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Martenal Discusion 4

Martenal Discusion 4

In this session, we review the key information to be communicated to women who have just given birth and their partners and families. This covers general care of both the mother and the baby and danger signs in the postnatal period. Special mention is made for supporting women with depression. This topic is used to practice facilitating family and group support and respecting the concerns of women. See Session 12 on birth spacing and postpartum family planning and Session 13 on breastfeeding, which are also important counseling topics for women and their families immediately after birth.

Go to:\sWhat skills will I develop?

Facilitating family and group support of women
Respecting the concerns of women
Providing information on postnatal care and danger signs in the new mother and baby
Tailoring to the specific needs of the depressed postnatal woman.
Image session11fu2
Go to:
What am I going to learn?
By the end of this session, you should be able to:
Communicate key information on postnatal care, including complications for the mother and baby.
Provide support to women with depression.
Go to: \sCare of the mother and newborn after birth.
Some women will give birth in the home with a skilled attendant; others may not have a skilled attendant. Some women who give birth in the facility will spend time following childbirth; WHO recommends that women not be discharged 24 hours after birth. Regardless of the place of birth, someone must accompany 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, the mother and baby must receive a postnatal examination as early as possible, preferably within 24 hours of birth. The mother and baby should receive a postnatal examination before discharge if the birth is at a facility.

There are several important points to discuss with the woman and her family following birth to ensure that the woman has adequate care. See the WHO PCPNC for additional information.

The importance of having someone nearby for the first 24 hours.
The importance and recommended timing of postnatal visits.
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. The new mother should also drink plenty of clean, safe water.
The importance of rest and sleep and the need to avoid hard physical labor.
Discussion of normal postpartum bleeding and lochia – discuss with women how much blood loss they can expect and for how long. When bleeding is more than normal, they should seek care urgently.
Discuss the danger signs for the woman and baby and the importance of seeking help quickly.
Personal hygiene in the context of local practices and the environment. Discuss with women the type of pads they will use, their disposal, and care of episiotomy in home conditions. Hand washing is particularly important to prevent infections. It is also important not to insert anything into the vagina.
Talk to them about when they can resume sexual relations and the importance of condom use to prevent STI and HIV transmission (see Sessions 12 and 14). (see Sessions 12 and 14). Sexual intercourse should be avoided until the perineal wound heals. Discuss the importance of birth spacing and counsel on using a family planning method.
Discuss infant feeding and breast care (see Session 13) and the importance of only taking prescribed medicines when breastfeeding.
Discuss the importance of the home environment for promoting the baby’s health and the mother’s recovery. For example, discuss the need for warmth, good ventilation, and hygiene for both mother and baby.
Discuss the importance of mother and baby sleeping under an insecticide-treated bednet in an area with malaria.
Timing of postnatal visits
Following childbirth, the woman and newborn should be examined within 24 hours by a health worker. At this time, also discuss with the woman and family the timing of subsequent visits and the immunization schedule for the baby. WHO recommends that a trained health worker visit the mother and baby at home, preferably within the first week after birth. If your facility does not conduct home visits, discuss with the mother how she will come to the facility or local clinic for these scheduled visits. These visits early in the postnatal period are important for the mother and baby. 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 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 (refer to the points above) (refer to the points above). Encourage her to ask questions during the examination and use her active listening skills to reflect on and clarify what she is telling you. Please help her to think of ways she can implement your advice. Sometimes, when women are unsure or hesitant, they voice concerns indirectly 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. 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.

First visit (could be a home visit) \swithin 1 week, preferably on day 3 \sSecond visit \s7-14 days after birth
Third visit \s4-6 weeks after birth
Explain the subsequent immunization schedule

Sexuality issues
These visits are a good time to discuss sexuality issues. Often the woman will come to see you or be alone at home with the baby. This can give you more privacy to discuss topics about which she may feel ‘shy.’ The timing of when a couple resumes sexual relations after childbirth is often guided by local sexual practices. Different communities and religious groups have different suggested periods of abstinence after childbirth. Being aware of this and respectful of these practices would be useful. 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 abstinence following childbirth. Hence, the woman may be at risk of contracting STIs and HIV.

