The ideal way to provide maternal and child health services is through health care delivered by skilled personnel in a health facility. However in some places there are many challenges to achieving this goal, such as shortage of trained health workers and facilities, and difﬁculties of access for rural populations to facility-based health care – including postnatal care.
It may take many years to solve all these challenges. Therefore, while working hard to strengthenthe health system and improve access to facility based care in rural communities, your current role as a Health Extension Practitioner is to focus on home visits for the delivery of postnatal care.
Routine core postnatal care for the mother
The routine care provided to the mother during the postnatal period is mainly preventive measures targeted towards the early detection of the common causes of maternal morbidity and mortality in rural communities. During every postnatal visit, you should do the following routine activity, even when the mother does not complain of anything.
Check the mother’s vital signs
Check the mother’s vital signs, i.e. her temperature, pulse rate, and blood pressure, and make sure they are within the normal range. Straight after the birth, check her pulse and blood pressure at least once every hour, and her temperature at least once in the ﬁrst six hours.
If her blood pressure is too low and falling, and her pulse rate is too fast and rising, she is going into shock. The most likely cause is a life-threatening hemorrhage. If there are no signs of bleeding from the vagina, she may be losing blood internally.
Check if her uterus is contracting normally
Palpate (feel) her abdomen to check contraction of the uterus to make sure it is ﬁrm. Immediately after the birth, you should be able to feel it contracting near the mother’s umbilicus (belly button), and it gradually moves lower in her pelvis over the next two weeks.
Check her uterus every 15 minutes for the ﬁrst two hours after birth and every 30 minutes for the third hour. If possible, check every hour for the following three hours. If the uterus is hard, leave it alone between checks. If it feels soft, rub the abdomen at the top of the uterus to help it to contract. Teach the mother to do this for herself.
Clean the mother’s belly, genitals and legs
Help the mother clean herself after the birth. Change any dirty bedding and wash blood off her body. Always wash your own hands ﬁrst and put on surgical gloves before you touch the mother’s genitals, just as you did before the birth. This will protect her from any bacteria that may be on your hands. Clean the mother’s genitals very gently, using soap and very clean water and a clean cloth. Do not use alcohol or any other disinfectant that might irritate her delicate tissues. Wash downward, away from the vagina. Be careful not to bring anything up from the anus toward the vagina. Even a piece of stool that is too small to see can cause infection.
Check for heavy bleeding (haemorrhage)
After the birth, it is normalfor a woman to bleed the same amount as a heavy monthly period. The blood should also look like monthly blood—old and dark,or pinkish. At ﬁrst, the blood comes out in little spurts or gushes when the uterus contracts, or when the mother coughs, moves, or stands up, but the ﬂow should reduce over the next two to three days and become the more watery reddish discharge known as lochia
Very heavy bleeding is dangerous. To check for heavy bleeding in the ﬁrst six hours after birth check the mother’s pads often — 500 ml (about two cups) of blood loss is too much. If she soaks one pad per hour, it is considered heavy bleeding. If the mother is bleeding heavily, and you cannot stop it, take her to the hospital. Watchfor signs of shock. Remember that postpartum haemorrhage is a major cause of maternal mortality and it can happen at any time in the postnatal period – though it is most common in the ﬁrst seven days.
Check the mother’s genitals for tears and other problems
Use a gloved hand to gently examine the mother’s genitals for tears, blood clots, or a haematoma (bleeding under the skin). If the woman has a tear that needs to be sewn, apply pressure on it for 10 minutes with a clean cloth or pad and refer her to the health centre. If the tear is small, it can probably heal without being sewn, as long as it is kept very clean to prevent wound infection.
Ask her to rest as much as possible and tell her she should not climb up or downsteps or steep hills. Someone else should do the cooking and cleaning for the family for a fewdays. To speed healing, she should also eat plenty of healthy food, keep the genital area clean (washing it with water after using the latrine) and cover it with a clean cloth or pad.
Bleeding under the skin (haematoma) or pain in the vagina
Sometimes the uterus gets tight and hard and there does not seem to be much bleeding, yet the mother still feels dizzy and weak. If this happens, she may have bleeding under the skin in her vagina called a haematoma. The skin in this area is often swollen, dark in colour, tender and soft.
Although a haematoma is painful, it is usually not serious unless it gets very large. If the haematoma is growing, press on the area with sterile gauze for 30 minutes or until it stops growing. If the mother has signs of shock, treat her for shock and take her to the nearest health facility so that the haematoma can be opened and the trapped blood can be let out.
Check to see if the cervix has prolapsed (dropped down to the vaginal opening. This problem is not dangerous, and the cervix will usually go back up inside the mother in a few days. Help the mother to raise her hips so that they are higher than her head. Ask her to do squeezing exercises with the muscles of her vagina and pelvic ﬂoor at least four times a day.
If the cervix stays at the vaginal opening for more than two weeks, the mother should be referred. A cervix that stays prolapsed can cause problems if the woman has another child.
Help the mother to urinate
A full bladder can cause bleeding and other problems. A mother’s bladder will probably be full after the birth, but she may not feel the need to urinate. Ask her to urinate with in the ﬁrst two to three hours. If she is too tired to get up and walk, she can squat over a bowl on the bed or on the ﬂoor. She can also urinate into a towel or thick cloth while lying down. If she cannot urinate, it mayhelp to pour clean,warm water over her genitals while she tries.