POSTPARTUM CARE

SECTION 4

The postpartum period

(puerperium) is from

the end of labour until

the genital tract has

returned to normal. It

usually last for 42 days.

INTRODUCTION

The Aims of Postpartum Care:

Support mother and family

Prevention, early diagnosis and treatment

of complications

Referral

counselling

The Aims of Postpartum Care:

Support of breastfeeding

Educate on nutrition, and supplementation

Counselling contraception and the

resumption of sexual activity

Immunization of infant

Is to increase the awareness of warning signal and appropriate

intervention at all level.

About 2/3 of the maternal deaths occur during the postnatal period

RATIONALE

NEEDS OF WOMEN AND NEWBORN

1.Information/counselling on:

Herself-Health

Self care

Sexual life

Nutrition

Contraception

NEEDS OF WOMEN AND NEWBORNNEEDS NEEDS OF WOMEN AND NEWBORN

2. Support on physical & psychological from :

Health care providers

Partner and family

Employer

NEEDS OF WOMEN AND NEWBORN

3.Health care for suspected or occurring complications eg PPH/Fever

4. Time to care for the baby (esp if on bottle feeding)

5. Help with domestic tasks

NEEDS OF WOMEN AND NEWBORN

6. Social reintegration into

her family and community

7. Protection from

abuse/violence Women

WOMEN MAY FEAR

Inadequacy ( physical and Emotional )

Loss of marital intimacy -

Isolation

Constant responsibility for care for the baby and

others

NEEDS OF NEWBORN

Information/counselling

Care of the baby

*Special Needs refer to Neonatal Care

NEEDS OF NEWBORN

Information/counselling

Breastfeeding

*Special Needs refer to Neonatal Care

NEEDS OF SPECIAL GROUPSNO. Problems Steps to be taken

Women staying in Remote area

Maternal Mortality Ratio (MMR) is higher compared to the general population

Higher incidence of pregnancy problems

Mobile group and inaccessible

Delay discharge from the hospital

Discharge to ‘pusat transit’/ any other health facilities and keep them there

Education of patients and support group

NEEDS OF SPECIAL GROUPS

NO. Problems Steps to be taken

Urban poor

Poor ante natal care leading to postpartum problems

Non-compliance to post natal care plan/ defaulter

Inaccessibility

Cost and implications

Education regarding the importance of post natal care especially those with problems

Reassurance, care is totally health directed

Availability of services at all centres

NEEDS OF SPECIAL GROUPS

NO. Problems Steps to be taken

Single mothers

They have poor social support

They are usually financially unstable

The pregnancy may be unwanted

Delay discharge They should be encouraged to see a social workers

Fees can be waived

Counselling should be given

Option on adoptions / social support should be given from the hospital

NEEDS OF SPECIAL GROUPS

NO. Problems Steps to be taken

Illegal immigrants

Poor ante natal care leading to postpartum problems

Non-compliance to post natal care plan/ defaulter

InaccessibilityCost and implication

Legal/ immigrant implication

Education regarding the importance of post natal care especially those with problem

Reassurance, care is totally health directed.

Waving charges for indicated care (Refer to fee act)

Availability services to all centres

FREQUENCY OF POSTNATAL CARE

1.Day 12.Day 2

3. Day 34.Day 45. Day 66.Day 107. Day 20

PLACES FOR POST NATAL CARE

Every visit

MotherHealth and well-being. Symptoms of abnormal lochia, Chest pain, Difficulty in breathing, Redness and inflammation of lower limbsCalf swelling and tenderness.

Every visit

Mother

Examination ofvital signs breast abdomenPerineum

These should be recorded in the Rekod Kesihatan Ibu KIK/1(a)/96 and KIK/1(b)/96 .

Ask Mother about Baby:Health and well-being. Feeding Bowel opening Passed urine Other concerns.

Every visit

Assessment On Baby

body weightbody temperatureeyes, skin umbilical cord. If the mother accompanies her baby in the

ward, the postnatal care should be continued for the mother by the hospital staff as scheduled.

When Necessary

Observe the feeding

Help the mother to improve the technique of breast feeding.

CHECK LIST TO IDENTIFY HIGH RISKS

Senarai semak bagi mengesan factor risiko semasa post

natal digunakan oleh anggota jururawat/ pegawai perubatan ketika menjalankan jagaan postnatal.

Ibu diberikan pemeriksaan post natal mengikut senarai semak dan carta alir adalah seperti dalam rajah 1.

Jika ibu tersebut diberi kod merah, kes tersebut haruslah

dirujuk ke hospital dan cara pengendaliannya adalah sepert

dalam jadual 1.

CHECK LIST TO IDENTIFY HIGH RISKS

Jika ibu tersebut diberi kod warna kuning, kes

dirujuk kepada pegawai perubatan/ Pakar Perubatan

Keluarga (FMS) klinik kesihatan atau hospital dan

cara pengendaliannya adalah seperti jadual 2.

Carta Alir Pengendalian Kes postnatal

JADUAL 1: PENGENDALIAN KES-KES BERISIKO KOD MERAH

JADUAL 2: PENGENDALIAN KES-KES BERISIKO KOD KUNING

APPENDIX 7

SENARAI SEMAK PEMERHATIAN PENYUSUAAN

STANDARD OPERATING PROCEDURE

FLOW CHART FOR INVESTIGATION AND REVIEW OF MATERNAL DEATH

NUTRITION

Motherseat a healthy balanced diet vitamins minerals.

plan simple and healthy meals that include choices from all of the recommended groups from the food pyramid.

