o&g update course 2012 hospital segamat

1. POSTPARTUM CARE
SECTION 4

2.  The postpartum period
(puerperium) is from the
end of labour until the
genital tract has returned to
normal. It usually last for
42 days.
INTRODUCTION

3. The Aims of Postpartum Care:
Support mother and family
Prevention, early diagnosis and treatment of
complications
Referral
counselling

4. The Aims of Postpartum Care:
Support of breastfeeding
Educate on nutrition, and supplementation
Counselling contraception and the resumption of
sexual activity
Immunization of infant

5. Is to increase the awareness of warning
signal and appropriate intervention at all
level.
 About 2/3 of the maternal deaths occur
during the postnatal period
RATIONALE

6. NEEDS OF WOMEN AND NEWBORN
1.Information/counselling on:
Herself-Health
Self care
Sexual life
Nutrition
Contraception

7. NEEDS OF WOMEN AND NEWBORNNEEDS
NEEDS OF WOMEN AND NEWBORN
2. Support on physical &
psychological
from :
Health care providers
Partner and family
Employer

8. NEEDS OF WOMEN AND NEWBORN
3.Health care for suspected or occurring
complications eg PPH/Fever
4. Time to care for the baby (esp if on bottle
feeding)
5. Help with domestic tasks

9. NEEDS OF WOMEN AND NEWBORN
6. Social reintegration into
her family and community
7. Protection from
abuse/violence Women

10. WOMEN MAY FEAR
Inadequacy ( physical and Emotional )
Loss of marital intimacy -
Isolation
Constant responsibility for care for the baby and
others

11. NEEDS OF NEWBORN
Information/counselling
Care of the baby
*Special Needs refer
to Neonatal Care

12. NEEDS OF NEWBORN
Information/counselling
Breastfeeding
*Special Needs refer to Neonatal Care

13. NEEDS OF SPECIAL GROUPS
NO. Problems Steps to be taken
Women
staying
in
Remote
area
Maternal Mortality Ratio
(MMR) is higher compared
to the general population
Higher incidence of
pregnancy problems
Mobile group and
inaccessible
Delay discharge from the
hospital
Discharge to ‘pusat transit’/
any other health facilities and
keep them there
Education of patients and
support group

14. NEEDS OF SPECIAL GROUPS
NO. Problems Steps to be taken
Urban
poor
Poor ante natal care
leading to postpartum
problems
Non-compliance to post
natal care plan/ defaulter
Inaccessibility
Cost and implications
Education regarding the
importance of post natal
care especially those
with problems
Reassurance, care is
totally health directed
Availability of services at
all centres

15. NEEDS OF SPECIAL GROUPS
NO. Problems Steps to be taken
Single
mothers
They have poor social
support
They are usually financially
unstable
The pregnancy may be
unwanted
Delay discharge They
should be encouraged to
see a social workers
Fees can be waived
Counselling should be
given
Option on adoptions / social
support should be given
from the hospital

16. NEEDS OF SPECIAL GROUPS
NO. Problems Steps to be taken
Illegal
immigrants
Poor ante natal care
leading to postpartum
problems
Non-compliance to post
natal care plan/ defaulter
Inaccessibility
Cost and implication
Legal/ immigrant
implication
Education regarding the
importance of post natal
care especially those with
problem
Reassurance, care is totally
health directed.
Waving charges for
indicated care (Refer to fee
act)
Availability services to all
centres

17. FREQUENCY OF POSTNATAL CARE
1.Day 1
2.Day 2
3. Day 3
4.Day 4
5. Day 6
6.Day 10
7. Day 20

18. PLACES FOR POST NATAL CARE

19. Every visit
Mother
Health and well-being.
Symptoms of abnormal lochia,
Chest pain,
Difficulty in breathing,
Redness and inflammation of lower limbs
Calf swelling and tenderness.

20. Every visit
Mother
Examination of
vital signs
breast
abdomen
Perineum
These should be recorded in the Rekod Kesihatan
Ibu KIK/1(a)/96 and KIK/1(b)/96 .

21. Ask Mother about Baby:
Health and well-being.
Feeding
Bowel opening
Passed urine
Other concerns.
Every visit

22. Assessment On Baby
body weight
body temperature
eyes, skin
umbilical cord.
If the mother accompanies her baby in the ward, the
postnatal care should be continued for the mother by
the hospital staff as scheduled.

23. When Necessary
Observe the feeding
Help the mother to improve the technique of
breast feeding.

24. CHECK LIST TO IDENTIFY HIGH RISKS
Senarai semak bagi mengesan factor risiko semasa post
natal digunakan oleh anggota jururawat/ pegawai
perubatan ketika menjalankan jagaan postnatal.
Ibu diberikan pemeriksaan post natal mengikut senarai
semak dan carta alir adalah seperti dalam rajah 1.
Jika ibu tersebut diberi kod merah, kes tersebut haruslah
dirujuk ke hospital dan cara pengendaliannya adalah sepert
dalam jadual 1.

25. CHECK LIST TO IDENTIFY HIGH RISKS
Jika ibu tersebut diberi kod warna kuning, kes
dirujuk kepada pegawai perubatan/ Pakar Perubatan
Keluarga (FMS) klinik kesihatan atau hospital dan
cara pengendaliannya adalah seperti jadual 2.

26.  Carta Alir Pengendalian Kes postnatal
 JADUAL 1: PENGENDALIAN KES-KES BERISIKO KOD MERAH
 JADUAL 2: PENGENDALIAN KES-KES BERISIKO KOD KUNING
 APPENDIX 7
 SENARAI SEMAK PEMERHATIAN PENYUSUAAN
 STANDARD OPERATING PROCEDURE
 FLOW CHART FOR INVESTIGATION AND REVIEW OF MATERNAL DEATH

27. NUTRITION
Mothers
eat a healthy
balanced diet
vitamins
minerals.
plan simple and healthy meals that include
choices from all of the recommended groups
from the food pyramid.

