1. Routine postpartum care for the woman Name of presenter: Prevention of Postpartum Hemorrhage Initiative (POPPHI) Project BASICS

2. 2 By the end of this session, participants will be able to: Describe essential care to provide to the postpartum woman. Provide counseling to the woman during the postpartum period. Objectives Note: Examination and care of the postpartum woman are beyond the scope of this course. A brief review of components of the examination and care will be provided, but the emphasis in this course will be on counseling the woman on self-care.

3. 3 Integration of maternal and newborn care The mother and her newborn are inseparable; both should be evaluated and treated at the same time. This presentation concentrates on care of the postpartum woman and complements the sessions on care of the newborn in the postnatal period.

4. Working in pairs Work in pairs with a participant sitting next to you. Tasks: Read the sections on male involvement, postpartum care, and the importance of routine couple visits in Chapter 7 in the Reference Manual. After 15 minutes, be ready to actively participate in a question/answer session. 4

5. When should the woman receive routine postpartum exams? At 1 hour and 6 hours after childbirth At least once a day when in the facility At discharge 2-3 days after childbirth 6 weeks after childbirth 5 More visits / exams may be needed depending on the woman’s health status or needs.

6. Basic Postpartum Care Throughout assessment, apply key tools: –Rapid assessment and management of the woman –Clinical decision-making –Interpersonal skills –Infection prevention practices –Record-keeping –Consider each finding in context of other findings 6

7. 7 What diseases and conditions will the postpartum woman be screened for? Malaria Tuberculosis Urinary tract infection Anemia Diabetes HIV/AIDS Sexually transmitted infections (syphilis, chlamydia, gonorrhea, trichomoniasis)

8. 8 What pregnancy-related complications will the postpartum woman be screened for? Postpartum infection –Metritis –Wound infection –Breast infection Hypertension Preeclampsia/Eclampsia Hemorrhage (immediate or delayed) Thrombophlebitis

9. What information will you gather during the history? Assess for all emergency and danger signs immediately and, if present, initiate the designated emergency response procedures and begin appropriate treatment and/or referral. Ask the woman if she now has or has had danger signs and respond appropriately. Check the woman’s medical record. Check records and take a detailed history to identify any problems/potential problems: social problems, medical problems, problems during the most recent pregnancy and birth, and reported symptoms/ problems. Review plans for family planning. 9

10. Postpartum visit: Physical exam (1) Assess general health. Check skin, noting lesions and bruises. Take the woman’s blood pressure, pulse, and temperature. 10 Examine the woman’s conjunctivae and the palms of her hands for pallor.

11. 11 Postpartum visit: Physical exam (2) Examine the woman’s breasts for engorgement, soreness, and cracked nipples. Examine the woman’s legs to assess for localized pain, tenderness, and hot spots.

12. 12 Postpartum visit: Physical exam (3) Examine the abdomen to assess involution of the uterus, the firmness and roundness of uterus, if there is tenderness (lower abdomen). Examine the perineum and genitalia for tears, swelling, tenderness, and pus. Observe lochia to assess color, odor, amount.

13. Evaluate findings from history and physical examination Based on analysis of findings: –Identify problems and complications. –Decide where and by whom the woman should receive care. Refer all women who need specialized care for any reason. –Decide if there is need for further laboratory tests or investigations. –Make a plan of care with the woman for all identified problems / complications / needs. –Identify plans for family planning. –Make a plan for counseling the woman on self- care and follow-up of any identified problems. 13

14. What laboratory examinations may need to be ordered in the postpartum? Hemoglobin levels RPR (or VDRL) Gram-stain and cultures for gonorrhea / chlamydia Wet mount of vaginal secretions HIV Check urine with dipstick or perform urinalysis Rapid test for malarial parasites Stool exam for ova and parasites 14

15. Make a plan of care Provide treatment for any medical conditions, illnesses, and infections detected. Manage any pregnancy-related complications. Provide prophylaxis for health promotion and disease prevention: TT, long lasting insecticidal nets (LLINs), iron/folate tablets, Vitamin A, broad-spectrum anti- helminthics, and other nutritional supplements as needed. Provide client-centered counseling for women and partners/supporters. 15

16. Routine care for the postpartum woman: Health promotion and disease prevention (1) 16 Give Vitamin A 200,000 IU. Provide preventive treatment for hookworm to prevent anemia in endemic areas. Provide iron/folic acid supplementation for at least 30 days postpartum to prevent and treat anemia. Give TT as needed.

