerated.
Trauma to the fetal head, such as excessive compression
or abnormal stretching, may tear the dura, particularly
the tentorium cerebelli, rupturing venous sinuses and
resulting in a subdural haemorrhage. Predisposing factors
include rapid, abnormal or excessive moulding, such as in
precipitate labour or rapid birth, malpositions, malpresen-
tations, cephalopelvic disproportion, or undue compres-
sion during forceps manoeuvres (Barker 2007).
If the haemorrhage is excessive, there is the potential for
severe shock, DIC and death. This emergency situation
requires immediate medical assistance – resuscitation, sta-
bilization and full supportive care, including blood trans-
fusion (Blackburn and Ditzenberger 2007).
A baby with a small haemorrhage may demonstrate no
signs and resolution is spontaneous. Alternatively, the
haemorrhage may initially be small but if blood continues
to leak, signs develop over several days. As blood accumu-
lates, there is cerebral irritation, cerebral oedema and
raised intracranial pressure. The baby is likely to vomit, be
unresponsive and have a bulging anterior fontanelle,
hypotonia, hyperthermia, apnoea, bradycardia and
convulsions.
Blood in a non-traumatic lumbar puncture may assist
in diagnosis as may cranial USS, computerized tomogra-
phy (CT) or magnetic resonance imaging (MRI). Support-
ive treatment focuses on replacing blood volume and
controlling the consequences of asphyxia and raised
intracranial pressure. Surgery to relieve pressure or sub-
dural taps or shunt placement to drain large collections of
blood may be required. A shunt is a drainage tube
surgically inserted and connected to a one-way valve
placed subcutaneously behind the ear. The valve’s outflow
tube is attached to a catheter allowing drainage into a
large vein in the neck, or into the peritoneum, allowing
reabsorption and elimination (Blackburn and Ditzen-
berger 2007). The prognosis for all affected babies except
those with massive haemorrhage is usually good (Barker
2007).
Haemorrhages due to disruptions
in blood flow
Subarachnoid haemorrhage
A primary subarachnoid haemorrhage involves bleeding
directly into the subarachnoid space. Preterm babies who
suffer perinatal hypoxia resulting in disruption of cerebral
blood flow are most often affected. A secondary haemor-
rhage involves leakage of blood into the subarachnoid
space from an intraventricular haemorrhage. Although
classified here as a haemorrhage due to a disruption in
blood flow, a subarachnoid haemorrhage may also occur
due to birth trauma similar to that which results in sub-
dural haemorrhage.
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Depending on extent of the haemorrhage, the affected
baby may demonstrate no signs while others may have
generalized convulsions from the second day of life and
have apnoeic episodes. Although rare, a massive subarach-
noid haemorrhage may occur and is usually fatal despite
emergency resuscitation and stabilization efforts.
Blood in a non-traumatic lumbar puncture may assist
in diagnosis, as may cranial USS, CT or MRI. Supportive
treatment focuses on replacing blood volume and control-
ling the consequences of asphyxia and raised intracranial
pressure. Surgery to relieve pressure or subdural taps or
shunt placement to drain large collections of blood may
be required (Barker 2007).
The condition is usually self-limiting. If post-
haemorrhagic hydrocephalus occurs, drainage via a shunt
may be required. The prognosis is usually very good for
all affected babies except those with related damage due
to hypoxia (Barker 2007).
Germinal matrix haemorrhage,
intraventricular haemorrhage and
periventricular haemorrhagic infarction
(intraparenchymal lesion)
Germinal matrix haemorrhage (GMH), intraventricular
haemorrhage (IVH) and periventricular haemorrhagic in­
farction (PHI), also known as intraparenchymal lesions
(IPL), primarily affect babies born at less than 32 weeks’
gestation and those weighing less than 1500 g at birth,
although term babies may be affected. The incidence and
severity of these haemorrhages/lesions are inversely cor-
related with gestational age.
There are three grades of GMH and IVH. A grade 1
haemorrhage into the germinal matrix is a germinal
matrix, periventricular or subependymal haemorrhage.
Extension of the haemorrhage into the lateral ventricle(s),
results in an IVH or grade 2 haemorrhage. The choroid
plexus of the lateral ventricles normally produces CSF. If a
grade 2 haemorrhage is complicated by blockage to the
outflow of CSF, post-haemorrhagic hydrocephalus devel-
ops and the ventricles dilate; a grade 3 haemorrhage
(Annibale 2012).
Initially it was understood that a grade 3 haemorrhage
may extend into the cerebral tissue, resulting in a paren-
chymal haemorrhage, known as a grade 4 haemorrhage
(Papile et al 1978). Volpe (1997) proposed that the intra-
ventricular clot in a grade 3 haemorrhage disrupts venous
drainage, causing stasis and infarction. Reperfusion of the
area causes haemorrhage into the infarcted area and
necrotic damage of the white matter. Therefore a grade
4 haemorrhage was reclassified as a complication of a
grade 3 IVH, referred to as a PHI with IPL used
interchangeably.
The stage of brain development is a crucial factor in the
aetiology of GMH, IVH and PHI/IPL. The two lateral ven-
tricles are lined with ependymal tissue. Tissue lying
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Section | 6 | The Neonate
immediately next to the ependyma is the germinal matrix,
also known as the subependymal layer. From 8 to 32
weeks’ gestation, neuroblasts and glioblasts are produced
in the germinal matrix and migrate to the cerebral cortex.
Neuronal migration is complete by 20 weeks’ gestation but
glial cell development and migration continues until
approximately 32 weeks’ gestation. During this period, a
rich blood supply is provided to the germinal matrix
through fragile immature capillaries that lack supporting
muscle or collagen fibres. These vessels are particularly
vulnerable to fluctuations in cerebral blood flow and pres-
sure, rupturing easily causing haemorrhage. The ability of
preterm babies to autoregulate cerebral blood flow and
pressure is immature, resulting in an increased vulnerabil-
ity to haemorrhage. After 32 weeks’ gestation the germinal
matrix becomes less active and by term has almost com-
pletely involuted; the capillaries become more stable and
autoregulation becomes established; therefore GMH, IVH
and PHI/IPL in more mature babies are less common than
in those babies born at less than 32 weeks’ gestation
(Annibale 2012).
The venous drainage from white matter and the deep
areas of the brain, including the lateral ventricles, involves
a peculiar U-turn route in the area of the germinal matrix.
Disruptions to venous flow lead to congestion, with a risk
of venous infarctions and ischaemia. With reperfusion of
these ischaemic areas, there may be haemorrhage demon-
strated as PHI (Volpe 2008).
Multiple factors may compromise cerebral haemody-
namics resulting in GMH, IVH and PHI/IPL. Early factors
include obstetric haemorrhage, lack of antenatal steroids,
low one minute Apgar score and low umbilical artery pH.
Later risk factors include acidosis, hypotension, hyperten-
sion, mechanical ventilation, apnoea, rapid volume
expansion, rapid administration of hyperosmolar solu-
tions, pneumothorax and tracheal suctioning. Also impli-
cated are excessive handling, exposure to light and noise,
lateral flexion of the baby’s head and crying (Annibale
2012; Blackburn 2013).
Most affected babies show no signs or signs that are
non-specific therefore the haemorrhage/infaction/lesion is
detectable only on USS. If the haemorrhage is larger or
extends, the clinical features may gradually appear and
worsen, including apnoeic episodes that become more
frequent and severe, bradycardia, pallor, falling packed cell
volume, tense anterior fontanelle, metabolic acidosis and
convulsions. The baby may be limp or unresponsive. If the
haemorrhage is large and sudden in onset, apnoea and
circulatory collapse may present (Annibale 2012). At-risk
babies should be screened by 7 days of life for GMH, IVH
or PHI/IPL using cranial USS. Serial scanning may deter-
mine any increase, extension or complication.
Care of at-risk babies is focused on prevention (Black-
burn and Ditzenberger 2007). The birth should be in a
regional obstetric unit with neonatal intensive care facili-
ties. Prenatal maternal steroids and postnatal surfactant
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replacement therapy should be administered. Postnatally,
haemodynamic stability is essential, as is prevention of
complications. Prevention of hypoxic events and blood
flow and pressure fluctuations is essential. Care is focused
on maintaining normothermia, normoglycaemia, oxy-
genation and comfort. Sophisticated monitoring equip-
ment and the judicious use of analgesic, sedative and
inotropic drugs may assist achieving and maintaining sta-
bility. The baby’s developmental needs should be met,
particularly in relation to supportive flexed positioning,
reduction in bright lighting, a quiet, undisturbed environ-
ment and appropriate interaction with parents and others
(Blackburn and Ditzenberger 2007).
Despite preventative measures, babies do develop GMH,
IVH and PHI/IPL. The outcome depends on the nature of
the haemorrhage/lesion and associated conditions/
complications. The neurological prognosis for babies with
a GMH or a small IVH is usually good. An IVH associated
with ventricular dilatation may resolve spontaneously
with no long-term consequences. However, with a large
IVH and ventricular dilatation, the accumulating CSF may
require temporary drainage using ventricular taps or exter-
nal ventricular drainage. Some babies may require perma-
nent CSF drainage via a shunt. Approximately 30–40% of
these babies will have cognitive or motor disabilities.
Approximately 50–80% of babies who have a large IVH
with either PHI/IPL or periventricular leukomalacia will
die; survival is usually complicated in the majority by
significant cognitive and motor disabilities. Long-term
follow-up is essential and parents need much support
(Blackburn and Ditzenberger 2007; Annibale 2012).
Periventricular leucomalacia
Although not a haemorrhage, periventricular leucomalacia
(PVL) is included here because of its association with
GMH, IVH and PHI/IPL. Between 27 and 30 weeks’ gesta-
tion, the area of white matter around the lateral ventricles
and within the watershed area of the deep cerebral arteries
is undergoing considerable development. It is sensitive to
any insult that results in reduced cerebral perfusion, such
as those associated with GMH, IVH, PHI/IPL and chorio-
amnionitis. The cerebral blood flow autoregulation ability
in preterm babies is limited, increasing their risk of devel-
oping PVL. Reduced perfusion results in areas of ischaemia
and degeneration of the nerve fibre tracts, disrupting nerve
pathways between areas of the brain and between the
brain and spinal cord. This softening and necrosis of the
white matter is PVL; it may be a classic focal necrotic cystic
type or a diffuse non-cystic type. Only the former is seen
on USS but MRI may detect both types (Blackburn and
Ditzenberger 2007; Volpe 2008; Zach 2012).
Similar pathogenesis is seen in the older preterm and
term baby, but the lesion occurs in the subcortical region
rather than the periventricular region. This is because the
watershed moves away from the ventricles to the cortex
 Trauma during birth, haemorrhages and convulsions
once the germinal matrix involutes. These lesions are
known as subcortical leucomalacia (Volpe 1997).
Care instituted to reduce the incidence of GMH, IVH
and PHI/IPL may reduce the incidence of PVL or the sever-
ity of the related ischaemic damage. The prognosis is vari-
able; some babies have little resulting impairment, others
develop cognitive and neurodevelopmental impairment
while the most severely affected babies may develop
spastic diplegic cerebral palsy (Blackburn and Ditzen-
berger 2007; Zach 2012).
Haemorrhages related to
coagulopathies
These haemorrhages occur due to disruption of the baby’s
blood-clotting abilities.
Vitamin K deficiency bleeding
Vitamin K deficiency bleeding (VKDB) may occur up to 6
months of age, although it more commonly occurs
between birth and 8 weeks of life. It was previously known
as haemorrhagic disease of the newborn (HDN). Several
proteins, factor II (prothrombin), factor VII (proconver-
tin), factor IX (plasma thromboplastin component), factor
X (thrombokinase) and proteins C and S, require vitamin
K for their conversion to active clotting factors. A defi-
ciency of vitamin K, as in VKDB, leads to a deficiency of
these clotting factors and resultant bleeding.
Vitamin K1 (phytomenadione/phytonadione/phyllo-
quinone) is poorly transferred across the placenta and
fetal liver stores are low. Any stores are quickly depleted
after birth and for normal clotting to occur, the baby must
receive dietary vitamin K1, the absorption of which requires
fat and bile salts. Vitamin K2 (menaquinone) is synthe-
sized by bowel flora and may assist in the conversion of
proteins to active clotting factors. Because the neonate’s
bowel is sterile, vitamin K2 production is restricted until
colonization has occurred. Therefore all newborns are
deficient in vitamin K and vulnerable to VKDB.
There are three forms of VKDB that were first described
by Lane and Hathaway (1985):
• ‘early’ (0–24 hours)
• ‘classical’ (1–7 days)
• ‘late’ (1–6 months, although the peak onset is before
8 weeks).
Early VKDB is rare, principally affecting babies born to
women who during pregnancy have taken anticonvul-
sants, e.g. phenytoin, barbiturates or carbamazepine;
antitubercular drugs, e.g. rifampin, isoniazid; or vitamin
K antagonists, e.g. warfarin (contraindicated during preg-
nancy) for treatment of their medical conditions. As these
drugs interfere with vitamin K metabolism, avoidance
during pregnancy reduces the risk of early VKDB. Taking
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Chapter | 31 |
vitamin K1 supplements during the last two weeks of preg-
nancy may prevent early VKDB (Nimavat 2012).
The babies most susceptible to developing classic VKDB
are those with birth trauma, asphyxia, postnatal hypoxia
and those who are preterm, or of low birth weight. They
are more likely to spontaneously bleed or have invasive
interventions resulting in bleeding that cannot be control-
led. Disruptions to the colonization of the bowel due to
antibiotic therapy, or lack of or poor enteral feeding, may
also result in classic VKDB.
The bowel of a breastfed baby colonizes with lacto­
bacilli that do not synthesize menaquinone. The amount
of vitamin K1 in breastmilk is naturally low, although
colostrum and hindmilk do contain higher levels than
foremilk. The vitamin K1 in breastmilk is considered
insufficient for the exclusively breastfed baby’s needs.
Artificial infant formulae are fortified with vitamin K1,
offering some prophylaxis against VKDB (Blackburn
2013). Therefore late VKDB occurs almost exclusively in
breastfed babies. However, babies who have liver disease
or a condition that disrupts vitamin K1’s absorption from
the bowel, for example cystic fibrosis, may develop late
VKDB (Blackburn 2013).
The baby who has VKDB may have bruising; or bleeding
from the umbilicus, puncture sites, the nose or the scalp;
or severe jaundice for more than one week and/or persist-
ent jaundice for more than 2 weeks. Gastrointestinal
bleeding manifests as melaena and haematemesis. In early
and late VKDB, there may be extracranial and intracranial
bleeding. With severe haemorrhage, circulatory collapse
occurs. Late VKDB is associated with higher mortality and
morbidity. Blood tests reveal prolonged prothrombin time
(PT) and partial thromboplastin time (PTT), with a normal
platelet count (Nimavat 2012).
Babies diagnosed with VKDB require investigation and
monitoring to assess their need for treatment. With all
forms of VKDB, the baby will require administration of
vitamin K1, 1–2 mg intramuscularly. In severe cases, when
coagulation is grossly abnormal and there is severe bleed-
ing, replacement of deficient clotting factors is essential. If
circulatory collapse and severe anaemia occur, blood
transfusion or exchange transfusion may be required.
Affected babies usually require other supportive therapy
to assist in their recovery.
As VKDB is a potentially fatal condition, prophylactic
administration of vitamin K is recommended for all babies
and is administered to all preterm and sick babies as part
of their treatment regime (Nimavat 2012; Blackburn
2013). For otherwise healthy term babies the National
Institute for Health and Clinical Excellence (NICE) (2006)
recommends that vitamin K1 1 mg given intramuscularly
after birth is the most effective prophylaxis for prevention
of early onset VKDB. Some vitamin K1 remains within
the muscle and acts as a slow release depot, providing
prophylaxis for classic and probably also for late VKDB
(Hey 2003).
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Section | 6 | The Neonate
While there are arguments against routine prophylaxis
(Midwives Information and Resource Service [MIDIRS]
Essence 2009), for healthy term babies whose parents
decline a single intramuscular injection of vitamin K1, an
oral prophylaxis regimen is recommended (NICE 2006),
although consensus on the most effective oral regime
appears elusive. It is suggested that whatever oral regime
is used, multiple doses are required in the first week of life
and if the baby is breastfed, a further dosing regime is
required until at least 12 weeks of age, if not longer. Such
prophylaxis should reduce the risk of all forms of VKDB,
however this is dependent on the involvement, motivation
and compliance of healthcare professionals and parents.
Medical advice should be sought if the baby vomits within
one hour of oral administration or is too unwell to take
the preparation orally.
All parents should be given the opportunity to discuss
vitamin K1 prophylaxis during pregnancy, understand the
specific management of preterm, sick and ‘at-risk’ babies,
and agree on their choice of prophylaxis. They should also
understand the signs and treatment of VKDB, especially if
their baby has one or more of the risk factors (NICE 2006;
MIDIRS Essence 2009).
Thrombocytopenia
Thrombocytopenia results from a decreased rate of forma-
tion of platelets or an increased rate of consumption and
is defined as a platelet count of less than 150 ×109/l, and
severe thrombocytopenia is a platelet count of less than
50 ×109/l (Bagwell 2007; Roberts and Murray 2008).
Thrombocytopenia may be classified according to fetal,
neonatal and late onset causes. Fetal causes include allo­
immunity, congenital infection and trisomies. Early onset
(less than 72 hours) neonatal causes include placental
insufficiency, perinatal asphyxia, perinatal infection, DIC
and alloimmunity. Late onset (after 72 hours) neonatal
causes include late onset sepsis, necrotizing enterocolitis,
congenital infection and autoimmunity.
The most at-risk babies are those with an older sibling
who was diagnosed with thrombocytopenia, babies born
preterm who have had chronic intrauterine hypoxia such
as with pregnancy induced hypertension or diabetes and
associated intrauterine growth restriction (Roberts and
Murray 2008).
Neonatal alloimmune thrombocytopenia (NAIT) occurs
when there is incompatibility between maternal and fetal
platelets. Maternal antibodies cross the placenta destroy-
ing the fetal platelets – a mechanism similar to that of
haemolytic disease of the newborn. If the fetus is severely
affected, an intracranial haemorrhage may result in fetal
death. If a previous sibling has developed NAIT, in subse-
quent pregnancies the fetus will be monitored using fetal
blood sampling and/or USS to determine the need for
maternal immunoglobulin administration and/or steroids
and/or intrauterine platelet transfusions, and possibly
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elective birth at 32–34 weeks’ gestation (Roberts and
Murray 2008). If diagnosed with NAIT postnatally, babies
usually require platelet transfusions to achieve and main-
tain a platelet count within normal limits.
Neonatal autoimmune thrombocytopenia may occur
in babies whose mothers have autoimmune conditions
such as idiopathic thrombocytopenic purpura or systemic
lupus erythematosis. The antibodies produced by the
mother against her own platelets may cross the placenta,
destroying the baby’s platelets. The resultant thrombocy-
topenia is usually mild, but in severe cases, immunoglob-
ulin administration is effective (Roberts and Murray
2008).
Thrombocytopenia may appear as a petechial rash, pre-
senting in a mild case with a few localized petechiae. In a
severe case there is widespread and serious haemorrhage
from multiple sites. Intracranial haemorrhage may be
fatal. Diagnosis is based on history, clinical examination
and a reduced platelet count. It is differentiated from other
haemorrhagic disorders because coagulation times, fibrin
degradation products and red blood cell morphology are
normal. Mild or moderate thrombocytopenia is usually
self-limiting and requires no treatment. In severe cases,
the treatment usually includes platelet concentrate
transfusion/s, although the optimum regime is yet to be
determined (Roberts and Murray 2008).
Disseminated intravascular coagulation
(consumptive coagulopathy)
Disseminated intravascular coagulation (DIC), also known
as consumptive coagulopathy, is an acquired coagulation
disorder associated with the release of thromboplastin
from damaged tissue, stimulating abnormal coagulation
in the microcirculation as well as excess fibrinolysis. There
is excessive consumption of clotting factors and platelets,
predisposing the baby to haemorrhage. DIC is secondary
to primary conditions. Maternal causes of neonatal DIC
include pre-eclampsia, eclampsia and placental abruption.
Fetal causes include severe fetal compromise, the presence
of a dead twin in the uterus and traumatic birth. Neonatal
causes include conditions resulting in hypoxia and acido-
sis, severe infections, hypothermia, hypotension and
thrombocytopenia (Bagwell 2007; Levi 2012).
As clotting factors and platelets are depleted and fibrin­
olysis is stimulated, the baby will develop a generalized
purpuric rash and bleed from multiple sites. With stimula-
tion of the clotting cascade, multiple microthrombi may
occlude vessels, with organ and tissue ischaemia, particu-
larly affecting the kidneys, resulting in haematuria and
reduced urine output. As the cycle of consumptive coagu-
lopathy continues, multiorgan failure results (Bagwell
2007; Levi 2012). The diagnosis is made from clinical signs
and laboratory findings that show a low platelet count,
low fibrinogen level, distorted and fragmented red blood
cells, low haemoglobin and raised fibrin degradation
 Trauma during birth, haemorrhages and convulsions
products (FDPs) with a prolonged PT and PTT (Bagwell
2007).
Treatment must focus on correction of the underlying
cause if possible and full supportive care will be required.
Control of DIC requires transfusions of fresh frozen
plasma, concentrated clotting factors and platelets. Cryo-
precipitate is an excellent source of fibrinogen. If anaemia
is diagnosed, transfusions of whole blood or red cell con-
centrate are required. Occasionally an exchange transfu-
sion of fresh heparinized blood may be performed, to
remove FDPs while replacing the clotting factors. If treat-
ment of the primary disorder and/or replacement of clot-
ting factors is ineffective, the administration of heparin
may reduce fibrin deposition (Levi 2012).
The prognosis depends on the severity of the primary
condition, as well as of the DIC, and the baby’s response
to treatment.
Haemorrhages related
to other causes
Umbilical haemorrhage
This usually occurs as a result of a poorly applied cord
ligature. The use of plastic cord clamps has almost elimi-
nated this type of haemorrhage, although it is essential to
avoid catching or pulling the clamp. Tampering with par-
tially separated cords before they are ready to separate is
discouraged. Umbilical haemorrhage is a potential cause
of death. A purse-string suture should be inserted if bleed-
ing continues after 15 or 20 minutes of manual pressure.
Vaginal bleeding
A small temporary vaginal discharge of bloodstained
mucus occurring in the first days of life, pseudomenstrua-
tion, is due to the withdrawal of maternal oestrogen. This
is a normal expectation but is included here for complete-
ness. Parents need to know that this is a possibility and is
self-limiting. Continued or excessive vaginal bleeding war-
rants further investigation to exclude pathological causes.
Haematemesis and melaena
These signs may present when the baby has swallowed
maternal blood during birth, or from cracked nipples
during breastfeeding. The diagnosis must be differentiated
from VKDB, from other causes of haematemesis that
include oesophageal, gastric or duodenal ulceration, and
from other causes of melaena, that include necrotizing
enterocolitis and anal fissures. These causes need specific
and usually urgent treatment.
If the cause is swallowed blood, the condition is self-
limiting and requires no specific treatment. If the cause is
cracked nipples, appropriate treatment for the mother
must be implemented.
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Chapter | 31 |
Haematuria
Haematuria may be associated with coagulopathies,
urinary tract infections and structural abnormalities of
the urinary tract. Birth trauma may cause renal contusion
and haematuria. Occasionally, after suprapubic aspiration
of urine, transient mild haematuria may be observed.
Treatment of the primary cause should resolve the
haematuria.
Bleeding associated with
intravascular access
Some sick or preterm babies require the insertion of cath-
eters, lines or cannulae into central or peripheral arteries
or veins, or both, to provide routes for blood sampling,
blood pressure monitoring or the infusion of fluids and
drugs. However, there is a risk of severe external haemor-
rhage if there is dislodgement of these from the vessel or
accidental disconnection from the sampling or infusion
equipment, and of severe haemorrhage if a central vessel
is punctured internally.
Skilled technique, close observation and careful hand­
ling of babies with intravascular access are imperative
to prevent potentially fatal haemorrhage. If an external
haemorrhage does occur, continuous pressure should be
applied to the site until natural haemostasis occurs or until
haemostatic sutures are inserted. If there is external bleed-
ing from an umbilical vessel, the cord stump should be
squeezed between the fingers until haemostasis occurs. A
replacement transfusion of whole blood or packed red
cells may be required. Internal haemorrhage may require
surgical intervention.
CONVULSIONS
A convulsion (seizure/fit) is a sign of neurological distur-
bance, not a disease, and the occurrence of a convulsion
is a medical emergency. Because the newborn brain is still
developing, its function is immature and there is an imbal-
ance between stimulation and inhibition of neural net-
works. Convulsions present quite differently in the
neonate and may be more difficult to recognize than those
of later infancy, childhood or adulthood (Volpe 2008).
Convulsive movements can be differentiated from jit-
teriness or tremors in that, with the latter two, the move-
ments are rapid, rhythmic, equal, are often stimulated
or made worse by disturbance and can be stopped by
touching or flexing the affected limb. They are normal in
an active, hungry baby and are of no consequence,
although their occurrence should be documented. Con-
vulsive movements tend to be slower, less equal, are
not necessarily stimulated by disturbance, cannot be
stopped by restraint, may be accompanied by abnormal
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Section | 6 | The Neonate
eye movements and cardiorespiratory changes and are
always pathological. Convulsive movements should also
be differentiated from the benign bilateral or localized
jerking that occurs normally in neonatal sleep, particularly
rapid eye movement sleep (Prasad 2012).
Abnormal, sudden or repetitive movements of any part
of the body that are not controlled by repositioning or
containment holds require investigation. Volpe (2008)
suggests that the type of movement can help classify the
convulsion as subtle, tonic, clonic or myoclonic:
• Subtle convulsions include movements such as
blinking or fluttering of the eyelids, chewing and
cycling movements of the legs, and apnoea. There
may or may not be associated abnormal
electroencephalogram (EEG) activity.
• Focal tonic convulsions affect one extremity and
abnormal brain electrical activity can be detected on
EEG. With generalized tonic convulsions, that are
more common than focal tonic convulsions, the
baby sustains a rigid extended posture, similar to
decerebrate posturing, that is not usually detected
on EEG.
• Focal clonic convulsions are unilateral, affecting the
face, neck or trunk or upper or lower extremity
whereas multifocal clonic convulsions affect several
areas of the body that jerk asynchronously and
migrate. The movements are slow (one to three jerks
per second), rhythmic and are most likely to be
associated with EEG activity.
• Myoclonic convulsions differ from clonic convulsions
in that they are faster and are not associated with
EEG activity. Focal myoclonic convulsions affect the
upper body flexor muscles. Multifocal myoclonic
convulsions affect several parts of the body with
asynchronous jerks. Generalized myoclonic
convulsions affect the upper and sometimes lower
extremities with jerking flexion movements.
During a convulsion the baby may have tachycardia, hyper-
tension, raised cerebral blood flow and raised intracranial
pressure, which predispose to serious complications.
As convulsions may be difficult to recognize, all at-risk
babies must be continuously assessed. The underlying
conditions that may result in a convulsion are classified as
central nervous system, metabolic, other and idiopathic
conditions (Table 31.1). Convulsions may be acute, recur-
rent or chronic (Blackburn and Ditzenberger 2007).
If a convulsion is suspected, a complete history and
physical and laboratory investigations related to the pos-
sible cause would be undertaken. An EEG may help detect
abnormal electrical brain activity and guide treatment.
Immediate treatment necessitates obtaining assistance
from a doctor while ensuring that the baby has a clear
airway and adequate ventilation, either spontaneously or
mechanically. The baby can be turned to the semi-prone
position, with the head in a neutral position. Gentle oral
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Table 31.1 Selected causes of neonatal convulsions
Category Selected causes
Central nervous Intracranial haemorrhage
system Intracerebral haemorrhage
Hypoxic-ischaemic encephalopathy
Kernicterus
Congenital abnormalities
Metabolic Acquired disorders of metabolism
Hypo- and hyperglycaemia
Hypo- and hypercalcaemia
Hypo- and hypernatraemia
Inborn errors of metabolism
Other Hypoxia
Congenital infections
Severe postnatally acquired
infections
Neonatal abstinence syndrome
Hyperthermia
Idiopathic Unknown
and nasal suction may be required to remove any milk or
mucus. If the baby is breathing spontaneously but is
cyanosed, facial oxygen is given. Active resuscitation may
be required. The need for intravenous access should be
assessed. Any necessary handling must be gentle and the
baby is usually nursed in an incubator to allow for obser-
vation and temperature regulation.
It is important that the nature of the convulsion is docu-
mented, noting the type of movements, the areas affected,
its length, the baby’s state of consciousness, colour change,
alteration in heart rate, respiratory rate or blood pressure
and immediate sequelae (Blackburn and Ditzenberger
2007).
The aims of care are to treat the primary cause/s (details
of which are not discussed in this chapter), and the phar-
macologic control of the convulsions. The latter is contro-
versial due to the potential for damage from the drugs
versus the potential damage from the convulsion on the
developing brain (Rennie and Boylan 2007; Volpe 2008).
While there is little robust research evidence for the use of
any anticonvulsants in neonates, there is consensus for the
use of such drugs, particularly when the baby experiences
prolonged or frequent convulsions (Volpe 2008; Jensen
2009).
If pharmacological treatment is prescribed, the drugs
most commonly used are phenobarbital and phenytoin;
less frequently benzodiazepines may be used. Newer anti-
convulsants such as topiramate and levetiracetam are
still being evaluated (Rennie and Boylan 2007; Volpe
2008; Jensen 2009). Anticonvulsant therapy may be
 Trauma during birth, haemorrhages and convulsions Chapter | 31 |

discontinued when convulsions cease, preferably before

the baby is transferred home.
The outcome for babies who have convulsions is likely
to depend on the cause, onset, type of convulsion and
frequency, whether it was demonstrated on EEG and
whether the tracing became normal following treatment,
what type of treatment was used and how long it was
before any treatment was successful. A good prognosis is
usual if convulsions were due to hypocalcaemia, hyponat-
raemia or an uncomplicated subarachnoid haemorrhage.
Much poorer prognoses are associated with severe hypoxic
ischaemia, severe IVH, severe infections and central
nervous system congenital abnormalities (Blackburn and
Ditzenberger 2007). Complications of neonatal seizures
may include cerebral palsy, hydrocephalus, epilepsy and
spasticity (Sheth 2011).
SUPPORT OF PARENTS
Box 31.1 Summary of key principles related to
the baby, parents and family
The baby must be valued as a baby by:
• using the baby’s name
• not predicting the future
• when sharing information, keeping the baby with the
parents if possible.
The parents and family must be respected by:
• facilitating parental support and empowerment
• acknowledging cultural and religious differences
• listening to their views and taking their concerns
seriously
• giving information honestly and sensitively using
uncomplicated language
• ensuring understanding and giving opportunities for
questions
• facilitating follow-up and providing further
information when required.

The care of parents is more comprehensively discussed Source: Scope 2003

elsewhere therefore in this section only specific aspects will
be summarized. Trauma during birth, haemorrhages and
convulsions are unexpected complications and parents
may be shocked and anxious, and perhaps find themselves
in a crisis situation. However, not all parents experience
such feelings and some can adapt quickly to their baby’s
condition (Fowlie and McHaffie 2004; Carter et al 2005;
McGrath 2007).
The extent of the midwife’s and other professionals’
contact with parents will depend on circumstances but the
experiences parents have at this time have longer-term
implications for them, their response to the situation,
their relationships with the multiprofessional teams
involved in their care as well as their interaction with and
care of their baby (McGrath 2007).
One of the most important aspects of caring for the
parents is in relation to communication. All parents are
entitled to be given information about their baby’s condi-
tion, treatment and care in ways that are considered
best practice. The ‘Right from the Start template’ (Scope
2003) provides an excellent guide, and the principles
related to the baby, parents and family are summarized
in Box 31.1.
Parental involvement in their baby’s care is essential
and the family-centered care/partnership with parents
approach should now pervade all midwifery and neonatal
settings. Midwives and neonatal nurses have an important
role in promoting adaptive coping mechanisms and
guiding parents to appropriate resources and support serv-
ices (POPPY Steering Group 2009). The baby charity BLISS
offers helpful information for parents and its website
includes a parent message board. Additional support and
information is available from specialized outside agencies
and the charity Contact a Family is a useful resource in the
longer term. (See Useful Websites, below.)

REFERENCES

Annibale D J 2012 Periventricular Saunders/Elsevier, Philadelphia, ch injuries. Advances in Neonatal Care

hemorrhage–intraventricular
hemorrhage. http://emedicine
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(accessed June 2013)
Bagwell G A 2007 Haematological
system. In: Kenner C, Lott J W (eds)
Comprehensive neonatal care: an
interdisciplinary approach, 4th edn.
10, p 245–51
Barker S 2007 Subdural and primary
subarachnoid haemorrhages: a case
study. Neonatal Network
26(3):143–51
Benjamin K 2005 Part 2: Distinguishing
physical characteristics and
management of brachial plexus
5(5):240–51
Blackburn S T 2013 Maternal, fetal and
neonatal physiology: a clinical
perspective, 4th edn. Elsevier,
Philadelphia, ch 8, p 239–40, ch 15,
p 546–51
Blackburn S T, Ditzenberger G R 2007
Neurologic system. In: Kenner C,

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Lott J W (eds) Comprehensive
neonatal care: an interdisciplinary
approach, 4th edn. Saunders/
Elsevier, Philadelphia, ch 12, p
277–94
BMJ (British Medical Journal) Evidence
Centre (2012) Erb’s palsy. http://
bestpractice.bmj.com/best-practice/
monograph/746 (accessed January
2013)
Brand M C 2006 Part 1: Recognizing
neonatal spinal cord injury.
Advances in Neonatal Care
6(1):15–24
Bruns A D 2012 Congenital facial
paralysis. http://emedicine.medscape
.com/article/878464 (accessed June
2013)
Carter J D, Mulder R T, Bartram A F
et al 2005 Infants in a neonatal
intensive care unit: parental
response. Archives of Disease in
Childhood, Fetal and Neonatal
edition 90(2): F109–F113
Foad S L, Mehiman C T, Foad M B et al
2009 Prognosis following neonatal
brachial plexus palsy: an evidence-
based review. Journal of Children’s
Orthopedics 3(6):459–63
Fowlie P W, McHaffie H 2004
Supporting parents in the neonatal
unit. British Medical Journal
329:1336–8
Hey E 2003 Vitamin K – what, why and
when. Archives of Disease in
Childhood Fetal and Neonatal
edition 88(2):F80–F83
Jensen F E 2009 Neonatal seizures: an
update on mechanisms and
management. Clinics in Perinatology
36(4):881.
Lane P A, Hathaway W E 1985 Vitamin
K in infancy. Journal of Pediatrics
106:351–9
Laroia N 2010 Pediatric cardiac birth
trauma. http://emedicine.medscape
.com/article/980112 (accessed June
2013)
Lee K G 2011 Caput succedaneum.
www.nlm.nih.gov/medlineplus/ency/
article/001587.htm (accessed June
2013)
Levi M M 2012 Disseminated
intravascular coagulation. http://
emedicine.medscape.com/
article/199627 (accessed June
2013)
Mavrogenis A F, Mitsiokapa E A,
Kanellopoulos A D et al 2011 Birth
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fractures of the clavicle. Advances in
Neonatal Care 11(5):328–31
McGrath J M 2007 Family: essential
partner in care. In: Kenner C, Lott J
W (eds) Comprehensive neonatal
care: an interdisciplinary approach,
4th edn, Saunders/Elsevier,
Philadelphia, ch 25, p 491–506
MIDIRS (Midwives Information and
Resource Service) Essence 2009
Vitamin K – the debate and the
evidence. www.midirs.org/
development/MIDIRSEssence.nsf/arti
cles/336837BED2143BE5802575D60
044F8E9 (accessed June 2013)
NICE (National Institute for Health and
Clinical Excellence) 2006 Routine
postnatal care of women and their
babies. NICE, London. Available at
www.nice.org.uk/nicemedia/pdf/
CG37NICEguideline.pdf (accessed
June 2013)
Nimavat E J 2012 Hemorrhagic disease
of the newborn. http://emedicine
.medscape.com/article/974489
(accessed June 2013)
Papile L A, Burnstein J, Burnstein R et al
1978 Incidence and evolution of
subependymal and intraventricular
hemorrhage: a study of infants with
birth weights less than 1500 g.
Journal of Pediatrics 92(4):529–34
Paul S P, Edate S, Taylor T M 2009
Cephalhaematoma – a benign
condition with serious
complications: case report and
literature review. Infant 5(5):146–8
POPPY Steering Group 2009 Family-
centred care in neonatal units. A
summary of research results and
recommendations from the POPPY
project. National Childbirth Trust,
London
Prasad M 2012 Neonatal seizure: what
is the cause? www.bmj.com/
content/345/bmj.e6003 (accessed
June 2013)
Pride H 2012 Superficial fat necrosis of
the newborn. http://emedicine
.medscape.com/article/1081910
(accessed June 2013)
Qureshi N H 2012 Skull fracture. http://
emedicine.medscape.com/
article/248108 (accessed June 2013)
Reid J 2007 Neonatal subgaleal
haemorrhage. Neonatal Network
26(4):219–27
Rennie J M, Boylan G 2007 Treatment
of neonatal seizures. Archives of
Disease in Childhood, Fetal
and Neonatal edition
92(2):F148–F150
Roberts I, Murray N A 2008 Neonatal
thrombocytopenia. Seminars in Fetal
and Neonatal Medicine
13(4):256–64
Sandmire H F, DeMott R K 2009
Controversies surrounding the causes
of brachial plexus injury.
International Journal of Gynecology
and Obstetrics 104(1):9–13
Saxena A K 2010 Paediatric torticollis
surgery. http://emedicine.medscape
.com/article/939858 (accessed June
2013)
Schierholz E, Walker S R 2010
Responding to traumatic birth.
Advances in Neonatal Care
10(6):311–15
Scope (2003) Right from the start
template. www.scope.org.uk/
help-and-information/publications/
right-start-template (accessed June
2013)
Semel-Concepcion J 2012 Neonatal
brachial plexus palsies. http://
emedicine.medscape.com/
article/317057 (accessed June
2013)
Sheth R D 2011 Neonatal seizures.
http://emedicine.medscape.com/
article/1177069 (accessed June
2013)
Sorantin E, Brader P, Thimary F
2006 Neonatal trauma. European
Journal of Radiology 60(2):
199–207
Thomas R, Harvey D 1997 Colour
guide: neonatology, 2nd edn,
Churchill Livingstone,
Edinburgh
Volpe J J 1997 Brain injury in the
premature infant. Clinics in
Perinatology 24(3):567–87
Volpe J J 2008 Neurology of the
newborn, 5th edn. Elsevier Health
Sciences, Philadelphia, ch 5,
p 203–44 and ch 11,
p 517–88
Vorvick L J, Kaneshiro N K 2011
Fractured clavicle in the newborn.
www.nlm.nih.gov/medlineplus/ency/
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.medscape.com/article/975728
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 Trauma during birth, haemorrhages and convulsions
FURTHER READING
Boxwell G (ed) 2010 Neonatal intensive
care nursing, 2nd edn. Routledge,
London
This book is primarily written for neonatal
nurses and teachers. Student midwives and
midwives would benefit from the additional
more detailed information about many of
the conditions addressed in this present
chapter. Chapters 3, 8, 9 and 18 are
recommended.
USEFUL WEBSITES
Advances in Neonatal Care (journal):
http://journals.lww.com/
advancesinneonatalcare
Archives of Disease in Childhood
(journal): http://adc.bmj.com
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Meeks M, Hallsworth M, Yeo H (eds)
(2010) Nursing the neonate, 2nd
edn. Wiley–Blackwell, Malaysia
Written primarily for neonatal nurses and
midwives, it provides a resource for other
professionals working in neonatal care.
Chapters 4, 14 and 17 are recommended.
BLISS: (premature and sick baby
charity): www.bliss.org.uk
Contact a Family:
www.cafamily.org.uk
Chapter | 31 |
Rennie J M 2012 Rennie and Roberton’s
Textbook of neonatology, 5th edn.
Elsevier, London
A classic textbook that gives excellent
explanations of physiology and discusses the
management of neonatal complications,
albeit from a mainly medical perspective.
Infant (journal for neonatal nursing and
paediatric healthcare professionals):
www.infantgrapevine.co.uk
Medscape:
http://emedicine.medscape.com
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 Chapter 32

Congenital malformations
Judith Simpson, Kathleen O’Reilly

CHAPTER CONTENTS Cardiac defects presenting with cyanosis 656

‘Acyanotic’ cardiac defects 658
Communicating the news 646 Central nervous system malformations 658
Palliative care 646 Anencephaly 659
Definition and causes 647 Spina bifida 659
Chromosomal abnormalities 649 Spina bifida occulta 659
Trisomy 21 (Down syndrome) 649 Hydrocephalus 660
Trisomy 18 (Edwards syndrome) 650 Microcephaly 660
Trisomy 13 (Patau syndrome) 650 Musculoskeletal deformities 660
Turner syndrome (XO) 650 Polydactyly/syndactyly 660
Gastrointestinal malformations 650 Limb reduction deficiencies 660
Gastroschisis and exomphalos 650 Talipes 661
Atresias 650 Developmental dysplasia of the hip 661
Anorectal malformations 652 Achondroplasia 662
Malrotation/volvulus 652 Osteogenesis imperfecta 662
Abnormalities of the skin 662
Meconium ileus (cystic fibrosis) 653
Vascular naevi 662
Hirschsprung’s disease 653
Capillary malformations 662
Cleft lip and cleft palate 653
Capillary haemangiomata
Pierre Robin sequence 654 (‘strawberry marks’) 662
Malformations relating to respiration 654 Pigmented (melanocytic) naevi 663
Diaphragmatic hernia 654 Genitourinary system 663
Congenital pulmonary airway Potter syndrome 663
malformation (CPAM) 655 Posterior urethral valves 663
Choanal atresia 655 Cystic kidneys 663
Laryngeal stridor 656 Hypospadias 664
Congenital cardiac defects 656 Cryptorchidism 664
Causes 656 Disorders of sexual development (DSD) 664
Prenatal detection 656 Congenital adrenal hyperplasia 664
Postnatal recognition 656 Androgen insensitivity syndrome 664

© 2014 Elsevier Ltd 645

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Section | 6 | The Neonate
Teratogenic causes 664
Fetal alcohol syndrome/spectrum 664
Support for the midwife 665
References 665
Further reading 666
Useful websites 666
The incidence of major congenital malformations
is 2–3% of all births, although this figure is
subject to familial, cultural and geographic
variations. It is therefore likely that every
practising midwife will at some time in their
career be confronted with the challenge of
providing appropriate care and support for such
babies and their families.
THE CHAPTER AIMS TO:
• address issues such as who should tell the parents
and how and when they should be told
• describe and explain specific congenital anomalies
• consider the psychological impact on staff and the
strategies that could be put in place to minimize the
accompanying stress.
COMMUNICATING THE NEWS
Improved prenatal screening and diagnostic techniques
(see Chapter 11) have led to the increased recognition of
malformations, particularly in early pregnancy. As a result
some women may make the decision to have their preg-
nancy terminated, whilst for others it provides time to
adjust to and begin to come to terms with the news that
their baby will be born with a particular problem. One
advantage of prenatal diagnosis is that, if necessary,
arrangements can be made for the mother to give birth in
a unit where appropriate specialist neonatal services are
available. The disadvantage of such a transfer is that the
mother may then be separated from family, friends and
the support of the midwives she knows best. This makes
it all the more imperative that the staff in these units are
sensitive to the needs of such women.
However, even with universal fetal screening not all mal-
formations will be identified prenatally and in this situa-
tion it is often the midwife who first notices an anomaly
either at birth or on routine newborn examination. Whilst
all anomalies should be notified to medical staff there is
sometimes uncertainty as to who should communicate the
news to the parents.
There is a very strong argument for suggesting that this
should be done by the midwife present at the birth. The
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midwife–mother relationship is, or ought to be, one of
mutual trust and respect. Honesty is an implicit tenet
of such a relationship. It is well recognized that one
of the first questions a mother will ask the midwife
after the birth is ‘is the baby all right?’ For the midwife
to be non-committal or economical with the truth is to
betray that trust. It is preferable that the midwife tells
both parents sensitively but honestly that she has
concerns, and shows them any obvious anomaly in the
baby.
Where there is doubt in the midwife’s mind, for example
in cases of suspected chromosomal disorders, it could be
argued that the issue is less clear cut. Discretion could
therefore be exercised in the precise form of words used,
but the intention of inviting a second opinion should be
made clear to the parents. It is advisable that both the
parents and the midwife are present when an experienced
paediatrician examines the baby and that the midwife is
present during any dialogue between the parents and
medical staff so that she is aware of exactly what has been
said. She is then in a position to clarify or repeat any
points that were not fully understood. Opportunities for
follow-up consultation with the paediatrician should be
offered as and when the parents desire. Patience, tact and
understanding are prerequisites for midwives caring for
these families.
Some malformations may appear minor to staff;
however, it is important to appreciate that parental percep-
tions may be quite different and that the degree of distress
can be unrelated to the apparent severity of the anomaly.
The psychological impact on parents of being told or
shown, or both, that their baby has a congenital malfor-
mation has been likened to the grieving process discussed
in Chapter 26. Great sensitivity is therefore required on
the part of the midwife when communicating with the
parents for the first time.
Whatever the anomaly, it is essential that families
receive accurate, consistent and appropriate information
about their baby’s condition. Since a comprehensive dis-
cussion of every malformation is clearly not possible,
selection has therefore been made of those the midwife is
most likely to encounter.
PALLIATIVE CARE
There are a number of severe congenital malformations
which are incompatible with sustained life, such as anen-
cephaly. Many of these conditions are diagnosed ante­
natally and, whereas some parents opt for termination of
the pregnancy, others choose palliative care after birth. It
is important that parents feel supported in the choices
they make. When parents opt to continue with the preg-
nancy, where possible, a plan should be made antenatally
with the parents for care of the baby when he or she is
 Congenital malformations Chapter | 32 |

born. Discussion with the parents should explore any
anxieties they may have, e.g. pain relief for the baby. It
should also include factual information about the likely
clinical course including how long the baby may survive
and a gentle explanation of the process of death. It is
important to be honest in cases where there is uncertainty.
It may also be appropriate at this time to explore any
specific wishes the parents may have, regarding religious
ceremonies for example.
After birth priority should be given to ensuring the
comfort of the baby whilst at the same time supporting
the parents. In cases where the baby survives for longer
than expected the specific aspects of the care plan may
need to be reviewed and discussed with parents (e.g.
feeding). It is important to treat the parents and the baby
with kindness and dignity at all times and to remember
that the life of the baby is precious to the parents no
matter how short that life is.
Providing end of life care for infants with severe con-
genital malformations can be difficult and emotionally
draining for staff. It is essential that staff caring for the
baby feel comfortable with clinical decisions and able to
discuss any concerns they have. A formal debrief within
the multi-professional team may be useful.
DEFINITION AND CAUSES
By definition, a congenital malformation is any defect in
form, structure or function. Identifiable defects can be
categorized as follows (Fig. 32.1):

CONGENITAL ABNORMALITIES

Mitochondrial
Chromosomal Single gene Multifactoral
DNA Teratogens
abnormalities defect diseases
disorders

Numerical Structural Mendelian

abnormalities abnormalities inheritance Diabetes mellitus
Hypertension
Spina bifida

Sex
Autosomes
chromosomes

Deletion Autosomal Autosomal X-linked

dominant recessive
Duplication

Inversion

Translocation

Down Congenital Duchenne

Turner Congenital Cystic
syndrome abnormalities muscular
syndrome spherocytosis fibrosis
(if unbalanced) dystrophy

Fig. 32.1 Causes of congenital abnormalities.

Adapted from Beattie J, Carachi R (eds) 2005 Practical paediatric problems: a textbook for MRCPCH. Hodder Education, London.

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Section | 6 | The Neonate
• chromosomal abnormalities
• single gene defects
• mitochondrial deoxyribonucleic acid (DNA)
disorders
• teratogenic causes
• multifactorial causes
• unknown causes.
Chromosomal abnormalities
Definitions of terms used in this and subsequent sections
are provided in the Glossary at the end of the book.
Every human cell carries a blueprint for reproduction in
the form of 44 chromosomes (autosomes) and two sex
chromosomes. Each chromosome comprises a number of
genes, which are specific sequences of DNA coding for
particular proteins. The zygote should have 22 autosomes
and one sex chromosome from each parent. Should a fault
occur in either the formation of the gametes or following
fertilization (see Chapter 5), abnormalities in chromo-
some number (aneuploidies) or structure (deletions,
duplications, inversions, translocations) may occur. Each
abnormal chromosomal pattern has a characteristic clini-
cal presentation, the most common of which will be dis-
cussed further.
Gene defects (Mendelian inheritance)
Genes are composed of DNA and each is concerned
with the transmission of one specific hereditary factor.
Genetically inherited factors may be dominant or
recessive.
A dominant gene will produce its effect even if present
in only one chromosome of a pair. An autosomal domi-
nant condition can usually be traced through several gen-
erations although the severity of clinical expression may
vary from generation to generation. Congenital spherocy-
tosis, achondroplasia, osteogenesis imperfecta, adult poly-
cystic kidney disease and Huntington’s chorea are examples
of dominant conditions.
A recessive gene needs to be present in both chromo-
somes before producing its effect. An individual who is
carrying only one abnormal copy of the gene (a heterozy-
gote) is unaffected. Examples of autosomal recessive con-
ditions are cystic fibrosis or phenylketonuria.
Some congenital malformations are a consequence of
single gene defects. In a dominantly inherited disorder
the risk of an affected fetus is 1 : 2 (50%) for each and
every pregnancy. In a recessive disorder, the risk is 1 : 4
(25%) for each and every pregnancy. In an X-linked reces-
sive inheritance the condition affects almost exclusively
males, although females can be carriers. X-linked reces-
sive inheritance is responsible for conditions such as hae-
mophilia A and B and Duchenne muscular dystrophy.
Spontaneous mutations commonly arise in X-linked
recessive disorders. When a woman is a carrier of an
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X-linked condition, there is a 50% chance of each of her
sons being affected and an equal chance that each of her
daughters will be carriers.
Work on the human genome continues to identify gene
defects; for example, polycystic kidney disease (see p. 663)
arises from a mutation on chromosome 6 and cystic fibro-
sis is due to a defect on chromosome 7. Recent advance-
ments in our understanding of inherited conditions
have focused on epigenetics. This is the study of factors
other than DNA structure which can alter gene expression.
Epigenetics is involved in genomic imprinting and
X-chromosome inactivation in humans. Epigenetic factors
influencing early development may be responsible for spe-
cific congenital syndromes. Continuing research may offer
further diagnostic and treatment options in the future.
Mitochondrial inheritance
Mitochondria are cellular structures responsible for energy
production. Mitochondria are always inherited from the
mother. Symptoms and signs of mitochondrial disorders
can be diverse but tend to occur in tissues that have high
energy requirements such as the brain and muscles. Exam-
ples are very rare but include, mitochondrial encephalo-
myopathy with lactic acidosis and stroke-like episodes
(MELAS) and myoclonic epilepsy with ragged red fibres
myopathy (MERRF) (Chinnery et al 1998).
Teratogenic causes
A teratogen is any agent that raises the incidence of con-
genital malformation. The list of known and suspected
teratogens is continually growing but includes: prescribed
drugs (e.g. anticonvulsants, anticoagulants and prepara-
tions containing large concentrations of vitamin A such as
those prescribed for the treatment of acne), drugs used in
substance abuse (e.g. heroin, alcohol and nicotine), envi-
ronmental factors such as radiation and chemicals (e.g.
dioxins, pesticides), infective agents (e.g. rubella, cytomeg­
alovirus) and maternal disease (e.g. diabetes). It should be
borne in mind that several factors influence the effect(s)
produced by any one teratogen, such as gestational age of
the embryo or fetus at the time of exposure, length of
exposure and toxicity of the teratogen. Direct cause and
effect is sometimes difficult to establish. Accurate record-
ing of all congenital malformations on central registers,
such as those included in the British Isles Network
of Congenital Anomaly Registers (BINOCAR; www
.binocar.org), facilitates the early recognition of new
teratogens.
Multifactorial causes
These are due to interactions between specific genes
(genetic susceptibility) and environmental influences
(teratogens).

Unknown causes
In spite of a growing body of knowledge, the specific cause
of many congenital anomalies remains unspecified and
they occur sporadically in families.
CHROMOSOMAL ABNORMALITIES
Trisomy 21 (Down syndrome)
The classic features of what is now known as Down (ubiq-
uitously referred to as Down’s) syndrome were first
described in 1866 by physician John Langdon Down
(Fig. 32.2). He recognized a commonly occurring com­
bination of facial features among individuals with low
intelligence. Characteristic features of Down syndrome
include: upslanting palpebral fissures, a small head with
flat occiput, small nose, small mouth with relatively large
tongue, short broad hands with an incurving little finger
(clinodactyly), a single palmar (simian) crease, a wide
space between the great toe and second toe (sandal gap),
Brushfield spots in the eyes and generalized hypotonia.
A B
Fig. 32.2 (A) Baby with Down syndrome: note slant of eyes and incurving little finger. (B) With good parental involvement
and stimulus these infants can reach maximum potential.
Photographs courtesy of Scottish Down’s Syndrome Association.
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Congenital malformations Chapter | 32 |
Not all of these manifestations need be present and any
of them can occur alone without implying chromosomal
aberration. Babies born with Down syndrome also have a
higher incidence of cardiac anomalies, cataracts, hearing
loss, leukaemia and hypothyroidism. Intelligence quotient
is below average, at 40–80.
Down syndrome arising sporadically as a result of a
non-disjunction process occurs in 95% of cases. Unbal-
anced translocation occurs in 2.5% of cases, usually
between chromosomes 14 and 21. Mosaic forms also
occur. There is no difference between the types in clinical
appearance. Parents who have a baby with Down syn-
drome, therefore, should be offered genetic counselling to
establish the risk of recurrence. The overall incidence of
Down syndrome is 1 in 700.
Although there may be little doubt in the midwife’s
mind that a baby has Down syndrome, she should be
careful not to make any definitive statements. Family
likeness alone may explain some babies’ appearance.
Parents themselves may voice their suspicions. If they do
not, a sensitive but honest approach should be made by
either the midwife or paediatrician to alert them to the
possibility and to request permission to conduct further
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investigations. It is inappropriate to transfer the baby to

the special care baby unit in order to carry out these inves- GASTROINTESTINAL
tigations under the guise of the baby being cold or sleepy. MALFORMATIONS
Investigations indicated include chromosome analysis
and echocardiography, because of the increased risk of
Most of the malformations affecting this system call for
congenital heart disease. Some centers offer rapid genetic
prompt surgical involvement, for example atresias, gastro-
diagnosis (see Chapter 11).
schisis and exomphalos. With increasing access to fetal
An individual baby’s needs will vary depending on
anomaly ultrasound screening at 18–20 weeks’ gestation,
whether there are any co-existing anomalies. Although
many are likely to be diagnosed prenatally (Haddock et al
initial feeding problems are common owing to general-
1996). If prenatal diagnosis has been made, the parents
ized hypotonia, breastfeeding should be encouraged
will be at least partially prepared. They should have had
if that is what the mother had planned. The parents are
the opportunity to meet with the paediatric surgeon who
likely to require a great deal of emotional support in
will explain the probable sequence of events. They should
the first few days following diagnosis. Providing audio-
also have had the opportunity to visit the specialist neo-
visual or reading material about Down syndrome for
natal unit in which their baby will be cared for. Once the
the parents may be helpful, or the address of the local
baby is born, prior to obtaining their consent for surgery,
branch of the Down Syndrome Association (see Useful
the paediatric surgeon will have a further discussion with
Websites).
the parents. If the baby’s condition allows, the parents
should be encouraged to hold the baby and take
photographs.
Trisomy 18 (Edwards syndrome)
This condition is found in about 1 in 5000 births. An extra Gastroschisis and exomphalos
18th chromosome is responsible for the characteristic fea-
Gastroschisis (Fig. 32.3) is a paramedian defect of the
tures. Facial features include a small head with a flattened
abdominal wall with extrusion of bowel that is not covered
forehead, a receding chin and frequently a cleft palate. The
by peritoneum. Closure of the defect is usually possible;
ears are low set and maldeveloped. The sternum tends to
the size of the defect will determine whether early primary
be short, the fingers often overlap each other and the feet
closure is possible or whether a temporary silo made from
have a characteristic rocker-bottom appearance. Malfor-
synthetic materials (e.g. Silastic) is necessary until the
mations of the cardiovascular and gastrointestinal systems
abdominal cavity is able to contain all the abdominal
are common. The lifespan for these children is short and
organs (Schlatter et al 2003).
the majority die during their first year.
Exomphalos or omphalocele (Fig. 32.4) is a defect in
which the bowel or other viscera protrude through the
umbilicus. Very often these babies have other anomalies,
Trisomy 13 (Patau syndrome) for example heart defects, which require evaluation prior
to surgery. The timing of surgical closure is again deter-
An extra copy of the 13th chromosome leads to multiple
mined by the size of the defect; small defects (exomphalos
abnormalities. These children have a short life. Only 5%
minor) undergo early primary closure whilst a large defect
live beyond 3 years. Affected infants are small and are
(exomphalos major) is encouraged to granulate over, prior
microcephalic. Midline facial abnormalities such as cleft
to delayed closure at 6–12 months (Lee et al 2006).
lip and palate are common and limb abnormalities are
The immediate management of both the above condi-
frequently seen. Brain, cardiac and renal abnormalities
tions is to cover the herniated abdominal contents with
may co-exist with this trisomy.
clean cellophane wrap (e.g. Clingfilm) or warm sterile
saline swabs to reduce fluid and heat losses and to give a
degree of protection. An orogastric or nasogastric tube
Turner syndrome (XO) should be passed and stomach contents aspirated. Transfer
of the baby to a surgical unit is then expedited.
In this monosomal condition, only one sex chromosome
exists: an X. The absent chromosome is indicated by ‘O’.
The child is a girl with a short, webbed neck, widely Atresias
spaced nipples and oedematous feet. The genitalia tend
to be underdeveloped and the internal reproductive Oesophageal atresia
organs do not mature. The condition may not be diag- Oesophageal atresia occurs when there is incomplete
nosed until puberty fails to occur. Congenital cardiac canalization of the oesophagus in early intrauterine devel-
defects may also be found. Mental development is usually opment. It is commonly combined with a tracheo-
normal. oesophageal fistula, which connects the trachea to the

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 Congenital malformations Chapter | 32 |

Fig. 32.4 Omphalocele defect with bowel visible through sac

in the lower part and abnormally lobulated liver in the sac in
the upper part.
From Rennie J M, Roberton N R C (eds) 1999 Textbook of
neonatology, 3rd edn, with permission of Churchill Livingstone.

Fig. 32.3 Gastroschisis showing prolapsed intestine to the

right of umbilical cord.
From Rennie J M, Roberton N R C (eds) 1999 Textbook of
neonatology, 3rd edn, with permission of Churchill Livingstone.

upper or lower oesophagus, or both. The commonest type

of malformation is where the upper oesophagus termi-
nates in a blind upper pouch and the lower oesophagus
connects to the trachea. Around 50% of cases are associ-
ated with other malformations either as part of a chromo-
somal disorder or a syndrome such as the VACTERL
spectrum (vertebral anomalies, anal anomalies, cardiac,
tracheoesophageal, radial aplasia, renal and limb anoma-
lies). Further evaluation, particularly of the heart, is
required prior to surgery (Pedersen et al 2012).
Oesophageal atresia should be suspected in the pres-
ence of maternal polyhydramnios and should be screened
for after birth in all such affected pregnancies. At birth the
baby may be described as ‘mucousy’ or may have ‘colour
changes’ associated with copious secretions. The midwife
should attempt to pass a wide bore orogastric tube but it Fig. 32.5 Oesophageal atresia. Coiled feeding tube in
may travel less than 10–12 cm. Radiography will confirm proximal pouch. Note vertebral and rib abnormalities. Distal
the diagnosis (Fig. 32.5). The baby must be given no oral gas confirms a tracheo-oesophageal fistula.
fluid but a wide bore oesophageal tube should be passed From Rennie J M, Roberton N R C (eds) 1999 Textbook of
into the upper pouch and connected to gentle continuous neonatology, 3rd edn, with permission of Churchill Livingstone.

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Section | 6 | The Neonate

suction apparatus. Ideally a double lumen (Replogle) tube

is used. The baby should be transferred promptly to a
surgical unit, ensuring that continuous suction is available
throughout the transfer. It is usually possible to anasto-
mose the blind ends of the oesophagus. If the gap in the
oesophagus is too large a series of bouginages can be
carried out in an attempt to stretch the ends of the
oesophagus, stimulate growth and thereby eventually
facilitate repair by end-to-end anastomosis. Very rarely, if
the repair is delayed, cervical oesophagostomy may be
performed to allow drainage of secretions. Meanwhile the
baby will need to be fed via a gastrostomy tube. This
method of feeding obviously deprives the baby of oral
stimuli. Such a baby may be given ‘sham’ feeds to allow
him/her to taste the milk and to promote sucking, swal-
lowing and normal development of the mandible.

Duodenal atresia
Atresia can occur at any level of the bowel but the duode-
num is the most common site. If this has not already been
diagnosed in the prenatal period, persistent vomiting
within 24–36 hours of birth will be the first feature
encountered. The vomit may contain bile unless the
obstruction is proximal to the entrance of the common
bile duct, in which case it will be non-bilious. Abdominal
distension is not necessarily present and the baby may
pass meconium. A characteristic double bubble of gas is
seen on radiological examination (Fig. 32.6). Treatment is
by surgical repair. This anomaly is commonly associated
with chromosomal disorders, in particular trisomy 21, Fig. 32.6 Double bubble of duodenal atresia. The stomach is
which accounts for 30% of cases of duodenal atresia. overlapping the duodenum with the second bubble being
seen through the stomach.
Anorectal malformations From Rennie J M, Roberton N R C (eds) 1999 Textbook of
neonatology, 3rd edn, with permission of Churchill Livingstone.
Careful examination of the perineum is an important
aspect of any newborn examination. An imperforate anus
should be obvious on examination at birth, but a rectal
atresia might not become apparent until it is noted that the
baby has not passed meconium. However, it is important to
remember that a history of passing meconium does not
exclude a diagnosis of an anorectal malformation. Occa-
sionally meconium is passed through a fistulous connec-
tion to the vagina, bladder or urethra and this may mask an
imperforate anus (Figs 32.7–32.9). Whatever the anatomi-
cal arrangement, all babies should be referred for surgery.

Malrotation/volvulus
This is a developmental abnormality where incomplete
rotation (malrotation) of the small bowel has taken place.
This predisposes the bowel to intermittent episodes of
twisting (volvulus) and obstruction. A baby with a malro-
tation may be entirely asymptomatic in the neonatal
period, however episodes of obstruction can lead to
bilious vomiting and abdominal distension. Due to the Fig. 32.7 Imperforate anus with recto-vesical fistula (1).
risks of severe, irreversible bowel damage secondary to Reproduced with permission of Donna Bain.

