Reflections: Postnatal care

So first things first, I am not Angela! I am Angela’s practice partner, Tami, and I joined North Surrey Midwives last year as an independent midwife. It’s been a year now since I spent a week living and working with Angela and getting to know what being an independent midwife (IM) was all about, and this seems like a good time to reflect on everything I have learnt during that time. I’ve tried to write this blog a few times now though and it seems I’ve already learnt enough to fill a book (a project for the future perhaps!?) so I am going to focus my first post on postnatal care. This may seem like a strange choice; I mean, I attended few home births during my midwifery training and have attended many more during this first year of independent practice, surely I should want to write about that! Well, I do. But interestingly, I have found that the biggest learning curve for me has been caring for my independent clients in the first 28 days after their baby is born.

Working within the NHS setting on a community team, we saw most women three times postnatally: the first visit the day after they returned home from hospital (so usually day 1 or 2 for most women), the second visit on day 5 when we would do the bloodspot screening test, and finally a visit on day 10 to discharge the woman and her baby to the care of the health visitor. I never thought much of the fact that we didn’t routinely see women on day 3 or 4, despite knowing that these days are often the most difficult for new mothers.

A woman’s milk usually ‘comes in’ around day 3, sometimes causing engorgement and her temperature to go up a bit, and it is around this time that the ‘baby blues’ can take hold. The first few days with a new baby are a bit of a whirl wind, and day 3 can be (this isn’t always the case of course) the day that exhaustion really hits you – loving care, support and reassurance are vital during these days. It wasn’t until I became an IM that I really saw all of this though – and learnt how vital postnatal care really is. I saw changes in my usually strong, outgoing clients – they were suddenly uncertain about following their instincts as they had done antenatally and during their labours.

At first I felt like I should have some intelligent solutions for them, something they could do or take to relieve the exhaustion and anxiety they might be feeling. But I soon came to realise that the most important thing is being able to talk about these feelings and be reassured that they are entirely normal at this stage after having a baby. Whether this is the first baby or the fourth, having someone come over for a cup of tea (but don’t worry we make our own!!) and a good chat about everything you are feeling during those first few days really can and does make a difference. When I initially met and worked with Angela, I remember being a bit shocked at her telling a client whose new baby was cluster-feeding every evening (ie. feeding more frequently than usual) to put a box-set on, put her feet up and have a glass of wine and settle in for the evening with her baby skin-to-skin. What was she doing – promoting wine while breastfeeding!?! Well, I visited the same woman with Angela a few days later and the change in her was immediately apparent: reassured that this behaviour was normal for her baby and then having a plan to cope with it (plus a little stress relief via the wine) made all the difference for her. And I have given that advice a few times myself now with similar effects!

One of the biggest learning curves when making the move from an NHS setting to independent midwifery has been not relying on hospital protocols to guide practice, but instead using the best evidence, collective wisdom of the very experienced midwives I work with, parent’s intuition and the full clinical picture to make decisions about care provided. For me, I have felt this difference most in the postnatal period, and particularly around expected weight gain of the newborn. Most hospital policies state that a baby who has lost more than 10% of her birth weight at day 5 should be transferred back into hospital for further checks. But is this really the best course of action for a baby that appears clinically well in every other sense (plenty of wet and dirty nappies, pink, active, alert, waking for feeds and perfectly latched when breastfeeding) and a mum with an absolute fear of hospitals? Transferring mum and baby into hospital in this case could potentially make the problem worse: mum will be anxious which will affect her milk supply, and baby may undergo invasive tests which could disrupt breastfeeding. In this case, lots of skin to skin contact and intensive support with breastfeeding and expressing, while keeping a close eye on the baby in the following days meant that mum and baby could stay at home and the baby quickly began to put weight on. For this baby, it was ‘normal’ to lose a bit more weight than usual in the first few days of life. For another baby it might not be – and this is the challenge of independent practice compared to working from guidelines.

Although I didn’t expect postnatal care to be an area in which I still had so much to learn, I have really enjoyed gaining all of this amazing knowledge from both the mums and babies I have cared for, and the midwives I have worked with over the past year. Midwifery is a career in which you are continually learning, and so I am sure this is just the beginning!

Tami x