By the end of this unit, participants will be able to:

• Explain the postpartum vaginal discharge and other postpartum symptoms.
• Describe any postpartum symptoms that are dangerous.
• Define "baby blues" and postpartum depression.
• Give three suggestions for dealing with the "baby blues."
• Demonstrate how to talk to clients about making decisions for their future.
• Describe key points to cover when discussing postpartum diet and exercise.
• Name at least three concerns of postpartum women regarding resuming sexual relations.
• Give three reasons why a woman should go for a postpartum check-up.
• Describe at least two ways parents can help siblings adjust to the arrival of a new baby.
• Describe strategies for involving fathers in infant care.
• Explore ethnic/cultural beliefs about postpartum recovery and care of the newborn.
• Discuss regular periodic care and discuss use of emergency room for primary care.
• Explore barriers in communication between mothers and healthcare providers.

6 hours

A. Postpartum Changes in a Women's Body
B. Postpartum Depression
C. Postpartum Diet and Exercise
D. Postpartum Check-up
E. Resuming Sexual Relations: Protection Against Pregnancy and Sexually Transmitted Diseases
F. Involving Fathers
G. Helping Siblings Cope with a New Baby
H. Planning for Your Baby's Healthcare
I. Planning for the Future
J. Communicating With Healthcare Professionals
K. Summary and Review

• Picture of father with children for discussion on how to involve fathers
• Resource Mothers. (1993). Handbook. Sterling, VA: INMED.
• Postpartum Home Visiting Guide (Handout #1)
• Things to watch for in the days after birth (Handout #2)
• Suggestions for dealing with the "baby blues" (Handout #3)
• Postpartum Home Visit Case Study (Handout #4)
• Goals for Myself (Handout #5)
• Role Play Scenarios (Training Aid #1)
• Role Play Feedback (Overhead #1)
• Post-unit Test
• Post-Unit Evaluation
• Newsprint, tape and markers, or blackboard and chalk
• Video equipment: video camera, tripod, tape, VCR, and television
• Video "What Lilly Learned -- Immunizations" , Altshul Group, Evanston, Ill 60201

Advance Preparation

• Read the Resource Mothers Handbook, Chapter 10, "Concerns of the New Mother."
• Assign this chapter to trainees as background reading.
• Collect pictures of fathers with babies
• Create appropriate role plays to use in practice sessions.
• Make sufficient copies of handouts.
• Try out video equipment. Set up video equipment to record role play and show prerecorded video.

Rationale:

• Vaginal discharge (lochia) lasts 1-6 weeks. It is red to dark red at first and gradually turns pink and then to a yellowish or white discharge. It may have a mild odor.
• Cramps or afterpains that feel like a menstrual cramp.
• Discomfort from an episiotomy or bruising.
• Hemorrhoids or constipation.
• Breast engorgement (fullness and hardness felt when milk first comes in).
• Exhaustion from the work of labor and taking care of the new baby.
• A woman who delivered by cesarean section may have pain at the incision site and extra soreness.

• Keep the vaginal area clean. Change pads each time you use the bathroom, then less often as the amount of lochia decreases. Do not use tampons. Take "sitz" baths to relieve soreness and to keep the area clean.
• Cramps are a sign that the uterus is decreasing in size and returning to its pre-pregnancy state. A woman who is breastfeeding her infant will notice that the sucking of the baby helps make the uterus contract. This is a good sign and should not cause concern. Try breathing and relaxation exercises to lessen the discomfort.
• Hemorrhoids are varicose veins in the anal area and are common during pregnancy and after delivery. Sitz baths can help relieve discomfort. Eating lots of fresh fruits and vegetables and drinking plenty of liquids, especially water, will help keep stools soft and avoid constipation.
• Don't overdo it. Get as much rest as possible. Sleep when the baby sleeps. Limit the number of visitors. Ask a family member or friend to come stay with you for a few days to help out.
• Apply warm towels to sore or engorged breasts. Take a warm shower. Express some milk. Wear a supportive bra, even at night while sleeping.
• A woman who had a cesarean delivery has just had surgery and her recovery period will be longer and slower.

Review Handout#1 Postpartum Home Visiting Guide. This can help PSS remember what information is important to obtain from the mothers.

2. Participants can help clients recognize the signs of trouble in their bodies and the need to get plenty of rest. There are some dangerous physical signs that could mean a serious infection. A woman should call her health care provider if she experiences any of these signs. Ask participants if they know these signs. Add any of the following that they do not mention. Have someone write them on newsprint with a red "warning" magic marker. Also refer to Handout #2.