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Fig. 32.8 Imperforate anus with recto-vesical fistula (2).
Reproduced with permission of Donna Bain.
Fig. 32.9 Imperforate anus with recto-vesical fistula and
napkin containing meconium stained urine.
Reproduced with permission of Donna Bain.
the obstruction of blood flow in the mesentery in unrec-
ognized volvulus, any newborn infant with bile-stained
vomiting requires urgent assessment. Surgical correction is
necessary if a malrotation is confirmed.
Meconium ileus (cystic fibrosis)
Some 15% of children with cystic fibrosis present with
meconium ileus in the neonatal period. This occurs
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Congenital malformations Chapter | 32 |
because the meconium is particularly viscous and causes
intestinal obstruction. There is accompanying abdominal
distension and bile-stained vomiting. Intravenous fluids
and a Gastrografin enema may relieve the obstruction but
sometimes surgery is required. Histology of any resected
bowel may indicate the likelihood of cystic fibrosis, but
genetic mutation analysis is required to confirm the diag-
nosis. Subsequent treatment of cystic fibrosis is supportive
rather than curative and involves optimized nutrition,
administration of pancreatic enzymes and a rigorous pro-
gramme of chest physiotherapy and antibiotics.
Hirschsprung’s disease
In this disease, which has an incidence of 1 in 5000 live
births, an aganglionic section of the bowel is present. This
means that peristalsis does not occur and the bowel there-
fore becomes obstructed. The baby will present with any
combination of delayed (>24 hours) passage of meco-
nium, abdominal distension and bile-stained vomiting.
Hirschsprung’s disease is often suspected from radiogra-
phy and contrast enema, however a rectal biopsy is
required to confirm the diagnosis. Surgical resection of the
aganglionic segment of bowel is indicated.
Cleft lip and cleft palate
The incidence of cleft lip occurring as a single malforma-
tion is 1.3 per 1000 live births. This anomaly may be
unilateral or bilateral. Since it is very often accompanied
by cleft palate, both will be considered together.
Clefts in the palate may affect the hard palate, soft
palate, or both. Some defects will include alveolar margins
and some the uvula. The greatest problem for these babies
initially is feeding. If the defect is limited to unilateral cleft
lip, mothers who had intended to breastfeed should be
encouraged to do so. Where there is the additional
problem of cleft palate, arranging for the baby to be fitted
with an orthodontic plate may facilitate breastfeeding but
this obviously does not afford the same stimulus as
nipple-to-palate contact. Expressed breast milk via a cup
is an alternative method but for those who wish to bottle-
feed there is a wide variety of specially shaped teats avail-
able to accommodate the different sizes and positions of
palate defects. Above all else, an unending supply of
patience and reassurance is required. The midwife should
encourage the mother and father to find the most success-
ful technique rather than ‘taking over’ since this may com-
pound any feelings of guilt or inadequacy the parents feel.
Early referral to the cleft palate team of paediatric or plastic
surgeon and orthodontists should be arranged. These
teams will also include specialist nursing staff, speech and
language therapists and audiologists.
Corrective surgery will be carried out at some stage,
however agreement regarding optimal timing remains
elusive (Manna et al 2009). To some extent a compromise
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Section | 6 | The Neonate
A B
Fig. 32.10 (A) Cleft lip and palate. (B) The repaired cleft.
From Raine P 1994 Cleft lip and palate, in Freeman N V et al, Surgery of the newborn, ch 34, p 375, with permission of Churchill Livingstone.
must always be made regarding the balance of risk from
surgery, the psychological impact of the malformation, the
effect on speech and language acquisition and future facial
growth. In general, lips are repaired between 10 and 12
weeks and palates between 6 and 18 months. It can be
helpful for the midwife to show families ‘before and after’
photographs of babies for whom surgery has been a
success (Fig. 32.10).
Clearly, although the midwife may offer valuable
support in these early days, she is limited in the length of
time she has available to help these families. Giving the
parents the address of a support group such as the Cleft
Lip and Palate Association (CLAPA) is useful (see Useful
Websites).
Pierre Robin sequence
Pierre Robin sequence is characterized by micrognathia
(hypoplasia of the lower jaw), posterior displacement of
the tongue, which allows it to fall backward and occlude
the airway, and a central cleft palate. This triad of anoma-
lies presents challenges for nursing care, notably airway
obstruction and feeding difficulties. Airway obstruction
can often be managed with fairly straightforward interven-
tions, such as prone positioning or the use of a nasopha-
ryngeal airway. In a minority of situations the anatomical
anomaly is so severe that surgery, for example jaw distrac-
tion or tracheostomy is required (Bacher et al 2010).
Feeding can be problematic with a high risk of aspiration
occurring. Some of these babies may be fitted with an
orthodontic plate to facilitate feeding. The action of
sucking will encourage development of the mandible.
Parents will need considerable support during what
may for some babies be a protracted period of
hospitalization.
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MALFORMATIONS RELATING
TO RESPIRATION
Making a successful transition from fetus to neonate
includes being able to establish regular respiration. Any
malformation of the respiratory tract or accessory respira-
tory muscles is likely to hamper this process.
Diaphragmatic hernia
This malformation occurs in 1 in 2000 live births and
consists of a defect in the diaphragm that allows hernia-
tion of abdominal contents into the thoracic cavity (Fig.
32.11). The extent to which lung development is compro-
mised as a result depends on the size of the defect and the
gestational age at which herniation first occurred. The con-
dition is increasingly diagnosed antenatally by ultrasound;
where there is prenatal diagnosis, birth in a specialist unit
is advisable. At birth, the condition may be suspected if
the baby is cyanosed and unexpected difficulty is experi-
enced in resuscitation. In addition, since the majority of
such defects are left-sided, heart sounds will be displaced
to the right. The abdomen may have a flat or scaphoid
appearance. Chest X-ray will confirm the diagnosis. Babies
with this condition usually have significant respiratory
distress and require intubation and mechanical ventila-
tion. A large bore nasogastric tube on free drainage should
be used to minimize gaseous distension of the displaced
abdominal viscera. Surgical repair of the defect is neces-
sary, but this is not urgent. It is more important to stabilize
the baby’s general condition before surgery. It is especially
critical to deal with the problem of persistent pulmonary
hypertension and right-to-left shunting of blood within

Fig. 32.11 Chest radiograph of infant at 1 hour of life,
showing left diaphragmatic hernia, displacement of air-filled
viscera into the hemithorax and a marked shift of
mediastinum and heart.
From Rennie J M, Roberton N R C (eds) 1999 Textbook of
neonatology, 3rd edn, with permission of Churchill Livingstone.
the heart. This may necessitate the use of newer ventilation
techniques and pharmacological agents such as nitric
oxide. Prognosis relates to the degree of pulmonary hypo-
plasia and reversibility of the pulmonary hypertension.
There is also the possibility of co-existent problems such
as cardiac defects or skeletal anomalies.
Congenital pulmonary airway
malformations (CPAM)
These include lesions formally known as congenital aden­
omatous malformation (CCAM), bronchopulmonary
sequestration (BPS) and congenital lobar emphysema. The
incidence is thought to be around 1 in 2000 live births
although an increasing number are being detected pre­
natally by ultrasound scanning. Antenatal complications
may include mediastinal shift and the development of
hydrops, although many lesions seem to regress during the
third trimester. Although most lesions are asymptomatic
in the neonatal period, some lesions may expand rapidly
after birth leading to air trapping, over-inflation and res-
piratory compromise. In such cases urgent surgical removal
of the abnormal lung tissue is necessary. Babies known
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Congenital malformations Chapter | 32 |
Nasal cavity Hard palate Bony atresia plate
Oral Tongue
airway
Epiglottis
Fig. 32.12 Choanal atresia. A bony plate blocks the nose.
From Rennie J M, Roberton N R C (eds) 1999 Textbook of
neonatology, 3rd edn, with permission of Churchill Livingstone.
prenatally to have a CPAM should be monitored closely
after birth for signs of respiratory distress.
Some CPAM have been reported to be associated with
lung infection and malignant change in later life. The true
incidence of such complications is unknown but is likely
to be low. However, even in asymptomatic patients, surgi-
cal removal may be undertaken in infancy in order to
prevent long-term complications.
Choanal atresia
Choanal atresia describes a unilateral or bilateral narrow-
ing of the nasal passage(s) with a web of tissue or bone
occluding the nasopharynx (Fig. 32.12). The incidence is
1 in 8000 live births. Tachypnoea and dyspnoea are cardi-
nal features, particularly when a bilateral lesion is present.
The diagnosis is made relatively easily by noting that the
baby mouth-breathes and finds feeding impossible
without cyanosis. In addition, nasal catheters cannot be
passed into the pharynx and if a mirror or cold metal
spoon is held under the nose no vapour will collect. A
helpful diagnostic aid is that the baby’s colour will improve
with crying. A unilateral defect may not be noticed until
the baby feeds for the first time. The midwife should there-
fore bear in mind the possibility of this problem if respira-
tory difficulty and cyanosis occur at this time. Maintaining
a clear airway is obviously essential and an oral airway
may have to be used to affect this. Surgery will be required
to remove the obstructing tissue.
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Section | 6 | The Neonate
Occasionally choanal atresia is associated with other
anomalies such as CHARGE syndrome, a condition in
which there are defects found in the eye (coloboma), the
heart, occasionally oesophageal atresia, usually growth
restriction, plus genital and ear abnormality.
Laryngeal stridor
This is a noise made by the baby, usually on inspiration
and exacerbated by crying. Most commonly the cause is
laryngomalacia. This is due to laxity of the laryngeal
cartilage which collapses inwards during inspiration.
Although it sounds distressing, the baby generally is
not at all upset. Laryngomalacia usually resolves over
time and intervention is only required in the most
severe cases.
There are a number of other causes of stridor in the
neonate which should be considered, particularly if the
stridor is accompanied by signs of respiratory distress or
feeding problems. Other causes include subglottic steno-
sis, laryngeal web, laryngeal cleft, vocal cord paralysis and
extrinsic compression by a vascular ring. Investigations
including laryngoscopy, bronchoscopy and barium
swallow may be necessary in order to establish the diag-
nosis in cases not typical of mild larynogomalacia.
CONGENITAL CARDIAC DEFECTS
Babies born with congenital heart defects comprise the
second largest group of babies born with malformations.
Approximately 8 per 1000 live births have some degree of
congenital heart disease and about one-third of these
babies will be symptomatic in early infancy.
Causes
Approximately 90% of cardiac defects cannot be attributed
to a single cause. Chromosomal and genetic factors
account for 8%, and a further 2% are thought to be caused
by teratogens. The critical period of exposure to teratogens
in respect of embryological development of cardiac tissue
is from the 3rd to the 6th week of gestation.
Prenatal detection
An increasing number of cardiac problems are being iden-
tified by means of detailed prenatal ultrasound scanning
(see Chapter 11). For babies with complex congenital heart
disease this enables a multidisciplinary plan for birth and
immediate neonatal care, to be made well in advance of
delivery. However, the detection of many defects is still
dependent upon accurate observations and examination
during the neonatal period.
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Postnatal recognition
Babies with congenital heart disease can present in a
number of ways: heart murmur, cyanosis, tachypnoea,
weak or absent femoral pulses. Those babies in whom the
pulmonary or systemic blood flow is dependent upon the
arterial duct may present with severe cyanosis or shock
when the duct closes.
It is obviously important to try to identify those infants
with life-threatening cardiac malformations prior to trans-
fer home. Additionally, early identification and referral of
babies with significant cardiac malformations is desirable.
Whilst it must be remembered that not all babies with
heart murmurs have an underlying cardiac malformation,
it should also be noted that some babies with significant
congenital heart disease may have no abnormal findings
at the time of their routine newborn examination. As an
adjunct to routine newborn examination some units
therefore also measure oxygen saturations. This has been
shown to improve the detection of some duct dependent
heart lesions (Ewer et al 2011).
Ideally, every baby should be examined by a competent
practitioner before going home. Although changing pat-
terns of postnatal care often mean early transfer home, a
baby with suspected congenital heart disease should not
be sent home until he/she has been reviewed by an expe-
rienced paediatrician or a definitive diagnosis has been
made. As some babies with significant congenital heart
disease may have no clinical signs prior to transfer, there
is a need for community midwives to be observant and to
communicate effectively with parents. Parents who report
any changes in the baby’s behaviour such as breathlessness
or cyanosis should never be ignored, but rather encour-
aged to seek medical advice promptly.
Traditionally, babies with cardiac anomalies have been
divided into two groups: those with central cyanosis and
those without, i.e. cyanotic and acyanotic congenital heart
disease.
Cardiac defects presenting
with cyanosis
Defects included in this group are:
• transposition of the great arteries
• pulmonary atresia
• tetralogy of Fallot
• tricuspid atresia
• total anomalous pulmonary venous drainage
• univentricular/complex heart.
Although cyanosis can be a presenting feature of a number
of non-cardiac conditions (e.g. respiratory disease, persist-
ent pulmonary hypertension of the newborn, sepsis), con-
genital heart disease should always be considered as a
possible explanation. Administration of oxygen to babies
with cyanotic heart disease may have little effect on their
oxygen saturation levels. This observation, along with other
 Congenital malformations Chapter | 32 |

routine investigations excluding other causes of cyanosis,

may suggest a diagnosis of cyanotic heart disease. The Aorta
definitive diagnostic investigation is echocardiography. Pulmonary
Cyanosis occurs when there is more than 5 g/dl of cir- artery
culating deoxygenated haemoglobin. In congenital cyan-
otic heart disease, abnormal anatomy leads to mixing of
oxygenated and deoxygenated blood ± inadequate pulmo-
nary blood flow or, in the case of transposition of the great Left
arteries, complete separation of the pulmonary and sys- atrium
temic circulations. In cases where there is severe obstruc- Right
tion to pulmonary blood flow, e.g. pulmonary atresia, atrium
there is often early presentation with marked cyanosis. Left
The most common cyanotic heart conditions are trans- ventricle
position of the great arteries and tetralogy of Fallot. Trans-
Right
position of the great arteries is the most common cyanotic ventricle
heart condition presenting in the neonatal period. This is
a condition wherein the aorta arises from the right ventri-
cle and the pulmonary artery from the left ventricle (Fig.
32.13). Consequently, oxygenated blood is circulated back A
through the lungs and deoxygenated blood back into the
systemic circulation. It is apparent therefore that, unless
there is an opportunity for oxygenated blood to access the
systemic circulation, either by means of a patent arterial Aorta
duct or through an accompanying septal defect, such a
baby will die. In congenital cardiac defects such as this Pulmonary
artery
where the patency of the arterial duct is essential for sur-
vival (‘duct-dependent’ lesions), a prostaglandin infusion
should be commenced in order to maintain ductal patency
pending more definitive management. For babies with
transposition of the great arteries a balloon septostomy is
often performed to enlarge the foramen ovale and allow
mixing of oxygenated and deoxygenated blood at atrial
level. Corrective surgery (arterial switch operation) is then
carried out, usually within a few weeks of birth.
Tetralogy of Fallot has four anatomical components;
pulmonary outflow tract obstruction, a ventricular septal
defect, right ventricular hypertrophy and an overriding
aorta (Fig. 32.14). It seldom presents with cyanosis in the
immediate newborn period, but this may become appar- B
ent within a few weeks of birth. Increasingly, the diagnosis
is made prenatally. Most babies with this condition remain Fig. 32.13 Transposition of the great arteries. (A) Normal.
well in the neonatal period. Surgical treatment options (B) Transposition.
include a Blalock Taussig shunt for cases where it is neces-
sary to increase pulmonary blood flow, and corrective
repair, usually within the first year of life.
Although prostaglandin infusion is life-saving for duct- Left-to-right shunts
dependent heart conditions it should be noted that it may
lead to apnoea, particularly when higher doses are • Persistent arterial duct (also known as persistent
required. It is essential that there are facilities to provide ductus arteriosus)
respiratory support available for any baby on an infusion • Ventricular or atrial septal defects.
of prostaglandin. These lesions may present with a murmur or, if the shunt
is large, with symptoms and signs of heart failure: tachy­
pnea, poor feeding, sweating, precordial heave, gallop
‘Acyanotic’ cardiac defects
rhythm or hepatomegaly.
These congenital cardiac conditions include left-to-right A persistent arterial duct is more common in preterm
shunt lesions and obstructive lesions. infants and surgical closure is sometimes necessary if

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Section | 6 | The Neonate
Aorta
Pulmonary
artery
Subpulmonary
stenosis VSD
Right
ventricular
hypertrophy
Fig. 32.14 Tetralogy of Fallot (VSD = ventricular septal
defect).
medical treatment with ibuprofen or indomethacin is inef-
fective. Term infants with a persistent arterial duct more
usually undergo cardiac catheterization with device closure
in childhood.
Ventricular septal defects are a common cause of
murmurs in the term infant. Many of these defects are
small, of no haemodynamic consequence and close spon-
taneously. Larger defects may lead to heart failure and
surgical closure may be necessary although not usually in
the neonatal period. (See Fig. 32.15.)
Obstructive lesions
• Coarctation of the aorta
• Pulmonary stenosis
• Aortic stenosis
• Hypoplastic left heart syndrome.
Some of these lesions may be difficult to pick up clinically
and a proportion of serious left heart obstructive lesions
are not diagnosed before transfer home. Such lesions
should always be considered in the baby with poor volume
femoral pulses or unexplained tachypnoea, remembering
that even severe lesions may have no associated murmur.
If the obstruction is severe, e.g. critical aortic stenosis, then
the systemic blood flow is often dependent upon the arte-
rial duct and the baby will become very unwell when this
closes. As in the duct-dependent cyanotic heart conditions,
a prostaglandin infusion may be required whilst further
investigations and discussions regarding the possibility of
surgical correction take place.
Coarctation of the aorta and aortic stenosis are usually
amenable to surgical correction. Hypoplastic left heart
syndrome remains a major surgical challenge, requiring a
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Aorta
Pulmonary
artery
VSD
Fig. 32.15 Ventricular septal defect (VSD).
number of surgical procedures in childhood, with a poor
long-term outcome. Because of this, some parents opt for
a palliative approach with no surgical intervention. Death
usually occurs within a few days, although it may take
substantially longer in some cases, particularly if the baby
is preterm. If palliation is the chosen care path, then the
priorities are to ensure the comfort of the baby and to
support the family. Whatever treatment decisions they
make, following confirmation of such a diagnosis there is
a substantial psychological impact on the parents, which
calls for particularly supportive management.
CENTRAL NERVOUS SYSTEM
MALFORMATIONS
Neural tube defects are the commonest malformations of
the central nervous system. They arise from abnormalities
during formation and closure of the neural tube, the
embryonic precursor of the central nervous system. Inges-
tion of folic acid supplements prior to conception and
during the early stages of pregnancy has helped to reduce
the incidence of such anomalies (Medical Research
Council [MRC] Vitamin Study Research Group 1991),
however they have not provided the hoped-for panacea.
Prenatal screening is very effective at identifying these mal-
formations (see Chapter 11) and some parents choose
selective termination of pregnancies where severe neural
tube defects are found. Many parents elect to continue
with their pregnancy and data from Wales suggest a rise in
live births with spina bifida over the last decade (Czapran
et al 2011).

Anencephaly
This major anomaly describes the absence of the forebrain
and vault of the skull. It is a condition that is incompatible
with sustained life but occasionally such a baby is born
alive. The midwife should wrap the baby carefully before
showing him/her to the parents. It is recognized that
seeing and holding the baby will facilitate the grieving
process (Chapter 26). It may be beneficial for the parents
then to see the full extent of the malformation, unpleasant
though it is. Seeing the whole baby will help them to
accept the reality of the situation and prevent imagination
of an even more gruesome picture.
Spina bifida
Spina bifida results from failure of fusion of the vertebral
column. If there is no skin covering the defect, there is
protrusion of the meninges, hence the term meningocele
(Fig. 32.16). The meningeal membrane may be flat
or appear as a membranous sac, with or without
Skin Vertebral arch Dura
Nerve Spinal
cord
Normal Occulta
Skin-covered Dura-covered
Meningocele
Flat meningomyelocele
Fig. 32.16 Various forms of spina bifida.
After Wallis S, Harvey D 1979 Disorders in the newborn, Nursing
Times 75: 1315–27, with permission of Nursing Times.
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Congenital malformations Chapter | 32 |
cerebrospinal fluid, but it does not contain neural tissue.
A meningomyelocele, on the other hand, does involve the
spinal cord (Fig. 32.17). This lesion may be enclosed, or
the meningocele may rupture and expose the neural tissue.
A meningomyelocele usually gives rise to neurological
damage, producing paralysis distal to the defect, and
impaired bladder and bowel function. The lumbosacral
area is the most common site for these to present, but they
may appear at any point in the vertebral column. When
the defect is at base of skull level it is known as an enceph-
alocele. The added complication here is that the sac may
contain varying amounts of brain tissue. Normal progres-
sion of labour may be impeded by a large lesion of this
type.
Immediate management involves covering open lesions
with a non-adherent dressing. Babies with enclosed lesions
should be handled with the utmost care in an attempt to
preserve the integrity of the sac. This will limit the risk of
meningitis occurring. A paediatric surgeon or neurosur-
geon should be contacted. Surgical intervention for myelo­
meningocele carries a high rate of success of skin closure,
but has no impact on any damage already present in the
cord or more distally. There is associated hydrocephalus
(see below) in up to 90% of cases, with the majority
requiring surgical shunting to prevent a rapid increase in
the intracranial pressure. It is seldom necessary to close
the back within 24 hours of birth and priority should be
given to stabilization of the baby and assessment of the
defect (Jensen 2012). Following examination of the baby,
discussion with the parents will allow them to make an
informed choice about whether or not they wish their
baby to have surgery.
Recent advances in the management of myelomenin-
gocele include prenatal surgery performed at around 26
weeks’ gestation (Adzick et al 2011). Clearly this option is
not without risk to both mother and fetus and evidence
of long-term benefit is yet to be established.
Spina bifida occulta
Spina bifida occulta (see Fig. 32.16) is the most minor
type of defect where the vertebra is bifid. There is usually
no spinal cord involvement. A tuft of hair or sinus at the
Fig. 32.17 Baby with meningomyelocele.
Reproduced with permission from Professor Robert Carachi.
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Section | 6 | The Neonate
base of the spine may be noted on first examination of the
baby. Ultrasound investigation will confirm the diagnosis
and rule out any associated spinal cord involvement.
Parents who have a baby with a neural tube defect
should be offered genetic counselling since there is a
50-fold increased risk of recurrence in future pregnancies
(Saleem et al 2009).
Hydrocephalus
This condition arises from a blockage in the circulation
and absorption of cerebrospinal fluid, which is produced
from the choroid plexuses within the lateral ventricles of
the brain. The large lateral ventricles increase in size and
eventually compress the surrounding brain tissue. It is a
common accompaniment to the more severe spina bifida
lesions because of a structural defect around the area of
the foramen magnum known as the Arnold–Chiari mal-
formation. Consequently, hydrocephalus may either be
present at birth or develop following surgical closure of a
myelomeningocele. In the absence of a myelomenin-
gocele, congenital aqueduct stenosis is the commonest
cause of hydrocephalus. The risk of cerebral damage may
be minimized by the insertion of a ventriculoperitoneal
shunt. As the baby grows, this will need to be replaced.
Attendant risks with these devices are that the line blocks
and that the shunt is a source for infection leading to
meningitis. The midwife must be alert for the signs of
increased intracranial pressure:
• large tense anterior fontanelle
• splayed skull sutures
• inappropriate increase in occipitofrontal
circumference
• sun-setting appearance to the eyes
• irritability or abnormal movements.
Microcephaly
This is where the occipitofrontal circumference is more
than two standard deviations below normal for gestational
age. The disproportionately small head may reflect a famil-
ial pattern of head growth, however it may also be a mani-
festation of abnormal brain development. Underlying
aetiologies include conditions that adversely affect the
early fetal brain, e.g. intrauterine infection, fetal alcohol
exposure, or chromosomal disorders. The longer-term
neurodevelopmental sequelae are determined by the
underlying cause but may include learning difficulties,
cerebral palsy and seizures.
MUSCULOSKELETAL DEFORMITIES
These range from relatively minor anomalies, for example
an extra digit, to major deficits such as absence of a limb.
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Polydactyly and syndactyly
Careful examination, including separation and counting
of the baby’s fingers and toes during the initial examina-
tion, is important otherwise anomalies such as syndactyly
(webbing) and polydactyly (extra digits) may go
unnoticed.
Syndactyly more commonly affects the hands. It can
appear as an independent anomaly or as a feature of a
syndrome such as Apert’s syndrome; this is a genetically
inherited condition in which there is premature fusion of
the sutures of the vault of the skull, cleft palate and com-
plete syndactyly of both hands and feet. Whether or not
any surgical division needs to be carried out depends on
the degree of webbing or fusion.
In polydactyly the extra digit(s) may be fully formed or
simply extra tissue attached by a pedicle. Even where there
is only a rudimentary digit without bone involvement,
better cosmetic results are obtained if the digit is surgically
excised rather than ‘tied off’. Surgical excision is mandatory
in more complex cases.
A family history of either of these defects is common,
and in this situation the mother is often anxious to
examine the baby for herself.
Limb reduction deficiencies
Limb reduction deficiencies describe the congenital
absence or hypoplasia of a long bone and/or digits. The
prevalence is around 0.7 per 1000 live births and the most
common identifiable cause, present in a third of cases, is
a vascular disruption defect (Gold et al 2011). An example
of this is an amniotic band-elated deficiency where the
amnion is believed to wrap itself around a developing
limb causing strangulation and necrosis. Other identifia-
ble causes include teratogens (such as thalidomide),
genetic mutations, chromosomal disorders or as part of a
syndrome such as the VACTERL spectrum described earlier
in the chapter (see page 651) (McGuirk et al 2001).
Limb reduction deficiencies may also be classified by
site (upper versus lower limb), or by type (transverse
versus longitudinal). In a transverse defect the limb has
developed normally to a particular level beyond which no
skeletal elements exist (Fig. 32.18), whilst in a longitudi-
nal defect there is a reduction or absence of an element(s)
within the long axis of the limb (Gold et al 2011).
Specific management plans are often reached only after
detailed assessment by an orthopaedic surgeon with a
special interest in limb malformations. For those who
require them, different types of prostheses are available
and can be fitted as early as 3 months of age. Innovative
surgical techniques such as limb lengthening or the trans-
ferring of toe(s) to hand to serve as substitute finger(s) are
proving successful for some children. Once again one of
the most helpful things the midwife can do in these early
days of parental adjustment is to offer the address of a

Fig. 32.18 A baby with a limb reduction defect quickly
learns to adapt.
Photograph courtesy of Reach.
support group such as Reach (see Useful Websites). This
appropriately named support group for parents of chil-
dren with upper limb deformities has branches through-
out the United Kingdom (UK).
Talipes
Talipes equinovarus (TEV, club foot) (Fig. 32.19) is the
descriptive term for a deformity of the foot where the
ankle is bent downwards (plantar flexed) and the front
part of the foot is turned inwards (inverted). Talipes cal-
caneovalgus describes the opposite position where the
foot is dorsiflexed and everted. TEV is a relatively common
malformation, occurring in 1 in every 1000 live births. It
is bilateral in 50% of cases and occurs in males more com-
monly than females, with a ratio of 2 : 1. Historically it was
thought that these deformities were more likely to occur
when intrauterine space was restricted, for example in
multiple pregnancy or oligohydramnios. It is now recog-
nized that there is an important genetic element involved
in their causation and parents who have had a baby with
TEV have a 1 in 30 risk of recurrence in future pregnancies.
TEV is also more likely to occur in conjunction with neu-
romuscular disorders such as spina bifida. In the mildest
form, postural TEV, the foot may be easily returned to the
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Congenital malformations Chapter | 32 |
Fig. 32.19 Congenital talipes equinovarus.
correct position. The midwife should encourage the
mother to exercise the baby’s foot in this way several times
a day. More severe forms will require one or more of
manipulation, splinting, or surgical correction. The advice
of an orthopaedic surgeon should be sought as soon as
possible after birth as early treatment with manipulation
or splinting may enhance results and minimize the need
for surgery. Care should be taken to ensure that, for babies
who have splints applied, the strapping is not too tight
and that the baby’s toes are well perfused.
Developmental dysplasia
of the hip
Congenital hip dysplasia is an abnormality more com-
monly found where there has been a breech presentation
at term, oligohydramnios, a foot deformity or a family
history in a first-degree relative. It most often occurs in
primigravida pregnancies and is commoner in girls than
boys. The left hip is more often affected than the right. The
dysplastic hip may present in one of three ways: dislo-
cated, dislocatable or with subluxation of the joint. Prena-
tal diagnosis by ultrasound is possible; most, however, are
diagnosed incidentally during the routine newborn exami-
nation. Any abnormal findings should be reported and the
baby referred for an orthopaedic opinion, ultrasound scan
of the hips, or both. Where the diagnosis is confirmed it
is usual for the baby to have a splint or harness such as
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Section | 6 | The Neonate
Fig. 32.20 Pavlik harness for congenital dislocation of hip.
From Barr D G D et al 1998 Disorders of bone, joints and connective
tissue, in Campbell A G M, McIntosh N (eds) Forfar and Arneil’s
textbook of pediatrics, ch 23, p 1628, with permission of Churchill
Livingstone.
the Pavlik harness (Fig. 32.20) applied, which will keep
the hips in a flexed and abducted position of about
60%. The splint should not be removed for napkin chang-
ing or bathing. Parents will require additional support in
learning how to handle and care for their baby. Particular
attention should be paid to skin care and checking for
signs of rubbing or excoriation.
Achondroplasia
Achondroplasia is an autosomal dominant condition
where the baby is generally small with a disproportion-
ately large head and short limbs. Some 80% of cases are
due to new mutations of fibroblast growth factor receptor
genes and hence these families may have no anticipation
of the disorder unless an antenatal diagnosis has been
made.
Osteogenesis imperfecta
Osteogenesis imperfecta (OI) is sometimes referred to as
brittle bone disease. It is due to a disorder of collagen
production that can result in multiple fractures either in
utero or at birth. There are eight different types and the
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severity of symptoms varies between types. Inheritance
was originally believed to be autosomal dominant;
however it is now recognized that autosomal recessive
forms exist as well as new mutations arising in a third
of cases (Basel and Steiner 2009). Recognition and
genetic counselling are therefore important for future
pregnancies.
ABNORMALITIES OF THE SKIN
Vascular naevi
These anomalies in the development of the skin can
be divided into two main types, which commonly
overlap.
Capillary malformations
These are due to defects in the dermal capillaries. The most
commonly observed are ‘stork marks’. These are usually
found on the nape of the neck. They are generally small
and will fade. No treatment is necessary.
Port wine stain
This is a purple–blue capillary malformation affecting the
face. It occurs in approximately 1 in 3000 live births. It is
generally fully formed at birth and does not regress with
time. However, laser treatment and the skilful use of
cosmetics will help to disguise the problem. The parents,
and later the child, may need substantial psychological
support.
Should the malformation mimic the distribution of the
ophthalmic branch of the trigeminal nerve, further mal-
formations in the eyes (glaucoma), meninges or brain
(epilepsy) may be suspected. This is known as the Sturge–
Weber syndrome.
Capillary haemangiomata
(‘strawberry marks’)
Capillary haemangiomata are not usually noticeable at
birth but appear as red, raised lesions in the first few weeks
of life (Fig. 32.21). These common lesions affect up to 10%
of the population by the age of 1 year. They are five times
more common in girls than boys and are also commoner
in preterm infants. They can appear anywhere in the body
but cause particular distress to the parents when they
appear on the face. However, parents may be reassured
that, although the lesion will grow bigger for the first few
months it will then regress with associated central pallor
(Fig. 32.22) and usually disappears completely by the age
of 5–6 years. No treatment is normally required unless the
haemangioma is situated in an awkward area where it is

Fig. 32.21 Evolving capillary haemangioma.
Reproduced with permission of Sharon Murphy.
Fig. 32.22 Regressing capillary haemangioma with typical
pallor.
Reproduced with permission of Sharon Murphy.
likely to be subject to abrasion, such as on the lip or
around the eye where it may interfere with vision. Treat-
ment with propranolol, steroids or pulsed laser therapy is
possible.
Pigmented (melanocytic) naevi
These are brown, sometimes hairy, marks on the skin that
vary in size and may be flat or raised. A minority of this
type of birthmark can become malignant. Surgical exci-
sion may be recommended to pre-empt this.
It is unlikely that treatment for any of these birthmarks
will be carried out in the immediate neonatal period
except in the case of larger pigmented naevi. The midwife’s
responsibilities are therefore to notify appropriate medical
staff and offer parents general emotional support.
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Congenital malformations Chapter | 32 |
GENITOURINARY SYSTEM
Improved prenatal screening and diagnostic techniques
(see Chapter 11) mean that information regarding urinary
tract architecture is often available at birth. In addition,
knowledge of liquor volume provides reassurance that
fetal renal function is adequate. If an anomaly has been
prenatally identified a plan regarding the timing of
postnatal investigation(s) and subsequent management
should be available at birth. Occasionally renal tract mal-
formations may be undiagnosed at birth, in which case
the absence of urine for 24 hours or a poor urinary stream
may indicate underlying problems.
Potter syndrome
The impact of fetal renal agenesis or severe hypoplasia was
first described in a series of stillborn infants by Edith
Potter, a perinatal pathologist, in 1946. A characteristic
facial appearance due to the compressive effects of long-
standing oligohydramnios is seen in association with limb
contractures. The presence of adequate liquor volume is
critical to the development of normal lungs and babies
with renal agenesis will all die at or shortly after birth as
a consequence of lung hypoplasia.
Posterior urethral valve(s)
This is a malformation affecting boys where the presence
of valves in the posterior urethra obstructs the normal
outflow of urine. As a result, the bladder distends, causing
back pressure on the ureters and kidneys. This will ulti-
mately cause bilateral hydronephrosis and renal parenchy-
mal damage. Prenatal diagnosis is common and in utero
intervention with the insertion of a shunt from the bladder
to the amniotic fluid is possible. Improved long-term renal
function following prenatal treatment is not guaranteed
and postnatal valve ablation remains the mainstay of treat-
ment (Salam 2006). Unfortunately even with early iden-
tification and management many of these boys will have
life-long renal impairment.
Cystic kidneys
Cystic changes within the kidney(s) are often identified
prenatally. Extensive bilateral changes are likely to be asso-
ciated with impaired renal function and oligohydramnios.
Unfortunately the prognosis in this situation is poor, with
some babies dying at birth and others developing renal
failure. The severest forms of polycystic kidney disease are
usually linked to an autosomal recessive inheritance, but
an autosomal dominant variety also occurs with a less
gloomy prognosis. Unilateral cystic changes, e.g. multi-
cystic dysplastic kidney, have a good prognosis assuming
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Section | 6 | The Neonate
that the contralateral kidney is normal. Postnatal renal
imaging and follow-up is required but the baby is usually
well at birth.
Hypospadias
Examination of a baby boy may reveal that the urethral
meatus opens on to the undersurface of the penis. The
meatus can be placed at any point along the length of the
penis and in some cases will open onto the perineum. This
abnormality often co-exists with chordee, in which the
penis is short and bent and the foreskin is present only on
the dorsal side of the penis. It is important that the parents
are made aware that circumcision should be deferred until
consultation with the paediatric surgeon is completed.
Cryptorchidism
Undescended testes may be unilateral or bilateral and occur
in 1–2% of male infants. If on examination of the baby after
birth the scrotum is empty, the undescended testes may be
found in the inguinal pouch. Sometimes the testis in this
position can be manipulated into the scrotal pouch. If
neither testis is palpable further investigation to exclude
endocrine or chromosomal causes is required. In unilateral
undescended testis parents should be encouraged to have
the baby examined at regular intervals. If descent of the
testis has not occurred by the time the child is one year old,
arrangements for orchidopexy may be made.
DISORDERS OF SEX
DEVELOPMENT (DSD)
DSD are a group of conditions in which the external geni-
talia and the reproductive organs do not develop normally.
They may present at birth when the baby’s external appear-
ance is neither definitely male nor female. In this very
challenging situation it is vital that the midwife is positive,
honest and does not assign a gender to the baby. Examina-
tion of the baby may reveal any of the following: a small
hypoplastic penis, chordee, bifid scrotum, undescended
testes (careful examination should be made to detect unde-
scended testes in the inguinal canal) or enlarged clitoris
and incompletely separated or poorly differentiated labia.
It can be impossible to differentiate by clinical examination
alone between female masculinization, male under-
virilization or mixed gender and expert clarification is
always needed. The decision of gender attribution is made
following chromosomal studies to determine genetic
make-up, hormone assays and consideration of the poten-
tial surgical options. In the longer term specialist multi-
disciplinary support, including clinical psychologists, is
essential for these children and their families.
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Congenital adrenal hyperplasia
This is the commonest cause of female masculinization
(i.e. genetically female with male-looking genitalia). In
this inherited condition the adrenal gland is stimulated to
overproduce androgens because of a deficiency of an
enzyme called 21-hydroxylase, which is necessary for
normal production of steroid from cholesterol. If aldos-
terone production is also reduced then these babies will
rapidly lose salt and may present collapsed and dehy-
drated. Urea and electrolyte levels, blood glucose and
17-hydroxy progesterone concentrations should be meas-
ured and appropriate fluid replacement given. Prenatal
diagnosis by genetic mutation analysis is possible and
facilitates prenatal steroid treatment to minimize viriliza-
tion in affected females (Forest 2004).
Androgen insensitivity syndrome
This is one of several causes of male under-virilization
(genetically male with female-looking genitalia). In this
condition cells are unresponsive to the effects of andro-
genic hormones. In the fetus this prevents normal mascu-
linization of the external genitalia despite the presence of
a Y chromosome.
TERATOGENIC CAUSES
Fetal alcohol syndrome/spectrum
Fetal alcohol exposure remains a leading cause of intel-
lectual impairment despite Department of Health recom-
mendations to drink no alcohol at all during pregnancy.
This reflects the difficulties of translating health promo-
tion objectives into successful outcomes, particularly in an
environment where the alcohol consumption of young
women is constantly increasing.
The teratogenic effects of alcohol include growth
restriction, distortion of craniofacial features and brain
damage (De Sanctis et al 2011). The midwife may be
alerted to the possibility of a baby being born with this
syndrome if there have been concerns about in utero
growth, particularly in the context of excess alcohol con-
sumption. Postnatally the following characteristics may
be recognizable: a small for gestational age infant with
microcephaly, small palpebral fissures, a smooth philtrum
and a thin upper lip. These facial features may become
less pronounced as the child grows, however microceph-
aly, small stature and behavioural problems remain. The
midwife will need to exercise excellent counselling skills
to provide much-needed support for the mother. Collab-
oration with social services is usually called for to ensure
that the care options decided are in the best interests of
the infant and family.
 Congenital malformations Chapter | 32 |

Establishing such a direct link between a teratogen and a
complex clinical pattern remains the exception rather than
the rule although as mentioned earlier accurate recording
of all congenital malformations on a central register can aid
early recognition of potential new teratogens.
SUPPORT FOR THE MIDWIFE
Caring for a mother whose baby has some major congeni-
tal malformation places extra demands on the midwife.
This stress is compounded if the anomaly was not antici-
pated prior to birth or if the midwife has not previously
encountered the particular problem. The exercising of
effective counselling and communication skills is invalu-
able in helping the family to adjust and in facilitating
appropriate lines of support. The extra effort expended can
be costly in terms not only of time but of the emotional
stress the midwife may experience.
It is important that support is available for midwives in
these situations and an opportunity to debrief with a
senior colleague(s) or named supervisor of midwives can
be helpful. Preparatory courses on grief and bereavement
counselling are also of some benefit as many parents with
affected babies will experience many of these emotions
(Chapter 26). Midwives who have acquired experience in
this realm should not, however, automatically be targeted
as the experts and always be called upon to fulfil this role.
Conversely, student midwives ought not to be deliberately
shielded from being involved in caring for such families.
The provision of quality care for parents who have a child
with a congenital malformation is contingent upon
meeting the needs of the carers.
Midwives may also find information available via the
Internet, however, they should be aware of the dubious
quality of some of this information. They should therefore
exercise caution in how they utilize it. It might also be wise
to caution parents, who often search the Internet for
further information, of this potential risk.

REFERENCES

Adzick N S, Thom E, Spong C et al Ewer A K, Middleton L J, Furmston A T McGuirk C K, Westgate M N, Holmes L

2011 A randomized trial of prenatal
versus postnatal repair of
myelomeningocele. New England
Journal of Medicine
364(11):993–1004
Bacher M, Linz A, Buchenau W et al
2010 Treatment of infants with Pierre
Robin sequence.
Laryngorhinootologie 89(10):
621–9
Basel D, Steiner R D 2009 Osteogenesis
imperfecta: recent findings shed new
light on this once well understood
condition. Genetic Medicine
11(6):375–85
Chinnery P F, Howell N, Lightowlers R
N et al 1998 MELAS and MERRF:
The relationship between maternal
mutation load and the frequency of
clinically affected offspring. Brain
121:1889–94
Czapran P, Gibbon F, Beattie B et al
2011 Neural tube defects in Wales:
changing demographics from 1998
to 2009. British Journal of
Neurosurgery 26:456–9
De Sanctis L, Memo L, Pichini S et al
2011 Fetal alcohol syndrome:
new perspectives for an ancient
and underestimated problem.
Journal of Maternal Fetal and
Neonatal Medicine 24(1):
34–7
et al 2011 Pulse oximetry screening
for congenital heart defects in
newborn infants (Pulse Ox): a test
accuracy study. Lancet 378:785–94
Forest M G 2004 Recent advances in the
diagnosis and management of
congenital adrenal hyperplasia due
to 21-hydroxylase deficiency. Human
Reproduction Update 10(6):469–85
Gold N B, Westgate M N, Holmes L B
2011 Anatomic and etiological
classification of congenital limb
deficiencias. American Journal of
Medical Genetics 155A(6):1225–35
Haddock G, Davis C F, Raine P A M
1996 Gastroschisis in the decade of
prenatal diagnosis. European Journal
of Paediatric Surgery 6:18–24
Jensen A 2012 Nursing care and surgical
correction of neonatal
myelomeningocele. Infant
8(5):142–6
Lee S L, Beter T D, Kim S S et al 2006
Initial nonoperative management
and delayed closure for the
treatment of giant omphaloceles.
Journal of Pediatric Surgery
41(11):1846–9
Manna F, Pensiero S, Clarich G et al
2009 Cleft lip and palate: current
status from the literature and our
experience. Journal of Craniofacial
Surgery 20(5):1383–7
B 2001 Limb deficiencies in
newborn infants. Pediatrics
108(4):E64
Medical Research Council Vitamin
Study Research Group 1991
Prevention of neural tube defects:
results of the Medical Research
Council Vitamin Study. Lancet
338:131–7
Pedersen R N, Calzolari E, Husby S et
al. EUROCAT Working Group 2012
Oesophageal atresia: prevalence,
prenatal diagnosis and associated
anomalies in 23 European regions.
Archives of Disease in Childhood
97(3):227–32
Salam M A 2006 Posterior urethral
valves: outcome of antenatal
intervention. International Journal of
Urology 13(10):1317–22
Saleem S N, Said A H, Abdel-Raouf M
et al 2009 MRI in the evaluation of
fetuses referred for sonographically
suspected neural tube defects: impact
on diagnosis and management
decisions. Neuroradiology
51(11):761–72
Schlatter M, Norris K, Uitvlugt N et al
2003 Improved outcomes in the
treatment of gastroschisis using a
preformed silo and delayed repair
approach. Journal of Pediatric
Surgery 38(3):459–64

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Section | 6 | The Neonate
FURTHER READING
Jones K L (ed) 2006 Smith’s
recognizable patterns of human
malformation, 6th edn. Saunders/
Elsevier, Philadelphia
USEFUL WEBSITES
Antenatal Results and Choices (ARC):
www.arc-uk.org
This website provides non-directive support
and advice to parents throughout the
antenatal testing process and when a
malformation has been diagnosed
Association for Spina Bifida and
Hydrocephalus (ASBAH):
www.asbah.org
Children’s Heart Federation:
www.chfed.org.uk
Cleft Lip and Palate Association
(CLAPA): www.clapa.com
Contact a Family: www.cafamily.org.uk
This website provides information and
support for families with disabled children.
666
This book provides a comprehensive and
systematic approach to dysmorphic
syndromes.
Cystic Fibrosis Trust (CF):
www.cftrust.org.uk
Down’s Syndrome Association:
www.downs-syndrome.org.uk
Genetic Alliance UK:
www.geneticalliance.org.uk
This is a national alliance of organizations
which support children and families
affected by genetic disorders.
On-line Mendelian Inheritance
in Man (OMIM):
www.ncbi.nlm.nih.gov/omim
Detailed information about clinical features
and genetics of inherited diseases
mebooksfree.com
Reach: The Association for Children
with Upper Limb Deficiencies:
www.reach.org.uk
Scottish Down’s Syndrome Association
(SDSA): www.dsscotland.org.uk
SOFT (Support Organization for
Trisomy 13/18): www.soft.org.uk
STEPS (National Association
for Children with Lower
Limb Deficiencies):
www.steps-charity.org.uk
 Chapter 33

Significant problems in the newborn baby

Stephen P Wardle, Carole England

CHAPTER CONTENTS Management of a baby with an

antenatal diagnosis of CHD 681
Introduction 668 Care of a baby with a murmur 681
Initial examination and recognition Jaundice 681
of problems 668 Bilirubin physiology 682
The skin 668 Physiological jaundice 682
The respiratory system 670 Pathological jaundice 685
Central nervous system 671 Late neonatal jaundice 687
The renal and genitourinary system 671 Haematological problems 688
The gastrointestinal tract 672 Bleeding 688
Recognition of problems at the time of Possible causes of bleeding abnormalities 688
resuscitation, including neonatal Metabolic problems 689
encephalopathy 672
Glucose homeostasis 689
Neonatal encephalopathy 672
Hypoglycaemia 689
Babies with less severe problems 674 Hyperglycaemia 690
Seizures and abnormal movements 674 Electrolyte imbalances in the newborn 691
Infection in the newborn 674 Sodium 691
Umbilical cord 675 Potassium 692
Bacterial infection in the newborn 675 Calcium 692
Viral infections acquired before or Inborn errors of metabolism in
during birth 676 the newborn 692
Toxoplasmosis 677 Phenylketonuria 693
Candida 678 Galactosaemia 694
Significant eye infections. 678 Endocrine problems 694
Respiratory problems 678 Thyroid disorders 694
Initial management of babies Adrenal disorders 695
presenting with respiratory distress 679 Pituitary disorders 695
Possible causes of respiratory distress Parathyroid disorders 695
in the newborn 679 Effects on the newborn of maternal
Congenital heart disease (CHD) 681 drug abuse/use during pregnancy 696

© 2014 Elsevier Ltd 667

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Section | 6 | The Neonate
Signs of withdrawal 696
Treatment 696
Cocaine 697
Discharge and long-term effects 697
References 697
Further reading 701
Websites 701
A wide variety of conditions may present in the
newborn baby that warrant early referral to the
neonatal multiprofessional team. The midwife
needs to be able to recognize and assess
problems that distinguish healthy babies from
those that are ill/sick. Some problems will be
life-threatening and will require urgent
assistance; others will be more subtle in their
presentation, but nevertheless remain important.
Knowledge of the signs, characteristics and
features of the conditions presented will enable
the midwife to make well-informed and
appropriate referrals, while also providing
valuable support for the parents before, during
and after the neonatologist has examined their
baby.
THE CHAPTER AIMS TO:
• assist the midwife in the assessment and
identification of the sick newborn baby
• summarize possible problems that may be identified
in a newborn baby and offer an approach to dealing
with them.
INTRODUCTION
The majority of newborn babies are born in good condi-
tion and require no intervention after birth except to be
dried with a warm towel and then to have skin-to-skin
contact with their mother (Chapter 29). Labour and birth
may have been straightforward but the baby may still need
to be observed at this time to ensure a healthy transition
from uterine to postnatal life. Approximately 5–10% of
babies will require admission to a neonatal unit. Many of
these are preterm babies or those with antenatally detected
problems; however 6–9% of term babies will also require
some type of neonatal care (Tracy et al 2007). The length
of time a mother spends in hospital with her newborn
baby has decreased significantly in recent years and many
babies may be born outside the hospital setting, at home
or in a midwifery-led unit. Context may impact on early
recognition and management of problems in the early
newborn period. The focus of this chapter is to aid the
early detection of problems to enable the midwife to
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distinguish the ill from the well baby and to decide when
intervention is required and what that initial action should
be. The aim is not to give detailed management about
conditions that will clearly need the involvement of the
neonatal specialists, but to summarize those conditions
that may first be recognized or come to the attention of
midwives and require their involvement.
INITIAL EXAMINATION AND
RECOGNITION OF PROBLEMS
Most of the information the midwife requires for the
assessment of a baby’s wellbeing comes from observation.
The normal term baby will lie with their limbs partially
flexed and active, the skin colour should be centrally per-
fused, indicating adequate oxygenation, and there should
be no rashes or skin lesions. After the initial observation
there should follow a more systematic examination to
ensure the newborn baby is well (Chapter 28). The follow-
ing areas should be examined carefully.
The skin
The skin of a neonate varies in its appearance and can
often be the cause of unnecessary anxiety in the mother,
midwife and medical staff. It is, however, often the first
sign that there may be an underlying problem in the baby.
The presence of meconium on the skin, which is usually
seen in the nail beds and around the umbilicus, in a baby
with respiratory problems may indicate meconium aspira-
tion as a factor. More generally, the skin of all babies
should be examined for pallor, plethora, cyanosis, jaun-
dice and skin rashes.
Pallor
A pale, mottled baby may be an indication of poor periph-
eral perfusion, however the hands and feet are often blue
soon after birth (acrocyanosis) and this does not indicate
an underlying problem. Always examine the baby’s face
and chest when assessing colour. The anaemic baby’s
appearance is usually pale pink, white or, in severe cases
where there is vascular collapse, grey. Other presenting
signs are tachycardia, tachypnoea and poor capillary refill
(CR) (press the skin briefly on the forehead or chest and
observe how long it takes for the colour to return; this
should be less than 2 seconds). The most likely causes of
anaemia immediately after birth are:
• a history in the baby of haemolytic disease of the
newborn (HDN)
• twin-to-twin transfusions in utero (which can cause
one baby to be anaemic and the other
polycythaemic)
 Significant problems in the newborn baby
• feto-maternal haemorrhage
• fetal haemorrhage from vasa praevia or bleeding
from the umbilical cord.
Pallor can also be observed in babies who are hypother-
mic or hypoglycaemic. Significant pallor can be associated
with:
• anaemia and shock
• respiratory disorders
• cardiac anomalies
• sepsis.
Plethora
Babies who are very red in colour may be described as
plethoric. Their colour may indicate a high level of circu-
lating red blood cells (polycythaemia). Newborn babies
can become polycythaemic if they are recipients of:
• twin-to-twin transfusion in utero
• a large placental transfusion.
Contributing factors may include deferred clamping of the
umbilical cord or holding the baby below the level of the
placenta, thereby allowing blood to flow into the baby and
giving a greater circulating blood volume (can occur in
unassisted births). Other babies at risk are:
• those that are small for their gestational age (SGA)
as a means to increase oxygen carrying capacity in
the hypoxic situation (Chapter 30)
• infants of diabetic mothers (IDM) as a result of
increased levels of growth hormone and an
overactive metabolism.
The diagnosis of polycythaemia is based upon levels
of haemoglobin and haematocrit (the relationship
between red blood cells and plasma in the blood) and
how they compare with normal values, based on gesta-
tional age. Some poor outcomes have been associated
with polycythaemia, however according to (Özek et al
2010) there is no evidence that a particular level of hae-
matocrit requires treatment nor that treatment is of any
benefit.
Cyanosis
Peripheral cyanosis of the hands and feet is common
during the first 24 hours of life and is of no significance.
Central cyanosis should always be taken seriously. The
tongue and mucous membranes are the most reliable indi-
cators of central colour in all babies and if they appear
blue this indicates low oxygen saturation levels in the
blood, usually of respiratory or cardiac origin. Episodic
central cyanosis may be an indication that the baby is
having convulsions. Central cyanosis always demands
urgent attention (see later sections on respiratory prob-
lems and assessment of the cyanosed baby).
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Chapter | 33 |
Other factors that affect the appearance
of the skin
Preterm babies have thinner skin that is redder in appear-
ance than that of term infants. In post-term babies, the
skin is often dry and cracked. The skin is a good indicator
of the nutritional status of the baby. The SGA baby may
look malnourished and have folds of loose skin over the
joints, owing to the lack or loss of subcutaneous fat. This
can predispose the baby to hypoglycaemia due to poor
glycogen stores in the liver and can also cause problems
with hypothermia. If the baby is dehydrated, the skin
looks dry and pale and is often cool to the touch. If gently
pinched, the skin will be slow to retract. Other signs of
dehydration are tachycardia, pallor or mottled skin,
sunken eyes and anterior fontanelle. The best clinical indi-
cator of dehydration is the baby’s reduced weight.
Skin rashes
Skin rashes are quite common in newborn babies but
most are benign and self-limiting. There are some rashes,
however, which may indicate significant illness and should
not be ignored:
• Petechiae or purpura rash over the upper part of the
body, particularly the face and chest, may occur due
to venous obstruction after normal or prolonged
birth. Petechiae can occur when there is a low
platelet count (thrombocytopenia as discussed later
in the chapter) and this may present with a petechial
rash over the whole body with prolonged bleeding
from puncture sites and/or the umbilicus and
bleeding into the intestinal system.
• Bruising can occur following breech extractions,
forceps and ventouse-assisted births. A sub-
aponeurotic haemorrhage (Chapter 31) can cause a
decrease in circulating blood volume, which can
result in anaemia and, if severe, hypotension.
• Vesicular rash is where small fluid-filled raised lumps
occur on the skin associated with some congenital
viral infections, in particular herpes simplex or
congenital chicken pox (Varicella). These can be very
serious infections in the newborn and should always be
carefully assessed. The midwife should enquire about
a history of maternal genital herpes infection
although it can occur without any known history of
infection. Referral for neonatal medical assessment is
essential and a diagnosis should be confirmed before
commencing treatment.
• Blistering rash is where areas of skin are raised and
are fluid-filled. The surface of the skin may also
slough off, leaving red raw areas. This can occur in
bacterial infections, in particular Staphylococcus
aureus, and in some rare but important skin diseases,
e.g. epidermolysis bullosa (EB), part of a group of
inherited skin conditions some of which are very
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Section | 6 | The Neonate
serious and associated with significant morbidity and
mortality. There may be a family history. It presents
as widespread tender erythema, followed by blisters,
which break leaving raw areas of skin or sometimes
yellow-filled bullae. This is particularly noticeable
around the napkin area but can also cause umbilical
sepsis, breast abscesses, conjunctivitis and, in
systemic infections, there may also be involvement
of the bones and joints. Babies with this condition
are likely to be very unwell and require admission to
a neonatal intensive care unit (NICU). A blistering
skin rash should always be treated with broad
spectrum intravenous (IV) antibiotics that
particularly cover S. aureus.
The respiratory system
Healthy babies should establish normal regular respira-
tion within minutes of birth. Many babies may display a
slightly irregular breathing pattern for a few minutes after
birth but should have regular respiration with a respiratory
rate of 40–60 by approximately 2 minutes. The baby’s
breathing pattern will alter depending on his/her level of
activity but a respiratory rate consistently above 60 breaths
per minute is considered as tachypnoea.
Cardiorespiratory adaptations at birth
• Before birth the lungs are fluid-filled. At birth the
newborn must clear this fluid in order to breathe
successfully. Some fluid is removed by physical
means during normal labour (Stephens et al 1998)
but most is absorbed into the pulmonary lymphatics
and capillaries.
• The lungs inflate and remain inflated as a result of
the presence of surfactant. In some preterm babies,
IDM and sick term babies, surfactant production
may be decreased, resulting in respiratory distress.
• Newborn babies are obligate nasal breathers.
Obstruction to the nares (nostrils) can therefore
result in serious respiratory distress.
• The shape of the newborn thorax and the rib
orientation tend to mean that the expansion
potential of the thorax is limited. The baby’s soft and
flexible ribs also make the chest wall subject to
collapse during increased respiratory efforts. To
compensate for this the baby tends to elevate lung
volume at end expiration by a rapid respiratory rate,
intercostal activity and grunting.
Because of the factors described above the clinical signs
of respiratory distress in the newborn are different from
other patient groups. The following features may be seen:
• Expiratory grunting is a characteristic noise and
occurs due to partial closure of the glottis during
expiration. The baby is attempting to preserve some
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internal lung pressure and prevent the airways from
collapsing completely at the end of the breath.
• Intercostal recession uses the intercostal muscles
more effectively, but as a result the spaces between
the ribs and the sternum are sucked in during each
breath.
• Tachypnoea is an increased respiratory rate that
occurs as the baby attempts to compensate for an
increased carbon dioxide concentration in the blood
and extracellular fluids. A normal respiratory rate in
the newborn is 40–60 breaths per minute.
• Nasal flaring is an attempt to minimize the effect of
the airways resistance by maximizing the diameter of
the upper airways. The nares are seen to flare open
with each breath.
• Apnoea is an absence of breathing for more than 20
seconds and may occur as a result of increasing
respiratory fatigue in the term baby. The preterm
baby may also experience apnoea of prematurity due
to immaturity of the respiratory centre and/or
obstructive apnoea from occluded airways.
A baby with significant signs of respiratory distress
should be reviewed by the neonatal team and should be
admitted to the NICU for further investigation and obser-
vation. Occasionally in the first few minutes after birth,
particularly following a caesarean section, a baby may
have mild respiratory abnormalities that settle quickly, but
babies with abnormal signs should always remain under
observation as deterioration can occur rapidly in some
cases. On initial assessment it may not be easy to distin-
guish the cause of the respiratory distress and further
evaluation, including a chest X-ray, may be required (the
initial assessment and treatment is described later in the
chapter).
The importance of body
temperature control
A neutral thermal environment is defined as the ambient
air temperature at which oxygen consumption or heat
production is minimal, with body temperature in the
normal range (Lissauer and Faranoff 2006). The normal
body temperature range for term babies is 36.5–37.3 °C.
Merenstein and Gardner (2011) assert the importance of
the neutral thermal environment and how everyone caring
for babies should understand the need for maintenance of
normal body temperature. Mothers are often hot during
labour and measures may be taken to produce a cooler
environment for the mother’s comfort. It is important to
always consider this effect and maintain a suitable envi-
ronmental temperature for the newborn baby. In addition
to skin-to-skin contact, this may require extra measures
like use of a radiant heater or cot warmer, in some circum-
stances. Environments that are outside the neutral thermal
environment may result in babies who are too cold or
too warm, who will attempt to regulate their temperature,
 Significant problems in the newborn baby
and this can destabilize more vulnerable babies such as
those of low birth weight (preterm and SGA). An abnor-
mal temperature, either high or low, can be an early sign
of an underlying problem such as an infection, a respira-
tory or cardiac problem, a metabolic abnormality or
encephalopathy.
Hypothermia is defined as a core body temperature
below 36 °C (Jain 2012). When the body temperature is
below this level the baby is at risk from cold stress. This
can cause complications such as increased oxygen con-
sumption, lactic acid production, apnoea and hypoglycae-
mia. In preterm babies cold stress may also cause a
decrease in surfactant production, which is associated with
increased mortality (Costeloe et al 2000; Confidential
Enquiries into Stillbirths and Deaths in Infancy [CESDI]
2003). The hypothermic baby often looks pale or mottled
and may be uninterested in feeding.
Hyperthermia is defined as a core temperature above
38.0 °C (Jain 2012). The usual cause of hyperthermia is
overheating of the environment, but it can also be an
important clinical sign of sepsis as the baby will attempt
to regulate its temperature by increasing his/her respira-
tory rate leading to an increased fluid loss by evaporation
through the airways. Other problems caused by hyperther-
mia are hypernatraemia, jaundice and apnoea.
Central nervous system
Assessment of a baby’s neurological status is usually
carried out on a baby who is awake but not crying. Impor-
tant signs are the tone and quality of a baby’s movements,
level of activity, posture and presence of normal newborn
reflexes. An abnormal posture such as neck retraction,
frog-like posture, hyperextension or hyperflexion of the
limbs, jittery or abnormal involuntary movements and a
high-pitched or weak cry, could be indicative of neurologi-
cal impairment and a need for investigation (Lawn and
Alton 2012).
Terminology that describes abnormal movement in
babies is very variable and includes fits, convulsions, seiz­
ures, twitching, jumpy and jittery. In contrast, a baby with
poor muscle tone is described as hypotonic or floppy. It is
often very difficult to distinguish a seizure from jitteriness
or irritability. The jittery baby has tremors, rapid move-
ment of the extremities or fingers that are stopped when
the limb is held or flexed. Jitteriness can be normal but is
sometimes seen in babies who are affected by drug with-
drawal or in babies with hypoglycaemia (see section on
seizures, p 674).
Hypotonia
Hypotonia describes the loss of muscle tension and tone.
As a result, the baby adopts an abnormal posture that is
noticeable on handling. If hypotonia and a lack of move-
ment have been significant features before birth then limb
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Chapter | 33 |
contractures may also be seen. Preterm babies below 30
weeks’ gestation have a resting position that is usually
characterized as hypotonic. By 34 weeks their thighs and
hips are flexed and they lie in a frog-like position, usually
with their arms extended. At 36–38 weeks’ gestation the
resting position of a healthy newborn baby is one of total
flexion with immediate recoil. Hypotonia in a term baby
is not normal and requires investigation. It is also impor-
tant to determine whether the hypotonia is associated
with weakness or normal power in the limbs, i.e. are there
spontaneous movements? Can the baby make normal
movements against gravity? There are several causes of
hypotonia in the newborn.
Systemic causes
• maternal sedation or drugs (in particular some
antidepressants)
• prematurity
• infection
• Down syndrome
• endocrine (e.g. hypothyroidism)
• metabolic problems (e.g. hypoglycaemia,
hyponatraemia, inborn errors of metabolism)
Central (brain) causes
• perinatal hypoxia-ischaemia or neonatal
encephalopathy (see p 672 below)
• traumatic brain injury
• structural brain abnormality, e.g. holoprosencephaly
Peripheral nervous system causes
• neurological problems (e.g. spinal cord injuries
sustained by difficult breech or forceps assisted
birth)
• neuromuscular disorders (e.g. spinal muscular
atrophy, myasthenia gravis related to maternal
disease, myotonic dystrophy etc.)
The renal and genitourinary system
Documentation of the passage of urine after birth is
important as it provides a record that may help if later
concerns arise. The genitourinary tract has the highest per-
centage of anomalies, congenital or genetic, of all the
organ systems. Prenatal diagnosis is possible with ultra-
sound and aids the early assessment and intervention that
is essential if kidney damage is to be prevented. Urine that
only dribbles out, rather than being passed with a good
stream, may be an indication of a problem with posterior
urethral valves. Other renal problems may present as a
failure to pass urine. The healthy baby usually passes urine
within 4–10 hours after birth. Urinalysis using reagent
strips will give information that may be helpful in diag-
nosis. Urinary infections in the newborn period are
uncommon. The signs of urinary tract infection are often
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Section | 6 | The Neonate
vague and can be mistaken for other problems. The baby
typically presents with lethargy, poor feeding, increasing
jaundice and vomiting. Urine infections when present are
important, however, because renal scarring can result.
Reduced urine output is usually due to low fluid intake,
often in breast-fed babies, but also consider:
• increased fluid loss due to hyperthermia, use of
radiant heaters and phototherapy units
• perinatal hypoxia-ischaemia
• congenital abnormalities
• infection.
The gastrointestinal tract
Assess the baby’s abdomen, looking for signs of disten-
sion, discoloration or tenderness. Most babies should feed
early and pass meconium within the first 8–12 hours of
birth. Healthy babies should be able to feed within 30
minutes of birth. Vomiting can be a sign of a problem but
the midwife should distinguish between possetting, which
occurs with winding and over-handling after feeding, and
vomiting due to overfeeding, infection or intestinal abnor-
malities. Whilst possetting small amounts of milk is
common, babies with large vomits should be evaluated,
as should babies with blood in their vomit. Vomit contain-
ing green material can occasionally be due to swallowed
meconium but green bile is usually unmistakable.
Bile-stained vomiting
There should never be green bile in the vomit of a newborn
baby and this always requires prompt investigation. It may
indicate bowel obstruction and in the newborn one of the
possible causes is malrotation and volvulus, which could
lead to bowel damage and bowel loss if not promptly
investigated. If bile-stained vomiting is seen or reported,
check the baby carefully looking for abdominal distension
or tenderness. Check that the anus is patent. An X-ray and
contrast study is usually required to rule out bowel
obstruction and malrotation. Other possible causes
include infection, bowel atresias, meconium ileus, anorec-
tal malformations or necrotizing enterocolitis (NEC).
NEC is generally a problem in premature babies but may
also occur in term babies, particularly those who have risk
factors such as perinatal hypoxia, polycythaemia and hypo-
thermia. It is an acquired disease of the small and large
intestine caused by ischaemia of the intestinal mucosa.
NEC may present with vomiting and this may be bile-
stained. The abdomen becomes distended, stools may be
loose and may have blood in them or the baby may not
open its bowels. In the early stages of NEC, the baby can
display non-specific signs of temperature instability, unsta-
ble glucose levels, lethargy and poor peripheral circulation.
As the illness progresses, the baby may become apnoeic
and bradycardic and may need respiratory support.
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Passage of meconium
According to Metaj et al (2003), 97% of babies will pass
meconium by 24 hours of age, an event that should be
documented. If a baby has not passed meconium then
examine the abdomen to look for signs of distension or
tenderness. Check that the anus is patent. Possible causes
of delayed passage of meconium include bowel atresia,
meconium ileus and imperforate anus. Hirschsprung’s
disease should be suspected in term babies with failure to
pass meconium in the first 48 hours after birth. Passage of
first meconium occurs later with earlier gestational age
(Kumar and Dhanireddy 1995).
The normal term baby usually passes about eight stools
a day. Breastfed babies’ stools are looser and more fre-
quent than those of bottle-fed babies, and the colour
varies more and sometimes appears greenish. The baby
who has a systemic infection can often display signs of
gastrointestinal problems, usually poor feeding and vom-
iting. Diarrhoea may be a feature of this or may indicate
a more serious gastrointestinal disorder such as NEC. Diar-
rhoea caused by gastroenteritis is unusual in the newborn
although it may be seen after the first week. Outbreaks of
viral diarrhoea due to Rotavirus have been reported. Babies
with this condition must be isolated and scrupulous hand-
washing must be adhered to (Isaacs and Moxon 1999).
Loose stools can also be a feature of babies receiving
phototherapy.
RECOGNITION OF PROBLEMS
AT THE TIME OF RESUSCITATION,
INCLUDING NEONATAL
ENCEPHALOPATHY
Aspects of resuscitation of the newborn are covered in
Chapter 29, but problems that might be encountered, or
may present during or immediately after resuscitation, will
be covered here. It is important to recognize promptly
those babies who have adapted poorly to extrauterine life
and are in poor condition at birth because of hypoxia-
ischaemia, or have tolerated the birth process poorly as a
result of pre-existing problems.
Neonatal encephalopathy
Neonatal encephalopathy is a clinical syndrome of abnor-
mal levels of consciousness, tone, primitive reflexes, auto-
nomic function and sometimes seizures in newborn
babies.
Which babies get encephalopathy?
The commonest cause is hypoxia-ischaemia, termed
hypoxic ischaemic encephalopathy (HIE), but it is
 Significant problems in the newborn baby Chapter | 33 |

important to remember that not all encephalopathy is due
to hypoxia-ischaemia.
Encephalopathy can be due to:
• cord obstruction (prolapse or compression)
• placental abruption
• breech
• shoulder dystocia etc.
In addition, other causes such as metabolic, infective, mal-
formation or trauma should also be considered. The term
neonatal HIE should be used only when there is clear
evidence of hypoxia and ischaemia. Globally, neonatal
HIE is a very large problem, with a high morbidity and
mortality in developing countries (Vannucci 1990). In the
United Kingdom (UK) and other developed countries the
incidence varies depending on the definition used but is
approximately 0.5/1000 live births (Levene et al 1986).
No specific treatment, other than general supportive treat-
ment, has been available for these babies but the advent
of whole body cooling following the publication of rand-
omized controlled trials of this intervention in 2005–9,
has improved the outcome for some babies and has
increased the need for prompt early identification and
treatment (Shankaran et al 2005; Azzopardi et al 2009;
Jacobs et al 2013). Midwives play a vital role in this new
approach.
Features suggestive of hypoxia-ischaemia are detailed in
Box 33.1.
Neonatal encephalopathy is often classified according
to a grading system (modified by Sarnat and Sarnat 1976;
see Table 33.1). In general, a neonatologist should be
asked to review any baby when:
• the heart rate remains <100 for more than 1 minute
• normal respiration is not established by 5 minutes
of age
• the Apgar score is <5 at 5 minutes
• gasping respiration is seen
• cord pH <7.0.
In these babies whole body cooling may be considered.
This treatment requires 72 hours of cooling of core body
temperature to 33–34 oC. Several studies have shown that
this treatment reduces the risk of cerebral palsy and
increases the likelihood of survival without significant dis-
ability by 50% (Shankaran et al 2005; Azzopardi et al
2009; Jacobs et al 2013). If cooling is being considered,
the neonatal team may commence ‘passive’ cooling before
Box 33.1 Features suggestive of
hypoxia-ischaemia
(A) Before birth:
– evidence of antenatal compromise
– decreased fetal movements
– abnormal fetal heart rate patterns
– low fetal pH
– meconium-stained amniotic fluid
(B) Poor condition at birth:
– low heart rate
– failure to establish normal respiration soon after
birth (apnoea or gasping respiration)
– acidotic cord pH
– cyanosis or pallor
(C) Abnormal neonatal neurology:
– decreased consciousness
– decreased tone
– poor suck and other primitive reflexes

