What nursing interventions are important during the first 24 hours after delivery?

What is in this session?

In this session we review the key information to be communicated to women who have just given birth and their partners and/or families. This covers general care of both the mother and the baby as well as danger signs in the postnatal period. Special mention is made for supporting women with depression.This topic is used to practise the skills of 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 counselling topics for women and their families immediately after birth.

What 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.

What am I going to learn?

By the end of this session you should be able to:

1. Communicate key information on postnatal care including complications for the mother and baby.

2. Provide support to women with depression.

Care 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 present. Some women who give birth in the facility will spend time there following childbirth. WHO recommends that a women not be discharged before 24 hours after 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. See the WHO PCPNC for additional information.

IMPORTANT ISSUES TO DISCUSS WITH WOMEN AND THEIR FAMILIES, IMMEDIATELY FOLLOWING BIRTH

• 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 labour.

• Discussion of normal postpartum bleeding and lochia – discuss with women how much blood loss they can expect, 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 and their disposal, and care of episiotomy in the context of 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). Sexual intercourse should be avoided until the perineal wound heals. Discuss the importance of birth spacing and counsel on the use of a family planning method.

• Discuss infant feeding and breast care (see Session13) and the importance of only taking prescribed medicines when breastfeeding.

• 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.

• In an area with malaria, discuss the importance of mother and baby sleeping under an insecticide-treated bednet.

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 the mother and baby be visited at home by a trained health worker, preferably within the first week after birth. 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. 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). Encourage her to ask questions during the examination and use your active listening skills to reflect on and clarify what she is telling you. 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. 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

Explain subsequent immunisation schedule

Sexuality issues

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’. The timing of when a couple resume sexual relations after childbirth is often guided by local sexual practices. 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. 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 STIs and HIV.

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 her body after childbirth that may affect resuming sexual relations. The tiredness that many women feel after childbirth means that they often have little desire for intercourse. The first time they have sex may be painful especially if they had 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 some reassurance that these things usually improve with time.

Providing adequate care in the home

In the immediate weeks following childbirth women need extra care, including partner and family support. 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.

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. 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. In some cases you may need to refer women to a nutrition counsellor, where available. 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

• 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).

• Reassure the mother that she can eat any normal foods - these will not harm the breastfeeding baby.

• Discuss any taboos that exist about foods which are nutritionally healthy.

• 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 very demanding, physically and emotionally. 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. Work with families to make sure everyone is aware of the care a mother needs. 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. 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. 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 also discuss how breastfeeding is progressing (see Session 13). 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. 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 woman

All women and their families need to be aware of danger signs during the postnatal period. Review the emergency plans they made during pregnancy and see whether they are still valid. Remind women to bring their maternal health record with them even for an emergency visit. It is important that you 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 with them following birth.

POSTPARTUM DANGER SIGNS IN THE WOMAN

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:

• vaginal bleeding has increased

• fits

• fast or difficult breathing

• fever and too weak to get out of bed

• severe headaches with blurred vision

• calf pain, redness or swelling; shortness of breath or chest pain.

She should go to the health centre 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

• infection in the area of the wound (redness, swelling, pain, or pus in wound site)

• smelly vaginal discharge

• severe depression or suicidal behaviour (ideas, plan or attempt)

Depression

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. 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, then 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:

• persistent sad or anxious mood, irritability

• low 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 be suffering from guilt or have negative feelings towards herself or her newborn. 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. Support groups can also help. If that is not possible then you may need to support her through this period yourself. If possible, meet her on a regular basis and use your skills to show empathy, listen to her and support her. Ask her consent to discuss with a family member or friend who she feels may also be able to provide her with support. 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 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. 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.

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. 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.

Reflect on your own 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 attitude of the community towards women who are 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 of the 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 to be sensitive to her condition. You can encourage them to offer practical and emotional support and to reassure her. 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.

Offer practical and emotional support to women who are suffering from depression after birth

Activity 1

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 may require additional emotional support.

In addition you or your colleagues may also suffer from periods when you require extra support and understanding as a consequence of 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!

1. Write a list of things that a woman can do for herself to improve her mental health. For example, walking, resting and quiet time, spending time with friends, praying or singing songs.

2. Write a list of things that other family members can do to support her, such as helping out with the work load, sitting and listening to her, providing an environment of care and support.

3. Now write down things that a group of women could do to help improve their mental health. For example, giving one another emotional or practical support or discussing problems and sharing solutions.

4. Do any support groups currently exist in the community? How could you help women in your community to start their own support groups or to better support each other?

5. 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 with women who are experiencing mental or emotional health problems.

6. In cases where depression is so severe that it does not respond to your interventions, are there more specialized counsellors available to whom you can refer?

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 for others a group outside the home might be more beneficial. 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.

REMINDER

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. Health workers 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 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

• meeting a friend

• getting out of the home or walking, or things which help them to let their feelings out

• singing, drawing or writing

• spiritual relief through prayer

• meditation

Support the woman in whatever way you can. This may include a home visit and/or extra postpartum appointments. Encourage her partner and family to support her practically and emotionally.

How to provide information and support for the care of the newborn after birth

In addition to physically assessing the newborn, you will need to be able 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.

As you ask the mother questions, remember to use simple, appropriate language. 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 at this time so that she will come to you when she has other concerns, which you may consider more serious. All mothers (but especially first time mothers) need lots of support and reassurance that they are caring for their babies appropriately. You can communicate some of this information by active demonstration, for example, showing the new mothers how to hold or lift a baby, so that they can see what to do, and giving them opportunities to ask questions and clarify any problems.

