Maternity - Postnatal Care in The First Week - CG - 2015

Postnatal care in the first week Clinical Guideline
This guideline has been developed by the Monash Womens Maternity Guideline Development Group in
consultation with Monash Newborn, to assist clinicians in all postnatal settings, in their approach to care of
women, following birth.
Target population for the guideline

This guideline identifies essential information for the care of mothers and babies that must be offered to
every woman in the early postnatal period.1 It also recommends the additional care required where there
is a deviation from normal recovery in either mother or baby.
This guideline addresses only common conditions and is not exhaustive.
Target users of the guideline

Monash Health medical staff and midwives.
Chapters
1. Planning postnatal care including: documentation and obstetric review.
2. Education and communication
3. Maternal health including:
a) Life threatening conditions in women
postpartum haemorrhage
genital tract or other sepsis
pre-eclampsia
thromboembolism.
b) Mental health including:
Perinatal depression, anxiety, adjustment to parenting issues, post partum psychosis.
Psychiatric Triage in community setting.
c) Physical health
headache
breast and nipple problems
breast engorgement, mastitis
perineal care
fatigue exclude anaemia
backache
diastasis of the rectus abdominis (DRAM)
constipation
haemorrhoids
faecal incontinence
urinary retention
urinary incontinence
Prompt Doc No: SNH0001507 v9.0

First Issued: 19/03/2012 Page 1 of 41 Last Reviewed: 13/04/2015
Version Changed: 21/12/2015 UNCONTROLLED WHEN DOWNLOADED Review By: 13/04/2018
Rhesus negative women

Rubella non-immune women
contraception
safety (family/ domestic violence)
discharge home from hospital.
4. Caesarean section (CS) postnatal care including:
assessment and observations
analgesia
antibiotics
thromboembolism risk post CS
anaemia assessment post CS
urinary catheter
wound care
5. Newborn health and well being including:
assessment after birth , newborn output parameters (nappies)
parenting and emotional attachment
physical examination and screening
newborn screening test (NST)
hepatitis B vaccination
vitamin k phytomenadione (Konakion )
jaundice
vitamin D
skin and cord
eyes
constipation, diarrhoea
candida infection (thrush)
newborn temperature fever hypothermia
safe home environment
nappy rash.
6. Newborn feeding including:
exclusive breastfeeding
expressing and storage of breast milk.
formula feeding.
Quick reference assessment and care planning TOOLs

Maternal vaginal birth (postnatal) assessment and care
Caesarean section (postnatal) assessment and care
Newborn in maternity (postnatal) assessment and care

1. Planning postnatal care

Women must have the opportunity to make informed decisions about their care and their babys care.
Planning postnatal care is ideally started in pregnancy and updated with each woman as soon as practical
after the birth.1
The initial care planning must include:1

1. Relevant variations or complications from pregnancy, intrapartum and immediate
postnatal period that might impact on postnatal care.1
(Examples might include: medical conditions, raised BMI, assisted birth, epidural, urinary
catheter, perineal trauma, haemorrhage, meconium liquor, low Apgars or breastfeeding not
initiated within the first hour).
2. Plans for the postnatal period, including length of inpatient stay, discharge date and level of
support at home.1
3. The role and details of other healthcare professionals involved in the care of the mother or
baby (for example: paediatric, social work or specialist services).1
The initial plans for care are documented in the inpatient medical record of either the mother or the baby.
Refer (MRF55) MATERNAL ASSESSMENT & EDUCATION RECORD, and (MRJ45) NEWBORN in
maternity ASSESSMENT & DISCHARGE PLANNER, with issues (or complications) noted in the
Progress Notes (MRJ01).
The postnatal plan for care is then to be reviewed with the woman and notes updated:
each change - over of care (shift in hospital or home visit)
if there is change in the condition of the mother or baby
after a significant event/procedure
at each obstetric ward round.
It is recommended complications or variations are detailed in the Progress Notes using a consistent
reporting outline, such as (C.A.O.S) :
Complication.
Action(s) taken.
Outcomes of the action(s) taken.
Specify is any further action(s) required.
If the postnatal period is uncomplicated, the midwifery head to toe assessments and education
may be recorded on the MRF55 (or MRF20 Education record where appropriate).
Obstetric ward rounds
The obstetric team will attend the postnatal ward daily and review the following women :
all women with an ongoing medical variance [includes women with substance abuse or
mental health concerns]
all women post CS on each day while in hospital
all women on first day post instrumental or complicated birth
any woman that a midwife requests to be medically reviewed.

2. Education and communication

Good communication between the clinicians and the woman is essential. Information must be tailored to the
needs of the individual, taking into account any cognitive or sensory disabilities, those who do not speak or
read English or read in their own language.1, Interpreter services must be accessed according to Monash
Heath Interpreter Service procedures.
Offer all women the opportunity to talk about their birth experiences and to ask questions about the care
they received.1
Women must be given information to enable them to promote their own and their babies health and
to recognise and respond to problems. Information on the following will be given within the time frames
recommended:1
the physiological process of recovery after birth (within 24 hours)
normal patterns of emotional changes in the postnatal period (within 1- 3 days)
common health problems as appropriate for both the mother and baby (within the first week).1
The Monash Health booklets Looking after yourself and your baby and Yes I'm going to breastfeed which
are generally provided to women during pregnancy, contain all this information in English. It is strongly
recommended clinicians utilise these booklets to reinforce information and prompt postnatal care
discussions.3
A copy of the booklet Breast feeding A new mothers guide (Australian Breast Feeding Association) is
available to all new mothers in the postnatal Bounty Bag.
The Victorian Government Child Health Record is a guide to parenthood and child health for the first five
years and a copy must be given to all women and its use explained (prior to discharge). 4 The Child Health
Record has translated sections in Arabic, Chinese, Polish, Spanish, Turkish and Vietnamese.
The Australian Government Parent Pack resource kit detailing the range of services, programs, Family
Assistance and Medicare application forms must also be provided soon after birth and its use explained.
Documenting education and information

Document the specific information provided and discussed with each woman on the (MRF55) MATERNAL
ASSESSMENT & EDUCATION RECORD or the (MRF20) Education record. Use clinical discretion for
further detailed notation in the progress notes when additional needs arise.

3. Maternal health
Most women can expect to have a healthy, safe and uncomplicated postnatal recovery; however it is
important to be aware of the problems that might be encountered during this time and actions to consider.
The urgency of the additional care which is required when a woman or baby develops health problems is
also an important factor to consider when caring for mothers and babies in the postnatal period. The
following table outlines the terms used in this document and gives an indication of what is meant by that
term.1
Terminology Explanation
Emergency Life-threatening or potential life-threatening situation that needs immediate action.
Urgent Potentially serious situation, that needs action as soon as is appropriate.
Non-urgent Continue to monitor and assess, inform appropriate staff as required.
3a Life threatening conditions in women

At an appropriate time after birth, the mother must be advised of the signs and symptoms of life-
threatening conditions, and what to do if any of the signs and symptoms occur :
Contact a midwife or obstetric staff member immediately (if in hospital).
Telephone 000 for emergency medical attention (if at home).
Signs and symptoms Conditions

Sudden and profuse blood loss or persistent Postpartum haemorrhage (PPH)
increased blood loss. Primary PPH within 24 hours of birth.
Significant faintness, dizziness, palpitations or rapid
Secondary PPH after the first 24 hours of birth up
pulse.
to six weeks postnatal.
Fever, shivering, abdominal pain and/or offensive Infection, particularly genital tract sepsis.
vaginal loss.
Headaches accompanied by one or more of the Pre-eclampsia & eclampsia.

following symptoms within the first 7 days after birth:
- visual disturbances
- nausea or vomiting.
Calf pain, redness or swelling usually unilateral. Thromboembolism.

Shortness of breath or chest pain. Deep venous thrombosis.
Pulmonary embolism.