17. Breast care: –Where breastfeeding, counsel how to prevent sore nipples, engorgement, and mastitis. –Where formula feeding, counsel on care of breasts and management of engorgement. Check CD4 count according to national protocols. Perform or refer the woman for clinical assessment and evaluation of the need for ARV treatment if eligible. Provide cotrimoxazole prophylaxis therapy (CPT), according to national guidelines. Care for women whose HIV status is positive (1) 17

18. Provide psychosocial support and link the mother to community support for HIV care and services. Provide an appointment for the next visit for HIV care according to national guidelines. Place the family in contact with an available community health worker/volunteer where available and feasible. Counsel on family planning. Care for women whose HIV status is positive (2) 18

19. 19 Work in groups of 2-3 participants. Tasks: Read the section on health promotion and disease prevention in Chapter 7 of the Reference Manual. You have 10 minutes to prepare a role play to demonstrate counseling a postpartum woman and her partner on the following subjects: –Group 1: Family planning for the breastfeeding woman. –Group 2: Family planning for the non-breastfeeding woman. –Group 3: Prevention of malaria / exclusive breastfeeding –Group 4: Hygiene / Rest –Group 5: Nutrition / Fluids Role play

20. Counsel on birth spacing and family planning. Provide family planning method for non-breastfeeding women. Routine care for the postpartum woman: Counseling for self-care (1) 20

21. Routine care for the postpartum woman: Counseling for self-care (2) Prevention of malaria. 21 Exclusive breastfeeding on demand

22. 22 Hygiene Rest Routine care for the postpartum woman: Counseling for self-care (3)

23. Nutrition 23 Fluids Routine care for the postpartum woman: Counseling for self-care (4)

24. Safer sex Resumption of sexual activity 24

25. Routine care for the postpartum woman: Develop a complication-readiness plan Recognize danger signs. Establish a financing plan/scheme. Develop a plan for decision-making. Arrange a system of transport. Establish a plan for blood donation where feasible. 25

26. 26 Routine care for the postpartum woman: Educate about danger signs (1) Vaginal bleeding: More than 2 or 3 pads soaked in 20- 30 minutes after delivery, OR Bleeding increases rather than decreases after delivery

27. Severe abdominal pain 27 Fever and too weak to get out of bed Routine care for the postpartum woman: Educate about danger signs (2)

28. 28 Fast or difficult breathing Severe headache, blurred vision Convulsions Routine care for the postpartum woman: Educate about danger signs (3)

29. 29 Pain in the perineum or draining pus Foul-smelling lochia Dribbling of urine or pain on micturition Routine care for the postpartum woman: Educate about danger signs (4)

30. 30 The woman doesn’t feel well. Breasts swollen, red or tender breasts, or sore nipples Routine care for the postpartum woman: Educate about danger signs (5)

31. Team work Divide into groups of 3-4 participants. TASKS: 1.You have 5 minutes to develop a catchy way to help women and their families remember danger signs in the postpartum period. 2.Present your team work to all of the participants. 31

32. Postpartum visit: Closing (1) Ask the woman if she has any further questions or concerns. Tell the woman when to return for routine postpartum care. Reassure the woman that she can return at any time she has questions or concerns. 32

33. Postpartum visit: Closing (2) Advise the woman to go to the hospital/health center immediately, day or night, WITHOUT waiting if she has any danger signs. Thank the woman for coming. Record the relevant details of care for the woman. 33

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35. 35 Review session objectives By the end of this session, participants will be able to: Describe essential care to provide to the postpartum woman. Provide counseling to the woman during the postpartum period.

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