Monday, December 29, 2008

6 weeks after the birth

I was talking with a midwife colleague who has recently set up her own independent midwifery practice, and she asked me about the 6 week postnatal check. Is it important? What are we trying to achieve?

Since I began private practice I have invited women in my care to come back to my home office at about 6 weeks. I don't mind if one comes at 5 weeks, and another at 8 weeks - I see it as a milestone, in that the mother and her baby return to visit me, after I have completed the postnatal 'care'. It's a good time for 'show and tell', and marks the end, for most new mothers, of their post-birth healing period.

So what do I expect to talk about, and to achieve in that follow-up consultation?

A midwife and woman who have established a bond of trust and respect within the professional partnership appreciate the opportunity to meet again. The 6-week visit is a time to close the professional relationship, which can be renewed in the future if the mother asks me to be her midwife again.

I can't overstate the value of focused, face to face, un-rushed time spent together without distraction. A great deal is communicated in eye contact, body language, and subtle, non verbal means.

I try to give the mother an opportunity to tell me any concerns that she might have. If there are any questions about what happened in the labour or birth, or postnatally. It's an opportunity to go through my notes with her in detail, and to give her a copy, if I haven't already done so.

I have a little list to work through, and discuss further when indicated:
Mother's general condition: does she look well? are you sleeping enough? how much?
Mother's recovery from birth: is your fundus palpable? has the lochia ceased? when? is your perineum fully healed, if there was a tear? would you like me to look at your perineum? are you experiencing any incontinence?
Mother's family planing: have you resumed sexual intercourse? have you any concerns about contraception? do you understand LAM (Lactation amenorrhoea method)?
Baby: general appearance - colour, activity, hearing, tummy time, fontanelles, smiling, responding, include weight and full physical check if the mother wishes
Baby's feeding: this is an opportunity to discuss any concerns the mother has. Most babies will want a feed during the consultation, and I look for opportunities to guide and encourage
Support network: have you linked in with peer support groups, such as BaBs (Birthing and Babies Support) and ABA (Australian Breastfeeding Association), mother groups through the Maternal and Child Health centre, or local community groups and churches?

There are no specific questions in my list that are intended to explore mental health issues. However, if there are cues for exhaustion or postnatal depression, this is an opportunity to go further if the mother is willing.

If we identify any matter in which healing or recovery is incomplete at 6 weeks, we can make a plan for further review, considering appropriate medical consultation.

An independent midwife is working primarily with well women: women who are healthy through their pregnancies, who carry their babies to Term, come into spontaneous labour, choose to work in harmony with their bodies in labour, progress without needing drugs for pain relief, and give birth to their babies under their own power. This evidence of 'wellness' is in fact an awesome achievement, for which our bodies are wonderfully made.

Yet we cannot assume that every woman and every baby will be well, even those who return for the 6-week postnatal check. A midwife's skill, in working with wellness, is also to identify anything that is abnormal, and guide her client in making a plan to address that issue. The same active decision making process that we use in pregnancy and birthing applies postnatally.

Midwives with caseloads are especially privileged in the way we can work, one to one, with women. But with that privilege comes an increase in our responsibility to the individual woman. The 6-week postnatal consultation is an opportunity for me, the midwife, to review the episode of care, reflect on the way in which I have learnt from this experience, and effect closure without leaving any loose ends.

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