Resumption of sexual activity post natally

Some Studies shown By eight weeks postpartum 71% of

respondents had resumed intercourse, and by ten weeks 90% of the women who had partners had resumed intercourse (Glazener 1997).

Another factor that influences sexual behavior post partum is pain related to perineal damage and sutures, caused by vaginal tears and episiotomies (Glazener 1997).

Resumption of sexual activity cont..

Mother and her partner should decide together

Sexual intercourse may be resumed after mother’s vaginal bleeding has stopped and stitches are healed (usually within 4- 6 weeks)

Be aware that sex first few times following birth may be painful – Advised for lubricants and comfortable positioning.

Contraception:

Counseling to all postnatal mothers regarding the risk of next pregnancy.

Should be started before any sexual activity.Offered to all Postnatal mothers especially

those high risk cases.Method as in MEC (MOH 2006)All high risk mothers should be registered in

both PPC and FP Clinic.

POSTNATAL EXERCISE

1. Pelvic floor exercise Start soon after birth. Reduce the possibility of stress incontinence and

restore the pelvic floor muscle strength.

2. Position Sitting, standing or crook lying

3. Steps Imagine you are trying to hold back a stream of

urine and tighten your muscles to prevent leaking.

Breath normally, hold for 5 seconds. Do not tighten the gluteal and thigh muscles Relax for 10 seconds Repeat 10 times

ABDOMINAL EXERCISE

Benefits: Strengthen the abdominal muscle Improve abdominal stabilization in the

activities of daily living.

Position: Lie on the floor with your knees bent

and head supported

Steps: Breath in, then breath out as you pull

in your abdomen and push your lower back down into the floor.

Hold for 5 seconds and relax/ Repeat 5 times.

PELVIC EXERCISE

Benefits: To maintain mobility of the pelvis To tone the natural abdominal corset Improve posture Prevent and relieve backache

Position: Lie down with the back supported, arm

by the side, knees bent together.

Steps: Tighten the abdominal muscles and

move the coccyx forward. Hold for 5 seconds. Repeat 5 times.

ARM EXERCISES

Benefits: Relieve heartburn. Improve circulation Improve breathing and lung expansion.

Position: Stand upright

Steps: Stand straight with feet apart. Keep

your shoulders back. Lift both arms as far back as you can

reach without bending your elbows. Move your arms forward by 180 .

Swing arms back again and repeat 5 times.

ANKLE EXERCISES

Benefits: Improve circulation Maintain range o motion.

Position: Long sitting – sitting on the floor with

both legs straight. Sitting – on the chair with the leg

supported or elevated.

Steps: Lift one foot off the floor and circle the

ankle several times, first one way the the other.

Don’t move your knee. Repeat with the other leg

WARNING SIGNS TO TERMINATE EXERCISE

Dyspnoea before exertion Dizziness Headache Chest pain Muscle weakness Calf pain or swelling (to rule out

thrombophlebitis)

COPING WITH DEATHS

GRIEF:

Emotional and somatic responses felt by an individual on the death of another individual.

More intense if the death occurs in a person who is closely related.

NORMAL GRIEF REACTION

MORTALITY BEREAVEMENT

Maternal Death

Stillbirth

Neonatal death

COUNSELLING

Death (Maternal or Stillbirth or Neonatal Death) The bereaved persons needs:

- talk about the loss

- express feelings of the sadness, guilt or anger

- understand the normal course of grieving

Help needed:

- to accept that loss is real

- to work though stages of grief

- to adjust to life without the deceased

GUIDELINES ON COUNSELING

Provide an environment and circumstances for feeling hurt ,guilty, angry or other strongly negative feelings.

Allow the spouse and relatives to ventilate.Validate the extent of grief.Be sensitive for the need for postmortem in cases

of sudden death.Encourage spouse to built a support network of

family and friend.Be alert for suicidal intention or behavior.Remember that grief takes time.

THE "DO"THE "DO" THE “DON’T”THE “DON’T”

Express sympathy

Talk about deceased by name

Elicit question about

circumstances of the death.

Elicit question about feeling

and about the death has

affected the person.

Have a casual or passive

attitude

Give statements that death is

for the best

Assume that the bereaved is

strong and will get through this

Avoid discussing the death

TEAR

T - To accept the reality of the loss

E - Experience the pain of the loss

A - Adjust to the new environment

without the lost object

R - Reinvest in the new reality

FORMATS USED FOR INVESTIGATION AND REVIEW OF MATERNAL DEATHS.

KIK/K1-1 -Penyiasatan Kematian Ibu Mengandung pind.Jul.91

KIK/K1-2 -Investigation of Maternal Deaths

KIK/K1-3 -Borang Maklumat Kes Kematian Ibu.

KIK/K1-4 -Feedback format on Maternal Deaths from State to the

District to State Level.

KIK/K1-5 Reporting Format to QA health Services Committee by technical Committee for Investigation and review of Maternal Deaths at District, State and National levels

KIK/K1-6 Borang Maklumat bedahsiasat Atas Kes Kematian Ibu

TERIMA KASIH