REMINDER

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 not necessary to wash the baby every day, but wash baby's face and bottom when needed. Make sure the room is warm when undressing baby.

• Provide nothing but breast milk day and night.

• You should see a health worker on day 3 and 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 his/her 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 – many times she is doing the right things and just needs reassurance. If there are problems which she identifies, follow the counselling procedures you have been practising 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 is able to carry out.

At this time you may also want to review any local practices that 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).

Danger signs for the newborn

In addition to advising parents and the family on 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, which will help you to communicate this information more effectively and that will help women and their families to remember the danger signs.

DANGER SIGNS FOR THE NEWBORN

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

• fits

• fever

• feels cold

• bleeding

• not feeding

• yellow palms and soles of feet

• diarrhoea

The mother and family should go to the health centre 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

• pus coming from the eyes or skin pustules

• irritated cord with pus or blood

• yellow 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, when possible show them what you are describing. Use the baby as a visual aid and for example, show them the normal breathing, show them 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.

REMINDER

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

Newborn babies with special needs

A baby who had difficulties breathing at the time of birth and needed resuscitation should be carefully monitored over the next 24 hours, with particular attention to the danger signs in the newborn. For these babies it is particularly important that they are kept warm and that extra attention is paid to the initiation of breastfeeding. These babies may have some difficulties in starting to breastfeed and the mother and baby might need more support. It is also important to explain to the parents of the baby what happened at the time of birth and the possible consequences of their baby not starting to breathe by him/herself, such as developmental delays.

Some babies are born very small, either because they have been born before nine months, or because their growth was restricted in the uterus. Mothers who are very young; who are expecting twins; who are involved in hard physical work during pregnancy; or who are over- or underweight, anaemic or have suffered from malaria or another infection during pregnancy; are at greater risk of giving birth before time or giving birth to a low birth-weight baby. Low birth-weight babies or babies born under 2500 gs are at greater risk of infections and dying. Make sure the parents of low birth-weight babies are aware of the danger signs in the newborn and know to seek help quickly. In particular, low birth-weight babies may have difficulties with breastfeeding. See Session 13 on breastfeeding for further information on how to support the mother of a low birth-weight baby to breastfeed.

Low birth-weight babies can be cared for using Kangaroo Mother Care. The Kangaroo Mother Care: Practical guide published by WHO (http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9241590351/en) gives further information on how to initiate Kangaroo Mother care in hospital. Kangaroo mother care involves skin-to-skin contact between mother and baby and exclusive breastfeeding. It allows the mother and baby to bond, while also keeping baby warm and able to breastfeed often.

Activity 2

This is a role-play activity. If you are not working through the Handbook with a group, try to find two colleagues who can help you with this role-play If you are part of a group, take turns playing the role of the new mother and the health worker.

This activity will build on some of the skills you practiced in Activity 2 in Session 9. Remember to:

• maintain eye contact, where culturally appropriate, nod and smile at appropriate times

• demonstrate open body language

• demonstrate empathy and respect through understanding/caring language

• do not sound harsh or judgemental, despite your own beliefs and values, or the time constraints of your job

• ask open-ended questions and listen actively

• do not give direct advice, but explore what the mother already knows

• paraphrase questions back to check understanding

• build on the mother's knowledge, so she can best engage in a solution.

Take some time to discuss the reasons mothers come to the health facility with their newborn. Make a list of possible scenarios. The person playing the mother can choose one and start the role play. For example:

• A young mother brings her 2-week old baby to the clinic with an infected umbilicus. Her mother-in-law had insisted it was necessary to apply a poultice to the cord.

• An adolescent mother brings her 1-week old baby in with a very mild rash, but really she wants to find out about family planning, as her boyfriend is pressuring her to resume sexual relations.

• A mother with 4 children and a new baby comes in complaining of fatigue. She looks sad, overwhelmed and she has been crying.

• A mother comes in for a routine check-up at 6 weeks. She is very thin and weak.

Think of other scenarios that you have encountered in your work, or that might occur in the community and setting you are working in.

The person doing the counselling should also consider:

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

Have you explored what it is about the mother's situation that prevents her from addressing her and her baby's needs?

Have you avoided using judgemental questions?

Have you reflected back what the mother said and built on her knowledge?

What information can you give her and how can you work with her to find a solution?

One participant should observe the role-play S/he will comment afterwards on what the person playing the health worker did well and make suggestions on how to improve the counselling session in future. Try to point out what was good in the counselling session and then make some suggestions about what could be improved next time.

What did I learn?

You should be able to communicate the essential messages relating to care of the mother and the newborn in the home after birth. You have learned the danger signs in the postnatal period for the woman and newborn and thought about how best to communicate these to women and their families. You have also learned how to care for and support women who are experiencing depression and how to mobilize support from families, communities and other women in similar situations. Remember, that often we ourselves may need support after providing emotional support to others. Some of the aids discussed here may be of use to you and your colleagues.

To help yourself, remember to reflect on what you are doing and how you are feeling. Take time for yourself to recharge your batteries, particularly if you have been through an emotional or stressful experience at work. Use your notebook to record your thoughts and feelings and share these with a trusted colleague if you think that will help, or identify other things you can do for yourself. Remember, an exhausted, unhappy health worker is unlikely to be able to provide the care and support the woman or family need.

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What are nursing interventions during the first stage of labor?

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