29. Resumption of sexual activity post
natally
Some Studies shown
 By eight weeks postpartum 71% of respondents
had resumed intercourse, and by ten weeks 90%
of the women who had partners had resumed
intercourse (Glazener 1997).
Another factor that influences sexual behavior
post partum is pain related to perineal damage
and sutures, caused by vaginal tears and
episiotomies (Glazener 1997).

30. Resumption of sexual activity cont..
Mother and her partner should decide together
Sexual intercourse may be resumed after mother’s
vaginal bleeding has stopped and stitches are
healed (usually within 4- 6 weeks)
Be aware that sex first few times following birth
may be painful – Advised for lubricants and
comfortable positioning.

31. Contraception:
Counseling to all postnatal mothers regarding the
risk of next pregnancy.
Should be started before any sexual activity.
Offered to all Postnatal mothers especially those
high risk cases.
Method as in MEC (MOH 2006)
All high risk mothers should be registered in both
PPC and FP Clinic.

32. POSTNATAL EXERCISE
1. Pelvic floor exercise
 Start soon after birth.
 Reduce the possibility of stress
incontinence and restore the pelvic floor
muscle strength.
2. Position
 Sitting, standing or crook lying
3. Steps
 Imagine you are trying to hold back a
stream of urine and tighten your muscles to
prevent leaking.
 Breath normally, hold for 5 seconds.
 Do not tighten the gluteal and thigh
muscles
 Relax for 10 seconds
 Repeat 10 times

33. ABDOMINAL EXERCISE
Benefits:
 Strengthen the abdominal muscle
 Improve abdominal stabilization in the
activities of daily living.
Position:
 Lie on the floor with your knees bent
and head supported
Steps:
 Breath in, then breath out as you pull
in your abdomen and push your lower
back down into the floor.
 Hold for 5 seconds and relax/
 Repeat 5 times.

34. PELVIC EXERCISE
Benefits:
 To maintain mobility of the pelvis
 To tone the natural abdominal corset
 Improve posture
 Prevent and relieve backache
Position:
 Lie down with the back supported, arm
by the side, knees bent together.
Steps:
 Tighten the abdominal muscles and
move the coccyx forward.
 Hold for 5 seconds.
 Repeat 5 times.

35. ARM EXERCISES
Benefits:
 Relieve heartburn.
 Improve circulation
 Improve breathing and lung expansion.
Position:
 Stand upright
Steps:
 Stand straight with feet apart. Keep
your shoulders back.
 Lift both arms as far back as you can
reach without bending your elbows.
 Move your arms forward by 180 .
Swing arms back again and repeat 5
times.

36. ANKLE EXERCISES
Benefits:
 Improve circulation
 Maintain range o motion.
Position:
 Long sitting – sitting on the floor with
both legs straight.
 Sitting – on the chair with the leg
supported or elevated.
Steps:
 Lift one foot off the floor and circle the
ankle several times, first one way the
the other.
 Don’t move your knee.
 Repeat with the other leg

37. WARNING SIGNS TO TERMINATE EXERCISE
 Dyspnoea before exertion
 Dizziness
 Headache
 Chest pain
 Muscle weakness
 Calf pain or swelling (to rule out thrombophlebitis)

38. COPING WITH DEATHS
GRIEF:
 Emotional and somatic responses felt by an
individual on the death of another individual.
 More intense if the death occurs in a person who is
closely related.

39. NORMAL GRIEF REACTION

40. MORTALITY BEREAVEMENT
 Maternal Death
 Stillbirth
 Neonatal death

41. COUNSELLING
Death (Maternal or Stillbirth or Neonatal Death)
 The bereaved persons needs:
- talk about the loss
- express feelings of the sadness, guilt or anger
- understand the normal course of grieving
 Help needed:
- to accept that loss is real
- to work though stages of grief
- to adjust to life without the deceased

42. GUIDELINES ON COUNSELING
Provide an environment and circumstances for feeling
hurt ,guilty, angry or other strongly negative feelings.
Allow the spouse and relatives to ventilate.
Validate the extent of grief.
Be sensitive for the need for postmortem in cases of sudden
death.
Encourage spouse to built a support network of family and
friend.
Be alert for suicidal intention or behavior.
Remember that grief takes time.

43. THE "DO"THE "DO" THE “DON’T”THE “DON’T”
 Express sympathy
 Talk about deceased by name
 Elicit question about
circumstances of the death.
 Elicit question about feeling
and about the death has
affected the person.
 Have a casual or passive
attitude
 Give statements that death is
for the best
 Assume that the bereaved is
strong and will get through this
 Avoid discussing the death

44. TEAR
T - To accept the reality of the loss
E - Experience the pain of the loss
A - Adjust to the new environment
without the lost object
R - Reinvest in the new reality

45. FORMATS USED FOR INVESTIGATION AND REVIEW
OF MATERNAL DEATHS.
KIK/K1-1 -Penyiasatan Kematian Ibu
Mengandung pind.Jul.91
KIK/K1-2 -Investigation of Maternal
Deaths
KIK/K1-3 -Borang Maklumat Kes
Kematian Ibu.
KIK/K1-4 -Feedback format on Maternal
Deaths from State to the
District to State Level.

46. KIK/K1-5 Reporting Format to QA
health Services Committee by
technical Committee for
Investigation and review of
Maternal Deaths at District,
State and National levels
KIK/K1-6 Borang Maklumat bedahsiasat
Atas Kes Kematian Ibu


47. TERIMA KASIH