C H A P T E R 2 3

1. C H A P T E R 2 3 Physiology and care during the puerperium

2. The chapter aim s to: • review the historical background of postnatal care • explore the role of the midwife in the assessment and care of women's postpartum health and wellbeing • review evidence for women's general health and wellbeing after childbirth • explore women's and their partners views and experiences of postnatal care.

3. The postnatal period • Following the birth of a baby, placenta and membranes, the newly birthed mother enters a period of physical and emotional/psychological recuperation استجمام • Skin-to-skin contact is advocated immediately following birth and during the postnatal period as there is clear evidence of benefit to the mother and father

4. T h e puerperium starts immediately after birth of the placenta and membranes and continues for 6 weeks. • In many cultures around the world 40 days • A general expectation is that by 6 weeks after birth a woman's body will have recovered sufficiently from the effects of pregnancy and the process of parturition.

5. Some women continue to experience health problems related to childbirth that extend well beyond the 6-week period defined as the puerperium • In some cases, healing and recovery can take up to a year following birth

6. postnatal period, defined ‘a period after the end of labour during which the attendance of a midwife upon a woman and baby is required, being not less than 10 days and for such longer period as the midwife considers necessary’

7. the provision of midwifery care will make a positive impact on the health and wellbeing of women

8. the quality of postnatal care provided to women and families in the first days and weeks after birth that can have a huge impact and affect mothers' and families' experiences of the transition to parenthood • Increasing birth rate, a shortage of midwives and ongoing financial constraints, this is an extremely challenging task for maternity service providers.

9. Historical background • It begin from 1902 due to high maternal mortality rates. • Despite a decline in death rates among all age groups in the general population, maternal mortality rates remained high.

10. The majority of maternal deaths were caused by puerperal infection as currently the leading cause of maternal mortality • important aspects of postnatal care. Routine observations, such as temperature, pulse, respirations, blood pressure, breast examination, uterine involution and observation of lochia, were introduced as well as a set pattern of postnatal visits.

11. Midwives were expected to visit twice a day for the first three days and then daily until day 10, commonly referred to as the ‘lying in period’ • maximum duration of postnatal care from 10 to 14 days ,increased to 28 days

12. two major changes happened that affected the pattern of postnatal care, those being the woman returning home much earlier following childbirth and the introduction of ‘selective visiting’ rather than specified days

13. most maternity services had changed from the daily home visits up to • the tenth postnatal day • to selective home visits • but there was wide variation in patterns of selective visiting

15. the maternity services should offer women more choice, greater continuity of care, more involvement in the planning of their care and should be midwifery-led • Today, a partnership approach, where the woman is encouraged to explore how she is feeling physically and emotionally and to seek the advice and support of the midwife

16. The importance of all newly birthed mothers ,what should be provided for the mother and baby in the days and weeks following birth

17. Framework and regulation for postnatal care • a period of prescribed bed rest, compliance with hospital regimens such as vulval swabbing, binding of legs and separation from her baby were thus routine procedures.

18. ‘sickness’ framework of care • postnatal wards for a week or more after birth and their babies were kept in nurseries with their feeds timed and measured, regardless of whether they were being breastfed or formula-fed.

19. mothers have the choice to return home in a few hours after the birth, as it is considered both safe and acceptable by society

20. The newly birthed mother linked with the support of her family and friends. • support mothers to make their own choices

21. Midwives and postpartum care • midwives have the knowledge and skills to determine when to be proactive and undertake specific observations when there are indications to do so. • the midwife needs to be able to acknowledge and recognize what are normal expected outcomes following birth and also be able to identify signs of what is not normal and when to instigate care that will involve further investigation, tests and the support of other health professionals.

22. It is the midwife's responsibility to ensure she is competent and to undertake any further necessary education and training if required to provide extended care (see Box 23.1).

23. The midwife's skills and knowledge • Keep your skills and knowledge up to date: • You must have the knowledge and skills for safe and effective practice when working without direct supervision. • You must recognise and work within the limits of your competence. • You must keep your knowledge and skills up to date throughout your working life. • You must take part in appropriate learning and practice activities that maintain and develop your competence and performance

24. Public health care • poverty and being socially disadvantaged is society leads to increased risk of poor health and wellbeing • ‘Healthy mothers are key for giving healthy babies a healthy start in life’ . • It is important that mothers and their family receive information and advice about healthy lifestyles.

25. Midwives have a vital role to promote healthy lifestyles to the mother, her partner and extended family during the postnatal period. • midwives cannot address public health issues alone and working collaboratively with other professionals and local communities and signposting لافتة to other services needs to occur.

26. Models of care to give more intense care and support to disadvantaged groups have been developed. • *accessible community- based services that would enable families with young children to improve their health and wellbeing

27. public health issues such as smoking cessation, breastfeeding rates , aimed to support children and young people up to the age of 19.

28. This center give benefit for mothers and their families.

29. The barrier is economic climate with budget reductions *community management models such as Working in tandem with Children's Centres is the Family Nurse Partnership (FNP)

30. FNP:for teenage first-time mothers, their partners and family find this approach acceptable programme Early indications show that there are some benefits and peer support is valuable. • An holistic maternal health and wellbeing programme, specifically designed to raise awareness of the general health and wellbeing of mothers, their babies and families

31. Postnatal workshops: • ‘I needed to talk about my birth as I was disappointed I had been induced, but I can understand why now.’ • ‘I didn’t know that most breast cancer is detected by the woman herself, I will start checking now.’ • ‘I feel guilty about smoking and now I have my daughter to think about I will seriously think about stopping.’ • ‘I'm finding being a mum hard. I'm always tired and feeling weepy but I feel a lot better once I have come to the class.'

32. Postnatal exercise classes: • ‘pelvic floor exercises properly • the exercises in early labour and used the positions • the Pilates and relaxation techniques.’ • Exercise to decrease body weight.’

33. Postnatal general comments: • I love being able to exercise with him on a mat next to me.’ • ‘I bring my mum as well. We both have enjoyed it.’.' • ‘It will be difficult for me to attend classes when I go back to work but I intend to walk more and exercise on a weekend.’ • ‘I have enjoyed coming to the sessions and I've loved being able to meet other mums.'