RESEARCH ARTICLES
Activities performed by nurses during home visit at postpartum
Maria Helena Soares da Nóbrega MazzoI; Rosineide Santana de BritoII; Flávia Andréia Pereira Soares dos SantosIII
IAssociate Professor of Graduate Nursing Program, Nursing Department of the Federal University of Rio Grande do Norte. PhD Student of the Post Graduate Nursing Program, Federal University of Rio Grande do Norte. Brasil. E-mail: helenamazzo@gmail.com
IIAssociate Professor of Graduate Nursing Program, Nursing Department of the Federal University of Rio Grande do Norte. Professor of the Post Graduate Nursing Program at the Federal University of Rio Grande do Norte. Brasil. E-mail: rosineide@ufrnet.br
IIIAssistant Professor of Graduate Nursing Program, Nursing Department of the Federal University of Rio Grande do Norte. Brasil. E-mail: flaviaandreia@bol.com.br
DOI: http://dx.doi.org/10.12957/reuerj.2014.15526
ABSTRACT: The puerperal assistance is still not satisfactory within the Family Health Strategy (FHS). The research objective was to identify the assistance provided to postpartum women for nurses. This is a qualitative and descriptive study, performed with 10 women attached in the area covered by the FHS, in the municipality of Lajes, Rio Grande do Norte, Brazil. Data were collected from April to May 2010, through semi-structured interviews, after approval from the Federal University of Rio Grande do Norte Ethics Committee, and subjected to content analysis. The results show that during the home visit, the nurse performed only the examination of the neonate. The guidelines were about the care with the newborn and the use of oral contraceptives. Therefore, it was noticed little care focused on the health of postpartum women and attention were directed, almost exclusively, to the child.
Keywords: Women's health; postpartum period; home visit; obstetrical nursing
INTRODUCTION
The postpartum period is considered risky, and requires a skilled assistance, based on risk prevention and health problems, promotion of physical comfort, as well as educational activities that enable the postpartum woman to care for themselves and their child. However, in most of the maternity hospitals, postpartum women are discharged without prior clarification about a reference in the public health system, which ensures the return of women to the Family Health Units (FHU) for postpartum review1.
Postpartum visit requires, from the professional who meets the woman at this moment, considering care in all dimensions. Woman, when faced with the reality of being a mother plus the household duties, child care, the doubts, the fears and unknowns arising from this new phase, inevitably need professional assistance to meet her needs. In this sense, it is understood that the nurse, but specifically the obstetric nurse, has technical conditions to meet this demand.
It is known that the nurse has as essence and specificity of the profession, caring human being. Their role is recognized by the ability and skill to understand the recipient of their care, in other words, the individual as a whole. As a member of the FHS team, nurse promotes interaction and the association between users, staff and the community, seeking to optimize the interventions in health care2.
With regard to the care of women in the FHS, the nurse assists them with tasks relating to prenatal care, the control of cervical and breast cancer, family planning and the postpartum period. So, nurses have their actions developed in the environment of health units and home, through home visits (HV). This activity is presented as a mean of enabling the continuation of assistance to women during pregnancy and childbirth.
Given this reality, it is considered that the assistance to postpartum women is not yet satisfactory at different care segments. This conception leads to assume that there are gaps relating to the actions of team working under the FHS, especially nurses, because they are closer to the woman on that phase. Therefore, in order to know the reality of the care to postpartum women under FHS, the following question arose: What are the actions developed by nurses with the postpartum women under the FHS? The study aimed to identify the assistance given by nurses to postpartum women. It is believed that the study will provide subsidies for the reorientation of health care activities, most notably nursing, to favor new momentum among postpartum women, their families and professionals in the context of primary care, with a view to minimize the problem involving the woman in the puerperal period.
LITERATURE REVIEW
With the pregnancy ending and child birth, a woman experiences a particularly important stage in her reproductive cycle.
During this period, which is called postpartum or puerperal, all involutive transformations and recovery of the maternal organism occurred during pregnancy are unfolded3.
The postpartum period is considered a risky phase, that requires skilled assistance based on the improvement of health conditions. In this stage, women are subject to complications that, if not identified or taken the appropriate action, tend to result in morbidity and mortality from preventable causes4.
