Postpartum Care

1. Postpartum Care Managing Complications in Pregnancy and Childbirth In many countries, the majority of maternal deaths occur postpartum. The most important intervention is to have a skilled provider at childbirth, including during the immediate postpartum period.In many countries, the majority of maternal deaths occur postpartum. The most important intervention is to have a skilled provider at childbirth, including during the immediate postpartum period.

2. 2 Postpartum Care Session Objectives To define essential elements of postpartum care To discuss best practices and technologies for postpartum care

3. 3 Postpartum Care Objectives of Postpartum Care Prevent or detect and manage complications arising during postpartum period, whether medical, surgical or obstetric Support mother and her family in transition to a new family constellation Promote and maintain physical, mental and social well-being of both mother and newborn by providing education on danger signals, nutrition, rest, sleep and personal hygiene, and by providing micronutrients, if necessary

4. 4 Postpartum Care Counsel on newborn care Support breastfeeding Counsel and provide services for contraception and resumption of sexual activity Immunize mother against tetanus Work with mother, her family and her community to prepare a plan in case of complication Objectives of Postpartum Care (continued)

5. 5 Postpartum Care What is Good Postpartum Care? Visits at 6 hours, 6 days and 6 weeks postpartum Care provided by skilled provider who attended childbirth (midwife, general practitioner or obstetrician/gynecologist) Integration of postpartum and newborn care Visit at 6 hours really means skilled provider at childbirth. If no skilled provider is available, then postpartum care should be done by a skilled person. The mother and newborn are the most important people. Need intense observation for first 6 hours following childbirth.Visit at 6 hours really means skilled provider at childbirth. If no skilled provider is available, then postpartum care should be done by a skilled person. The mother and newborn are the most important people. Need intense observation for first 6 hours following childbirth.

6. 6 Postpartum Care Components of Postpartum Care Visit Early detection and management of complications Complication readiness Promoting health and preventing disease Woman-centered education and counseling

7. 7 Postpartum Care Early Detection and Management of Complications Malnutrition: General health, night blindness, goiter Depression/psychosis: Mood Infection: Temperature Pre-eclampsia: Blood pressure, proteinuria Anemia: Hemoglobin, conjunctiva/tongue/palms Breast problems: Breast examination, assessment of breastfeeding, newborn’s weight Depression may be missed because it is not made a priority. Emotional and psychological support is the FOUNDATION of the Safe Motherhood “building”.Depression may be missed because it is not made a priority. Emotional and psychological support is the FOUNDATION of the Safe Motherhood “building”.

8. 8 Postpartum Care Early Detection and Management of Complications (continued) Subinvolution: Fundal height Incontinence/fistula: Bowel and bladder function Thrombophlebitis: Homan’s sign, inspection of legs Genital infection: Perineum, lochia/bleeding/discharge, rapid plasma reagin (RPR)

9. 9 Postpartum Care Complication Readiness Establish savings plan/scheme Make plan for decision-making Arrange system of transport Establish plan for blood donation PLAN AHEAD.PLAN AHEAD.

10. 10 Postpartum Care Promoting Health and Preventing Disease Iron/Folate: 1 tablet to be taken by mouth once a day for at least 40 days postpartum Six monthly presumptive treatments with broad-spectrum anti-helminthics in areas of significant prevalence Sleeping under a bednet Vitamin A: One dose of 200,000 IU within 30 days after childbirth in vitamin A deficient regions

11. 11 Postpartum Care Promoting Health and Preventing Disease (continued) Iodine supplementation: 400–600 mg by mouth or IM as soon as possible after childbirth if never given, or if given before the third trimester (only in areas where deficiencies exist) Tetanus toxoid RPR, HIV (voluntary testing) Whether the testing is accepted is based on counseling effectiveness, including the client’s perception of the counselor and the time spent counseling.Whether the testing is accepted is based on counseling effectiveness, including the client’s perception of the counselor and the time spent counseling.

12. 12 Postpartum Care Woman-Centered Education and Counseling: Danger Signals for Woman Heavy or sudden increase in vaginal bleeding Fever Vaginal discharge with unpleasant odor Painful or hot breast(s) Abdominal pain Excessive tiredness Edema in hands and face Severe headache Woman’s danger signals: vaginal bleeding, symptoms of infection and symptoms of pre-eclampsia.Woman’s danger signals: vaginal bleeding, symptoms of infection and symptoms of pre-eclampsia.

13. 13 Postpartum Care Woman-Centered Education and Counseling: Danger Signals for Newborn Cord red or draining pus Suckling poorly Eyes swollen, sticky or draining pus Cold to touch in spite of rewarming Hot to touch in spite of undressing Difficulty breathing Lethargy Convulsions Newborn danger signals: Failure to thrive, lethargy, poor feeding and symptoms of infectionNewborn danger signals: Failure to thrive, lethargy, poor feeding and symptoms of infection

14. 14 Postpartum Care Woman-Centered Education and Counseling: Nutrition Intake should be increased by 10% (not physically active) to 20% (moderately or very active) to cover energy cost of lactation Eating more of staple food (cereal or tuber) Greater consumption of non-saturated fats Avoid all dietary restrictions Encourage foods rich in iron (e.g., liver, dark green leafy vegetables, etc.) Do not reduce diet: Replenish stores for healing Extra energy for breastfeedingDo not reduce diet: Replenish stores for healing Extra energy for breastfeeding

15. 15 Postpartum Care Fatigue and disturbed sleep patterns Genital lacerations/episiotomy Hypo-estrogenization of the vagina Libido Power issues in marriage Resumption of sexual activity Woman-Centered Education and Counseling: Factors that Affect Women’s Sexual Desire After Childbirth No limitNo limit

16. 16 Postpartum Care Inform about all contraceptive choices in postpartum period (ideally done antenatal as well) Facilitate free informed choice for all women Reinforce that non-hormonal methods (lactational amenorrhea, barrier methods, IUD and sterilization) are best options for lactating mothers Initiate progestogen-only methods after 6 weeks postpartum to breastfeeding women, if woman chooses a hormonal method Advise against use of combined oral contraceptives in breastfeeding women in the first 6 months after childbirth or until weaning, whichever comes first Woman-Centered Education and Counseling: Family Planning

17. 17 Postpartum Care Importance, benefits and management of breastfeeding Positioning and attaching newborn to breast Need to avoid supplementary feeds Encourage breastfeeding on demand Woman-Centered Education and Counseling: Breastfeeding

18. 18 Postpartum Care Forms of Postpartum Care Likely to Be Ineffective or Even Harmful Breastfeeding Limiting suckling time to 10 min. on each breast or any other arbitrary period Restricting frequency of breastfeeds to once in 3 hours or to any other arbitrary period Giving artificial teats and pacifiers to breastfed infants Providing bottle supplements with water, glucose or formula while breastfeeding is becoming established Prescribing hormonal contraceptives during first 6 weeks postpartum Undermining efforts at successful breastfeedingUndermining efforts at successful breastfeeding

19. 19 Postpartum Care Forms of Postpartum Care Likely to Be Ineffective or Even Harmful (continued) Hormonal treatment of postpartum depression Separate counseling of woman on breastfeeding and on contraception Lactation inhibition by estrogens or bromocriptine Lactation inhibition is not effective in drying up milk faster than nature.Lactation inhibition is not effective in drying up milk faster than nature.

20. 20 Postpartum Care Summary Good postpartum care includes: Care by skilled provider Focus on mother and newborn Multiple visits Detection and management of complications in a timely fashion Interventions and education to promote continued good health of the mother and newborn Focus on mother and newborn.Focus on mother and newborn.