Make women aware that a health worker may come for a home visit for postnatal care three days after birth.
Make women aware that a health worker may come for a home visit for postnatal care three days after birth.
Encourage women to return to the health facility with their newborn babies for routine health checks or if any danger signs are present.

It is important to tell women about the changes to their bodies after childbirth that may affect resuming sexual relations. Many women feel tired after childbirth, so they often have little desire for intercourse. The first time they have sex may be painful, especially if they have stitches to their perineum. Damage and strain to their internal pelvic muscles, which happens during childbirth, will mean that sex may ‘feel different.’ Many women will need information about these normal changes and reassurance that these things usually improve over time.

Providing adequate care in the home
In the immediate weeks following childbirth, women need extra care, including partner and family support. Labor and childbirth are physically demanding, as is breastfeeding and looking after a newborn. Therefore, women must regain their strength and health as they adjust to life with their new babies.

Women in the postnatal period need to maintain a balanced diet, just as they did during pregnancy. Iron and folic acid supplementation should also continue for 3 months after birth. Women who are breastfeeding require additional food and should drink sufficient clean water. It would help if you spent more time on nutrition counseling with women who are very thin and with adolescents who may need additional information to help them get a balanced diet. In some cases, you may need to refer women to a nutrition counselor, where available. It is important to note that poverty may prohibit women from accessing certain foods. Exploring less expensive options can be a valuable part of the counseling session.

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 (give examples of how much to eat) (give examples of how much to eat).
Reassure the mother that she can eat normal foods – these will not harm the breastfeeding baby.
Discuss any taboos that exist about nutritionally healthy foods.
Talk to her partner or other family members to encourage them to ensure that the woman eats enough and avoids hard physical work.
The first few weeks with a new baby are physically and emotionally demanding. Women need to rest and care for themselves as they recover from labor and birth. This often requires that other family members and friends help out. Work with families to ensure everyone knows the care a mother needs. Use your questioning skills to determine whether women are looking after themselves and determine 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. The postnatal period is when you may have to discuss issues with the family to help them identify solutions to problems that may have arisen since birth. 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 coping.

During each postpartum visit, you should discuss how breastfeeding progresses (see Session 13). (see Session 13). Also, talk to women about any plans they have to return to work or school and how this might affect breastfeeding and the care of the baby. 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.

Go to: \sDanger signs for the woman.
All women and their families must be aware of danger signs during the postnatal period. Review the emergency plans they made during pregnancy and see whether they are valid. Remind women to bring their maternal health records, even for an emergency visit. You must discuss danger signs with every woman, as the majority of maternal deaths occur in the first week after birth. Consider making a tool or an aid for women to take home after birth.

She should go to the hospital or health center immediately, day or night.

SHE SHOULD NOT WAIT if she has any of the following danger signs:

Vaginal bleeding has increased \sfits \sfast or difficult breathing \sfever, and too weak to get out of bed \ severe headaches with blurred vision \scalf pain, redness or swelling, shortness of breath, or chest pain.
She should go to the health center as soon as possible if she has any of the following signs:

swollen, red, or tender breasts or nipples \ problems urinating or leaking \ increased pain or infection in the perineum \sinfection in the area of the wound (redness, swelling, pain, or pus in wound site) (redness, swelling, pain, or pus in wound site)
smelly vaginal discharge
severe depression or suicidal behavior (ideas, plan, or attempt) (ideas, plan or attempt)
Go to:
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 longer. 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.