Postpartum haemorrhage (PPH)

General advice and information
Daily assessment of the uterus by abdominal palpation or measurement is unnecessary where there
is a normal vaginal loss.1
When there is suspicion of retained placenta or membrane products inform the woman there is an
increased likelihood of abnormal bleeding or passing of clots.
Symptoms and signs
Sudden or profuse blood loss or blood loss accompanied by any of the signs and symptoms of
shock, including tachycardia, hypotension, hypo-perfusion and change in consciousness.
Excessive or offensive vaginal loss, abdominal tenderness or occasionally fever.
Associated symptoms and signs of blood loss are faintness, dizziness, palpitations or tachycardia.
Assessment
Ask each woman about her well-being and vaginal blood loss at each change - over of care.1
Where there is any abnormal vaginal blood loss, additional assessment is required and includes:
- duration of heavier loss, the colour, estimated amount (associations i.e. common to have an
short term increased loss after breast feeding or when rising up from lying down)
- any clots passed, amount, and if they contain placental tissue or membranes
- vital signs
- assessment of uterine involution.
Any abnormalities in the size, tone and position of the uterus must be evaluated further. If no uterine
abnormality is found, the obstetric team must be notified and consider other causes of symptoms.
(Urgent action)
Actions
Signs and symptoms of primary postpartum haemorrhage must be managed as per specific
Primary postpartum haemorrhage procedure. (Emergency action)
- Call for help
- identify and treat the cause (tone, trauma, tissue or thrombin)
- resuscitate mother: ongoing level of resuscitation dependant on maternal response to blood
loss, cause and treatment.
Refer to Primary postpartum haemorrhage for post emergency observations, assessments and
care planning considerations.
If PPH > 500 mL or the last haemoglobin (Hb) < 100 g/L consider a full blood examination (FBE)
between 24 - 36 hours.5
Signs and symptoms of severe secondary postpartum haemorrhage are to be managed similarly:
(Emergency action). If at home call for an ambulance, massage the uterus to contract and expel
any clots. If breast feeding, put baby to the breast, reassure and keep mother warm while waiting for
paramedic support.

Genital tract sepsis or other sepsis

Daily assessment of temperature is unnecessary in the absence of any signs and or
symptoms of infection.1
Symptoms and signs
Fever, shivering, abdominal pain.
Offensive vaginal loss or increased vaginal blood loss.
Symptoms suggestive of infection in other non-genital sites, for example dysuria,
cough, breast tenderness or redness.
Assessment
Ask the woman about her wellbeing and vaginal blood loss at each changeover of
care.1
Temperature should be taken and documented if infection is suspected.1
If the temperature is above 38o C, give paracetamol 1 g (2 x 500 mg) tablets and
repeat measurement within 2 hours.
If the temperature remains above 38o C, on the second reading or there are other
observable symptoms and measurable signs of sepsis, further evaluation by the
obstetric team is required.1 (Emergency action)
Actions
Appropriate examination and investigations should be undertaken to localise the site
of infection i.e. HVS, MSU.
Consider starting appropriate empirical antibiotic therapy until the cause of sepsis is
identified and specific antibiotic therapy can be started. Refer online - Therapeutic
Guidelines - severe sepsis: female genital tract source.
Where a woman has been diagnosed with mastitis, refer to breast feeding section of
this document.

Pre-eclampsia
Daily assessment of blood pressure or proteinuria is unnecessary in women with uncomplicated
pregnancy and birth.1
Symptoms and signs
Severe or persistent headache.
Visual disturbance, upper quadrant abdominal pain, vomiting.
Hyperreflexia and clonus may be present.
Assessment
At least one blood pressure (BP) must be taken and documented with a full set of observations prior
to transfer to postnatal care, even if they have been normotensive throughout their pregnancy and
labour.1
Actions
Women with severe or persistent headache must be evaluated further as per specific guideline by
the obstetric team and pre-eclampsia considered. (Emergency action)
If diastolic blood pressure is between 90 mmHg and 105 mmHg and there are no other signs or
symptoms of pre-eclampsia, repeat measurement of blood pressure within 2 hours. If still
elevated, further evaluation is required by the obstetric team.
If diastolic blood pressure is between 90 mmHg and 105 mmHg and accompanied by another
sign or symptom of pre-eclampsia, evaluate further by the obstetric team as per Preeclampsia
and severe preeclampsia procedure. (Emergency action)
If diastolic blood pressure is between 90 mmHg and 105 mmHg and does not fall below 90
mmHg within 4 hours, the obstetric team must review as per specific guideline. (Emergency
action)
If diastolic blood pressure is greater than 105 mmHg the obstetric team must review further.
(Urgent action)
When a mother has a confirmed diagnosis of pre-eclampsia refer to Hypertensive disorders in
pregnancy pre-eclampsia/eclampsia clinical guideline for subsequent clinical assessment and
care planning considerations.

Thromboembolism
Monash Health has a Thromboprophylaxis policy and Thromboprophylaxis risk assessment tool for venous
embolism prevention including pregnant and postnatal women.
Encourage all women to mobilise as soon as appropriate after birth.
Homans sign as a routine tool for evaluation of thromboembolism is not recommended. 1
Postnatal thomboprophylaxis is recommended in the following women:
- elective caesarean section + 2 additional risk factors
- emergency caesarean section during labour.
Additional recognised perinatal risk factors include: 6,7
- age > 35 years
- parity > 4
- obesity (BMI >30 at booking)
- mid-cavity instrumental birth
- significant surgical procedure postnatal (i.e. > 45 minutes)
- gross varicose veins
- sepsis
- preeclampsia
- immobility for > 4 days
- major current illness.
Symptoms and signs
Unilateral calf pain, redness or swelling.
Pleuritic chest pain or shortness of breath.
Assessment
Daily examination of the legs for calf tenderness, redness or swelling is recommended in women
who are at higher risk of thromboembolism.
If a deep vein thrombosis (DVT) is suspected the mother must be evaluated by the obstetric
team.1 (Emergency action)
If a pulmonary embolism (PE) is suspected the mother must be evaluated for pulmonary embolism
by the obstetric team. 1 (Emergency action)
Actions
Women who are at a higher risk of thromboembolism must be offered specific management to
decrease their risk, for example low molecular weight heparin (enoxaparin) 40 mg subcutaneous
daily for 7 days /or until fully mobile.1,6,7
Appropriate investigations to consider include: Doppler leg ultrasound or if a pulmonary embolism
is suspected a chest X-ray must be performed and a computed tomography pulmonary angiogram
(CTPA) or ventilationperfusion (V/Q) lung scan.8
D-Dimer testing in pregnancy is not particularly helpful.8
Where a woman has been diagnosed with thromboembolism refer to Monash Health
anticoagulation treatment procedures for subsequent assessment and care planning considerations.
3b Maternal mental health

Pregnancy and early parenthood can be a time in a woman's life when the risk of developing a
mental health problem increases. Depression and anxiety in the perinatal period occurs in
approximately 16% of women.9
Anxiety symptoms both with and without depression are common in the perinatal period (during
pregnancy and the post-partum period).
At each changeover of care /or home visit ask the woman how she is feeling and if she feels
supported. Listen non-judgementally; give reassurance where appropriate. Offer a copy of the
Beyond Blue booklet Emotional health during pregnancy and early parenthood which explains
postnatal depression, its symptoms and effective strategies to deal with it.
All women should have a perinatal psycho-social risk assessment including assessment of :
past history of mental health problems (for example depression, anxiety disorders,
schizophrenia, bipolar disorder)
available support (socially isolated, teenager or difficult relationships)
current or past physical abuse/violence or substance abuse issues
current life events / major stressors (e.g: unplanned pregnancy, difficult birth, unwell infant,
death in family) 9
unresolved baby blues (usually resolve within 10-14 days).1,9
Look for signs or symptoms of maternal mental health problems (lowered mood, feelings of guilt
/worthlessness /inadequacy, appetite changes, sleep disturbance not related to baby, suicidal
thoughts).
Encourage the woman and her family to report any changes in emotional state and behaviour that
are different from her normal pattern or of concern.1
Encourage all women to help look after their mental health by looking after themselves. Refer to
Looking after yourself and your baby.
Puerperal psychosis occurs in 1.2 /1000 births for first time mothers.
Action
Women showing signs or symptoms of puerperal psychosis (expressing delusional beliefs about
self, family members or baby; and or behaving in a bizarre fashion) she must be evaluated further
with referral to appropriate Mental Health Services. (Emergency action)
If an inpatient escalate to senior obstetric and midwifery staff or specialist teams involved to
assist with referrals to:
- Psychiatric Services.
- Social work referral.
If at home escalate to the midwife in charge, and contact Psychiatric Triage for arranging
Crisis Assessment and Treatment (CAT) Services. The CAT service assists people who are
in crisis with mental problems. Strict geographical boundaries apply based on where person
is at time of need (refer following page).
Where there is suspicion or concern of child abuse this should be evaluated further as per
vulnerable childrens protocol. (Emergency action)