• A temperature of 100 or more
• Painful urination
• Breasts that have a red, warm, painful sore
• Increased vaginal bleeding or discharge that is heavier than a normal period. Passing a clot that is as large as your hand
• Vaginal discharge with a strong, bad odor
• No bowel movement for three days
• Constant, severe pain in the lower abdomen
• Hot, red, painful spot on the legs

• Alone and scared in their new role as mother
• Exhausted
• Too much help from family members; just wanted to be alone with their baby

Were all their feelings positive? Why or why not? What is meant by the "baby blues" or postpartum depression? Is there a difference?

Discuss that "baby blues" can be caused by many things including being overwhelmed by new responsibility, lack of sleep, and hormonal changes after birth.

Distribute Handout #3, suggestions for dealing with the "baby blues." In small groups of three or four, have trainees brainstorm other suggestions they would give their clients to beat the "baby blues." These might include things mothers in your community can do or things your program might do. After a few minutes, come back together. Ask a spokesperson from each small group to share with the whole group one suggestion she thought was particularly good. Repeat this rotation until everyone has contributed.

2. Group discussion. There are times when the "baby blues" become much more serious. What is the difference between baby blues and postpartum depression? Work together on a definition, such as: Postpartum depression (or any kind of depression) is a serious loss of interest or pleasure in all or almost all usual activities and pastimes.

Ask participants if they have ever had close contact with someone suffering from depression. What are some of the signs they might see in a client suffering from postpartum depression? Add any of the following possible responses that they do not bring up:

• Sleep problems, both having trouble staying asleep and sleeping too much
• Staying in bed all day
• Physical signs like headaches, stomach problems, weight gain
• Abuse of alcohol or other drugs
• Feelings of hopelessness
• Talk about suicide
• Unable to concentrate
• Feelings of worthlessness and guilt
• Easily annoyed
• Withdrawing from relationships
• Lack of concern for baby
• Concern they may harm the baby
• Lack of appetite

• Talk it over with your supervisor. Decide together on a plan of action.
• Help the client make an appointment with a mental health counselor.
• Help the client get to an appropriate support group meeting.
• Give the client hotline telephone numbers to call if she thinks she may hurt herself or her baby

• Women need their strength and really should wait a few weeks before they diet. Breastfeeding women do not need a diet to lose weight. But they need to eat a variety of nutritious foods and avoid empty calories. Their bodies need more of the same healthy foods they ate during their pregnancy, but they should not worry about gaining weight.
• Exercise helps contribute to feeling of well-being. Exercise aids in healing and increasing strength. Kegels help tone and strengthen the vaginal and surrounding muscles. [If you need more information, refer to the Handbook.] Abdominal exercises help tighten the tummy and bring back the waist line.

• Help plan or prepare a healthy meal with a client during your visit.
• Suggest that when a client does have time to cook, she prepare a casserole dinner and then freeze half of it for another meal later on in the week.
• If the weather is nice, go for a stroll with the baby during your visit.
• Spend a few minutes doing exercises.

• Every woman wants to make sure she is healing properly.
• She will have a chance to discuss options and make a decision about a birth control method to avoid or delay another pregnancy.
• She can discuss any concerns she has about resuming sexual relations.
• In some clinics, the baby can be seen and possibly immunized before or after her appointment.
• It is a good way of proving to herself that she matters and she is worth this special effort.
• Discuss questions she may have about her labor and birth.

• Postpartum vaginal discharge taking a long time to go away
• Pain during intercourse
• The baby interrupting sex
• Having to wait to have sex until after their six week checkup
• Getting pregnant again
• Getting a sexually transmitted disease
• When will their menstrual period come back
• Breasts "leaking" during sex
• Feeling too tired for sex

• Women who do not breastfeed can expect their menstrual cycle to return within six to twelve weeks after delivery.
• Women who are breastfeeding may not get their period again until their child starts eating solids (sometime between four to six months of age) or until they stop breastfeeding.
• A woman can get pregnant even before she has had her first menstruation after pregnancy so a client should use contraceptive protection.
• If her partner has an STD, she will expose herself to it unless she uses the right protection. PSS' should encourage the client to have her partner get treated.
• Take the first sexual encounter after the baby is born slowly. Don't do anything that feels too uncomfortable. Use K-Y jelly to help with lubrication if you are breastfeeding or real sore. The soreness will go away with time -- maybe up to six months. Wait until after the postpartum bleeding has stopped before you have sex to avoid any possibility of getting an infection. If possible, wait to have sex again until the six week check-up so that you can discuss contraception with your health care provider and be checked to be sure that you have healed well. If you are having sex before you see a health care provider, be sure and discuss family planning options with your PSS. [Note: Family Planning is covered in detail in Unit 9.]

