Care of the mother and new born after birth
Some women will give birth in the home with a skilled attendant; others may not have a skilled attendant present. Some women who give birth in the facility will spend time there following childbirth.
World Health Organisation (WHO) recommends that a woman not be discharged before 24 hours after giving the birth. Regardless of the place of birth, it is important that someone accompanies the woman and newborn for the first 24 hours after birth to respond to any changes in her or her baby's condition. Many complications can occur in the first 24 hours.
Following childbirth at home, it is important that the mother and baby receive a postnatal examination as early as possible, preferably within 24 hours of birth. If the birth was at a facility, mother and baby should receive a postnatal examination before discharge.
There are a number of important points to discuss with the woman and her family following birth to ensure that the woman has adequate care.
Important issues to discuss with women and their families immediately following birth:
1. The importance of having someone nearby for the first 24 hours.
2. The importance and recommended timing of postnatal visits.
3. The importance of the new mother eating more and healthier foods – discuss in the context of local practices and taboos to ensure women have access to good nutrition.
4. The new mother should also drink plenty of clean, safe water.
5. The importance of rest and sleep and the need to avoid hard physical labour.
6. Discussion of normal postpartum bleeding and Lochia – discuss with women how much blood loss they can expected, and for how long. When bleeding is more than normal, they should seek care urgently.
7. Discuss the danger signs for the woman and baby and the importance of seeking help quickly.
8. Personal hygiene in the context of local practices and the environment. Discuss with women the type of pads they will use and their disposal, and care of episiotomy in the context of home conditions.
9. Hand washing is particularly important to prevent infections. It is also important not to insert anything into the vagina.
10. Talk to them about when they can resume sexual relations and the importance of condom use to prevent STD and HIV transmission. Sexual intercourse should be avoided until the perineal wound heals.
11. Discuss the importance of birth spacing and counsel on the use of a family planning method.
12. Discuss infant feeding and breast care and the importance of only taking prescribed medicines when breastfeeding.
13. Discuss the importance of the home environment for promoting the health of the baby and recovery of the mother. For example, discuss the need for warmth, good ventilation and hygiene for both mother and baby.
14. In an area with Malaria, discuss the importance of mother and baby sleeping under an insecticide-treated bed-net.
Timing of postnatal visits:
1. Following childbirth the woman and newborn should be examined within 24 hours by a health worker.
2. At this time also discuss with the woman and family the timing of subsequent visits and the immunization schedule for the baby.
3. WHO recommends that the mother and baby be visited at home by a trained health worker, preferably within the first week after birth.
4. If your facility does not carry out home visits, discuss with the mother how she will come to the facility or local clinic for these scheduled visits.
5. Early in the postnatal period, these visits are important for the mother and baby.
6. It is also an important opportunity to ensure the establishment of breastfeeding and address any difficulties with attachment and positioning.
How to provide information and support for the care of the Mother after birth:
The Pregnancy, Childbirth, Postpartum and Newborn Care(PCPNC)provides a list of practical tasks that need to be carried out following birth, if you do not have the PCPNC you should follow the norms and standards established in your facility.
Explain the reasons behind the tasks you are carrying out and discuss with the woman any advice or recommendations you have for her to ensure appropriate care in the home during the postnatal period.
1.Encourage her to ask questions during the examination and use your active listening skills to reflect on and clarify what she is telling you.
2. Help her to think of ways she can implement your advice. Sometimes, when women are unsure or hesitant they voice concerns in an indirect manner rather than directly raising an issue. Be aware of her body language and the non-verbal signs she may be showing you. Repeat back to her in different words what you think she is saying to see if you have understood.
3. At the end of the postnatal examination, remind her that she can come to the health facility at any time if she has questions, reassure her and make sure she feels supported.
Schedule of postnatal visits for mother and newborn:
1. First visit(could be a home visit) within one week preferably on day 3.
2. Second visit within 7-14 days after birth.
3. Third visit within 4-6 weeks after birth.
4. Explain subsequent immunisation schedule.
5. Sexuality issues
A. These visits are a good time to discuss sexuality issues. Often the woman will come to see you or be on her own at home with the baby. This can give you more privacy to discuss topics about which she may feel "shy"
B. The timing of when a couple resume sexual relations after childbirth is often guided by local sexual practices.
C. Different communities and religious groups have different suggested periods of abstinence after childbirth. It would be useful to be aware of this and to be respectful of these practices.
