Postpartum period: study of guidelines for Primary Health Care

Santos, Eliane Gomes dos; Rattner, Daphne

doi:10.1590/1806-9304202500000063-en

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ORIGINAL ARTICLES • Rev. Bras. Saude Mater. Infant. 25 • 2025 • https://doi.org/10.1590/1806-9304202500000063-en linkcopy

Postpartum period: study of guidelines for Primary Health Care

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives: to identify convergences and divergences between the recommendations of the World Health Organization and those of the Ministry of Health for postpartum care in Primary Health Care.

Methods: descriptive documentary research using institutional documents available electronically carried out through a comparative reading of the recommendations of the World Health Organization and the Ministry of Health between the years 2022-2024; 38 of the 63 recommendations of the World Health Organization were compared, excluding those at the hospital level, central management and those very similar.

Results: convergent recommendations were identified: universal eye screening, universal neonatal hearing screening and routine neonatal vaccination; partially convergent recommendations: management regarding breast engorgement, guidance on physical activities and vitamin D supplementation for children; and divergent recommendations: routine pelvic floor muscle training, use of a validated instrument for the screening for depression and anxiety in the postpartum period, vitamin A supplementation in the postpartum period and appropriate time for the newborn’s first bath.

Conclusion: among the recommendations studied, 31.6% were convergent, 36.8% were partially convergent and 31.6% divergent. The partially convergent and divergent recommendations totaled 68.4%, indicating the need for their revision by the Ministry of Health.

Key words
World Health Organization; Primary health care; Postpartum period; Newborn; Guidelines as topic

Puerperal Woman Assessment
Category of recommendation	World Health Organization	Ministry of Health
Recommended	19. Psychosocial and/or psychological interventions during the antenatal and postnatal period are recommended to prevent postpartum depression and anxiety.⁸	Prevention of postpartum depression, early identifying manners of mental suffering of the woman with previous assistance, highlight the importance of the support network in the prevention.¹ Observe carefully the psychic and social conditions of the woman, as well as the presence of anxiety.⁵
Context-specific recommendationa	20. Oral iron supplementation, either alone or in combination with folic acid supplementation, may be provided to postpartum women for 6-12 weeks following childbirth for reducing the risk of anemia in settings where gestational anemia is of public health concern.⁸	Prescription of iron supplementation (40mg/day), up to three months after delivery, for women with and without anemia diagnosis.¹,⁵
Recommended	24. Provision of comprehensive contraceptive information and services during postnatal care is recommended.⁸	To investigate reproductive planning, whether the woman intend to have more children, if she intends to use contraceptive methods, which were the already used ones and which one she prefers.¹ To guide about the return of sexual activities and clarify uncertainties.⁵
Newborn Care
Recommended	26. Universal newborn screening for abnormalities of the eye is recommended and should be accompanied by diagnostic and management services for children identified with an abnormality.⁸	To verify the execution of the Red Reflex Test.⁵ To assess pupillary light reflex with the red reflex test or Bruckner test.⁵ In case of abnormality, the assessment with an ophthalmologist should occur urgently.⁴
Recommended	27. Universal newborn hearing screening (UNHS) with otoacoustic emissions (OAE) or automated auditory brainstem response (AABR) is recommended for early identification of permanent bilateral hearing loss (PBHL). UNHS should be accompanied by diagnostic and management services for children identified with hearing loss.⁸	To guide the family for performing Universal Neonatal Hearing Screening (UNHS) or newborn hearing screening.⁴ To verify the execution of newborn hearing screening.⁵
Recommended	34. Newborn immunization should be promoted as per the latest existing WHO recommendations for routine immunization.⁸	To identify whether doses of BCG and HBV vaccines were provided in the maternity hospital, referring to its execution if necessary.¹,⁴,⁵
Recommended	37. Gentle whole-body massage may be considered for term, healthy newborns for its possible benefits to growth and development.⁸	The habit of performing massages may help the child with a quieter sleep.⁴ Shantala massage contributes to the strengthening of the mother and baby bond, helps with the reestablishment of normal functions and soothing, eases abdominal cramps and improves sleep, promoting mother and child health.¹
Recommended	41. Psychosocial interventions to support maternal mental health should be integrated into early childhood health and development services.⁸	Psychosocial maternal assistance is provided by eSF, which is also responsible by the management of infant growing and development.¹,⁴,⁵ The mother with high-risk of postpartum depression should be referred to specialized care.¹,⁵
Recommended	43b. Health-facility staff who provide infant feeding services, including breastfeeding support, should have sufficient knowledge, competence and skills to support women to breastfeed.⁸	The puerperium assistance in PHC is provided by eSF,¹,⁴,⁵ composed of professionals with presumed knowledge and technical skill to guide about breastfeeding and mother and child nutrition.
Health Systems and Health Promotion Intervention
Recommended	48. Home visits during the first week after birth by skilled health personnel or a trained community health worker are recommended for the postnatal care of healthy women and newborns. Where home visits are not feasible or not preferred, outpatient postnatal care contacts are recommended.⁸	Home visits (HV) in the first week after birth.¹,⁴ HV and return of the mother and NB to the healthcare services within seven and ten days after birth.¹
Recommended	50a. Task sharing the promotion of health-related behaviors for maternal and newborn health to a broad range of cadres, including lay health workers, auxiliary nurses, nurses, midwives and doctors, is recommended.⁸	The care provided to puerperal women and NBs in PHC is performed by the eSF.¹,⁴,⁵
Recommended	50b. Task sharing the provision of recommended postpartum contraception methods to a broad range of cadres, including auxiliary nurses, nurses, midwives and doctors, is recommended.⁸	The actions related to contraceptive methods/reproductive planning are performed by the eSF.¹,⁵