Psychiatric Triage
Psychiatric Triage is the first point of contact with mental health services in the community setting. Mental
Health Triage can be contacted for information, assessment and referral - 24 hours a day, 7 days a week.
Strict geographical boundaries based upon where the person is at the time.
Central East
This Mental Health Service Area covers: Manningham (Local Government Area), Monash-Waverley East,
Monash-Waverley West, Whitehorse-Box Hill and Whitehorse-Nunawading West (Statistical Local Areas).
Telephone: 1300 721 927
Dandenong
This Mental Health Service Area covers: Greater Dandenong, Casey, Cardinia (Local Government Areas)
and Frankston-East (Statistical Local Area). Telephone: 1300 369 012
Inner South East
This Mental Health Service Area covers: Port Phillip, Stonnington (Local Government Areas) and Glen Eira-
Caulfield (Statistical Local Area). Telephone: 1300 363 746
Middle South
This Mental Health Service Area covers: Bayside and Kingston (Local Government Areas). Telephone:
1300 369 012
Outer East
This Mental Health Service Area covers: Maroondah, Knox, Yarra Ranges (Local Government Areas) and
Whitehorse-Nunawading East (Statistical Local Area).Telephone: 1300 721 927
Peninsula
This Mental Health Service Area covers: Mornington Peninsula and French Island (Local Government
Areas), Kingston-South and Frankston-West (Statistical Local Areas) Telephone: 1300 792 977
Ask for direction and advice from the intake worker as to how to handle the patient until they are able to
accept them. If they dont accept the case ask what you should be observing and when you would need to
contact them. If you are worried that someone is of imminent and serious risk of harming themselves or
someone else it is important that you clearly identify and document your reasons for forming that belief.

3c Maternal physical health
Headache
Advise women who have had an epidural or spinal anaesthesia to report any severe headache,
particularly one that occurs while sitting or standing.
Avoid factors that precipitate headaches and ensure rest during the day.
Assessment
At each changeover of care ask women if they are experiencing headaches.1
If headaches are present ask about associated symptoms:
- visual disturbance
- epigastric pain
- neck stiffness.
Actions
Symptoms of a post-dural headache must be evaluated further with a referral made to anaesthetics.
(Urgent action)
Management of a mild postnatal headache is based on the differential diagnosis of headache type.
If analgesia is required, paracetamol is generally first line, unless contraindicated.1
Offer women with tension or migraine headache advice on relaxation and how to avoid factors
associated with the onset of headaches.1
Emergency action is required when there are:
- symptoms of pre-eclampsia (see section on same above)
- headache associated with neck stiffness or pyrexia
- headache associated with visual disturbance or neurological deficit.

Breast and nipple problems

Discuss supply and demand principles.
Breasts must be assessed regardless of method of infant feeding.
Reassure women that brief discomfort at the start of breast feeds in the first few days is not
uncommon, and this generally does not persist.1,19
Advise women that if their nipples are painful or cracked, it is probably due to incorrect attachment 1
(refer assessment below).
Advise women that their breasts may feel tender, firm and painful when milk comes in at or
around 3 days after birth.1
Advise breast feeding women to wear a well-fitting bra that does not restrict her breasts.1
Advise women who are suppressing lactation to wear supportive bras and to avoid expressing or
stimulating milk production. Gentle massage may be necessary to keep breasts comfortable for
some women.
All breastfeeding women must be offered to be shown how to hand express.1
Women must be advised to report any signs and symptoms of mastitis including flu like symptoms,
red, tender and painful breasts to a midwife or doctor urgently.
Assessment
Each changeover of care, ask the woman about the comfort of her breasts.
Breast feeding women a womans experience with breastfeeding must be discussed with her at
each shift or change of care to identify any need for additional support. 1 (Refer to Infant Feeding
Section of this document and to the specific breast feeding guidelines for assessment of
positioning, attachment and effective feeding).
Inspect nipples of breast feeding women for signs of trauma or infection at least daily while in
hospital and teach the mother signs to watch for.
Actions
Following maternal and neonatal assessment and examination, a Breast Feeding Plan (MRF34)
may be initiated in response to complications as per specific guideline.
If nipple pain persists in breast feeding women after repositioning and re-attachment (and after
excluding anatomical variance and vasospasm) assessment for thrush must be considered.1
If an insufficiency of milk is perceived by the woman, attachment and positioning must be
reviewed and her babys health must be evaluated. (Non Urgent action)
- Reassurance must be offered to support the woman to gain confidence in her ability to
produce enough milk for her baby. If the baby is not taking sufficient milk directly from the
breast and supplementary feeds are necessary, expressed breast milk can be given.
- Supplementation with fluids other than breast milk is not recommended.1, Exception to this
would be where recommended by a paediatrician i.e. a baby experiencing neonatal
abstinence syndrome (NAS) may require top-ups for comfort or to prevent excessive weight
loss until breast milk supply is established.
Consider referral to a lactation clinic for any feeding difficulties after discharge.

Breast engorgement
Is treated with:
- Either by baby feeding from both breasts or if necessary, expressing until breasts are
softened and ensuring breasts are comfortable.
- gentle breast massage to stimulate flow
- warm shower /or heat compress for a few minutes before breast feeding
- cold compresses applied to breasts after breastfeeding/expressing can relieve discomfort
and swelling
- simple analgesia such as paracetamol.1
Mastitis
Women with signs and symptoms of mastitis must be offered assistance with positioning and
attachment and advised to:
- continue breastfeeding and/or expression to ensure effective milk removal; if necessary, this
may be with gentle massaging of the breast to overcome any blockage
- take analgesia compatible with breastfeeding, for example paracetamol
- ensure adequate fluid intake.
If signs and symptoms continue for more than a few hours of self-management, a woman must
be advised to contact her midwife, lactation consultant or doctor again urgently. If the signs and
symptoms of mastitis have not eased, the woman must be evaluated as she may need antibiotic
therapy prescribed as per Therapeutic Guidelines Antibiotics.10 (Urgent action)
If an inpatient refer for obstetric review.
If at home refer to general practitioner (GP) or Emergency Department.

Perineal care
Topical cold therapy, for example crushed ice or gel pads, are effective methods of pain relief for
perineal pain.1
If analgesia is required, paracetamol should be used in the first instance unless contraindicated.1
If cold therapy and paracetamol are not effective, consider oral or rectal non-steroidal anti-
inflammatory medication (e.g. Diclofenac) unless contraindicated.1 (Non-urgent action)
Discuss perineal hygiene, including frequent changing of sanitary pads and washing hands before
and after doing this.
Recommend daily bathing or showering to keep the perineum clean.1
Avoid constipation.1,
Assessment of the perineum
Visual assessment of the perineum if the woman has pain or discomfort even if there was no
reported trauma.
Ask women who have sustained trauma whether they have any concerns about the wound
healing process which might include pain, discomfort, oedema, stinging or offensive odour.1
Women who have sustained trauma requiring repair should have a perineal assessment each
shift in the first 24 hours, and then daily whilst in hospital and at each home visit in the first
week when indicated.
Actions
If a woman has sustained any perineal trauma refer to the Perineal trauma management
procedure for immediate and subsequent management.
A referral to the physiotherapist must be offered to all women who have sustained 3rd or 4th
degree perineal trauma.
A referral to the dietitian must be offered to all women who have sustained 3rd or 4th degree
perineal trauma.
Signs and symptoms of infection, inadequate repair, wound breakdown, vulval haematoma or
non-healing must be evaluated further by the obstetric team. (Urgent action)
If an inpatient refer to senior obstetric staff.
If at home discuss with the obstetric team on - call and consider referral to the Emergency
Department.

Fatigue
Women who report tiredness should be helped to plan rest periods.1, Refer to Looking after yourself
and baby.
Assessment
Ask each woman about fatigue at each changeover of care.
Check for symptoms and signs of anaemia i.e. pallor, headache, continuing excessive blood loss.
Actions
If persistent postnatal fatigue impacts on the womans care of herself or baby, underlying physical,
psychological or social causes should be evaluated further. (Urgent action)
If a woman has had a postpartum haemorrhage or is experiencing persistent fatigue, evaluate to
exclude anaemia. (Urgent action)
Where a womans haemoglobin is low treat with specific dietary advice and iron and vitamin C
supplementation. Ensure this is communicated at discharge to the womans doctor to enable
appropriate follow up.
Backache
Women experiencing backache in the postnatal period should be managed as in the general
population.1 Encourage normal activity and not bed rest, refer to Looking after yourself and your
baby.
Advise the woman on correct posture when handling, lifting and feeding her baby.
Actions
Heat pack.
If analgesia is required, paracetamol should be used, unless contraindicated.1
A referral to a physiotherapist may be considered.

