Post Partum Management and Breastfeeding

Defining the postpartum period

The words "postpartum" and "postnatal" are sometimes used interchangeably. The postpartum period (also called the puerperium) according to Western textbook definitions starts shortly after the birth of the placenta. Neither "postpartum period" nor "puerperium” is officially defined. WHO has, however, formally designated the first 28 completed days after birth of the infant as the neonatal period. Although not officially sanctioned, traditionally the postpartum period is supposed to end 6 weeks after birth.

Aims and timing of postpartum care

The aims of care in the postpartum period are:

• support of the mother and her family in the transition to a new family constellation, and response to their needs
• prevention, early diagnosis and treatment of complications of mother and infant, including the prevention of vertical transmission of diseases from mother to infant
• referral of mother and infant for specialist care when necessary
• counselling on baby care
• support of breastfeeding
• counselling on maternal nutrition, and supplementation if necessary
• counselling and service provision for contraception and the resumption of sexual activity
• immunization of the infant.

The first hours after birth

The baby
The care in the first hours or first day includes meeting the physiological needs of the newborn and assessing the baby carefully. The physical assessment of the newborn has two purposes: to determine the anatomic normality for the first time in a new life and to determine the state of health.
Care in the first hours includes:

• thermal protection by providing a warm environment and not separating the mother and the newborn to prevent hypothermia of the baby.
• supporting frequent and exclusive breastfeeding and assisting the mother if necessary to adopt correct breastfeeding practice.
• cleanliness and clean cord care.
• weighing the baby.
• examination of the newborn for health in order to reassure the mother and to recognize problems early.
• frequent observation by the mother who knows about the danger signs.
• administering vitamin K to the baby if country policy prescribes it, either by injection or orally. However, the evidence for routine administration of vitamin K to all newborns to prevent the relatively rare haemorrhagic disease of the newborn is still lacking.
• starting immunization with BCG and hepatitis B vaccine, and the first dose of oral poliomyelitis vaccine, as recommended. In countries and populations at high risk of tuberculosis infection, infants receive BCG as soon as possible after birth.

The mother

The first hours postpartum are extremely important.

During this time caregivers should:

• assess maternal well-being, measure and record blood pressure and body temperature.
• assess for vaginal bleeding, uterine contraction and fundal height regularly.
• identify signs of serious maternal complications, in particular haemorrhage, eclampsia and
• infections and instigate treatment.
• suture the perineum where necessary

The first week postpartum
Maternal and newborn assessment and advice
In the first week postpartum assessment of the condition of mother and baby is important, together with appropriate advice and counselling, particularly where this is the woman’s first child. The postpartum visit during the first week should include:
The Mother

• General well-being, micturition (especially the first 8-12 hours, see ), possible complaints.
• Abdomen: fundal height, distended bladder?
• Perineum, vaginal haemorrhage, lochia, haemorrhoids.
• Legs: thrombophlebitis, signs of thrombosis?
• Temperature, if there is reason to suspect infection. Body temperature of 38.0°C is abnormal, especially during the first days after delivery.
• Assessment and help with breastfeeding, to prevent problems.

Assessing the baby
A routine neonatal examination does not take more than 5-10 minutes and should be done in a quiet, warm and clean environment, preferably in daylight and with parents present.

Assessment should include:

• asking the mother how she feels about the baby, how the baby is feeding and about any concerns
• general condition: is the baby active, feeding well and frequently? (be alert for the "too good baby", who never cries)
• if necessary, observing breastfeeding and helping the mother to improve the technique
• skin: is it clean (no pustules), not jaundiced?
• are eyes clean (not draining pus)?
• if the baby is not active, not feeding well or other abnormalities are observed more thorough examination should be done.

The first months

If mother and baby are healthy, after the first week frequent support by a caregiver is no longer necessary. Traditionally, the mother is asked to come back for a check-up 6 weeks after birth. However, in the meantime she will need advice on the condition of the baby, and possibly on breastfeeding or other problems that may arise. At the age of 6 weeks, the baby receives a second dose of OPV and the first dose of the diphtheria/pertussis/tetanus (DPT) vaccine.

Baby’s growth should be assessed.

What should be done at the check-up consultation of the mother 6 weeks after delivery?
First of all the caregiver should ask the woman about her well-being and possible complaints or problems. There is more maternal morbidity in the postpartum period than most caregivers are aware of. Traditionally a vaginal examination is performed to check the healing of a large tear, or if the woman complains about pain or other discomfort. Haemoglobin may be measured, especially if anaemia has occurred during pregnancy or in the postpartum period, and if necessary a prescription of iron may again be given. It is important, if possible, to involve the husband or partner in the consultation. Often women and their partners feel the need to discuss the course of labour, and events that occurred at that time. Questions should be answered, and information given.

Integrated care

Traditionally, after 6 weeks the postpartum period ends. However, the care should not end then: in many countries follow-up consultations for baby care are organized; at 10 and 14 weeks after birth further immunizations of the baby are planned. If baby health care clinics are available, the immunizations are best integrated in the care of these clinics. Theoretically, the best time to end postpartum care is 6 months after birth.

Breastfeeding

The establishment and maintenance of breastfeeding should be one of the major goals of good postpartum care. Human breast milk is the optimal food for newborn infants.
Through the ages the human species has been dependent on it for its reproduction, animal milk being used only as an emergency measure if no human milk was available, usually with disastrous consequences. Only in the second half of the 20th century have modified cow’s milk preparations or "formula" become readily available which are closer to human milk in nutrient quantity, but still very different in quality, and lacking in immune factors. In developed countries, differences in mortality between breastfed and artificially fed infants are small, but there is an abundance of literature on the advantages of breastfeeding for the prevention of infant and later morbidity (Howie 1990). In developing countries artificial feeding is associated with a much higher infant morbidity and mortality than breastfeeding, primarily caused by infections and malnutrition (Habicht 1986, Victora 1986, Feacham and Koblinsky 1984).
The immunological properties of breast milk are unique (Welsh & May 1979). Immunoglobulin A (IgA) is of major importance, and is present in particularly high concentration in the colostrum produced during the first few days. IgA probably acts by preventing bacterial adherence to epithelial cell surfaces in the gut and upper respiratory tract (Cravioto et al 1991). Human milk contains both T and B lymphocytes, another mechanism by which the neonate benefits from maternal immunological experience (Bertotto et al 1990). Apart from its immunological qualities, breast milk also contains essential amino acids, and long chain polyunsaturated fatty acids which are not present in animal milks and which may be of great importance for the developing brain (Van Biervliet et al 1992).

Source: http://www.who.int/reproductive-health/publications/msm_98_3/msm_98_3_6.html

Contributed by John Lee