Where is the midwife during puerperium?

A few years ago I was writing my thesis, titled “Midwifery care during puerperium: needs- and care recommendations evaluation”. Today I am revisiting that topic, in an even more informed way and with a salutogenic view.

First of all, it is necessary to describe who midwives are and why they can be the main reference point during puerperium:

The midwife is the only professional who has global-, social- and health competences to accompany and assist the woman and the baby throughout all the phases of the maternity path; they are a health specialist and have the opportunity and the job to protect physiological processes (V. Schmid)

And there it is, described, the puerperium: woman, baby, family, paths, continuity. Because midwives know it: the after-birth period is a special phase of the woman’s- and the baby’s life that involves personal and social aspects.

It is characterized by strong emotions, important physical changes, changes in the interpersonal relationships, and it coincides with the acquisition of a new role, a new identity, especially in woman at their first experience.

Given how strong such changes are and what a strong adaptation capacity they require, the familiar environment, the chance to have a practical help in the management of common everyday activities, and the psychological- and emotional support are important elements in defining the quality of the experience the woman is going to have.

Furthermore, the social changes of the last few decades must be taken into account: the new families are often far from their own families and the women, who often work, have their first child at an always older age in comparison to past generations, and often they also have not had any experience in caring for other children.

This all helps us understand how puerperium is an extremely delicate and “critical” time for the woman, during which you do not just need a clinical evaluation of biological phenomena that characterize it, but it is also essential to plan a care intervention that takes the psychological-, emotional-, relational-, and social dimensions into account, aspects which public health services dealing with birth care should take into account.

Therefore, the care goals for puerperium are to:

• Offer support and assistance to the mother and the baby during the first life weeks in order to promote the physiology of post-natal adaptation
• Promote breastfeeding
• Promote the new family’s wellbeing
• Guarantee clinical check-ups during the first postpartum days
• Prevent or tempestively diagnose conditions, whether organic or relational. Current scientific evidence demonstrate that support is a key element in pursuing such goals. Support is intended as bidirectional relationship that implies an emotional exchange between the parties and that includes:

• Offering orientation
• Offering a concrete, tangible assistance
• Giving emotional support by being present, listening, reassuring and giving confirms

This kind of care intervention does, in fact, help make the woman more self-confident and independent and develop her competences in caring for the baby.

An analysis of healthcare standards during puerperium showed that this very phase suffers a care void linked, in most cases, to the lack of services or to the underuse of them where present, due to a lack of connection between the hospital and the area.

This leads to a reduction in the efficiency of intervention, with a consequent waste of resources and worsening of the quality. The implementation of a hospital-area network represents, therefore, a key goal to pursue. The activation should include the creation of assistance- and support projects for puerperium and the implementation of easy-access procedures for diagnostic assessments and consults with specialists, and the definition of organizational rules and responsibility levels. Moreover, structured, and integrated intervention programmes and the continuity among “before”, “during”, and “after” birth are key aspects in promoting the mother- and the baby’s physical health, as well as in the short- and long-term relational development, as shown by considerable evidence in scientific literature.

The midwife is the healthcare provider who accompanies the woman, the baby, the partner, and the families at the same time through all the phases of the maternity path. Therefore, they are the best figure for offering continuity in supporting and strengthening the mother’s biological, affective, and relational competence, the psychic- and mental competence, and the mother’s social competence.

Healthcare providers working in the maternal- and child field act more and more as facilitators of endogenous competences, yet the promotion of the mother’s competence and trust in caring for the baby are still overlooked aspects. The negative effects of an inadequate, incomplete, or abusive communication on the promotion of self-confidence can be way more significant and long-term than it is commonly thought. A specific training is therefore desirable.

The active listening methodology, alongside problem solving, offer a simple and straightforward way to respect every mother’s choices and may be empowering for the mother herself, as she is the one deciding, not the provider advising or prescribing. Problem solving starts with listening, analyses the question in detail before giving information, to tailor the information required to head towards a personal choice. It means evaluating with the woman which steps are feasible and are to take or to plan. This way, the choice turns into a knowledge- and decisional process supported by the care person. According to all these aspects, the assistance during puerperium represents the true challenge for all healthcare providers who deal with attending the birth path.

For this reason, the current “care void” outlines a space that is all to be filled and built.

Bibliography

1. Schmid V., Salute e Nascita – La salutogenesi in gravidanza, ed. Urra, 2007
2. VV.AA., Raccomandazioni per l’assistenza alla madre in puerperio e al neonato, documento approvato dalle seguenti Società: Associazione Culturale Pediatri (ACP), Società Italiana di Neonatologia (SIN), Società Italiana di Pediatria (SIP), Federazione Italiana Medici Pediatri (FIMP), Società Italiana di Pediatria Preventiva e Sociale (SIPPS), Società Italiana di Medicina Perinatale (SIMP), Società Europea di Medicina Perinatale, Società Italiana di Ginecologia ed Ostetricia (SIGO), Associazioni Ostetrici Ginecologi Ospedalieri Italiani (AOGOI), Associazione Andria., Società Italiana di Psicoprofilassi Ostetrica (SIPPO), Federazione Nazionale Collegi delle Ostetriche, Associazione Nazionale Culturale Ostetriche Parto a Domicilio, Sindacato Ostetriche Italiane (SOI), Federazione Nazionale Collegi IPASVI
3. VV.AA., Postnatal care up to 8 weeks after birth, NICE Clinical Guideline N°37, 2006
4. VV.AA., Clinical Guidelines for the Establishment of the Exclusive Breastfeeding, ILCA International Lactation Consultant Association, 2005
5. VV.AA., Breastfeeding Council: Training Courses; Participant’s Manual., Who/cdr/93.4 unicef/Nut/93.2, 1993
6. Rapisardi G., Le visite domiciliari nel puerperio, Azienda ospedaliera A. Meyer, Florence  
7. Pescetto L., De Cecco D., Pecorari N., Ragni N., Ostetricia e ginecologia, Società Editrice Universo, Rome 2006
8. Chalmers B., Mangiaterra V., Porter R., Who principles of perinatal care: the essential antenatal, perinatal, and postpartum care course, 2001.
9. VV.AA., Lo stato di salute delle donne in Italia, primo rapporto sui lavori della commissione “Salute della donna”, Ministero della Salute, Roma, marzo 2008, Progetto obiettivo materno infantile del Ministero della Salute, D. M. del 24/4/2000
10. King F.S., Helping mothers to breastfeed, African Medical and Research Foundation, 1992  
11. Bennett V.R., Brown L.K., Manuale dell’ostetrica di Myles, ed. Ermes, 1995
12. Reeder S.J., Martin L.L., Maternity Nursing: Family, Newborn, and Women’s Health, Lippincott Williams & Wilkins, 1996

Bibliography

http://verenaschmid.eu/  

http://www.saperidoc.It

http://www.ncbi.nlm.nlh.gov/pubmed/

Aida Hilviui