Diastasis of the rectus abdominus muscles (DRAM)

Diastasis of the rectus abdominis muscle (DRAM) is the stretching of the connective tissue of the
lineae albae between the two bands of the superficial rectus muscles caused by hormonal and/or
mechanical factors during pregnancy.
DRAM may result in the reduced ability to stabilise pelvis/spine which may contribute to the
development of lower back pain.
Symptoms and signs
Pendular-like abdomen in standing.
Bulging of abdominal contents between the superficial rectus muscles during postural changes such
as getting out of bed.
Separation as noted in assessment below.
Assessment
Assessment should occur prior to discharge. [This includes women post caesarean section, once the
woman is moving around comfortably, and being aware it is not always accurate because
sometimes their effort is reduced due to pain (or fear of pain) inhibition].
Ask the woman to lie flat in the crook lying position (knees bent) with no pillows.
Separation should be assessed, at the umbilicus and 5cm above umbilicus i.e. 2 measurements
taken.
Assess with the flats of fingers in the midline as the woman lifts her head and shoulders off the bed
during exhalation.
Feel for the amount of separation between the muscles. Observe for midline bulging.
Actions
All post-natal women should be encouraged to attend a physiotherapy post-natal class.
DRAM > 3 finger width gap +/- midline bulging should be referred to physiotherapy for further
assessment and appropriate treatment.
Constipation
Women should have bowels open within 3 days of birth.
Assessment
Ask women about their normal pattern and if they have opened their bowels by day 3 after the
birth.1
Actions
Women who are constipated and uncomfortable should have their diet and fluid intake assessed.1
Offer women advice on how to improve their diet. Refer to Looking after yourself and your baby
A fibre supplement bulking laxative such as Fybogel (one sachet taken with water in the morning
and evening after meals) may be recommended if dietary measures are not effective. 1
Contraindicated if intestinal obstruction or ileus suspected.15

Haemorrhoids
Women with haemorrhoids should be advised to take dietary measures to avoid constipation.1
Actions
Anusol or Scheriproct Ointment may be offered for the relief of haemorrhoid pain or anal itching.
Anusol may be applied to the affected area twice daily. Scheriproct can be applied up to four
times on the first day of treatment only. Once the condition is controlled, use once or twice per
day, for a maximum of 7 days.16
Women with a severe, swollen or prolapsed haemorrhoid or any rectal bleeding should be
evaluated further. (Urgent action)
If an inpatient refer for obstetric review.
If at home refer to a general practitioner.
Faecal incontinence
Faecal incontinence is a rare event and requires urgent evaluation.(Urgent action)
Actions
Women with faecal incontinence should be assessed by senior obstetric staff to exclude non
repaired sphincter damage or fistula.(Urgent action)
Referral to Urogynaecology services may be required.

Urinary retention
Women should be encouraged to void within 1-2 hours of vaginal birth. The maximum tolerance to
void is six (6) hours.1,17
Normal voided volumes are 200 - 400 mL.17 Early postpartum voids may be larger (400+mL).
Diuresis may occur in the first 24 - 48 hours resulting in increased voiding frequency (normal 8
times in 24 hours).
Women may experience a change in sensation and volumes passed following birth, therefore, it is
important to monitor for loss of sensation or abnormal voiding patterns.
Women who have had an indwelling urinary catheter during labour or birth should have
this removed once full sensation to the legs returned. Careful consideration should be given to
timing of removal at night time. The opportune time may be when the mother is awake to feed her
baby or when observations are due, and when the woman is ready.
Postpartum urinary has been reported to occur in up to 10-15 % of women.17 Factors which
increase the risk immediately postpartum include:
history of voiding difficulties
instrumental birth/ shoulder dystocia
prolonged second stage
episiotomy, excessive perineal trauma/ significant oedema or haematoma
change in sensation to void after birth
suspected or reported incomplete bladder emptying
epidural, spinal or pudendal block
catheterisation during or after birth.
Symptoms and signs of postpartum urinary retention:

Frequency, urgency, lower abdominal pain, no sensation to void, inability to void, palpable
bladder, overflow incontinence, rising fundus.
Assessment
The first void in all women should be assessed and documented:
time and sensation (normal - decreased - absent)
if any difficulties initiating void, feeling of incomplete emptying, frequency of voiding
assess If bladder remains palpable
fundal position pre and post void.
Action
If urine has not been passed within 6 hours after the birth (or of catheter removal) and the
woman is awake efforts to assist urination should be advised, such as taking a warm shower,
privacy, analgesia and ambulation.1
If any difficulties initiating void, feeling of incomplete emptying, frequency of voiding.
o assess If bladder remains palpable
o fundal position pre and post void.
o If difficulties continue after first void refer to Womens Health physiotherapist (patient
should be seen prior to discharge)

Regardless of perceived hydration status, if simple measures to encourage micturition are not
immediately successful and / or incomplete emptying is suspected, bladder volume must be
assessed :
clinically by palpating the uterine fundus
If the fundus is displaced upward to the right, encourage double voiding (.this involves
leaning forwards or even standing slightly to alter the angle of the bladder neck, waiting
for two minutes after the initial void and trying again).
If the double voiding technique is unsuccessful pass an in/out catheter and
commence a fluid balance chart (FBC) (Urgent action)
Bladder scanner is not an accurate tool in the first few weeks after childbirth. In the
presence of symptoms of retention, catheterisation will be required to confirm a
diagnosis.
An immediate post void residual volume of less than 50 mL is normal. A significant post
void residual volume is likely to be greater than 100 -150 mL.17,18,19

Assessment with a fluid balance chart includes:
fluid intake
void volumes, frequency of voids and times
Note any episodes of urinary incontinence; difficulties encountered initiating void, painful or
poor bladder sensation, or feeling of incomplete emptying.
If, following assessment with in/out catheter and fluid balance chart, the woman is still unable to
void after a further six hours:
Insert an indwelling urinary catheter for 24 - 48 hours. (Urgent action)
Commence prophylactic antibiotics.
Management following re-catheterisation:

Where the urinary volume is found to be in excess of 600 mL leave the catheter indwelling on free
drainage for 48 hours, to allow the bladder to recover from severe over- distension. (Urgent action).
After removal of the catheter (in/out or in-dwelling) observe three (3) documented voids (200-400
mL or greater) before ceasing the FBC.
Suspect urinary retention if voiding pattern is one of frequent small voids (<100 mL).
If signs or symptoms of retention remain, perform intermittent catheterisation
immediately post void to ensure a normal residual volume before the woman is
discharged home.
Women who continue to have significant residual urine volumes or retention after removal of
the indwelling catheter may be offered the choice between management with another indwelling
catheter or intermittent self catheterisation.
A referral to the Continence Nurse Advisor/ Senior Womens Health Physiotherapist
/Urology Nurse for ongoing follow up and monitoring.
Good practice points:

To prevent risk of infection when inserting a urinary catheter always:

use a new Foley catheter each time

use a strict aseptic technique.
For further advice on case management of possible voiding dysfunction, during office hours do
not hesitate to call the Womens Health Physiotherapist at the site.
Refer : Urinary retention postnatal procedure
Urinary incontinence
Urinary incontinence is a relatively common symptom after childbirth (30-60%).
Actions
Explain benefits and encourage pelvic floor exercises.
Women with involuntary leakage of urine should have a referral to the physiotherapist for pelvic
floor exercises.
Women with unresolved or worsening urinary incontinence should be evaluated further with a referral
made to the Urogynaecology service.1 (Non urgent action)

Rhesus negative women

Anti-D immunoglobulin must be offered to every non-sensitised Rhesus D-negative woman
within 72 hours following the birth of an Rh-D-positive baby ( see Rhesus (D) negative women
(maternity) procedure)
Actions
Administer 625 international units Rh D Immunoglobulin by deep intramuscular injection,
preferably into the deltoid muscle.
Note: women with a positive Kleihauer will require a higher dose of Anti-D immunoglobulin as
indicated by Blood Bank.
Women who are non immune for Rubella

Measles, Mumps, Rubella vaccination (MMR) must be offered to women who are non immune
for Rubella on antenatal screening. The vaccination can be offered at any time following birth and
before discharge from hospital.
Breastfeeding is not contra-indicated.13
Actions
Administer 0.5 mL Measles-Mumps-Rubella (M-M-R ii) once by deep subcutaneous or
intramuscular injection.13
Advise women to use appropriate contraception and avoid getting pregnant for 1 month after
receiving MMR. [Do not say You cant get pregnant as this may be misconstrued as having
contraceptive properties].
Contraindications to Measles-Mumps-Rubella (M-M-R ii) include:
1) known allergy to components
2) impaired immunity
3) recent administration of antibody - containing blood products.
Note: Blood transfusion with washed red blood cells is not a contraindication13 however washed cells are
not routinely issued.
RH (D) immunoglobulin (anti D) does not interfere with the antibody response to MMR vaccine and may be
administered at the same time, in separate syringes, and into different limbs.13