Table 33.1 Grading criteria for neonatal encephalopathy

Grade 1 (mild) Grade 2 (moderate) Grade 3 (severe)

Clinical Hyper-alert, staring Lethargy, hypotonia Decreased consciousness
features Mild decreased tone/activity Seizures Hypotonia
Poor feeding for up to 24 Poor suck/feeding for >24 Frequent prolonged seizures
hours hours Multi-organ involvement – breathing,
kidneys, blood pressure affected
Absent gag/sucking reflexes
Management May be able to stay with Will need neonatal admission. Intensive care, cooling
mother on postnatal ward May require cooling
but needs observation/
feeding support
Outcome Complete recovery, normal Most recover well but up to Generally poor
(Jacobs et al outcome 25% may have long-term Death or significant neurodisability
2013) neurological problems. likely, but with cooling approximately
Cooling has significant 70% die or have major disability
benefits

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Section | 6 | The Neonate
Fig. 33.1 Cooling jacket.
a firm decision is made. This means active warming of the
baby is stopped and the baby’s body temperature is
allowed to fall passively towards the levels required. This
is only a temporary measure though while a decision
is being made, equipment is being prepared or transfer is
being organized. Active cooling requires the use of a
cooling jacket or mattress (see Fig. 33.1) to cool the whole
body, or sometimes a cap to cool the head. The treatment
is started as soon as possible after diagnosis (maximum
within 6 hours) and then continued for 72 hours, after
which the baby is gradually warmed. A systematic review
of 10 randomized controlled trials (RCTs) (1320 babies in
total) by Jacobs et al (2013) reported a lower risk of death
in cooled babies (whole body or head) in the first 18
months of life than in babies treated by standard care. In
three of these studies with 18-month follow-up (767
babies in total) the combined risk of death and severe
disability was significantly lower in cooled babies com-
pared with those treated by standard care, and cooling
increased survival with normal neurological function
compared with standard care at 18-month follow-up. In
summary therefore, using cooling decreases the risks of
death by more than 20% and increases the chance of
survival without disability by 50%.
Babies with less severe problems
Some babies with neonatal encephalopathy may not have
clinically obvious signs immediately and repeated assess-
ment is necessary in babies who have risk factors such as
those listed above. In some of these babies there will be
poor feeding and low tone for the first 24 hours after birth.
These babies need careful observation and may need addi-
tional feeding support but they are often well enough to
remain with their mother rather than being admitted to
the NICU. Babies with this pattern of encephalopathy
should improve after 24 hours and should not have any
long-term consequences of their encephalopathy. Babies
with a mild encephalopathy like this have not been shown
to benefit from whole body cooling.
Seizures and abnormal movements
Seizures in the newborn period can be difficult to recog-
nize; however, they are an important indicator of
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potentially serious problems and their recognition is
therefore important. The most common cause is neonatal
encephalopathy, most commonly HIE, but readily treata-
ble causes such as hypoglycaemia must not be missed.
Seizures in newborns differ from those in later life. They
are often subtle and difficult to differentiate from other
normal behaviour. Different types of seizures may be seen
and include tonic seizures (sustained posturing of the
limbs or trunk or deviation of the head), clonic (usually
involves one limb or one side of the body jerking rhyth-
mically at 1–4 times per second) or myoclonic (rapid
isolated jerking of muscles). Subtle seizures may include
behaviours such as repetitive lip smacking, staring, blink-
ing or repetitive movements of the limbs such as cycling
movements.
Causes of seizures
Seizures in the newborn almost always have an identifia-
ble cause, e.g.
• HIE (49%)
• cerebral infarction (neonatal stroke) (12%)
• cerebral trauma (7%)
• infections (meningitis or encephalitis) (5%)
• metabolic abnormalities, including hypoglycaemia
(3%)
• narcotic drug withdrawal (4%).
It is important to distinguish seizures from jitteriness and
neonatal sleep myoclonus, both of which are benign. Jit-
teriness is symmetrical rapid movements of the hands and
feet. It is often stimulus-sensitive and may be initiated by
sudden movement or noise and there are no associated
eye movements. Benign sleep myoclonus involves bilateral
or unilateral jerking during sleep. It occurs during active
sleep, is not stimulus-sensitive and tends to be seen in
upper limbs more than lower limbs. It is important to
ensure that the newborn is not at risk from the seizure, so
ensure that the airway is clear and the baby is breathing.
Ensure that readily treatable causes are identified and
treated. In particular check the blood sugar to exclude
hypoglycaemia, and electrolytes to include calcium and
sodium; also consider infection. Hypocalcaemia can be a
readily treatable cause of seizures in women with vitamin
D deficiency.
INFECTION IN THE NEWBORN
Infection in the newborn contributes significantly to mor-
bidity and mortality and possible infection is one of the
commonest reasons for newborn babies becoming unwell
and requiring admission to a neonatal unit. Newborn
babies may acquire infections antenatally (transplacental
infection), during birth, or after birth.
 Significant problems in the newborn baby
Umbilical cord
Until its separation, the umbilical cord can be a focus for
infection by bacteria that colonize the skin of the newborn.
The umbilical stump should be dry. If peri-umbilical
redness occurs or a discharge is noted, infection should be
considered and it may be necessary to commence antibi-
otic therapy in order to prevent an ascending infection.
Babies are protected from infection by the passive transfer
of antibodies from their mother. The major advantage of
this is that they receive passive immunity for those infec-
tions they are most likely to come into contact with. The
immune system is functional at birth and newborn babies
can also mount their own humeral (antibody) response
to new infections; however, preterm babies are particularly
vulnerable to infection as placental transfer of IgG mainly
occurs after 32 weeks’ gestation and their own antibody
response is immature.
Bacterial infection in the newborn
Early signs of infection may be subtle and difficult to
distinguish from other problems. The mother or midwife
may simply feel the baby is ‘off colour’ or not right. The
physical signs that may be apparent are:
• Temperature instability. This may be a low
temperature just as much as an increased
temperature. Always take seriously and carefully
assess any normally grown baby who is unable to
maintain a temperature of 37 oC with a normal room
temperature and normal wrapping/clothing.
• Lethargy or poor feeding. In general, babies,
particularly those who are breastfeeding, will not get
very large volumes of colostrum in the first 24 hours
after birth, however they should show an interest in
feeding, be able to attach to the breast and have a
sucking reflex.
• Unexplained bradycardia (heart rate <100/min) or
tachycardia (heart rate >180/bpm) and any apnoea
or episodes of cyanosis.
• Increased respiratory rate or signs of respiratory
distress.
• Irritability, abnormal movements.
• Skin mottling, rashes, prolonged capillary refill time.
If bacterial infection is suspected then antibiotics should
be commenced and investigations performed (often
referred to by neonatologists as a ‘septic screen’). Antibiot-
ics are generally given until blood and cerebrospinal fluid
(CSF) cultures have confirmed no growth of pathogenic
organisms (usually 36–48 hours). The investigations per-
formed are usually:
• blood culture
• full blood cell count and blood film
• C-reactive protein measurement
• lumbar puncture for examination and culture of CSF.
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Chapter | 33 |
Treatment of infection and management
of babies with risk of infection
The overall aim is to reduce the risk of septicaemia and
life-threatening septic shock in this vulnerable group. Bac-
terial infections are an important cause of neonatal mor-
bidity and mortality. The two commonest organisms in
the newborn are group B streptococcus (GBS) and
Escherichia (E.) coli, which are both organisms the baby
may come into contact with via the maternal birth canal.
Risk factors for early onset neonatal infection include the
following (Oddie and Embleton 2002; Ungerer et al 2004;
Royal College of Obstetricians and Gynaecologists [RCOG]
2012):
• maternal intrapartum fever
• prolonged rupture of membranes greater than
18 hours
• prematurity less than 37 weeks
• maternal genital tract colonization with GBS
• previous baby with GBS disease.
These factors are therefore used in the UK to decide which
babies should receive antibiotics based on a risk-based
approach. In high-risk pregnancies, early onset neonatal
GBS infection can be reduced with antibiotics during
labour (Law et al 2005). Similarly, antibiotic use for
preterm rupture of membranes is associated with reduced
neonatal morbidity (Kenyon et al 2010). Generally there-
fore risk factors should be identified before labour so that,
if possible, intrapartum antibiotics should be given at least
4 hours prior to birth to obtain maximal antibiotic con-
centration in the amniotic fluid (Pylipow et al 1994).
There is, however, also some evidence that suggests
2 hours may be adequate (de Cueto et al 1998). In babies
with more than one risk factor, observation or treatment
with antibiotics after birth can be considered.
The age of presentation of early onset GBS varies
between studies. In a prospective UK study, when intrapar-
tum antibiotics were not given, 50% of babies with early
onset GBS presented by 1 hour of age, 72% by 24 hours
and 92% by 48 hours (Oddie and Embleton 2002). Brom­
berger et al (2000), in a retrospective study, found that
95% of term babies with early onset GBS presented within
the first 24 hours of life. Additionally, intrapartum antibi-
otics did not alter the constellation and timing of onset of
clinical signs of early onset GBS. Therefore if babies are
well by 12 hours of age they are unlikely to develop early
onset disease.
Group B streptococcus (GBS) infection
It is estimated that about one in 2000 babies born in the
UK and Ireland develop early onset GBS infection. This
means that every year in the UK (with 680 000 births a
year) around 340 babies will develop early onset GBS
infection. GBS is recognized as the most frequent cause of
sepsis in the newborn (Oddie and Embleton 2002; Heath
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Section | 6 | The Neonate
et al 2004). A survey by the Public Health Laboratory
Service (PHLS) GBS Working Group during a 13-month
period in 2000 and 2001 identified a total of 568 cases of
invasive GBS disease (early and late onset) in the UK and
Republic of Ireland (Heath et al 2004). This is equivalent
to a total incidence of 0.72 per 1000 live births; the inci-
dence for early onset disease (n = 377) was 0.48 per 1000
live births and for late onset disease (n = 191) was 0.24 per
1000 live births. Overall mortality of the disease was 9.7%
(n = 53): 10.6% (n = 38) early onset and 8% (n = 15) late
onset.
One-third of the population carry GBS in the gut and
over 20% of women have vaginal colonization (Barcaite
et al 2008). In the United States of America (USA),
Australia and several European countries, screening of
pregnant women is used with treatment with antibiotics
during labour, which is effective at reducing the incidence
of early onset GBS. This approach, however, has not been
shown in trials to reduce the risk of death or long-term
harm from GBS; its introduction in the UK has been hotly
debated but the introduction of screening has not been
recommended (United Kingdom National Screening
Committee [UKNSC], 2012). The current UK recommen-
dations (RCOG 2012; UKNSC 2012) are therefore based
on a risk factor approach described above, whereby intra-
partum antibiotic prophylaxis (IAP) is offered to all
women with recognized risk factors for early onset GBS
disease. Mathematical modelling in the USA suggests that
this approach will result in approximately 25% of women
being offered IAP with a decrease in the incidence of early
onset GBS disease of 50.0–68.8% (RCOG 2012). UK data
suggest that approximately 16% of pregnancies will have
one or more risk factors for early onset GBS disease and
approximately 60% of early onset GBS cases will have a
risk factor (Oddie and Embleton 2002; RCOG 2012).
Meningitis
Neonatal meningitis is an inflammation of the mem-
branes covering the brain and spinal column caused by
such organisms as GBS, E. coli, Listeria monocytogenes and,
less often, Candida and herpes. In the UK, neonatal men-
ingitis is most often caused by GBS (Law et al 2005). In
Australia and New Zealand, the incidence of GBS early
onset neonatal bacterial meningitis decreased significantly
between 1993 and 2002, while the incidence of E. coli
meningitis remained the same (May et al 2005).
Very early signs are often non-specific, followed by those
of meningeal irritation and raised intracranial pressure
such as crying, irritability, bulging anterior fontanelle,
increasing lethargy, tremors, twitching, severe vomiting,
diminished muscle tone and alterations in consciousness.
Babies may also present with abnormal neurological signs.
Early diagnosis and treatment are critical to prevent col-
lapse and death. Diagnosis may be confirmed by examina-
tion of CSF. Very ill babies require intensive care,
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intravenous fluids and antibiotic therapy. Although acute
phase mortality has declined in recent years, long-term
neurological complications still occur in many surviving
babies. De Louvois et al (2005) report that in one group
aged 5 years, 23% had a serious disability, with isolation
of bacteria from CSF the best single predictor. For such
babies, long-term comprehensive developmental assess-
ment is essential, including audiometry and vision testing.
Viral infections acquired before
or during birth
Rubella and varicella (chickenpox) can be major causes
of fetal morbidity and mortality, as can the protozoa
toxoplasmosis. Infections may be acquired through the
placenta, from amniotic fluid, or the birth canal. For man-
agement of sexually transmissible and reproductive tract
infections see Chapter 13. The acronym TORCH is often
used for congenital infections:
• Toxoplasmosis
• Other (includes syphilis)
• Rubella
• Cytomegalovirus
• Hepatitis/HIV
All of these may cause significant illness in the newborn.
Rubella
For most immunocompetent children and adults (includ-
ing pregnant women), the rubella virus causes a mild,
insignificant illness spread by droplet infection. Congeni-
tal rubella syndrome (CRS) in the newborn however
remains a major cause of developmental anomalies that
include blindness and deafness (Banatvala and Brown
2004). Maternal rubella is now rare in many countries as
a result of successful rubella vaccination programmes
(Robinson et al 2006). In most industrialized countries
the measles, mumps and rubella (MMR) vaccine has sig-
nificantly reduced the incidence of rubella (Wright and
Polack 2006), although in recent years in the UK and some
other countries, vaccination rates have declined due to
press scare stories that have resulted in a lower uptake of
the vaccine. It is feared this may result in a rise in the in-
cidence. Countries without routine MMR programmes
report rates similar to those of industrialized countries
before vaccination became available (Banatvala and
Brown 2004). Midwives need to emphasize the impor-
tance of avoiding contact with rubella during pregnancy,
as reinfection has been reported despite previous vaccina-
tion. As part of their extended public health role, midwives
can encourage vaccination for seronegative women before
and after – but not during – pregnancy, and also discuss
the importance of vaccinating their child. Generally indi-
viduals will only be infected with rubella once during their
lifetime as they then develop an antibody response.
 Significant problems in the newborn baby
Primary rubella infection is most likely to cause problems
if it is acquired in the first 12 weeks of pregnancy and in
this situation maternal–fetal transmission rates are as high
as 85%. Intrauterine infection is unlikely when the mo­
ther’s rash appears before, or within 11 days after the last
menstrual period, and with proven infection later than the
16th week, the risk of severe fetal sequelae is much lower
(Enders et al 1988). First trimester infection can result in
spontaneous abortion and in surviving babies, a number
of serious and permanent consequences. These include
cataracts, sensorineural deafness, congenital heart defects,
microcephaly, meningoencephalitis, dermal erythropoi­
esis, thrombocytopenia and significant developmental
delay (Banatvala and Brown 2004; Bedford and Tookey
2006).
Diagnosis and treatment
Congenital rubella can be recognized when there has been
a maternal history of infection during pregnancy, or as a
result of anomalies detected in the fetus or the newborn.
All women have screening for rubella titres at booking
in the UK. Those with negative titres cannot be offered
immunization during pregnancy but can be offered it after
pregnancy. They should also avoid contact with anyone
known to have the illness during pregnancy. If there is any
contact then rubella titres should be measured with
increased surveillance of the fetus. Most women with first
trimester infection may request termination of pregnancy.
Babies with CRS are highly infectious and should be iso-
lated from other babies and pregnant women (but not
their own mothers). Long-term follow-up is essential, as
some problems may not become apparent until the baby
is older.
Varicella zoster
Varicella zoster virus (VZV) is a highly contagious virus of
the herpes family that causes varicella (chickenpox).
Transmitted by respiratory droplets and contact with
vesicle fluid, it has an incubation period of 10–20 days and
is infectious for 48 hours before the rash appears until
vesicles crust over. After primary infection the virus remains
dormant in the sensory nerve root ganglia and with any
recurrent infection can result in herpes zoster (shingles).
Primary infection during pregnancy can result in serious
adverse outcomes (Meyberg-Solomayer et al 2006).
Incidence and effects during pregnancy
Fetal effects vary with gestation at the time of maternal
infection. During the first 20 weeks of pregnancy the baby
has about a 2% risk of fetal varicella syndrome (FVS).
Signs can include skin lesions and scarring, eye problems,
such as chorioretinitis and cataracts. Skeletal anomalies
include limb hypoplasia. Severe neurological problems
may include encephalitis, microcephaly and significant
developmental delay. About 30% of babies born with skin
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Chapter | 33 |
lesions die in the first months of life. From 20 weeks’ gesta-
tion up to almost the time of birth, infection can result in
milder forms of neonatal varicella that do not result in
negative sequelae for the neonate. The child may have
shingles during the first few years of life. Maternal infec-
tion after 36 weeks, and particularly in the week before the
birth (when cord blood VZV IgG is low) to 2 days after,
can result in infection rates of up to 50%. About 25% of
those infected will develop neonatal clinical varicella.
Most affected babies will develop a vesicular rash and
about 30% will die. Other complications of neonatal vari-
cella include pneumonia, pyoderma and hepatitis.
Diagnosis and treatment
Diagnosis can be made if there has been a recent history
of maternal chickenpox, and polymerase chain reaction
(PCR) to identify VZV in amniotic fluid. Antenatal ultra-
sound may confirm the effects of fetal varicella syndrome,
e.g. limb contractures and deformities, cerebral anomalies,
borderline ventriculomegaly, intracerebral, intrahepatic
and myocardial calcifications, articular effusions and intra-
uterine growth restriction (IUGR) (Degani 2006; Meyberg-
Solomayer et al 2006).
Most pregnant women with chickenpox will need a
great deal of information and support. Women infected
during the first 20 weeks may request termination of preg-
nancy. Although mother and baby should be isolated from
others, they should always be kept together. Varicella
zoster immune globulin (VZIG) can be offered to sero­
negative pregnant women who are exposed to chickenpox,
within 72 hours of contact, and always within 10 days.
VZIG should also be offered to a baby whose mother
develops chickenpox between 7 days before and 28 days
after the birth, or whose siblings at home have chickenpox
(if the mother is seronegative). Although no clinical trials
have shown that antiviral chemotherapy prevents fetal
infection, the antiviral drug acyclovir may reduce the mor-
tality and risk of severe disease in some groups, particu-
larly if VZIG is not available. These include pregnant
women with severe complications, and newborns if they
are unwell or have added risk factors such as prematurity
or corticosteroid therapy (Sauerbrei & Wutzler 2000;
Hayakawa et al 2003).
Toxoplasmosis
Toxoplasmosis is caused by Toxoplasma gondii (T. gondii), a
protozoan parasite infecting up to a third of the world’s
population. It is found in uncooked meat, cat and dog
faeces. Primary infection can be asymptomatic, or charac-
terized by malaise, lymphadenopathy and ocular disease.
Primary infection during pregnancy can cause severe
damage to the fetus (Montoya and Liesenfeld 2004).
Childhood-acquired infection also causes half of toxo-
plasma ocular disease in UK and Irish children (Gilbert
et al 2006).
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Incidence and effects during pregnancy include bottle use during the first 2 weeks, the presence
of siblings (Morrill et al 2005) and antibiotic exposure
Risks for the infected fetus can include intrauterine death,
(Dinsmoor et al 2005). Breastfeeding women may also
low birth weight, enlarged liver and spleen, jaundice,
have infected breasts, with flaky or shiny skin of the
anaemia, intracranial calcifications, hydrocephalus, retino-
nipple/areola, sore, red nipples and persistent burning,
choroidal and macular lesions. Infected neonates may be
itching or stabbing pain in the breasts (Chapter 34). Risk
asymptomatic at birth, but can develop retinal and neuro-
factors for maternal thrush include bottle use in the first
logical disease. Those with subclinical disease at birth can
2 weeks after the birth, pregnancy duration of >40 weeks
develop seizures, cognitive and motor problems and
(Morrill et al 2005), and intrapartum antibiotic use (Dins­
reduced cognitive function over time (Gilbert et al 2006;
moor et al 2005).
Schmidt et al 2006; Systematic Review on Congenital Toxo-
Accurate diagnosis and treatment of thrush is important
plasmosis [SYROCOT] Group 2007). In one group of 38
for continued breastfeeding. Morrill et al (2005) found
children with confirmed toxoplasma infection, 58% had
only 43% of women with thrush 2 weeks after the birth
congenital infection. Of these, 9% were stillborn while 32%
were breastfeeding at 9 weeks, compared with 69% of
of the live births had intracranial abnormalities and/or
women without.
developmental delay, and 45% had retinochoroiditis with
Cutaneous candidiasis often co-exists with oral thrush
no other abnormalities. Of the 42% of children infected
and presents as a moist papular or vesicular skin rash,
after birth, all had retinochoroiditis (Gilbert et al 2006).
usually in the region of the axillae, neck, perineum or
The effectiveness of antenatal treatment in reducing the
umbilicus. Although it is usually benign, recognition and
congenital transmission of T. gondii is not proven. A meta-
treatment is important in preventing problems (Smolinski
analysis of 1438 treated mothers (26 cohorts) also
et al 2005). Management includes keeping the area dry
found no evidence that antenatal treatment significantly
and applying topical nystatin. In preterm babies the thin
reduced the risk of clinical signs (SYROCOT 2007).
cutaneous barrier, invasive procedures and immune
Babies with congenital toxoplasmosis are usually treated
system immaturity may contribute to the early onset of
with pyrimethamine, sulfadiazine and folinic acid for an
systemic Candida infection. Antifungal prophylaxis may be
extended period (Montoya and Liesenfeld 2004; Schmidt
used to prevent systemic Candida colonization. Systemic
et al 2006).
candidiasis in a preterm baby is a serious problem and
requires a prolonged course of treatment with intravenous
Prevention antifungal medication. It is associated with significant
morbidity and mortality.
Midwives have an essential role in prevention as health
education can result in a 92% reduction in pregnancy
seroconversion. Breugelmans et al (2004) found the most Significant eye infections
effective strategy was a leaflet explaining toxoplasmosis
Eye infection caused by Chlamydia or Gonococcus will
and how to avoid the condition during pregnancy, with
present with a red sore eye with a large amount of purulent
this information reinforced in antenatal classes. In the UK,
discharge, usually after the first week after birth. Ophthal-
NHS Choices (2013) website provides useful information,
mia neonatorum is defined in England as any purulent eye
as well as the Toxoplasmosis Trust for women, their fami-
discharge within 21 days of birth, and in Scotland as eye
lies and healthcare professionals. Appropriate information
inflammation within 21 days of birth accompanied by a
includes advising women about washing kitchen surfaces
discharge. A swab must be taken for culture and sensitivity
following contact with uncooked meats, stringent hand-
testing, with immediate medical referral. Identification of
washing and avoiding cat and dog faeces.
the organism responsible is essential as chlamydial and
gonococcal infections can cause conjunctival scarring,
Candida corneal infiltration, blindness and systemic spread. Treat-
ment includes local cleaning and care of the eyes with
Candida is a Gram-positive yeast fungus with a number of normal saline, and appropriate drug therapy for the baby
strains (see Chapter 13). Candida (C.) albicans is responsi- and mother if required.
ble for most fungal infections, including thrush in babies.
Infection can affect the mouth (oral candidiasis), skin
(cutaneous candidiasis) particularly the nappy area and
internal organs (systemic candidiasis). Oral candidiasis is RESPIRATORY PROBLEMS
a common mild illness that may present as white patches
on the baby’s gums, palate or tongue. It can be acquired There are several important causes of respiratory distress
during birth or from caregivers’ hands or feeding equip- in the newborn, which are not always easy to distinguish.
ment. Raw areas (removed by sucking) on the edge of the The commonest are infection, transient tachypnoea of the
baby’s tongue can assist diagnosis. Risk factors for thrush newborn (TTN) and surfactant-deficient lung disease of

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 Significant problems in the newborn baby
prematurity. The latter (also named hyaline membrane
disease in the past) is confusingly called respiratory dis-
tress syndrome (RDS), but this is just one possible cause
of respiratory distress in newborn babies.
Initial management of babies
presenting with respiratory distress
Babies who are unwell should be assessed in a good light,
ideally on a resuscitaire if available so that oxygen and
airway support can be given if necessary. If a baby shows
any of the signs of respiratory distress after birth he/she
should be closely observed. In general any baby who has
a respiratory rate >80/min and central cyanosis should be
reviewed urgently. In distinguishing the cause and impor-
tance of clinical signs, the history of the pregnancy and
birth are clearly important. Relevant factors are:
• gestation
• meconium in amniotic fluid
• mode of birth (caesarean section vs vaginal)
• high vaginal swabs during pregnancy
• antenatal scans.
Observe for:
• the respiratory rate, heart rate, work of breathing,
colour
• the colour for cyanosis and skin perfusion, pallor,
mottled or white
• the baby’s level of activity and tone
• whether the baby has been able to feed – babies
with significant respiratory distress will not feed and
should not be allowed to feed
• apnoea, and listen for heart rate. Proceed as for
resuscitation at birth (see Chapter 29).
If the baby is breathing:
• position the airway with the head in a neutral
position and if necessary use a jaw thrust to help
keep the airway patent
• avoid suction unless the baby clearly has fluid
(blood/vomit) obstructing the upper airway
• give air/oxygen via a face mask if the baby is initially
cyanosed
• liaise with the neonatal medical team with regard to
further intervention
• consider admission to a NICU for further
investigations and intervention if a significant
respiratory distress persists.
Possible causes of respiratory
distress in the newborn
Infection (particularly GBS)
All newborn babies presenting with features of respiratory
distress should be treated with IV antibiotics until infec-
tion is excluded as this may be the only presenting feature
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Chapter | 33 |
and it can be very difficult to distinguish from other causes
of respiratory distress. A number of infectious disease
processes present with signs of respiratory distress in the
newborn. All babies presenting with respiratory distress
need to be treated for infection until there is proof to the
contrary.
Meconium aspiration syndrome
Meconium in the amniotic fluid is common and usually
does not require treatment or intervention if the baby is
in good condition at birth and shows no signs of respira-
tory distress. Meconium aspiration occurs because
hypoxia-ischaemia causes the fetus to pass meconium into
the amniotic fluid. This meconium is generally unprob-
lematic unless the baby gasps or breathes in the meco-
nium. Gasping respiration may also occur as a result of
hypoxia-ischaemia. Consequently, it is the baby showing signs
of fetal hypoxia which develops meconium aspiration syndrome.
Greenough and Milner (2012) report the incidence for
meconium aspiration syndrome in one UK hospital as
0.2/1000 live births; however, this incidence is low and
other countries, such as the USA, have higher disease rates
of 2–5/1000 (Greenough and Milner 2012). The initial
respiratory distress may be mild, moderate or severe with
a gradual deterioration over the first 12–24 hours in mod-
erate or severe cases. The baby may present with cyanosis,
increased work of breathing and a barrel-shaped chest.
This chest appearance occurs as a result of air trapping,
leading to hyperexpansion of the lungs. The meconium
can become trapped in the airways and cause a ball-valve
effect: air can enter the lung during inhalation, the meco-
nium then blocks the airway during expiration so that air
accumulates behind the blockage. This accumulation can
then lead to the rupture of the alveoli and cause the baby
to develop a pneumothorax. Where the meconium has
contact with the lung tissue a chemical pneumonitis
occurs and there is a risk of super-added infection. Endo­
genous surfactant is also broken down in the presence of
meconium.
These babies may need intensive care and ventilation to
prevent further deterioration. Modalities such as nitric
oxide (Finer and Barrington 2006) are of benefit in reduc-
ing death or the need for extracorporeal membrane oxy-
genation (ECMO) in some babies. ECMO has been shown
to increase survival by 50% (UK Collaborative ECMO Trial
Group 1996). A number of the most severely affected
babies will have signs of respiratory distress for some
months, with ongoing residual respiratory problems
during early childhood.
Transient tachypnoea of the newborn (TTN)
The recorded incidence of TTN varies widely, partly as a
result of the variety of recording methods, differences in
radiological interpretation and clear diagnostic features. It
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is frequently seen as a diagnosis of exclusion of other pos-
sible respiratory causes. Nevertheless, babies present with
mild to moderate signs of respiratory distress and usually
require admission to the NICU for further observation.
Supplemental oxygen may be required, however the con-
dition gradually resolves during the 24 hours following
birth. The chest X-ray may show a streaky appearance with
fluid in the horizontal fissure of the right lung that con-
firms the diagnosis, but sometimes it is only the clinical
course that distinguishes between this, respiratory distress
syndrome (RDS) and infection. The lungs are completely
fluid-filled before birth and most of this is squeezed out
through chest compression, the rest is absorbed via the
lymphatic system. Babies born by elective caesarean
section are at increased risk because the thorax has not
been squeezed while the baby descends into the vagina.
Being born this way appears to increase the risk of respira-
tory morbidity by approximately six times. In addition,
birth at each week below 39 weeks approximately doubles
the risk (Morrison et al 1995). Although these babies tend
to require initial care on a NICU, their stay is usually of
a short duration with the provision of oxygen and
observation.
Respiratory distress syndrome (RDS)
RDS is generally a condition that affects preterm babies,
however it can also occur in those born at term as other
disorders like maternal diabetes can also inhibit surfactant
production. Approximately 50% of babies born before 30
weeks’ gestation develop RDS while 1% of all newborn
babies may develop the condition (Greenough and Milner
2012). Surfactant is made up of phospholipids and pro-
teins and is produced by the type II pneumocytes to reduce
the surface tension within the alveoli, preventing their
collapse at the end of exhalation. Collapsed alveoli require
much greater pressures and exertion to re-inflate them
compared to partially collapsed alveoli. The introduction
of surfactant therapy into neonatal care during the 1980s
and 1990s, combined with much wider use of antenatal
steroids in the 1990s, significantly decreased the mortality
and morbidity previously seen in RDS.
In preterm babies with RDS the clinical picture is of a
baby with progressive respiratory distress developing over
the first hours. The X-ray typically has a homogenous
ground-glass appearance (indicating poorly aerated
alveoli) with air bronchograms (black air-filled bronchi
seen against white airless alveoli), although this may be
less obvious if the baby has already received exogenous
surfactant. Babies with RDS experience increasing respira-
tory distress and work of breathing. It may take 48–72
hours to reach the peak of the disease without the admin-
istration of exogenous surfactant. Resolution of the associ-
ated inflammation and the hyaline membrane formation
may take up to 7 days in the unsupported baby. In
extremely preterm babies surfactant is often given on the
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labour suite at birth, although alternative approaches
using continuous positive airways pressure (CPAP) can
also be used (Morley et al 2008; SUPPORT 2010). Exogen­
ous surfactant can be given as ‘rescue treatment’ if the baby
develops significant early signs.
Pneumothorax
Pneumothoraces may occur spontaneously in 1% of the
newborn population either during or after birth; however,
only one-tenth will be seen (Steele et al 1971). A pneu-
mothorax at birth may be caused by the large pressures
generated by the baby’s first breaths, which may be in the
range of 40–80 cmH2O. This can lead to alveoli distension
and rupture that allows air to leak to a number of sites,
most notably the potential space between the lung pleura.
Babies receiving any assisted ventilation have an increased
susceptibility to a pneumothorax. This could be due to
either maldistribution of the ventilated gas in the lungs,
high ventilation settings or baby-ventilator breathing
interactions. Spontaneous pneumothorax can occur in
otherwise healthy term babies. They may present with
signs of respiratory distress on the postnatal ward.
Although it is difficult to diagnose a pneumothorax in the
absence of a chest X-ray, there may be reduced breath
sounds on the affected side, displaced heart sounds and a
distorted chest/diaphragm movement. A baby with a sus-
pected pneumothorax will need closer observation and
may need intervention with a chest drain, although many
spontaneously breathing term babies can be managed
without a chest drain as long as they are closely observed.
Most pneumothoraces will resolve spontaneously.
Congenital diaphragmatic hernia (CDH)
CDH has an incidence of 3.5/1000 live births. It is an
important condition because despite improvements in
neonatal care reported, mortality rates remain high
(Wright et al 2010). Most babies with a diaphragmatic
hernia have a prenatal diagnosis, usually made at the 20th
week anomaly scan; in some babies, however, the diagno-
sis is not made until after birth. In babies where there is
a prenatal diagnosis most neonatologists manage these
babies with immediate intubation, insertion of a large
bore nasogastric (NG) tube to decompress the stomach
and bowel and early sedation/muscle relaxation. This
allows optimal ventilation as early as possible to try to
allow the underdeveloped lungs to expand and to try to
prevent significant problems with persistent pulmonary
hypertension and continual right-to-left shunting of blood
through the foramen ovale and ductus arteriosus. Inten-
sive care is difficult in these babies and the priorities are
to maintain good ventilation and perfusion to avoid
hypoxia. A surgical repair of the diaphragm will usually be
performed at 2–7 days after birth. In all babies presenting
with respiratory distress a chest X-ray is important to look
 Significant problems in the newborn baby
for the cause, and one of the possibilities that can be rec-
ognized is a CDH. Babies with this condition typically
have unilateral chest movement, heart sounds and an apex
beat on the right side (in the case of left-sided CDH, which
is more common) and a scaphoid abdomen. Babies with
a postnatal diagnosis of CDH have a much better progno-
sis, with greater expected survival rates (van den Hout et al
2010).
Upper airway obstruction and stridor
Upper airway obstruction in the newborn is uncommon
but is characterized by noisy breathing on inspiration,
different to grunting, which is an expiratory noise. The
importance is that obstruction to the upper airway signifi-
cantly increases the work of breathing for a newborn, and
in the short term, in the most severe cases, this could lead
to respiratory arrest. Babies with stridor therefore always
need neonatal medical assessment. It is important to
assess the degree of respiratory distress and assess whether
the baby is managing to breathe comfortably despite the
stridor. There are many possible causes, the commonest
being laryngomalacia, which tends not to cause significant
respiratory distress but the work of breathing may increase
when the baby is placed on his/her back. External com-
pression of the trachea is a serious condition, so any baby
with stridor must always be carefully assessed by a
neonatologist.
CONGENITAL HEART DISEASE (CHD)
CHD (moderate or severe) occurs in 6/1000 live births but
only 25% show signs in the neonatal period (Fyler 1980).
Early diagnosis is extremely important for some condi-
tions and it is vital that newborn babies are examined
carefully to look for signs of CHD (see Chapter 28). There
are a number of ways that CHD may present in the
newborn period and these give some clues as to the under-
lying anatomical diagnosis:
• prenatal diagnosis on antenatal scan
• associated with a syndrome or other congenital
problems, e.g. Down syndrome
• asymptomatic murmur
• cyanosis
• sudden collapse
• heart failure.
Management of a baby with an
antenatal diagnosis of CHD
In a baby where an antenatal diagnosis of CHD has been
made, early intervention may be required depending on
the type of lesion. Usually an antenatal plan of postnatal
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Chapter | 33 |
care will have been made and should be available to those
providing postnatal care. For some types of serious con-
genital malformations (transposition of the great arteries,
pulmonary atresia [with or without VSD], Fallot’s tetral-
ogy, coarctation of the aorta, hypoplastic left heart syn-
drome) these will involve giving a prostaglandin infusion
to maintain patency of the ductus arteriosus. Wherever the
baby is born, immediate stabilization and transfer to a
cardiology centre will be required. Some types of CHD do
not need intervention, but the baby will need follow-up
with a cardiologist.
Care of a baby with a murmur
Babies who are detected to have an asymptomatic heart
murmur on their newborn check (see Chapter 28) should
be carefully evaluated by having a careful examination to
look for other signs of cardiac disease. Oxygen saturation
measurement using a pulse oximeter shows normal values
>96%. Be aware that babies with a saturation of 85% often
do not look cyanosed on visual inspection, so measuring the
saturation of oxygen on haemoglobin is an effective way
of assessing the baby’s respiratory and cardiac status and
represents good practice. Measuring pre- and post-ductal
saturations can be useful alongside measuring the blood
pressure in all four limbs to look for signs of coarctation
of the aorta (lower pressures in lower limbs). All babies
with a cardiac murmur should be evaluated by a neona-
tologist and local guidelines are usually in place for appro-
priate cardiac referral.
JAUNDICE
Jaundice is one of the most common conditions needing
medical attention in newborn babies. Jaundice refers to
the yellow coloration of the skin and the sclera caused by
a raised level of bilirubin in the circulation (hyperbilirubi-
naemia). Approximately 60% of term and 80% of preterm
babies develop jaundice in the first week after birth, and
about 10% of exclusively breastfed babies are still jaun-
diced at one month of age. In most babies early jaundice
is harmless. However, a few babies will develop very high
levels of bilirubin, which can be harmful if not treated.
Clinical recognition and assessment of jaundice can be
difficult, particularly in babies with dark skin tones. Once
jaundice is recognized, there is uncertainty about when to
treat, and there is widespread variation in the use of pho-
totherapy and exchange transfusion. In the UK a national
guideline produced by the National Institute for Health
and Clinical Excellence (NICE 2010) has tried to standard-
ize monitoring and treatment and similar guidelines exist
in other countries (American Academy of Paediatrics
[AAP] 2004).
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Bilirubin physiology broken down in the reticuloendothelial system (liver,

spleen and macrophages). Haemoglobin from these cells
In order to understand when jaundice is important and is broken down into the byproducts of haem, globin and
why the fat soluble, unconjugated bilirubin concentration iron. Haem is converted to biliverdin and then to uncon-
might be raised, it is important to understand its metabo- jugated bilirubin. Globin is broken down into amino
lism. Bilirubin is produced as one of the breakdown prod- acids, which are used by the body to make proteins. Iron
ucts of haemoglobin (Fig. 33.2A,B). Ageing, immature or is stored in the body or used for new red blood cells. The
malformed red cells are removed from the circulation and unconjugated bilirubin is then transported to the liver.
Once in the liver, unconjugated bilirubin is detached from
albumin, combined with glucose and glucuronic acid
Physiological change in bilirubin concentration after birth
and conjugation occurs using the enzyme uridine diphos-
300 phoglucuronyl transferase (UDP-GT). The conjugated
Bilirubin cencentration (µmol/l)

bilirubin is now water-soluble and available for excretion.

250
Conjugated bilirubin is excreted via the biliary system into
200 the small intestine where normal bacteria change the con-
jugated bilirubin into urobilinogen. This is then oxidized
150 into orange-coloured urobilin. Most is excreted in the
100 faeces, with a small amount excreted in urine (Ahlfors and
Wennberg 2004; Kaplan et al 2005).
50

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Physiological jaundice
A Days after birth All newborn babies have a rise in unconjugated bilirubin
during the first few days after birth. This occurs for several
Red blood cells
Broken reasons:
down to • The turnover of haemoglobin is high in the fetus
Haem + globin
and newborn but before birth the bilirubin from the
fetus is removed via the placenta.
• At birth, as the more efficient lungs increase oxygen
levels, there is haemolysis of excessive RBCs that are
Excessive production
now not needed.
of haem leads to high
bilirubin levels • At birth the newborn liver enzymes systems may be
immature and not as effective.
Bilirubin
As a result of these factors there is a rise in serum uncon-
jugated bilirubin in healthy babies during the first few
Liver days after birth and this physiological jaundice follows a
characteristic pattern (see Fig. 33.3). Typically, babies on
Conjugated to glucuronic Conjugated the first day after birth will not appear jaundiced but most
acid in hepatocytes bilirubin babies will look yellow by day 3–4. As unconjugated
bilirubin levels rise, the serum albumin becomes saturated
and then any excesses spills over into the blood plasma.
95% of bile salts reabsorbed
10% of urobilirubin Unconjugated bilirubin is fat-soluble and will deposit in

Conjugated
Total serum bilirubin (µmol/l)

bilirubin 500 Exchange transfusion

Portal vein 400 Phototherapy
Small bowel
300
5% of bile salts excreted
Urobilirubin 200
90% of urobilirubin
100
B 0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Fig. 33.2 Bilirubin pathway. (A) Physiological change in Days after birth
bilirubin concentration after birth. (B) Production and
circulation of bilirubin. Fig. 33.3 Bilirubin chart.

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 Significant problems in the newborn baby
subcutaneous fat, which makes the skin look yellow. Once
these sites are saturated, the brain is the next target, par-
ticularly the basal ganglia. High levels of unconjugated
bilirubin can potentially be a serious problem because it
can cross the blood–brain barrier and be deposited in the
basal ganglia in the brain. This can cause a bilirubin
encephalopathy and in the longer term can result in cere­
bral palsy and learning difficulties. The cerebral palsy is
typically an athetoid type due to the site of the damage in
the brain. Kernicterus is the pathological (post mortem)
finding of bilirubin encephalopathy. Whilst bilirubin
encepalopathy is a serious complication it is rare because
of the decrease in incidence of Rhesus haemolytic disease
since the introduction of anti-D prophylaxis (Chapter 11)
and the use of other interventions to control high uncon-
jugated bilirubin levels in babies. In recent years, however,
there have been concerns that the incidence is increasing
again (Manning et al 2007) and midwives can play a
pivotal role in trying to prevent this devastating
complication.
Causes of concern in physiological jaundice
There are several situations where a midwife should be
concerned about jaundice in the newborn:
• Jaundice in the first 24 hours after birth.
• History of antibodies (which may cause RBC
haemolysis) identified on the maternal antibody
screen.
• Any baby who is visibly jaundiced. The serum
bilirubin (SBR) level should be checked as the visual
assessment of jaundice is not sufficiently accurate
(NICE 2010).
• Any baby who remains jaundiced beyond 14 days
of age.
Early physiological jaundice
(within first 5 days after birth)
Possible causes include:
• physiological jaundice
• haemolysis (Rhesus isoimmunization, ABO
incompatibility, other blood group antigen
problems)
• infection
• bruising
• polycythaemia
• dehydration (unlikely in the first 48 hours but must
be considered in babies presenting between 2–7 days
after birth, particularly those who are breast fed).
This is not an exhaustive list but these are the causes that
midwives will encounter on a daily basis. As a general rule,
haemolysis must always be considered when a baby is
jaundiced in the first 24 hours after birth.
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Chapter | 33 |
Assessment and diagnosis
of physiological jaundice
Two initial important questions are:
• Is the jaundice physiological due to the normal
process of breakdown of bilirubin or the presence of
another pathological process?
• Is the baby at risk of bilirubin encephalopathy?
Individual risk factors
The initial assessment of a baby should include identifying
risk factors for jaundice. These include any disease or dis-
order that increases bilirubin production, or alters the
transport or excretion of bilirubin. For example:
• birth trauma or evident bruising (increased
production of unconjugated bilirubin)
• family history of significant haemolytic disease or
jaundiced siblings
• maternal antibodies at booking
• evidence of infection
• prematurity
• timing of jaundice, for example, within the first 24
hours (suggesting haemolysis). Jaundice at 3–6 days
of age could be related to dehydration, particularly
in a breast-fed baby. Always take a feeding history
and check the baby’s weight when presenting at this
age to check hydration status. Even with significant
weight loss, exclude other causes too.
Physical assessment includes observation of the extent
of changes in skin and scleral colour, skin bruising or
cephalhaematoma (Chapter 31) and other clinical signs
such as lethargy and decreased eagerness to feed with
accompanying dehydration. Consider signs of infection
(temperature, vomiting, irritability or high-pitched cry).
Also observe for dark urine and light stools, which could
indicate intrahepatic or extrahepatic obstructive disease.
Laboratory investigations will always include SBR. If the
bilirubin level is high then the following investigations
should also be carried out:
• direct Coomb’s test (DCT) to detect presence of
maternal antibodies on baby’s red blood cells
• blood groups (baby and mother) and Rh type for
possible incompatibility
• haemoglobin concentration to assess anaemia/
polycythaemia
• conjugated bilirubin if there are any factors to
suggest conjugated hyperbilirubinaemia.
Management of physiological jaundice
If maternal antibodies were present on the booking screen,
the neonatal team should be informed and regular SBR
concentrations should be checked. These babies may need
early phototherapy. In the case of Rh-D antibodies and
some other blood group antigens with a high likelihood
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Section | 6 | The Neonate
of causing haemolysis, other interventions such as the use
of immunoglobulin or exchange transfusion are likely to
be needed, so many of these babies may need admission
to a NICU. Plotting the SBR concentration on a chart is
always useful to see how the level compares with photo-
therapy intervention and/or exchange transfusion inter-
ventions. An example of a bilirubin chart is shown in Fig.
33.3. The trend or change in bilirubin can also be assessed
from the chart as a guide to whether the level is rising too
quickly or is following a normal physiological pattern.
Treatment strategies for physiological jaundice include
phototherapy, immunoglobulin therapy and occasionally
exchange transfusion.
Phototherapy
The use of light therapy was first discovered by the observa-
tion in the 1950s at Rochford Hospital, Essex, that babies
cared for in sunlight became less jaundiced, as was
described by Dobbs and Cremer (1975). It works because
ultraviolent blue light (wavelength 420–448 nm) catalyses
the conversion of transbilirubin into the water-soluble
cis-bilirubin isomer. This can then be excreted via the
kidneys. Its use is based on SBR levels and the individual
condition of each baby and standardized charts are used
to guide treatment (NICE 2010). Commercially available
phototherapy systems include those delivering light via
fluorescent bulbs, halogen quartz lamps, light-emitting
diodes and fibreoptic mattresses (Stokowski 2006). Con-
ventional phototherapy systems use high intensity light
from conventional white and/or blue, blue–green and tur-
quoise fluorescent phototherapy lamps. Fibreoptic light
systems use a woven fibreoptic pad that delivers high
intensity light with no ultraviolet or infrared irradiation.
They can be used as bilibeds in especially adapted cots or
fitted around the chest and abdomen of the baby. These
systems may be more comfortable for babies and allow
easier accessibility and handling for parents.
Phototherapy is a very safe and effective treatment. Side-
effects are mild but can include hyperthermia because of
increased fluid loss and dehydration, damage to the retina
from the high intensity light, lethargy or irritability,
decreased eagerness to feed, loose stools, skin rashes and
skin burns and alterations in a baby’s state and neurobe-
havioural organization. Phototherapy may be intermittent
or continuous (Lau and Fung 1984) with mild/moderate
jaundice and has been described as being delivered at
home (Walls et al 2004), although babies need to be care-
fully selected for this approach and it is not suitable for
all. Babies receiving phototherapy should be nursed naked
in an incubator or cot with lid, a minimum of 40 cm from
the light. In addition phototherapy equipment should be
routinely checked for safety. The baby’s temperature
should be measured and recorded at least 4-hourly, more
frequently if unstable, and the baby should be turned
regularly to maximize exposed areas of skin. For overhead
fluorescent therapy the baby’s eyes should be shielded
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using Posey eye shields. If eye shields are used, these
should not be applied too tightly to avoid constriction to
the scalp and excessive pressure over eyes and they should
be removed regularly and the baby’s eyes inspected for
signs of infection. Application of topical creams or lotions
should be avoided as there is a risk of burns and blistering.
Particular attention should be paid to careful cleaning and
drying of the skin, especially if the stools are loose. The
baby should be assessed regularly for signs of dehydration
using as a measure urine output or frequency of wet
nappies. Consider not nursing babies on a white sheet
because of reflective glare. Parents should be informed of
the need for phototherapy and normal parental consent
obtained and contact encouraged for routine care. The
baby may not always have to receive continuous photo-
therapy and the phototherapy unit can be removed/
switched off during cares and feeds (for up to 30 minutes
in every 3 hour period is acceptable while on single
phototherapy). However, if the baby is requiring multiple
phototherapy this should not be interrupted.
Stopping phototherapy
The SBR should be measured at least every 6–12 hours
whilst phototherapy continues. It should be monitored
more frequently when the rate of rise is rapid. Photo-
therapy may be safely discontinued when the bilirubin is
50 µmol/l below the threshold. Repeat SBR measurement
is necessary 12–18 hours after ceasing phototherapy to
check for rebound hyperbilirubinaemia.
Immunoglobulin
Infusion of a set volume of pooled human immunoglobu-
lin is an effective treatment which may help to prevent the
need for an exchange transfusion (Gottstein and Cooke
2003). It is used with isoimmune haemolysis and may
help to mop up excessive antibodies, preventing a rapid
rise in bilirubin. It may help to prevent exchange transfu-
sions but may slightly increase the risk of needing a later
top-up transfusion but these are safer and less invasive.
Exchange transfusion
If the bilirubin level cannot be controlled with photo-
therapy and good hydration and the level exceeds recom-
mended limits (NICE 2010) an exchange transfusion is
performed to prevent the bilirubin level reaching levels
known to be linked to bilirubin encephalopathy. Exchange
transfusion carries significant risks and should always be
carried out in a neonatal intensive care unit (refer to indi-
vidual hospital guideline) with experienced operators.
Complications can result from the procedure and from
blood products. Babies with other medical problems are
more likely to have severe complications, such as hypo­
calcaemia and thrombocytopenia. It involves transfusing
a large volume of blood to the baby (double the baby’s
blood volume or 160 ml/kg) whilst removing blood from
 Significant problems in the newborn baby
the baby, usually via an umbilical venous catheter. This
process removes excess bilirubin and, if the cause is isoim-
munization, antibodies that may be causing the RBC
haemolysis. With haemolytic disease of the newborn sen-
sitized erythrocytes are replaced with blood that is com-
patible with both the mother’s and the baby’s serum.
Pathological jaundice
Haemolytic jaundice
As described above, jaundice within the first 24 hours after
birth is assumed to be due to haemolysis until proven
otherwise. Haemolysis is increased haemoglobin destruc-
tion in the fetus or newborn and has several causes, the
most important being blood group incompatibility. This
can occur due to various antibodies, but the most impor-
tant is caused by Rhesus (Rh-D) isoimmunization/
incompatibility. This occurs if blood cells from a
Rhesus-negative
mother Rhesus-positive
fetus
Fig. 33.4 Normal placenta with no communication between
maternal and fetal blood.
Rhesus-negative
mother Rhesus-positive
baby
Fig. 33.6 Maternal production of Rhesus antibodies
following introduction of Rhesus-positive blood.
Rhesus-negative Anti-Dlobin
nog
mother im u
m
Fig. 33.8 Anti-D immunoglobulin administered within
72 hours of birth or other sensitizing event.
Figs 33.4–33.9 Isoimmunization and its prevention.
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Chapter | 33 |
Rhesus-positive baby enter a Rhesus-negative mother’s
bloodstream. Her blood treats the D antigen on positive
blood cells as a foreign substance and produces antibod-
ies. These antibodies can then cross the placenta and
destroy fetal red blood cells (see Figs 33.4–33.9).
While other causes of increased haemolysis are impor-
tant, this condition is emphasized because of the mid-
wife’s critical role in the injection of anti-D immunoglobulin
(anti-D Ig). Without this anti-D prophylaxis, Rh-D isoim-
munization can cause severe haemolytic disease of the
newborn (HDN) with significant mortality and morbidity
(NICE 2010). With the effectiveness of anti-D prophylaxis,
antibodies against other blood groups are now more
common than anti-D (e.g. anti-A, anti-B and anti-Kell).
Although few antibodies to blood group antigens other
than those in the Rh system cause such severe haemolytic
disease of the newborn, some report mortality and mor-
bidity with antibodies other than anti-D. These include
anti-E haemolytic disease of the fetus or newborn (Joy
Rhesus-negative
mother Rhesus-positive
fetus
Fig. 33.5 Fetal cells enter maternal circulation through
‘break’ in ‘placental barrier’, e.g. at placental separation.
Rhesus-negative
mother Rhesus-positive
Isoimmunized fetus
Fig. 33.7 In a subsequent pregnancy maternal Rhesus
antibodies cross the placenta, resulting in haemolytic disease
of the newborn.
Rhesus-negative
Rhesus-negative red blood cells
mother
Rhesus-positive
red blood cells
Rhesus antibodies
Haemolysed Rhesus-positive
red blood cells
Fig. 33.9 Anti-D immunoglobulin has destroyed fetal
Rhesus-positive red cells and prevented isoimmunization.
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Section | 6 | The Neonate
et al 2005), and anti-Kell (van Dongen et al 2005). ABO
incompatibility can also occur and is the most frequent
cause of mild to moderate haemolysis in neonates.
Rh-D isoimmunization
Rh-D isoimmunization is commonest among Caucasians,
about 15% of whom are Rh-negative, compared with
3–5% of African and about 1% of Asian populations
(Bianchi et al 2005). Before the introduction of anti-D Ig
in 1969, Rh-D isoimmunization was a major cause of
perinatal mortality and morbidity. In England and Wales,
about 500 cases of Rh-D haemolytic disease of the fetus
and newborn still occur each year, resulting in 25–30
deaths and 15 children with major permanent develop-
mental problems (NICE 2010).
Causes of Rh-D isoimmunization
The placenta usually acts as a barrier to fetal blood enter-
ing the maternal circulation (Fig. 33.4). However, during
pregnancy or birth, fetomaternal haemorrhage (FMH) can
occur, when small amounts of fetal Rh-positive blood can
cross the placenta and enter the Rh-negative mother’s
blood (Fig. 33.5). The woman’s immune system produces
anti-D antibodies (Fig. 33.6). In subsequent pregnancies
these maternal antibodies can cross the placenta and
destroy the red cells of any Rh-positive fetus (Fig. 33.7).
Rh-D isoimmunization can result from any procedure or
incident where positive blood leaks across the placenta, or
from any other transfusion of Rh-positive blood (e.g.
blood or platelet transfusion or drug use). Haemolytic
disease of the fetus and newborn caused by Rh-D isoim-
munization can occur during the first pregnancy. However,
in most cases sensitization during the first pregnancy
or birth leads to extensive destruction of fetal red blood
cells during subsequent pregnancies (Finning et al 2004;
Bianchi et al 2005; Geifman-Holtzman et al 2006;
NICE 2010).
Prevention of Rh-D isoimmunization
Most cases of Rh-D isoimmunization can be prevented by
injecting anti-D Ig within 72 hours of birth or any other
sensitizing event (Fig. 33.8). Anti-D Ig is a human plasma-
based product that is used to prevent women producing
anti-D antibodies. Anti-D Ig is of value to women with
non-sensitized Rh-negative blood who have a baby with
Rh-positive blood type (Fig. 33.9). It is not used when
anti-D antibodies are already present in maternal blood. As
well, anti-D Ig does not protect against the development
of other antibodies that cause haemolytic disease of the
newborn.
Routine prophylaxis
In the UK since 2002 (and some other countries), routine
antenatal anti-D prophylaxis at 28 and 34 weeks’ gestation
is recommended for all non-sensitized Rh-negative women
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(NICE 2008). With postnatal anti-D Ig prophylaxis, about
1.5% of Rh-negative women still develop anti-D antibod-
ies following a first Rh-positive pregnancy. A meta-analysis
(Allaby et al 1999) and Cochrane Review (Crowther et al
2013) suggest the antenatal sensitization rate is further
reduced by routine antenatal prophylaxis. Antenatal
prophylaxis should always be given following possible
sensitization events such as spontaneous miscarriage
before 12 weeks, any threatened, complete, incomplete or
missed abortion after 12 weeks of pregnancy, termination
of pregnancy by surgical or medical methods regardless of
gestational age, fetal death in utero or stillbirth, ectopic
pregnancy or amniocentesis, cordocentesis, chorionic
villus sampling, fetal blood sampling or other invasive
intrauterine procedure such as shunt insertion. In addi-
tion, postnatal prophylaxis should be given. A systematic
review of six eligible trials of more than 10 000 women
found when given within 72 hours of birth (and other
antenatal sensitizing events), anti-D Ig lowered the inci-
dence of Rh isoimmunization 6 months after birth and in
a subsequent pregnancy, regardless of the ABO status of
the mother and baby (Crowther and Middleton 1997).
Management of Rh-D isoimmunization
Destruction of fetal RBCs results in fetal anaemia and less
oxygen reaches fetal tissue, and oedema and congestive
cardiac failure can develop. Lesser degrees of red cell
destruction may result in fetal anaemia only, while exten-
sive haemolysis can cause hydrops fetalis and fetal death.
Mortality rates are higher for those with hydrops fetalis
(van Kamp et al 2005). Early referral to specialist care for
women with Rh-D antibodies detected at booking is essen-
tial. While early specialist care influences fetal outcome
(Ghi et al 2004; Craparo et al 2005; van Kamp et al 2005),
ongoing midwifery information and support are also
important. Treatment aims to reduce the effects of haemo-
lysis. Intensive fetal monitoring is usually required, and
often a high level of intervention throughout the preg-
nancy. Monitoring and treatment can include the princi-
ples outlined in Box 33.2.
Postnatal treatment of isoimmunization
Management aims to monitor the SBR level so that early
intervention can be made if the level is high or increasing
rapidly to try to prevent levels reaching those that might
be harmful. The following factors are worthy of
consideration:
• Using phototherapy from birth helps to prevent a
rapid rise in some babies.
• Regular SBR measurements from birth every 4 hours.
• A low haemoglobin concentration at birth may
indicate the need for early intervention with an
exchange transfusion.
• If the SBR level is increasing too rapidly or is too
high then intervention is required.
 Significant problems in the newborn baby
Box 33.2 Key principles in the management
and treatment of isoimmunization
• In early pregnancy maternal blood is grouped for Rh
type, and women who are Rh-negative are screened
for antibodies (indirect Coombs’ test). A positive test
indicates the presence of antibodies, or sensitization.
• Maternal blood is re-tested frequently to monitor any
increase in antibody titres. Even with low anti-D levels,
sudden and unexpected rises in serum anti-D levels
can result in hydrops fetalis.
• Red blood cells obtained by chorionic villus sampling
can be Rh-phenotyped as early as 9–11 weeks’
gestation.
• If antibody titres remain stable, ongoing monitoring is
continued.
• If antibody titres increase, Doppler ultrasonography of
the middle cerebral artery peak systolic velocity is used
for non-invasive diagnosis of fetal anaemia. This
procedure is as sensitive as amniocentesis in predicting
anaemia and bilirubin breakdown products, has less
associated risk and can safely replace invasive testing
in the management of isoimmunized pregnancies (Joy
et al 2005; Mari et al 2005; van Dongen et al 2005;
Oepkes et al 2006).
• Intravenous immunoglobulin (IVIG) blocks fetal red cell
destruction, reducing maternal antibody levels, and
may be used to maintain the fetus until intrauterine
fetal transfusion can be performed (see below).
• Intrauterine intravascular transfusion can be used to
treat fetal anaemia until the fetus is capable of
survival outside the uterus (Craparo et al 2005; van
Kamp et al 2005).
• Detailed fetal neuroimaging using multiplanar
sonography and/or magnetic resonance imaging may
be used to assess brain anatomy in fetuses with
severe anaemia (Ghi et al 2004).
• The ongoing severity of the haemolysis and the
condition of the fetus will influence the duration of
the pregnancy. In general, a gestational age greater
than 34 weeks is aimed for to minimize the
complications of prematurity.
Treatment depends upon the baby’s condition. Careful
monitoring but less aggressive management may be ade-
quate, with mild to moderate haemolytic anaemia and
hyperbilirubinaemia. Severely affected babies often require
early admission to the NICU. Babies with hydrops fetalis
are pale, have oedema and ascites. In some cases photo-
therapy alone can be effective and is very useful to help to
prevent the need for exchange transfusion, which carries
many more risks. Despite this, exchange transfusion is
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Chapter | 33 |
often required, and later packed cell transfusion may be
needed to increase haemoglobin levels as babies are at risk
of ongoing haemolytic anaemia and this may occur up to
6–8 weeks of age. Treatment with IVIG can be effective at
blocking ongoing haemolysis, with shorter duration of
phototherapy and fewer exchange transfusions although
this may also increase the likelihood of a later ‘top-up’
blood transfusion (Gottstein and Cooke 2003).
ABO isoimmunization
ABO isoimmunization usually occurs when the mother is
blood group O and the baby is group A, or sometimes
group B. Individuals with type O blood develop antibod-
ies throughout life from exposure to antigens in food,
Gram-negative bacteria or blood transfusion and by the
first pregnancy may already have high serum anti-A and
anti-B antibody titres. Some women produce IgG antibod-
ies that can cross the placenta and attack to fetal red cells
and destroy them (see effects of isoimmunization in the
discussion below referring to Rhesus disease). ABO incom-
patibility is also thought to protect the fetus from Rh
incompatibility as the mother’s anti-A and anti-B antibod-
ies destroy any fetal cells that leak into the maternal cir-
culation. Although first and subsequent babies are at risk,
destruction is usually much less severe than with Rh
incompatibility. In most cases haemolysis is fairly mild
but can be more severe. ABO isoimmunization can, rarely,
cause severe fetal anaemia and hydrops fetalis.
Antibodies are not often detected in pregnancy and it is
usually a diagnosis made in a baby with an unexpectedly
high SBR level. Postnatal management depends on the
severity of haemolysis and, as with isoimmunization, aims
to prevent bilirubin levels that may be harmful. The diag-
nosis is usually made after birth in an unexpectedly jaun-
diced baby. The direct Coombs’ test is positive and the
maternal and baby’s blood groups are consistent with
ABO incompatibility (i.e. maternal group O and baby A
or B or AB). As with other causes of haemolysis, if babies
require phototherapy it is usually commenced at a lower
serum bilirubin level (140–165 µmol/l or 8–10 mg/dl). In
rare cases, babies with high SBR levels require exchange
transfusion. IVIG administration to newborns with signifi-
cant hyperbilirubinaemia due to ABO haemolytic disease
(with a positive direct Coombs’ test) has reduced the need
for exchange transfusion (Miqdad et al 2004).
Late neonatal jaundice
This is generally defined as a bilirubin concentration that
remains raised beyond 14 days of age. There are a number
of causes and investigation is important because, whilst
uncommon, some of the causes are conditions that have
significant long-term implications if not treated and treat-
ments are available which are effective if used early
enough.
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Section | 6 | The Neonate
Causes of late neonatal jaundice
Any disease or disorder that increases bilirubin production
or alters transport or metabolism of bilirubin is superim-
posed upon normal physiological jaundice. It is best to
divide the causes into those conditions that cause a raised
unconjugated bilirubin (fat soluble) and those that cause
a raised conjugated bilirubin (water soluble).
Late neonatal (>14 days) unconjugated
hyperbilirubinaemia
Increased red cell destruction or haemolysis causes raised
SBR levels and blood type/group incompatibility, includ-
ing Rhesus (Rh-D) and ABO incompatibility, anti-E and
anti-Kell. Other factors include sepsis, particularly urinary
tract infection, hypothyroidism and galactosaemia. Non-
immune haemolysis features spherocytosis (fragile red cell
membranes) and enzyme deficiencies. Glucose-6-phos-
phate dehydrogenase (G6PD) is an enzyme that maintains
the integrity of the cell membrane of RBCs and deficiency
results in increased haemolysis. G6PD deficiency is an
X-linked genetic disorder carried by females that can affect
male babies of African, Asian and Mediterranean descent.
Late neonatal (>14 days) conjugated
hyperbilirubinaemia
Always consider this when there are pale stools and dark
urine. Important causes can include:
• biliary atresia
• dehydration, starvation, hypoxia and sepsis (oxygen
and glucose are required for conjugation)
• TORCH infections (toxoplasmosis, others, rubella,
cytomegalovirus, herpes)
• other viral infections (e.g. neonatal viral hepatitis)
• other bacterial infections, particularly those caused
by E. coli
• metabolic and endocrine disorders that alter uridine
diphosphoglucuronyl transferase (UDPGT) enzyme
activity (e.g. Crigler–Najjar disease and Gilbert’s
syndrome)
• other metabolic disorders such as hypothyroidism
and galactosaemia.
HAEMATOLOGICAL PROBLEMS
Bleeding
Bleeding is generally rare in the newborn, however there
are a small number of significant conditions that can result
in bleeding of which the midwife should be aware. Blood
from the gastrointestinal tract (vomiting or passed per
rectum as malaena) is sometimes seen and the common-
est cause is swallowed maternal blood. This is supported
if there is a clear history of maternal bleeding and
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bloodstained amniotic fluid. The baby should be carefully
evaluated and the possibility of bleeding from the gas-
trointestinal tract considered. This could occur if there was
a clotting or platelet abnormality, or occasionally with
some serious gastrointestinal disorders such as NEC.
Possible causes of bleeding
abnormalities
Vitamin K-deficient bleeding (VKDB)
Early VKDB, occurring in the first 48 hours, is rare and
usually occurs to babies born to mothers who have
received medications that interfere with vitamin K metab-
olism. These include the anticonvulsants phenytoin,
barbiturates or carbamazepine, the antitubercular drugs
rifampicin or isoniazid and the vitamin K antagonists war-
farin and phenprocoumarin. It is prevented by giving
vitamin K to the mother (except those that require ongoing
anticoagulation) in the last weeks of pregnancy and ensur-
ing a dose of intramuscular (IM) vitamin K is given to the
baby. Vitamin K is given to all newborn babies by virtue
of their mother’s consent, usually as an IM injection to
prevent VKDB. If there is unexplained bruising or bleeding
it is important to check that vitamin K has been given as
some mothers will decline from giving consent. Classic
VKDB occurs in the first week of life, often in sick babies
or those slow to establish feeds. Gastrointestinal bleeding
is common and may be severe, epistaxis or unexplained
bruising or oozing from the umbilical cord are common
features. Bleeding into the brain is uncommon. It is pre-
vented by ensuring that an early first dose of vitamin K is
given by any route.
Late VKDB occurs from the first week up to 6 months,
usually between 4 and 12 weeks. This form is more com-
monly associated with intracranial bleeds (30–50%) than
classic VKDB, and this can be fatal or leave permanent
disability. It is almost completely confined to fully breast-
fed babies. About half will have an underlying liver disease
or other malabsorptive state. Late VKDB can be optimally
prevented by 1 mg vitamin K IM at birth or significantly
reduced by repeated doses of oral vitamin K.
Thrombocytopenia
A low platelet count may present with bleeding or a
petechial rash. It may be due to:
• maternal idiopathic thrombocytopenic purpura
(ITP), where autoimmune maternal antibodies
destroy maternal and fetal platelets
• isoimmune thrombocytopenia, where maternal
antiplatelet antibodies destroy fetal platelets of a
different group
• congenital infections, both viral and bacterial
• drugs, administered to mother or baby
• severe Rhesus haemolytic disease.
 Significant problems in the newborn baby
Haemophilia and other inherited problems
Haemophilia A is an X-linked recessive disorder, which
therefore affects only boys. Females may be carriers. The
diagnosis is often known or suspected antenatally because
of a family history. In these cases investigation should
occur after birth and IM injections and invasive procedures
should be avoided. The diagnosis can be made by checking
a clotting profile and should always be considered in a
male baby who has unexpected bleeding.
METABOLIC PROBLEMS
Many metabolic abnormalities can occur in the newborn,
particularly in preterm or IUGR babies. By far the most
common problem is hypoglycaemia.
Glucose homeostasis
The fetus has a constant supply of glucose via the placenta.
Following birth, this supply of nutrients ceases and there
is a fall in glucose concentration (Srinivasan et al 1986).
At the same time, however, endocrine changes (decrease
in insulin and a surge of catecholamines and release of
glucagon) result in an increase in glycogenolysis (break-
down of glycogen stores to provide glucose), gluconeogen-
esis (glucose production from the liver), ketogenesis
(producing ketones, an alternative fuel) and lipolysis
(release of fatty acids from adipose) bringing about an
increase in glucose and other metabolic fuel. Problems
arise in the newborn when there is either a lack of glyco-
gen stores to mobilize (preterm and IUGR babies) or
excessive insulin production (infants of diabetic mothers)
or when the babies are sick and have a poor supply of
energy and increased requirements.
Low glucose concentrations are a potential problem in
the newborn because if there is a lack of fuel or nutrients
available for the brain, cerebral dysfunction and poten-
tially brain injury may occur. The problem for those caring
for newborn babies is not only to identify those who are
at risk and treat them appropriately, but also to avoid
excessive treatment and investigation in babies where
intervention is not required.
Hypoglycaemia
The definition of hypoglycaemia is controversial and many
different definitions can be found in the literature (Koh
et al 1988b). The problem is that defining a specific level
of blood glucose is unhelpful because a baby’s ability to
compensate and use alternative fuels may be as important
as the specific glucose concentration. Pragmatically,
however, a specific level is helpful for management pur-
poses. The consensus appears to favour a cut-off value in
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Chapter | 33 |
the newborn of 2.6 mmol/l although the evidence for the
use of this level is not strong. This figure comes mainly
from two studies (Koh et al 1988a; Lucas et al 1988). Koh
et al (1988a) demonstrated abnormal sensory-evoked
brain stem potentials in a small number of term babies.
This did not occur in any infants where the blood glucose
was above 2.6 mmol/l, whether or not signs were present
(Koh et al 1988a). In addition, and perhaps more impor-
tantly, in a retrospective study of preterm infants the neu-
rological outcome was less favourable if the blood glucose
concentration had been <2.6 mmol/l on ≥5 days during
the neonatal period (Lucas et al 1988). These studies
suggest that levels of blood glucose concentration above
2.6 mmol/l are likely to be safe but they do not take into
account the baby’s ability to compensate for low glucose
concentrations. Lower values may be safe in some babies.
Signs of hypoglycaemia
A baby who has signs of hypoglycaemia has a glucose concentra-
tion that is too low and this should be treated whatever the exact
glucose level. The signs of hypoglycaemia are lethargy, poor
feeding, seizures and decreased consciousness level. Jitteri-
ness is commonly ascribed to hypoglycaemia but is a
common feature in the newborn and alone should not be used
as an indication for measuring blood glucose concentration.
Healthy term babies
It is likely that healthy term babies are able to tolerate low
blood glucose concentrations using compensatory mecha-
nisms and use alternative fuels such as ketone bodies,
lactate or fatty acids (Hawdon et al 1992). These babies
may have blood glucose concentrations as low as
2.0 mmol/l without any ill-effects because, if responding
normally, they are likely to have increased ketone body
concentrations so that fuel is available for the brain
(Hawdon et al 1992). Term babies who are breastfed are
particularly likely to have low blood glucose concentra-
tions, probably because of the low energy content of
breastmilk in the first few postnatal days. However, these
babies have higher ketone body concentrations to com-
pensate (Hawdon et al 1992) and they are unlikely, there-
fore, to suffer any ill-effects. Unfortunately, however,
routine measurements of ketone body concentrations are
not readily available and when glucose measurements are
made in these babies it becomes difficult for practitioners
to resist giving treatment that may involve supplementary
formula feeding or even IV dextrose at the expense of
breastfeeding. This should obviously be avoided unless
there are other clinical indications for intervention.
Because of their ability to counter-regulate, clinically well,
appropriately grown, full-term babies who are feeding do
not require monitoring of their glucose concentration.
Doing so would result in many babies being inappropri-
ately treated.
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Section | 6 | The Neonate
Babies at risk of neurological sequelae
of hypoglycaemia
Babies where monitoring and treatment should be consid-
ered are those in whom counter-regulation may be
impaired. Preterm babies (<37 completed weeks) and
IUGR babies (<3rd centile for gestation) have lower glyco-
gen stores and cannot therefore mobilize glucose as
rapidly during the immediate postnatal period. In addi-
tion they also have immature hormone and enzyme
responses and are less likely to be enterally fed at an early
stage. Infants of diabetic mothers (IDM) frequently have
low blood glucose concentrations because of an excess of
insulin production. This is produced by the fetal pancre-
atic gland as a result of stimulation by increased maternal
glucose concentrations. This excess of insulin also acts as
a growth factor and brings about excessive fat and glyco-
gen deposition. This is why these infants have a character-
istic appearance and are relatively macrosomic (Fig. 33.10;
note macrosomic appearance with increased adiposity). A
study by the Confidential Enquiry into Maternal and Child
Health (CEMACH 2005) demonstrated that practice across
the UK varies with regard to the management of IDM and
many babies appear to be inappropriately admitted to
NICU. This should be avoided where possible but it
requires the ability to monitor these babies on routine
postnatal wards. In sick babies following perinatal
hypoxia-ischaemia or sepsis there may also be low sub-
strate stores compounded by feeding difficulties that add
to the problem. Also consider babies with inborn errors
of metabolism (discussed later in this chapter).
Diagnosis, prevention and management
of hypoglycaemia
Term babies who are admitted to the postnatal ward and
are feeding should not have blood glucose measured
Fig. 33.10 Macrosomic infant.
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unless they are symptomatic. In particular, breastfeeding
information and intervention should not be based on
blood glucose concentrations. Prevention is important in
at-risk babies and they should therefore have:
• adequate temperature control – keep warm
• early breastfeeding within 1 hour of birth (100 ml/kg
per day if formula feeding)
• frequent feeding (≤3 hourly)
• a blood glucose check immediately before the
second feed and then 4–6 hourly thereafter.
There is no advantage in checking the blood glucose con-
centration earlier than this providing there are no clinical
signs as it is likely to be low and the appropriate treatment
at this stage is to feed the baby. If there are signs of
hypoglycaemia, the glucose should be checked and treat-
ment given immediately. Breastfed babies are particularly
difficult to manage in this situation as it is important
to avoid supplemental feeding with formula to promote
successful breastfeeding but the risks associated with
significant hypoglycaemia in at risk-babies outweigh
this advantage. If the blood glucose concentration is
<2.6 mmol/l then a feed should be given at an increased
volume and decreased frequency (2 hourly or even
hourly). This may require supplementary feeding with
colostrum or formula milk for those who are being breast-
fed and the use of a nasogastric tube should always be
considered.
If the blood glucose concentration remains low despite
these measures and there is an adequate feed volume
intake, then IV treatment with dextrose is required. It is
important in this situation that enteral feeding is contin-
ued as colostrum/milk contains much more energy than
10% dextrose and promotes ketone body production and
metabolic adaptation. If the blood glucose concentration
is >2.6 mmol/l before the second and third feed then
glucose monitoring can be discontinued but feeding
should continue at 3-hourly intervals. In babies where
enteral feeding is contraindicated for some reason, IV
10% dextrose at least 60 ml/kg on the first day should
commence.
Hyperglycaemia
Hyperglycaemia is much less of a clinical problem than
hypoglycaemia and occurs predominantly in preterm and
severely affected IUGR babies. It is also seen in term babies
in response to stress, especially following perinatal
hypoxia-ischaemia, surgery or drugs (especially corticos-
teroids). In general no treatment is required. In preterm
babies it is usually a transient phenomenon related to the
immature autoregulation or inability to deal with exces-
sive glucose intakes. In general, treatment is not required
unless there is significant loss of glucose in the urine that
may cause an osmotic diuresis. If treatment is required the
rate of glucose infusion can be decreased, but there may
 Significant problems in the newborn baby
be some advantages in this situation of giving an IV insulin
infusion. This allows glucose input to continue and suf-
ficient calories to continue to be given and may result in
better weight gain (Collins et al 1991).
ELECTROLYTE IMBALANCES IN
THE NEWBORN
In the first few days after birth all babies lose weight due
to a loss of extracellular fluid. This diuresis and loss of
weight is associated with cardiopulmonary adaptation; it
occurs rapidly in healthy babies but may be delayed in
those with RDS. As extracellular fluid is lost there is a net
loss of both water and sodium over these first few days
after birth, although the baby’s serum sodium should
remain within the normal range. The healthy baby should
lose up to 10% of its birth weight. This weight loss is physi-
ological and should be expected.
Sodium
Sodium is normally excreted via the kidney, controlled by
the renin–angiotensin system. This control mechanism is
functional in the preterm baby but loss of sodium may
occur in these babies because of renal tubule unrespon-
siveness. Term breastmilk has relatively little sodium
(<1 mmol/kg per day), showing that the healthy newborn
can preserve sodium via the kidney in order to maintain
growth. Normal sodium requirements are 1–2 mmol/kg
per day in term babies and 3–4 mmol/kg per day in
preterm babies. Changes in serum sodium reflect changes
in sodium and water balance. In order to assess changes
in sodium concentration it is important to know a baby’s
weight as hypernatraemia in the presence of a loss of
weight suggests dehydration whereas when there is weight
gain it is due to fluid and sodium overload. Hyponatrae-
mia in the presence of weight gain represents fluid over-
load whereas a reduced sodium with inappropriate weight
loss represents sodium depletion. The normal serum
sodium concentration is 133–146 mmol/l (Ayling and
Bowron 2012).
Hyponatraemia
Hyponatraemia is due either to fluid overload or sodium
depletion. The latter may be due to inadequate intake or
excessive losses.
Fluid overload
In the first few days after birth this is the commonest cause
of a low sodium concentration. It is commonly seen in
babies receiving IV fluids or in babies with oliguric renal
failure or those on medication, e.g. indomethacin given to
preterm babies. Appropriate treatment is to limit the fluid
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Chapter | 33 |
intake whilst maintaining normal sodium intake with
appropriate intravenous fluids.
Sodium depletion
The causes include renal loss in preterm babies, which is
treated by increasing sodium intake to compensate for the
losses. Some preterm babies may require a very large daily
intake of IV sodium with their IV fluids when losses are
high. Also consider loss of sodium into the bowel due to
ileus (intestinal obstruction, sepsis or prematurity) or
severe vomiting. Diuretics can affect the loss and occasion-
ally adrenocortical failure. This is rare but may be due to
congenital adrenal hyperplasia or hypoplasia, or adrenal
haemorrhage in a sick baby.
Hypernatraemia
Increased sodium concentration is almost always due to
water depletion and loss of extracellular fluid but can also
rarely be due to an excessive sodium intake. These causes
can again be easily differentiated, by weighing the baby to
assess the change since birth.
Water depletion
This is rare in term babies but does occur occasionally in
babies with an inadequate intake of breastmilk. It is more
common in preterm babies. The causes include:
• transepidermal water loss in preterm babies – this
occurs particularly in babies <28 weeks’ gestation
and can be prevented by adequate environmental
humidity and regular weighing to gauge fluid loss to
predict fluid requirements
• excessive urine output in preterm babies during
recovery from RDS
• high rates of fluid loss during vomiting, diarrhoea or
bowel obstruction
• inadequate lactation.
Water depletion is perhaps the most important cause of
hypernatraemia. The incidence has been estimated as
2.5/10 000 live births and it typically occurs in term babies
of breastfeeding primiparous mothers (Oddie et al 2001).
It can be associated with significant morbidity and even
mortality (Edmondson et al 1997), however, it can be
prevented with sufficient assistance and supervision of
feeding. Babies typically present at 5–9 days of age with
lethargy and poor feeding. They have lost >15% of their
birthweight and are usually significantly jaundiced. The
serum sodium concentration can be between 150 and
200 mmol/l.
In general, many babies are not weighed during this
period. Mothers who are breastfeeding can be discouraged
by the fact that their baby has lost weight despite a
good technique and this can serve to undermine breast-
feeding no matter how carefully the physiology of the
phenomenon is explained. Additionally (particularly in
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Section | 6 | The Neonate
primiparous mothers) lactogenesis is only just starting at
between 48 and 72 hours. Thus the volume of milk trans-
ferred to the baby is still rising sharply between 72 and 96
hours of age. However, weighing babies during this period
can be very useful when a baby is unwell or if there are
concerns about intake and fluid and electrolyte balance. It
has been suggested that routine weighing of babies may
be useful to prevent dehydration and hypernatraemia in
breastfed babies with referral to hospital if weight loss
exceeds 10% (van Dommelen et al 2007). The baby’s fluid
deficit can be calculated from the loss in weight and this
is then replaced by gradual rehydration over 24–48 hours.
Feeding can continue but IV treatment is often required
with normal saline and dextrose. Assistance with lactation
can then be given to continue to promote breastfeeding.
Excessive sodium intake
In general this is rare in term babies, although it may be
seen in sick preterm babies due to excessive bicarbonate
and other sodium-containing fluids. Causes are:
• incorrect fluid prescription
• excessive administration of sodium bicarbonate
• incorrectly formulated powdered feeds
• Münchausen’s syndrome by proxy – intentional
administration of salt to a baby.
Potassium
Potassium is the major intracellular cation. A low serum
concentration therefore implies significant potassium
depletion. Abnormalities in serum potassium concentra-
tion are important because they can cause significant
arrhythmias. Potassium concentrations can be severely
affected by measurement technique, and any haemolysis
of the blood sample, especially from capillary sampling,
is likely to lead to a falsely high value.
Hyperkalaemia
Causes include:
• acidosis
• acute renal failure
• congenital adrenal hyperplasia.
Treatment is to remove all potassium supplements from
IV fluids, and to consider giving calcium resonium rectally,
calcium gluconate IV, sodium bicarbonate to increase pH
and IV glucose and insulin. In general these measures will
be required only where there is a serum potassium that is
very high (>8 mmol/l) and/or evidence of an abnormal
electrocardiogram (ECG) or arrhythmia.
Hypokalaemia
Causes include:
• inadequate intake of potassium
• bowel losses (vomiting or diarrhoea)
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• diuretic therapy
• hyperaldosteronism.
Hypokalaemia is treated by adding potassium to IV infu-
sion fluids or orally. The normal daily requirement of
potassium is 2 mmol/kg per day.
Calcium
Calcium metabolism is closely linked to phosphate
metabolism and these are very important minerals in rela-
tion to bone development. This is of particular importance
in preterm infants as they need much higher concentra-
tions of phosphate and calcium. These are given as IV
supplements, by supplementing breastmilk with fortifier
(Lucas et al 1996) or by giving specific preterm milk
formula rather than term formula. High serum calcium
concentrations are unusual but there are rare but impor-
tant causes of low serum calcium. The normal serum con-
centration is 2.2–2.7 mmol/l but this must be interpreted
with the serum albumin concentration as serum calcium
is bound to albumin therefore a low albumin concentra-
tion will lead to a falsely low serum value. Calcium con-
centrations fall within 18–24 hours of birth as the baby’s
supply of placental calcium ceases but accretion into bone
continues. In the past, hypocalcaemia during the first week
after birth used to be caused by giving unmodified cow’s
milk. This has a high phosphate concentration and a rela-
tively low calcium concentration that depressed the serum
calcium concentration and caused seizures. This is now
rare with modern formula feeds.
Hypocalcaemia can cause seizures, tremors, jitteriness,
lethargy, poor feeding and vomiting. Severe signs can be
treated by IV replacement of calcium. Longer-term man-
agement depends on the cause. Hypocalcaemia can be
caused by:
• prematurity
• significant hypoxia-ischaemia
• renal failure
• hypoparathyroidism including DiGeorge syndrome
(see later)
• maternal diabetes mellitus.
INBORN ERRORS OF METABOLISM
IN THE NEWBORN
Inborn errors of metabolism (IEM) are rare inherited dis-
orders occurring in approximately 1 in 5000 births. They
result mainly from enzyme deficiencies in metabolic path-
ways leading to an accumulation of substrate, leading to
toxicity. In utero, the placenta provides an effective dialysis
system for most disorders, removing toxic metabolites.
Most affected babies are therefore initially born in good
condition with normal birth weight. A high index of
 Significant problems in the newborn baby Chapter | 33 |

