Nutrition:

• A regular diet should be offered as soon as the woman requests food and is conscious.
  
• Intake should be increased by 10% (not physically active) to 20% (moderately or very active) to cover energy cost of lactation.
  
• Women should be advised to eat a diet that is rich in proteins and fluids:
  
• Eating more staple foods (cereal or tuber).
• Greater consumption of non-saturated fats.
• Encourage foods rich in iron (e.g., liver, dark green leafy vegetables, etc.).
• Avoid all dietary restrictions.

Breastfeeding:

• Early skin to skin contact of mother and baby and immediate initiation of breastfeeding
  
• Initiate breastfeeding within the first one hour.
  
• Incase breastfeeding can‘t be started due to either maternal or newborn illness, feeding the baby has to be initiated if possible by milk expressed from the mother herself.
  
• The mother and the baby should not be separated by any means; they must room together.
  
• Women should be encouraged to maintain exclusive breast feeding for six months and should be educated about effective breastfeeding practices, as well as common breastfeeding problems, how to continue breastfeeding for two years and to start complementary feeding after six months.
  

You will learn about breastfeeding advice regarding HIV-infected women in Session 8 of this module.

Postpartum education and counselling include:

• Correct positioning of the baby at the breast.
  
• Glucose, or sugar water.
  
• Exclusive breast feeding only and do not give the baby other fluids like herbs, encouraging breastfeeding on demand.
  
• If there is a medical contraindication to breastfeeding, firm support of the breasts can suppress lactation. For many women, tight binding of the breasts, cold packs, and analgesics followed by firm support effectively control temporary symptoms while lactation is being suppressed.
  

Postpartum family planning:

• All postpartum women should receive family planning education and counselling before discharge.
  
• Ideally, counselling for postpartum contraception should start during the antenatal period, and should be an integral part of antenatal care.
  
• Women who had no antenatal care and those who did not receive counselling during the ante natal period should be counselled for family planning in the immediate postpartum period after their own and their baby‘s condition have stabilised.
  
• Women should be informed about the advantages of birth spacing for at least two years before getting pregnant again and about different family planning options.
  
• Women should also be given a choice of receiving a family planning method in the health post or during a home visit for follow-up within the first 40 days postpartum.
• Facilitate free, informed choice for all women:
  
• The provider should make sure that the mother is not in pain and that her other concerns have been addressed.
  
• Reinforce that non-hormonal methods (lactational amenorrhea, barrier methods, IUD and sterilisation) are best options for lactating mothers.
  
• Initiate progesterone - only methods after six weeks postpartum to breastfeeding women, if woman chooses a hormonal method
  

Exercise:

• Normal activities may be resumed as soon as the woman feels ready.
  
• When to start routine exercise depends on the woman; its safety depends on whether complications or disorders are present. Usually, exercises to strengthen abdominal muscles can be started once the discomfort of delivery (vaginal or cesarean) has subsided, typically within one day for women who deliver vaginally and later for those who deliver by cesarian section.
  
• Sit-ups or curl-ups, (rising from supine to semi-setting position), done in bed with the hips and knees flexed, tighten only abdominal muscles, usually without causing backache.
  

Personal hygiene and perennial care:

• If delivery was uncomplicated, showering and bathing are allowed.
  
• Vaginal douching is avoided in early puerperium, till after bleeding stops completely and all wounds are healed.
  
• The vulva should be cleaned from front to back.
  
• Maintaining good bowel function can prevent or help relieve existing haemorrhoids, which can be treated with warm sitz baths.
  

Emotional support:

• Transient depression (baby blues):  The mother may become depressed for the time being. It is common during the first week after delivery. Symptoms are typically mild and usually, subside by 7 to 10 days. The treatment is supportive care and reassurance.
  
• Persistent depression: This is a long-standing depressive disorder).lack of interest in the baby, the idea of self-killing or others, hallucination (created imagination in the absence of a stimulus), delusions, or psychotic behaviour may require intensive counselling and antidepressants or antipsychotic drugs, so referral is mandatory.
  
• Women with a preexisting mental disorder are at high risk of recurrence or exacerbation during the puerperium and should be monitored closely.
  

Sexual activity:

Intercourse may be resumed after cessation of bleeding and discharge, and as soon as desired and comfortable to the woman. However, a delay in sexual activity should be considered for women who need to heal from lacerations or episiotomy repairs.

• Sexual activity after childbirth may be affected due to decreased sexual desire (due to fatigue and disturbed sleep patterns, genital lacerations /episiotomy).
  

Bladder care:

• Avoid distention and encourage urination: voiding must be encouraged and monitored to prevent asymptomatic bladder overfilling.
  
• Do not routinely catheterize unless retention necessitates catheterization (e.g.retention of urine due to pain from periurethral laceration at vaginal delivery)
  
• Rapid diuresis may occur, especially when oxytocin is stopped.
  

Pain management:

• Common causes: after-pain and episiotomy
  
• Episiotomy pain: immediately after delivery, ice packs may help reduce pain and oedema at the site of an episiotomy or repaired laceration; later, warm site baths several times a day can be used. Analgesics can be used if the pain is not relieved.
  
• Contractions of the involution uterus, if painful (after-pain), may require analgesics.
  
• Commonly used analgesics include:
• Aspirin 600 mg,
• Acetaminophen 650 mg.
• Ibuprofen 400 mg orally every 4 to 6 hours.

Follow-up visits:

• You should inform the mother about the home visit and make a schedule it with the time which is convenient to her.
  
• Tell the mother about the danger signs and to respond as soon as possible. You have learned about the danger signs on the mother and on the newborn in study session 1 of this module.