Contraception
Offer women information regarding contraception and discuss when to resume contraception.
Offer all women a copy of the Monash Health information brochure Contraception options after
birth.
Actions
Obstetric staff should write a prescription for contraceptives if required.
Women who may have difficulty accessing contraception care (for example women who do not speak
English or young mothers) may require additional help before discharge with an appointment or contact
details for a contraception clinic. i.e. Hospital based contraceptive counselling clinic or Family Planning
Services Victoria.
Safety family /domestic violence

General advice and Information
Health professionals must be aware of the risks, signs and symptoms of domestic abuse and
who to contact for advice and management.
Refer to Monash Health Vulnerable Children procedure:
Mandatory reporting as per Section 184 of the Children, Youth and Families Act 2005
midwives, nurses and doctors, teachers and the police are Mandated Reporters and must report
to Child Protection when, in the course of their professional duty they form the belief that a child is
in need of protection as legally defined in the Children, Youth and Families Act 2005.
Educational guidance for health care professionals

www.cyf.vic.gov.au/every-child-every-chance
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_
4126161

Discharge from hospital

The length of stay (LOS) and the preparations required to return home must be discussed with
all women in the third trimester of pregnancy.1,24
It is important to review these discussions within an hour of giving birth or as soon as
practicable within the first few hours and offer Extended Postnatal Care (EPC) services.
Women and babies who are well can be supported to go home within 4 hours of birth if this is
their plan and they have adult support at home.
The expected LOS for a well woman and baby after a vaginal birth is generally:
- multigravida - same day or within 24 hours
- primiparous - same day or within 48 hours
- assisted vaginal birth (forceps or vacuum) within 48 hours or less.
This is on the understanding that extended postnatal care (EPC) will visit the following day and
continue support these women at home according to their needs.
The LOS after a caesarean section (elective or emergency) is generally 72 hours unless
otherwise indicated. This is on the understanding that:
- discharge planning emphasises the need for ongoing analgesia
- adequate analgesia is provided for women to take home
- extended postnatal care (EPC) continues to support these women at home according to
their needs.
- medical staff are asked to ensure that discharge scripts are prepared well in advance to
facilitate timely patient discharge.
However, women who are recovering well after a caesarean, are apyrexial and do not have
complications may consider planned early discharge (after 24 hours) from hospital and follow
up by Extended Postnatal Care (EPC) visits at home in the first week.1,20 This practise is not
associated with increased infant or maternal readmissions.20
Women and or babies with special needs may require an extended LOS i.e. babies being
assessed for Neonatal Abstinence Syndrome (NAS).
Complete a home visiting safety assessment to enable risk management strategies to be put in
place in a timely manner and avoid delays in discharge.
All women requiring ongoing medical care should have a medical discharge documented
ahead of discharge, and a medical discharge letter sent to the womans GP.
Refer to the Monash Health booklet Looking after yourself and your baby and Going home
after a caesarean section fact sheet to provide anticipatory guidance on what to expect after
discharge.

4. Caesarean section (CS) postnatal care
In addition to general postnatal care, women who have had a CS must be provided with specific care
related to recovery after CS.20
Post CS assessment and observations:
After transfer from the recovery room, assessment and documentation of the following must be made:
pain
sedation
respiratory rate
heart rate
blood pressure
temperature
intravenous infusions
vaginal loss
urinary output
surgical site drainage and wound.
At the following intervals:
half hourly for two hours, then
2 hourly for 4 hours, then
4 hourly for remainder of the first 24 hours post-operative.20
twice daily for remainder of inpatient stay.
Daily examination of the legs for calf tenderness, redness or swelling is recommended in women who are
at higher risk of thromboembolism If these observations are not stable, more frequent observations and
obstetric review are recommended.20
For women who have had intrathecal or epidural opioids in a continuous infusion, post removal
there must be a minimum for 12 hours: 2 hourly respiratory rate, sedation and pain scores during
normal waking hours. 2 hourly respiratory rate only during normal sleeping hours. 21,22
For women who have had patient-controlled analgesia with opioids, there must be hourly
monitoring of respiratory rate, sedation and pain scores throughout use and for at least 2 hours after
discontinuation of treatment.20
Be aware of the Monash Health Acute Pain Service medical record documentation requirements
Intravenous Analgesia (MRG23) or Regional Analgesia (MRG25) as appropriate.
CS post operative analgesia

Women who have a CS must be prescribed and encouraged to take regular analgesia for
postoperative pain.20
Discuss any pain relief requirements at each contact. If pain relief is ineffective, evaluate further by
the obstetric team and or acute pain team.(Urgent action)

CS antibiotics
Prophylactic antibiotics must be given intra operatively to reduce risk of infection post CS. 20 Refer to
Surgical - Antimicrobial Prophylaxis procedure.
Thromboembolism risk
Women must be assessed for risk using the Monash Health Venous Thromboembolism Risk Assessment
and Prevention
Encourage early mobilisation and pay particular attention to women who have symptoms such as cough or
shortness of breath or leg symptoms, such as a painful swollen calf.20
Anaemia post CS
If blood loss > 500 mL or haemoglobin (Hb) < 100 g/L consider a full blood examination (FBE)
between 24 - 36 hours.5
Urinary catheter
The urinary catheter is not to be removed until the woman has full sensation in her legs as assessed
by Bromage score after a regional anaesthetic. Refer to Falls Prevention (Maternity) Standard Care.
If the woman experiences urinary symptoms following the removal of the urinary catheter or is
unable to void six hours after removal of catheter, evaluate further.(Urgent action)
Consider urinary alkaliniser (i.e. Ural, Citravescent or Citralite) for short term relief of urinary
symptoms.
Consider the possible diagnosis of:
- urinary tract injury (occurs in about 1 per 1000 CS)
- urinary tract infection
- urinary incontinence (occurs in about 4% of women after CS).20

CS wound care
Moist healing principles must be used for wound care,23 such as Opsite post-op visible.
Other dressings are either less absorbent than Opsite post-op visible or opaque which does not
allow wound inspection without removal of the dressing.
Wound care must include:
Leave dressing intact if seal integrity maintained. Opsite post-op visible is best left intact for 5
days.
If wound cannot be visualised through the dressing adequately, consider removal at 48 hours for
visual assessment, unless otherwise indicated by the surgeon.
Pressure dressings must be removed within the first 24 hours.
Monitor for systemic signs and symptoms of infection (such as temperature).
Assess the wound for local signs of infection (such as increasing pain, redness localised heat,
swelling, odour discharge or dehiscence) at each change of care/visit.
Plan to remove sutures, clips or drains if appropriate as indicated on the operative notes.
After dressing is removed, advise the woman how to take care of the wound: 20
- shower or wash twice daily lifting skin folds if necessary to wash and gently dry the area
- not to reapply a dressing unless suggested by doctor or midwife
- wear loose clothing, use cotton underwear
- women with abdominal overhang must be advised to place a clean dressing in the fold and
to change it when moist.
If evidence of infection evaluate further.(Urgent action)
- If an inpatient: record vital signs, escalate to senior obstetric staff and take swabs for micro
culture and sensitivity.
- If at home refer to General Practitioner.
If evidence of or severe wound disruption.(Urgent action)
- If an inpatient: escalate to senior obstetric staff and take swabs for micro culture and
sensitivity.
- Dress the wound using : Aquacel rope Convatec and cover with Opsite post op
visible. Aquacel rope is hydrofibrer it will stay intact as a gel so is recommended for
highly exuding wounds. It is also a deslougher. If dressing leaking occurs, change the
outer dressing only. Leave Aquacel rope in for 3 to 4 days. Redress as above if required.
- For further wound care advice the stomal therapist at each site can be contacted
(preferably in between 0900-1200 hours).
- If at home refer to the Emergency Department.