D. A woman is often embarrassed to ask when she can resume intercourse and may already be pressured by her husband or partner. In some cases, the partner may have had sexual intercourse outside the relationship during the period of abstinence following childbirth and hence the woman may be at risk of contracting STDs and HIV.
E. Make women aware that a health worker may come for a home visit for postnatal care three days after birth.
F. Encourage women to return to the health facility with their newborn babies for routine health checks or if any danger signs are present.
G. It is important to tell women about the changes to her body after childbirth that may affect resuming sexual relations.
H. The tiredness that many women feel after childbirth means that they often have little desire for intercourse.
I. The first time they have sex may be painful especially if they had stitches to their perineum.
J. Damage and strain to their internal pelvic muscles which happens during childbirth will mean that sex may ‘feel different’.
k. Many women will need information about these normal changes and some reassurance that these things usually improve with time. Providing adequate care in the home.
L. In the immediate weeks following childbirth women need extra care, including partner and family support.
M. Labour and childbirth are physically demanding, as is breastfeeding and looking after a newborn baby. It is therefore very important that women regain their strength and maintain their health as they adjust to life with their new baby.
N. Women in the postnatal period need to maintain a balanced diet, just as they did during pregnancy.
O. Iron and folic acid supplementation should also continue for 3 months after birth.
P. Women who are breastfeeding require additional food and should drink sufficient clean water.
Q. You should spend more time on nutrition counselling with women who are very thin and with adolescents who may need additional information to help them get a balanced diet.
R. In some cases you may need to refer women to a nutrition counsellor, where available.
S. It is important to note that poverty may prohibit women from accessing certain foods. Exploring less expensive options can be a helpful part of the counselling session.
Counselling on nutrition:
1. Advise the woman to eat a greater amount and variety of healthy foods, such as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, cheese and milk to help her feel strong and well.
2. Reassure the mother that she can eat any normal foods - these will not harm the breastfeeding baby.
3. Discuss any taboos that exist about foods which are nutritionally healthy.
4. Talk to her partner or other family members to encourage them to ensure that the woman eats enough and avoids hard physical work.
5. The first few weeks with a new baby are very demanding, physically and emotionally.
6. Women need to rest and take care of themselves as they recover from labour and birth. This often requires that other family members and friends help out.
7. Work with families to make sure everyone is aware of the care a mother needs.
8. Use your questioning skills to find out whether women are looking after themselves and find out the level of support they are getting from their families. Find out if she is getting enough rest and support. Work with her to identify ways that this could be improved.
9. The postnatal period is a time when you may have to discuss issues with the family as a whole to help them identify solutions to problems that may have arisen since the birth.
10. Some women are overwhelmed following the birth of a child, but despite this they feel that they must get back to their usual routine as quickly as possible to show that they are coping. As a health worker, you need to be able to identify women who are coping, from women who are having trouble in coping.
11. During each postpartum visit you should also discuss how breastfeeding is progressing.
12. Also talk to women about any plans they have to return to work or school,how this might affect breastfeeding and the care of the baby.
13. Find out whether they have made any plans and review them together,or help them to make a plan if they do not already have one.
Danger signs for the women:
1. All women and their families need to be aware of danger signs during the postnatal period.
2. Review the emergency plans they made during pregnancy and see whether they are still valid.
3. Remind women to bring their maternal health record with them even for an emergency visit.
4. It is important that you discuss danger signs with every woman as the majority of maternal deaths occur in the first week after birth.