• Allow fathers time to learn how to take care of their babies. Sometimes it is hard for a mother to resist looking over his shoulder and telling him "the right way" to diaper or feed the baby. No one likes having someone look over his or her shoulder when trying something new; fathers are no exception to this rule. They need to learn by doing?
• Parenting Support Specialists can try to schedule the postpartum home visit at a time when the father is home too. Remember to address both parents during the meeting, not just the mother. Have some questions prepared just for the father. Ask him how he is adjusting to sleepless nights to sharing his wife with new baby or to learning how to change a diaper or bathe the baby. Find out what advice he has for other new dads.
• Fathers can burp the baby, change diapers, give the baby baths, and take the baby for walks to give the mother a break.

• It is okay to ask her how she is feeling about the baby's father. This will give her a chance to express her concerns, if any, about the father's involvement or absence.
• A single mother can ask for and get more help and support from family members and friends in caring for the baby.
• A single mother can try to get male family members to care for and work to establish close relationships with her children.

1. Discussion. Ask participants to share their or their friends' or family members' experiences with bringing a new baby home to older children. Did they have a hard time at first? How did they handle any problems that came up?

Chapter 10 of the Handbook has a list of suggestions for involving other children in welcoming the new baby home. Ask participants if they can add to this list from their own experiences with their families. Tell them they can photocopy this list to share with those program clients who have another child/children at home.

• Improves health between babies.
• Focusses on overall health and not just pregnancy health.
• Includes breast and gynecological examinations.
• Includes PAP test.

• Review the American Pediatric Association's guidelines for immunization and any other well baby checks. Include information through 16 years.

• Prolong life
• Prevent disease/infection
• Promote growth and development
• Promote wellness of the community

1. A pediatrician or nurse will present on health awareness for parents of newborns. He/she will discuss the information the professional needs to be provided by mothers in order to support the family's health care needs.

2. Discussion of barriers to healthcare providing that result in negative perceptions of mothers.

• Moms may be uncomfortable and the office or clinic may not be a friendly place.
• Mom may have had a bad experience previously.
• Mom may not give appropriate eye contact.
• Mom may be very different from the healthcare provider (ie. poorer. less educated, less articulate) and therefore hard to understand.
• Moms may be dealing with many uncertainties (ie. money, food, home) and not able to fully concentrate on baby's care; this can be frustrating to the healthcare provider.
• There may be a conflict between patient priority and healthcare provider priority.
• Mom may have a lack of knowledge about he health care system and how it works.
• Moms may not have enough money, have problems with transportation and anticipate long waits.
• Providers may be busy, not pleasant and not aware of the various factors in the moms' lives.
• Providers may not have an understanding of cultural beliefs and practices.

3. PSS will engage in role plays to improve strategies in communication with healthcare providers. use Training Aid #2

Include the following strategies into the role plays:

• Make up your mind to talk openly to your healthcare provider
• Practice describing your concerns so that the provider can understand.
• Recognize that you know yourself and your baby better than anyone. -When you talk about your baby, be able to describe her eating and sleeping patterns, what her crying is like, what calms her. If she is sick, be ready to give her temperature, describe the symptoms and how long she has had these and be ready with the questions you have. Many people write these down because it is hard to remember everything.

1. Discussion and Exercise. Can I find someone to watch my baby so I can go back to school or work? Can I find a job with flexible hours? How can I involve my baby's father in the care of my baby? Ask participants to describe some of the hard decisions or choices that they faced after having a baby and how they resolved them. Distribute Handout #4, Postpartum Home Visit Case Study. Have participants pair up. Share responses with the group.
2. Distribute Handout #5, Goals for Myself. Have participants practice helping a "client" solve problems and make decisions about her future. Explain that they also can use this form when making a postpartum home visit. It is one way to help a client begin thinking about her future. In groups of two, have each participant take turns helping her "client" fill in the handouts. Have them use an example of a tough decision that they themselves -- or someone close to them -- faced after having a baby. After the PSS helps her client work through a problem, give the trainees some time to share with each other how they solved their real life problem.
3. After everyone has had a chance to share and help solve a problem, bring the group back together. Ask participants to share how their partner solved a difficult problem. Use this opportunity to give each other a pat on the back for making what can often be some of life's most difficult decisions.
4. Ask participants if they found filling out the form helpful. Will it be helpful to clients? Why or why not? Would they change it in any way to make it more useful to their clients?

1. Go around the group and first ask each person to say one thing they have found useful or one thing they would like to know more about from this unit. Next time around, ask them to say one thing they have changed their mind about, or something they did not like about the Unit (and why).
2. Return to the objectives. Review them and make sure that the group feels that they have met the objectives for the Unit.
3. Have participants complete the post-unit evaluation form.
4. Distribute post-unit test.