When the mother experiences low energy, fatigue, sleep, or appetite problems, she may have postnatal blues. True postnatal depression is when a woman is depressed considerably for more than two weeks, enough to disturb her routine activities. She may also experience any of the following:
Martenal Discusion 4
persistent sad or anxious mood, irritability \slow interest in or pleasure from activities that used to be enjoyable \ difficulties carrying out usual work, school, domestic or social activities
negative or hopeless feelings about herself or her newborn \ multiple symptoms (aches, pains, palpitations, numbness) with no clear physical cause.
In addition, she may suffer guilt or have negative feelings towards herself or her newborn. Sometimes, 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 healthcare facility. Support groups can also help. If that is not possible, you may need to support her through this period yourself. If possible, meet her regularly, use your skills to show empathy, and listen to and support her. Ask her consent to discuss with a family member or friend who she feels may also be able to support her. Involve her in social activities and activities that used to make her happy in the past. If depression is mild, regular physical exercise can help a lot.

Supporting depressed women
Women who have depression need emotional support. Reassure them that this is usually a temporary condition for 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. Try to talk to the woman’s family and explain to them the need for extra support. Verify that she and the newborn are getting the care they need.

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, they may feel inadequate as mothers, contributing to their depression. Some mothers may not be able to care for themselves or their babies 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.

Reflect on your attitudes towards women who suffer from the postpartum blues or a more severe form of sadness and depression. Have you been able to be supportive of them? Do you think this is a serious issue? How prevalent is it in your community? What is the community’s attitude towards women experiencing postnatal depression? Discuss with some colleagues to get their impression about how many women may suffer from this. Interview some women who have recently given birth and ask them if they have felt any signs mentioned in the box on the previous page.

You can play a vital role in encouraging the partner and family to listen to the woman and be sensitive to her condition. You can encourage them to offer practical and emotional support and to reassure her. Try to maintain regular follow-ups with women suffering from depression and their families to ensure they get the support they need.

Offer practical and emotional support to women suffering from depression after birth.
Offer practical and emotional support to women suffering from depression after birth.
Activity 1 \sImage session11fu5.jpg1 hour

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To help you find ways to support women who are experiencing depression or require additional emotional support.

Although this activity is written in the context of depression following birth, there will be many other times when you have to counsel depressed women or women who are feeling sad. Women with special needs may be more likely to experience periods of intense sadness or depression and require additional emotional support.

In addition, you or your colleagues may also suffer from periods when you require extra support and understanding due to the roles you have to play and the support you give to others. The tasks you carry out in this activity can be used for all the women you see, as well as for your colleagues and yourself!

Write a list of things a woman can do to improve her mental health. For example, walking, resting, quiet time, spending time with friends, praying, or singing songs.
Write a list of things other family members can do to support her, such as helping with the workload, sitting and listening to her, and providing an environment of care and support.
Now write down things a group of women could do to help improve their mental health. For example, giving one another emotional or practical support, discussing problems, and sharing solutions.
Do any support groups currently exist in the community? How could you help women in your community to start their support groups or to better support each other?
Discuss the lists with colleagues and finalize them together. Distribute copies of the list so you and your colleagues can use them as a resource for women experiencing mental or emotional health problems.
In cases where depression is so severe that it does not respond to your interventions, are there more specialized counselors available to whom you can refer?
Image session11fu7.jpg Our View

Women often find it beneficial to have a group of people with whom to discuss and share their problems and emotions. Some women get support and reassurance from their partners and families, but a group outside the home might be more beneficial for others. Women can help one another think through problems and generate options that help to solve these problems.

Find out if a support group exists, and build on this group. If none exist, you could start a new group, but starting up a support group can be a difficult and time-consuming task. 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, cannot function normally and neglects herself and the baby, you need to refer her to more specialized help. Health workers or counselors trained to treat depression can offer more advanced psychosocial treatments. They can prescribe medication or refer to mental health specialists if this does not work.

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 and is not left alone. Remove means of self-harm and assign someone to ensure her safety while you arrange specialist mental health care.