• plasma ammonia concentration

Box 33.3 Clinical features associated with many • coagulation tests.
diagnoses – a combination of these features
Many other investigations may be necessary and useful,
could be indicative of an IEM
but in general, investigations need to be discussed with a
• Septicaemia
consultant biochemist or paediatrician with an interest in
metabolic disorders. Principles of emergency management
• Hypoglycaemia
are to reduce any abnormal load on affected pathways by
• Metabolic acidosis
removing toxic metabolites and stimulating residual
• Convulsions enzyme activity. Hypoglycaemia is corrected, adequate
• Coma ventilatory support and hydration are maintained, convul-
• Cataracts sions are treated and significant metabolic acidosis is
• Cardiomegaly treated with IV sodium bicarbonate, and electrolyte abnor-
• Jaundice/liver disease malities are corrected. In general, antibiotics are frequently
• Severe hypotonia given as infection may have precipitated metabolic decom-
• Unusual body odour pensation and occasionally dialysis may also be required
• Dysmorphic features (Wraith and Walker 1996).
• Abnormal hair
• Hydrops fetalis Phenylketonuria
• Diarrhoea Phenylketonuria (PKU) is important, first because it is a
treatable cause of brain injury and second because it is
possible to successfully screen for it during the first week
of life in order to identify affected individuals and treat
them appropriately to produce a favourable outcome.
suspicion is needed when evaluating an acutely sick PKU is an autosomal recessive disorder of protein
neonate, as many disorders are treatable and early diagno- metabolism that has an incidence of approximately 1 in
sis and treatment can reduce morbidity. It has been 10 000 in the UK. Babies with PKU are born in good condi-
estimated that 20% of babies presenting with sepsis in tion but begin to be affected by their condition during the
the absence of risk factors have an inborn error of first few weeks/months after birth. Untreated it leads to
metabolism. severe learning difficulties/disability (IQ <30). However, if
The mode of inheritance is usually autosomal recessive, it is identified early (within the first 3 weeks), it can be
therefore family history is crucial and the following infor- treated by a diet specifically restricted in phenylalanine.
mation should be sought: The common type is caused by the absence of or reduction
in an enzyme called phenylalanine hydroxylase which, in
• any affected siblings
the liver, converts the essential amino acid phenylalanine
• previous stillbirth/neonatal death
to another essential amino acid, tyrosine. The toxic accu-
• parental consanguinity
mulation of phenylalanine and the deprivation of tyrosine
• features associated with feeding, fasting or a surgical
leads to brain damage.
procedure
PKU is particularly suitable for mass screening because
• improvement when feeds are stopped and relapse on
there is a simple widely available diagnostic test and
restarting.
because treatment is effective. Midwives collect the blood
A clinical examination often reveals little specific evidence sample for PKU screening in the UK between days 5 and
and the baby can appear healthy. The features in Box 33.3 8 after birth with the knowledge that the baby has been
may be seen in isolation with many diagnoses, however taking milk feeds. The level of phenylalanine is analysed
multiple features indicate that an underlying IEM should and babies with increased levels need to be prescribed a
be seriously considered low phenylalanine diet and have further assessment to
The following laboratory tests are a basic first step in the determine whether they are affected by the ‘classic’ type of
investigation process: the disease or other variants. If it is treated early, the prog-
• full blood count nosis for PKU is good and normal intelligence can result.
• septic screen Affected people will have to stay on a low phenylalanine
• creatinine, urea and electrolytes (including chloride) diet for life and women who wish to conceive need to
• liver enzymes pre-conceptionally have their diet reviewed to prevent
• blood gas congenital abnormalities like microcephaly in their devel-
• blood glucose and lactate concentration oping fetus. This is because fetal brain injury may result
• urine reducing substances (sugar) from exposure to high concentrations of phenylalanine
• urine ketones (dipstick) and its metabolites in the mother.

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Section | 6 | The Neonate
Galactosaemia
Galactosaemia is a disorder of carbohydrate metabolism
that is autosomal recessive in inheritance and has an inci-
dence of 1 in 60 000. It is caused by an absence or severe
deficiency of the enzyme galactose-1-phosphate uridyl-
transferase (often referred to as Gal-I-P UT). This enzyme
is important for converting galactose to glucose and since
milk’s main sugar lactose is a disaccharide containing
glucose and galactose, babies with this condition rapidly
become affected when fed either human breastmilk or
cow’s milk formulae. The metabolite that builds up and is
harmful is galactose-1-phosphate.
The clinical signs of the disorder are those of liver failure
and renal impairment. Affected babies tend to present
with vomiting, hypoglycaemia, jaundice, bleeding, acido-
sis, failure to gain weight and hypotonia during the first
few days after birth. Another important clinical feature is
congenital cataract. Affected babies may also present with
septicaemia (particularly E. coli) due to damage to intesti-
nal mucosa by high levels of galactose in the bowel. Galac-
tosaemia is an important differential diagnosis to consider
when dealing with a baby with unresponsive hypoglycae-
mia and prolonged or severe jaundice. Babies with galac-
tosaemia will have galactose but not glucose in their urine.
The diagnosis therefore can be made by looking for urine-
reducing substances (galactose) using a Clinitest, whereas
a urine test for glucose will be negative. Confirmation of
the diagnosis is by assay of the enzyme level (Gal-I-P UT)
within red blood cells.
Treatment is with a lactose-free milk formula, com-
menced as soon as the diagnosis is suspected. This results
in a rapid correction of the abnormalities. However, cata-
racts and mild brain injury have occurred even when galac-
tosaemic babies have been fed lactose-free milk from birth.
Screening for this disorder is possible but many babies will
have presented before the screening test is available and
there is little evidence to suggest that diagnosis at or soon
after birth gives a better long-term outlook than diagnosis
by rapid screening of the deteriorating sick baby.
ENDOCRINE PROBLEMS
Endocrine problems in the newborn are relatively rare but
may be serious, even life-threatening, but are nearly always
treatable so identification and diagnosis is important. Dis-
orders of blood glucose homeostasis have already been
described so this section will concentrate on other endo-
crine abnormalities that may present in the newborn.
Thyroid disorders
The thyroid gland produces hormones that have an effect
on the metabolic rate in most tissues. They are also
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essential for normal neurological development. Thyroid
stimulating hormone (TSH) is produced by the anterior
pituitary gland and this stimulates production of T3 and
T4 by the thyroid gland with a feedback mechanism to the
anterior pituitary.
Hypothyroidism
The incidence of hypothyroidism in the newborn is 1 in
3500. There are several possible causes for hypothyroidism
in the newborn, including abnormalities in gland forma-
tion (thyroid dysgenesis), defects in hormone synthesis
(dyshormonogenesis) and rarely secondary pituitary
causes. The latter causes a decrease or lack of TSH, whereas
primary (thyroid) causes result in very high TSH values.
The presentation is, however, the same, although this has
implications for screening. Babies with hypothyroidism
tend to be large, post term and have a large posterior
fontanelle. They have coarse features and often have an
umbilical hernia. These features are often missed, which
is why screening for this disorder is so important. Untreated
babies develop impaired motor development with growth
failure, a low IQ, impaired hearing and language prob-
lems. With treatment the physical signs of hypothyroidism
do not appear but the intellectual and neurological prog-
nosis is poor unless treatment is started within the first few
weeks of life and this should always occur when affected
babies are detected by screening. Screening for hypothy-
roidism involves measuring thyroid stimulating hormone
(TSH) on a blood spot taken at 5–8 days of age. This
method detects almost all cases, however it cannot detect
cases caused by secondary (pituitary) hypothyroidism that
will have a low TSH. This condition is, however, much less
common, with an incidence of 1 in 60 000 to 1 in 100 000
(Fisher et al 1979).
Hyperthyroidism
Graves’ disease is an autoimmune disorder that causes
hyperthyroidism. Neonatal hyperthyroidism occurs rela-
tively rarely but is possible when the mother has or has
had Graves’ disease. It occurs not because of neonatal
autoantibodies but as a result of the transfer of maternal
thyroid stimulating immunoglobulins. These are auto­
antibodies that are produced and act in the same way as
TSH. This can occur when a mother has active, inactive or
treated Graves’ disease (Teng et al 1980). Thyrotoxicosis in
the fetus can lead to preterm labour, low birth weight,
stillbirth and fetal death, but only a small percentage of
babies of mothers with Graves’ disease show signs of thy-
rotoxicosis. In the baby the signs are irritability, jitteriness,
tachycardia, prominent eyes, sweating, excessive appetite
and weight loss. These may be present immediately after
birth or presentation may be delayed for as long as 4–6
weeks (Skuza et al 1996). The baby therefore needs to be
 Significant problems in the newborn baby Chapter | 33 |

observed for this period and treatment will be required

with anti-thyroid medication if any signs appear.

Adrenal disorders
The adrenal glands are vital for the normal function of
many systems within the body. They are divided into a
medulla and a cortex. The medulla produces catecho-
lamines, which help to maintain blood pressure and are
produced at times of stress. Abnormalities of function of
the adrenal medulla are not described in the newborn. The
adrenal cortex produces three groups of hormones – glu-
cocorticoids, mineralocorticoids and sex hormones – that
have distinct functions. Glucocorticoids regulate the
general metabolism of carbohydrates, proteins and fats on
a long-term basis. They have a particular role in modifying
the metabolism in times of stress. Mineralocorticoids regu-
late sodium, potassium and water balance. The sex hor-
mones are responsible for normal development of the
genitalia and reproductive organs. Abnormalities in func-
tion of the glands represent the functions of these different
groups of hormones.

Fig. 33.11 Female infant with ambiguous genitalia due to

Adrenocortical insufficiency congenital adrenal hyperplasia.
This is caused by congenital hypoplasia, adrenal haemor-
rhage, enzyme defects or can be secondary to pituitary
established (see Chapter 28). The biochemical diagnosis
problems. It generally presents with the signs of hypogly-
is made by analysing urine and plasma for steroid hormone
caemia, vomiting, poor feeding and weight gain with pro-
metabolites. Treatment is as for adrenocortical insuffi-
longed jaundice. The baby may have hyponatraemia,
ciency by replacement of glucocorticoid and mineralocor­
hypoglycaemia, hyperkalaemia and acidosis. Treatment is
ticoid hormones. Virilized girls may also require surgical
by IV therapy with glucose and electrolytes followed
intervention to correct the genital abnormalities.
by replacement of corticosteroid and mineralocorticoid
hormones.

Adrenocortical hyperfunction
This may occur in the form of congenital adrenal hyper-
plasia (CAH). This is the name given to a group of inher-
ited disorders that are due to deficiency of enzymes
responsible for hormone production within the adrenal
gland. The most common enzyme deficiency results in an
excess of androgenic hormones but a deficiency of gluco-
corticoid and mineralocorticoids often also occurs. These
disorders can cause abnormalities in the formation of the
genitalia leading to ambiguous genitalia (virilization of
females or inadequate virilization of males) (see Fig.
33.11) and features of adrenal insufficiency (vomiting,
diarrhoea, vascular collapse, hypoglycaemia, hyponatrae-
mia, hyperkalaemia). The classification of disorders of
sexual differentiation has been revised in recent years.
For more information see the consensus statement by
Hughes et al (2006).
It is important to make a prompt diagnosis. The genetic
sex must be determined (chromosome analysis) and it is
important not to assign a sex until the diagnosis has been
Pituitary disorders
Pituitary insufficiency is rare in the newborn. It may occur
in association with other abnormalities, particularly
midline developmental defects. Presentation is with signs
of glucocorticoid deficiency (hypoglycaemia), prolonged
jaundice or signs of hypothyroidism. Growth hormone
deficiency generally causes hypoglycaemia but no other
signs in the newborn. When it is recognized, treatment is
with replacement of the missing hormones.
Parathyroid disorders
The parathyroid glands are responsible for control of
calcium metabolism but abnormalities of the parathyroid
glands are rare causes of hypocalcaemia and hypercalcae-
mia in the newborn. When hypoparathyroidism does
occur it may be familial or may occur in association with
deletions of chromosome 22 (22q11 deletion or DiGeorge
syndrome). The signs associated with hypocalcaemia are
detailed above.

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Section | 6 | The Neonate
EFFECTS ON THE NEWBORN OF
MATERNAL DRUG ABUSE/USE
DURING PREGNANCY
The incidence of drug use within the UK population has
a large geographical variation. As a result the incidence of
drug withdrawal amongst babies also has a markedly
varying incidence. Inner city areas are more likely to be
affected but even within cities large variation is seen in the
incidence of problems.
Opiates and other drugs cross the placenta and the fetus
during pregnancy is likely to be exposed to the same peaks
and troughs of drug exposure as the mother. Withdrawal
may be manifested before birth. The increased incidence
of fetal distress may be related in part to drug withdrawal
during labour but the effects of drugs and withdrawal on
the fetus and newborn are related to the timing of drug
doses. Babies born to mothers who have used illicit drugs
during pregnancy are at risk of withdrawal effects. Other
problems that are more common in these pregnancies are:
• obstetric complications of pregnancy including
placental abruption, IUGR, signs of fetal
compromise during labour, stillbirth
• poor attendance for antenatal care
• non-disclosure of information regarding drugs taken
during pregnancy
• risk of infectious disease (hepatitis B and C, and
HIV)
• social problems such as poor housing, chaotic
lifestyle, care of other children
• poor attendance for neonatal follow-up.
Attendance for antenatal care and supervision during
pregnancy may be improved by midwifery support and
community liaison. It is important to identify these
women during pregnancy in order to try to prevent some
of the above problems and offer appropriate support.
Identification during pregnancy also allows screening for
infectious diseases and this is particularly important for
hepatitis B and HIV where treatments are available to
decrease the chance of the newborn being affected.
Signs of withdrawal
Many drugs have been reported to cause problems of with-
drawal in the newborn. The most common seen in the UK
are opiates in the form of heroin and methadone but
barbiturates, benzodiazepines, cocaine and ampheta-
mines are also frequently seen. Multidrug use is common
and usually leads to prolonged difficult withdrawal. Each
drug has a different half-life and this leads to different
patterns of withdrawal behaviour. In general methadone
produces effects for longer periods than heroin (Herzlin-
ger et al 1977) but benzodiazepines may also contribute
to this (Sutton and Hinderliter 1990).
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The signs most frequently seen are jitteriness, irritability
and constant high-pitched crying. Babies often fail to settle
between feeds and are hyperactive. When feeds are offered
they often feed voraciously although some have a poor
suck. Vomiting is common. Diarrhoea and an irritant
nappy rash are also often seen. Sneezing and yawning are
also seen alongside episodes of high temperature in the
absence of infection. In rare circumstances babies may also
have seizures.
Several scoring systems have been developed to help to
guide when to give pharmacological treatment (Finnegan
et al 1975). These scoring systems aim to make the assess-
ment more objective, however most of the features and
their severity are difficult to quantify. Babies assessed for
signs of drug withdrawal by a scoring system are less likely
to be inappropriately treated and may have a shorter hos-
pital stay. It is important not to over-treat them with drugs
as the long-term effects are not clear and the treatment
may then be difficult to withdraw. Also treatment in many
maternity hospitals means admitting the baby to the
NICU therefore possibly separating mother and baby. On
the other hand babies who are withdrawing appear to be
in discomfort, which arguably warrants management, but
the long-term effects of withdrawal are also unclear. From
experience the most useful feature is whether the baby
settles and sleeps between feeding. If the baby does, then
pharmacological treatment may be unnecessary.
Treatment
Treatment can be divided into general care given to these
babies and pharmacological treatment. It is important, if
at all possible, to keep mother and baby together. Bonding
with and care of these babies by their mother should be
positively encouraged. The mother is likely to be feeling
upset and guilty because of the baby’s appearance/
behaviour and the co-existing social problems involved
with these families makes for a challenging time for all
involved. Breastfeeding can be encouraged as long as there
is no evidence of HIV or ongoing drug use (heroin and
cocaine) that precludes this. Some recommend limiting
this to mothers who are taking methadone on a dose that
is less than 20 mg/day (Committee on Drugs, American
Academy of Pediatrics 1989). A quiet environment with
reduced light and noise is helpful in keeping stimuli
to a minimum. Swaddling is useful and feeds may need
to be given frequently. These babies will often take large
volumes of milk, which is acceptable as long as vomiting
is not a problem. Rocking or cradling are also useful
interventions.
Pharmacological treatment
Several different treatments have been recommended in
the past. Previously, the four drugs recommended for
use were paregoric (a mixture of alcohol and opiate),
 Significant problems in the newborn baby Chapter | 33 |

phenobarbitone, diazepam and chlorpromazine (Com-
mittee on Drugs, American Academy of Pediatrics 1998).
A number of randomized trials have been performed
attempting to assess the use of various drugs in the treat-
ment of neonatal abstinence syndrome (NAS) (Theis et al
1997). It seems logical to treat opiate withdrawal with
opiates and now the two most commonly used treatments
are oral methadone and oral morphine. These appear to
control withdrawal seizures much more effectively (Lawn
and Alton 2012). They can be given in increasing doses if
necessary until the features are controlled and then the
dose gradually reduced. A possible dosing regimen for oral
morphine is shown below:
• initially 0.04 mg/kg morphine sulphate oral 4-hourly
• then 0.03 mg/kg morphine sulphate oral 4-hourly
• then 0.02 mg/kg morphine sulphate oral 4-hourly
• then 0.01 mg/kg morphine sulphate oral 4-hourly.
The dose is reduced every 24 hours if the baby is feeding
well and settling better between feeds. If the feeding and
settling does not improve or profuse watery stools and
excessive vomiting continue, other treatment needs to be
considered. Other medication may sometimes be useful,
e.g. clonazepam for benzodiazepine use or chloral hydrate
as a general sedative.
Cocaine
Cocaine deserves special mention because its effects on the
newborn are different. It is a larger problem in the USA than
in the UK but the incidence of its use during pregnancy is
unknown. It is only present in maternal urine for 24 hours
after exposure therefore detection is difficult (Zuckerman
et al 1989). It can produce significant withdrawal signs
although these are often less severe and less troublesome
than with other drugs, but it is associated with many other
harmful effects on the fetus (Fulroth et al 1989). These
include significant fetal IUGR, brain injury due to
haemorrhage or infarction (Hadeed and Siegel 1989),
abnormalities of brain development, limb reduction
defects and atresias of the gastrointestinal system. Correla-
tion between cocaine exposure, small head size and devel-
opmental scores has been reported (Chasnoff et al 1992).
Discharge and long-term effects
Discharge must be planned with the involvement of other
support agencies. This may include a planning meeting
involving all agencies concerned with the care of the
mother and baby. Although it seems intuitive that expo-
sure to drugs in utero would cause neurodevelopmental
impairment, this is not borne out by carefully controlled
studies (Lifschitz et al 1985). This implies that impair-
ment in intellectual outcome in these children relates to
other adverse prenatal and postnatal factors. Babies born
to these mothers are smaller and have smaller head cir-
cumferences (Kandall et al 1976). However, it is difficult
to be certain about the exact causes of any long-term
harmful effects because so many factors are involved, all
of which are interlinked. These include:
• the effects of the drugs themselves on the developing
fetus
• the use of other harmful substances by mothers who
use drugs (e.g. cigarettes and alcohol)
• the effect of pregnancy complications
• the effect of the withdrawal syndrome on the
developing neonate
• the effect of treatment to prevent withdrawal
behaviours
• the effect of the home environment of the chaotic
drug-user for the developing child
• genetic effects
• reporting bias means that negative associations with
drug-taking are more likely to be reported (Koren
et al 1989).

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 Chapter 34

Infant feeding
Sally Inch

CHAPTER CONTENTS Cessation of lactation 723

Complementary and supplementary feeds 724
Introduction 704 Human milk banking 725
The breast and breastmilk 704 Choosing breast or formula milk 725
Anatomy and physiology of the breast 704 Feeding with formula milk 726
Lactogenesis 705 Types of formula milk 726
Milk production and the mother 706 Choosing a breastmilk substitute 727
Properties and components of breastmilk 707 Preparation of an artificial feed 727
Management of breastfeeding 710 Feeding the baby with the bottle 728
Exclusive breastfeeding for the first Healthy Start (and the Welfare
6 months of life 710 Food Scheme) 729
Antenatal preparation 711 Midwives and the International Code of
The first feed 711 Marketing of Breastmilk Substitutes 729
The next feed 711 The Baby Friendly Hospital Initiative 729
Effective positioning for the mother 711 References 730
Effective positioning for the baby 712 Further reading 736
Attaching the baby to the breast 712 Useful websites and contact details 736
The role of the midwife 715
Feeding behaviour 716
Midwives have a key role in supporting mothers
Expressing breastmilk 718 to breastfeed successfully. It is strongly in the
Care of the breasts 719 interest of both individual mothers and the
Breast problems 719 community as a whole that those who chose to
breastfeed are enabled to do so for as long as
Difficulties with breastfeeding 720 they want. The reasons women give for
Feeding difficulties due to the baby 721 discontinuation are consistent over time and
Contraindications to breastfeeding 723 internationally: they think they do not have
enough milk, breastfeeding is painful and they
have problems getting the baby to feed.
Preventing these distressing problems requires a
Author’s note: In this chapter, where the masculine pronoun has been
multifaceted approach that has to start with
used to refer to a baby this is simply to avoid the cumbersome ‘he or effective, practical and evidence-based training
she’ and to more clearly distinguish the baby from the mother. of all those who offer help and support to

© 2014 Elsevier Ltd 703

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Section | 6 | The Neonate

breastfeeding mothers, especially in the first

week of their baby’s life. THE BREAST AND BREASTMILK
For those mothers who cannot, or choose not
to breastfeed, the midwife has an equally Anatomy and physiology
important role in ensuring that the baby is fed
safely and appropriately. of the breast (Fig. 34.1)
The breasts are compound secreting glands, composed of
varying proportions of fat, glandular and connective
tissue, and arranged in lobes. Each lobe is divided into
THE CHAPTER AIMS TO:
lobules consisting of alveoli and ducts.
• explain the structure and function of the female Because of the intimate and congruous connection
breast between fat and glandular tissue within the breast (Nickell
• describe the properties and components of
breastmilk
• emphasize the role of the midwife in ensuring Rib
breastfeeding success for both mother and baby Skin
Intercostal
• discuss the role of breastmilk expression and human muscle
milk banking Pectoral Subcutaneous fat
• describe the different causes of difficulty with muscle
breastfeeding Cooper’s Intraglandular fat
• discuss the use of formula feeding and the various ligament
products available Nipple
• outline the requirements and recommendations Lobes Nipple duct
of the International Code of Marketing of
Retroglandular
Breastmilk Substitutes and the Baby Friendly Hospital Areola
fat
Initiative
Lobules Lactiferous
ducts

INTRODUCTION A

Breastfeeding for the first 6 months of life is the ideal start

for babies. Breastfeeding improves infant and maternal
health and cognitive development in both developed and Breast cells
developing countries, and it is the single most important filled with milk
preventive approach for saving children’s lives (Renfrew
and Hall 2008). Low breastfeeding rates in the United
Kingdom (UK) have led to a progressive increase in the
incidence of illness that has a significant cost to the
National Health Service (NHS). Recent calculations from
a mere handful of illnesses (where breastfeeding is thought
Nipple containing
to have a protective effect and enough data existed to
narrow ducts
determine total cost of care expected for each episode of
a particular disease) revealed potential annual savings to
the NHS from a moderate increase in breastfeeding rates
of about £40 million per year (Renfrew et al 2012). The
true cost savings are likely to be much higher (UNICEF– Milk droplets
UK 2012a). Bunches of milk cells
The problems that deter women from breastfeeding can
mostly be prevented (Renfrew and Hall 2008). This B
requires a multi-faceted approach, with implementation
of the UNICEF–UK Baby Friendly Initiative at its core Fig. 34.1 (A) Anatomy of the breast (reproduced with
(NICE 2008). permission of Liz Ellis). (B) Cross-section of the breast.

704
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and Skelton 2005), the relative proportion of fat to glan-
dular tissue is difficult to calculate non-invasively. However,
analysis of 21 non-lactating breasts (surgically removed for
carcinoma in situ) (Vandeweyer and Hertens 2002)
revealed that the percentage weight of fat per breast varied
from 3.6 to 37.6. Mammographic studies of non-lactating
breasts have reported breast glandularity decreasing with
age (Jamal et al 2004).
Investigations carried out on 25 sections of central
breast tissue removed during breast reduction operations
performed on women with an average body mass index
(BMI) of 28, found a mean of 61% fat (Cruz-Korchin et al
2002). On average, the women’s central breast area con-
tained only 7% glandular tissue and 29% connective
tissue. This finding, that larger breasts contain relatively
more fat, is supported by an observational study of 136
patients with an average BMI of 32, undergoing breast
reduction surgery (Nickell and Skelton 2005).
Research on the volumes of 20 complete duct systems
(lobes) in an autopsied breast, found considerable varia-
tion in the proportion of breast tissue serviced by each
duct. The largest lobe drained 23% of breast volume, 50%
of the breast was drained by three ducts and 75% by the
largest six. Conversely, eight small duct systems together
accounted for only 1.6% of breast volume (Going and
Moffat 2004).
Ultrasound investigations of the lactating breasts of 21
subjects (Ramsay et al 2005) identified nine or so milk
ducts per breast (range being 4–18), fewer than previously
believed but commensurate with the investigations con-
ducted by Love and Barsky (2004). Taneri et al (2006)
examined 226 mastectomy specimens and found the mean
number of ducts in the nipple duct bundle was 17.5. This
is significantly higher than the number reported to open
on the nipple surface. They reflected that this discrepancy
could be due to duct branching within the nipple or the
presence of some ducts that do not reach the nipple surface.
Taken together, the intimate and inseparable relation-
ship between fat and glandular tissue, the uneven distribu-
tion of milk glands and the high variability in the number
of milk ducts, have implications for those women who
require breast surgery. This is especially the case with
women who have breast reduction surgery, as the loss of
only a few ducts may inadvertently compromise a woman’s
future ability to breastfeed (see below).
The alveoli contain milk-producing acini cells, sur-
rounded by myoepithelial cells, which contract and propel
the milk out (Fig. 34.2). Small lactiferous ducts, carrying
milk from the alveoli, unite to form larger ducts. Several
large ducts (lactiferous tubules) conveying milk from one
or more lobes emerge on the surface of the nipple. Myoepi­
thelial cells are oriented longitudinally along the ducts
and, under the influence of oxytocin, these smooth muscle
cells contract and the tubule becomes shorter and wider
(Woolridge 1986; Ramsay et al 2004). The tubule distends
during active milk flow, while the myoepithelial cells are
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Infant feeding Chapter | 34 |
Fig. 34.2 Alveoli surrounded by myoepithelial cells, which
propel the milk out of the lobule.
maintained in a state of contraction by circulating oxy-
tocin for about 2–3 minutes. The fuller the breast when
let-down occurs, the greater the degree of ductal distension
(Ramsay et al 2004).
The human nipple, in common with other mammalian
nipples, is covered with epithelium and contains cylindri-
cally arranged smooth muscle and elastic fibres. When this
contracts and the nipple becomes erect, a tight sphincter
is formed at the end of the teat (Cross 1977) to prevent
unwanted loss of milk from the mammary gland when it
is not being suckled.
Surrounding the nipple is an area of pigmented skin
called the areola, which contains Montgomery’s glands.
These produce a sebum-like substance, which acts as a
lubricant during pregnancy and throughout breastfeeding.
Breasts, nipples and areolae vary considerably in size from
one woman to another.
The breast is supplied with blood from the internal and
external mammary arteries and branches from the inter-
costal arteries. The veins are arranged in a circular fashion
around the nipple. Lymph drains freely from the two
breasts into lymph nodes in the axillae and the
mediastinum.
During pregnancy, oestrogens and progesterone induce
alveolar and ductal growth, and stimulate the secretion of
colostrum. Other hormones (such as growth hormone,
prolactin, epidermal growth factor, fibroblast growth
factor, human placental lactogen, parathyroid hormone-
related protein and insulin-like growth factor) are involved,
governing a complex sequence of events that prepares the
breast for lactation (Neville et al 2002).
Lactogenesis
Once the alveolar epithelial cells have developed into lac-
tocytes, around mid pregnancy (Lactogenesis I), they are
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able to produce small quantities of secretion: colostrum.
Although some women may produce as much as 30 ml
per day in late pregnancy (Cox et al 1999), the production
of milk is held in abeyance until after 30–40 hours follow-
ing the birth, when levels of placental hormones have
fallen sufficiently to allow the already high levels of prol-
actin to initiate milk production (Lactogenesis II). Contin-
ued production of prolactin is caused by touch, as the
baby feeds at the breast, with concentrations highest
during night feeds. Prolactin is involved in the suppression
of ovulation, and some women may remain anovular until
lactation ceases, although for others the effect is not so
prolonged (Kennedy et al 1989; Ramos et al 1996) (see
Chapter 27).
Maternal nutritional intake and nutritional status are
known to affect birth outcome, and the fetus in utero. The
mother’s diet during pregnancy may also programme the
fetus, affecting health in adult life (Hall Moran 2012), but
the effects of maternal nutrition on the development of
the mammary gland in pregnancy are less well known.
Evidence from rats (Kim and Parks 2004) suggests that
undernutrition may actually enhance cell growth and milk
production. Torgersen et al (2010) found no differences in
the risk of cessation of exclusive breastfeeding in mothers
with and without eating disorders. Overnutrition (obesity),
however, has been shown to adversely affect lactogenesis
II (Rasmussen 2007).
If breastfeeding (or expressing) is delayed for a few days,
lactation can still be initiated because prolactin levels
remain high, even in the absence of breast use, for at least
the first week (Kochenour 1980). However, the establish-
ment of lactation is more secure if breastfeeding or
expressing begins as soon after birth as possible.
Prolactin seems to be much more important to the ini-
tiation of lactation than to its continuation. As lactation
progresses, the prolactin response to suckling diminishes
and milk removal becomes the driving force behind milk
production. This is known to be due to the presence in
secreted milk of a whey protein that is able to inhibit the
synthesis of milk constituents (Prentice et al 1989; Daly
1993; Wilde et al 1995).
The protein collects in the breast as the milk accumu-
lates, exerting negative feedback control on the continued
production of milk. Removal of this autocrine inhibitory
factor (sometimes referred to as Feedback Inhibitor of Lacta-
tion: FIL) by extracting the milk, allows milk production
to accelerate.
Because this mechanism acts locally within the breast,
each breast can function independently of the other. It is
also the reason that milk production slows as the baby is
gradually weaned from the breast. If necessary, it can be
increased again if the baby is put back to the breast more
often, perhaps because of illness.
Milk is synthesized continuously into the alveolar
lumen, where it is stored until milk removal from the
breast is initiated. Only when oxytocin is released, and the
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myoepithelial cells contract, is milk made available to the
suckling baby. Milk release is under neuroendocrine
control. Tactile stimulation of the breast also stimulates
the oxytocin, causing contraction of the myoepithelial
cells. This process is known as the let-down or milk-ejection
reflex and makes the milk available to the baby. This
occurs in discrete pulses throughout the feed and may
trigger bursts of active feeding.
In the early days of lactation, this reflex is uncondi-
tioned. Later, as it becomes a conditioned reflex, the
mother may find her breasts responding to the baby’s cry
or other circumstances associated with the baby or feeding.
In one small study, psychological stress (mental arithmetic
or noise) was found to reduce the frequency of the oxy-
tocin pulses without affecting the amplitude of the pulse.
Neither was there any effect on either prolactin levels or
the amount of milk the baby received (Ueda et al 1994).
Milk production and the mother
The human mother manages the process of lactation in an
entirely different way from her non-primate counterpart.
Much of the mis-information to which women are sub-
jected derives from extrapolation from veterinary and
dairy science (Woolridge 1995). Adequate milk produc-
tion is largely independent of the mother’s nutritional
status and BMI (Prentice et al 1994).
Dietary surveys in developed countries have consistently
found calorie intake to be less than the recommended
amount (Whitehead et al 1981; Butte et al 1984). Control-
led trials conducted in developing countries have demon-
strated that giving extra food to mothers, even those who
were poorly nourished, did not increase the rate of growth
of their babies (Prentice et al 1980, 1983). It has been
suggested that metabolic efficiency is enhanced in lactat-
ing women, thus enabling them to conserve energy and
subsidize the cost of their milk production (Illingworth
et al 1986).
The lactational performance of the human female is
compromised when undernutrition is sufficiently severe,
but it appears that this occurs only in famine or near-
famine conditions. As milk production appears to drive
appetite, rather than the reverse, hunger effectively regu-
lates the calorie intake of a breastfeeding woman, and the
practice of encouraging breastfeeding mothers to eat exces-
sively should be abandoned. Similarly, if healthy breast-
feeding women wish to undertake strenuous exercise from
6–8 weeks after birth, or to lose weight (500–1000 g/
week), they can be assured that neither the quality nor the
quantity of their milk will be affected (Dewey et al 1994;
Dusdieker et al 1994). Exclusive breastfeeding combined
with low fat diet and exercise will result in more effective
weight loss than diet and exercise alone (Hammer et al
1996; Dewey 1998).
Milk production is similarly unaffected by fluctuations
in the woman’s fluid intake. It has been repeatedly
 Infant feeding Chapter | 34 |

demonstrated that neither a significant decrease (Dearlove 90

and Dearlove 1981) nor a significant increase (Morse et al 2
80 4
1992) in maternal fluid intake has any effect on milk
production or the baby’s weight. 70 x=68.7 n=20
8
n=1
60
*

Milk intake (g)

Properties and components
of breastmilk
Human milk varies in its composition:
• with the time of day (e.g. fat content is lowest in the
morning and highest in the afternoon)
• with the stage of lactation (e.g. the fat and protein
content of colostrum is higher than in mature milk)
• in response to maternal nutrition (e.g. although the
total amount of fat is not influenced by diet, the type
of fat that appears in the milk will be influenced by
what the mother eats)
• because of individual variations.
The most dramatic change in the composition of milk
occurs during the course of a feed (Hall 1979). At the
beginning of the feed the baby receives a high volume of
relatively low fat milk (the foremilk). As the feed
progresses, the volume of milk decreases but the propor-
tion of fat in the milk increases, sometimes to as much as
five times the initial value (the hindmilk) (Jackson et al
1987). The baby’s ability to obtain this fat-rich milk is not
determined by the length of time he spent sucking at the
breast, but by the quality of the attachment to the breast.
The baby needs to be well attached so that the tongue can
be used to maximum effect, stripping the milk from the
breast, rather than relying solely on the mother’s milk
ejection reflex. A poorly attached baby may have difficulty
in obtaining enough fat to meet their needs, resorting to
very frequent feeds to obtain sufficient calories from
low-fat feeds. A well-attached baby may, however, obtain
all he requires in a very short time.
The length of the feed, provided that the baby is well
attached, is thus determined by the rate of milk transfer
from mother to baby. If milk transfer occurs at a high rate,
feeds will be relatively short; if it occurs slowly, feeds will
be longer (Woolridge et al 1982) (Fig. 34.3). Milk transfer
seems to be more efficient (and thus feeds are shorter) in
a second lactation than in a first (Ingram et al 2001).
Fats and fatty acids
For the human baby, with its unique and rapidly growing
brain, fat, not proteín, in human milk has particular sig-
nificance. Some 98% of the lipid in human milk is in the
form of triglycerides: three fatty acids linked to a single
molecule of glycerol. More than 100 fatty acids have so
far been identified, about 46% being saturated fat and
54% unsaturated fat. Over the past decade, there has been
an explosion of interest in the unsaturated fatty acid
content of human milk, particularly in the long chain
50 * 5
40
*
30
20
10
* Indicates change of breast
0
0 2 4 6 8 10 12 14 16 18 20 22
Minutes of feed
Fig. 34.3 Pattern of milk intake at a feed for 20 6-day-old
babies.
From Woolridge et al 1982, with permission.
polyunsaturated variety (LC-PUFAs), because of their role
in brain growth and myelination (Fernstrom 1999). Two
of them, arachidonic acid (AA) and docosahexanoic acid
(DHA) appear to play an important role in the develop-
ment of the retina and visual cortex of the newborn. Fat
also provides babies with >50% of their calorific require-
ments (Picciano 2001). Fat is utilized very rapidly because
the milk itself contains the enzyme bile-salt-stimulated
lipase, needed for fat digestion, but in a form that becomes
active only when it reaches the baby’s intestine. Pancreatic
lipase is not plentiful in the newborn, so a baby who is
not fed human milk is less able to digest fat.
Cholesterol, a risk factor for coronary heart disease
(CHD) in adults, occurs in human milk at higher levels
than are currently present in infant formulae (Kamelska
et al 2012). However, these high levels not only play an
important role in brain growth and development (Scholtz
et al 2013), but also paradoxically lower the cholesterol
concentration in blood in later life (Owen et al 2008).
Carbohydrate
The carbohydrate component of human milk is provided
chiefly by lactose, providing the baby with about 40% of
calorific requirements. Lactose is converted into galactose
and glucose by the action of the enzyme lactase in order
to be more readily metabolized and absorbed. These
sugars provide energy to the rapidly growing brain. Lactose
enhances the absorption of calcium, promoting the growth
of lactobacilli, which increase intestinal acidity thus reduc-
ing the growth of pathogenic organisms in the baby.
Protein
Human milk contains less protein than any other mam-
malian milk (Akre 1989a). This accounts in part for its

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Section | 6 | The Neonate
more transparent appearance. Human milk is whey-
dominant, which is mainly α-lactalbumin, and forms soft,
flocculent curds when acidified in the stomach.
Allergies occur less frequently in breastfed babies than
in those fed with formula milk. This may be because the
infant’s intestinal mucosa is permeable to proteins before
the age of 6–9 months and proteins in cow’s milk can act
as allergens. In particular, bovine β-lactoglobulin, which
has no human milk protein counterpart, is capable of
producing antigenic responses in atopic infants (Bahna
1987; Adler and Warner 1991).
Occasionally a baby may react adversely to substances
in their mother’s milk that come from her diet. However,
this is rare and can usually be resolved by the mother
identifying and avoiding the foods that cause the adverse
reaction so that she may continue to breastfeed. Another
bovine whey protein, bovine serum albumin, has been
implicated as the trigger for the development of insulin-
dependent diabetes mellitus (Vaarala et al 1999; Paronen
et al 2000).
Vitamins
All the vitamins required for good nutrition and health are
supplied in breastmilk, and although the actual amounts
vary from mother to mother, none of the normal varia-
tions poses any risk to the infant (Hopkinson 2007).
Fat-soluble vitamins
Vitamin A
Vitamin A is present in human milk as retinol, retinyl
esters and beta carotene. Colostrum contains twice the
amount present in mature human milk, giving colostrum
its yellow colour. Bile-salt-stimulated lipase (present in
human milk: see Fatty acids, above) assists the hydrolysa-
tion of the retinyl esters and may account for the rarity of
vitamin A deficiency in breastfed babies in affluent socie-
ties (Fredrikzon et al 1978; Leaf 2007).
Vitamin D
Vitamin D plays an essential role in the metabolism of
calcium and phosphorus in the body, preventing osteoma-
lacia in adults and rickets in children. It is not strictly a
vitamin, but a hormone triggered by ultraviolet light. The
principal unfortified dietary source of vitamin D is fish
liver oils, with butter, eggs and cheese contributing much
smaller amounts. In the UK, only margarine fortification
with 2800–3520 IU/kg of vitamin D is compulsory. In
other countries, vitamin D fortification of various other
foods is either compulsory or permitted.
Vitamin D is the name given to two fat-soluble com-
pounds: calciferol (vitamin D2) and cholecalciferol (vitamin
D3). A plentiful supply of 7-dehydrocholesterol, the precur-
sor of vitamin D3, exists in human skin, and needs only
to be activated by sufficient ultraviolet light (<30 min of
summer sunlight a day) to become fully potent.
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For light-skinned babies, exposure to sunlight for 30
minutes per week wearing only a nappy, or 2 hours per
week fully clothed but without a hat, keeps vitamin D
requirements within the lower limits of the normal range
(Specker et al 1985). However, latitude and strength of the
sunlight is important. In Scandinavia, photo-conversion
of 7-dehydrocholesterol has been found to occur only
between March and October, with a maximum in June and
July (Moan et al 2008). In the UK, reseachers in Aberdeen
found that sunlight exposure in summer and spring pro-
vided 80% of the baby’s total annual intake of vitamin D
(Macdonald et al 2011). Those living in regions where
exposure to the sun is low have always been at risk for
vitamin D deficiency (Garza and Rasmussen 2000).
In order to ensure adequate stores in the baby’s liver at
birth, pregnant women would need to maintain own their
vitamin D levels at a high enough level to supply sufficient
amounts via the placenta, as the concentration of vitamin
D in human milk is low. However, social mobility, cultural
considerations and concerns over skin cancer from sun-
light have increased the risk of vitamin D deficiency by
reducing the skin’s exposure to sunlight. In the UK this is
of particular concern in women and infants of Asian and
Afro-Caribbean ethnic origin (Gregory et al 2000; Leaf
2007).
Maternal vitamin D deficiency during pregnancy has
been implicated as a risk factor for diabetes, ischaemic
heart disease and tuberculosis. In addition to the previ-
ously known paediatric problems of hypocalcaemic con-
vulsions, dental enamel hypoplasia, infantile rickets and
congenital cataracts in early life, vitamin D deficiency has
been shown to affect neonatal head and linear growth and
may adversely affect the developing fetal brain (Shaw and
Pal 2002).
The National Institute for Health and Clinical Excellence
(NICE) (2008) published specific recommendations to
guide health professionals in advising women about the
benefits of taking a vitamin D supplement of 10 µg per day
during pregnancy and while breastfeeding. Such advice is
also supported by the Department of Health (DH) (2009).
In addition, healthy breastfed babies should receive a
vitamin D supplement from 6 months of age as part of a
multivitamin supplement. Unless a baby who is being fed
on formula milk is considered to be at risk, they would not
routinely require any vitamin D supplementation as this
will already be contained within the formula milk.
Vitamin E
Although vitamin E is present in human milk, its role is
uncertain. It appears to prevent the oxidization of poly­
unsaturated fatty acids and may prevent certain types of
anaemia to which preterm infants are susceptible.
Vitamin K
Vitamin K is the generic name for a group of structurally
similar, fat-soluble vitamins. The two naturally occurring

forms of this vitamin are vitamin K1 (phytonadione)
found in green leafy vegetables, and K2 (menaquinone),
which is synthesized by gut flora. It has been suggested
that, by 2 weeks of age, the breastfed baby’s gut flora
should be synthesizing adequate amounts of vitamin K2
(Akre 1989b).
Vitamin K is essential for the synthesis of blood-clotting
factors II, VII, IX and X. It is present in human milk and
absorbed efficiently. Because it is fat-soluble, it is present
in greater concentrations in colostrum and in the high-fat
hindmilk (Kries et al 1987). The increased volume of milk
as lactation progresses means that the baby obtains twice
as much vitamin K from mature milk than from colostrum
(Canfield et al 1991). Greer (1997) found that marked
increases in breastmilk concentrations of vitamin K, with
corresponding increases in babies’ blood levels, can be
obtained by giving mothers oral vitamin K, although this
subsequently received little attention.
Vitamin K deficiency bleeding (VKDB), formerly called
haemorrhagic disease of the newborn, is a coagulation
disturbance in newborns due to vitamin K deficiency. The
incidence of classic VKDB, occurring between 1 and 7 days
of life, ranges from 0.25 to 1.7 cases per 100 births (Willacy
2010). However, those instances where VKDB occurs in the
first 24 hours of life are largely confined to the babies of
mothers who were taking medications such as isoniazid,
rifampicin, anticoagulants and anticonvulsant agents in
pregnancy. Late VKDB occurs between 2 weeks and 12
weeks of life and occurs predominantly in exclusively
breastfed babies as vitamin K is added to infant formula
milks, but may also occur in any baby who is unable to
absorb the fat-soluble vitamin K (see Chapter 31).
There has been much debate over which babies are at
risk of VKDB, and if supplements should be given after
birth and how these should be given. Puckett and Offringa
(2000) found that a single intramuscular (IM) dose (1 mg)
was more effective than a single oral dose at achieving
appropriate plasma vitamin K levels at 2 weeks and 1
month, but achieved lower plasma vitamin K levels than
a 3-dose oral schedule at 2 weeks and at 2 months. It was
recommended by NICE (2006a) that all babies should be
offered intramuscular vitamin K within the first 24 hours
of birth. However, where parents declined to give consent
to the injection, they should be offered an oral form of
the vitamin, with the further explanation that this would
need to be given several times in the first few weeks to be
effective.
In the two years following the issuing of this guidance,
Busfield et al (2013) found that all (236) of the consultant
maternity units they surveyed were offering vitamin K rou-
tinely at birth. In 72% of units it was offered intramuscu-
larly, 20% offered parents a choice and the remaining 8%
offered an oral, multidose regime. They identified 11
babies as suffering from VKDB after birth, of these, six
had received no prophylaxis (five because the parents
withheld consent) and two had received incomplete oral
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Infant feeding Chapter | 34 |
prophylaxis. The remaining three developed VKDB despite
intramuscular prophylaxis.
Water-soluble vitamins
Unless the mother’s diet is seriously deficient, breastmilk
will contain adequate levels of the water-soluble vitamins,
B and C. Since they are fairly widely distributed in foods
(vitamin C in most fruit and vegetables), a diet signifi-
cantly deficient in one vitamin will be deficient in others
as well. Thus, an improved diet will be more beneficial
than artificial supplements. Water-soluble vitamins are
actively transported across the placenta throughout
pregancy.
Vitamin B complex
Vitamin B complex consists of eight water-soluble vita-
mins: thiamine (B1), riboflavin (B2), niacin (B3), pantho-
tenic acid (B5), pyridoxine (B6), biotin (B7), folic acid
(B9) and cyanocobalamin (B12). All play an important
role in metabolism in the body.
Vitamin C
Vitamin C (L-ascorbic acid) is an antioxidant that helps
protect cells from free radical damage. It is necessary to
form collagen, and thus plays a role in growth and repair
of bone, skin and connective tissue. It also assists the body
to absorb iron. With some vitamins, e.g. vitamin C and
thiamine, a plateau may be reached where increased
maternal intake has no further impact on breastmilk
Minerals and trace elements
Iron
Healthy term babies are usually born with a high haemo-
globin level (16–22 g/dl), which decreases rapidly after
birth. The iron recovered from haemoglobin breakdown
is re-utilized. Babies also have ample iron stores, sufficient
for at least 4–6 months. Although the amounts of iron are
less than those found in formula milks, the bioavailability
of iron in breastmilk is very much higher: 70% of the iron
in breastmilk is absorbed, against 10% from formula milk
(Saarinen and Siimes 1979). The difference is due to a
complex series of interactions taking place within the gut.
Babies receiving fresh cow’s milk or formula may become
anaemic because the cow’s milk protein, especially if
unmodified, can irritate the lining of the stomach and
intestine, leading to loss of blood into the stools (Ziegler
2011).
Zinc
A deficiency of this essential trace mineral may result in
the baby’s failure to thrive and development of typical skin
lesions. Although there is more zinc present in formula
milk than in human milk, the bioavailability is greater in
human milk. Breastfed babies maintain high plasma zinc
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Section | 6 | The Neonate
values compared with formula-fed babies, even when the
concentration of zinc is three times that of human milk
(Sandstrom et al 1983; Khaghani et al 2010) as zinc is
actively transported from the maternal circulation to the
mammary gland (Krebs 1999). Preterm babies may need
zinc supplements.
Calcium
Calcium is more efficiently absorbed from human milk
than from breastmilk substitutes because of the higher
calcium : phosphorus ratio of human milk. Formula milks
based on cow’s milk inevitably have higher phosphorus
content than human milk.
Other minerals
Human milk has significantly lower levels of calcium,
phosphorus, sodium and potassium than formula milk.
Copper, cobalt and selenium, however, are present at
higher levels. The higher bioavailability of these minerals
and trace elements ensures that the baby’s needs are met
while also imposing a lower solute load on the neonatal
kidney than do breastmilk substitutes.
Anti-infective factors
Leucocytes
During the first 10 days following birth, there are more
white cells/ml in breastmilk than there are in blood.
Macrophages and neutrophils are among the most com-
mon leucocytes in human milk and they surround and
destroy harmful bacteria by their phagocytic activity.
Immunoglobulins
Five types of immunoglobulin have been identified in
human milk: IgA, IgG, IgE, IgM and IgD. Of these the most
important is IgA, which appears to be synthesized and
stored in the breast. Although some IgA is absorbed by the
baby, the majority is not. Instead, it coats the intestinal
epithelium and protects the mucosal surfaces against entry
of pathogenic bacteria and enteroviruses. It affords protec-
tion against Escherichia coli, salmonellae, shigellae, strep-
tococci, staphylococci, pneumococci, poliovirus and the
rotaviruses.
The mother’s body is also able to monitor and respond
to potential pathogens in her infant’s environment from
moment to moment via an elegant system known as GALT
and BALT (gut-associated lymphoid tissue and bronchus-
associated lymphoid tissue) or the broncho-mammary and
entero-mammary circulation. Pathogens that enter the
mother’s respiratory or gastrointestinal tract stimulate pre-
committed lymphocytes in the bronchial submucosa or in
the Peyer’s patches of the small intestine. The activated
Beta cells migrate via the blood to the mammary (and
salivary) glands where they become transformed into
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plasma cells that start secreting large quantities of the
appropriate neutralizing antibody into the milk.
Lysozyme
Lysozyme kills bacteria by disrupting their cell walls. The
concentration of lysosyme increases with prolonged lacta-
tion (Hamosh 1998; Montagne et al 2001).
Lactoferrin
Lactoferrin binds to enteric iron, thus preventing poten-
tially pathogenic E. coli from obtaining the iron they need
for survival. It also has antiviral activity against human
immunodeficeincy virus (HIV), cytomegalovirus (CMV)
and herpes simplex virus (HSV), by interfering with virus
absorption or penetration (Liu and Newberg 2013).
Bifidus factor
Bifidus factor in human milk promotes the growth of
Gram-positive bacilli in the gut flora, particularly Lactoba-
cillus bifidus, which discourages the multiplication of
pathogens. Babies fed on cow’s-milk-based formulae,
however, have more potentially pathogenic bacilli present
in the flora of their gut.
Hormones and growth factors
Epidermal growth factor and insulin-like growth factor
stimulate the baby’s digestive tract to mature more quickly
and strengthen the barrier properties of the gastrointesti-
nal epithelium. Once the initially leaky membrane lining
the gut matures, it is less likely to allow the passage of
large molecules, and becomes less vulnerable to micro-
organisms. The timing of the first feed has a significant
effect on gut permeability, which decreases markedly if the
first feed takes place soon after birth.
MANAGEMENT OF BREASTFEEDING
Exclusive breastfeeding for the first
6 months of life
Human milk is species-specific. In 2003, the Global Strat-
egy for Infant and Young Child Feeding called for all
mothers to have access to skilled support to initiate and
sustain exclusive breastfeeding for 6 months and ensure
the timely introduction of adequate and safe complemen-
tary foods with continued breastfeeding up to 2 years or
beyond (World Health Organization [WHO]/UNICEF
2003). This was echoed in the same year by the Depart-
ment of Health and is still current policy (DH 2011).
It has been known for some time that exclusively breast-
fed babies who consume enough breastmilk to satisfy
their energy needs will easily meet their fluid require-
ments, even in hot dry climates (Sachdev et al 1991; Ashraf
 Infant feeding Chapter | 34 |

et al 1993). Extra water does nothing to speed the resolu-
tion of physiological jaundice, should it occur (Carvahlo
et al 1981; Nicoll et al 1982). The only consistent effect of
giving additional fluids to breastfed infants is to reduce
the time for which they are breastfed (Fenstein et al 1986;
White et al 1992).
Antenatal preparation
Breasts and nipples are altered by pregnancy (Chapter 9).
Increased sebum secretion obviates the need for cream to
lubricate the nipple. Women who have inverted and non-
protractile (flat) nipples often find that they improve
spontaneously during pregnancy (Hytten and Baird 1958).
If not, help given with attaching the baby to the breast
after birth often results in successful breastfeeding. Neither
the wearing of Woolwich shells nor Hoffmann’s exercises
are of any value (Main Trial Collaborative Group 1994)
and should not be recommended, nor should any other
unevaluated commercially available device. Education of
the mother is likely to be more effective than any physical
exercises.
The first feed
The mother should have her baby with her immediately
after birth. Early and extended skin contact ensures the
cues that indicate that the baby is ready to feed will not
be missed. Early feeding contributes to the success of
breastfeeding, but the time of the first feed should, to a
large extent, depend on the needs of the baby. Some may
demonstrate a desire to feed almost as soon as they are
born; others show no interest until they are an hour or so
old (Widström et al 1987; Righard and Alade 1990).
Babies of mothers who have received narcotics in labour
may be sleepy and thus require additional support to
breastfeed so they do not lose an excess of weight in the
first week (Dewey et al 2003).
The first feed should be supervised by the midwife. If it
proceeds without pain and the baby is allowed to end the
feed spontaneously, both mother and baby will have been
helped to begin the learning process necessary for effective
breastfeeding in a happy and positive way.
Midwives [RCM] 2002). Mothers who receive the right
help and education at the start will require less support
and remedial intervention later.
Effective positioning for the mother
A comfortable position is a prerequisite of comfortable
breastfeeding. A woman who has recently given birth,
especially one new to breastfeeding, may need some help
with this.
After a caesarean section, or where the perineum is very
painful, lying on her side may be the only position a woman
can tolerate in the first few days after birth, as shown in
Fig. 34.4. It is likely that she will need assistance in placing
the baby at the breast in this position, because she has
only one free hand. When feeding from the lower breast
it may be helpful to raise her body slightly by tucking the
end of a pillow under her ribs. Once the woman can do
this unaided, she may find this a comfortable and conven-
ient position for night feeds, enabling her to get more
sleep.
If the woman shares her bed with her baby in hospital,
the hospital’s guidelines on bed-sharing should be fol-
lowed. All mothers, whether they intend to bed-share at
home or not, should receive guidance on the subject from
the midwife (NICE 2013). Guidance on this complex and
sometimes emotive issue is available for both parents and
health professionals (UNICEF 2011a; UNICEF 2011b).
Alternatively, the mother may prefer to sit up to feed her
baby, as in Fig. 34.5. In the early days following the birth,

The next feed

All mothers should be offered help with the next feed,
within approximately 6 hours of birth or earlier if desired.
Once the baby is feeding satisfactorily the mother should
be told about the cause and prevention of sore nipples,
being advised to seek help if any problems arise. She
should also be informed about the changes that will take
place in her breasts during the following few days. Helping
mothers to understand that breastfeeding is a learned, not Fig. 34.4 Mother lying on her side.
an instinctive, skill enables them to be patient with them- Reproduced with kind permission from the Health Education Board
selves and their babies during this time (Royal College of for Scotland.