5. Newborn health and wellbeing

Healthy babies have normal colour for their ethnicity, maintain a stable body temperature, and
pass urine and stools at regular intervals. They initiate feeds, suck well on the breast (or bottle)
and settle between feeds. They are not excessively irritable, tense, sleepy or floppy. 1 Babies do
not generally lose more than 10% of birth weight.
During any assessment or physical examination encourage parents to be present to promote
participation in the care of their baby and enable them to learn more about their babys needs. 1
Parents must be offered information and advice to enable them to:
- assess their babys general condition
- identify signs and symptoms of common health problems seen in babies
- contact a healthcare professional or emergency service if required.1
Assessment
An initial assessment of the newborn is performed soon after birth to detect significant
abnormalities, birth injuries and cardio respiratory disorders that may compromise a successful
adaptation to extra uterine life. See specific procedure.
For the initial 4 hours after birth all healthy term newborns should have 1 hourly temperature,
respiratory and heart rate, colour and cord check undertaken and documented.
Refer separate procedure for list of Observations (Neonatal) Babies in Maternity
For babies born to women using opioids refer: Neonatal Abstinence Syndrome (NAS) - Guideline for
Babies at Risk
Vital signs of a healthy baby should fall within the following ranges:
respiratory rate normally 30-60 breaths per minute
heart rate normally 100-160 beats per minute
temperature is normally 36.5 - 37.30 C 25
While in hospital neonatal assessment /checks is performed daily, preferably in the parents
presence. This check should include:
correct identification labels
colour and general condition
skin integrity.
Assess weight soon after birth and reassess again after 48 hours. Assess sooner rather than
later if baby is dry, jaundiced or feeding poorly.
Note: Babies in the maternity ward who are 35-36+6 weeks gestation and/or infants weighing
2.0 -2.5kg under paediatric care should be weighed every 48 hours as per the Care of the
well late preterm and/or 2.0-2.5kg baby on the postnatal ward

Normal parameters for newborn output 31
0-24hrs Urine and meconium passed.
24-48hrs 2+wet nappies for breastfed infants, 3+ for formula fed infants.
Meconium/ transitional stools.
48-72hrs 3+ wet nappies.

Transitional stools / mustard.
72-96hrs 4+ wet nappies.

Transitional stools/ yellow (BF) or greenish-brown (AF)
96+hrs 5+ wet nappies.

Mustard / yellow stools.
Actions
Concerning findings are to be evaluated further with referral to the appropriate neonatal medical
staff. (Urgent action)
Ensure parents have been offered a copy of Looking after yourself and your baby booklet and
point out the last page, which details signs of serious illness and what to do when at home.
Parenting and emotional attachment

- Assessment for emotional attachment should be carried out at each postnatal contact.
- Offer parents information and support in adjusting to their new role and responsibilities within the
family unit.
Newborn physical examination and screening

A complete examination of the baby should take place during the mothers hospital stay with the
mother /parent present, preferably after the first 24 hours following birth.1 See Neonate
Assessment and examination for discharge
The aims of any physical examination should be fully explained to, and the results shared with the
parents and recorded in the newborn medical record and the child health record.1
A hearing screen should be completed in the first week.1
Actions
Abnormal significant or concerning findings are to be evaluated further with referral.

Newborn Screening Test (NST)

Document birth weight for current weight on the card. The baby does not need to be weighed
again to complete the card.
Provide the mother with a copy of the Genetic Health Victoria information pamphlet.
Refer specific Newborn Screening Test and genetic Health education for health professionals.
Important note: Monash Health has not adopted the separate, standalone form to be filled out when
a parent declines newborn testing. It is preferred that, consistent with other consent and decline
practices, the parents refusal or acceptance is to be noted in the newborn clinical record (MRJ45)
including confirmation having provided specific advice about testing .

Hepatitis B vaccination
It is recommended all newborn babies are vaccinated against Hepatitis B.
With parental consent Hepatitis B vaccine for neonatal immunisation should be given to all
infants soon after birth. The greatest benefit is if the vaccine is given within 24 hours of birth. The
neonatal dose should not be given after 7 days.
- 0.5 mL (5 micrograms) single dose Hepatitis B vaccine (H-B -Vax-11 paediatric).
- Intramuscular injection into the anterolateral aspect of the upper thigh.
May be administered at the same time as the Phytomenadione injection 1mg (Konakion
paediatric) is given, but in the opposite leg.13
For more Victorian Government information:
immunise.health.gov.au/
http://www.health.vic.gov.au/immunisation/factsheets/infant-hepatitis-b.htm
Note: Hepatitis B immunoglobulin is also required for babies of Hepatitis B positive mothers to
minimise risk of neonatal infection.
Vitamin K - phytomenadione (Konakion)

It is recommended all newborn babies are given vitamin K.
All parents should be offered Phytomenadione (Konakion) prophylaxis for their babies to prevent
the rare but serious and sometimes fatal disorder of vitamin K deficiency bleeding.1
Phytomenadione injection should be administered soon after birth, on admission to postnatal (not in
the birth suite unless the woman is remaining within the same room until discharge).
- 1 mg (0.1mL) Phytomenadione injection from 2 mg/0.2mL MM paediatric intramuscular
injection into the anterior-lateral aspect of the upper thigh.17
If parents decline intramuscular Phytomenadione, oral must be offered as a second line option with
a clear explanation that multiple doses are required.
- 2 mg (0.2mL) orally within hours of birth
- 2 mg (0.2mL) further dose at 3 days of age
- 2 mg (0.2mL) further dose again at 4 weeks.
* Parents consenting to oral regimen must be provided with oral Vitamin K information and an explanation
of the importance of ensuring the third dose at 4 weeks which they will be required to arrange through their
own GP.1,
- An oral dispenser is provided with each pack.
- Providing a script for 2 mg (0.2mL) at 4 week dose will enable the parents to purchase a
single dose rather than packet of 5.

Jaundice
Parents must be advised to contact a midwife or doctor if their baby is jaundiced, their jaundice is
worsening, or their baby is passing pale stools.1 Refer relevant pages in Looking after yourself and
your baby.
Jaundice observed < 24 hours of age is always pathological.
If jaundice develops in babies aged 24 hours or older, its intensity should be monitored and
systematically recorded along with the babys overall well-being with particular regard to hydration
and alertness. See specific Jaundice in healthy term and near term Infants procedure
The mother of a breastfed baby who has signs of jaundice should be actively encouraged to
breastfeed frequently, and the baby awakened to feed if necessary.1
If the baby is not feeding well, expressing breast milk and top up feeding with expressed milk should
be considered.
The practice of exposing the naked baby to direct or indirect sunlight is not recommended as it puts
the baby at risk of sunburn and skin damage. Encourage and recommend parents position their
baby in a light area (filtered through a window or light curtains).
All babies require a systematic assessment of risk for developing hyperbilirubinaemia before
discharge to inform EPC/ Monash Children @ Home with follow-up arrangements.
Action
Babies who develop jaundice in the first 24 hours after birth should be evaluated further with
referral for neonatal /paediatric review.(Emergency action)
For detail of jaundice assessment with Serum bilirubin (SBR) or transcutaneous bilibrubin (TcB)
refer Jaundice in healthy term and near term Infants
If a baby is significantly jaundiced or appears unwell, evaluation of the serum bilirubin level (SBR)
should be carried out with referral for neonatal /paediatric review. (Urgent action)

Vitamin D
If the mothers last antenatal results (booking, 28 weeks or other) have been 75nmol/L there is
no need to assess the babys vitamin D status, or to recommend supplementation.
All breastfed babies born to a mother known to be vitamin D deficient (<75 nmol/L on last results
during pregnancy) should be offered a cholecalciferol bolus (50,000 IU) dose orally for their
babies to prevent serious sequelae of vitamin D deficiency. A single dose of cholecalciferol
(Vitamin D) mixture should provide sufficient vitamin D stores for four months.
Babies who are formula feeding do not require additional supplementation.
If maternal vitamin D status is unknown and the baby is breastfed then the administration of
vitamin D should be guided by risk factors (skin colour, skin coverage etc).
Action
The neonatal dose of cholecalciferol mixture is 50,000 units (0.5mL of 100,000 IU/mL).
A single oral dose administered in a 1 mL oral dispenser as indicated following maternal
consent.
The single dose must be documented on the Newborns Medication Chart in the once only doses
section. Refer Vitamin D in pregnancy and the term newborn.
Skin and cord

All new parents should be offered the opportunity to bathe their newborn under close supervision.
Parents should be advised that cleansing agents added to babys bath water, lotions or medicated
wipes are not required. The only cleansing agent suggested, where it is needed, is a mild non-
perfumed soap.1
Parents should be informed recommended umbilical care includes:
- dry the cord stump after bathing
- keep the cord dry by exposing to air where possible above nappy
- wash hands after handling the cord stump
- cord will generally drop off after 5-7 days
- clamp removal is not routinely required.1
Action
In the presence of inflammation or redness of base of umbilicus baby to be referred for medical
review.
Babies with signs of umbilical flare or excessive offensive exudate require medical evaluation.
(Urgent action)
- If an inpatient refer for neonatal /paediatric review.
- If at home refer to Emergency Department.