ENCOURAGE WOMEN TO DO THINGS FOR THEMSELVES THAT THEY ENJOY SUCH AS \smeeting a friend \ getting out of the home or walking, or things which help them to let their feelings out \ssinging, drawing or writing \sspiritual relief through prayer \smeditation
Support the woman in whatever way you can. This may include a home visit and extra postpartum appointments. Encourage her partner and family to support her practically and emotionally.

Go to: \sHow to provide information and support for the care of the newborn after birth.
In addition to physically assessing the newborn, you will need to communicate effectively with the mother, father, and family to assess how the newborn is doing. You need to provide practical guidance and support for breastfeeding (see Session 13) as well as information on cord care and other care in the home for the baby.

Remember to use simple, appropriate language when you ask the mother questions. Treat any concerns she raises about her baby or her role as a mother with respect, even if her worries might appear unnecessary to you. You should maintain her trust so that she will come to you when she has other concerns that you may consider more serious. All mothers (especially first-time mothers) need lots of support and reassurance that they are appropriately caring for their babies. You can communicate some of this information by active demonstration, for example, showing the new mothers how to hold or lift a baby so they can see what to do and giving them opportunities to ask questions and clarify any problems.

It is important to provide mothers, fathers, and families with practical advice on how to care for the baby during the first few days.

Keep the baby warm – a baby should wear 1-2 layers more than an adult. If cold, put a hat on the baby’s head.
Care for the umbilical cord. Do not put anything on the stump.
Keep the baby clean. It is unnecessary to wash the baby every day, but wash the baby’s face and bottom when needed. Make sure the room is warm when undressing the baby.
Provide nothing but breast milk day and night.
You should see a health worker on day 3, between 7 and 14 days, and 4-6 weeks after birth. At the 6-week visit, the baby will be immunized.
Let the baby sleep on their back or side.
Keep the baby away from smoke.
It is not recommended to expose the baby to direct sun.
Some women may need extra support with a particular issue, such as breastfeeding. Women may also want information or support about any problems that their babies have. Remember, when an issue is raised, the first thing you should do is find out how much the woman already knows and what she is already doing – often, she is doing the right things and needs reassurance. If there are problems that she identifies, follow the counseling procedures you have been practicing to help her identify possible solutions. Together with her, weigh the advantages and disadvantages of solutions and put together a plan of action that she feels she can carry out.

At this time, you may also want to review any local practices families may want to carry out with the baby. Discuss with them the consequences of some practices which may be harmful (Review the list of harmful, harmless, and helpful practices you developed in Session 4 Activity 1). (Review the harmful, harmless, and helpful practices you developed in Session 4 Activity 1).

Go to: \sDanger signs for the newborn.
In addition to advising parents and the family on the general care of the newborn, it is important to alert them to danger signs.

As for the mother, there are also danger signs for the newborn that mothers and families need to identify and respond to immediately. Think about how to discuss and review this information with families. Consider obtaining or developing support materials to help you communicate this information more effectively and help women and their families remember the danger signs.

Advise the mother and family to seek care immediately, day or night. They should not wait if the baby has any of these signs:

difficulty in breathing or indrawing \sfits
fever \sfeels cold \sbleeding \snot feeding \syellow palms and soles of feet \sdiarrhoea
The mother and family should go to the health center as soon as possible if a baby has any of the following signs:

Difficulty feeding (poor attachment, not suckling well) \ is taking less than 8 feeds in 24 hours \spus coming from the eyes or skin pustules \sirritated cord with pus or blood \syellow eyes or skin.
Ulcers or thrush (white patches) in the mouth – explain that this is different from normal breast milk in the mouth
When explaining the danger signs to parents and caregivers, show them what you are describing when possible. Use the baby as a visual aid and, for example, show them normal breathing, where pustules might appear, or where the redness of cord infections will be seen. Take some time to observe normal feeding patterns, techniques, and positioning and discuss the most common difficulties they are likely to experience.

Advise families on the importance of birth registration. Consider making a list of instructions on where and when to go that you can give to families.