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Fig. 34.5 Mother feeding sitting up.
Reproduced with kind permission from the Health Education Board
for Scotland.
it is particularly important that the mother’s back is
upright at a right-angle to her lap. This is not possible if
she is sitting in bed with her legs stretched out in front of
her, or sitting in a chair with a deep backward-sloping seat
and a sloping back. Both lying on her side and sitting cor-
rectly in a chair with her back and feet supported enhance
the shape of the breast and allow ample room in which
to manoeuvre the baby.
Effective positioning for the baby
The baby’s body should be turned towards the mother’s
body (Fig. 34.6) so that the baby is coming up to her
breast at the same angle as her breast is coming down to
the baby.
The more the mother’s breast points down, the more
the baby needs to be on his back (Fig. 34.7). The advice
to have the baby tummy to tummy may be mistakenly taken
to imply that the baby should always be lying on his side.
However, taking account of the angle of the dangle might
be more useful.
If the baby’s nose is opposite his mother’s nipple, being
brought to the breast with the neck slightly extended, the
baby’s mouth will be in the correct relationship to the
nipple (Fig. 34.8).
Attaching the baby to the breast
The baby should be supported across the shoulders, so
that slight extension of the neck can be maintained. The
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Fig. 34.6 Baby turned towards the mother’s body.
From an original drawing by Hilary English.
baby’s head may be supported by the extended fingers of
the mother’s supporting hand (Fig. 34.9) or on the moth-
er’s forearm (Fig. 34.10). It may be helpful to wrap the
baby in a small sheet (Vancouver wrap), as shown in Fig.
34.11, so that his hands are by his side.
Healthy term babies are equipped with a number of
primitive reflexes that enable them to obtain the nourish-
ment they require. At birth, all reflexes are of brainstem
origin, with minimal cortical control. As the baby matures,
higher, cortical pathways develop and the reflexes disap-
pear sequentially: rooting at about 4 months of age and
tongue protrusion by about 6 months of age (Bagnall
2005).
If the newborn baby’s mouth is moved gently against
the mother’s nipple, the baby will open his mouth wide,
as shown in Fig. 34.12. As the baby drops his lower jaw
and darts his tongue down and forward, he should be
moved quickly to the breast. The intention of the mother
should be to aim the baby’s bottom lip as far away from
the base of the nipple as is possible. This allows the baby
to draw breast tissue as well as the nipple into his mouth
with his tongue. If correctly attached, the baby will have
 Infant feeding Chapter | 34 |

Fig. 34.8 The baby’s mouth opposite the nipple, the neck
slightly extended.
From an original drawing by Jenny Inch.

Fig. 34.7 Baby’s body in relation to the mother’s body,

depending on the angle of the breast.
From an original drawing by Hilary English.

formed a teat from the breast and the nipple (Fig. 34.13)
(Woolridge 1986, 2011).
The nipple should extend almost as far as the junction
of the hard and soft palate. Contact with the hard palate
triggers the sucking reflex. The baby’s lower jaw moves up
and down, following the action of the tongue. Although
the mother may be startled by the physical sensation, she
should not experience pain. If the baby is well attached,
minimal suction is required to hold the teat within the
oral cavity. The tongue can then apply rhythmical cycles
of compression and relaxation so that milk is removed
from the ducts. This view of the main mechanism a baby Fig. 34.9 Mother supporting the baby’s head with her
uses to remove milk from the breast has been recently fingers.
challenged (Geddes et al 2008), but even more recently Reproduced with kind permission from the Health Education Board
confirmed by further ultrasound studies (Monaci and for Scotland.

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Fig. 34.12 A wide gape.

Photo courtesy of the Health Education Board for Scotland and
Mark-it TV www.markittelevision.com.

Fig. 34.10 The baby’s head is supported by the mother’s

forearm.
Reproduced with kind permission from the Health Education Board
for Scotland.

Fig. 34.11 The Vancouver wrap to keep the baby’s hands by
his side.
Fig. 34.13 The baby has formed a ‘teat’ from the breast and
the nipple, which causes the nipple to extend back as far as
the junction of the hard and soft palates. The lactiferous
ducts are within the baby’s mouth. A generous portion of
areola is covered by the bottom lip.
Reproduced from Woolridge 1986, with permission.

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Woolridge 2011). Although the tongue is used from time
to time to generate increased suction pressure aiding milk
removal, this is superimposed on the peristaltic action and
does not occur in isolation (Woolridge 2011).
The baby feeds from the breast rather than from the
nipple, and the mother should guide her baby towards her
breast without distorting its shape. The baby’s neck should
be slightly extended and the chin in contact with the
breast. If the baby approaches the breast as illustrated in
Fig. 34.8, a generous portion of areola will be taken in by
the lower jaw, but it is positively unhelpful to urge the
mother to try to get the whole of the areola in the baby’s
mouth (see Fig. 34.14).
The role of the midwife
The midwife’s role during the first few feeds is twofold.
First, she must ensure that the baby is adequately fed at
the breast. Secondly her role is to support the mother in
developing the necessary practical positioning and attach-
ment skills so that she is able to feed her baby independ-
ently. Whilst the baby is reflexly equipped for breastfeeding,
mothers are not. For all primate mothers breastfeeding is
a learned/socially acquired skill. A common pitfall is the
assumption that breastfeeding is instinctive for the mother.
All new mothers, but particularly those who have never
experienced breastfeeding before, require encouragement
and reassurance (emotional support), advice and guid-
ance on the fundamentals of effective attachment so that
feeding is pain free (practical support), and factual infor-
mation about breastfeeding (informational support) in
small, manageable quantities. Some mothers will need
more help and support than others.
Fig. 34.14 The baby’s lower jaw takes in a generous amount
of the areola.
Photo courtesy of the Health Education Board for Scotland and
Mark-it TV www.markittelevision.com.
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Infant feeding Chapter | 34 |
Many mothers who have had babies before require as
much support with breastfeeding as those who have given
birth to their first baby. Reasons for this include:
• Previous unsuccessful breastfeeding.
• Breastfeeding may have gone well last time by
chance rather than knowledge.
• The new baby may behave very differently, or have
different needs, from the mother’s previous baby/
babies.
• The mother may have recently fed (or still
be feeding) a toddler and has forgotten
quite how much help a new baby requires to
breastfeed.
• Their previous baby may have been born at a time
when underpinning information now known to be
outdated was thought to be correct.
Hands-on help from the midwife
Where possible, breastfeeding support from the midwife
should always be hands off, but pragmatically, it may be
necessary for the midwife to help the mother attach the
baby to the breast for the first few feeds. In this case, the
midwife should think of her own comfort, as well as that
of the mother and the baby. The midwife will put less
strain on her own back if she kneels on a foam mat
beside the mother, rather than bending over her (see
Fig. 34.15).
Fig. 34.15 The midwife is kneeling by the mother to assist
her with attaching the baby to the breast.
Reproduced with kind permission of Nancy Durrel-McKenna.
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Section | 6 | The Neonate
The midwife should also consider which hand guides
the baby most skilfully. For example, a right-handed
midwife helping a mother who is lying on her left side
will attach the baby to the left breast with her right hand.
Instead of asking the mother to turn on her right side so
that she can feed from the right breast, the midwife could
raise the baby on a pillow and attach him to the right
breast, again using her right hand. Alternatively, if the
mother is sitting up, she could consider placing the baby
under the mother’s arm on the right side, so that she can
again use her right hand.
Once a baby has fed efficiently he is more likely to do
so again and from this point the mother can begin to learn
how to feed her baby independently. If the midwife needs
to give hands-on help to the mother, she should also
explain what she is doing, and the reason, so that the
mother learns from the encounter. The importance of
observing babies as they go to the breast and feed cannot
be overemphasized. The midwife cannot be confident the
baby has attached correctly and feeds effectively if she does
not see it happen.
Feeding behaviour
A breastfeeding baby typically performs one of three activi-
ties (Monaci and Woolridge 2011):
1. Doing nothing.
2. Stimulating the mother’s nipple, without swallowing
milk (non-nutritive sucking/simply sucking).
3. Sucking and swallowing milk (nutritive sucking/
swallowing).
After an initial burst of nipple stimulation that is short
frequent sucking, two sucks per second, the baby begins
swallowing – slow, deep, one suck per second (nutritive)
sucking – and feeds vigorously with few pauses (Bosma
et al 1990). As the feed progresses, pausing occurs more
frequently and lasts longer. Pausing is an integral part of
the baby’s feeding rhythm and should not be interrupted.
The midwife should simply encourage the mother to
allow the baby to pace the feed. The change in the pattern
generally relates to milk flow.
The foremilk is more generous in quantity but lower in
fat than the hindmilk delivered at the end, which is thus
higher in calories (Woolridge and Fisher 1988). If the baby
receives an excessive quantity of foremilk as a result of
either poor attachment or premature breast switching (see
below), it may result in increased gut fermentation causing
colic, flatus and explosive stools (Woolridge and Fisher
1988; Evans et al 1995). This is the commonest cause of
colic in breastfed babies (see Fig. 34.16) and is resolved in
this case by improving attachment. Neither simeticone
preparations, which are often prescribed for this condi-
tion, nor commonly used complementary medicines, have
been shown to be of value (Metcalf et al 1994; Perry et al
2011; Cohen and Albertini 2012).
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Finishing the first breast and finishing
a feed
The baby will release the breast when he has had sufficient
milk from it. His ability to know this may be controlled
either by the calories he has received or by the change in
the volume available. He should be offered the second
breast after he has had the opportunity to expel any wind,
which he may take according to appetite.
The baby should not be deliberately removed from the
breast before he releases it spontaneously, unless the
mother is experiencing pain, in which case the baby
should be reattached, if still willing to feed. Taking the
baby off the first breast before he has finished may cause
two problems. First, the baby is deprived of the high
calorie hindmilk; second, if adequate milk removal has
not taken place, milk stasis may occur ultimately leading
to the mother developing mastitis or experiencing reduced
milk production, or both. Provided that the baby starts
each feed on alternate sides, both breasts should be used
equally. If a baby does not release the breast or will not
settle after a feed, the most likely reason is that he has not
been correctly attached to the breast and was therefore
unable to remove the milk efficiently.
Other reasons for babies withdrawing from the breast
are:
• incorrect attachment
• the milk flow is very fast and the baby needs to let
go and pause
• the baby has swallowed air with the generous flow of
milk that occurs at the beginning of a feed and
requires an opportunity to expel wind.
There is no justification for imposing either one breast per
feed or alternatively both breasts per feed as a feeding
regimen.
Timing and frequency of feeds
A healthy term baby knows better than anyone else how
often and for how long he needs to be fed. This is now
being described as responsive feeding, superseding the
terms baby-led feeding and demand feeding (UNICEF–UK
2012b). The baby who remains close to his mother can
signal his need to feed so that the feed can begin while he
is still calm. When the baby wakes up he will start to move
about, beginning with movement of the head and mouth,
including licking his lips. Finally the baby finds something
to suck, which is usually his fingers. If the mother misses
these feeding cues the baby may then start to cry. Crying
is a sign of distress, which is a late sign of hunger, and as
a result, the baby will need to be calmed before he can
feed effectively.
It is not unusual in the first day or so for the baby to
feed infrequently, and have 6–8 hour gaps between effec-
tive feeds, each of which may be quite long (Inch and
Garforth 1989; Waldenström and Swensen 1991). This is
 Infant feeding Chapter | 34 |

Poor attachment Food allergens GIT infections

Feed mismanagement (e.g. limiting feed Frequent, high volume (and thus high Compromised lactase activity at the brush
duration, insisting on two breasts per feed) lactose), low fat feeds border of the small intestine

Fast gastric clearance Lactose overload in

(low fat) infant’s small intestine

Osmotic gradient 'pulls' water Excess lactose fermented by

into infant’s large intestine bacteria in infant’s large intestine

Frequent, watery, Gas production, mainly methane and Acid production

explosive, green stools carbon dioxide

Perianal acid burns

Infant flatulence, pain, screaming, unsettled behaviour ……….'colic'

Lactose overload – or – colic in the breastfed baby

• Baby poorly attached – reduced fat intake
• Baby soon hungry again - gastric emptying time more rapid – (low fat feed)
• More frequent feeds - more lactose - (lactose concentration constant)
• Amount of lactose in the gut may transitorily exceed lactase production – resulting in signs of lactose intolerance/lactase deficiency
• Accumulated undigested lactose creates an osmotic gradient that draws water into the bowel
• Bacteria in the baby’s gut are provided with more substrate than usual, which they eagerly attack as an energy source, producing
large quantities of gas in the process (mostly carbon dioxide and methane)
• Dissention of the gut by both fluid and gas produces pain (cramping) and looser, green stools

Fig. 34.16 Causes of colic.

normal, providing the mother with the opportunity to
sleep if she needs to. As milk volume increases, the feeds
tend to become more frequent and a little shorter. It is
unusual for a baby to feed less often than six times in 24
hours from the 3rd day and most babies are taking at least
six feeds every 24 hours by the time they are one week old.
Babies who feed infrequently may be consuming less milk
than they need, or they may be unwell, or both, whereas
babies who feed frequently (10–12 feeds in 24 hours after
they are a week old) may be poorly attached to the breast.
The feeding technique and the baby’s weight should
be monitored. However, individual mother–baby pairs

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Section | 6 | The Neonate
develop their own unique pattern of feeding and, provid-
ing the baby is thriving and the mother is happy, there is
no need to change it.
Volume of the feed
Well-grown term babies are born with good glycogen
reserves and high levels of antidiuretic hormone (ADH).
Consequently babies do not need large volumes of milk
or colostrum before they become available physiologi-
cally. In the first 24 hours, the baby takes an average of
7 ml per feed and by the second 24 hours, this has
increased to 14 ml per feed (RCM 2002; Santoro et al
2010). No precise information is available on the actual
volume of breastmilk an individual baby requires in order
to grow satisfactorily. Previous recommendations (150 ml/
kg) were based on the requirements of formula fed babies,
and these can therefore be used only as a guideline (Davies
et al 1972).
Weight loss and weight gain
Most newborn babies lose some weight during their first
week of life. There is a general expectation that the baby
will regain their birthweight by 10–14 days. There is less
agreement about how great a weight loss is normal or
acceptable. Although the figure of 10% is often cited as the
upper limit of normal, there is little evidence to support a
figure as high as this. Data from nine studies conducted
between 1986 and 1999 suggest a normal range of 3–7%;
and normative data on 435 breastfed babies born in a
Scottish Baby Friendly Hospital, reported median maximum
weight loss of 6.6% (Macdonald et al 2003).
Monitoring milk transfer
A noticeable change in the baby’s sucking/swallowing
pattern is the most consistent sign of milk transfer. Soft
but audible swallows may also be heard at the beginning
of the feed. Most mothers are aware that their breast feels
softer after the baby has fed well. A well-fed baby will
release the breast spontaneously, appear satisfied and
remain content.
Over the first four days of life, the baby’s stools change
from black meconium to the characteristic yellow stool,
typical of a baby fed on breastmilk. A stool that is still
changing at 96 hours of life could indicate that further
attention needs to be paid to the way the mother is feeding
her baby. Similarly, urine output should increase from one
or more wet nappies per day in the first two days of life,
to three or more over the next two days. From the end of
the first week onwards, the baby’s urine output should
have increased such that there are around six or more wet
nappies evident.
An assessment of milk transfer should be made at each
postnatal contact. This should ideally be done daily for
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the first week, to reduce the risk of babies losing an unac-
ceptable amount of weight. An assessment tool, suitable
for use by face-to-face or telephone contact, has been
developed by UNICEF–UK for this purpose (UNICEF–UK
2010a).
Difficulty with attachment is the commonest reason for
babies failing to obtain enough milk. If the baby is diffi-
cult to attach, because he is sleepy or because the breast
tissue is inelastic, the same principles should apply in this
situation as when the baby and mother are separated by
illness or prematurity: namely, to support the mother in
hand expression to encourage the establishment of lacta-
tion. If this is not accomplished, the mother’s lactation
will be in arrears of her baby’s requirements by the time
he is in need of larger volumes around the 3rd/4th day.
If the mother is still not able to feed effectively by the
end of the first week, it is important that she expresses her
milk, using either her hands or an effective breast pump,
so that her lactation is maintained and her baby is fed.
Ongoing help from the midwife to improve breastfeeding
is essential.
Expressing breastmilk
Although all women who choose to breastfeed their babies
should know how to hand express milk, routine expression
of the breasts should not be part of the normal manage-
ment of lactation, even for mothers who have given birth
by caesarean section (Chapman et al 2001). Provided no
limitation is placed on either feed frequency or duration,
and the baby is attached effectively, the volume of milk
produced will be in accordance with the requirements of
the baby. This should prevent the occurrence of problems
such as breast engorgement requiring removal of milk by
hand/pump.
Expression is appropriate in the following situations, if:
• there is concern about the interval between feeds in
the early perinatal period (expressed colostrum
should always be given in preference to formula milk
to healthy term babies)
• there are difficulties in attaching the baby to the
breast
• the baby is separated from the mother, due to
prematurity or illness
• there is concern about the baby’s rate of growth, or
the mother’s milk supply (expressing to top up with
the mother’s own milk may be necessary in the short
term while the cause of the problem is resolved)
• the mother needs to be separated from her baby for
periods (occasionally or regularly), as the baby gets
older.
Manual expression of milk
Manual expression has several advantages over mechanical
pumping and should be taught to all mothers. It is usually

the most efficient method of obtaining colostrum. Some
mothers will find hand expressing superior to any breast
pump.
Expressing with a breast pump
If it is possible and practical, the mother should be able
to experiment with a variety of breast pumps to discover
what will suit her best (Auerbach and Walker 1994) as not
all pumps work well for every woman.
Manually operated pumps
Most manually operated pumps are not efficient enough
to allow initiation of full lactation but they can be useful
when expressing is required once lactation is established.
It is helpful for midwives to explain to mothers that these
pumps function most efficiently if the vacuum phase is
considerably longer than the release phase.
Electrically controlled pumps
Some electrically controlled pumps provide a regular
vacuum and release cycle, with variability in the strength
of the suction and others also vary the frequency of the
cycle. Double pumping is possible with most models, and
this has repeatedly been shown to be of benefit, either
reducing the time for which the mother needs to use the
pump at each session to obtain the available milk (Groh-
Wargo et al 1995; Hill et al 1999), or increasing the
volume of milk obtained for term babies (Auerbach 1990)
and preterm babies (Jones et al 2001).
How much and how often?
Mothers of preterm babies who begin expressing milk by
a pump as soon as possible after birth and use the pump
a minimum of six times per 24 hours, are more likely to
sustain lactation at adequate levels than those who delay
expressing or express less frequently. In a Baby Friendly
hospital the mother will be advised to express her milk at
least 8 times in 24 hours, including once at night. The
earlier the mother is able to express good volumes of milk
in a 24 hours period, the better the outlook for sustaining
adequate milk production for her baby. Breast massage
(Jones et al 2001) and kangaroo care (see Fig. 30.6, p 626):
holding the baby in skin to skin contact between the
mother’s breasts (Hill et al 1999) have also been positively
associated with enhanced milk production.
No time limit should be set for the length of each
expressing session. The mother should be guided by the
milk flow, not the clock. Expressing should continue until
milk flow slows, followed by a short break, and each breast
should be expressed twice, either separately (sequential
pumping) or together (double pumping). When milk flow
slows for the second time, the session should end. Fre-
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Infant feeding Chapter | 34 |
quent expressing sessions are more likely to have the
desired effect than lengthy, infrequent sessions.
Inadequate milk volume, followed by declining produc-
tion, is a common problem for mothers who are express-
ing their milk for their preterm baby. In order to prevent
this from happening, the midwife should discuss with
the mother the value of early initiation of expressing, the
appropriate use and correct size of equipment and the
importance of the frequency of expression, rather than
trying to rescue failing lactation pharmacologically. It
may also be helpful to show the mother how to express
hands free, using an expressing brassiere to hold the
breast shields securely in place. For examples of hands-
free expressing please go to http://www.phdinparenting
.com/blog/2010/9/13/hands-free-pumping-options-for
-breastfeeding-moms.html.
Storage of breastmilk
NICE (2008) advises that expressed milk can be stored for
up to:
• 5 days in the main part of a fridge, at 4 °C or lower
• 2 weeks in the freezer compartment of a refrigerator
• 6 months in a domestic freezer, at −18 °C or lower.
Care of the breasts
Daily washing is all that is necessary for breast hygiene.
Brassieres may be worn in order to provide comfortable
support and are useful if the breasts leak and breast pads
(or breast shells) are used.
Breast problems
Sore and damaged nipples
The cause is almost always trauma from the baby’s mouth
and tongue, which results from incorrect attachment of
the baby to the breast. Correcting this will provide imme-
diate relief from pain and allow rapid healing to take
place. Epithelial growth factor, contained in fresh human
milk and saliva, may aid this process.
Resting the nipple enables healing to take place but
makes the continuation of lactation much more compli-
cated because it is necessary to express the milk and to use
some other means of feeding it to the baby. Nipple shields
should be used with caution, and never before the mother
has begun to lactate, as the baby is unlikely to extract
colostrum via a shield. They may make feeding less
painful, but often they do not. Their use does not enable
the mother to learn how to feed her baby correctly, and
their longer-term use may result in reduced milk transfer
from mother to baby. This in turn may result in mastitis
in the mother (reduced milk removal), slow weight gain
or prolonged feeds in the baby (reduced milk transfer), or
both. If mothers choose to use them, they should be
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Section | 6 | The Neonate
advised to seek help with learning to attach the baby
comfortably without a nipple shield as soon as practicable
(McKechnie and Eglash 2010).
Other causes of soreness
Infection with Candida albicans (thrush) can occur,
although it is not common during the first week following
the baby’s birth. Sudden development of pain after a
period of trouble-free feeding is suggestive of thrush. The
nipple and areola are inflamed and shiny, and pain typi-
cally persists throughout the feed. The baby may show
signs of oral or anal thrush. Both mother and baby should
receive concurrent fungicidal treatment, such as micona-
zole, and it may take several days for the pain in the nipple
to disappear.
Dermatitis
Sensitivity may develop to topical applications such as
creams, ointments or sprays, including those used to treat
thrush.
Anatomical variations
Short nipples
Short nipples should not cause problems as the baby is
able to form a teat from both the breast and nipple.
Long nipples
Long nipples can lead to poor feeding because although
the baby is able to latch on to the nipple, he is unable to
draw any breast tissue into his mouth, due to the length
of the nipple.
Abnormally large nipples
If the baby is small, his mouth may not be able to get
beyond the nipple and onto the breast. Lactation can be
initiated by expressing, by hand or by pump, provided the
nipple fits into the breastshield. As the baby grows and the
breast and nipple become more protractile, breastfeeding
may become possible.
Inverted and flat nipples
If the nipple is deeply inverted it may be necessary to initi-
ate lactation by expressing and delay attempting to attach
the baby to the breast until lactation is established and the
breasts have become soft and the breast tissue more elastic.
Difficulties with breastfeeding
Engorgement
This condition occurs around the 3rd or 4th day following
the baby’s birth. The breasts become hard, often oedema-
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Box 34.1 Babies who are difficult to attach
Inelastic breast tissue, overfull or engorged breasts or
deeply inverted nipples may present the baby with more
of a challenge.
• If the breast is engorged, pushing away the oedema
by gently manipulating the tissue that lies under the
areola may be all that is required.
• Hand expression, or the use of a breast pump, may
relieve fullness to the point where the baby can draw
in the inner tissue to create the necessary teat from
the breast.
• If attachment is still difficult, try asking the mother
to lie on her side with the short edge of a pillow
under her ribs to raise the breast off the bed.
The midwife may need to assist the baby in
attaching.
• If the midwife is unable to attach the baby to
the breast, the mother should be shown how
to hand express and how to give her colostrum
to her baby.
• It may also be necessary to show the mother how to
use a breast pump (hand or electric). However, in the
first 24–48 hours colostrum is usually best expressed
by hand.
When attachment is difficult, the priorities should be
to ensure that the baby is adequately fed on his mother’s
milk, and to work on making the breast tissue more
elastic (both of which can be facilitated by hand or
electrical expressing). Attaching the baby to the breast
directly can come later.
tous, painful and sometimes appear flushed. The mother
may be pyrexial. Engorgement is usually an indication that
the baby is not keeping pace with the stage of lactation.
Engorgement may occur if feeds are delayed or restricted
or if the baby is unable to feed efficiently because he is
not correctly attached to the breast.
Management should be aimed at enabling the baby to
feed well (Box 34.1). In severe cases the only solution will
be the gentle use of a pump. This will reduce the tension
in the breast and will not cause excessive milk production.
The mother’s fluid intake should not be restricted, as this
has no effect on milk production.
Deep breast pain
In most cases, deep breast pain responds to improvement
in breastfeeding technique and is likely to be due to raised
intraductal pressure caused by inefficient milk removal.
Although it may occur during the feed, it typically occurs
afterwards. This distinguishes it from the sensation of
the let-down reflex, which some mothers experience as a

fleeting pain. Very rarely, deep breast pain may be the
result of ductal thrush infection.
Mastitis
In the majority of cases, mastitis, an inflammation of the
breast, is the result of milk stasis, not infection, although
infection may supervene (Thomsen et al 1984). Typically,
one or more adjacent segments of breast tissue are
inflamed through milk being forced into the connective
tissue of the breast, and appear as wedge-shaped areas of
redness and swelling. If milk is forced back into the blood-
stream, the woman’s pulse and temperature may rise and
in some cases flu-like symptoms, including shivering
attacks or rigors, may occur. The presence or absence of
systemic symptoms does not help to distinguish infectious
from non-infectious mastitis (WHO 2000).
Non-infective (acute intramammary) mastitis
Non-infective (acute intramammary) mastitis results from
milk stasis and may occur during the early days of breast-
feeding as the result of unresolved engorgement or at any
time due to poor feeding technique when milk from one
or more segments of the breast is not being efficiently
drained by the baby. It occurs much more frequently in
the breast that is opposite the mother’s dominant side for
holding her baby (Inch and Fisher 1995). Pressure from
fingers or clothing has been blamed for causing the condi-
tion, without any supporting evidence. It is extremely
important that breastfeeding from the affected breast con-
tinues, otherwise milk stasis will increase further, provid-
ing ideal conditions for pathogenic bacteria to replicate.
An infective condition could then arise, leading to abscess
formation if left untreated.
Where supervision is available from the midwife, 12–24
hours could elapse to ascertain whether the mastitis can
be resolved by helping the mother to improve her feeding
technique and encouraging her to allow the baby to com-
plete the first breast initially. If supervision is not available
or if there is no improvement during the 24 hours period,
antibiotics such as cephalexin, flucloxacillin or erythromy-
cin, should be given prophylactically (WHO 2000; RCM
2002).
Infective mastitis
The main cause of superficial breast infection is damage
to the epithelium, allowing bacteria to enter the underly-
ing tissues. The damage usually results from incorrect
attachment of the baby to the breast, which has caused
trauma to the nipple. The mother therefore requires urgent
assistance to improve her feeding technique, as well as
appropriate antibiotics. Multiplication of bacteria may be
enhanced by the use of breast pads or shells. In spite of
antibiotic therapy, abscess formation may occur. Infection
may also enter the breast via the milk ducts if milk stasis
remains unresolved (WHO 2000).
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Infant feeding Chapter | 34 |
Breast abscess
A fluctuant swelling develops in a previously inflamed
area: namely a breast abscess. Pus may be discharged from
the nipple. Simple needle aspiration may be effective, or
incision and drainage may be necessary (Dixon 1988). It
may not be possible for the baby to feed from the affected
breast for a few days, however milk removal should con-
tinue by expression with breastfeeding recommencing as
soon as practicable as this would reduce the chances of
further abscess formation (WHO 2000). A sinus that
drains milk may form, but it is likely to heal in time.
Blocked ducts
Lumpy areas in the breast are not uncommon, due to
distended glandular tissue. If such lumps become very firm
and tender and sometimes flushed, they are often described
as blocked ducts. This description carries with it the image
of a physical obstruction within the lumen of the duct.
However, this is very rarely the cause of the symptoms. It
is much more likely that milk drainage has been somewhat
uneven due to less than optimal attachment and that
secreted milk is trying to occupy more space than is actu-
ally available, causing the alveoli to distend. Milk may
subsequently be forced out into the connective tissue of
the breast where it causes inflammation. The inflammatory
process narrows the lumen of the duct by exerting pressure
on it from the outside as the tissue swells, resulting in
mastitis or incipient mastitis. Consequently, the solution is
to improve milk drainage by improved attachment, with
possibly milk expression, and to treat the accomp­anying
pain and inflammation. Massage, often advocated to clear
the imagined blockage, may make matters worse, as all it
does is force more milk into the surrounding tissue.
White spots/epithelial overgrowth
Very occasionally, a ductal opening in the tip of the nipple
may become obstructed by epithelial overgrowth. A white
blister is evident on the surface of the nipple, effectively
causing a physical obstruction closing off the exit points
from one or more milk-producing sections of the breast.
This may sometimes be resolved by the baby feeding. Alter-
natively, after the baby has fed and the skin is softened, the
blister may be removed with a clean fingernail, a rough
flannel, or a sterile needle. True blockages of this sort tend
to recur, but once the woman understands how to deal
with them, the progression to mastitis can be avoided.
Feeding difficulties due to the baby
Colic in the breastfed baby
Figure 34.16 represents diagrammatically the causes and
effects of secondary lactose intolerance – or ‘colic’ – in the
breastfed baby.
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Section | 6 | The Neonate
Although not all abdominal discomfort is due to poor
attachment, symptoms of ‘colic’ in a breastfed baby, such
as abdominal discomfort, excessive flatus/wind, explosive
stools, light green stools, may often be explained in terms
of the foremilk/hindmilk mixture that the baby receives
during the course of the feed/day.
If the baby is not well attached, he may not be able to
access the fat-rich milk as the feed volume diminishes.
Since it is the fat that provides most of the calories, as well
as slowing gastric emptying time, the poorly attached baby
will be hungry again sooner than he would be if he had
been well attached. Once again (unless the mother makes
changes to the attachment) the baby will receive another
‘low fat’ feed.
Over 24 hours the baby will have consumed a much
greater volume of milk than he would have done if he had
been better attached. Since the concentration of lactose in
milk is fairly constant, he will have also received much more
lactose than otherwise. This excess lactose in the gut may
transitorily exceed the amount of the enzyme lactase
which the baby’s intestinal brush border is able to gener-
ate. The baby thus exhibits the signs of lactose intolerance/
lactase deficiency. The accumulated undigested lactose
creates an osmotic gradient that draws water into the
bowel. Added to which the bacteria in the baby’s gut are
provided with more substrate than usual, which they
eagerly attack as an energy source, producing large quanti-
ties of gas in the process (mostly carbon dioxide and
methane). Distension of the gut by both fluid and gas
produces pain (cramping) and looser stools. These are
often green in colour due to the presence of bile that has
not been re-absorbed. Depending on the extent of the
lactase deficiency and the quantity of lactose ingested,
symptoms can range from mild abdominal discomfort to
severe dehydrating diarrhoea.
(Among the pharmaceutical industry’s responses has
been the production of ‘over the counter’ simethicone and
lactase, which distraught mothers can buy. Not only are
there no good quality trials demonstrating their effective-
ness in breastfed babies, there is a much simpler solution
than trying to fix the symptoms – which is to address the
cause – and improve attachment.)
If the baby who is not well attached can consume suf-
ficient milk in each 24-hour period to get the calories he
needs, he will grow. But he may have to feed very fre-
quently to achieve this. Frequent feeds may in turn increase
his mother’s milk supply, giving rise to the frustrating
scenario of a mother with an abundant supply, yet a baby
who is feeding ‘round the clock’. If the baby simply cannot
hold enough milk, the situation above will be com-
pounded by a baby who is also failing to grow well.
Cleft lip
Provided that the palate is intact, the presence of a cleft in
the lip should not interfere with breastfeeding because the
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vacuum that is necessary to enable the baby to attach to
the breast is created between the tongue and the hard
palate, not the breast and the lips.
Cleft palate
Because of the cleft, the baby is unable to create a vacuum
and form a teat out of the breast and nipple. There is no
reason why the mother should be discouraged from
putting the baby to the breast, for comfort, pleasure or
food, provided that she is aware of the above and appreci-
ates that it is likely that she will need to give her baby her
expressed milk as well. A variety of measures are available
to support feeding in infants thus affected until surgery
can take place (around 6 months of age) but little to
suggest that many of these babies will successfully breast-
feed (Reid 2004; Garcez and Guigliani 2005).
Tongue tie (Ankyloglossia)
If the baby cannot extend his tongue over his lower gum
he is unlikely to be able to draw the breast deeply into
his mouth to feed effectively (Johnson 2006). This
may be due to the tongue being short or because the
frenulum, which is the whitish strip of tissue attaching the
tongue to the floor of the mouth, is too tight or not
stretchy enough. As the baby tries to lifts his tongue, the
tip may sometimes become heart-shaped as the frenulum
pulls on it.
Increasingly it is argued that more emphasis should be
placed on tongue function rather than simply its appear-
ance as tongue movement is more complex than simply
the ability to protrude it beyond the gum ridge. Many
practitioners maintain that when attention to attachment
does not resolve a breastfeeding problem, a full assess-
ment should be carried out, observing any impairment of
activities that require a functional tongue (Hazelbaker
2010).
The National Institute for Health and Clinical Excel-
lence recommended that the surgical release of the frenu-
lum (frenotomy) was safe, only taking a few seconds to
perform in a young baby (NICE 2005). The procedure is
usually bloodless and painless and its practice is further
supported by evidence from clinical trials (Dollberg et al
2006; Hogan et al 2005) and ultrasound studies (Ramsay
2005; Geddes et al 2008).
Blocked nose
Babies normally breathe through their noses. Obstruction
causes great difficulty with feeding because they have to
interrupt the process in order to breathe. Blockages caused
by mucus may be relieved with a twist of damp cotton
wool, or by instilling drops of normal saline before a feed
(Bollag et al 1984).

Down syndrome
Babies who have Down syndrome can be successfully
breastfed, although extra help and encouragement may be
necessary initially (Chapter 32).
Prematurity
Preterm infants who have developed sucking and swallow-
ing reflexes may successfully breastfeed, which is consid-
ered to be less tiring than taking a feed by bottle (Meier
and Cranston-Anderson 1987). However, if the reflexes are
not strongly developed, the baby may tire before the feed
is complete and complementary feeding by nasogastric
tube may be necessary.
Babies who are too immature to breastfeed may be able
to cup-feed, as an alternative to being tube-fed (Lang et al
1994). Less mature babies who are unable to suck or
swallow will be dependent on receiving nutrition via arti-
ficial methods such as tube-feeding and intravenous
alimentation.
Illness or surgery
In general, babies recover quickly following illness or
surgery, but if they have never been to the breast, or if
feeding has been interrupted for a long period, the mother
will require skilled help from the midwife to initiate or
re-establish feeding.
Contraindications to breastfeeding
Breastfeeding may have to be suspended temporarily fol-
lowing the administration of certain drugs, e.g. chloram-
phenicol, or following diagnostic techniques using
radiopharmaceuticals. Most regions have drug centres/
hospital pharmacy information services where advice may
be sought about the safety of drugs for lactating women.
Carcinoma
If the mother has carcinoma, the cytotoxic treatment she
receives will make it impossible to breastfeed without
causing harm to the baby. However, if she wishes to, she
could express and discard her milk for the duration of the
treatment and resume breastfeeding later. If she has had a
mastectomy, she may feed successfully from the other
breast. The woman may also be able to breastfeed follow-
ing a lumpectomy for carcinoma, but it is advisable to seek
advice from her surgeon.
Breast surgery
Neither breast reduction nor augmentation is an inevita-
ble contraindication to breastfeeding, but much depends
on the techniques used. Where possible, advice should be
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Infant feeding Chapter | 34 |
sought from the surgeon. If the nipple has been displaced,
the duct system may not be patent. Nickell and Skelton
(2005) recommend that if surgery is proposed for a
woman who wishes to breastfeed in the future, it may be
possible to alter the surgery to preserve the ductal system.
Ultimately, the only way to determine if the breast will
function effectively is to test it by encouraging the baby to
go to the breast.
Breast injury
Injuries caused by scalding to the chest in childhood
may cause such severe scarring that breastfeeding is impos-
sible. Burns or other accidents may also cause serious
damage.
One breast only
It is perfectly possible to feed a baby effectively using just
one breast. If the mother has only one functioning breast,
she should be reassured that each breast works independ-
ently of the other. If the baby is offered only one breast,
that breast will make enough milk to feed that individual
baby. There are documented cases of women feeding two
babies with just one breast (Nicolls 1997).
Human immunodeficiency virus
(HIV) infection
Human immunodeficiency virus (HIV) may be transmit-
ted in breastmilk. In developed countries, where formula
milk feeding is relatively safe, the mother may be advised
not to breastfeed if she is HIV-positive (Chapter 13). In
countries where formula feeding is a significant cause of
infant mortality, exclusive breastfeeding for the first 6
months may be the safer option (Coutsoudis et al 1999;
Coovadia et al 2007; WHO et al 2010).
Cessation of lactation
Suppression of lactation
If a mother chooses not to breastfeed, or if she has a late
miscarriage or stillbirth, lactation will still commence. The
woman may experience discomfort for a day or two, but
if unstimulated the breasts will naturally cease to produce
milk. Very rarely, severe discomfort with engorgement
occurs. Expressing small amounts of milk once or twice
can afford great relief without interfering with the rapid
regression of the condition. The mother will be more com-
fortable if her breasts are supported, but it is doubtful if
binding the breasts contributes anything towards suppres-
sion (Swift and Janke 2003).
There is no basis on which to advise the mother
to restrict her fluid intake or to seek a prescription for a
diuretic, which will be equally ineffective (Hodge 1967).
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Section | 6 | The Neonate
These measures merely add to the woman’s discomfort by
making her thirsty. Pharmacological suppression of lacta-
tion with dopamine receptor agonists such as bromocrip-
tine and cabergoline is effective but is not recommended
for routine use. Bromocriptine and cabergoline are cur-
rently licensed in the UK, although bromocriptine had its
licence withdrawn in the United States of America (USA)
some time ago.
Discontinuation of breastfeeding
Discontinuing lactation abruptly once breastfeeding has
become established may cause serious problems for the
woman, leading to engorgement, mastitis or even a breast
abscess. The woman should be encouraged to mimic
normal weaning by expressing her breasts, reducing the
frequency over several days or possibly weeks. The gradual
reduction in the volume of milk removed from the breasts
results in a corresponding diminution in the production
of milk. Eventually the woman should be encouraged to
express only if she feels uncomfortable. Pharmacological
suppression using cabergoline might be appropriate fol-
lowing the death of a baby.
Returning to work
If the breastfeeding mother returns to work, her baby will
require feeding in her absence. If the woman wishes her
baby to continue taking breastmilk, she will need to
express her milk in advance. However, if the woman finds
it difficult to express her milk at work, her baby could
receive a formula feed (or solid food, if over 6 months),
while she is away, but continue breastfeeding at all other
times. Returning to work does not mean that breastfeeding
has to be terminated.
Weaning from the breast
When the mother or the baby decides to stop breastfeed-
ing, feeds should be tailed off gradually. Breastfeeds may
be omitted, one at a time, and spaced further apart. Adding
supplementary foods should not begin until about 6
months of age. If the mother uses solid food to give the
baby tasters and the experience of different textures before
weaning, these should be given after the breastfeed. Solid
foods given to the baby before the breastfeed (weaning)
will result in them taking less milk from the breast and
less milk being produced. Allowing the baby to lead the
process of weaning (Rapley 2012) may make the transition
much easier.
Complementary and
supplementary feeds
Complementary feeds or top-ups are feeds given to the baby
after a breastfeed. Complementary feeds of breastmilk sub-
stitutes (formula milk) should be given as a last resort, not
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as an alternative to helping the mother with breastfeeding
or expressing milk. Exposure to non-human milk proteins
has been implicated in the development of type 1 diabe-
tes, eczema and wheeze/asthma (Renfrew et al 2012).
Even a single exposure can sensitize susceptible infants
(Host 1991).
The 2010 Infant Feeding Survey (McAndrew et al 2012)
found that 31% of babies born in UK hospitals received
breastmilk substitutes while in hospital. The mothers of
these babies were three times more likely to have given up
breastfeeding by the time their baby was a week old, in
comparison with mothers whose babies received only
breastmilk.
About 10% of newborns are at risk of hypoglycaemia
(Chapter 33), and may thus need a higher calorific intake
straight from birth than their mothers can provide. Where
possible this should be the mother’s expressed colostrum
or human milk obtained from a human milk bank.
Babies who are well but sleepy (Box 34.2), jaundiced
(Chapter 33), unsettled (Box 34.3), or difficult to attach
(see Box 34.1 above), should be given their mother’s own
expressed milk if necessary, in addition to being offered
the breast.
If complementary feeds are clinically indicated and the
mother cannot express sufficiently, donor milk from a
human milk bank could be used. Donors are serologically
tested for HIV and other conditions.
If the baby is very young, additional feeds should be
given by oral syringe or cup, rather than by bottle. An oral
syringe (or dropper) will reduce wastage and the use of a
cup would allow the baby to remain more in control of
their intake. If the difficulty persists, for example with
attachment, the mother may find it quicker and more
Box 34.2 ‘Sleepy’ babies
Provided that the baby is otherwise well, which will be
determined by examining the baby from time to time,
there is no evidence that long intervals between feeds
have any adverse affect. As few as three feeds in the first
24 hours of life is within the normal range.
• The baby should remain close to the mother, in
accordance with UNICEF–UK (2012b guidelines). The
mother will thus be able to respond immediately to
her baby’s feeding cues.
• The baby could be roused at intervals, possibly by
changing the nappy, and being offered the breast.
• The baby could be undressed down to the nappy and
placed in skin contact with the mother and offered
the breast.
• The mother could be shown how to hand express
some colostrum, and how to give this to the baby.
• It is unnecessary to measure the baby’s blood glucose
levels (see Chapter 33).

Box 34.3 If the baby is unsettled
An unsettled baby of any age that is crying again soon
after he has been fed may not have been well attached.
• Observe what the mother is doing and, if necessary,
guide her or help her directly.
• If the attachment is good, then the baby may be
reacting to being removed from the closeness of the
mother’s body. If the mother needs to sleep, suggest
that she feeds lying down and help her if necessary.
However, it is imperative that the baby’s safety is
maintained should the feed take place in the bed.
• The mother might try to express some colostrum/milk
to give to the baby if she is concerned that the baby
has not received all that he can from the breast
• Some babies will appear unsettled even if they have
fed well at the breast. The baby may be
uncomfortable. The act of changing the nappy may
help; so may wrapping the baby comfortably but
securely and providing rhythmic motion, such as
walking or holding the baby over the shoulder or over
the forearm, both of which apply gentle pressure to
the baby’s abdomen to help settle him down
• Show the mother what you are doing, so that she
learns appropriate coping strategies from you.
• If you give the baby formula or a dummy to settle
him, that is what the mother will do when she goes
home
• Do not offer to remove the baby. Separating mother
and baby, particularly removing the baby at night in
the mistaken belief that the mother will benefit if she
does not wake to breastfeed her baby at night, is
strongly correlated with reduced breastfeeding success
(WHO, 1998).
• If the mother asks you to, and you agree to take the
baby away to settle, return the baby to her when he
wakes again to be fed.
efficient to give her expressed milk to the baby by bottle.
There is no evidence that the baby will subsequently refuse
the breast in these circumstances (Brown et al 1999;
Howard et al 2003; Flint et al 2007).
Supplementary feeds are feeds given in place of a breastfeed.
There is no justification for their use except in exceptional
circumstances, such as severe illness or unconsciousness.
This is because each breastfeed that is missed by the baby
interferes with the establishment of lactation and affects
the mother’s confidence in being able to successfully breast-
feed her baby.
Human milk banking
Research over the past couple of decades has demonstrated
the effectiveness of pasteurization as a means of destroying
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Infant feeding Chapter | 34 |
Box 34.4 Donated breastmilk
If you are offering a mother donated human milk for her
baby for any reason, she might find the information
below helpful in deciding whether to accept it.
• All human milk donors meet the same criteria as
blood donors; they are in a low risk group to start
with and give consent to an HIV blood test
• All human milk donors sign a form to that effect and
all have their blood tested.
• Almost all donors are currently feeding their own
baby while donating.
• No donated milk is used for any baby until the results
of the donor’s blood test have been received.
• All donated milk is collected in sterilized bottles, kept
in the fridge and frozen within 24 hours of
expression.
• When it arrives, still frozen, at the milk bank, it is
thawed, a small sample taken for bacteriological
screening and the rest is pasteurized.
• After pasteurization another small sample is taken (for
post-pasteurization bacteriological screening) and the
rest refrozen in a holding freezer.
• Only when the results of both samples have been
received is the milk transferred to the freezer from
which it can be used for preterm and term babies.
• Donors are not paid for the milk they donate: it is
freely given! Quite often, mothers choose to donate
milk because their own babies were themselves
helped in this way by the generosity of other mothers.
HIV (Eglin and Wilkinson 1987) and the importance of
human milk in preventing necrotizing enterocolitis (NEC)
(Quigley et al 2008). This resulted in the formation of the
UK Association for Milk Banking (UKAMB) in 1998 and
re-establishing human milk banks.
Banked human milk is used predominantly for preterm
and sick babies. Occasionally, if there is sufficient, it is
used for term babies whose mothers are temporarily
unable to meet their babies’ needs with their own expressed
milk. Mothers who are offered donated milk for their
babies must have sufficient information about the collec-
tion and screening of human milk to enable them to make
an informed choice whether or not to accept it (see
Box 34.4).
CHOOSING BREAST OR
FORMULA MILK
Although the majority of women who choose to breast-
feed have made this decision very early on, some may not
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Section | 6 | The Neonate
make a final decision until after giving birth. The subject
of infant feeding should be part of an ongoing conversa-
tion that the woman has with her midwife as her pregancy
progresses. During these conversations the midwife should
share the value of skin contact for all mothers and babies,
explore what parents already know about breastfeeding
and help them to appreciate the value of breastfeeding as
protection, comfort and food so they can make an
informed choice (UNICEF–UK 2012b).
Observing a baby being breastfed can strongly influence
the decision to breastfeed either positively or negatively,
depending on the context (Hoddinott and Pill 1999). This
is of particular relevance for women for whom theoretical
knowledge may have less power than embodied knowl-
edge. Peer group support can influence both initiation and
continuation of breastfeeding (Fairbank et al 2000) and
introducing pregnant women to other mothers who are
breastfeeding young babies may also be helpful. This is
now done in many ‘Baby Cafés’ throughout the UK.
Time should be taken during the antenatal period
to talk briefly about the day-to-day progress and manage-
ment of early breastfeeding. The woman should be
aware that:
• Breastfeeding is a learned skill.
• It should not hurt.
• She does not need to be taught the major details of
management until after the baby is born.
The midwife’s responsibility to the woman is to ensure
that her choice is fully informed, rather than to persuade
her to breastfeed. This cannot be achieved if the midwife
withholds information from her. The nutritional and
immunological consequences of not breastfeeding are
seen in population studies, and are to do with relative
risks. It is not possible to narrow the risk down to the
individual. Nevertheless, all pregnant women should be
made aware that, compared with a fully breastfed baby, a
baby fed on formula milk from birth is:
• five times more likely to be hospitalized with
gastroenteritis (within the first 3 months of life)
• five times more likely to suffer from urine infections
(within the first 6 months of life)
• twice as likely to suffer from chest infections (within
the first 7 years of life)
• twice as likely to suffer from ear infections (within
the 1st year of life)
• twice as likely to develop atopic disease where there
is a family history
• up to 20 times more likely to develop necrotizing
enterocolitis if born prematurely.
Additionally, the pregnant woman should know that she
may increase her own risk of postnatal depression, pre-
menopausal breast cancer, ovarian cancer and osteoporo-
sis if she does not breastfeed (UNICEF and Department of
Health 2012).
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FEEDING WITH FORMULA MILK
Most breastmilk substitutes (infant formulae) are modi-
fied cow’s milk. The minimum and maximum permitted
levels of named ingredients, and named prohibited ingre-
dients in all cow’s milk-based (and soya infant) formulae
have to meet strict criteria (Infant Formula and Follow-on
Formula Regulations 2007). However, considerable varia-
tions in composition exist within the legally permitted
ranges.
The two main components are skimmed milk, which is a
by-product of butter manufacture, and whey, which is a
by-product of cheese manufacture. Breastmilk substitutes
may contain fats from any source, animal or vegetable,
except from sesame and cotton, provided that they do not
contain >8% trans isomers of fatty acids. The fat source
may not always be apparent from reading the label: for
example oleo is beef fat and would be unacceptable to
Hindus and vegetarians, and oils of vegetable origin may
have come from marine algae. Formula milks may also
contain soya protein, maltodextrin, dried glucose syrup
and gelatinized and pre-cooked starch.
Types of formula milk
There are two main types of formula milk: whey-dominant
and casein-dominant. Both can be used from birth. There
is a comprehensive and quarterly updated report for
health professionals called Infant Milks in the UK (Crawley
and Westland 2013) produced by an independent charity,
First Steps Nutrition Trust.
Whey-dominant formulae
In these, a small amount of skimmed milk is combined
with demineralized whey. The ratio of proteins in the
formulae approximates to the ratio of whey to casein
found in human milk (60 : 40). These feeds are more easily
digested than the casein-dominant formulae, which have
an effect on gastric emptying times, with feeding patterns
that more closely resemble those of breastfed babies.
Casein-dominant formulae
Although these formulae are also promoted as suitable for
use from birth and are aimed at mothers whose babies are
hungrier, their use is not recommended for young babies.
Whilst the macronutrient proportions (fat, carbohydrate,
protein, etc.) are the same as in whey-dominant formulae,
more of the protein is in the form of casein (20 : 80). The
higher casein content causes large, relatively indigestible
curds to form in the baby’s stomach, intending to make
them feel full for longer. There is no evidence that babies
settle better or sleep longer if given these milks (Taitz and
Scholey 1989; Thorkelsson et al 1994).

Milks for babies intolerant of
standard formulae
Predicting which babies will be prone to allergies is an
inexact science. It is estimated that the likelihood of a baby
being predisposed to allergy is about 20–35% if one
parent is affected, 40–60% if both parents are affected and
50–70% if both parents have the same allergy (Brostoff
and Gamlin 1998).
Hydrolysate formula
Hydrolysate formula is made of cow’s milk, cornstarch and
other foods, treated with digestive enzymes so that the
milk proteins are partially broken down. It has been
thought in the past that these alternatives carry less risk of
allergy than standard formulae.
Some of these (prescription-only) hydrolysates are
intended to treat an existing allergy, and others are designed
for preventative use in babies who are at high risk of devel-
oping cow’s milk protein allergy and who are not breast-
feeding (Brostoff and Gamlin 1998). Not only are these
substances considerably more expensive than either stand-
ard or soya-based formula, NICE (2008) guidance now
maintains that there is insufficient evidence that infant
formula based on partially or extensively hydrolysed cow’s
milk protein helps prevent allergies.
Whey hydrolysates
These formulae are made from the whey of cow’s milk
(rather than from whole milk) and have been thought to
be potentially more useful for highly allergenic babies.
Amino-acid-based formula,
or elemental formula
Amino-acid-based formula, or elemental formula has a
completely synthetic protein base, providing essential and
non-essential amino acids, together with fat, maltodextrin,
vitamins, minerals and trace elements. This type of formula
milk is very expensive.
Soya-based formula
Soya-based formula was developed as a response to the
emergence of cow’s milk protein intolerance in babies fed
on formula milk. However, there has been mounting evi-
dence that soya-based formula’s high phytoestrogen
content could pose a risk to the long-term reproductive
health of infants (Martyn 1999; Minchin 2001). Conse-
quently soya-based formula milk should be used only in
exceptional circumstances to ensure adequate nutrition,
for example with babies of vegan parents who are not
breastfeeding or babies who are unable to tolerate alterna-
tives, such as amino-acid formulae (Crawley and Westland
2013).
Many babies who are intolerant of cow’s milk are also
intolerant of soya. Early soya formula feeding runs the risk
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Infant feeding Chapter | 34 |
of inducing soya protein intolerance in the child and soya
protein is much harder to avoid in the weaning diet than
dairy products.
Goat’s milk formula
The European Food Standards Agency (EFSA) (2006) con-
cluded that there were insufficient data to establish the suit-
ability of goat’s milk protein as a protein source in infant
formula, and since March 2007 infant milks based on goat’s
milk were no longer sold in the UK. However, in 2012, EFSA
revised their conclusion on the suitability of goat’s milk as
a protein source for infant and follow-on formula milks
and the expectation was that the Infant Formula and
Follow-on Formula (England) Regulations (2007) would
be changed sometime in 2013 to allow goat’s milk-based
infant milks (Crawley and Westland 2013). However, at the
time of going to press these changes have yet to be made.
Choosing a breastmilk substitute
Although not always enforced, it is an offence under UK
law to sell any infant formula as being suitable from birth
unless it meets the criteria set out in the Infant Formula
and Follow-on Formula Regulations (2007). Despite
claims made by formula manufacturers, there is no
obvious scientific basis on which to recommend one
brand over another.
It is not necessary for the mother to stick to one brand,
and if she finds that one formula milk does not suit her
baby she could try an alternative brand. This has been
made easier by the availability of ready-to-feed sachets or
cartons, with which mothers can experiment without
having to buy large quantities of formula milk. Babies
with underlying metabolic disorders, such as galactosae-
mia or phenylketonuria, however, require the appropriate,
prescribable breastmilk substitute.
As formula milks are highly processed, factory-produced
products, there inevitably can arise inadvertent errors,
such as too much or too little of an ingredient, accidental
contamination, incorrect labelling and foreign bodies. It
is therefore imperative that mothers are advised to inspect
the contents of the tin or packet before use and if it looks
or smells strange, return it to the seller.
Preparation of an artificial feed
The introduction of ready-to-feed formula in hospital may
save staff time, but it reduces the likelihood that the
mother who chooses to feed her baby with formula milk
will have been shown how to prepare a bottle feed
safely before she goes home (Kaufmann 1999). It is now
required, in Baby Friendly-accredited hospitals that all
mothers intending to formula-feed their baby are given the
information they need to do so in a way that reduces the
risk to the baby (UNICEF–UK 2012b).
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Section | 6 | The Neonate
All powdered formula feed available in the UK is now
reconstituted using one scoopful (the scoop being pro-
vided with the powder) to 30 ml of cooled boiled water.
Clear instructions about the volumes of powder and water
are also printed on the container. Many of the major UK
manufacturers of formula milk now produce ready-to-feed
cartons, reducing the risk of over- or under-concentration,
but precluding universal use through higher cost. Another
advantage of ready-to-feed formula is that the contents are
sterile whereas powdered milk, in tins or packets, is not.
In response to growing concerns about bacterial con-
taminants in these powders, the WHO produced guidelines
on the safe preparation, storage and handling of powdered
infant formula (WHO 2007), and the Food Standards
Agency (FSA) and Department of Health subsequently
changed their recommendations in relation to reconstitu-
tion. Anyone making up feeds from powder is advised to
make each feed just before it is needed, using water that
has boiled and cooled to 70 °C, adding the powder, allow-
ing the milk to cool and giving the feed straight away. Any
remaining milk should be discarded (DH 2012).
The water supply
It is essential that the water used is free from bacterial
contamination and any harmful chemicals. It is generally
assumed in the UK that boiled tap water will meet
these criteria, but from time to time this is shown not
to be the case. If bottled water is used, a still, non-
mineralized variety suitable for babies must be chosen and
it should be boiled as usual. Softened water is usually
unsuitable.
Feeding equipment
Concern over the nitrosamine content of rubber teats and
dummies was addressed in the EU in 1993, and since
1995, teats and dummies that do not comply with the
1993 directive (EFSA 1993) have been prohibited. However
teats that are frequently boiled can quickly become spongy
and swollen. The alternative, silicone teats, have been
known to split with repeated use. Mothers should be
advised to check teats regularly for signs of damage and
discard them if in doubt.
No bottle teat is like a breast. Real-time ultrasound
measurements of infants during sucking using different
types of teats were made by researchers (Nowak et al
1994) to determine the percentage of lengthening, lateral
compression and flattening of the teats. Comparison with
data obtained from studies using breastfed infants showed
none of the teats lengthened like the human nipple. Scheel
et al (2005) investigated the relative merits of three differ-
ent types of teats. The rate of milk transfer for the preterm
babies studied was the primary outcome measure. Suction
amplitude and duration of the generated negative intraoral
suction pressure were also measured. No type of teat had
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any advantage over any other. The mother should feel free
to experiment, and use the type of teat that seems to suit
her baby. It may be easier for the baby to use a simple soft
long teat than industry-labelled orthodontic teats (Kassing
2002).
Feeding bottles must also meet the UK standard. This
means they will be made of food-grade plastic and have
relatively smooth interiors. Crevices and grooves in a
bottle make cleaning difficult. Patterned or decorated
bottles make it less easy to see whether the bottle is clean.
Sterilization of feeding equipment
Effective cleaning of all utensils used should be demon-
strated to the mother and methods of sterilization dis-
cussed. The most important prerequisite is that all
equipment is thoroughly washed in hot, soapy water and
well rinsed before proceeding further. If boiling is to be
used, full immersion is essential and the contents must be
boiled for 10 minutes. If cold sterilization using a
hypochlorite solution is the method of choice, the utensils
must be fully immersed in the solution for the recom-
mended time. The manufacturer’s advice must be followed
when rinsing items removed from the solution. If the item
is to be rinsed, previously boiled water should be used and
not water directly from the tap. Steam and microwave
sterilization are also possible, but the mother should
check that her equipment can withstand such methods.
Bottle teats
The size of the hole in the teat causes much anxiety to
mothers. It is probably a good idea to have several teats
with holes of different sizes so that the mother can experi-
ment as necessary. To test the hole size, turn the bottle upside
down and the milk should drip at a rate of about one drop per
second.
Feeding the baby with the bottle
The baby must never be left unattended while feeding
from a bottle and mothers should be warned about the
dangers of bottle propping. The mother should try to simu-
late breastfeeding conditions for the baby by holding the
baby close, maintaining eye-to-eye contact and allowing
the baby to determine his intake. The baby should be held
fairly upright, with his head supported in a comfortable,
neutral position.
The innate skills a baby has for breastfeeding should also
be used when feeding from a bottle. The baby’s lips should
be touched to elicit the mouth to open wide and the teat
should follow the line of the baby’s tongue, so that the baby
uses the teat effectively. The bottle should be held horizon-
tal to the ground, tilted just enough to ensure the baby is
taking milk, not air, through the teat (UNICEF–UK 2010b).