The Ministry of Health worried about the rates of maternal and neonatal mortality launched, among other initiatives, in 1984, the Program of Comprehensive Assistance to Women’s Health (PCAWH), with the proposal of decentralization, hierarchy, regionalization and equity of health care for women's health. Besides PCAWH, other strategies have been implemented, for example, the Program for the Humanization of Childbirth (PHC) in 2002, which calls for quality care during pregnancy and childbirth, also contemplating the postpartum period5,6.
In this approach, it is important to remember that the end of the follow-up of a pregnant woman is performed with a childbirth review visit, which should happen at FHU and through HV. For this, it is necessary to consider assistance in two phases: early puerperal review and late puerperal review, held between the seventh and tenth days, respectively, and 42 days after birth.
The PHC considers this an essential activity throughout the care for women during pregnancy and childbirth. The postpartum care have the aim of evaluating the health of women and newborns as well as accompany the return of the maternal organism to pre-pregnancy condition7,8.
METHODOLOGY
This is a descriptive study with a qualitative approach, developed in the municipality of Lajes, Rio Grande do Norte, Brazil, along with 10 postpartum women. The selection of participants obeyed the following inclusion criteria: age equal to or older than 18 years old, be enrolled in the area of the four teams that make up FHS in the municipality; be entered in Prenatal System; have favorable cognitive conditions to answer the questionnaire and be a maximum of 60 days postpartum. The number of participants was determined in accordance with the principles of saturation data, that is, when the depositions brought no new information.
Prior to data collection, it was given permission from the Municipal Department of Health of the municipality under study, approved by the Federal University of Rio Grande do Norte Ethics Committee, with Certificate of Presentation for Ethics Appreciation (CPEA) No. 00228.0.051.000-09 and Opinion No. 443/2009. It was also considered puerperal women’s consent by signing the Informed Consent Form (ICF). It is emphasized that to ensure anonymity of the interviewee, each participant was referenced with the letter E followed by a number, in order of interview. Data were collected from April to May 2010, through semi-structured interviews. For this, we used a previously prepared script containing sociodemographic questions and a guiding question. Data were collected by using a voice recorder and then were transcribed. In the phase of analysis and interpretation of information, the data were worked out according to the content analysis of Bardin9, and analyzed following the principles of Symbolic Interactionism by Blumer10. We conducted a reassessment of information in order to organize them into categories. Subsequently, the revaluation of records was made, as well as the inferences and the interpretation. From the data processing, two categories emerged: Recognition of the need of physical examination by postpartum women and nurses valued more examination of the newborn in HV.
RESULTS AND DISCUSSION
1st Category
The data treatment process revealed that postpartum women recognized the need of physical examination.
It is understood that the physical and gynecological examination in the postpartum period is an activity developed by the team and especially by nurses during home visits. This activity should be performed from seven to ten days after childbirth and also 42 days after childbirth, as recommended by the Ministry of Health11. However, according to the informants, most interviewees attested not have received home visits and considered the actions of professionals limited to the FHU.
In general, the testimony led to understand that the home visit, as a way to accompany women during the postpartum period, is highly important. It is realized the need for health professionals to extricate themselves from traditional crystallized procedures, to adopt a form of interaction contextualized and in tune with the beliefs and values of women and their families12.
With regard to the physical and gynecological examination, there was unanimity on the absence of them, even for the postpartum women who were visited:
She [...] interviewed me asking how I was, then she solved my doubts [...] and asked: will not you examine me? [...] She said: no, do not you want to make sterilization? It is only missing ten days; wait to complete 40 days [...] we will talk in the office. (E3)
At follow-up of postpartum women, health professionals should attend them not only with guidelines, but also perform the physical and gynecological examination focusing on biopsychosocial aspects. Therefore, it is recognized that women's health professionals have a responsibility to assist them, leading them to experience the process of motherhood in a quiet and peaceful way13.
The home presents itself as an important setting for extension of the principles of humanization and care, considering it can increase the safety and confidence of the mother to experience the puerperium14.
The postpartum care was mentioned by interviewees as an opportune moment to adopt procedures to prevent complications. This is clearly observed when the woman expresses the imperative desire to be examined, highlighting the knowledge for need of physical and gynecological examination in postpartum:
I want her to examine me. To examine the breast, to do preventive exam, I did not do it during the nine months of pregnancy. (E2)
During the examination of the puerperal woman, the professional must be aware to all involutive manifestations and related to the recovery of mother’s genitalia, particularly the uterus, which is the first organ to undergo changes from early to late gestatorial phase15.