Visit: Special Needs Newborn Babies
A baby with difficulty breathing at birth and requires resuscitation should be closely monitored for the next 24 hours, with special attention paid to the newborn’s danger signs. These babies must be kept warm, and that special attention is paid to the initiation of breastfeeding. These babies may have difficulty breastfeeding, and the mother and baby may require additional assistance. It is also critical to explain to the baby’s parents what happened during birth and the potential consequences of their baby not starting to breathe independently, such as developmental delays.

Some babies are born very small, either because they were born before nine months or because their growth in the uterus was restricted. Very young mothers, expecting twins, doing hard physical labor during pregnancy, overweight or underweight, anemic, or have suffered from malaria or another infection during pregnancy are at a higher risk of giving birth prematurely or having a baby with a low birth weight. Low birth weight babies, or babies weighing less than 2500 g, are at a higher risk of infection and death. Assure that the parents of low-birth-weight babies are aware of the danger signs in their newborn and know how to seek help as soon as possible. Low birth weight babies, in particular, may struggle with breastfeeding. More information on how to help the mother of a low birth-weight baby breastfeed can be found in Session 13 on breastfeeding.

Kangaroo Mother Care can help with low birth weight babies. WHO’s Kangaroo Mother Care: Practical Guide ( perinatal health/9241590351/en) provides more information on how to begin Kangaroo Mother care in a hospital setting. Skin-to-skin contact between mother and baby and exclusive breastfeeding are important aspects of kangaroo mother care. It allows the mother and baby to bond while keeping the baby warm and allowing him to breastfeed frequently.

Image session11fu5.jpg1 hour Activity 2

session11fu6.jpg is an image of a session.

to hone your skills in advising new mothers

This is a role-playing exercise. If you are not reading the Handbook in a group, try to find two colleagues who can assist you with this role-play. Take turns playing the roles of the new mother and the health worker if you’re in a group.

This activity will build on some of the skills you practiced in Session 9’s Activity 2. Keep in mind to:

Maintain eye contact and, when culturally appropriate, nod and smile.
display open body language
despite your beliefs and values or the time constraints of your job, demonstrate empathy and respect through understanding/caring language. Do not sound harsh or judgemental
ask open-ended questions and actively listen
Instead of giving direct advice, investigate what the mother already knows.
Back-and-forth questions to check to understand and expand on the mother’s knowledge so she can best engage in a solution.
Take some time to discuss why mothers bring their newborns to the hospital. Make a list of potential outcomes. The person playing the mother can select one and begin the role-playing. As an example:

A young mother brings her 2-week-old baby to the clinic because his umbilicus is infected. Her mother-in-law had insisted on applying a poultice to the cord.
An adolescent mother brings in her 1-week-old baby with a very mild rash. Still, she wants to learn about family planning because her boyfriend pressures her to resume sexual relations.
A mother with four children and a new baby arrives complaining of exhaustion. She appears depressed and overwhelmed and has been crying.
At 6 weeks, a mother comes in for a routine check-up. She is frail and thin.
Consider other scenarios you’ve encountered at work or that might occur in the community and workplace setting.

The person providing the counseling should also consider the following:

What open questions can you use to establish two-way communication and reassure the mother?

Have you investigated what it is about the mother’s situation that prevents her from meeting the needs of herself and her baby?

Have you avoided asking derogatory questions?

Have you considered what your mother said and built on it?

What information can you provide her, and how can you collaborate with her to find a solution?

One participant should observe the role-play. Afterward, they should comment on what the person playing the health worker did well and suggest how to improve the counseling session in the future. Try to highlight what went well in the counseling session and then make suggestions for how it could be improved the next time.
Case Study: A client had an SVD (spontaneous vaginal delivery) today. The labor and delivery nurse gives you a shift report and notes the client is RH Negative and her infant is RH Positive.

Discuss the drug RhoGAM (immune globulin), including:

Nursing Implications
Indications for Use
Contraindications for Use

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