When correctly prepared, modern formula milks do not
cause hypernatraemia as did the older types. There is there-
fore no need to give the baby extra water.
The stools and vomit of a baby fed on formula milk
have an unpleasant sour smell. The stools tend to be more
formed than those of a breastfed baby and, unlike a breast-
fed baby, there is a real risk that the artificially fed baby
may become constipated.
Healthy Start (and the Welfare
Food Scheme)
In 1940 the Welfare Food Scheme was established in the
UK, providing tokens to families on low incomes to be
exchanged for liquid milk or breastmilk substitutes. This
scheme was replaced, in November 2006, by the Healthy
Start Initiative. This scheme broadened the nutritional base
of the Welfare Food Scheme to allow fruit and vegetables
as well as liquid milk or breastmilk substitutes to be
obtained through the exchange of fixed value vouchers at
a range of food and supermarket outlets. Those eligible to
receive the vouchers include:
• Pregnant women and families with children under
the age of 4 years who receive:
■ Income Support
■ Income-based Jobseeker’s Allowance or
■ Child Tax Credit (but not Working Tax Credit),
with an annual family income of ≤£16 190 a year
2013/2014)
• All pregnant women under the age of 18, whether or
not they are receiving benefits or tax credits.
Those eligible for vouchers are also entitled to free vitamin
supplements for themselves, and for their children from
6 months until their 4th birthday.
Midwives and the International
Code of Marketing of Breastmilk
Substitutes
In 1981, the combined forces of WHO and UNICEF pro-
duced a marketing code (WHO 1981), which was adopted
at the 34th World Health Assembly. The code has major
implications for the work of midwives. Although it is at
present a voluntary code in most countries, some coun-
tries now have the code enshrined in law. Recommenda-
tions include:
• No advertising or promotion in hospitals, shops or
to the general public (this includes posters and
advertisements in mother-and-baby books).
• Not giving free samples of breastmilk substitutes to
mothers.
• No free gifts relating to products within the scope of
the code to be given to mothers (including discount
coupons or special offers).
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Infant feeding Chapter | 34 |
• No financial or material gifts to health workers for
the purpose of promoting products, nor free or
subsidized supplies to hospitals or maternity wards.
• Information provided by manufacturers to health
workers should include only scientific and factual
material, and not create or imply a belief that
bottle-feeding is equivalent or superior to
breastfeeding.
• Health workers should encourage and protect
breastfeeding.
The code does not prevent mothers from feeding their
babies with infant formula, but rather seeks to contribute
to safe, adequate nutrition for babies and to promote and
protect breastfeeding.
THE BABY FRIENDLY HOSPITAL
INITIATIVE
The Baby Friendly Hospital Initiative (BFI) was an initia-
tive launched worldwide in 1991 (and in the UK in 1994)
by WHO and UNICEF to encourage hospitals to promote
practices supportive of breastfeeding. It was focused
around the 10 steps to successful breastfeeding (Box 34.5),
with which all hospitals who wish to achieve Baby Friendly
status must comply (WHO/UNICEF 1989). Evidence for
Box 34.5 The 10 steps to successful
breastfeeding
1. Have a written breastfeeding policy that is routinely
communicated to all healthcare staff.
2. Train all healthcare staff in skills necessary to
implement this policy.
3. Inform all pregnant women about the benefits and
management of breastfeeding.
4. Help mothers initiate breastfeeding soon after birth.
5. Show mothers how to breastfeed and how to
maintain lactation even if they should be separated
from their infants.
6. Give newborn infants no food or drink other than
breastmilk, unless medically indicated.
7. Practice rooming-in: allow mothers and infants to
remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or dummies to breastfeeding
infants.
10. Foster the establishment of breastfeeding support
groups and refer mothers to them on discharge from
hospital or clinic.
WHO/UNICEF 1989
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Section | 6 | The Neonate

the 10 steps is contained in the WHO/UNICEF document
of the same name (Vallenas and Savage 1998). This has
subsequently been extended to community-based facili-
ties, neonatal units and university training programmes
for midwifery and health visiting, all of which can be BFI-
accredited in their own right. In addition, all accredited
Baby Friendly facilities must fully implement the Interna-
tional Code on the Marketing of Breastmilk Substitutes.
Mothers should expect a certain standard of care from
a Baby Friendly hospital (UNICEF–UK 2011c):
When pregnant:
• To have a full discussion about caring for and
feeding their baby, including the benefits of
breastfeeding, so that they have all the facts to make
an informed choice.
When the baby is born:
• To be given their baby to hold against their
skin straight after they are born, for as long as
they want
• To have a midwife offer them help to start
breastfeeding as soon as possible after the baby is
born
• To have their baby stay with them at all times.
If they decide to breastfeed:
• To be shown how to hold the baby and how to help
him latch on – making sure the baby gets enough
milk and feeding is not painful
• To be given accurate and consistent advice about
how to breastfeed and to make enough milk for the
baby
• To be shown how to express milk by hand
• To receive information about how to get more
support for breastfeeding, should they need it, once
they leave hospital
• That the baby will not be given water or artificial
baby milk, unless this is needed for a medical
reason.
A mother can expect that staff will support her if she
decides that she wants to care for her baby differently or
she does not want the information offered. If she decides
to feed her baby with formula milk, she can expect to be
asked if she wants to be shown how to make up a bottle
feed safely and correctly.
The National Institute for Health and Clinical Excel-
lence (NICE 2006a) recommended that all maternity care
providers should implement an externally evaluated,
structured programme encouraging breastfeeding, using
the BFI as a minimum standard. Thus all such healthcare
providers should either implement NICE guidance or
perform a risk assessment if they reject it (that is, placed
on a risk register). Rejection on the grounds of cost, which
has often been cited as a reason for not implementing BFI
in the past, is unlikely to be acceptable, as NICE econo-
mists have documented the fact that implementation
would be cost-effective (NICE 2006b; UNICEF–UK 2012a).

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Section | 6 | The Neonate
FURTHER READING
Hale T, Hartmann P 2007 Hale and
Hartmann’s textbook of human
lactation. Hale Publishing, Amarillo
TX
A multi-author textbook, in six sections:
anatomy and biochemistry, immunobiology,
management of the infant, management of
the mother, maternal and infant nutrition
and medications.
Hall Moran V (ed) 2012 Maternal and
infant nutrition and nurture:
controversies and challenges, 2nd
edn. Quay Books, London
This multi-author book uses a
sociobiological perspective to examine the
complex interaction between political,
sociocultural and biological factors in food
and health in relation to maternal and
infant nutrition.
Inch S, Fisher C 1999 Breast-feeding:
into the 21st century. NT clinical
monographs, No. 32. Emap
Healthcare, London. Available at
www.amazon.ca/dp/190249976X
A concise but wide-ranging review of the
importance of breastfeeding, the difficulties
facing midwives who want to help
breastfeeding women and the ways in
which these might be overcome.
USEFUL WEBSITES AND CONTACT DETAILS
Association of Breastfeeding Mothers:
www.abm.me.uk
Helpline: tel 0300 330 5453
Baby Milk Action:
www.babymilkaction.org
34 Trumpington Street, Cambridge CB2
1QY. Tel 01223 464420
Baby Feeding Law Group:
www.babyfeedinglawgroup.org.uk/
The Baby Feeding Law Group is made up
of leading UK health professional and
mother support organizations working to
strengthen UK baby feeding laws in line
with UN recommendations.
736
mebooksfree.com
Infant Formula and Follow-on Formula
Regulations 1995; updated 2007
Stationery Office, London. Online.
Available at: www.legislation.gov.uk/
uksi/2007/3521/contents/made
This is the UK government’s response to the
European Directive 1991 (91/321/EEC OJ
No. L175, 4.7.91), which sought to
persuade all EU countries to adopt the
International Code of Marketing of
Breastmilk Substitutes. It still falls short of
the code in several important respects,
notably in relation to advertising.
Palmer G 2009 The politics of breast-
feeding, 3rd edn. Pinter and Martin,
London
This book links biology and politics (sexual,
economic and environmental) in an
exploration of the consequences of women’s
changing role in society and the
acceleration of the Industrial Revolution,
which created the demand for ‘artificial
milks’.
Renfrew M J, Fisher C, Arms S 2004
Breastfeeding: how to breastfeed
your baby, 3rd edn. Celestial Arts,
Berkeley, CA
Taking up where texts addressed primarily
to health workers leave off, the authors
Breastfeeding Network:
www.breastfeedingnetwork
.org.uk
BfN Supporterline: tel 0300 100 0210
CLAPA (Cleft Lip And Palate
Association):
www.clapa.com
235–237 Finchley Road, London NW3
6LS. Tel 020 7431 0033
Healthy Start Initiative:
www.healthystart.nhs.uk
La Leche League:
www.laleche.org.uk
Helpline: tel 0845 120 2918
blend wisdom, experience, idealism and
learning to produce a clear, basic
breastfeeding guide that is focused primarily
at mothers.
World Health Organization (WHO)/
UNICEF 1981 International Code of
Marketing of Breast Milk Substitutes.
Online. Available at: www
.babymilkaction.org/regs/thecode
.html
This was adopted by a resolution
(WHA34.22) of the World Health
Assembly in 1981. A copy of the code can
also be obtained from Baby Milk Action
(see Useful Websites and Contact Details,
below).
World Health Organization (WHO)
1989 Protecting, promoting and
supporting breast-feeding: the special
role of maternity services. A Joint
WHO/UNICEF Statement. WHO,
Geneva
This is the document that first set out the
10 steps for successful breastfeeding, which
formed the basis of the global Baby Friendly
Hospital Initiative, and makes
recommendations concerning the structure
and function of (maternity) healthcare
services.
National Childbirth Trust:
www.nct.org.uk
Tel: 0870 444 8708; enquiry line:
0870 444 8707
UNICEF UK Baby Friendly Initiative:
www.babyfriendly.org.uk
Africa House, 64–78 Kingsway, London
WC2B 6NB. Tel: 0300 330 0700
A short video How to hand express is
available at: www.unicef.org.uk/
BabyFriendly/Resources/AudioVideo/
Hand-expression/
Glossary of terms and acronyms
Abruptio placenta: Premature
separation of a normally situated
placenta. This term is commonly
used from viability (24 weeks).
Acridine orange: A stain used in
fluorescence microscopy; it that
causes bacteria to fluoresce green
to red.
Aetiology: The science of the cause
of disease.
Affective awareness: An awareness
of feelings and ability to express
them.
Affective neutrality: Known as
professional detachment.
Alveoli: Terminal sacs at the end of
the bronchial tree where gaseous
exchange takes place.
Anhedonia: The loss of pleasure.
Amenorrhoea: Absence of
menstrual periods.
Amniotic fluid embolism
(AFE): The escape of amniotic
fluid through the wall of the
uterus or placental site into the
maternal circulation, triggering
life-threatening anaphylactic
shock in the mother. (The word
‘embolism’, denoting a clot, is a
misnomer.)
Amniotomy: Artificial rupture of the
amniotic sac.
Anteflexion: The uterus bends
forwards upon itself.
Anterior obliquity of the
uterus: Altered uterine axis. The
uterus leans forward due to poor
maternal abdominal muscles and
a pendulous abdomen.
Anteversion: The uterus leans
forward.
Antigen: A substance that stimulates
the production of an antibody.
Anuria: Lack of urine production.
Apnoea: An absence of breathing for
more than 20 seconds.
Asynclitism: The presentation of the
fetal head at an oblique angle
between the axis of the presenting
part of the fetus and the pelvic
planes during labour/childbirth
(also known as obliquity).
Atresia: Closure or absence of an
usual opening or canal.
mebooksfree.com
Augmentation of labour:
Intervention to correct slow
progress in labour.
Bandl’s ring: An exaggerated
retraction ring seen as an oblique
ridge above the symphysis pubis
between the upper and lower
uterine segments, which is a sign
of obstructed labour.
Basal body temperature: The
temperature of the body when at
rest. In natural family planning,
it is taken as soon as the woman
wakes from sleep and before any
activity occurs or after a period of
at least 1 hour’s rest.
Basal plate: The maternal side of
the placenta.
Beneficence: To do good.
Bicornuate uterus: A structural
congenital malformation of the
uterus that results in two horns;
commonly referred to as a
‘heart-shaped’ uterus.
Bioavailability: The degree to which
or rate at which a drug or other
substance becomes available to
the target tissue after
administration.
Bioequivalent: Acting on the body
with the same strength and similar
bioavailability as the same dosage
of a sample of a given substance.
Bipolar disorder: A mental illness or
mood disorder where the
individual experiences periods of
depression and elevated mood
(mania). (Previously known as
manic depression.)
Birth centres: These may be
freestanding (away from hospital)
or in hospital grounds or in the
hospital. The emphasis is on
providing a less medical
environment and supporting
normal birth.
Bishop’s Score: Rating system to
assess suitability of cervix for
induction of labour.
Bregma: Anterior fontanelle.
Burns–Marshall manoeuvre: A
method of breech birth involving
traction to prevent the fetal neck
from bending backwards.
Caput succedaneum: A diffuse
oedematous swelling under the
scalp but above the periosteum.
Cardiotocogram/graphy
(CTG): Measurement of the fetal
heart rate and uterine contractions
on a machine that is able to
provide a paper printout of the
information it records.
Care of the Next Infant (CONI): A
programme of support facilitated
by The Lullaby Trust (previously
known as the Foundation for the
Study of Infant Deaths [FSID]).
Caseload practice: A personal
caseload where named midwives
care for individual women.
Central venous pressure (CVP)
line: An intravenous (IV) tube
that measures the pressure in the
right atrium or superior vena cava,
indicating the volume of blood
returning to the heart and by
implication, hypovolaemia.
Cephalhaematoma
(cephalohaematoma): An
effusion of blood under the
periosteum that covers the skull
bones.
Cephalopelvic disproportion
(CPD): Disparity between the size
of the woman’s pelvis and the
fetal head.
Cerclage: Non-absorbable suture
inserted to keep cervix closed.
Cervical eversion: Physiological
response by cervical cells to
hormonal changes in pregnancy.
Cells proliferate and cause the
cervix to appear eroded.
Cervical intra-epithelial neoplasm
(CIN): Progressive and abnormal
growth of cervical cells.
Cervical ripening: Process by which
the cervix changes and becomes
more susceptible to the effect of
uterine contractions. Can be
physiological or artificially
produced.
Cervicitis: Inflammation of the
cervix.
Choanal atresia: (Bilateral)
membranous or bony obstruction
of the nares; the baby appears
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 Glossary of terms and acronyms
blue when sleeping and pink
when crying.
Chorionic plate: The fetal side of
the placenta.
Choroid plexus cyst: Collection of
cerebrospinal fluid within the
choroid plexi, from where
cerebrospinal fluid is derived.
Chromosome: An organized
structure of DNA and organized
proteins that carries genes.
Coloboma: A malformation
characterized by the absence of or
a defect in the tissue of the eye;
the pupil can appear keyhole-
shaped. It may be associated with
other anomalies.
Colposcopy: Visualization of the
cervix using a colposcope.
Commensal: Micro-organisms
adapted to grow on the skin or
mucous surfaces of the host,
forming part of the normal flora.
Conjoined twins: Identical twins
where separation is incomplete so
their bodies are partly joined
together and vital organs may be
shared.
Coronal suture: Membranous tissue
separating the frontal bones from
the parietal bones.
Couvelaire uterus (uterine
apoplexy): Bruising and oedema
of uterine tissue seen in placental
abruption when leaking blood is
forced between muscle fibres
because the margins of the
placenta are still attached to the
uterus.
Cricoid pressure: A technique
whereby pressure is exerted on the
cartilaginous ring below the larynx
(the cricoid) to occlude the
oesophagus and prevent reflux.
Cricoid pressure is employed
during the induction of a general
anaesthetic to prevent acid
aspiration syndrome.
Cryotherapy: Use of cold or freezing
to destroy or remove tissue.
Cryptorchidism: Undescended
testes, which may be unilateral or
bilateral.
Decidualization: The structural
changes that occur in the
endometrium in preparation for
implantation.
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De-infibulation: Being opened.
Delusion: A false fixed belief that is
impenetrable to reason.
Deontology: Duty-based theory.
Deoxyribonucleic acid (DNA): The
substance containing genes. DNA
can store and transmit
information, can copy itself
accurately and can occasionally
mutate.
Diastasis symphysis pubis: A
painful condition in which there
is an abnormal relaxation of the
ligaments supporting the pubic
joint; also referred to as pelvic
girdle pain.
Dichorionic twins: Two individuals
who have developed in their own
separate chorionic sacs.
Diploid: Containing two sets of
chromosomes.
Disseminated intravascular
coagulation/coagulopathy
(DIC): A condition secondary to a
primary complication where there
is inappropriate blood clotting in
the blood vessels, followed by an
inability of the blood to clot
appropriately when all the clotting
factors have been used up.
Dizygotic (binovular): Formed from
two separate zygotes.
Ductus arteriosus: A temporary
fetal structure which leads from
the bifurcation of the pulmonary
artery to the descending aorta.
Ductus venosus: A temporary fetal
structure which connects the
umbilical vein to the inferior
vena cava.
Dyspareunia: Painful or difficult
intercourse experienced by the
woman.
Ectoderm: The outermost layer of
three primary germ cell layers
present in the early embryo.
Ectopic pregnancy: An abnormally
situated pregnancy, most
commonly in a uterine tube.
Endocervical: Relating to the
internal canal of the cervix.
Endoderm: The innermost layer of
three primary germ cell layers
present in the early embryo.
Epicanthic folds: A vertical fold of
skin on either side of the nose
which covers the lacrimal caruncle.
They may be common in Asian
babies, but may indicate Down
syndrome in other ethnic groups.
Episiotomy: A surgical incision
made to enlarge the vaginal orifice
during childbirth.
Erb’s palsy: Paralysis of the arm due
to the damage to cervical nerve
roots 5 and 6 of the brachial
plexus.
Erythematous: Reddening of the
skin.
Erythropoiesis: The process by
which erythrocytes (red blood
cells) are formed. After the 10th
week of gestation, erythropoiesis
production rises and seems to be
involved in red cell production in
the bone marrow during the third
trimester.
Exomphalos (omphalocele): A
defect in which the bowel or other
viscera protrude through the
umbilicus.
External cephalic version (ECV):
The use of external manipulation
on the pregnant woman’s
abdomen to convert a breech to a
cephalic presentation.
False-negative rate: The proportion
of affected pregnancies that would
not be identified as high risk. Tests
with a high false-negative rate
have low sensitivity.
False-positive rate: The proportion
of unaffected pregnancies with a
high-risk classification. Tests with
a high false-positive rate have low
specificity.
Female genital mutilation
(FGM): Also known as female
circumcision. Any procedure that
intentionally alter or cause injury
to the external female genital
organs for non-medical reasons.
Four main types are reported.
Ferguson reflex: Surge of oxytocin,
resulting in increased contractions,
due to stimulation of the
cervix, and upper portion of
the vagina.
Fetal reduction: The reduction in
the number of viable fetuses/
embryos in a multiple (usually
higher multiple) pregnancy by
medical intervention.

Feto-fetal transfusion syndrome:
Also known as twin-to-twin
transfusion syndrome (TTTS).
Condition in which blood from
one monozygotic twin fetus
transfuses into the other fetus via
blood vessels in the placenta.
Fetus-in-fetu: Parts of a fetus may
be lodged within another fetus.
This can only happen in
monozygotic twins.
Fibroid (fibromyoma): Firm, benign
tumour of muscular and fibrous
tissue.
Foramen magnum: A large opening
in the occipital bone of the skull
through which the spinal cord
exits.
Foramen ovale: A temporary
structure of the fetal circulation
allowing blood to be shunted
from the right to left atrium in
utero.
Fossa ovalis: Oval shaped
depression in the intra-atrial
septum. Formed following the
closure of the foramen ovale at
birth.
Framing effect: A means of
cognitive bias insofar that
individuals react differently to a
particular choice such as antenatal
screening tests, based on the
manner in which the information
is presented, i.e. whether they
perceive the risk of screening as a
loss or a gain.
Fraternal twins: Dizygotic
(non-identical).
Fundal height: The distance
between the upper part of the
uterus (the fundus) and the upper
part of the symphysis pubis (the
junction between the pubic bones).
This assessment is undertaken to
assess the increasing size of the
uterus antenatally and decreasing
size postnatally.
Funis: The umbilical cord.
Gastroschisis: A paramedian defect
of the abdominal wall with
extrusion of bowel that is not
covered by peritoneum.
Glabella: The area between the
eyebrows.
Globalization: The increased
interconnectedness and
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Glossary of terms and acronyms
interdependence of people and
countries.
Grande multipara: A woman who
has given birth five times or more.
Greater vestibular glands
(Bartholin’s glands): Two small
glands that open on either side of
the vaginal orifice, located in the
posterior part of the labia majora.
Group practice: A small group of
midwives who provide care for a
group of women.
Haematuria: Blood in the urine.
Haemostasis: The arrest of bleeding.
Hallucinations: A sensory perception
in the absence of any stimulus.
Any of the five sensory modality
can be affected.
Haploid: Containing only one set of
chromosomes.
HELLP syndrome: A condition of
pregnancy characterized by
haemolysis, elevated liver enzymes
and low platelets.
Herpes gestationis: An
autoimmune disease precipitated
by pregnancy and characterized by
an erythematous rash and blisters.
Homan’s sign: Pain is felt in the calf
when the foot is pulled upwards
(dorsiflexion). This is indicative of
a venous thrombosis and further
investigations should be
undertaken to exclude or confirm
this.
Homeostasis: The condition in
which the body’s internal
environment remains relatively
constant within physiological
limits.
Hydatidiform mole: A gross
malformation of the trophoblast
in which the chorionic villi
proliferate and become avascular.
Hydropic vesicles: Fluid-filled sacs,
or blisters.
Hypercapnia: An abnormal increase
in the amount of carbon dioxide
in the blood.
Hyperemesis gravidarum:
Protracted or excessive vomiting in
pregnancy.
Hypertrophy: Overgrowth of tissue.
Hypogastric arteries: Temporary
fetal structures that branch off
from the internal iliac arteries and
become the umbilical arteries
when they enter the umbilical
cord.
Hypospadias: A condition where the
urethral meatus opens on to the
undersurface of the penis.
Hypothermia: A core body
temperature below 36 °C.
Hypotonia: The loss of muscle
tension and tone.
Hypovolaemia: Reduced circulating
blood volume due to external loss
of body fluids or to loss of fluid
into the tissues.
Hypoxia: Lack of oxygen.
Hypoxic ischaemic encephalopathy
(HIE): Condition where there is
evidence of hypoxia and
ischaemia.
Hysteroscope: An instrument
used to access the uterus via
the vagina.
Immunoglobulins: Antibodies.
Induction of labour: Intervention to
stimulate uterine contractions
before the onset of spontaneous
labour.
Intermittent positive pressure
ventilation (IPPV): Inflation
breaths are given to clear lung
fluid and ventilatory breaths are
given to remove excess CO2 and
provide oxygen.
Internationalization: Has no agreed
definition but best describes the
process of harmonizing
relationships from a cross-cultural
or international perspective.
Intervillous spaces: The spaces
between the chorionic villi that fill
with maternal blood.
Intraepithelial: Within the
epithelium, or among epithelial
cells.
Intrahepatic cholestasis of
pregnancy (ICP): An idiopathic
condition of abnormal liver
function.
Jaundice: Yellow coloration of the
skin and the sclera caused by a
raised level of bilirubin in the
circulation (hyperbilirubinaemia).
Kleihauer test: A standard blood
test used to quantitatively assess
or measure the degree of feto-
maternal haemorrhage.
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 Glossary of terms and acronyms
LAM: A method of contraception
based upon an algorithm of
lactation and amenorrhoea over a
6-month time period.
Lamda: Posterior fontanelle.
Lamdoidal suture: Membranous
tissue separating the occipital
bone from the two parietal bones
of the fetal skull.
Lanugo: Soft downy hair that covers
the fetus in utero and occasionally
the neonate. It appears at around
20 weeks’ gestation and covers the
face and most of the body. It
disappears by 40 weeks’ gestation.
Layer of Nitabusch: A collaginous
layer between the endometrium
and myometrium.
Ligamentum arteriosum:
Permanent ligament formed from
the ductus arteriosus following
birth.
Ligamentum teres: Permanent
ligament formed from the
umbilical vein following birth.
Ligamentum venosum: Permanenet
ligament formed from the ductus
venosus following birth.
Linea nigra: A common dark line of
pigmentation running
longitudinally in the centre of the
abdomen below and sometimes
above the umbilicus.
Lochia: A Latin word traditionally
used to describe the vaginal loss a
woman experiences following the
birth of a baby.
Løvset manoeuvre: A manoeuvre
for the birth of the fetal shoulders
and extended arms in a breech
presentation.
Macrosomia: Large baby weighing
4–4.5 kg or greater.
Malposition: A cephalic presentation
other than normal well-flexed
anterior position of the fetal head,
e.g. occipitoposterior.
Malpresentation: A presentation
other than the vertex, i.e. face,
brow, compound or shoulder.
Mauriceau–Smellie–Veit
manoeuvre: A manoeuvre to
assist the birth of the fetal head
in a breech presentation that
involves jaw flexion and shoulder
traction.
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McRoberts manoeuvre: A
manoeuvre to rotate the angle of
the symphysis pubis superiorly
and release the impaction of the
anterior shoulder of the fetus
when there is shoulder dystocia.
The woman brings her knees up
to her chest.
Mendelson’s syndrome: A chemical
pneumonitis caused by the reflux
of gastric contents into the
maternal lungs during a general
anaesthetic.
Meningitis: Inflammation of the
membranes covering the brain
and spinal column.
Mentum: Chin.
Mesenchyme: A mesh of embryonic
connective tissue.
Mesoderm: The middle layer of
three primary germ cell layers
present in the early embryo.
Microchimerism: The presence of a
small number of cells in one
individual that originated in a
different individual.
Midwife-led care: Midwives or a
midwife take the lead role in care
of a woman or group of women.
Miscarriage: Spontaneous loss of
pregnancy before viability.
Modified Early Obstetric Warning
Score (MEOWS): A chart or track
and trigger system used to record
maternal observations or
physiological vital signs
antenatally and postnatally for all
mothers who are hospitalized in
the maternity service.
Monoamniotic twins: Two
individuals who have developed
in the same amniotic sac.
Monochorionic twins: Two identical
individuals who have developed in
the same chorionic sac.
Monozygotic (monozygous):
Formed from one zygote (identical
twins).
Moulding: The change in shape of
the fetal head that takes place
during its passage through the
birth canal.
Multifetal reduction: see Fetal
reduction.
Naegele’s rule: A method of
calculating the expected date of
birth.
Natural family planning (NFP):
Methods of contraception based
on observations of naturally
occurring signs and symptoms of
the fertile and infertile phases of
the menstrual cycle.
Necrotizing enterocolitis (NEC): An
acquired disease of the small and
large intestine caused by
ischaemia of the intestinal
mucosa.
Neonatal encephalopathy: A
clinical syndrome of abnormal
levels of consciousness, tone,
primitive reflexes, autonomic
function and sometimes seizures
in newborn babies.
Neoplasia: Growth of new tissue.
Neurulation: The formation of the
neural plate and its transformation
in to the neural tube.
Nerve innervation: Nerve supply.
Neutral thermal environment
(NTE): The range of
environmental temperature over
which heat production, oxygen
consumption and nutritional
requirements for growth are
minimal, provided the body
temperature is normal.
Non-maleficence: Do no harm.
Oedema: The effusion of body fluid
into the tissues.
Oligohydramnios: Abnormally
small amount of amniotic fluid in
pregnancy.
Oliguria: The production of an
abnormally small amount of
urine.
One-to-one midwifery: One
midwife takes responsibility for
individual women with a partner
backing up the named midwife.
Such a system integrates a high
level of continuity of caregiver and
midwifery-led care. It is
geographically based and includes
women who are both ‘high risk’
and ‘low risk’.
PaCO2: Carbon dioxide partial
pressure. Measures the partial
pressure of dissolved carbon
dioxide. This dissolved CO2 has
moved out of the cell and into the
bloodstream. The measure of a
PaCO2 accurately reflects the
alveolar ventilation.

PaO2: Arterial oxygen partial pressure.
Measures the partial pressure of
oxygen in the arterial blood. It
reflects how the lung is
functioning but does not measure
tissue oxygenation.
Paronychia: An inflamed swelling of
the nail folds; acute paronychia is
usually caused by infection with
Staphylococcus aureus.
Partnership: A relationship of trust
and equity through which both
partners are strengthened and
power is diffused.
Peak mucus day: A retrospective
assessment of the last day of
highly fertile mucus which is
observed vaginally or felt around
ovulation.
Pedunculated: Stem or stalk.
Pemphigoid gestationis: see Herpes
gestationis.
Perinatal: Events surrounding labour
and the first 7 days of life.
Perinatal mental illness: A term
used both nationally and
internationally to emphasize
the importance of psychiatric
disorder in pregnancy as well as
following childbirth and the
variety of psychiatric disorders
that can occur at this time,
in addition to postnatal
depression.
pH: A solution’s acidity or alkalinity
is expressed on the pH scale,
which runs from 0 to 14.
This scale is based on the
concentration of hydronium (H+)
ions in a solution expressed in
chemical units called moles per
litre (mol/l). Solutions with a pH
less than 7 are said to be acidic
and solutions with a pH greater
than 7 are basic or alkaline. Pure
water has a pH very close to 7.
When the fetus is hypoxic the
increased acid produced raises the
acidity of the blood and the pH
falls.
Phenylketonuria (PKU): An
autosomal recessive disorder of
protein metabolism.
Pill-free interval: The 7 days when
no pills are taken during
combined oral contraceptive
regimen.
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Glossary of terms and acronyms
Placenta accreta: Abnormally
adherent placenta into the muscle
layer of the uterus.
Placenta increta: Abnormally
adherent placenta into the
perimetrium of the uterus.
Placenta percreta: Abnormally
adherent placenta through the
muscle layer of the uterus.
Placenta praevia: A condition in
which some or all of the placenta
is attached in the lower segment
of the uterus.
Placental abruption: see Abruptio
placenta.
Placentation: The forming of the
placenta.
Polyhydramnios: An excessive
amount of amniotic fluid in
pregnancy. Also referred to as
hydramnios.
Polyp: Small growth.
Porphyria: An inherited condition
of abnormal red blood cell
formation.
Postnatal blues: A transitory
emotional or mood state,
experienced by 50–80% of women
depending on parity.
Postnatal period: The period after
the end of labour during which
the attendance of a midwife
upon the woman and baby is
required, being not less than 10
days and for such longer period as
the midwife considers necessary.
Postpartum: After labour.
Precipitate labour: The expulsion
of the fetus within 3 hours of
commencement of contractions.
Pre-eclampsia: A condition peculiar
to pregnancy, which is
characterized by hypertension,
proteinuria and systemic
dysfunction.
Primary postpartum haemorrhage
(PPH): A blood loss in excess
of 500 ml or any amount that
adversely affects the condition of
the mother within the first 24
hours of birth.
Progestogen: Synthetic progesterone
used in hormonal contraception.
Prostaglandins: Locally acting
chemical compounds derived
from fatty acids within cells. They
ripen the cervix and cause the
uterus to contract.
Proteinuria: Protein in the urine.
Proteolytic enzymes: Enzymes that
break down proteins.
Pruritus: Itching.
Psychosis: A disorder of the mental
state that affects mood and
cognitive processes which may
cause the individual to lose touch
with reality (i.e. hallucinations
and delusional thoughts are
usually present).
Ptyalism: Excessive salivation.
Pudendal block: This is the
procedure where local anaesthetic
is infiltrated into the tissue around
the pudendal nerve within the
pelvis; employed for some
operative procedures during
vaginal births.
Puerperal psychosis: Describes
a rare but serious psychiatric
emergency and the most severe
form of postpartum affective
(mood) disorder.
Puerperal sepsis: Infection of the
genital tract following childbirth;
still a major cause of maternal
death where it is undetected and/
or untreated.
Puerperium: A period after
childbirth where the uterus and
other organs and structures that
have been affected by the
pregnancy are physiologically
returning to their non-gravid state,
lactation is establishing and the
woman is adjusting socially and
psychologically to motherhood.
Usually described as a period of
up to 6–8 weeks.
Quickening: The first point at which
the woman recognizes fetal
movements in early pregnancy.
Reciprocity: A mutual relationship
between two individuals where
there is an exchange of positive
regard for each other.
Regional anaesthesia: More
commonly are epidural and
intrathecal (spinal) anaesthetic.
Retraction: The process by which
the uterine muscle fibres shorten
after a contraction. This is unique
to uterine muscle.
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Rubin’s manoeuvre: A rotational
manoeuvre to relieve shoulder
dystocia. Pressure is exerted over
the fetal back to adduct and rotate
the shoulders.
Sandal gap: Exaggerated gap
between the first and second toes.
Secondary postpartum
haemorrhage: Any abnormal or
excessive bleeding from the genital
tract occurring between 24 hours
and 12 weeks postnatally.
Selective fetocide: The medical
destruction of a malformed twin
fetus in a continuing pregnancy.
Sinciput: The forehead.
Sheehan’s syndrome: A condition
where sudden or prolonged shock
leads to irreversible pituitary
necrosis characterized by
amenorrhoea, genital atrophy and
premature senility.
Short femur: Shorter than the
average thigh bone, when
compared with other fetal
measurements.
Shoulder dystocia: Failure of the
shoulders to spontaneously
traverse the pelvis after birth of
the fetal head.
Speculum (vaginal): An instrument
used to open the vagina.
Subinvolution: The uterine size
appears larger than anticipated for
the number of days postpartum,
and may feel not well contracted.
Uterine tenderness may be
present.
Succenturiate lobe: A small extra
lobe of placenta separate from the
main placenta.
Surfactant: Complex mixture of
phospholipids and lipoproteins
produced by type 2 alveolar cells
in the lungs that decreases surface
tension and prevents alveolar
collapse at end expiration.
Symphysiotomy: A surgical incision
to separate the symphysis pubis
and enlarge the pelvis to aid birth
of the baby.
Symphysis pubis dysfunction: see
Diastasis symphysis pubis.
Tachypnoea: Increased respiratory
rate that occurs as the baby
attempts to compensate for an
increased carbon dioxide
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concentration in the blood and
extracellular fluids.
Talipes: A complex foot deformity,
affecting 1/1000 live births and
more common in males. The
affected foot is held in a fixed
flexion (equinus) and in-turned
(varus) position. It can be
differentiated from positional
talipes because the deformity in
true talipes cannot be passively
corrected.
Team midwifery: Midwives are
team-based rather than on a ward
or within a community base. The
team takes responsibility for a
number of women. Teams may be
restricted to hospital or
community, or cover both.
Tentorium cerebelli: An arched fold
of the dura mater, covering the
upper surface of the cerebellum.
Teratogen: An agent believed to
cause congenital malformations,
e.g. thalidomide.
Tocophobia: A fear of childbirth.
Torsion: Twisting.
Torticollis: The result of tightness
and shortening of one
sternomastoid muscle.
Tregs: Adapted T regulator cells that
play a part in immunity.
Trizygotic: Formed from three
separate zygotes.
Trophoblasts: Peripheral cells
surrounding the blastocyst.
Twin-to-twin transfusion
syndrome: see Feto-fetal
transfusion syndrome.
Uniovular: Monozygotic.
Unstable lie: After 36 weeks’
gestation, a lie that varies between
longitudinal and oblique or
transverse is said to be unstable.
Uterine involution: The
physiological process that starts
from the end of labour and results
in a gradual reduction in the size
of the uterus until it returns to its
non-pregnant size and location in
the pelvis.
Uterotonics: Also known as
oxytocics or ecbolics.
Pharmacological agents/drugs (e.g.
syntometrine, syntocinon,
ergometrine and prostaglandins)
that are used in the active
management of the third stage of
labour to stimulate the smooth
muscle of the uterus to contract.
Utilitarianism: Providing the greatest
good for greatest number.
Vanishing twin syndrome: The
reabsorption of one twin fetus
early in pregnancy (usually before
12 weeks).
Vasa praevia: A rare occurrence in
which umbilical cord vessels pass
through the placental membranes
and lie across the cervical os.
Vasculogenesis: The formation of
new blood vessels.
Vernix caseosa: White creamy
substance protecting the fetus
from dessication and present from
18 weeks gestation.
Wharton’s jelly: Gelatinous
substance surrounding the
umbilical cord.
Withdrawal bleed: Vaginal bleeding
due to withdrawal of hormones.
Wood’s manoeuvre: A rotational
or screw manoeuvre to relieve
shoulder dystocia. Pressure is
exerted on the fetal chest to rotate
and abduct the shoulders.
Zavanelli manoeuvre: Last choice of
manoeuvre for shoulder dystocia.
The head is returned to its
pre-restitution position, then the
head is flexed back into the vagina.
Birth is by caesarean section.
Zygosity: Describing the genetic
make-up of children in a multiple
birth.
Acronyms
ABPM: ambulatory blood pressure
monitoring
ACE: angiotensin converting enzyme
ACTH: adrenocorticotrophic
hormone
ADH: anti-diuretic hormone
AED: antiepileptic drug
AFLD: acute fatty liver disease
AGA: appropriate for gestational age
AIDS: acquired immunodeficiency
syndrome
ALT: Alanine Transaminase
ANP: atrial natriuretic peptide
Anti HBe: hepatitis B e-antibodies
APEC: Action on Pre-Eclampsia

APH: Antepartum Haemorrhage
APS: antiphospholipid syndrome
ARB: angiotensin receptor blocker
ARM: artificial rupture of the
membranes/Association of Radical
Midwives
ART: antiretroviral therapy
ASD: atrial septal defect
ATP: adenosine triphosphate
BALT: bronchus-associated lymphoid
tissue
BFI: Baby Friendly Initiative
BMI: body mass index
BMR: basal metabolic rate
BNF: British National Formulary
BNP: brain natriuretic peptide
BOC: British Oxygen Company
BP: blood pressure
BTS: British Thoracic Society
CCG: Clinical Commissioning Group
C. Diff: Clostridium difficile
CHD: congenital heart disease
CHRE: Council for Healthcare
Regulatory Excellence (now PSA
Professional Standards Authority)
CIN: cervical intraepithelial neoplasia
CINORIS: Clinical Negligence and
Other Risks Indemnity Scheme
CMACE: Centre for Maternal and
Child Enquiries
CMB: Central Midwives Board
CEMACH: Confidential Enquiry into
Maternal and Child Health.
CESDI: Confidential Enquiries into
Stillbirths and Deaths in Infancy
CMV: cytomegalovirus
CNS: central nervous system
CNST: Clinical Negligence Scheme
for Trusts
COC: combined oral contraceptive
COMET: The Comparative Obstetric
Mobile Epidural Trial
CQC: Care Quality Commission
CRH: corticotrophin-releasing
hormone
CRT: capillary refill time
CSF: cerebral spinal fluid
CSII: continuous subcutaneous
insulin infusion
CT: computerized tomography
CTG: cardiotograph/cardiotocogram
CVA: cerebral vascular accident
CVS: chorionic villus sampling
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Glossary of terms and acronyms
DCSF: Department for Children,
Schools and Families (until 2010;
now DfE)
DDH: developmental dysplasia of the
hip
DfE: Department for Education
DH/DoH: Department of Health
DHA: docosahexanoic acid
DMPA: depot medroxyprogesterone
acetate
DVT: deep vein thrombosis
EBM: expressed breast milk
ECG: electrocardiogram/graphy
E. Coli: Escherichia coli
ECM: extracellular matrix
EFM: electronic fetal monitoring
EFSA: European Food Standards
Agency
eGFR: epidermal growth factor
receptor
EHC: emergency hormonal
contraception
ELBW: extremely low birth weight
(below 1000 g)
ENB: English National Board for
Nursing, Midwifery and Health
Visiting
ENT: ear,nose and throat
ERPC: evacuation of retained
products of conception
ESC: Essential Skills Clusters
EU: European Union
FASD: fetal alcohol spectrum
disorders
FBC: full blood count
FIL: feedback inhibitor of lactation
FPA: Family Planning Association
FSA: Food Standards Agency
FSH: follicle stimulating hormone
FSRH: Faculty of Sexual and
Reproductive Health
GALT: gut-associated lymphoid tissue
GAS: Group A streptococcus
GBS: Group B streptococcus
GDM: gestational diabetes mellitus
GF: glomerular filtrate
GFR: glomerular filtration rate
GNC: General Nursing Council
GnRH: gonadotrophic-releasing
hormone
GP: General Practitioner
GTD: gestational trophoblastic
disease
GTI: genital tract infection
GTN: gestational trophoblastic
neoplasia
GTT: glucose tolerance test
HAART: highly active antiretroviral
therapy
Hb: haemoglobin
HbA: adult haemoglobin
HbAS: sickle cell trait (heterozygous)
HbA1c: glucated/glycosylated
haemoglobin
HBeAg: hepatitis B e-antigen
HbF: fetal haemoglobin
HbH: haemoglobin H disease
HbSS: sickle cell anaemia/disease
(homozygous)
HBV: hepatitis B virus
HCAI: healthcare-acquired infection
hCG: human chorionic
gonadotrophin
hCG-H: hyperglycosylated human
chorionic gonadotrophin
hCS: human chorionic
somatomammotropin hormone
HDCU: high dependency care unit
HDL: high-density lipoprotein
HDN: haemorrhagic disease of the
newborn
HEI: Higher Education Institution
HIV: Human Immunodeficiency
Virus
hPGL: human placental growth
hormone
hPL: human placental lactogen
HPT: home pregnancy test
HPV: human papilloma virus
HSCIC: Health and Social Care
Information Centre
HSE: Health Survey for England
HSV: herpes simplex virus
HVS: high vaginal swab
ICM: International Confederation of
Midwives
ICU: intensive care unit
IFCC: International Federation of
Clinical Chemistry
IHD: ischaemic heart disease
IOM: Institute of Medicine
IM: intramuscular
IQ: intelligence quotient
ITP: Intention to Practice
IUCD: intrauterine contraceptive
device
743
 Glossary of terms and acronyms
IUFD: intrauterine fetal death
IUGR: intrauterine growth restriction
IUS: intrauterine system
IV/IVI: intravenous/intravenous
infusion
IVF: in vitro fertilization
JEC: Joint Epilepsy Council
L3: third lumbar vertebra
LA: Local Authority
LARC: long-acting reversible
contraceptive
LBW: low birth weight (below 2500 g)
LC-PUFA: long chain poyunsaturated
fatty acids
LFT: liver function test
LGA: large for gestational age
LH: luteinizing hormone
LMP: last menstrual period
LMWH: low molecular weight
heparin
LSA: Local Supervising Authority
LSAMO: Local Supervising Authority
Midwifery Officer
MA: mentoanterior
MCH: mean cell/corpuscular
haemoglobin
MCV: mean cell/corpuscular volume
MH(P)RA: Medicines and Healthcare
Products Regulatory Agency
MI: myocardial infarction
MIDIRS: Midwives Information
Resource Service
MODY: mature onset diabetes of the
young
MOH: Medical Officer of Health
MPV: mean platelet volume
MRI: magnetic resonance imaging
MRSA: methicillin-resistant
Staphylococcus aureus
MSU/MSSU: mid-stream specimen
of urine
MSW: Maternity Support Worker
NCT: National Childbirth Trust
NET-EN: norethisterone enanthate
NHS: National Health Service
NHSLA: National Health Service
Litigation Authority
NICE: National Institute for Health
and Clinical Excellence/National
Institute for Health and Care
Excellence (from 2013)
744
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NICU/NNICU: neonatal intensive care
unit
NIPE: neonatal and infant physical
examination
NMC: Nursing and Midwifery
Council
NOP: Notification of Practice
NPEU: National Perinatal
Epidemiology Unit
NPSA: National Patient Safety
Agency
NTD: neural tube defect
OA: occipitoanterior
OC: obstetric cholestasis
OF: cccipitofrontal
OP: occipitoposterior
PAP: pulmonary artery pressure
PCA: patient-controlled analgesia
PCT: Primary Care Trust
PDA: patent ductus arteriosus
PE: pulmonary embolism/embolus
PET: pre-eclampsia toxaemia
PGP: pelvic girdle pain
PID: pelvic inflammatory disease
PIH: pregnancy-induced hypertension
PND: postnatal depression
POC: point of care
POP: progesterone-only pill
PPI: proton pump inhibitor
PPROM: preterm prelabour rupture
of the membranes
PREP: Post-Registration Education
and Practice
PROM: prelabour rupture of
membranes
PSA: Professional Standards
Authority
PTH: parathyroid hormone
RAAS: renin–angiotensin–
aldosterone system
RCoA: Royal College of Anaesthetists
RCM: Royal College of Midwives
RCOG: Royal College of
Obstetricians and Gynaecologists
RCPCH: Royal College of Paediatrics
and Child Health
RCT: randomizd controlled trial
RCUK: Resuscitation Council of the
United Kingdom
RHA: Regional Health Authority
RNA: ribonucleic acid
RPF: renal plasma flow
SACN: Scientific Advisory Committee
on Nutrition
SANDS: Stillbirth and Neonatal
Death Society
SBAR: situation, background,
assessment and recommendation
SFH: symphysis fundal height
SGA: small for gestational age
SHA: Strategic Health Authority
SI: Statutory Instrument
SIGN: Scottish Intercollegiate
Guidelines Network
SLE: systemic lupus erythematosus
SPRM: selective progesterone
receptor modulator
STI: sexually transmitted infection
SUDEP: sudden unexpected death in
epilepsy
SUI: stress urinary incontinence
T11: eleventh thoracic vertebra
TBG: thyroxine-binding globulin
TBV: total blood volume
TED: thromboembolism deterrent
TENS: transcutaneous electrical nerve
stimulation
TRH: thyrotropin-releasing hormone
TSH: thyroid-stimulating hormone
UK: United Kingdom
UKAMB: United Kingdom
Association for Milk Banking
UKCC: United Kingdom Central
Council for Nursing, Midwifery
and Health Visiting
UKOSS: United Kingdom Obstetric
Surveillance System
UNAIDS: United Nations Programme
on HIV/AIDS
UNICEF: United Nations
International Children’ Fund
UPSI: unprotected sexual intercourse
USA: United States of America
US(S): ultrasound (scan)
UTI: urinary tract uifection
VE: vaginal examination
VKDB: vitamin K deficiency bleeding
VLBW: very low birth weight (below
1500 g)
VSD: ventricular septal defect
VTE: venous thromboembolism
WHO: World Health Organization

Illustrations are comprehensively
referred to from the text. Therefore,
significant items in illustrations
(figures and tables) have only been
given a page reference in the absence
of their concomitant mention in the
text referring to that illustration.
A
ABC mnemonic for postpartum
haemorrhage treatment, 409
ABC(DE) protocol
maternal, 488
eclamptic seizure, 252
neonatal, 612
abdomen (baby)
in breech birth, 384–385
neonatal, examination, 596
abdomen (maternal)
caesarean section incision, 464–465
distension, 163
examination in labour and birth
breech presentation, 357–358
brow presentation, 449
initial, 337
examination in pregnancy, 190–196
hydramnios, 238
multiple pregnancy, 293–294
occipitoanterior position,
436–437
oligohydramnios, 238–239
palpation see palpation
shoulder presentation, 450
examination in puerperium, 505
muscles, laxity as cause of shoulder
presentation, 450
pain, 222
ovulation (=mittelschmerz), 94,
569, 584
pressure (in labour) in upper region,
epidural analgesia, 369
mebooksfree.com
Index
ABO blood groups
isoimmunization, 687
typing, 216
booking visit, 188
abortion (induced ending of
pregnancy), 227–228, 558–559
combined oral contraceptive pill
following, 574
for fetal abnormality, 558–559
for other reasons, 559
abrasions, neonatal, 593, 630
abscess, breast, 721
absence seizures, 278t
accelerations, 346
accountability (and the NMC), 31–32
acetabulum in developmental
dysplasia of hips, 606–607
achondroplasia, 662
aciclovir (acyclovir), varicella zoster,
677
acid–base status and labour pain, 352
acini cells, milk-producing, 705
Aconite, labour pain, 352
acrocyanosis (peripheral cyanosis/at
extremities), 592, 668–669
acrosome reaction, 95
act utilitarianism, 38–39
active management of 3rd stage of
labour, 400–404
acupuncture for hyperemesis
gravidarum, 228–229
acyanotic cardiac defects, 657–658
acyclovir, varicella zoster, 677
adenoma, pituitary, 245
adipokines, 254
adjustment reactions, 538
administration see organization and
administration
adoption, relinquishment for, 558
adrenal glands
congenital hyperplasia, 597, 664,
695
fetal, 115
maternal, 170–171
tumour, 248
neonatal disorders, 695
adrenaline (epinephrine)
blood pressure and, 244
labour pain and, 352
stress and, 532
adrenocorticotrophic hormone
(ACTH), maternal, 169–171
adult respiratory distress syndrome,
490
adverse incidents, serious, 48–49
advocacy, 17
aerobic glycolysis, neonatal, 598–599
affective awareness, 12
affective neutrality, 11–12
afferent (sensory) pathways and labour
pain, 350–351
afterpains, 506
aganglionosis, congenital
(Hirschsprung’s disease), 653,
672
AIDS see human immunodeficiency
virus
airway (neonatal)
congenital pulmonary airway
malformation, 655
upper, obstruction, 681, 722
airway management (in resuscitation)
maternal, 488
eclamptic seizure, 252
hypovolaemic shock, 490
neonatal, 612–613
difficulties in establishing open
airway, 613–614
albumin in pregnancy, 154
alcohol, 187
fetal exposure, 664–665
aldosterone, 86, 170–171, 244
excess production (Conn’s
syndrome), 248
745
 Index
all fours position, 371–372, 378–379
breech birth, 382
Mauriceau–Smellie–Veit
manoeuvre, 383
occipitoposterior position, 439
shoulder dystocia, 481
All Wales Clinical Pathway for Normal
Labour, 388
allantois, 98–99
allergy
breast vs bottle-feeding, 708
to formula milk components, 727
alloimmune thrombocytopenia,
neonatal, 638
alveoli (breast), 705
alveoli (fetal lung), 114–115
ambiguous genitalia, 597, 664, 695
amenorrhoea, 94
lactational, 583–585
amino acids
in formulae milk, 727
in pregnancy, 165
amniocentesis, twin pregnancy, 292
amnion, 106
in twin pregnancy, 291, 298
see also membranes
amniotic cavity, 98
amniotic fluid, 107
embolism, 485–486
in labour, 332
meconium in (meconium staining),
376, 620–621
volume, 107
abnormalities see
oligohydramnios;
polyhydramnios
calculation, 236
amniotomy (artificial rupture of the
membranes), 267, 296, 333,
424
anaemia
fetal, surveillance for, 217
maternal, 273–274
iron-deficiency see iron
physiological anaemia, 273
postpartum haemorrhage in, 408
screening for, 215–216
twin pregnancy and, 294
anaerobic glycolysis, neonatal,
598–599
anaesthesia see general anaesthesia;
regional analgesia/anaesthesia
anal… see anorectum and entries below
anal atresia (imperforate anus), 596,
652
anal cleft (purple) line, 338–340, 369
anal dilatation and gaping, 369
anal incontinence (faecal
incontinence), 320, 507, 524
746
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anal sphincters, 57–60 impact of reduced visits, 180
external, 60 initial assessment see booking visit
internal, 60 key principles, 180b
obstetric injury (OASIS), 319–320 models, 182
examination, 314 obese women, 255–256
follow-up, 312 occipitoanterior position, 437–438
postoperative care after repair, ongoing, 196–199
320 patterns/schedules, 180–181
repair, 318–320 referral for additional support see
anal triangle, 55 referral
analgesia (pain relief) twin pregnancy, 293
in caesarean section, 468–471 unstable lie, 452
postoperative, 466 antenatal diagnosis (prenatal
in labour/vaginal birth, 352–356, diagnosis)
374–375 brow presentation, 449
anal sphincter repair, cardiac defects see heart disease
postoperative, 320 (baby)
in cardiac disease, 267 congenital malformations see
forceps extraction, 461 malformations
multiple pregnancy, 296 face presentation, 445
non-pharmacological, 352–353 occipitoanterior position, 436–437,
pharmacological, 353–356 442
ventouse extraction, 458 shoulder presentation, 450
postnatal termination following, 558–559
afterpains, 506 antenatal education (for birth and
perineal pain, 508 parenting), 127–142
anaphylactic shock, 489 aims, 130b
anatomical variations, placenta and attendance, maximising, 137–140
cord, 108–109 content, 133–136
androgen insensitivity syndrome, 664 defining learning outcomes,
android pelvis, 68–69, 68t 136–137
occipitoanterior position with, 436 evidence, 129
anencephaly, 659 leading group sessions, 129–133
face presentation with, 444–445 multiple pregnancy, 293
angiomas, 168 research and policy background,
angiotensin, 84, 150–151, 170–171 127–129
blood pressure and, 244 antenatal haemorrhage see
angiotensinogen, 84 haemorrhage (maternal),
anhedonia, 543 antenatal
ankyloglossia, 722 antenatal screening, 203–219
anorectum at booking visit, 187–189
maternal, 57–60 congenital malformations see
examination in perineal trauma, malformations
314 discussing options, 206
neonatal fetal, 189, 208–214
examination, 596 limitations, 204–205
malformations, 652 maternal, 214–217
see also anal sphincters; anal triangle mental illness, 549
antacids in caesarean section, multiple pregnancy, 292
Mendelson’s syndrome principles, 204–205
prevention, 470 roles and responsibilities of
antenatal care/management (incl. midwives, 205–208, 212
visits), 179–202 set up, 205–208
access, 182 antepartum… see entries under
aim, 180–182 antenatal
breastfeeding preparations, 189, 711, anteroposterior diameter of pelvic
730 inlet, 66–67
cardiac disease, 266 anthropoid pelvis, 68t, 69
diabetic women, 260–261 occipitoanterior position with, 436

antibiotics
in caesarean section, prophylactic,
464
combined oral contraceptive pill
and, 573
neonatal infection
eye, 605–606
group B streptococcus, 675–676
progestogen-only pill and, 575
antibodies (immunoglobulins)
neonatal, 601
breastmilk and, 601, 710
red cell (maternal), 686
screening for, 216–217
therapeutic administration (incl.
passive immunization)
anti-D Ig see anti-D prophylaxis
physiological administration, 684
varicella zoster, 677
anticonvulsants/antiepileptics
maternal
eclampsia, 252
epilepsy, 278–279
folate deficiency caused by,
274–275
as mood stabilizers, 548
neonatal, 640–641
anti-D prophylaxis, 190, 226,
685–686
pregnancy loss, 227–228
antidepressants, 544–547
in bipolar illness, 549
antidiuretic hormone (ADH;
vasopressin), 85–86, 151, 169
blood pressure and, 244
anti-emetics with opiates in labour,
354
anti-epileptics see anticonvulsants
antihypertensive drugs, 247b
in labour, 248
in pre-eclampsia, 250–251
postnatal, 251
anti-infective factors in breastmilk,
710
antipsychotics, 547
antiretroviral drugs, 280–281
antithrombotic therapy, 266
antiviral drugs
HIV, 280–281
varicella zoster, 677
anus see anorectum and entries under
anal
anxiety, 532–533
antenatal screening, 204, 207
postnatal, 543
see also fear
anxiety disorders, 532, 539
aorta
maternal, dissection, 268
mebooksfree.com
Index
neonatal auscultation, fetal heart, 194
coarctation, 658 labour
stenosis, 658 breech presentation, 358
Apert’s syndrome, 660 initial, 337
Apgar score, 612 intermittent, 344–345
apnoea, neonatal, 670 multiple pregnancy, 294
appendix in pregnancy, 163 occipitoanterior position, 437
appetite changes, 162 auscultation, neonatal heart, 603–604
areola, 705 authority rules, 38
arms autoimmune thrombocytopenia,
in breech births, 382 neonatal, 638
extended, 384–385 autonomy, respect for, 38
in shoulder dystocia, birth of awareness
posterior arm, 481–482 emotional (midwives’), 8, 12–13
see also limbs fertility, 582–585
aromatherapy, 352 of loss (=realization), 556
arterial duct see ductus arteriosus
arteries
B
fetal development, 112
maternal baby see fetus; infants; neonates;
blood gases, 159 preterm babies
supply see blood supply ‘baby brain’, 159
artifical feeds see formula feeding Baby Friendly Hospital Initiative,
artificial pancreas, 259 718–719, 727, 729–730
artificial rupture of the membranes backache
(chorioamnion), 267, 296, 333, with epidural anaesthesia, 356b
424 in occipitoposterior position, 438
ascorbic acid, breastmilk, 709 postnatal, 523
asepsis in 3rd stage of labour, 404 bacterial infection, neonatal, 675–676
asphyxia (fetal) bacterial vaginosis (BV), 279
in breech birth, 387b bacteriuria, asymptomatic, 160b, 282
in shoulder dystocia, 483 booking visit assessment for, 188
aspirin, pre-eclampsia, 250t bag and mask ventilation, neonatal,
assessment strategies in Global 613
Standards for Midwifery BALT (bronchus-associated lymphoid
Education (2010), 7 tissue), 710
assisted conception, pregnancy Bandl’s ring, 331–332, 429, 484
problems, 228 Barlow manoeuvre, 606–607
asthma, 269–270 baroreceptors and blood pressure,
asylum-seekers, 16 244
asynclitism, pelvic brim in, 69b barrier contraceptives, 578–581
atherogenic dyslipidaemia, 254 spermicide use, 581
atonic seizures, 278t Bartholin’s glands, 56
atonic uterus, 406, 409 basal body temperature in natural
atosiban acetate, 240 family planning, 583
atresias basal metabolic rate in pregnancy, 164,
choanal, 613–614, 655–656 255
gastrointestinal, 650–652 baseline rate on CTG, 345
anal (imperforate anus), 596, 652 variability, 346
atrial natriuretic peptide, 151–152, 244 basic life support, 487–489
atrial septal defect (ASD), maternal, 268 bathing
attachment in labour, 343
to breast, 712–715 postnatal perineal pain, 508
difficulties, 718–719, 720b, 722 battledore insertion of cord, 109
reattachment after removal, 716 bed-sharing and breastfeeding, 711
parent–baby, 556 beneficence, 38
attitude (head), 121, 194 benign sleep myoclonus, 674
audit, 46 bereavement, 555–567
Audit Committee, 29 twin, 304
747
 Index

best practice birthing room breast, 705

Down syndrome screening, 209
in postnatal care, 509
with twins, 720
beta-blockers, 247
bicornuate uterus, 75
bifidus factor, 710
bikini line incision for caesarean
section, 464–465
bile-stained vomiting, 672
biliary disease, 235–236
bilirubin
conjugated, 682
physiology, 682
raised levels see hyperbilirubinaemia
serum measurements in treatment of
isoimmunization, 687–688
unconjugated, 682
Billings (cervical secretions) method,
583
bimanual compression/pressure
in postpartum haemorrhage
treatment, 409–411
in reversal of face presentation, 447
binovular twins see dizygotic
biochemistry, pregnant vs non-
pregnant, 155t
see also laboratory tests
biparietal diameter, 121
bipartite placenta, 109
biphasic combined oral contraceptive
pill, 570
bipolar illness, 539–540
postpartum, 541
in pregnancy, 540
prevention, 549
treatment, 546–548
birth (birthing; delivery)
adaptation to extrauterine life,
117–118, 670
in breech presentation, mode,
359–360
giving see childbirth
head see head
multiple, 296–297
delay with second twin, 299
delayed interval birth of second
twin, 299
operative see operative births
trauma, claims arising from, 36
use/definition of term (in place of
delivery), 334
weight see weight
see also childbirth
birth marks, vascular, 593, 662–663
birth plans, 15, 199, 334–335
birth pool/water birth, 378
breech birth and, 381
birthing ball, 371–372
environmental considerations, 336
equipment, 343
low birth weight babies and, 622
music therapy provision, 353
transfer from, 406
bisacromial diameter, 121
bitemporal diameter, 121
bitrochanteric diameter, 121
black and ethnic minority women,
15–16
bladder, 87–88
full (immediately after birth),
problems caused by, 405, 407
in labour, care, 344
in 2nd stage, 377
in pregnancy and childbirth, 156,
160
voiding see micturition
blastocele, 96–97
blastocyst, 96–97
implantation see implantation
blastomeres, 96–97
blastulation, 96–97
bleeding/blood loss (vaginal)
antenatal, early, 222–226
discussed at antenatal visit, 190
antenatal, later see haemorrhage
(maternal), antenatal
in caesarean section, postoperative,
467
menstrual see menstruation
neonatal, 639, 688
in vitamin K deficiency, 637–638,
688, 709
postpartum, 506–507
after operative birth, 519–520
after vaginal birth, 518–519
stopping see haemostasis
see also haemorrhage
blistering rash, 669–670
blood
circulation/flow see circulation
clot and clotting see clot; clotting
cord, sampling, 404
fetal (in labour), sampling, 347–348
gases (maternal), 159
loss, 3rd stage of labour, estimation,
404
see also bleeding; haemorrhage
neonatal
intracranial haemorrhages due to
disrupted flow of, 635–637
physiology, 600
volume increases (hypervolaemia),
maternal, 150–153, 272
blood (vascular) supply
anorectum, 60
bladder, 88
kidney, 83
levator ani, 62
ovaries, 77
testes/scrotum, 78
ureters, 87
urethra, 89
uterine tube, 76
uterus, 74
vagina, 72
vulva, 56
see also haematology
blood cells
full count at booking visit, 188
red see red blood cells
white, in pregnancy, 156–157
blood group assessment, 216–217
booking visit, 188
see also isoimmunization
blood pressure in pregnancy, 152–153,
244–245
abnormalities see hypertension;
supine hypotensive syndrome
adaptations (in pregnancy),
152–153, 245
at booking visit, 188
measurement/monitoring, 245
in diabetics, 261
in eclampsia, 253
in labour, 341
postnatal, 505
in pre-eclampsia, 250t
regulation, 244
see also central venous pressure
blood tap in spinal anaesthesia, 469
blood tests
booking visit, 188
pre-eclampsia, 250t
blood vessels (vasculature)
fetal development, 112–114
in pregnancy, changes, 149–153
in resistance, 144–148
blue skin, neonatal, 592, 612,
668–669
with good muscle tone, 613
‘blues’, postnatal, 536–537, 541
differentiation from psychosis, 541
body mass index (BMI), 165–166,
254–255
at booking visit, 187–188, 255
size classification using, 254
Bolam standard, 35
bonding/attachment, 556
bone
brittle, 662
fractures, neonatal, 633
mineral density and depot
medroxyprogesterone acetate,
575–576