The respondents also considered the postpartum a complicated period, and compared with the care they received during the prenatal period.
The postpartum period is a little complicated. It could be better, we should be better treated, a greater attention, like the one we received on prenatal period. (E5)
The statements showed the reality experienced by postpartum women. This reality exposes them to diseases and complications, considering the peculiarities on postpartum. Furthermore, they denote the gap between professional practice and the recommendations by the Ministry of Health. In the context of puerperal assistance, anamnesis, clinical and gynecological assessment, the behaviors with respect to family planning, hygiene, nutrition, physical activity, care of the newborn, breastfeeding and women's rights need to be considered in the daily lives of professionals involved in the care for women in the postpartum period16.
From the perspective of Symbolic Interactionism it is possible to say that the participants of this study have established an interactive process with the experienced situation, leading them to consider physical and gynecological examination as a means of preventing harm to their health. When interacting, they attributed meaning to their puerperal condition and to postpartum examination as a means of avoiding complications. It is emphasized that in this process the recognized care they received contributed greatly to establishment of actions for their welfare as a women and mothers.
2nd Category
Regarding the newborn, the testimonies indicated that nurses valued more the examination of the neonate during HV, despising the complaints of the woman with her own body.
I received the team at my house, but they only examined the baby. I complained that I was with a sore vagina and they prescribed an ointment, but did not look the wound [...]. I got a yellow discharge that I did not have not before delivery, and it has bad smell. (E4)
Although the medicine was indicated, the interviewee hinted dissatisfaction with the conduct of the professional, because it was not given attention to her complaint. At that time the gynecological examination was essential for decision making in the face of reported need.
In HV, complaints of postpartum woman also deserve to be considered because the absence of a careful look at this time can exacerbate a pathological process.
The postpartum period is a phase in which the woman needs physical and mental attention. Care should not be focused only in the child. The focus of attention at this time should be the puerperal woman 17. Upon examination of women in the postpartum period it is critical to observe lochia, to inspect the perineal region and in case of cesarean section, the abdominal incision, to make sure the proper healing of the surgical wound and the appearance of complications such as hematomas, infection, dehiscence, among others15. In addition, it allows detecting relevant changes such as anemia, depressive states, infection, and other puerperal complications2.
During the postpartum consultation, family planning must be emphasized considering the specificities regarding their fears and taboos, as well as the cultural, economic, social and spiritual aspects of the couple.
Thus, the role of the nurse in the postpartum period is to provide comprehensive, skilled and humanized care to the mother and child, focusing on the need to support women in their process of psychic reorganization and in the bond with their baby, body changes, breastfeeding, resumption of sexual activity and family planning, in order to minimize the anxieties and fears of women18.
It is noteworthy that in this study, the information sent to postpartum women was restricted to prevent future pregnancy by offering oral contraceptives:
Then the nurse said as she passed the first box: You take these pills and when you have sex use a condom for 10 days, because this medicine is weak, it may happen that in those 10 days you get pregnant. (E6)
This clinical follow-up allows establishing procedures to ensure proper delivery intervals, protecting women and improving perinatal outcomes. However, the care given to women during pregnancy and puerperal period is linked to the routines and resistant to humanization. Women are generally treated as adjuncts, on a precise care process, when they should be recognized as subjects19.
CONCLUSION
Although the respondents have demonstrated to recognize the importance of postpartum care, they did not have access to effective professional follow up, leading to the conclusion that the activities performed by nurses under the FHS in the locality in which the study was conducted were limited, turning to the examination of the newborn, withdrawing itself from that envisaged by the Ministry of Health.
Given this evidence, it is necessary to rethink initiatives to fill the gap in relation to comprehensive postpartum care, since the lack of such care can expose women to complications and death. In addition, this is a period of new developments in the puerperal woman’s life, who longs for a professional support able to meet her expectations, to answer her questions and also to play care activities toward self-reliance and empowerment, essential to maternal performance.
Thus, considering the postpartum care as one of the preventive measures of puerperal complications and upon the testimony, it is clear that at this stage there is possibility of risks and hazards to the physical and psychological status of the mother, with repercussions in the newborn and family as a whole. Therefore, the pregnancy-postpartum period involves a range of concerns not only related to the birth of the child, but also to what may happen to the woman's body. Thus, for the respondents, the prevention of complications is directly related to care promoted by the health team.
The results suggest the need for a rethinking of the activities performed by nurses to the parturient in the context of primary health care.
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