5. Consider making a tool or an aid for women to take home with them following birth.
Postpartum danger signs in the women:
She should go to the hospital or health centre immediately,day or night.She should not wait if she has any of the following danger signs:
a. Vaginal bleeding has increased fits.
b. Fast or difficult breathing.
c. Fever and too weak to get out of bed.
d. Severe headaches with blurred vision.
e. Calf pain, redness or swelling; shortness of breath or chest pain.
f. Swollen, red or tender breasts or nipples.
g.Have problems while urinating, or experience leaking.
h. Increased pain or infection in the perineum.
i. Infection in the area of the wound(redness, swelling, pain, or pus in wound site).
J. Smelly vaginal discharge.
k. Severe depression or suicidal behaviour (ideas, plan or attempt).
1. The birth of a new baby can lead to many emotional changes. Many women go through a period of mild depression following the birth of a baby. There is a need to differentiate between "Postnatal blues"(feeling down) which usually occur in the first week and can last up to two weeks after birth, and postnatal depression which is much more severe and usually lasts for a longer period.
2. You may well have a local word for the mild depression or ‘blues’ that women experience following birth. Use this word when you discuss the topic with women and their families to differentiate it from postnatal depression, which is different.
3. When the mother experiences low energy, fatigue, sleep or appetite problems, then she may have postnatal blues.
4. True postnatal depression is when a woman is depressed considerably for more than two weeks, enough to disturb her routine activities.
5. Persistent sad or anxious mood, irritability.
6. Low interest in or pleasure from activities that used to be enjoyable.
7. Difficulties carrying out usual work, school,domestic or social activities negative or hopeless feelings about herself or her newborn.
8. Multiple symptoms(aches, pains, palpitations, numbness) with no clear physical cause.
9. In addition she may be suffering from guilt or have negative feelings towards herself or her newborn.
10. In some cases a woman may feel so depressed that she wants to end her life. If you identify a new mother with depression then you should refer her as soon as possible to the nearest health care facility.
11. Support groups can also help. If that is not possible then you may need to support her through this period yourself.
12. If possible, meet her on a regular basis and use your skills to show empathy,listen to her and support her.
13. Ask her consent to discuss with a family member or friend who she feels may also be able to provide her with support.
14. Involve her in social activities and activities that used to make her happy in the past.
15. If depression is mild, regular physical exercise can help a lot.
16. Supporting depressed women: Women who have depression need emotional support. Reassure them that this is usually a temporary condition that happens to some women who have given birth. It sometimes helps if women know that feeling depressed following the birth of a baby is normal and many women experience these feelings.
17. Try and talk to the woman's family and explain to them the need for extra support at this time. Verify that she and the newborn are getting the care they need.
18. Some relatives and even sometimes health workers may not take the concerns of women they see seriously. If women feel their concerns are not taken seriously, this may make them feel inadequate as mothers, which will contribute to their depression.
19. Some mothers may not be able to care for themselves or their baby properly. This is particularly true for women with special needs and adolescents in particular.
Under no circumstances should anyone verbally or physically abuse a mother who is having problems caring for her baby.
20. Reflect on your own attitudes towards women who suffer from the postpartum blues or a more severe form of sadness and depression.
21. You can play a vital role in encouraging the partner and family to listen to the woman and to be sensitive to her condition.
22. You can encourage them to offer practical and emotional support and to reassure her.
23. Try to maintain regular follow-up with women who are suffering from depression and their families, to ensure they are getting the support they need.
24. Offer practical and emotional support to women who are suffering from depression after birth.
25. Women with special needs may be more likely to experience periods of intense sadness or depression and may require additional emotional support.
26. Women often find it beneficial to have a group of people with whom to discuss and share their problems and emotions.
27. Some women get support and reassurance from their partners and families but for others, a group outside the home might be more beneficial.
28. Women can help one another think through problems and generate options that help to solve these problems.
29. You could encourage new mothers to consider forming a group. Provide suggestions for what they might discuss and help them set ground rules for privacy and confidentiality.
If the mother suffers most of the time and cannot function normally, neglects herself and/or the baby, you need to refer her to more specialized help. Physicians or counsellors trained to treat depression can offer more advanced psychosocial treatments or if this does not work, they can prescribe some medication, or refer to mental health specialists.
If there is a risk of self-harm, or the mother is having thoughts about suicide, it is important that she gets urgent help and support without any delay.