748
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 Index

booking (for antenatal visit), late, 182
booking visit (initial assessment),
183–187
body mass index at, 187–188, 255
bottle feeding see formula feeding
bowel (intestine)
maternal, postnatal problems, 507,
524
neonatal
malrotation/volvulus, 652–653
protrusion through umbilicus
(omphalocele), 650
see also specific parts
Bowman’s capsule, 83, 85
bra (brassiere), milk-expressing, 719
brachial plexus trauma, 632–633
brain
fetal, 115
maternal/in pregnancy, 159
cardiovascular centre, 244
shock effects, 490
neonatal, intracranial haemorrhage
and stage of development,
635–636
see also central nervous system;
encephalopathy; neurological
disorders
brain natriuretic peptide, 151–152
Braxton Hicks contractions, 145–146,
148, 333–334
breast, 704–710
anatomy and physiology, 704–705
cancer (incl. carcinoma)
breastfeeding contraindicated, 723
combined oral contraceptive pill
and, 572
first, finishing feeding, 716
massage/stimulation
for expressing milk, 719
inducing labour, 426
one-breast-only breastfeeding, 723
postnatal
care, 505, 719
deviation from normal physiology
and potential morbidity, 518f
engorgement, 720
factors affecting breastfeeding,
723
problems, 525, 719–720
weight in pregnancy, 166
breast pumps, 719
with attachment difficulties, 720
with engorgement, 720
breastfeeding, 704, 710–725
1st feed, 711
2nd (next) feed, 711
amenorrhoea, 583–585
antenatal help and preparation, 189,
711, 730
behaviour, 716–718
cardiac disease and, 268
contraindications, 723
depressive illness and, 545
drug intake considerations
anticonvulsants, 548
antipsychotics, 547
lithium, 548–549
SSRIs, 547
tricyclic antidepressants, 546
exclusive (up to 6 months), 710–711
management, 710–725
obesity and, 256
problems and difficulties, 718,
720–721
promotion initiative (worldwide)
from 1991, 729–730
soon after birth, benefits, 405–406
twins, 299–301
preparation for, 293
separate vs simultaneous, 301
uterine contraction with, 398
vitamin K deficiency and, 637, 709
see also lactation; rooting reflex;
sucking reflex
breastmilk, 704–710
banking for donation, 725
components, 707–710
antibodies, 601, 710
ejection (let-down) reflex, 705–706,
720–721
expressing, 718–719
production see lactation
properties, 707–710
storage, 719
substitutes see formula feeding
transfer
monitoring/assessment, 718
rate determining length of feed,
707
breathing
maternal, eclamptic seizure, 252
neonatal, 598, 612–613
LBW babies, 624
management in respiratory
distress, 679
see also rescue breaths; ventilatory
breaths
breathlessness, 158b
breech presentation, 193, 356–360
1st stage of labour, 356–360
assessment, 341b
2nd stage of labour, 380–387
complications, 387
causes, 357
cord prolapse, 477
diagnosis, 357–359
engagement with, 193
incidence, 356–357
injury, 631
positions, 357, 381
professional responsibilities, 387
sacrum (as denominator) with, 196
types, 357, 381
undiagnosed, 381
vaginal birth see vaginal birth
bregma, 120
brittle bone disease, 662
broad ligaments, 73
in pregnancy, 144
bromocriptine
lactation suppression, 723–724
prolactinoma, 264
bronchoconstriction in asthma, 270
bronchodilators, asthma, 270
bronchus-associated lymphoid tissue
(BALT), 710
brow presentation, 121, 448–449
occipitoposterior position converted
to, 442
bruises, neonatal, 593, 669
buttocks, 631
face (with face presentation), 448
bulbospongiosus muscle, 57
bulbourethral glands, 79
bullous (blistering) rash, 669–670
burden of proof of negligence, 36
burial, 224, 564
Burns Marshall manoeuvre, 382–383
buttocks
bruising/oedema, 631
internal rotation, 380
restitution, 380
button-hole tear of rectal mucosa,
312t, 314, 442
C
cabergoline, lactation suppression,
723–724
caesarean section, 463–472
breastfeeding and, 711
indications and their classification,
463–464
induction of labour and scar from,
424
malpresentations
breech, 359
shoulder, 451
multiple pregnancy, 294
operative procedure, 464–465
postnatal ward care after, 467–468
postoperative care, 466–468
postpartum haemorrhage with, 408
post-traumatic stress disorder, 537
psychological support and role of
midwife, 465
requested by women, 465

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research and incidence of, 471–472
tackling high/rising rates, 470
vaginal birth after, 466
wounds and their healing, 521–522
calcium
maternal intake, 165
neonatal/infant, 692
breastfeeding and, 710
imbalances, 692
calcium channel blockers in
pregnancy, 247
calendar method of contraception,
583–584
cancer (malignancy)
breast see breast
cervical, 223–224
cervical see cervix
combined oral contraceptive pill
and, 572
Candida albicans (incl. thrush), 678
maternal, 279
postnatal, and feeding, 720
neonatal, 678
cannulas see catheters and cannulas
capacity/competency (mental) and
consent, 35, 207
labour and, 337
capillary haemangiomata (strawberry
marks), 662–663
capillary malformations, 662
caput succedaneum, 369–370, 372,
376, 630–631
cephalhaematoma and, 633–634
carbamazepine, 548
carbetocin, 401
carbohydrates
breastmilk, 707
metabolism, 164
wound healing and, 521t
carbon dioxide (blood)
maternal, arterial partial pressure,
159
neonatal, accumulation/excess,
612–613
carbon monoxide screening at first
antenatal visit, 187
carboprost, postpartum haemorrhage,
409
carcinoma
breast see breast
cervical, 223–224
chorionic (choriocarcinoma),
226–227
cardiac… see heart and entries under
cardio…
cardinal ligaments, 72
cardinal veins, 112
cardiogenic shock, 489
cardiomyopathy, peripartum, 269
cardiopulmonary resuscitation see
resuscitation
cardiotocography (CTG; electronic fetal
monitoring)
labour, 333
continuous, 345–347
normal, 346, 347b
pathological, 347, 347b, 348f
suspicious, 347, 347b, 348f, 376
multiple pregnancy, 295–296
cardiovascular centre of medulla
oblongata, 244
cardiovascular system
amniotic fluid embolism signs and
symptoms, 485
fetal, 112–114
neonatal, 600
NIPE (Newborn and Infant
Physical Examination), 602
pregnancy-related changes,
149–157
see also circulation
care (maternity - general aspects)
antenatal see antenatal care
duty of see duty of care
NHS outcomes framework relating
to, 46b
organization, 11
postnatal see postnatal period
women-centred, 13
Care of the Next Infant (CONI), 185
carers in loss, formal, 563–564
caries, dental, 161–162
Caring for Our Baby (theme in
antenatal education
programme), 136
casein-dominant formulae, 726
casuistry, 39
catheters and cannulas
intravascular, bleeding associated
with, 639
subarachnoid space misplacement,
469–470
urinary, caesarean section, 464
causation in negligence claims, 36
caution order, 30
cavernous haemangioma, 593
Central Midwives Boards, 27, 39–40
episiotomies and, 321
central nervous system
neonatal
assessment, 671
malformations, 658–660
in pregnancy, 159
see also neurological disorders
central venous pressure monitoring in
shock, 491
cephalic presentation see head
cephalic version, external, 357, 450
cephal(o)haematoma, 633–634
and caput succedaneum, 633–634
cerebral haemorrhage with face
presentation, 448
cerebral palsy arising from negligence,
36
cerebrospinal fluid leak, neonatal, 598
cervical ligaments, transverse, 72
cervix (uterine neck), 73
canal, 73
cancer
combined oral contraceptive pill,
572
in pregnancy, 223–224
diaphragm covering, 580
dilatation (in labour), 329–330
charting (cervicograph), 338
checking before encouraging
pushing, 385
examination/assessment
for labour induction, 422
in labour, 341b
mucus plug see mucus plug
os (in pregnancy)
multips, 330
in placenta praevia, 231, 232f
palpation, as natural family
planning method, 583
in pregnancy, 148–149
carcinoma, 223–224
cerclage, 226
ectropion, 223
effacement/taking up, 149,
329–330
inelastic/incompetent, 226
os see subheading above
polyps, 223
ripening and other changes (in
pregnancy), 148, 422
drugs inducing, 267, 423–424
secretions (natural family planning
method), 583
sweep (of membranes - CMS),
419–420, 422–423
vault caps covering, 581
Chadwick’s sign, 149, 171
Changes for Me and Us (theme in
antenatal education
programme), 133–134
chemoreceptors and blood pressure,
244
chest
maternal, compressions, 488–489
neonatal, examination, 596
chickenpox (varicella), 677
fetal/congenital/neonatal, 669, 677
maternal, 677
childbirth (giving birth; intrapartum
period)

750
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antenatal education for see antenatal
education
brow presentation diagnosed in, 449
caesarean section indicators in, 464
cardiac disease and, 267
diabetes management, 261–262
eclampsia and, 252
expected date, determination,
184–185
face presentation diagnosed in, 445
fear, 533–534
language, 334
midwife–woman relationships and,
10–11
mother’s experience of, 559
loss of anticipated experience,
559
making it a positive one, 430–431
multiple pregnancy, 296–297
delay of birth of second twin, 299
delayed interval birth of second
twin, 299
obesity risks, 256
occipitoposterior position in, 442
diagnosis of, 438
operative methods see operative
births
pelvis in, 65
personal account, 388b
place for see place
plans, 15, 199, 334–335
previous history see obstetric history
prolactinoma, 265
shoulder presentation, diagnosis,
450–451
social context, 13–18
unstable lie in, management, 452
urinary tract changes in, 89–90
uterine rupture in, signs, 484
see also birth; labour
children see infants; minors; neonates;
teenage mothers
Children’s Centres, 138, 501–502, 510
Chlamydia trachomatis, 279–280
neonatal, 279–280, 595, 605–606,
678
screening, 189
chloasma, 167–168
choanal atresia, 613–614, 655–656
cholestasis, obstetric, 235–236, 257
cholesterol
in breastmilk, 707
pregnancy and, 165
chorioamnion see membranes
chorioamnionitis, 239
choriocarcinoma, 226–227
chorion, 104, 106
chorion frondosum, 103
chorion laeve, 103
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villus/villi, 103
villus/villi, sampling (CVS)
dichorionic placenta, 292
Down syndrome, 209–210
women with cardiac defects/disease,
266
chorionicity of twins
determination, 288–292
importance, 291–292
relationship between zygosity and,
291t
chromosomes, 95b
abnormalities causing
malformations, 648–650
sex see sex chromosomes
circulation (blood flow)
at birth, adaptations, 117–118
failure see shock
fetal, 116–117
postnatal, 522
deviation from normal physiology
and potential morbidity, 518f
disorders, 522
observation, 505
in pregnancy, regional, 153
eclamptic seizure, management,
252
placental, 106, 146
uterine, 146
see also cardiovascular system
circumcision
female see female genital mutilation
male, hypospadias and, 596
circumvallate placental, 109
citalopram, 547
clavicular fracture, 633
cleanliness in labour, 343
environmental, 336
cleft lip and/or palate, 594–595,
653–654, 722
Clinical Commissioning Groups, 44
clinical effectiveness, 44
clinical governance, 44–49
Clinical Negligence Scheme for Trusts,
47
clinical preceptor/teacher in Global
Standards for Midwifery
Education (2010), 6
clitoris, 56
partial or total removal/excision,
315, 316f, 317
clonic convulsions, neonatal, 640
Clostridium difficile, 46
clot(s) (blood), placental, assessment,
405
puerperal, 507
clothing in labour
maternal, 343
midwife’s, 337
Index
clotting (coagulation), maternal, 156
disorders/failure, 234–235
with amniotic fluid embolism,
486
postpartum haemorrhage in, 412
hypercoagulable state, 156, 266, 272
normal (in pregnancy), 230, 234
clotting (coagulation), neonatal, 600
disorders, haemorrhage with,
637–639
clozapine, 547
clubfoot
positional, 597–598
structural (congenital talipes
equinovarus), 597, 661
CMV see cytomegalovirus
coagulation see clotting
cocaine, 697
coccyx, 64
Code, The, 32–34, 501b
record-keeping, 509b
coitus interruptus, 582
colic in breastfed baby, 721–722
collapse, postnatal, 517
collective responsibility, 31
collegial relationships, 11
colloids, hypovolaemic shock, 490
coloboma, 605
colon in pregnancy, 163
colostrum, 601, 707–708
expressed, 718, 720, 724–725
hypoglycaemia and, 730
vitamins in, 708–709
colour, neonatal skin, 612
assessment, 592, 668–669
coma, myxoedema, 263
combined hormonal contraceptives
injectable, 574
oral (COC), 570–574
future developments, 586–587
hypertension and, 279, 572
missed, 573
patch, 574
vaginal ring, 574
comfort in labour
in 1st stage, 343
in 2nd stage, 377
communication (with mothers/
parents), 534
at booking visit, 183–184
of congenital malformations,
650–652
difficulties, 16–17
emergency, 476
in labour, 334
neonatal examination, 598
in resuscitation with parents present,
614
see also information; talking
751
 Index
community setting see home
(or community setting)
compaction with fetal descent, 380
companion (birthing), 335
support in 2nd stage of labour for,
375–376
see also partner
compensated shock, 489
competency (mental) see capacity
complementary feeds (to
breastfeeding), 724–725
compound presentation, 452, 477
compression support stockings
thromboembolism prevention,
266–268, 271, 277, 467, 522,
525–526
varicosities, 190
conception
assisted, pregnancy problems, 228
evacuation of retained products of,
225
see also pre-conception period
condition see health and well-being
conditions of practice order, 30
interim, 30
condom
female, 579
male, 579
spermicide-lubricated, 581
conduct, standards of, 34
Conduct and Competence Committee,
30
Confidential Enquiries into Maternal
Deaths, psychiatric causes, 538,
550
Congenital Disabilities (Civil Liability)
Act (1976), 36
congenital infections
chickenpox/varicella, 669, 677
rubella, 676–677
syphilis, 281
congenital malformations see
malformations
conjoined twins, 298
conjoint longitudinal coat of anal
sphincters, 60
conjugate (anteroposterior) diameter
of pelvic inlet, 66–67
conjunctival haemorrhage, 595
conjunctivitis, neonatal (ophthalmia
neonatorum), 595, 596f,
605–606, 678
Conn’s syndrome, 248
consensual panel determination
(NMC), 30–31
consent (inc. informed consent), 35–36
antenatal screening, 206–207
labour and, 337
mental capacity and, 35, 207
752
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consequentialism (utilitarianism),
38–39
constipation, 164b
with analgesia in postoperative anal
sphincter repair, 320
consumptive coagulopathy see
disseminated intravascular
coagulation
contact (mother–baby), 625–626
lost baby, 560–561
skin-to-skin, 296, 299, 398, 465,
499–500, 599–600, 622, 711
social, 625
continence, postnatal, 507
see also anal incontinence; urinary
incontinence
continuing professional development
standard, 35
continuous care and support in labour,
336
prolonged labour, 428
continuous electronic fetal monitoring,
345–347
continuous subcutaneous insulin
infusion pumps, 258–259
contraception, 569–588
barrier methods see barrier
contraceptives
counselling see counselling
emergency, 581–582
future of, 586
hormonal methods see hormones
hypertensive women, 279
long-acting reversible, 575–578, 586
natural methods, 582–585
role of midwife, 570
contractions (uterine), 331
in 2nd stage of labour, 368–369,
376
expulsive, 369
in 3rd stage of labour, 397
rub up, 409
Braxton Hicks, 145–146, 148,
333–334
intensity, 331
at onset of labour, 329
sustaining (with uterotonics) in
treatment of postpartum
haemorrhage, 409
contractual accountability, 31–32
convoluted tubules, 83
convulsions see seizures
cooling
neonate
induced, in encephalopathy,
673–674
unwanted, 598–599
postnatal perineal pain, 508
copper IUCD see intrauterine systems
cord see umbilical cord
cornea (neonatal), examination, 595
coronal suture, 118
coronary angioplasty, 269
corpora cavernosa, 79
corpus luteum, 94, 143
corpus spongiosum, 79
cortical nephrons, 83
cortical reaction (at fertilization), 95
corticosteroids (steroids), asthma
inhaled, 270
tablets, 270
cortisol, maternal, 169, 171
cotyledon, 104
broken fragments, 405
retained, 407
counselling
antenatal screening, 207
Down syndrome, 209
haemoglobinopathies, 211
contraception
sterilization, 585–586
subdermal contraceptive implants,
577
grief and bereavement, 665
multifetal pregnancy reduction,
305
neural tube defect, 660
preconception, 266, 276, 278
termination of pregnancy for fetal
abnormality, 559
Couvelaire uterus, 233
cow’s milk protein intolerance, 727
creatinine measurements in pregnancy,
155t, 161
cremation, 224, 564
cretinism, 170
cricoid pressure in caesarean section in
Mendelson’s syndrome
prevention, 470
crowning, 377
right occipitoposterior position,
440
crown–rump length and Down
syndrome, 209
crying (midwife) with bereaved
parents, 564
cryptorchidism, 664
crystalloids, hypovolaemic shock, 490
culture
diaphragm (contraceptive) and,
580
emotion and, 12
loss and, 557
curriculum in Global Standards for
Midwifery Education (2010), 7
Cushing’s syndrome, 248
cuts and lacerations, neonatal, 593,
629–630

cyanocobalamin supplements, 275
cyanosis, neonatal, 592, 669
cardiac defects causing, 656–657
peripheral/at extremities
(acrocyanosis), 592, 668–669
cyproterone in combined oral
contraceptive pill, 570–571
cystic fibrosis, meconium ileus,
653
cystic kidney, 663–664
cytomegalovirus (CMV), 280
screening, 189
cytotrophoblast, 97, 102–103, 168
D
dating of pregnancy, ultrasonography,
418
deaths/mortalities
fetal
induction of labour, 421
vasa praevia, 477
infants (incl. neonates)
early, 558
multiple, 304
sudden infant death syndrome,
previous occurrence (woman or
in family), 185
maternal, 564
in epilepsy, 278
in genital tract infection, 279
in psychiatric illness, 550
in septic shock, 492
in shoulder dystocia, 483
perinatal (in general), 557–558
see also abortion; bereavement;
feticide; life-threatening
conditions; loss; miscarriage;
stillbirths
decelerations, 346
atypical variable, 346
late, 346
typical variable, 346
decidua, 101, 146
decidua basalis, 101, 103
decidua capsularis, 101, 103
decidua vera/parietalis, 101
reaction (decidualization), 101,
104–105, 143, 168
decubitus ulcer prevention in labour,
343
deep transverse arrest, 442
deep vein thrombosis (DVT), 190,
229, 271–273, 522
defence mechanisms in loss and grief,
556
deflexion of head in occipitoanterior
position, 437f–438f, 442–443,
451
mebooksfree.com
deformations
developmental see malformations
pelvic, 69
deinfibulation, 317–318
personal account, 323
delivery (birthing)
baby see birth
placenta, cardiac disease and,
267
see also birth; caesarean section;
vaginal birth
delusions, psychotic, 541
denial (of loss), 556
denominators (with presentations),
196
dental health, 161–162
deontology, 39
depot medroxyprogesterone acetate,
575–576
depression (and depressive illness),
537
postnatal, 136
see also antidepressants; bipolar
illness
deprivation (poverty), 15
dermatitis, breast, 720
dermatology see skin
descent
fetal head see head
placenta see placenta
desogestrel in combined oral
contraceptive pill, 570–571
development
fetal see fetus
neonatal/postnatal
intracranial haemorrhage and
stage of brain development,
635–636
LBW/preterm baby, 625
twins, 302
sex, disorders, 597, 664, 695
structural abnormalities see
malformations
developmental dysplasia of hips,
606–607, 661–662
diabetes mellitus, 165, 257–262
family history of, 186, 258
gestational see gestational diabetes
mellitus
induction of labour, 421
infant hypoglycaemia in, 690
macrosomia and, 618–619
maturity onset diabetes of the young
(MODY), 259
secondary, 259
shoulder dystocia and, 479
type 1, 257–262
type 2, 254, 257, 259–262
diamniotic twins, 291
Index
diamorphine (heroin)
abuse, 696
caesarean section, postoperative,
466
labour, 354
diaphragm (contraceptive), 579–581
diaphragmatic hernia, congenital,
654–655, 680–681
diarrhoea, neonatal, 672
diastolic murmur, 603–604
dichorionic twins, 288–294, 297
chorionic villus sampling, 292
premature expulsion of placenta,
299
ultrasound examination, 292
diclofenac (incl. Voltarol)
anal sphincter repair, postoperative,
320
perineal pain (postnatal), 508
diet
deficiency, pelvic anomalies, 70
at first antenatal visit, 186
in labour, 343–344
see also nutrition
digestive system see gastrointestinal
system
digit(s)
anomalies, 597–598
blood pressure-measuring devices,
245
dinoprostone inducing labour, 267,
423–424
disability
baby born with, 559
twin, 304
women with, 14–15
disadvantaged groups/women,
13–17
booking visit, 184
midwives meeting needs of, 17–18
discharge home in drug abuse, 697
discussion in antenatal education
sessions, promoting, 131–132
disseminated intravascular coagulation
(consumptive coagulopathy)
maternal, 273
in amniotic fluid embolism, 486
neonatal, 638–639
distress, psychological, 537
headache as precursor of, 523
diuretics in hypertension, 247
dizygotic (binovular/DZ) twins, 288,
292
monozygotic vs, 95–96, 288
DNA, free fetal, 214
documentation see records and
documentation
domestic abuse, 184, 509–510
dominant gene disorders, 648
753
 Index
dopamine agonists
lactation suppression, 723–724
prolactinoma, 264–265
Doppler assessment of fetal heart rate
labour, 344–345
multiple pregnancy, 295–296
double pumping, 719
double uterus, 75
doula, 336, 503–504
Down syndrome (trisomy 21),
208–210, 649–650
breastfeeding, 723
screening, 207–210, 213
drospirenone in combined oral
contraceptive pill, 570–571
drug(s) (medical)
breastfeeding see breastfeeding
lactation-suppressing, 723–724
placental transfer and risk to fetus,
105
anticonvulsants, 548
antipsychotics, 547
lithium, 548
SSRIs, 546–547
tricyclic antidepressants, 546
records in labour, 344
standards for management of, 35
toxicity, 492
treatment with see medical
management and specific (types
of) drugs
drug abuse see substance abuse
drying the baby, 611–612
Duchenne–Erb (Erb’s) palsy, 632
ducts, lactiferous/milk, 705
blocked, 721
ductus arteriosus (arterial duct),
116–117
at birth, 117–118
patent persistent (PDA), maternal,
uncorrected, 268
patent persistent (PDA), neonatal,
602, 645, 657–658
lesions dependent (for
haemodynamic stability) on,
657–658
ductus venosus, 112, 116–117
at birth, 117
duodenal atresia, 652
duplications, uterine, 75
dural puncture-related headache, 356b,
357
duty of care, 32, 36, 39, 47
breach, 36–37
dyslipidaemia, atherogenic, 254
dysmenorrhoea, 94
dyspnoea (breathlessness), 158b
dystocia, 427
shoulder see shoulder
754
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E
ears
fetal, 115–116
neonatal, examination, 594
eating see diet; nutrition
Ebstein’s anomaly and lithium, 548
ecbolics see uterotonics
eclampsia, 251–253
fulminant, 251
ectoderm (embryo), 97
neural tube development from, 115
ectopic (mainly tubal) pregnancy,
148–149, 225–226
education
maternal
antenatal see antenatal education
diabetes, 261
midwife, ICM global standards, 4–8
see also information
Edwards’ levels of ethics, 38b
Edwards’ syndrome, 650
egg see oocyte
ejaculatory ducts, 79
ejection murmur, 603
electrically-controlled breast pump,
719–720
electrolyte imbalances in newborns,
691–692
electronic fetal monitoring see
cardiotocography
elemental formulae, 727
ellaOne, 582
embolism
amniotic fluid, 485–486
pulmonary see pulmonary
embolism
embryo development, 97, 111
stem cells in see stem cells
timescale, 111, 113
embryoblast, 97–99
emergency
contraception, 581–582
threat to health, 475–495
antepartum haemorrhage, 232,
234
breech presentation classed as,
356–357
communication in, 476
inborn errors of metabolism,
693
emesis see vomiting
emotion(s)
in labour, 335, 535–536
midwives’, 8–13
developing awareness of, 8,
12–13
managing, 11–12
postnatal, 526, 536
in pregnancy
antenatal screening impact on,
204–205
normal changes, 535–536
see also distress
emotion work, 9
sources, 9–11
emotional intelligence, 12
encephalopathy, neonatal, 672–674
end-of-life care with congenital
malformations, 646–647
endocrine system (and activity)
adult female/maternal, 168–171
disorders, 257–265
kidney, 84
placenta, 104–105, 168–169
fetal, 115
neonatal, disorders, 694–695
see also hormones
endoderm (embryo), 97
endometrial cycle (menstrual cycle),
92f, 94–95
endometrium, 73, 144
combined oral contraceptive pill
and cancer of, 572
implantation into see implantation
in menstrual/endometrial cycle,
94–95
in pregnancy see decidua
endorphins, 351
transcutaneous electrical nerve
stimulation and, 353
endotracheal intubation in caesarean
section, difficult/failed, 470–471
enemas, 343
engagement (fetal head descent into
pelvic brim) see head
enkephalins, 351
enoxaparin, 266
enterocolitis, necrotizing (NEC), 672
Entonox see nitrous oxide + oxygen
environment (physical)
in labour, 336
cleanliness, 336
position and, 372
LBW babies and optimization of,
625–626
environmental and genetic factors,
disorders due to combination
of, 648
epiblast, 97–98
epidermolysis bullosa, 669–670
epididymis, 78
epidural (regional) analgesia/
anaesthesia, 354–356, 371b
caesarean section, 467–469
postoperative care after, 467
postoperative use, 466
technique, 469

cardiac disease patients, 267
complications, 356
multiple pregnancy, 296
spontaneous vaginal birth and, 371b
upper abdominal pressure
(in labour) and, 369
epilepsy, 277–279
epinephrine see adrenaline
episiotomy, 313
postpartum haemorrhage relating to,
407
repair, 318
in shoulder dystocia, 481
training (in performance and
repair), 321
epithelial overgrowth (nipple), 721
Epstein’s pearls, 595
epulis, pregnancy, 161
ERASMUS programme, 8
Erb–Duchenne (Erb’s) palsy, 632
Erb–Klumpke palsy, 632
ergometrine, 400
cardiac disease and, 267
combined oxytocin and, 400
in postpartum haemorrhage
treatment, 409
erythema, palmar, 168
erythrocytes see red blood cells
erythropoietin, 84
Essure, 585
ethics, 37–39
frameworks and theories, 37–39
standards of, 34
ethnic minority women, 15–16
ethnocentrism, 16
eumenorrhoea, 94
European Action Scheme for the
Mobility of University Students
(ERASMUS) programme, 8
European Convention for the
Protection of Human Rights
and Fundamental Freedoms, 32
European Union Standards for
Nursing and Midwifery, 4
evacuation of retained products of
conception, 225
evidence-based research and practice,
3, 12
postnatal care, 509
EVRA (combined hormone patch), 574
examination, maternal (incl. physical)
abdominal see abdomen
breech presentation, 357–358
in labour, 358–359
brow presentation, antenatal, 449
face presentation, intrapartum, 445
at initial assessment, 187–196
as indicator for referral for
additional support, 183
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midwife’s, 189–196
recognition of problems, 668–672
in labour in 1st stage, 327, 340
breech presentation, 358–359
initial, 337
membranes see membranes
occipitoanterior position
antenatal, 436–437
intrapartum, 438
placenta, 404–405
post-mortem (baby), 561
shoulder presentation
antenatal, 450
intrapartum, 450–451
see also observation; palpation
examination, neonatal
daily, 598–601
first, 592–598
NIPE (Newborn and Infant Physical
Examination), 601–607
exchange transfusion in physiological
jaundice, 684–685
excretion, fetal, 105
exercise
first antenatal visit and, 186–187
postnatal, 508–509
women’s views at postnatal
classes, 502
exomphalos, 650
expectant management
3rd stage of labour, 398–400,
403–404
prolonged pregnancy, 419
expected date of birth, determination,
184–185
experiences
midwife, of loss, 559
mother
in antenatal education groups,
sharing, 130b
of childbirth see childbirth
in fetal ultrasonography, 211–212
Expert Reference Group on antenatal
education
Preparation for Birth and Beyond,
133–136, 138
systematic review, 129
on wants and needs of stakeholders,
138
expiratory grunting, 670
extension of fetal head, 374
left mentoanterior position, 445
right occipitoposterior position, 440
external cephalic version, 357, 450
external rotation of head, 371–372,
374, 375f, 378
breech presentation, 381
left mentoanterior position, 446
right occipitoposterior position, 441
Index
extracorporeal membrane oxygenation
in meconium aspiration
syndrome, 679
eyes
fetal, 115–116
neonatal
first examination, 595
infections, 595, 605–606, 678
NIPE (Newborn and Infant
Physical Examination),
605–606
F
face, fetal, 120
bruising with face presentation, 448
presentation, 121, 193–194,
444–448
causes, 444
complications, 448
labour management, 447–448
mentum as denominator with,
196
occipitoposterior position
converted to, 442
primary vs secondary, 444
reversal, 447
trauma, 448, 631
face, neonatal
examination, 594–595
instrumental delivery-related
trauma, 462–463
palsy (facial nerve damage),
462–463, 594f, 631–632
face to pubis presentation,
undiagnosed, 442
facilities in Global Standards for
Midwifery Education (2010), 7
faculty in Global Standards for
Midwifery Education (2010), 6
faeces (stools)
maternal, incontinence (anal
incontinence), 320, 507, 524
neonatal/infant, 601
bottle-fed baby, 729
breast-fed baby, 718
fallopian tubes (oviducts; salpinges;
uterine tubes), 75–76
occlusion (for sterilization),
585–586
in pregnancy, 144
ectopic pregnancy in tubes,
148–149, 225–226
Fallot’s tetralogy, 657
family
loss impacting on, 563
parenthood and relationship with
other members of, 556
postpartum care centering on, 516
755
 Index

family history, 186 ferrous salts spontaneous/accidental loss see

diabetes mellitus, 186, 258 antenatal, 274 miscarriage
Family–Nurse Partnership (FNP) postnatal, 524–525 teratogens see teratogens
programme, 138 fertilisation, 95–96 in unstable lie causation, 452
postnatal care and, 502 fertility well-being see health and well-being
fascia (pelvic), vagina, 72 awareness (natural family planning), fetus-in-fetus, 298
fat(s) 582–585 fever (pyrexia), neonatal, 599
body (in general), distribution future (after childbirth), 509 fibrin, 234
related to disease, 254 problems, 558 breakdown (fibrinolysis), 234
breast, 704–705 fetal haemoglobin, 114, 275 deposits, HELPP syndrome, 253
in breastmilk, 707 fetal membranes, 106 fibroids (leiomyomas; fibromyomata)
wound healing and, 521t fetal surface of placenta, 104 degeneration, 227
fat-soluble vitamins, 708–709 feticide, 228 postpartum haemorrhage relating to,
fathers selective, 305 408
in antenatal education fetus, 111–123 fits see seizures
inclusion, 138–139 adaptation to extrauterine life, Five Rhythms method, 343
numbers, 139 117–118, 670 flexion (of fetus in labour), 373, 376
in antenatal screening, unknown/ amniotic fluid embolism effects, lateral, 374, 380
unavailable/declining tests, 486 in occipitoposterior position, 440
211 antepartum haemorrhage and the failure, 441–442
impact of loss, 563 appraisal of fetus, 230 in mentoanterior position (right),
see also parenthood; partner effects of haemorrhage, 230 446
fatigue/tiredness, postnatal, 508, 526 asphyxia see asphyxia ventouse extraction and point of, 459
fatness, measures of, 254 axis pressure, 333 floppy (hypotonic) baby, 612–614, 671
fatty acids in breastmilk, 707 blood sampling in labour, 347–348 fluid balance
fatty liver, 253 death see death maternal, 166
fear development and maturation, labour, 341
of giving birth, 533–534 112–116 neonatal overload, 691
in psychosis, 541 timescales, 111, 113 fluid management
see also anxiety diabetes and risk to, 260 hypovolaemic shock, 490
feeding, infant, 703–736 diagnosis of abnormality see septic shock, 492
complementary/supplementary to antenatal diagnosis fluoxetine, 547
breastfeeding, 724–725 distress or compromise, 296, 345, focal (partial) neonatal convulsions/
discussed at antenatal visit, 189 456 seizures, 640
LBW babies, 624–625 excretion, 105 folic acid
poor, indicating bacterial infection, growth see intrauterine growth deficiency, 274–275
675 head see head twin pregnancy and, 294
twins, 299–301 heart see heart diabetic women, 261
see also breastfeeding; formula in instrumental delivery supplements, 275
feeding as contraindicator, 457 antiepileptic drugs and, 278–279
feet as indicator, 456 follicle(s), ovarian, 93–94
in breech presentation, 357 intrauterine growth restriction see also Graafian follicles
in labour, 359 related to factors in, 620 follicle-stimulating hormone (FSH)
neonatal, examination, 597–598 lie, 194 females, 91–92
female baby genitalia malformations see malformations in ovarian cycle, 93–94
examination, 597 movements see movements in pregnancy, 169
male-looking, 664, 695 nutrition, 105 males, 80
female genital mutilation (FGM/ obesity and risk to, 255 follicular phase of ovarian cycle, 93–94
genital cutting/female position, 196 fontanelles, 116, 118–120
circumcision), 314–317 presentation see presentation anterior, 120
personal account, 322b–323b prevention of rejection, 102 posterior, 120
repair, 318 prolonged pregnancy and its impact food cravings, 162
see also women on, 418–419 see also diet; feeding; nutrition
FemCap, 581 respiration, 105 foot see feet
Femilis (and Femilis Slim), 578 rights, 36 footling breech, 357
feminization (under-virilization), screening, 189, 208–214 foramen magnum, 118
male, 664 in shoulder dystocia, morbidity, 483 foramen ovale, 112, 116, 118
femoral fracture, 633 in shoulder presentation causation, at birth, 118
Ferguson reflex, 330, 368–369, 428 450 closure, 117

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forceps, 456, 460–463
breech presentation, 384, 456
characteristics, 460
classification, 460
complications, 462–463
neonatal trauma, 629–630
contraindications, 457
indications, 456
procedure, 460–461
types, 460
see also instrumental vaginal birth
forebrain, fetal, 115
foregut, 115
forehead region (fetal skull), 120
foremilk, 707, 716
forewaters, 332
rupture see rupture of the
membranes
formal carers in loss, 563–564
formula (bottle) feeding, 726–729
allergy and, 708
breastfeeding compared with,
morbidity problems, 708, 726
choosing a feed, 727
as complementary or supplementary
feeds to breastfeeding, 724–725
equipment, 728
sterilization, 728
intolerance to standard formulae,
727
preparation of feed, 727–728
technique, 728–729
twins, 299–300
preparation for, 293
types of milk, 726–727
‘framing’ effect, 207–208
frank breech, 357
Fraser competence, 35–36
frenotomy in tongue tie, 722
frontal bones, 118
frontal suture, 120
full blood count at booking visit, 188
functional vital capacity, 158
funeral, 561, 564
midwives at, 564
see also burial; cremation
funic souffle, 146
G
galactosaemia, 694
gall bladder in pregnancy, 163
disease, 236
GALT (gut-associated lymphoid tissue),
710
gametes see oocyte; spermatozoon
gases, blood, in pregnancy, 159
Gaskin manoeuvre, 481
gastric… see stomach
mebooksfree.com
gastrointestinal (digestive) system
fetal, 115
maternal
changes, 161–164
shock affecting, 490
neonatal, 600–601
examination for problems, 672
malformations, 650–654
gastro-oesophageal junction in
pregnancy, 162–163
gastroschisis, 650
gastrulation, 97
gate-control theory of pain, 351–352
general anaesthesia
caesarean section, 470–471
care following, 467
postpartum haemorrhage relating to,
407
general fluid pressure (in labour), 332
generalized neonatal seizures, 640
genetic disorders
congenital malformations due to,
648
cardiac, 266
family history of, 186
of metabolism, 692–694
genitalia see female genital mutilation;
reproductive system
genitourinary system (neonatal)
examination for disorders, 671–672
malformations, 81, 663–664
germ cells see oocyte; spermatozoon
germinal matrix haemorrhage (GMH),
635–637
gestational age, 618
appropriate growth for, 618
assessment (at birth), 622–623
large for, 618
small for see small for gestational
age
gestational diabetes mellitus (GDM),
165, 260–262
shoulder dystocia and, 479
gestational hypertension, 246–247
gestational trophoblastic disease,
226–227, 249
gestodene in combined oral
contraceptive pill, 570–571
Getting to Know Our Unborn Baby
(theme in antenatal education
programme), 134b
Gillick competence, 35–36, 337
Giving Birth and Meeting Our Baby
(theme in antenatal education
programme), 134
glandular tissue, breast, 704–705
Glasgow Coma Score, hypovolaemic
shock, 491
globalization, 4–8
Index
glomerulus, 83
filtration, 85
in pregnancy, 161
selective reabsorption in, 85–86
glucagon, 257
fetal, 115
glucocorticoids, adrenal, 695
glucose, maternal blood (glycaemia)
abnormal values see hyperglycaemia;
hypoglycaemia
assessment and management, 253,
261
intrapartum, 261
normal values, 165
glucose, neonatal blood (glycaemia),
689
abnormal levels, 689–691
homeostasis, 689
tests, 262, 690
glucose tolerance test (GTT),
256–257
glycaemia see glucose
glycolysis, neonatal, 598–599
glyc(osyl)ated haemoglobin, 259–260
goat’s milk formulae, 727
gonadotrophins
human chorionic see human
chorionic gonadotrophin
pituitary see follicle-stimulating
hormone; luteinizing hormone
gonorrhoea (N. gonorrhoeae infection)
maternal, 280
neonatal eye infection, 595,
605–606, 678
Goodell’s sign, 148, 171
governance, clinical, 44–49
Graafian follicles, 93–94
rupture, 94
grandparents, impact of loss, 563
granular cells, 83
granuloma, pyogenic, 161
Graves’ disease
maternal, 264
neonatal, 694–695
gravidity and attendance at antenatal
sessions, 137–140
great arteries, transposition, 604b,
657
grief (in loss), 556–557
in multiple pregnancy/birth of one
baby, 304
stages, 556–557
in termination of pregnancy,
558–559
group A streptococcus, 281
group B streptococcus (GBS), 281,
675–676
respiratory distress, 679
screening, 189, 215
757
 Index
growth
appropriate (for gestational age), 618
charts, LBW and preterm babies, 623
fetal see intrauterine growth
undergrown see small for gestational
age
weight in assessment of, 618
growth factors in breastmilk, 710
growth hormone
human placental, 105
pituitary, deficiency, 695
grunting, expiratory, 670
guidelines (in clinical governance),
44–45
gut-associated lymphoid tissue, 710
Gygel, 581
gynaecoid pelvis, 68, 68t
GyneFix, 578
H
haem in pregnancy, 154, 275
haemangioma(ta), 593
capillary/strawberry, 662–663
haematemesis, 639
haematology
maternal/in pregnancy
disorders, 247
normal changes, 153–157
tests (compared with non-
pregnant woman), 155t
neonatal, disorders, 688–689
haematoma, postpartum, 413
haematuria, 639
haemoglobin
fetal, 114, 275
glyc(osyl)ated (HbA1c), 259–260
postnatal levels and assessment, 524
in pregnancy, 154
see also anaemia
haemoglobin H disease, 275
haemoglobin S, 276–277
haemoglobinopathy, 275–277
screening for, 189, 210–211, 215–216
haemolysis, elevated liver enzymes and
low platelets (HELLP)
syndrome, 253
haemolytic disease of the newborn
(HDN), 188, 216, 684–686
haemolytic jaundice, 685–686
haemophilia, 689
haemorrhage (baby), 633–639
cerebral (fetal), with face
presentation, 448
conjunctival (neonatal), 595
support of parents, 641
haemorrhage (maternal), antenatal
(and unspecified or in general),
229–235
758
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arrest, 490
see also bleeding
haemorrhage (maternal), postpartum,
406
care after, 414
multiple pregnancy, 299, 407
primary, 406–412
causes, 406–408, 412, 487
maternal observation following,
412–413
prophylaxis, 408
signs, 408
treatment, 409–412
secondary, 413
timing of components of active
management in relation to
incidence of, 403
haemorrhoids, 164b
haemostasis (stopping bleeding)
endogenous
with placental separation and
descent, 397–398
in wound healing, 520f
in postpartum haemorrhage, 409
hair growth, maternal, 167b
hand(s), neonatal
examination, 597–598
malformations, 660
see also manual techniques
handling the baby, 625–626
hands-free milk expression, 719
hands-off technique, 377
breech birth, 381, 385
hands-on-help from midwife in
breastfeeding, 715–716
haploidy oocyte, 94
at fertilization (and haploid sperm),
95
Hashimoto’s disease, 263
head (fetal)
attitude, 121, 194
birth of
in breech presentation, 381–384
in breech presentation, delay, 385
in face presentation, 447–448
normal, 377–378
in shoulder dystocia, reinsertion
of head after, 482–483
circumference (HD) measurement
at birth, 593–594
ultrasound, 213
deflexion in occipitoanterior
position, 437f–438f, 442–443,
451
descent into pelvic brim and
engagement, 148, 193, 342f,
373, 376
breech birth, 382
extension see extension
high, cord prolapse or presentation
with, 477
moulding see moulding
presentations (cephalic
presentation), 121, 193–194,
373–374
assessment in 1st stage of labour,
341b
engagement with, 193
mechanism of labour in, 373–374
varieties, 195f
rotation see external rotation;
internal rotation
stations in relation to pelvic canal,
342f
head (neonatal)
examination, 593–594
feeding and support for, 624, 712
heat loss, 623
headache
dural puncture-related, 356b, 357
postnatal, 523
Health Act (1999), 28
Health and Social Care Act (2012), 27,
501–502
health and well-being/condition
fetal
in 1st stage of labour, 344–348
in 2nd stage of labour, 376
in diabetes, tests for, 261
indicators of, 196–198
multiple pregnancy, compromise,
296
maternal antenatal
in 1st stage of labour, assessment,
340–341
in 2nd stage of labour, 374–379
as indicator for referral for
additional support, 183
indicators of, 196
maternal postnatal, 515–529
expectations, 508–509
future, 509
identifying deviation from
normal, 517–525
immediate untoward events for
mother, 516–517
life-threatening conditions and
morbidity, 516
problems, 515–529
partner and other companions, in
2nd stage of labour, 375–376
see also medical conditions/
disorders; Our Health and
Wellbeing; sexual health
Health Care and Associated
Professions (Indemnity
Arrangements) Order (2013),
37
 Index

Health Committee, 30 HELPERR acronym, 480 hormones

Healthy Start Initiative, 729 HELPP (haemolysis, elevated liver adrenal, 695
heart (fetal) enzymes and low platelets) disorders relating to, 695
growth and development, 112 syndrome, 253 breast/lactation and, 705
rate see heart rate Henle’s loop, 83 in breastmilk, 710
heart (maternal) heparins (low molecular weight), 266 contraception using, 570–575
anatomical changes, 149–153 after caesarean section, 467 emergency, 581–582
failure, shock (=cardiogenic shock), hepatic disorders, 235–236, 253 injectable, 574
489 hepatitis, viral, 236 long-acting reversible, 575–578,
output, 152 hepatitis A, 237, 280 586
in hypovolaemic shock, 489 hepatitis B, 237, 280 oral see oral contraceptive pill
output in labour diagnosis/screening, 189, 214, skin patch, 574
pain affecting, 352 237 vaginal ring, 574
positioning affecting, 267 hepatitis C, 237, 280 kidney, 84
heart (neonatal) diagnosis/screening, 189, 237 male, 80
murmur see murmur hepcidin, 154 maternal, 168–171
NIPE (Newborn and Infant Physical hernia, congenital diaphragmatic, blood pressure and, 244
Examination), 602 654–655, 680–681 placental, 104–105, 168–169
sounds, 603 heroin see diamorphine in mental illness prophylaxis, 549
heart disease (baby), congenital, 602, herpes simplex, neonatal, 669 reproduction (in females) and,
656–658, 681 herpes zoster, 677 91–100
causes/risk factors, 656 high assimilation pelvis, 69 HPV (human papilloma virus), 281
lithium, 548 hindbrain, fetal, 115 human chorionic gonadotrophin
SSRIs, 547 hindgut, 115 (hCG), 101, 105, 168–169
postnatal detection (incl. hindmilk, 707, 716 pregnancy loss, 224
examination), 602, 656 hindwaters, 332 pregnancy testing, 171
prenatal diagnosis/detection, 656 rupture see rupture of the human chorionic
management with, 681 membranes somatomammotrophin
heart disease (maternal), 265–269 hips (and hip bones), 62–63 hormone, 105
acquired, 268–269 developmental dysplasia, 606–607, human immunodeficiency virus (HIV)
congenital, 265, 268 661–662 and AIDS, 280–281
care, 266–268 Hirschsprung’s disease, 653, 672 breastfeeding and, 723
hypertension associated with, 248 histamine and blood pressure, 244 postpartum haemorrhage and, 408
preconception care and, 266 history (woman’s), and its recording tests, 214
diagnosis, 265 at booking visit, 184–186 booking visit, 189
heart rate (fetal) indicating referral for additional human papilloma virus, 281
auscultation see auscultation antenatal support, 183 human placental growth hormone,
Doppler assessment see Doppler in labour at onset, 337 105
assessment HIV see human immunodeficiency human placental lactogen, 105, 169
electronic monitoring see virus Human Rights Act (1999), 32
cardiotocography home (or community setting) see also rights
in labour, 344–345 antenatal visit, 199 humeral fracture, 633
1st stage, 344–345 birth at, 199, 335 humoral immunity in pregnancy, 157
2nd stage, 376, 385 breech, 360 hyaline membrane disease (neonatal
intermittent assessment, 344–345 option of, 182 respiratory distress syndrome),
normal, 346, 347b cord prolapse management, 479 680
overall classification of features, multiple births and their care at, hydatidiform mole, 226–227
346–347 302 hydralazine, 247
pathological, 347, 347b, 348f placental retention at, 412 hydramnios see polyhydramnios
suspicious, 347, 347b, 348f, 376 postnatal haemorrhage, secondary, hydrocephalus, 660
multiple pregnancy, 294–296 413 hydrolysate formulae, 727
heart rate (neonatal), 596 postnatal visit, 503–504, 526–527 hydrostatic pressure in replacement of
heartburn, 162–163 home-from-home, birthing rooms as, inverted uterus, 487
heat (baby) 336 hydrotherapy, labour pain, 352–353
loss, 598–599, 611–612 Home Start, 305, 545–546 21-hydroxylase deficiency, 597, 664
preterms, 623 homeopathy and labour pain, 352 hyperbilirubinaemia (neonatal), 681
overheating (hyperthermia), 599 homosexual women, 17 late conjugated, 688
Hegar’s sign, 148, 171 HOOP (Hands-Off Hands-Poised) late unconjugated, 688
help see support and help trial, 377–378 hypercoagulable state, 156, 266, 272

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 Index

hyperemesis gravidarum, 228–229 hypothyroidism postpartum haemorrhage associated

hyperglycaemia maternal, 263–264 with, 407
maternal, 257–258 neonatal, 694 ritual, 420
neonatal, 690–691 hypotonic (floppy) baby, 612–614, infants
hyperinsulinaemia 671 feeding see feeding
maternal, 164–165 hypovolaemic shock, 489–491 micturition, 89
neonatal, 623–624 hypoxia mother’s relationship with see
hyperkalaemia, neonatal, 692 fetal, 457 relationships
hyperlipidaemia (dyslipidaemia), healthy baby, 376 preterm see preterm babies
atherogenic, 254 maternal response to, 244 sleeping, safety advice, 199, 626
hypernatraemia, neonatal, 691–692 hypoxic–ischaemia encephalopathy see also neonates; sudden infant
hypertension (and hypertensive (HIE), neonatal, 672–673 death syndrome
disorders), 244–253, 522–523 infections (maternal), 279–282
chronic (benign/essential), 244–248, antibiotic prophylaxis for caesarean
I
523 section, 464
superimposed pre-eclampsia, 248 identity, twins, 303 healthcare-associated, 46
combined oral contraceptive pill ileus, meconium, 653 placenta as barrier to fetal infection,
and, 279, 572 iliococcygeus, 61 105
definitions, 246b iliopectineal eminence, 65 in labour, 336–337
non-pregnant population, 246b iliopectineal line, 65 postnatal
in pregnancy, 246b ilium, 62 breast, 721
gestational, 246–247 imaging, fetal, new technologies, caesarean section wound, 522
history of, 185–186 214 vulnerability to/potential causes/
induction of labour, 248, 421 immune system prevention, 519
in labour, 341 neonate and, 105, 601, 675 testing/screening for, 214–215
postnatal, 522–523 breastmilk factors and, 710 at booking visit, 188–189
in pregnancy, 244–253 in pregnancy, 156–157 see also immune system; sepsis
complications, 247 preventing of fetal rejection, 102 infections (neonatal), 674–678
management, 247b immunization see antibodies; breastfed vs formula-fed babies, 726
secondary, 248–249 vaccination breastmilk factors in protection
hyperthermia (overheating), 599, 671 immunoglobulins see antibodies from, 710
hyperthyroidism imperforate anus (anal atresia), 596, congenital see congenital infections
maternal, 263, 263t 652 eye, 595, 605–606, 678
neonatal, 694–695 implant, subdermal contraceptive, hyperbilirubinaemia in, 688
hyperventilation in pregnancy, 159 576–577 respiratory distress due to, 679–681
hypervolaemia (increased blood implantation (trophoblast into urinary tract, 671–672
volume) in pregnancy, endometrium), 97, 101–102 infertility, 558
150–153, 272 bleed, 222–226 infibulation, 316f
hypoblast, 97–99 incapacity see capacity see also deinfibulation
hypocalcaemia, neonatal, 692 incontinence inflammatory phase of wound healing,
in hypoparathyroidism, 695 faecal/anal, 320, 507, 524 520f
hypogastric arteries, 116 urinary see urinary incontinence information (for women and parents),
at birth, 118 indemnity insurance, professional, 37, 17
hypoglycaemia, 258 182 in antenatal education groups,
maternal (risk with insulin), Indemnity Order (2013), 37 139–140
257–259, 261 indicative sanctions, 30 sharing, 129–131
severe, 258 individuality with twins, 303 in antenatal screening, 207
neonatal, 262, 623–624, 689–691, induction of labour, 420–426 amount needed, 207
695 alternative (non-surgical or on blood groups and red cell
hypokalaemia, neonatal, 692 pharmacological) approaches antibodies, 216
hyponatraemia, neonatal, 691 to, 426 for haemoglobinopathies, pre-test,
hypoparathyroidism, neonatal, 695 contraindications, 422b 211
hypospadias, 596, 664 indications, 421 at booking visit, 184
hypotension cardiac disease, 267 see also communication; education;
in labour, 341 hydramnios, 238 knowledge
epidural analgesia-related, 356b hypertensive women, 248, 421 informed consent see consent
in supine position in pregnancy, multiple pregnancy, 294 infundibulum, fallopian, 76
152b pre-eclampsia, 251, 421 inhalation anaesthesia in caesarean
hypothermia, neonatal, 671 methods, 422–425 section, 470

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inhalation analgesia see nitrous oxide
+ oxygen
inhaler, asthma, 270
inherited disorders see genetic
disorders
inhibin, 93–94
injectable contraceptive, combined,
574
injury (trauma)
maternal
breast, affecting breastfeeding,
723
in epileptic seizure, 278
with face presentation, 448, 631
in instrumental delivery, 462
levator ani, 62
with occipitoposterior position,
443
pelvic deformation (following
fracture), 70
pelvic floor, 523
perineal see perineum
postpartum haemorrhage caused
by, 412
neonatal, 593, 629–643
with face presentation, 448
haemorrhage due to, 633–635
in instrumental delivery, 462–463,
629–630
with occipitoposterior position,
443
skin, 593, 629–631
support of parents, 641
innervation see nerve supply
innominate bones, 62–63
‘inside baby’, 559
inspection see observation
instrumental vaginal birth, 456–457
complications, 462–463
neonatal trauma, 462–463,
629–630
contraindications, 457
failure, 463
indications, 456
insulin (fetal), 115
insulin (maternal), 164–165, 257, 261
administration, 258–259
hypoglycaemia risk see
hypoglycaemia
postnatal, 262
insulin-dependent (type 1) diabetes
mellitus, 257–262
insulin growth factor (IGF), 105
insurance, professional indemnity, 37,
182
integumentary system, fetal, 116
intelligence
emotional, 12
kindness with, 10–11
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Index
intention to practice documentation, Investigating Committee, 30
39–40 iodine
intercostal recession, 670 deficiency, 170, 263
interim conditions of practice order, 30 requirements, 170
interim suspension order, 30 Ireland, Midwives (Ireland) Act (1918),
intermittent positive pressure 27, 39–40
ventilation, neonatal, 613 iris (neonatal), examination, 595
internal rotation of buttocks, 380 iron (in pregnancy)
internal rotation of head, 373, 376 deficiency causing anaemia,
in left mentoanterior positions, 445 273–274
in occipitoposterior position, postnatal, 524–525
440–441 twin pregnancy, 294
long, 441 metabolism, 154
short, 441–442 tablets/supplements
in right sacro-anterior position, 381 antenatal, 274
internal rotation of shoulders, 374, postnatal, 524–525
380–381 iron (infant breastfeeding), 709
in left mentoanterior position, 446 ischaemic heart disease, 269
in right occipitoposterior position, ischioanal fossa, 61
441 ischiocavernosus muscle, 57
International Code of Marketing of ischium, 62–63
Breastmilk Substitutes, 729 islet cell transplants, 259
International Confederation of isoimmune thrombocytopenia,
Midwives, Global Midwifery 667
Standards, 4–8 isoimmunization
internationalization, 4–8 ABO, 687
Internet, parental information, 137 Rhesus see Rhesus status
interpretation services, 334 itching see pruritus
inter-pubic ligaments, 65
intestine see bowel
J
intracranial haemorrhage, 634–637
with face presentation, 448 jaundice
intraepithelial neoplasia, cervical, 223 maternal, 235–236
intrahepatic cholestasis of pregnancy neonatal, 681–688
(obstetric cholestasis), 235–236, late, 687–688
257 pathological, 685–687
intraparenchymal lesions physiological, 682–685
(periventricular haemorrhagic jaw
infarction; IPL; PHI), 635–637 breastfeeding and, 712–715
intrapartum period see childbirth small/hypoplastic, 594–595, 654
intrathecal anaesthesia see spinal thrust, 613–614
anaesthesia joints, pelvic, 64
intrauterine growth (fetal growth), judgements (in ethics), 38
112–116 justice, 38
restriction (IUGR), 618–621 juvenile-onset (type 1) diabetes
asymmetrical growth in, 620–621 mellitus, 257–262
causes, 620b juxtamedullary cells, 83
symmetrical growth in, 619–620 juxtamedullary nephrons, 83
timescales, 111, 113
intrauterine systems/devices
K
copper (non-medicated), 577–578
emergency use, 582 Kali Carbonate, labour pain, 352
levonorgestrel-impregnated, 578 kangaroo care, 625–626, 719
intravascular bleeding, bleeding ketones and ketoacidosis in diabetes,
associated with, 639 257–258
intraventricular haemorrhage (IVH), ketosis and postpartum haemorrhage,
635–637 408
intubation in caesarean section, key performance indicators (KPI) of
difficult/failed, 470–471 antenatal screening, 205
761
 Index
kidney (maternal), 81–84 recognition, 333–334
disease subsequent care, 338–344
in diabetes, 260 2nd stage, 367–393
hypertension in, 248 cardiac disease patients, 267
failure controversial areas, 368b
with amniotic fluid embolism, cord prolapse diagnosis in, 479
486 delay in, 429
in shock, 490 maternal response, 370–373
filtration, 85 mechanism, 373–374
in pregnancy, 160 midwifery care, 374–379
selective reabsorption, 85–86 nature, 368–369
kidney (neonatal), 600 occipitoposterior position in, 439,
examination for disorders, 671–672 442
malformations, 81, 663–664 phases and duration, 370
Kielland’s forceps, 460 recognition, 369–370
kindness, intelligent, 10–11 3rd stage, 395–416
Kiwi Omnicup™, 457–458 active management, 400–404
Klumpke’s palsy, 632 cardiac disease patients, 267
knee–chest position, 478–479 care of women in, 398–404
breech birth, 382 completion, 404–406
knee presentation, 357 complications, 406–414
kneeling position, 371–372 expectant management, 398–400,
in antenatal preparation, 437–438 403–404
vaginal breech birth, 382–385 mismanagement as cause of
knowledge postpartum haemorrhage,
in antenatal education groups, 407
sharing, 130b physiology, 396–398
on antenatal screening, 207 active phase, 328–329, 370
in The Code, 501b delay in, 427
see also information asthma and, 270
cardiac disease and, 267
as continuous process, 328
L
defining, 328
labetalol, 247 emotions, 335, 535–536
pre-eclampsia, 250–251, 250t epilepsy, 279
labia genital mutilation and, 317
labia majora, 56 hydramnios, 238
labia minora, 56 hypertensive women, 248
lacerations, 318 hyperthyroidism and, 264
laboratory tests induction see induction
cardiac disease, 265 iron-deficiency anaemia, 274
disseminated intravascular latent phase, 328–329, 370
coagulation, 638–639 delay in, 426–427
inborn errors of metabolism, 693 malpositions/malpresentations and
physiological jaundice, 683 course and outcome of
see also biochemistry; blood tests; face presentation, 446–447
haematology occipitoanterior positions,
labour, 311–325, 327–393, 395–433, 441–442
435–453, 455–473 multiple pregnancy see multiple
1st stage, 327–366 pregnancy
cardiac disease patients, 267 myometrial preparation for, 144
duration/length, 330 obesity and, 256
face presentation, 447 obstructed (mechanically) see
initial meeting with midwife, obstructed labour
334–338 onset (spontaneous physiological
mechanical factors, 332–333 labour), 328–330
occipitoposterior position in, 439, recognition, 329
442 pain see pain
physiology, 330–333 precipitate, 430
762
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postpartum haemorrhage relating
to, 407
pre-eclampsia, 251, 341
preparation (of mother) for,
198–199
preterm, causes, 621b
progress, assessment, 338–340, 428
partogram, 329, 338, 425
progress, failure, 426–429
prolonged, 426–429
left mentoanterior position, 446
postpartum haemorrhage relating
to, 407
twin pregnancy, 288–292
psychological context see
psychological dimensions
rhythms, 328
sickle cell disease, 277
thalassaemia and, 276
thromboembolic disease risk,
271–272
transition/transitional phase,
328–330
controversial areas, 368b
maternal response to, 370–373
midwifery care, 374–379
nature, 368–369
urinary tract infection in, 282
lacerations and cuts, neonatal, 593,
629–630
lactase
deficiency, 722
simethicone and (‘over-the-
counter’), 722
lactation, 705–707
amenorrhoea (method), 583–585
cessation, 723–724
combined oral contraceptive pill
and, 573–574
mother and, 706–707
onset (lactogenesis), 705–706
twins, 300
see also breastfeeding
lactiferous ducts, 705
lactoferrin, 710
lactogen, human placental, 105, 169
lactose (in breastmilk), 707, 722
intolerance, 721–722
lacunar stage of implantation, 102
lambda (fontanelle), 120
lambdoidal suture, 118
lamotrigine, 548
language
of childbirth, 334
twins, development, 302
woman
difficulties, 16–17
interpretation services, 334
lanugo, 107, 116
 Index

large for gestational age, 618 ligaments environmental optimization,

laryngeal stridor, 656, 681 bladder, 88 625–626
last menstrual period (LMP), 185, 418, pelvic, 64–65 instrumental delivery, 456
618 uterine, 72–73 management, 622–625
lateral flexion (of fetus), 374, 380 in pregnancy, 144 maternal obesity and, 256
in left mentoanterior position, 446 light hazards (for baby), 626 presentations, 618
lateral position in 2nd stage of labour, lightening (feeling of baby dropping), see also preterm babies
left, 371 148 lower limb see leg
law (legal issues), 32–37 lignocaine (lidocaine), postnatal, Lullaby Trust, 185
abortion, 227–228, 227b perineal pain, 508 Lunelle, 574
accountability under the law, 31–32 limbs, neonatal lungs
historical context, 27–28 examination, 597–598 at birth, 670
see also medicolegal considerations; reduction deficiencies, fetal, 114–115
statutory regulation 660–661 maternal/in pregnancy
learning disabilities/difficulties, 15 see also arms; legs function, 158
booking visit, 184 linea alba, 167–168 gastric content aspiration into, in
learning disability, 539 linea nigra, 167–168, 190 caesarean section, 470
left lateral position in 2nd stage of lip, cleft palate and/or, 594–595, shock effects, 490
labour, 371 653–654, 722 meconium aspiration into, 679
left-to-right shunts, 657–658 lipid metabolism, 165 see also respiratory system
leg(s) listening after childbirth, 526–527 luteal phase of ovarian cycle, 94
fetal, in breech presentation, lithium, 548 luteinizing hormone (LH)
extended, 357, 359, 384 prophylactic, 549 females, 91–92
maternal lithotomy, supported, in assessment of computer monitoring
cramps, 167 perineal trauma, 313–314 (contraceptive method), 584
oedema see oedema litigation, 35 in ovarian cycle, 93–94
see also limbs NHS Litigation Authority (NHSLA), in pregnancy, 169
legal issues see law; medicolegal 35, 47, 321 males, 80
considerations liver lying positions
legislation, 32 fetal, 115 mother lying on side for
see also specific Acts maternal, 163–164 breastfeeding, 711
leiomyoma see fibroids disorders, 235–236, 253, 257 sleeping infant, 626
Leopold’s manoeuvres, 438 shock effects, 490 lymphatic drainage
lesbians, 17 see also HELPP syndrome anorectum, 60
let-down reflex, 705–706, 720–721 local action plan with supervisor bladder, 88
leucocytes (following LSA investigation), kidney, 83
in breastmilk, 710 48b ovaries, 77
in pregnancy, 156–157 Local Supervising Authorities (LSA), testes/scrotum, 78
leucomalacia, periventricular, 40–41, 49 ureters, 87
636–637 Midwifery Officer, 41–42, 48–49 urethra, 89
leucorrhoea, 149, 189–190 outcomes an investigation by, 48 uterine tube, 76
levator ani muscle, 61, 89 location of birth see place uterus, 74
Levonelle, 581–582 lochia, 507 vagina, 72
levonorgestrel-impregnated IUS, 578 locked twins, 298 vulva, 56
liability, vicarious, 37 longitudinal layer of anal sphincters, lysozyme in breastmilk, 710
lidocaine, postnatal, perineal pain, 508 60
lie, fetal, 194 longitudinal lie, 194, 197f
M
transverse see transverse lie loop of Henle, 83
unstable, 451–452 loss, 555–567 macerated fetus, shoulder presentation,
life support, basic, 487–489 accidental see miscarriage 450
life-threatening conditions care, 560–564 Mackenrodt’s ligaments, 72
infant with cardiac malformations, forms, 557–559 McRoberts manoeuvre, 480
656 grief in see grief macrosomia
maternal, 45 in healthy childbearing, 559 diabetes and, 618–619
antenatal bleeding, 232 meaning, 555–556 maternal obesity and, 256
postnatal, 516 see also bereavement; death; grief postpartum haemorrhage incidence
see also death Løvset manoeuvre, 382, 384–385 related to, 407
lifestyle at first antenatal visit, low birth weight (LBW) babies, shoulder dystocia, 479
186–187 617–628 magnetic resonance imaging, fetal, 214