Eye care
The most common cause of a discharging non-red eye in the first week is due to nasolacrimal duct
obstruction.
Advise parents how to keep eyes clean.
- With newborn bathing, wipe softly across eye lids from inner canthus to outer canthus, with
clean damp cotton wool ball or soft cloth. Do not wipe eyes when wide open as this may cause
trauma.
- If seeking to irrigate the eye, drop clean water or saline in inner corner of open eye. Then place
babys back along forearm gently moving baby from side to side to wash fluid across the open
eye.
Action
Babies with very purulent (infective conjunctivitis)or persistent discharge require further
evaluation.
- If at home refer to a general practitioner.
Constipation
Usually does not occur in fully breast fed babies.
If a baby is constipated and is formula fed the following should be evaluated:
- feed preparation and technique
- quantity of fluid taken
- frequency of feeding
- composition of feed.1
Action
If a baby has not passed meconium within 24 hours, the baby should be assessed for anal patency,
and referral made for neonatal /paediatric review to determine the cause, which may be related to
feeding patterns or underlying pathology.(emergency action)
Diarrhoea
A baby who is experiencing increased frequency and/or looser stools than usual (above the normal
breast fed loose motion) should be evaluated (Urgent action)
- If at home refer to Emergency Dept or general practitioner (GP).

Candida / candidiasis (Thrush)

If candidiasis (thrush) is identified in the baby, the mother should be offered information and
guidance about relevant hygiene practices.1
All babies have Candida albicans as part of normal gastrointestinal flora.
Thrush should be treated with an appropriate anti-fungal medication if causing pain to the woman or
the baby.1,
The breast feeding mother should be treated at the same time as her baby to prevent adverse
effects or re-infection.
Symptoms and signs
The baby may (or may not) have signs of thrush such as white oral plaques in the mouth (tongue
and inside cheeks) or red papular rash with satellite lesions around the anus and genitals.
If no signs in the baby, it may be assumed the baby has an over growth of Candida if the mother has
been diagnosed with nipple thrush.
Action
Baby - medication choices include:
1. Miconazole oral gel (Daktarin).26,27,28
- The miconazole oral gel should be applied in small amounts (1/4 teaspoon size) with a
clean finger, until all mucosa surfaces have been coated (not just the tongue).
- Apply oral gel four times a day after feeding for a week, then daily.
- Advise parents to only apply the viscous product as directed to avoid choking in young
babies.28
2. Nystatin oral suspension (Mycostatin Topical).1,
- 1mL applied to the babys mouth four times a day after feeding for one two weeks then
once a day until symptoms resolve.
Mother
- The first line treatment of nipple thrush in the lactating mother is direct application of Miconazole oral
gel (Daktarin) to nipples after feeds (at least 4 times a day). 27,28,29
- Where symptoms persist oral fluconazole is a safe and effective treatment for recurrent or
persistent cases 26,27,28 150 mg capsule every 2nd day (x 3 doses) followed by Nystatin tablets 2, 3
times a day.

Newborn temperature
The temperature (heart rate and respiratory rate) of a baby does not need to be taken after the initial
post birth observations, unless there are specific risk factors: for example refer specific procedures
- Meconium liquor birth-fetal neonatal care quick reference
- Care of the well late preterm and/or 2.0-2.5kg baby on the postnatal ward
- risk factors for Group B streptococcal (GBS).
Refer parents to the signs of serious illness in the newborn in Looking after yourself and your
baby.
Newborn fever
Action
A temperature between 37.3 38 degrees Celsius should be evaluated further and causes such as
overheating excluded. Temperature should be repeated in 1 hour. (Urgent action)
A temperature of 38 degrees Celsius or more is abnormal and the cause should be
evaluated.(emergency action)
Cold baby hypothermia

Action
A temperature below 36.5 degrees Celsius should be evaluated further and simple causes such as
insufficient clothing or position in a draughty area excluded.
See Maintaining Thermoregulation chapter of the Monash Newborn Clinical Guideline
Care of the well late preterm and/or 2.0-2.5kg baby on the postnatal ward.
Advise mother of simple warming measures (extra clothing or blanket, skin to skin with mother).
Persistent axilla temperature <36.0C despite adequate clothing and feeding, must be evaluated
further (Urgent action)
An unstable temperature in a term baby may be a clinical sign of sepsis.

Safe environment for baby

Parents must be given advice on creating and maintaining a safe environment.
Advise parents not to walk around in the hospital with baby in arms (risk of being knocked,
slippery floor, busy).
Never leave a baby alone on a change table /or adult bed.
Parents must be given information about Sudden Infant Death Syndrome (SIDS).1
Promote safe sleeping and explain risks with bed sharing as per specific Infant safe sleeping
Guideline.
Parents must be given information on settling babies.
Parents must be given information to never shake a baby.
Assess the home sleeping arrangements on extended postnatal care (EPC) visits.
Promote the correct use of basic safety equipment, including, infant car seats and smoke
alarms.
Nappy rash
For babies with nappy rash the following possible causes should be considered:
- Hygiene and skin care.
- Sensitivity to detergents, fabric softeners or external products that have contact with the skin
(i.e. alcohol nappy wipes).
- Presence of infection.1
The practice of exposing the inflamed naked area to direct or indirect sunlight is not recommended
as it puts the baby at risk of sunburn and skin damage.41
Action
If painful nappy rash persists it is usually caused by thrush, and treatment with antifungal treatment
should be considered.
If after a course of treatment the rash does not resolve, it should be evaluated further by the GP.
(Non-urgent action)

6. Newborn feeding
Exclusive breastfeeding is the preferred method of infant feeding for the first 6 months.
All women whether intending to breast feed or not, should be encouraged to have skin to skin
contact with their babies as soon as possible after birth, and to avoid separation of the woman and
baby within the first hour of birth.1, 12,29
Women who wish to breast feed are to be supported to initiate breastfeeding ideally in the initial
hour, or as soon as possible after birth.
While women with Hepatitis C (HCV) are generally able to breast feed, breastfeeding is
contraindicated in HCV positive women with cracked or bleeding nipples or symptomatic liver
disease.
Breastfeeding is not recommended with current maternal intravenous drug use.
Breastfeeding is contraindicated in women who are HIV positive, have active tuberculosis, acquired
syphilis or where there are rare metabolic disorders of infants such as galactosemia.
In the first 24 hours women should be given information on the benefits of breastfeeding, the
benefits of colostrum and demand feeding. Support should be culturally appropriate.1
From the first feed, women must be offered skilled support with breastfeeding to enable comfortable
positioning of the mother and baby and to ensure that the baby attaches correctly to the breast to
establish effective feeding and prevent concerns such as sore nipples.1
Additional support with positioning and attachment must be offered to women who have:
- had a narcotic or general anaesthetic, as the baby may not initially be responsive to
feeding1
- had a caesarean section,1 particularly to assist with handling and positioning the baby to
protect the womans abdominal wound (where possible skin to skin contact and breast
feeding should occur in recovery room).
- had initial contact with their baby delayed1
- inverted or flat nipples1
- previous breast feeding difficulties1
- obesity.30
Unrestricted breastfeeding frequency and duration must be encouraged.1 Advise women that babies
generally stop feeding when they are satisfied, which may follow a feed from only one breast.
Babies should always be offered the second breast after winding.1
Advise women that if their baby is not attaching effectively he or she may be encouraged by the
woman teasing the babys lips with the nipple to get him or her to open their mouth, 1 and expressing
colostrum onto the nipple.
Women must be advised of the indicators of good attachment, positioning and successful feeding.1
Refer Breast feeding practice standards, information and education procedure
Women must be given information about breastfeeding support groups.1,28,29
The ABA booklet Breast feeding a new mothers guide is provided to all new mothers in the

postnatal Bounty Bag.
Expression and storage of breast milk

General Advice and Information
Breast pumps should be available in hospital for all women.1
Refer Breast Milk Safe management and storage procedure
Action
All breastfeeding women should be shown how to hand express their colostrum or breast milk and
advised on how to correctly store and freeze it.1
Refer Breast Milk Safe management and storage procedure
Note: Mothers whose babies are unwell and requiring nursery care may require more information
and support with expressing by hand and electric pump.
Formula feeding
Women who are intending to formula feed must be advised during pregnancy of the need to bring
the formula of their choice with them when they come to hospital.
All parents and carers who are giving their babies formula feed must be offered appropriate and
tailored advice on formula feeding to ensure this is undertaken as safely as possible.1 Provide a
copy of the AGRIN pamphlet The right way to prepare powdered infant formula in Australia.
A woman who wishes to feed her baby formula milk must be taught how to make feeds using
correct, measured quantities of formula, as based on manufacturers instructions, and how to clean
and sterilise bottles and teats and how to store formula milk.1
Parents and family members must be advised that milk, either expressed milk or formula should not
be warmed in a microwave.1
Breastfeeding women who want information on how to prepare formula feeds must be advised on
how to do this.1
Links to related procedures:

Breast feeding practice standards, information and education procedure
Breast Milk Safe management and storage procedure
Continuous Epidural Analgesia Infusions
Diagnostic Imaging - Deep Vein Thrombosis
Diagnostic Imaging - Suspected PE in pregnancy or post-partum period
Falls Prevention (Maternity) Standard Care
Hypertensive disorders in pregnancy pre-eclampsia/eclampsia clinical guideline
Infant safe sleeping Clinical Guideline.
Observations (neonatal ) babies in maternity
Perineal trauma management
Primary postpartum haemorrhage procedure
Rhesus (D) negative women (maternity) procedure
Thromboprophylaxis risk assessment tool.

Urinary retention postnatal

Vitamin D in pregnancy and the term newborn.
Care of the well late preterm and/or 2.0-2.5kg baby on the postnatal ward
References
1. National Institute for Health and Clinical Excellence (NICE) (2014) Routine postnatal care of women and
their babies, Clinical Guideline 37, The National Collaborating Centre for Primary Care, London.
www.nice.org.uk/CG037
2. Victorian Department of Human Services, (2004) A communication protocol for Victorian public
maternity services and the Maternal Child Health Service, Melbourne Victoria
http://www.education.vic.gov.au/Documents/about/research/protocolcontinuitycare.pdf
3. Yelland J., Krastev A and Brown S (2003) Evaluating Practice and the Organisation of Care at Monash
Health and Sandringham Hospital (epocs) ,Centre for the Study of Mothers and Childrens Health,
Carlton
4. Victorian Government (2011) Child Health Record, The Department of Education and Early Childhood
Development,
5. Taylor DJ, Phillips P, Lind T. Puerperal haematological Indices, British Journal of Obstetrics and
Gynaecology ,June 1981. Vol. 88. pp 601-606
6. Marik and Plante (2008) Venous Thromboembolic Disease and Pregnancy The New England Journal
of Medicine vol. 359 pp. 2025-2033
7. Obstetricians and Gynaecologists Thromboembolic Disease in Pregnancy and the Puerperium. Green-
top Guideline (2007) vol. 28 pp 1-17
8. Eichinger. D-dimer testing in pregnancy. Pathophysiology Haemostasis Thrombosis (2004) vol. 33 (5-6)
pp. 327-329
9. Beyond Blue (2011) Clinical Practice Guidelines for Depression and related disorders - anxiety, bi-polar
disorder and puerperal psychosis - in the perinatal period'
www.beyondblue.org.au/index.aspx?link_id=6.1246 ; www.beyondblue.org.au
10. Therapeutic Guidelines Antibiotics. Revised June 2006.Therapeutic Guidelines (etg30, March 2010)
Ltd http://online.tg.org.au/ip/
11. The Breast feeding Network, (2009) Thrush and breast feeding, Scotland
www.breastfeedingnetwork.org.uk
12. Australian National Breast feeding 2010-2015 , Australian Government Department of Health and
Aging, Canberra
th
13. Australian Immunisation Handbook, 10 Edition electronic version updated January 2014
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/EE1905BC65D40BCFCA2
57B26007FC8CA/$File/handbook-Jan2014v2.pdf
14. Australian Medicines Handbook, 2008

15. Fybogel PRESCRIBING INFORMATION,MIMS On line accessed on line 03/12/08.

16. Scheriproct Ointment PRESCRIBING INFORMATION Mims Online updated at 18/10/2006 accessed
on line 11/03/09
17. Government of South Australia, Perinatal Practice Guidelines, Section 6 , Chapter 108 - Postpartum
bladder dysfunction .Last reviewed: 20 October 2009, accessed on line 2nd June
2010 http://www.health.sa.gov.au/ppg
18. Yip S, Sahota D, Pang MW, Et al. Screening test model using duration of labor for detection of
postpartum urinary retention. Neurourol Urodyn. 2005;24:248-53.

19. Bick, D, MacArthur, C, Knowles, H., and Winter, H. (2009). Postnatal Care: Evidence and Guidelines for
Management. 2nd edition, Edinburgh: HarcortPublishers Ltd.
20. National Institute for Health and Clinical Excellence (NICE) (2004) Caesarean Section
www.nice.org.uk/nicemedia/pdf/CG013fullguideline.pdf
21. Monash Health (Continuous intrathecal analgesia infusions Acute Pain Management.
22. Monash Health Continuous Epidural Analgesia Infusions Acute Pain Management.
23. Australian Wound Management Association Incorporated 1st Edition, May 2002
24. The Three Centres Consensus Guidelines on Antenatal Care,(2001),Victoria
25. Rennie,J.(2005) Roberton's Textbook of Neonatology, Fourth edition
26. Chetwynd EM. Ives TJ. Payne PM. et al, (2002), Fluconazole for postpartum candidal mastitis and
infant thrush, Journal of Human Lactation, vol18, no 2, May, pp 168-171
27. Brent, N, (2001) Thrush in the breastfeeding dyad: Results of a survey on diagnosis and treatment
Clinical Pediatrics; September 2001; 40: 503-506
28. The Breast feeding Network, (2009) Thrush and breast feeding, Scotland
www.breastfeedingnetwork.org.uk
29. World Health Organisation (WHO) 10 Steps to Successful Breastfeeding
30. Maternity & Newborn Clinical Network (2011) Care of the obese pregnant women and weight
management in pregnancy, Department of Health, Victoria
http://www.health.vic.gov.au/clinicalnetworks/maternity.htm
31. Australian Breastfeeding Association (ABA), (2011), Normal nappies what to expect.
www.breastfeeding.asn.au
Document Management
Policy supported: Evidence-based clinical care.
Executive Sponsor: Chief Operating Officer
Person Responsible: Midwifery Coordinator [Facilitator Maternity Guideline Development Group].
Authorisation Date: 27/03/15 Maternity Executive Committee
Review Date: 27/03/2018
Version Number: 3
If this is a hard copy it might not be the latest version of this document. Please see the Monash Health site for
current documents.
Disclaimer
The maternity clinical practice procedures and guidelines have been developed having regard to general circumstances. It is the responsibility of
every clinician to take account of both the particular circumstances of each case and the application of these procedures and guidelines. In
particular, clinical management must always be responsive to the needs of the individual woman and particular circumstances of each pregnancy.
These procedures and guidelines have been developed in light of information available to the authors at the time of preparation. It is the
responsibility of each clinician to have regard to relevant information, research or material which may have been published or become available
subsequently. Please check this site regularly for the most current version.


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Postnatal care in the first week Clinical Guideline

Target population for the guideline

Target users of the guideline

Prompt Doc No: SNH0001507 v9.0

Rhesus negative women

Quick reference assessment and care planning TOOLs

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1. Planning postnatal care

The initial care planning must include:1

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2. Education and communication

Documenting education and information

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Emergency Life-threatening or potential life-threatening situation that needs immediate action.

Urgent Potentially serious situation, that needs action as soon as is appropriate.

Non-urgent Continue to monitor and assess, inform appropriate staff as required.

3a Life threatening conditions in women

Signs and symptoms Conditions

Headaches accompanied by one or more of the Pre-eclampsia & eclampsia.

Calf pain, redness or swelling usually unilateral. Thromboembolism.

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Postpartum haemorrhage (PPH)

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Genital tract sepsis or other sepsis

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3b Maternal mental health

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Inner South East

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3c Maternal physical health

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Breast and nipple problems

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Diastasis of the rectus abdominus muscles (DRAM)

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Symptoms and signs of postpartum urinary retention:

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Management following re-catheterisation:

Good practice points:

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use a new Foley catheter each time

Refer : Urinary retention postnatal procedure

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Rhesus negative women

Women who are non immune for Rubella

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Safety family /domestic violence

Educational guidance for health care professionals

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Discharge from hospital

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4. Caesarean section (CS) postnatal care

CS post operative analgesia

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