763
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 Index
males
contraception
condoms, 579
pill, 586–587
sterilization, 586
genitalia/reproductive system,
77–80
female-looking, 664
neonatal, examination,
596–597
malformations, congenital fetal/
neonatal (structural
abnormalities/anomalies), 189,
211–214, 645–666
antenatal screening and diagnosis,
646
detailed anomaly scan, 211–214
detection rates, 212b
cardiac see heart disease
CNS, 658–660
communicating the news, 646
definition and causes, 647–649
drugs causing see teratogens
face presentation with, 444
gastrointestinal, 650–654
genitourinary, 81, 663–664
multiple pregnancy, 297
musculoskeletal, 660–662
palliative care, 646–647
respiratory system/tract, 654–656
skin, 645, 662–663
support for midwife, 665
vascular, 593, 662
malformations, congenital maternal
(structural abnormalities/
anomalies)
kidney, 81
heart see heart
pelvis, 70
uterus, 74–75
malignancy see cancer
malpositions, 435–443
as instrumental delivery indicator,
456
malpresentations, 444–452
breech considered as, 360
cord prolapse or presentation, 448,
451, 477
definition, 435
multiple pregnancy, 298
malrotation of bowel, 652–653
manic component of bipolar illness,
547–548
manual techniques
expression of breast milk
manual expression, 718–720
manually-operated pump,
719–720
removal of placenta, 411
764
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rotation
from malpositions, 439–440
in shoulder dystocia, 481–483
Marfan syndrome, 268
Marmot Review, 14, 181–182
masculinization (virilization), female,
664, 695
mask of pregnancy, 167–168
massage
aromatherapy (in labour), 352
breast see breast
fundal, 409
perineal, 198
mastitis, 721
maternal surface of placenta, 104
see also women
maternity care see care
maternity services, obesity and,
255–256
maturity-onset (type 2) diabetes, 254,
257, 259–262
maturity-onset (type 2) diabetes of the
young, 259
Mauriceau–Smellie–Veit manoeuvre,
383–384
mean cell volume (MCV), 154, 156
at booking visit, 188
in thalassemia, 275
meconium, 115, 596, 601, 613–614
in amniotic fluid (meconium
staining), 376, 620–621
aspiration syndrome, 679
ileus, 653
passage, assessment, 672
medical conditions/disorders,
243–286
hepatic, 235–236, 253, 257
history-taking, 185–186
instrumental birth, 456
twin pregnancy and exacerbation of,
294
see also health
medical management (incl. drugs/
pharmacotherapy)
abortion, 228
diabetes, 259, 261
drug abuse, 696–697
eclamptic seizure, 252
ectopic pregnancy, 226
hyperthyroidism, 264
labour induction, 267
miscarriage, 225
psychiatric disorders, 546–548
see also drugs and specific (types of) of
drugs
Medical Officer of Health, 40
medicines see drugs
medicolegal considerations, perineal
injury, 321
mediolateral episiotomy, 313
continuous suturing, 319f
training, 321
medroxyprogesterone acetate, depot,
575–576
medulla oblongata, cardiovascular
centre, 244
megaloblastic anaemia, 274–275
meiosis, 93, 95
melaena, 601, 639
melanocytic (pigmented) naevi, 593,
663
melasma, 167–168
membranes (chorioamnion), 106
cervical sweeping (CMS), 419–420,
422–423
delivery, 399, 402–403
examination
after delivery, 404–405
in labour, 341b
infection (chorioamnionitis), 239
retained, 407
rupture of see rupture of the
membranes
stretching and sweeping, 199
men see males
menarche, 25
Mendelian inheritance, malformations
associated with, 648
Mendelson’s syndrome in caesarean
section, 470
meningitis, neonatal, 676
meningocele, 659
meningomyelocele
(myelomeningocele), 659
menopause, 91–92
menorrhagia, 94
menstrual cycle, 92f, 94–95
in natural family planning, 583–584
menstrual history at booking visit,
184–185
menstruation (menstrual phase;
period), 94
disorders, 94
last (LMP), 185, 418, 618
onset in life (menarche), 91–92
mental capacity see capacity
mental health, 531–553
problems see distress; psychiatric/
mental disorders
service provision, 548–549
vulnerability factors, 533f
mentoanterior positions, 446
left, 444f, 445–446
right, 444f
mentolateral positions, 444f
mentoposterior positions, 444f,
446–448
persistent, 447–448

mentovertical (MV) diameter, 120
mentum as denominator with face
presentation, 196
MEOWS (Modified Early Obstetric
Warning Scoring) system, 47,
267, 487–488
hypovolaemic shock, 491
meptazinol in labour, 354
mesoderm (embryo), 97
metabolic syndrome, 254
metabolism (maternal)
changes, 164–165
disorders, 253–257
metabolism (neonatal), disorders,
689–691
causing convulsions, 640t
genetic causes (inborn errors of
metabolism), 692–694
metal ventouse cups, 457
metformin, 259, 261
methadone, 696
treatment using, 696–697
methicillin-resistant Staphylococcus
aureus, 46
methotrexate, ectopic pregnancy,
226
methyldopa, 247
Michaelis’ rhombus, 338–340, 369
microcephaly, 593–594, 660
microchimerism, 102
micrognathia (small/hypoplastic jaw),
594–595, 654
micropenis, 596
micturition (urination/voiding), 89
immediately after birth,
encouraging, 405
in labour, 344
mid-stream urine testing, 215
midbrain, fetal, 115
midgut, 115
MIDIRS (MIDwives Information
Resource Service), 131
midline episiotomy, 313
midwife
in congenital malformations,
support for, 665
in contemporary practice, 3–23
definition and scope, 4
first meeting of woman with, 183
internationalization/globalization,
4–8
loss (incl. death) and the, 563–564
maternal, 564
midwife care, 560–564
midwife experiences, 559
professional issues, 25–52
public health role, 181–182
relationships see partnership;
relationships
mebooksfree.com
roles and responsibilities in practice
see roles (midwives) and
responsibilities
as ventouse practitioner, 460
midwife-led continuity of care, 336
midwifery
contemporary practice, 3–23
emotional context see emotion
professional issues, 25–52
Midwifery Committee, 29
Midwifery Officer (of LSA), 41–42,
48–49
Midwives Act (1902), 27, 39–40
Midwives Act (1936), 40
Midwives Act (1951), 27, 40
MIDwives Information Resource
Service (MIDIRS), 131
Midwives (Ireland) Act (1918), 27,
39–40
Midwives Rules and Standards, 32–35,
387–388
Midwives (Scotland) Act (1915), 27,
39–40
Midwives (Scotland) Act (1951), 27,
40
milia, 593
milk see breastmilk; formula feeding
Millennium Development Goals, 8
mineral(s)
infant breastfeeding and, 709–710
maternal
deficiency, pelvic anomalies, 70
renal reabsorption, 86
wound healing and, 521t
mineralocorticoids, adrenal, 695
minor(s) (under-16s), consent issues
for, 35–36
labour and, 337
minority groups, ethnic, 15–16
minute volume, 158
miscarriage (spontaneous pregnancy
loss), 224–225, 558
combined oral contraceptive pill
following, 574
complete, 224–225
incomplete, 224
inevitable, 224
IUCD and, 578
lactation and, 723–724
missed/silent, 224
repeated/recurrent, 225
history of, 185
threatened, 224–225
misoprostol (prostaglandin E1
analogue)
induction of labour, 267
prolonged pregnancy, 424
postpartum haemorrhage, 409
third stage of labour, 401
Index
mitochondrial disorders, 648
mittelschmerz, 94, 569, 584
mobility see movements and motions
Modified Early Obstetric Warning
Scoring system see MEOWS
molar pregnancy, 226–227, 249
Mongolian blue spots, 593
monoamniotic twins, 288, 291
monochorionic twins, 288–293, 297
labour onset, 294
malformations, 297
premature expulsion of placenta,
299
twin-to-twin transfusion syndrome,
297
ultrasound examination, 292
monophasic combined oral
contraceptive pill, 570
monozygotic (uniovular/identical/MZ)
twins, 288, 292
dizygotic vs, 95–96, 288
mons pubis, 56
mood stabilizers, 547–548
morning sickness, 162
Moro reflex, 608
mortalities see deaths
morula, 96–97
mother see women
motherhood see parenthood
motions see movements
moulding, 122
brow presentation, 449f
face presentation, 448, 448f
movements and motions (mobility)
fetal, 116
as indicators of well-being,
196–198
in normal labour, 373–374
quickening, 116, 171
see also specific movements
maternal
in labour, 343
postnatal, 525–526
neonatal, abnormal, 671, 674
MRSA (methicillin-resistant
Staphylococcus aureus), 46
mucosa (and mucous membrane)
bladder, 88
rectal, button-hole tear, 312t, 314,
442
uterine endometrium, 73
vagina, 72
mucus plug
in ovulation, 583
in pregnancy (=show), 327,
332–333, 369
multidisciplinary team care
cardiac disease, 265–267
diabetes, 260–261
765
 Index

twin pregnancy, 293 myoclonus and myoclonic seizures/ adaptation to extrauterine life,
ultrasound scans and, 212 convulsions 117–118, 670
multifactorial disorders, 648 maternal, 278t breastfeeding difficulties related to,
multigravid women, attendance at neonatal, 640 721–723
antenatal sessions, 137–140 benign sleep myoclonus, 674 contact with parent see contact
multiparity as risk factor for cord myometrium, 73–74, 144 deaths see deaths
prolapse or presentation, 477 in pregnancy, 144–146 in diabetes
Multiple Births Foundation (MBF), 305 myxoedema coma, 263 care, 262
multiple pregnancy (incl. twins), risk to, 260
287–307 drug misuse and see substance abuse
N
complications, 297–299 examination see examination
cord prolapse, 298, 477 Naegele’s pelvis, 70 feeding see feeding
postpartum haemorrhage, 299, Naegele’s rule, 185 haemolytic disease (HDN), 188,
407 naevi (vascular), 662 216, 684–686
diagnosis, 292 pigmented, 593, 663 healthy term baby
missed, 299 nasal… see nose low birth weight see low birth
incidence, 288 nasogastric tube feeding of baby, 624 weight
labour, 294–297 National Amniotic Fluid Embolism recognition through screening
management, 295–296 Register, 486 assessment, 591–609
onset, 294 National Health Service (NHS) resuscitation, 611–615
postnatal period, 299–303 Clinical Negligence Scheme for immediate care, 405–406
reduction, 305 Trusts, 47 immunity see immune system
selective feticide, 305 Litigation Authority (NHSLA), 35, infections see infections
shoulder presentation, 450 47, 321 injury see injury
sources of help, 305 outcomes framework relating to instrumentally-delivered,
types (of twin pregnancy), 288–292 maternity care, 46b complications, 462–463
UK statistics (1985–2011), 289t National Institute for Health and Care mother’s relationship with see
multipotent stem cells, 99 Excellence (NICE) guidelines attachment; relationships
multips os, 330 antenatal visiting patterns, 180–181 obesity (maternal) risks to, 256
murmur, 603–604, 681 breastfeeding, 730 preterm see preterm babies
precordial, 603 caesarean section prolonged pregnancy and its impact
muscle(s) (maternal) indications, 463–464 on, 418–419
abdominal, laxity as cause of reducing rates, 471–472 safety and protection concerns,
shoulder presentation, 450 vaginal birth following, 466 510
perineal, 57 for clinical practice (in general), 45 significant problems causing illness,
uterus see uterus diabetes, 260 recognition, 667–701
muscle(s) (neonatal) vitamin D supplementation, 708 zygosity determination, 292
assessment, 601, 612 National Screening Committee of the neoplasms see tumours
tone, 612 United Kingdom, 204–206, 208 nephron, 82–83
blue skin and good tone, 613 on Down syndrome, 209 nephropathy, diabetic, 260
see also hypotonic baby on haemoglobinopathies, 210–211 nerve supply (innervation)
trauma, 631 on infectious diseases, 214–215 maternal
muscle layers/coats on mental illness, 549 anal sphincters, 60
bladder, 88 on ultrasound scans, 211 bladder, 88
perineal, in suturing (after trauma), natural family planning, 582–585 kidney, 83–84
319 nausea, 162, 228–229 labour pain and its transmission
ureters, 87 neck and, 349–350
uterine tube, 76 examination in neonate, 595–596 levator ani, 62
vagina, 72 umbilical cord around (at birth), ovaries, 77
musculoskeletal system 378 perineum, 57
fetal, 153 neck reflex, asymmetric tonic, 608 testes/scrotum/spermatic cord,
maternal, 167 necrotizing enterocolitis, 672 78
neonatal, 601 negligence, 36 ureters, 87
deformities, 660–662 voluntary risk-pooling scheme for urethra, 89
music therapy, labour pain, 353 claims, 47 uterine tube, 76
myelomeningocele, 659 Neisseria gonorrhoeae see gonorrhoea uterus, 74
myocardium neonates (newborns; baby early after vagina, 72
enlargement (cardiomegaly), 269 birth), 591–609, 611–615, vulva, 56
infarction, 269 617–643, 645–701, 703–736 neonatal, trauma, 631–633

766
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nervous system
central see central nervous system
fetal, 115–116
peripheral (neonatal), hypotonia
relating to, 671
neural tube development, 115
defects in, 115, 658, 660
neurocranium, 116
neurogenic shock, 489
neurological assessment (baby), 671
neurological disorders
maternal, 279–282
neonatal
convulsions due to, 640t
examination for, 607
hypoglycaemia causing, 690
see also central nervous system;
peripheral nervous system
neuromuscular disorders, hypotonia,
671
neutral position, baby in, 612
neutrality, affective, 11–12
Neville–Barnes forceps, 460
Newborn and Infant Physical
Examination (NIPE), 601–607
see also neonates
NHS see National Health Service
NICE see National Institute for Health
and Care Excellence
nicotine replacement therapy, 187
nifedipine, 247
nipple, 705
in breastfeeding
anatomical variations affecting
feeding, 720
attachment to see attachment
ducts in nipple, 705
sore or damaged, 719–720
white spots/epithelial overgrowth
(nipple), 721
stimulation inducing labour, 426
nitrous oxide + oxygen (Entonox),
353–354
cardiac disease patients, 267
nociceptors, 350–352
noise hazards (for baby), 626
non-insulin-dependent (type 2)
diabetes mellitus, 254, 257,
259–262
non-maleficence, 38
nonoxinol-9, 581
non-steroidal anti-inflammatory drugs
(NSAIDs)
afterpains, 506
caesarean section, postoperative, 466
norepinephrine and blood pressure,
244
norethisterone enathenate, injectable,
576
mebooksfree.com
norgestimate in combined oral
contraceptive pill, 570–571
nose, neonatal
blocked, 722
examination, 594
flaring of nostrils, 670
see also nasogastric tube feeding
notochord, 98
nuchal fold thickness, 213
nuchal translucency, 209
increased, dealing with, 212–213
Nurses, Midwives and Health Visitors
Act (1979), 27
repeal, 28
review, 27
Nursing and Midwifery Council
(NMC), 29–32
committees, 29–30
consensual panel determination
(NMC), 30–31
functions, 29
membership, 29
referral to (following an LSA
investigation), 48b
Register see Register
responsibility and accountability
and the, 26–27
Nursing and Midwifery Order 2001: SI
2002 No: 253, 29–32, 40–41
nutrition (baby)
fetal, 105
infant see feeding
nutrition (woman/mother)
breastfeeding and, 706
breastmilk composition and, 707
in labour, 343–344
pelvic anomalies due to dietary
deficiency, 70
in pregnancy, needs, 254–255
in puerperium, 505
wound healing and, 521t
see also diet
NuvaRing, 574
O
obesity, maternal, 253–257
oblique diameter of pelvic inlet, 66–67
oblique lie, 194, 197f
observation and inspection (maternal)
abdominal (in pregnancy), 190
hydramnios, 238
multiple pregnancy, 293–294
occipitoanterior position, 436
oligohydramnios, 238–239
hypovolaemic shock, 491
in labour
in 1st stage, 340–341
in 2nd stage, 376
Index
pain control and, 355–356
prolonged labour, 428
placenta and membranes, 404–405
postpartum, 504–509
haemorrhage, 412–413
observation and inspection (neonatal)
cardiovascular function, 602
eye, 605
obsessive–compulsive symptoms,
postnatal, 543
obstetric history, previous, 185
as indicator
for caesarean section, 464
for referral for additional
antenatal support, 183
obstructed labour, 331–332, 429–430
face presentation, 448
occipitoposterior position, 443
obstruction (blockage)
cardiac defect causing, 658
lactiferous ducts, 721
neonatal upper airway, 681, 722
occipital bone, 118
protuberance, 118, 120
occipitoanterior positions
direct, 198b
left and right, 198b, 198f, 373
positions other than, 435–443
occipitofrontal (OF) diameter, 120,
440
occipitolateral positions
instrumental delivery, 456
left and right, 198b, 198f
occipitoposterior positions, 436–443
antenatal diagnosis, 436–437
antenatal preparation, 437–438
birth in see childbirth
causes, 436
complications, 442–443
direct, 198b
instrumental delivery, 456
left, 198b, 198f, 437f
midwifery care, 439
persistent, 441, 443, 443f
right, 198b, 198f, 437f, 439f
mechanisms, 440–441
occipitotransverse position, manual
rotation from, 439
occiput denominator with vertex
presentation, 196
occiput region (fetal skull), 120
malpositions, 435–443
posterior rotation, 385
oedema (maternal), 190
lower leg, 166
postnatal, 522–523
in pre-eclampsia, 249
oedema (neonatal), buttocks, 631
oesophageal atresia, 650–652
767
 Index
oesophagogastric (gastro-oesophageal)
junction in pregnancy, 162–163
oestradiol, 104, 169
oestriol, 104, 169
oestrogens
in combined oral contraceptive pill,
570
dominance, 571f, 572
mode of action, 571
in labour, 328–329
in ovarian and menstrual cycle,
93–95
placental, 104, 169
oestrone, 104, 169
oestrone-3-gluronide females,
computer monitoring
(contraceptive method), 584
olanzapine, 547
oligohydramnios, 81, 238–239
omphalocele, 650
oocyte (egg; female gamete; ovum), 91
fertilisation, 95–96
formation, 93
release see ovulation
oogonia formation (oogenesis), 93
operative births, 455–473
prerequisites, 457
puerperium after
practical skills for care, 525–526
uterus and vaginal loss, 519–520
techniques for lowering rate of, 456b
see also caesarean section; forceps;
ventouse
ophthalmia neonatorum (neonatal
conjunctivitis), 596f, 605–606,
678
ophthalmoscopy, neonatal, 605
opiates/opioids
abuse, 696
pharmacological treatment,
696–697
caesarean section, postoperative, 466
labour, 354
continuous epidural infusion, 355
oral changes in pregnancy, 161–162
oral contraceptive pill
combined see combined hormonal
contraceptives
male, 586–587
missed/forgotten, 573, 575
progestogen-only, 574–575
Order, the (Nursing and Midwifery
Order 2001): SI 2002 No: 253,
29–32, 40–41
organ see systems and organs
organization and administration
Global Standards for Midwifery
Education (2010), 6b–7b
maternity care, 11
768
mebooksfree.com
orogastric tube feeding of baby, 624
Ortolani manoeuvres, 606–607
Osiander’s sign, 171
ossification of skull, 118
osteogenesis imperfecta, 662
osteomalacic pelvis, 70
Our Health and Wellbeing (theme in
antenatal education
programme), 134–136
outcomes
from Local Supervisory Authority
investigation, 48
NHS outcomes framework relating
to maternity care, 46b
ovarian artery, 74
ovarian cycle, 92–94
ovarian hyperstimulation syndrome,
228
ovarian ligaments, 73
ovaries, 76–77
cancer, combined oral contraceptive
pill and, 572
cysts, progestogen-only pill and,
574
overheating (hyperthermia), 599, 671
oviducts see fallopian tubes
ovulation, 94
in natural family planning methods,
583–584
pain (mittelschmerz), 94, 569, 584
oxygen
maternal, arterial partial pressure,
159
neonatal, blown onto face, 613
see also extracorporeal membrane
oxygenation; nitrous oxide +
oxygen
oxytocin, 128, 169
in childbirth, administration (incl.
Syntocinon) for induction or
augmentation of labour, 251,
267, 296, 299, 424–425
cardiac disease patients, 267
with ergometrine see ergometrine
postpartum haemorrhage and,
403, 407
postnatal release causing uterine
contractions, 505
in breastfeeding, 398, 405–406
oxytoxics see uterotonics
P
pain, 349–356
abdominal see abdomen
acute vs chronic, 350
back, 167
breast, deep (breastfeeding mother),
720–721
labour-related, 349–356
physiology, 349–351
relief see analgesia
stimulus and sensation, 349
transmission, 349–350
pelvic girdle, 229
perineal, postpartum, 507–508,
520–521
theories, 351–352
see also afterpains; backache; colic;
headache
palate, cleft lip and/or, 594–595,
653–654, 722
palliative care with congenital
malformations, 646–647
pallor, neonatal, 592, 668–669
palmar erythema, 168
palmar reflex, 608
palpation (cervical) as natural family
planning method, 583
palpation (maternal abdominal)
breech presentation, 357–358
in labour, 358–359
in labour and childbirth, 340
breech presentation, 358–359
brow presentation, 449
face presentation, 445
postnatal, 505, 518
in pregnancy, 191–193
hydramnios, 238
multiple pregnancy, 294
occipitoanterior position,
436–437
oligohydramnios, 239
in placenta praevia, 231
uterus, 190–191
palpation (neonatal), cardiovascular
function, 602–603
pancreas, artificial, 259
Papanicolaou (Pap) smear, 148,
223
parathyroid gland disorders, neonatal,
695
paraurethral glands, 89
parent(s)
antenatal education see antenatal
education
communication to see
communication
contact (physical) with see contact
information for see information
at labour, care of, 374–376
of mother, relationship changes,
539
of newborn
resuscitation and communication
with, 614
in trauma/haemorrhages/
convulsions, support for, 641

parenthood and parenting (and
motherhood)
antenatal education for see antenatal
education
ideology, 534–535
social context, 13–18
transition to, 509–510, 534–535
parietal bones, 118
parity and risk of cord prolapse or
presentation, 477
paroxetine, 547
partial (focal) neonatal convulsions/
seizures, 640
partner
multiple births and mother’s
relationship with, 302
red cell antibody testing, 217
sleep disturbances after birth of
baby, 526
support from, 134–136
support in 2nd stage of labour for,
375–376
see also companion; father; lesbians;
parenthood
partnership
supervisors and midwives
(supervisees) in, 43
women and midwives in, 10, 12, 18
postnatal care, 500
see also Family–Nurse Partnership
programme
partogram/partograph, 329, 338, 427
passages (in the 3 ‘Ps’), 427–428
passenger (in the 3 ‘Ps’), 427
Patau syndrome, 650
patch contraceptive, 574
patient-controlled analgesia (PCA)
caesarean section, 469
postoperative, 466
labour, 354
patient focus, 44
Pavlik harness, 661–662
Pawlik’s manoeuvre, 193
peak expiratory flow, asthma, 270
PEGASUS (Professional Education for
Genetic Assessment and
Screening), 211
pelvic inflammatory disease, copper
IUCD and, 578
pelvis (pelvic region), 62–69
diameters, 66–67
false pelvis, 66
joints, 64
ligaments, 64–65
orientation, 67
pelvic brim, 65
in asynclitism, 69b
diverging dimensions, 68
fetal head descent into see head
mebooksfree.com
pelvic canal
axis, 67
measurements, 66f
stations of fetal heard in relation
to, 342f
pelvic cavity, 65
diameters, 67
pelvic floor, 61–62
damage, urinary continence
problems, 523
pelvic girdle (bony pelvis), 61–62
pain, 229
pelvic inlet diameter, 66–67
pelvic outlet, 65–66
diameters, 67
planes, 67
in pregnancy (and childbirth), 65,
451
palpation, 192–193
soft tissue, displacement in 2nd
stage of labour, 369
true pelvis, 65–66
types (size and shapes) incl.
contracted pelvis and unusual
or abnormal types/shapes,
68–69
face presentation and, 444
occipitoanterior position and,
436
shoulder presentation, 450
penis, 79
neonatal
examination, 596
urethra opening on undersurface
(hypospadias), 596, 664
performance, standards of, 34
perimetrium, 74, 144
in pregnancy, 144
perinatal loss, 557–558
perineum, 56–61
central point (perineal body), 61
infiltration anaesthesia caesarean
section, 468
massage, 198
postpartum pain and discomfort,
507–508, 520–521
shaving, 343
trauma, 312, 520–521
1st degree, 312t, 318
2nd degree, 312t, 318
3rd degree, 312t, 315f
4th degree, 312t, 315f
button-hole tear, 312t, 314, 442
definition, 312
medicolegal considerations, 321
minimization factors and
strategies, 312
postpartum care, 507
trauma, repair, 318–319, 507
Index
postpartum haemorrhage and,
407
training, 321
period see menstruation
peripheral nervous system disorders,
hypotonia, 671
periventricular haemorrhagic infarction
(PHI), 635–637
periventricular leucomalacia, 636–637
pernicious anaemia, 274–275
Persona, 584
personal information at booking visit,
184
personal liability, 37
personal protective equipment, 337
personal responsibility, 31
personality disorders, 539
petechiae, 669
pethidine (in labour), 354
cardiac disease patients, 267
phaeochromocytoma, 248
pharmacological agents see drugs;
medical management
phenylketonuria, 693
phobia of giving birth, 533–534
photographs of lost/dead baby, 561
phototherapy, physiological jaundice,
684
phylloquinone see vitamin K
physical examination see examination
physiological care in 3rd stage of
labour, 398–400
phytomenadione/phytonadione see
vitamin K
pica, 162
Pierre Robin sequence, 594–595, 654
pigmented birth marks, 593, 663
Pinard stethoscope, fetal heart, 194
labour
1st stage, 337, 344–345
2nd stage, 376
pituitary gland (and its hormones)
fetal, 115
maternal, 169
tumours, 264–265
neonatal, disorders, 695
place (location) of birth, options, 182
breech presentation and, 360
forceps and, 461
placenta, 101–110, 166, 168–169
abruption, 109, 230, 231t, 233–234
postpartum haemorrhage, 407
adherent
morbidly (placenta accreta), 102,
232, 412
partially, 411
wholly, 411
anatomical variations, 108–109
circulation/blood flow, 106, 146
769
 Index
delivery/birthing, 400–403
cardiac disease and, 267
postpartum haemorrhage
treatment before/without,
411
postpartum haemorrhage
treatment following, 409–411
descent, 396–398
signs, 399
drug passage across see drugs
early development, 101–103
examination, 404–405
hormones/endocrine activity,
104–105, 168–169
intrauterine growth restriction
related to, 620
manual removal, 411
retained (of whole or part), 407
at home, 412
previous history of, as cause of
postpartum haemorrhage,
407–408
treatment of postpartum
haemorrhage with, 411–412
separation, 396–398
incomplete, 407
signs, 399
at term, 103–109
twin/multiple pregnancy
examination (after delivery),
297
premature expulsion, 299
types, 288–292
placenta accreta (morbidly adherent),
102, 232, 412
placenta praevia, 230–233
degrees, 230–231
incidence, 231
management, 231–232
postpartum haemorrhage, 407
shoulder presentation, 450
placental souffle, 146
placing reflex, 608
plantar reflex, 608
plasma protein in pregnancy, 154
platelets, low see HELPP syndrome;
thrombocytopenia
platypelloid pelvis, 68t, 69
plethora, 669
pluripotent stem cells, 99
pneumothorax, neonatal, 680
polarity (uterus in 1st stage of labour),
330
policies
in antenatal education, 127–129
in clinical governance, 44–45
polycystic kidney disease, 663–664
polycythaemia, neonatal, 623, 669
polydactyly, 597, 660
770
mebooksfree.com
polyhydramnios (hydramnios), 238
cord prolapse, 477
face presentation, 444
multiple pregnancy, 294, 297
postpartum haemorrhage relating to,
407
shoulder presentation, 450
polyps, cervical neck, 223
popliteal fossa pressure in breech
birth, 384
port wine stain, 593, 662
position/posture
fetal, 196
breech presentation and, 357, 381
other than occipitoanterior
(=malpositions), 435–443
infant
breastfeeding, 712
sleeping, 626
maternal in breastfeeding, 711–712
maternal in labour
in 1st stage (with normal
presentation), 343
in 2nd stage (with normal
presentation), 371–373
in breech presentation, 360
cardiac output influenced by, 267
in multiple pregnancy, 296
in occipitoposterior position, 439
in perineal trauma minimization,
312b
in prolapsed cord management,
478–479
in shoulder dystocia, 480
positive pressure ventilation, neonatal
intermittent, 613
Post Registration Education and
Practice (PREP) Standards,
34–35, 43
posterior rotation of occiput, 385
post-mortem examination of baby, 561
postnatal period (postpartum period;
puerperium), 499–529,
531–553, 555–567, 569–588
breech birth and examination of
mother in, 385
cardiac disease and, 267–268
care during
family-centred, 516
framework and regulation for, 501
midwives in, 501–504
provision and need for, 502–503
self-care and recovery, 526
contraception, 570
basal body temperature
measurement, 583
cervical palpation method, 583
cervical secretions method, 583
combined hormone patch, 574
combined oral contraceptive pill,
573–574
diaphragm, 580–581
fertility monitoring device, 584
progestogen-impregnated IUS,
578
progestogen injections, 576
progestogen-only pill, 575
progestogen subdermal implants,
577
rhythm (calendar) method,
584
defining, 499–500
diabetes management, 262
eclampsia management, 252–253
epilepsy, 279
haemorrhage see haemorrhage
(maternal), postpartum
health and health problems after see
health
historical background, 500
hypertension management, 248
hyperthyroidism, 264
hypothyroidism, 263–264
iron-deficiency anaemia, 274
multiple birth and, 299–303
obesity, 256b
observations see observation
operative birth and see operative
birth
physiological changes, 504–509
pre-eclampsia management, 251
prolactinoma, 265
psychological context, 532–537
disorders see psychiatric/mental
disorders
emotions, 526, 536
sickle cell disease, 277
talking and listening, 526–527
thalassaemia, 276
thromboembolic disease prevention,
271–273, 522
women-focused, 516
postnatal ward after caesarean section,
care in, 467–468
postoperative care
anal sphincter repair, 319–320
caesarean section, 466–468
postpartum period see postnatal
period
post-traumatic stress disorder, 537
posture see position
potassium (and its imbalances), 692
Potter sequence/syndrome, 81, 238,
663
poverty, 15
powers (in the 3 ‘Ps’), 427
practical skills work in antenatal
education sessions, 132–133

practice
best see best practice
conditions of see conditions of
practice
intention to practice documentation,
39–40
LSA practice programme (following
an LSA investigation), 48b
obligations of, 33b
requirements for, 33b
scope of, 33–34, 33b
standard, 35
Practice Committees, 29–30
pre-conception period
antiepileptic drugs, 278
cardiac disease, 266
diabetes, 260
epilepsy and antiepileptic drugs, 278
hormonal contraception
combined oral contraceptive pill,
573
injectable progestogens, 576
progestogen-only pill, 575
subdermal progestogen implant,
577
sickle cell disease, 277
thalassaemia, 276
precordial murmur, 603
pre-eclampsia, 246, 249–251
labour, 251, 341
induction, 251, 421
management, 249–251
severe, 246, 251
superimposed (in chronic
hypertension), 248
pre-embryonic period, 96–99
pregnancy, 127–177, 179–219,
221–307
breastfeeding preparation and
promotion in, 189, 711, 730
changes/adaptations (anatomical
and physiological) in, 143–177
common disorders arising from,
171–173
discussed at antenatal visit, 189
pelvis, 65, 167
urinary tract, 89–90, 159–161
dating by ultrasonography, 418
diagnosis/tests, 171
drugs in see drugs; substance abuse
early (before 24th week), 92f
common problems, 222–226
placenta in, 101–103
thalassaemia and diagnostic tests
in, 276
ectopic, 148–149, 225–226
education in see antenatal education
history (previous) see obstetric
history
mebooksfree.com
with IUCD, miscarriage risk, 578
later (after 24th week), common
problems, 229–235
medical condition see medical
conditions
midwife–woman relationships and,
10–11
molar, 226–227, 249
multiple see multiple pregnancy
prolonged see prolonged pregnancy
psychological context, 532–537
disorders, 539–541
emotions, 535
risk factors arising in, 199b
social context, 13–18
‘tentative’, 204
termination (induced or
spontaneous) see abortion;
miscarriage
prelabour (premature) rupture of the
membranes (PROM), 333,
360–361
induction of labour, 421
preterm see preterm prelabour
rupture of the membranes
prelacunar stage of implantation, 102
premature babies see preterm babies
premature expulsion of placenta, twin
pregnancy, 299
premature labour, causes, 621b
premature rupture of the membranes,
preterm see preterm prelabour
(preterm premature) rupture of
the membranes
prenatal… see entries under antenatal
Preparation for Birth and Beyond
(Expert Reference Group’s),
133–136, 138
presentations (fetal), 121, 193–194
abnormal see malpresentations
appearance of presenting part,
369–370
assessment in 1st stage of labour,
341b
compound, 452, 477
denominators, 196
engagement and, 193
multiple pregnancy, 295f
malpresentations, 298
normal see vertex presentation
pressure
bimanual see bimanual
compression/pressure
blood see blood pressure
cord, release (with prolapsed cord),
478–479
cricoid, in caesarean section in
Mendelson’s syndrome
prevention, 470
Index
fundal, gentle, 411
hydrostatic, in replacement of
inverted uterus, 487
suprapubic, in shoulder dystocia,
480–481
upper abdominal (in labour),
epidural analgesia and, 369
vacuum, for ventouse extraction,
459
pressure symptoms, multiple
pregnancy, 294
pressure ulcer prevention in labour,
343
preterm babies (premature babies),
621–622
breastfeeding, 723
characteristics, 621–622
cord prolapse or presentation, 477
delayed cord clamping, 402
infection, vulnerability, 675
shoulder presentation, 450
small for gestational age, 618
see also low birth weight babies
preterm labour, causes, 621b
preterm prelabour (preterm
premature) rupture of the
membranes (PPROM),
239–240, 361
multiple pregnancy, 298
primitive reflexes (neonatal), 607
breastfeeding-related, 608, 712
primitive streak, 97
principles (in ethics), 38
procedural rules, 38
Professional Education for Genetic
Assessment and Screening
(PEGASUS), 211
professional issues (for midwives),
25–52
professional accountability, 31–32
professional detachment (affective
neutrality), 11–12
professional indemnity insurance,
37, 182
Professional Standards Authority, 27
progesterone
blood pressure and, 244
in labour, 328–329
in ovarian and menstrual cycle,
94–95
placental, 104–105, 169
selective receptor modulators,
582
progestogen (contraceptive use)
alone
emergency use, 581–582
injectable, 575–576
IUCD impregnated with, 578
oral, 574–575
771
 Index
combined oral contraceptive pill,
570
in 1st/2nd/3rd generation pills,
570–571
dominance, 571f
mode of action, 571
prolactin, maternal, 169
lactation and, 706
pituitary tumour secreting
(prolactinoma), 264–265
proliferation, vascular, 593
proliferative phase
menstrual cycle, 94–95
myometrial development in
pregnancy, 144
wound healing, 520f
prolonged labour see labour
prolonged pregnancy, 418
incidence, 418–419
induction of labour, 421
prone sleeping position, warning, 626
prostaglandin(s) (in general)
3rd stage of labour, 401
postpartum haemorrhage
treatment, 409
in duct-dependent disease, infusion,
657
endogenous, cervical ripening and,
424
prostaglandin E1 analogue see
misoprostol
prostaglandin E2 inducing labour,
267, 418–419
prostate gland, 79
protective role of placenta, 105
protein
breastmilk, 707–708
cow’s milk, intolerance, 727
plasma, in pregnancy, 154
wound healing and, 521t
protein hormones, placental, 105
proteinuria (in pre-eclampsia), 249
labour and, 341
tests/determination, 250b, 250t
prothrombin, 156, 234
prothrombotic state in metabolic
syndrome, 254
protocols (in clinical governance),
44–45
pruritus, 168, 236
in cholestasis, 257
psoas major muscle, 86
psychiatric/mental disorders, 538–550
definition, 538b
mild to moderate, 538–540,
544–545
postnatal, 136, 526, 541–545
headache as precursor of, 523
in pregnancy, 539–541
772
mebooksfree.com
prevention/prophylaxis, 549–550
serious/severe, 532, 538, 540–541
treatment, 545–549
types, 532–533
see also bereavement; grief
psychological dimensions, 531–553
caesarean section, midwife’s role in
psychological support, 465
female genital mutilation, 323
labour and birth, 335, 532–537
fear, 533–534
impact on partner, 375–376
pain, 349
personal account of psychological
trauma, 388
prolonged labour, 428
multiple births
identity and individuality, 303
isolation at home of new mother,
302
mother–baby, 301
mother–partner, 301
siblings of multiples, 303
triplets (and higher order births),
303
pregnancy (in general) see
pregnancy
see also bereavement; distress;
emotions; grief; loss;
psychiatric/mental disorders;
stress; support
psychological treatments, 545
psychosis
in pregnancy, 540
prevention, 549
puerperal, 541–542
see also antipsychotics
psychosocial impact of antenatal
screening, 204–205
ptyalism, 162b
pubis (pubic bones), 63
face to (presentation), undiagnosed,
442
symphysis see symphysis pubis
public
involvement, 44
self-regulation and the, 26–27
trust, 34
public health care
postpartum period and, 501–502
role of midwife, 181–182
pubocervical ligaments, 73
pubococcygeus, 61
puborectal muscle, 61
pubovesical ligament, 88
pudendal nerve, 62
anal triangle, 57, 60
perineum, 57
vulva, 56
pudendal nerve block
caesarean section, 468
ventouse extraction, 458
puerperium see postnatal period
pulmonary embolism, 272–273
amniotic fluid, 485
postnatal, 522
see also lung
pulse monitoring
maternal, intrapartum, 340–341,
345
maternal postnatal, 504, 517
neonatal, 602–603
purple (anal cleft) line, 338–340, 369
purpura
maternal idiopathic
thrombocytopenic, 667
neonatal, 669
pushing (active), 370–371
avoiding, 370–371
in breech birth, 382
checking cervical dilatation before
encouragement of, 385
pyogenic granuloma, 161
pyrexia, neonatal, 599
Q
Qlaira, 570, 572–573
quadruple pregnancy, UK statistics
(1985–2011), 289t
quadruple testing, 209
quality standards, antenatal, 181
quickening, 116, 171
quins, UK statistics (1985–2011), 289t
R
rachitic pelvis, 70
radiology (imaging), fetal, new
technologies, 214
randomized controlled trials, 18–19
rashes, 669–670
Raynaud’s phenomenon, 264
realization (awareness) of loss, 556
recessive gene disorders, 648
records and documentation
antenatal screening, 205–206
intention to practice, 39–40
labour and birth, 338, 387–388,
406
breech, 385
medicines, 344
loss (incl. death), 564
neonatal examination, 598
developmental dysplasia of hip,
607
in Rules and Standards, 34,
387–388

rectum, 57
trauma (in childbirth), 312t
button-hole tear of mucosa, 312t,
314, 442
examination for, 314
see also anorectum
red blood cells (erythrocytes)
fetal, formation, 114
maternal
antibodies see antibodies
mass/size/shape changes,
153–154
see also mean cell volume
red reflex, 605
referral for additional antenatal
support, 183b
pre-eclampsia, 249–250
red cell antibodies, 217
reflexes (neonatal)
primitive/primary see primitive
reflexes
red, 605
refugees, 16
regional analgesia/anaesthesia
in caesarean section, 468–470
care following, 467
epidural see epidural analgesia
Register, 26, 28
removal from, 30
striking off order see striking off
order
voluntary, 31
restoration (following striking off
order), 31
regulation, statutory see statutory
regulation
regurgitant murmur, 603
relationships
midwife–colleague, 11
midwife–mother/woman, 10–11
postnatal, 526
see also partnership
mother–baby/neonate/infant
in depressive illness, 544–545
in multiple births, 301
in psychosis, 542
see also attachment
mother–parents of mother, changes,
534
mother–partner (couples’)
in antenatal education, 134–136
lesbians, 17
in multiple births, 302
relaxation, postnatal, 508–509
relaxin, 94, 158, 167–168
REM sleep, fetal, 116
remodelling phase of wound healing,
520f
Remuneration Committee, 29
mebooksfree.com
renal pelvis, 82
renal system see kidney; urinary tract
renin, 83–84, 170–171
renin–angiotensin–aldosterone system
(RAAS), 150–151, 166
reporting (in Rules and Standards), 33b
reproductive capacity see fertility
reproductive cycle, 91–100
reproductive system (genitalia)
females
baby, examination, 597
changes in pregnancy, 144–149
external, 55–56
infections in pregnancy, 279
internal, 70–77
fetal, 115
males see males
neonatal, 601
ambiguous genitalia, 597, 664,
695
first examination, 596–597
NIPE (Newborn and Infant
Physical Examination), 607
see also genitourinary system
rescue breaths, 488–489
research, 18
antenatal education, 127–129
evidence-based see evidence-based
research and practice
resolution (in grief for loss), 556–557
resources in Global Standards for
Midwifery Education (2010), 7
respiration
fetal, 105
neonatal, malformations relating to,
654–656
respiratory distress, neonatal,
598–599, 678–681
causes, 678–681
initial management, 679
signs, 598–599, 670
respiratory distress syndrome
adult (ARDS), 490
neonatal, 680
respiratory rate
labour pain and, 352
neonatal, observation, 596
respiratory status assessment
in hypovolaemic shock, 491
postnatal, 504, 517
respiratory system
amniotic fluid embolism signs and
symptoms, 485
fetal, 114–115
neonatal, 670–671
disorders/problems, 678–681
initial examination and recognition
of problems, 670–671
malformations, 654–656
Index
in pregnancy, 157–159
disorders, 269–270
responsibilities see roles (midwives)
and responsibilities
rest, postnatal, 508–509
restitution (fetal movement in labour),
374, 378
buttocks, 380
in left mentoanterior position,
446
in right occipitoanterior position,
441
resuscitation (cardiopulmonary)
baby, 611–615
recognition of problems at time
of, 672–674
mother, 488, 592–598
postpartum haemorrhage, 409
see also ABC(DE) protocol
retained products of conception,
evacuation, 225
retraction ring, 331–332
return to practice programme, 35
return to work and lactation cessation,
724
Rhesus status (and isoimmunization
and subsequent disease), 105,
685–686
assessment, 216
booking visit, 188
partner testing, 217
causes, 105, 686
management of isoimmunization,
686
prevention of isoimmunization with
anti-D prophylaxis see anti-D
prophylaxis
rheumatic heart disease, 268–269
rhombus of Michaelis, 338–340, 369
rhythm (calendar) method, 583–584
ribs (and rib cage)
neonatal, 670
in pregnancy, 158
rickets, pelvic deformation, 70
rights (human), 32
fetus and, 36
risk (in general)
in antenatal screening
biases in interpreting information
on, 207
explaining, 207–208
assessment at booking visit, 187
management, 44, 47–49
Robert’s pelvis, 70
roles (midwives) and responsibilities
antenatal screening, 205–208, 212
with associated problems in
pregnancy, 222
breastfeeding, 715–716, 726
773
 Index
in caesarean section, psychological
support, 465
contraception, 570
disseminated intravascular
coagulation, 235
female genital mutilation, 317
in labour and childbirth, 361,
374–379
breech, 387
confidence concerning birthing
position, 372
in induction of labour, 425–426
initial examination of woman,
337
initial meeting with, 334–338
pain control and, 355–356
in prolonged labour, 428–429
NMC and, 31–32
occipitoposterior position, 439
postnatal care, 501–504
prolonged pregnancy, 420
psychiatric disorders, 545
sexual health, 570
roles (parenting), change and conflict,
534
rooting reflex, 608, 712
rotation
external see external rotation
internal see internal rotation
manual therapeutic manoeuvres see
manual techniques
posterior, of occiput, 385
round ligaments, 73
in pregnancy, 144
rub up a contraction, 409
rubella
congenital, 676–677
immune status assessment, 215
booking visit, 189
Rubin manoeuvre, 481
rule(s), ethics and, 38
rule utilitarianism, 38–39
Rules and Standards, Midwives, 32–35,
387–388
rupture of the membranes/waters
breaking (forewaters and/or
hindwaters), 369
artificial, 267, 296, 333, 424
failure (in labour), 333
prelabour and preterm see prelabour
rupture of the membranes;
preterm prelabour rupture of
the membranes
S
sacral dimple, 598
sacro-anterior position, right, 380–381
sacrococcygeal joint, 64
774
mebooksfree.com
sacrococcygeal ligaments, 65 sense organs, fetal, 115–116
sacrocotyloid dimension (pelvic inlet), sensory (afferent) pathways and labour
67 pain, 350–351
sacroiliac joints, 64 sepsis
sacroiliac ligaments, 64 postnatal, 516
sacrospinous ligaments, 64 shock due to, 489–492
sacrotuberous ligaments, 64 serious adverse incidents, 48–49
sacrum, 63 sertraline, 547
as denominator with breech services
presentation, 196 in Global Standards for Midwifery
safety Education (2010), 7
fetal ultrasonography, 211 maternity, obesity and, 255–256
infant sleeping, advice, 199, 626 mental health, 548–549
sagittal suture, 118 sexual health, future, 586
saliva in pregnancy, 161–162 sex chromosomes, 95, 115
excess (ptyalism), 162b conditions linked to gene defects
salmon patch haemangioma, 593 on, 648
salpinges see fallopian tubes sex determination, 95, 115
sanctions (by NMC), 30 sex development, disorders, 597, 664,
sarcomeres of respiratory muscle in 695
pregnancy, 158 sex hormones, adrenal, 695
Saving Mothers’ Lives, 538, 550b sextuplets, UK statistics (1985–2011),
SBAR tool, 476 289t
schizophrenia, 539 sexual development, indifferent state
postnatal symptoms of, 541 of, 115
sclera (neonatal) sexual health
first examination, 595 role of midwife, 570
NIPE (Newborn and Infant Physical services, future, 586
Examination), 605 shingles, 677
scope of practice (=Rule 5), 33–34, shivering (baby), inability, 598–599,
33b 623
Scotland see Midwives (Scotland) Act shock (circulatory failure), 489–492
screening classification, 489
antenatal see antenatal screening shock (psychological) with loss, 556
neonatal, 591–609 shoulders
principles, 592b birth, 378–379
scrotum, 78 dystocia, 479–483
neonatal, examination, 597 incidence, 479
Seasonale and Seasonique, 586–587 management and manoeuvres,
secretory phase of menstrual cycle, 95 480–483
seizures/convulsions/fits outcomes, 483
maternal risk factors, 479–480
eclamptic, 251–252 warning signs and diagnosis, 480
epileptic, 277–279 internal rotation see internal
neonatal, 639–641, 674 rotation
causes, 674 presentation, 193–194, 449–451,
support of parents, 641 477
selective progesterone receptor show (mucus plug), 327, 332–333,
modulators, 582 369
selective serotonin reuptake inhibitors, shower in labour, 343
546–547 shunts, left-to-right, 657–658
self-care, postnatal, 526 siblings
self-regulation, 26–27 impact of loss, 563
seminal vesicles, 79 of multiples, 303
seminiferous tubules, 78, 80 sickle cell disease, 276–277
semi-recumbent positions (for labour depot medroxyprogesterone acetate
and birth), 360, 371 and, 576
breech birth, 381–384 screening for, 189, 210
and delayed birth of head, 385 signposting parents, 136

silicone (soft/silicone) ventouse cups,
457, 463
simethicone and lactase, 722
Simpson’s forceps, 460
Sims’ position, exaggerated
1st stage of labour, 439
prolapsed cord, 478–479
sinciput region (fetal skull), 118, 120
sinus rhythm,, neonatal, 602–603
sitting positions
for breastfeeding, 711–712
for labour and birth, 371
supported, 371–372, 374
skeleto-muscular system see
musculoskeletal system
Skene’s ducts, 89
skimmed milk in formula feeds, 726
skin (fetal), 116
skin (maternal)
disorders, 236
perineal, suturing (after trauma),
319
postnatal, 505
pregnancy-related changes,
167–168
inspecting for, 190
preparation for caesarean section,
464
pressure ulcer prevention in labour,
343
skin (neonatal), 592–593
care, 599–600
colour see colour
examination (for problems),
592–593, 668–670
lesions, 593, 600, 668–670
traumatic, 593, 629–631
vascular malformations/birth
marks, 593, 662–663
rashes, 669–670
skin patch contraceptive, 574
skin-to-skin contact (woman–baby),
296, 299, 398, 465, 499–500,
599–600, 622, 711
skull, fetal, 116, 118–122
in breech birth, vault born slowly,
385
diameters, 120–121
divisions, 118–120
fracture at birth, 633
moulding, 122
sleep
fetal, 116
infant
benign sleep myoclonus, 674
safety advice, 199, 626
maternal, disturbances, 159
postnatal (and partner), 526
‘sleepy’ babies, feeding, 724b
mebooksfree.com
small for gestational age, 618–621
hypoglycaemia, 623
preterm and, 618
small intestine in pregnancy, 163
smoking
combined oral contraceptive pill
and, 572
first antenatal visit and, 187
sniffing position, 613
social circumstances established at
booking visit, 184
social contact with baby, 625
social context of pregnancy/childbirth/
motherhood, 13–18
social impact of antenatal screening,
204–205
social mode of (postnatal) care, 503
social support see support
socioeconomic disadvantage (incl.
poverty), 15
sodium, neonatal, 691–692
depletion, 691
excess intake, 692
imbalances, 691–692
sodium valproate, 548
soft tissue displacement in 2nd stage
of labour, 369
soft ventouse cups (silicone/silastic
cups), 457, 463
somatic syndrome in depressive
illness, 543
somatosensory function and pain,
350–351
somersault manoeuvre, 378
soya-based formulae, 727
spermatic cord, 78
spermatozoon, 91
formation (spermatogenesis), 80
oocyte fertilisation by, 95–96
spermicides, 581
sphygmomanometer, 245
spina bifida, 659
occult, 598, 659–660
spinal (intrathecal) anaesthesia for
caesarean section, 469
postoperative care, 467
spine
maternal, deformation with
concurrent pelvic deformation,
70
neonatal, examination, 598
spiral arteries, 106, 146
remodelling/modification, 106,
146
failure, 145
spirometry, asthma, 270
squatting position, 371–372
SSRIs (selective serotonin reuptake
inhibitors), 546–547
Index
standards
antenatal quality, 181
Global Standards for Midwifery
Education (2010), 6
for medicines management, 35
Midwives Rules and Standards, 32–35,
387–388
for preparation and practice of
supervisors of midwives, 42
Staphylococcus
postnatal infection, 519
s. aureus, methicillin-resistant, 37
startle reflex, 608
status asthmaticus, 270
status epilepticus, 278
statutory regulation, 26
abortion, 227–228, 227b
postnatal care, 501
statutory instruments, 28
statutory supervision, 39–43,
47–48
stem cells (in embryonic
development), 99
harvesting, 99
sterilization (microbial), feeding
equipment, 728
sterilization (reproductive), 585–586
feeding equipment, 728
female, 585–586
male, 586
steroid hormones, placental, 104–105
see also corticosteroids;
glucocorticoids;
mineralocorticoids
stethoscope, fetal heart, 194
labour
1st stage, 337, 344–345
2nd stage, 376
stillbirths, 557–558
lactation and, 723–724
multiple vs singleton, 304f
stomach
maternal, 163
content aspiration into lungs, in
caesarean section, 470
neonatal, 600–601
tube feeding, 624
stools see faeces
strawberry haemangioma, 593,
662–663
streptococcus
group A, 281
group B see group B streptococcus
postnatal infection, 519
stress (psychological), 532–533
see also distress
stretch marks (stretch marks),
167–168, 190
stretching the membranes, 199
775

preconception care and, 260,
277–278
SSRIs, 547
warfarin, 266
terminal care with congenital
malformations, 646–647
termination of pregnancy (induced or
spontaneous) see abortion;
miscarriage
testes/testicles, 78
neonatal
examination, 597
undescended, 664
testosterone, 80
tetralogy of Fallot, 657
thalassaemia, 275–276
screening for, 189, 210–211
α-thalassaemia, 275
β-thalassaemia, 275–276
sickle cell and, 243
thermoregulation (temperature
control), neonatal, 598–599,
670–671
LBW babies, 623
twin babies, 299
three-dimensional ultrasonography,
214
thrombin, 234
thrombocytopenia (low platelets)
maternal, 638
see also HELPP syndrome
neonatal, 638, 688
thrombocytopenic purpura, maternal
idiopathic, 667
thromboembolic disease (venous
thromboembolism), 270–273
combined oral contraceptive pill
and risk of, 572
prevention (thromboprophylaxis),
270–271
in caesarean section, 465
postnatal, 271–273, 522
thromboembolic-deterrent (TED)
compression support stockings,
266–268, 271, 277, 467, 522,
525–526
thromboplastin, 234
thrombosis, 266
deep vein, 190, 229, 271–273, 522
disposition in metabolic syndrome,
254
history of, 185
management, 266
thrush see Candida albicans
thyroid
disease
maternal, 262–264
neonatal, 694–695
function, maternal, 169–170
mebooksfree.com
Index
thyrotoxicosis (hyperthyroidism), 263, tricyclic antidepressants, 546
263t tri-iodothyronine (T3), maternal, 170,
thyroxine (T4), maternal, 170, 262 262
administration in hypothyroidism, excess, 262–263
263–264 tripartite placenta, 109
excess, 262–263 triphasic combined oral contraceptive
tiredness, postnatal, 508, 526 pill, 570
tocolytics in preterm prelabour rupture triplets (and higher orders
of the membranes, 240 pregnancies/births), 303
tocophobia, 533–534 UK statistics, 289t, 303f
tongue tie, 722 trisomy 13, 650
tonic-clonic seizures, maternal, 278t trisomy 18, 650
tonic neck reflex, asymmetric, 608 trisomy 21 see Down syndrome
tonic seizures/convulsions trophoblast, 97, 146
maternal, 278t implantation see implantation
neonatal, 640 trophoblastic disease, gestational,
top-up (complementary) feeds, 226–227, 249
724–725 trunk diameters, 121
TORCH, 676, 688 trust, public, 34
torticollis, 631 tube feeding of baby, 624
totipotent stem cells, 99 tubules (renal), secretion by, 86
touch, mother–baby, 625–626 tumours (neoplasms)
toxic chemicals, placenta transfer, 105 adrenal gland, 248
toxic (septic) shock, 489–492 malignant see cancer
toxicity, drug, 492 pituitary, 264–265
toxoplasmosis, 677–678 tunica albuginea, 78
screening, 189 tunica vaginalis, 78
tracheal intubation in caesarean tunica vasculosa, 78
section, difficult/failed, 470–471 Turner syndrome, 650
traction twin pregnancy see multiple pregnancy
controlled (on umbilical cord) see twin reversed arterial perfusion, 298
umbilical cord twin-to-twin transfusion syndrome,
in forceps birth, 461 297
in ventouse birth, 457, 459 Twins and Multiple Births Association
adverse effects, 462–463 (TAMBA), 305
training
NIPE (Newborn and Infant Physical
U
Examination), 607
perineal repair, 321 ulipristal acetate, 582
transcutaneous electrical nerve ultrasonography (abdominal/fetal)
stimulation (TENS), 353 dating of pregnancy, 418
transitional epithelium diabetic women, 261
bladder, 88 hydramnios, 238
ureter, 87 in hypertensive disorders, 248
urethra, 88 oligohydramnios, 239
transport mechanisms, placental, 106 for screening, 211–214
transposition of the great arteries, 1st trimester, 212–213
604b, 657 2nd trimester (incl. 18+0 to 20+6
transverse cervical ligaments, 72 weeks), 213
transverse diameter of pelvic inlet, safety, 211
66–67 three-dimensional, 214
transverse lie, 194, 197f, 477 twin pregnancy, 292
shoulder presentation, 451 women’s experiences, 211–212
trauma see injury see also Doppler assessment
travelling families, 17 umbilical arteries, 112
Trendelenburg posture, prolapsed cord umbilical cord, 107
management, 478–479 anatomical variations, 108–109
Treponema pallidum see syphilis around neck (at birth), 378
trials, randomized controlled, 18–19 blood sampling, 404
777
 Index

breaking, 411 urinary incontinence (and other inversion, 486–487

clamping and cutting, 379, 399,
401–402
with cord around neck, 378
early, 401
late/delayed, 402
timing in relation to postpartum
haemorrhage incidence, 403
controlled traction, 399, 402–403
and counter-traction, 403
timing in relation to postpartum
haemorrhage incidence, 403
loosening gently (in breech), 385
presentation, 478
definition, 477
predisposing factors, 477
prolapse, 385, 477–479
definition, 477
diagnosis, 478
in malpresentations, 448, 451, 477
management, 478–479
in multiple pregnancy, 298, 477
in occipitoposterior position, 438
occult, 477
predisposing factors, 477
stump see umbilicus
umbilical veins, 112
at birth, 117
umbilicus (and umbilical stump)
bleeding from, 639
bowel protruding through
(omphalocele), 650
examination, 637
infections, 675
UNICEF
Baby Friendly Hospital Initiative
(with WHO), 718–719, 727,
729–730
International Code of Marketing of
Breastmilk Substitutes and, 729
uniovular twins see monozygotic twins
unsettled babies, feeding, 725b
upper limb see arm
upright birth positions, 343, 371–372
breech birth, 360, 381–385
urachus, 88
urea measurements in pregnancy, 155t,
161
ureters, 82, 86–87
in pregnancy and childbirth, 156,
160
urethra
females, 88–89
males
opening on penis undersurface
(hypospadias), 596, 664
orifice, 56
posterior, valves, 663
urinalysis see urine
urinary problems)
antenatal, 161b
postnatal, 507, 523–524
urinary tract (baby)
fetal, 115
infection, 671–672
malformations, 663–664
see also genitourinary system
urinary tract (female), 81–90
catheterization in caesarean section,
464
in pregnancy and childbirth, 89–90,
159–161
infection, 281–282
urination see micturition
urine, 84–86
characteristics, 84
production/output, breastfed baby,
718
production/output, maternal, 85–86
in pregnancy and childbirth, 90
tests (incl. urinalysis from mid-
stream specimens), 215, 282
at booking visit, 188
in labour, 341
in proteinuria, 250
urogenital system see genitourinary
system; reproductive system;
urinary tract
urogenital triangle, 56–57
uterine souffle, 146
uterine tubes see fallopian tubes
uterosacral ligaments, 73
uterotonics (oxytoxics; ecbolics) in 3rd
stage of labour, 399
breech birth and, 382
caesarean section, 465
postpartum haemorrhage (PH) and
timing of administration in
relation to incidence of PH, 403
in treatment of PH, 409
uterus, 72–74
anterior obliquity, 444
atonic, 406, 409
bimanual compression in
postpartum haemorrhage
treatment, 409–411
emptying, in postpartum
haemorrhage treatment, 409
fundus, 73
dominance (first stage of labour),
330
eclamptic seizure and, 252
massage, 409
measuring height (in pregnancy ),
191
palpation (in pregnancy), 191
pressure (gentle), 411
acute, 486–487
classification by severity, 486
subacute and chronic, 486
involution, 505–507, 518
in labour
in 1st stage, actions, 330–332
in 2nd stage, actions, 368–369
contractions see subheading above
at onset of labour, 329
malformations, 74–75
muscles
contractions see contractions
laxity causing shoulder
presentation, 441–442
retraction, see subheading below
neck see cervix
postnatal
changes, 505
deviation from normal physiology
and potential morbidity, 518f
morbidity after operative birth,
519–520
morbidity after vaginal birth,
518–519
in pregnancy, 144–148
apoplexy, 233
divisions, 148
fibroids see fibroids
glands, 102
palpation see palpation
shape and size change, 147–148
resting tone (in labour), 331
retraction (in labour), 331
in 3rd stage of labour, 397
retraction ring, 331–332
rupture, 484–485
segments (upper and lower in
labour)
formation, 331
lower uterine segment technique
for caesarean section, 465
utilitarianism, 38–39
V
vaccination
HPV, 281
rubella, 189, 676–677
VACTERL spectrum, 650–651, 660
vacuum extraction see ventouse
vagina (maternal), 70–72
blood loss from see bleeding;
haemorrhage
in labour and childbirth,
examination, 340
brow presentation, 449
face presentation, 445
indications, 340

778
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initial, 337
occipitoposterior position, 438
shoulder presentation, 450–451
misoprostol, for induction of labour,
424
orifice/introitus, 56
in perineal injury, suturing, 318–319
in pregnancy, 149
leucorrhoea (white discharge),
149, 189–190
vagina (neonatal), bleeding, 639
vaginal birth/delivery
assisted see instrumental vaginal
birth
breech presentation, 356–360,
380–387
1st stage of labour, 356–360
2nd stage of labour, 380–387
assisting manoeuvres, 384–385
checklist, 385b
facilitation, 382–385
instrument-assisted, 384, 456
brow presentation, unlikeliness, 449
epidural analgesia and, 371b
multiple pregnancy, 294
previous caesarean section and, 466
uterus and vaginal loss after,
518–519
vaginal ring, combined hormonal,
574
valproate (sodium), 548
Valsalva manoeuvre in 2nd stage of
labour, 371
cardiac disease and, 267
valvular rheumatic heart disease,
268–269
Vancouver wrap, 712
varicella see chickenpox
varicella zoster virus, 677
varicose veins in pregnancy, 153, 190
vasa praevia, 109, 476–477
vascular birth marks, 593, 662–663
vascular endothelial growth factor
(VEGF), 105
vasculature see blood supply; blood
vessels
vasectomy, 579
vasodilation in pregnancy, 150–151
vasopressin see antidiuretic hormone
veins
central venous pressure monitoring
in shock, 491
fetal development, 112–114
supply to female reproductive
organs see blood supply
thrombosis see thromboembolic
disease; thrombosis
varicose, in pregnancy, 153, 190
velamentous insertion of cord, 109
mebooksfree.com
Venereal disease research laboratory
(VDRL) test, 188
venlafaxine, 547
venous sinuses, 122
ventilation, neonatal intermittent
positive pressure, 613
ventilatory breaths for babies, 613
ventouse (vacuum extractor), 457–460
complications, 462
contraindications, 462–463
neonatal trauma, 629–630, 639
failure, 463
indications, 456
procedure, 458–459
types, 457–458
use, 458
precautions, 459
see also instrumental vaginal birth
ventricles (brain), haemorrhage from
(IVH), 635–637
ventricles (heart)
ejection murmur, 603
septal defect (VSD)
maternal, 268
neonatal, 602, 658
verbal consent, 36
vernix caseosa, 107, 116
vertex presentation, 121, 193–194
occiput as denominator with, 196
positions in, 198b, 198f
see also specific types of vertex
presentation
vertex region of fetal skull, 120
vesicular rash, 669
vestibular glands, greater, 56
vestibule, vulval, 56
bulbs, 56
vicarious liability, 37
viral infections, neonatal, 676–677
Virchow’s triad, 271–272
virilization (masculinization), female,
664, 695
visceral pain, 351
visits see antenatal care; booking visit;
home
vital capacity, 158
vital signs, postnatal, 504–505, 517
vitamin(s) (in general)
breastmilk, 708–709
deficiency, pelvic anomalies, 70
wound healing and, 521t
vitamin A, breastmilk, 708
vitamin B complex, breastmilk, 709
vitamin C, breastmilk, 709
vitamin D, 708
breastmilk, 708
deficiency, 674, 708
supplementation, 165, 708
vitamin E, breastmilk, 708
Index
vitamin K (phytomenadione/
phytonadione/phylloquinone),
708–709
neonatal/infant
administration and
supplementation, 600,
637–638, 688, 709
breastmilk source, 709
deficiency (and associated
bleeding), 637–638, 688, 709
in obstetric cholestasis, supplements,
236
vitelline arteries, 112
vitelline duct, 98–99
vitelline veins, 112
Voltarol see diclofenac
voluntary removal from Register, 31
voluntary risk-pooling scheme for
negligence claims, 47
volvulus, 652–653
vomiting (emesis)
maternal, 162, 228–229
neonatal
bile-stained, 672
blood-stained (haematemesis),
639
vulnerable women, 13, 184
vulva, 55–56
W
Wales, All Wales Clinical Pathway for
Normal Labour, 388
warfarin, 266
warming in hypovolaemic shock, 490
warts, genital, 281
water, body
maternal, 166
neonatal depletion, 691–692
water birth see birth pool
water-soluble vitamins, 709
water supply for infant feed
preparation, 728
waters breaking see rupture of the
membranes
weaning from breast, 724
weight, maternal, 165–166
at booking visit, 187–188
gain in pregnancy, 254–255
postnatal difficulties in losing
weight after, 256–257
see also obesity
weight, neonatal, 617–618
classification, 617–618
loss followed by gain, 601, 718
see also low birth weight
Welfare Food Scheme, 729
well-being see health and well-being
Wharton’s jelly, 107
779
 Index
whey
in breastmilk, whey-dominance, 708
in formula feeds, 726
hydrolysates, 727
whey-dominant formulae, 726
white blood cells in pregnancy,
156–157
white spots (nipple surface), 721
WHO see World Health Organization
Who Is There for Us? People and
Resources (theme in antenatal
education programme), 136
Why Mothers Die in the UK, 538
Winterton Report (1992), 500
withdrawal (in drug abuse), babies,
696
pharmacological treatment,
696–697
signs, 696
withdrawal method (coitus
interruptus), 582
women (as users/clients/mothers)
amniotic fluid embolism morbidity,
486
in antepartum haemorrhage
effects on woman, 230
initial appraisal of woman, 230
attachment to baby, 556
caesarean section requested by, 465
care of or centred on, 13
immediate care after birthing,
405–406
in induction of labour, 425–426
in loss, 561–563
in multiple births, 302
postnatal, 516
in second stage of labour,
398–404
communication with see
communication
contact with baby see contact
counselling see counselling
death see death
disadvantaged see disadvantaged
groups
examination see examination
experiences see experiences
information for see information
780
mebooksfree.com
injury see injury
in instrumental delivery
complications, 462
as forceps delivery indicator, 456
intrauterine growth restriction
related to, 620
in loss
care of, 561–563
contact with baby, 560–561
milk production and, 706–707
numbers in antenatal education
group, 139
obesity risks to, 255
postnatal, 256
in partnership with midwives see
partnership
in postnatal period
care focused on, 516
contact with/visits by midwife,
503–504
immediate untoward events,
516–517
potentially life-threatening
conditions, 516
views of, 502b
in postpartum haemorrhage
observation, 412–413
resuscitation, 409
prolonged pregnancy and its impact
on, 418–419
psychosocial impact of antenatal
screening, 204–205
puerperium see postnatal period
relationships with others see
relationships
screening for disorders, 214–217
in shoulder dystocia, morbidity,
483
in shoulder presentation causation,
449–450
in transition and third stage of
labour, response, 370–373
in unstable lie causation, 451
see also female baby genitalia; female
genital mutilation
Woods manoeuvre, 481
work, lactation cessation with return
to, 724
workshops, postnatal, women’s views,
502
World Health Organization (WH)
Baby Friendly Hospital Initiative
(with UNICEF), 718–719, 727,
729–730
breastfeeding promotion initiative,
729–730
formula feeding, 728–729
labour defined by, 328
wound, postnatal, 520–522
care after caesarean section, 467
deviation from normal physiology
and potential morbidity, 518f
healing, phases, 520f
problems, 520–522
Wrigley’s forceps, 460
written consent, 36
X
X chromosomes, 95, 115
conditions linked to defects on,
648
XO (Turner) syndrome, 650
Y
Y chromosome, 95, 115
young mothers see minors; teenage
mothers
Z
Zavanelli manoeuvre, 482–483
zinc, infant breastfeeding, 709–710
zona pellucida
penetration by sperm, 95
in pre-embryonic period, 96–97
zygosity of twins, 95–96, 288
determination, 288–292
after birth, 292
relationship between chorionicity
and, 291t
zygote
development, 96–99
formation (by fertilisation),
95–96