Puerperal Woman Assessment
Category of recommendation	World Health Organization	Ministry of Health
Context-specific recommendation	2a. In high HIV burden settings, catch-up postpartum HIV testing is needed for women of HIV-negative or unknown status who missed early antenatal contact testing or retesting in late pregnancy at a third trimester visit.⁸	To offer HIV testing with pre and post test counseling to women who did not perform it during pregnancy and delivery.¹
Recommended	8. For treatment of breast engorgement in the postpartum period, women should be counseled and supported to practice responsive breastfeeding, good positioning and attachment of the baby to the breast, expression of breastmilk, and the use of warm or cold compresses, based on a woman’s preferences.⁸	To examine breasts, verifying the presence of engorgement or scars that impair breastfeeding¹ To observe and assess breastfeeding for the search for a good positioning and latch¹ To guide towards the manual expression of breastmilk, the storage and the donation of exceeding breastmilk to a Breastmilk Bank¹. In case of engorged breasts, always perform the manual expression of the breastmilk to ease the latch and avoid scars.¹ To guide the execution of soft massages with circular movements; frequent breastfeeding without pre-established schedule; use of nursing bra with large and firm straps; use of cold compress, and painkillers in case of pain⁵
Recommended	10. For the prevention of mastitis in the postpartum period, women should be counseled and supported to practice responsive breastfeeding, good positioning and attachment of the baby to the breast, hand expression of breastmilk, and the use of warm or cold compresses, based on a woman’s preferences.⁸	To clarify about care with breasts in order to avoid mastitis,⁵ whenever possible, to guide the mother to maintain breastfeeding in the impaired breast¹,⁵ and to start the breastfeeding by the non-affected breast, to express adequately the breasts with manual expression.⁵ The latch and positioning should be corrected if necessary.¹ Offer emotional support, maternal rest and abundant hydration.⁵ In case of pain or fever, prescribe medication.⁵ Perform antibiotic therapy.⁵ Prevention is similar of those cases of breast engorgement and scars.⁵ Mastitis demands medical assessment for the definition of the adequate drug treatment.¹
Recommended	12. Dietary advice and information on factors associated with constipation should be offered to women for the prevention of postpartum constipation.⁸	To investigate and guide about nutrition,¹ frequent hydration, adequate nutrition in small portions.⁵
Recommended	22. All postpartum women without contraindication should⁸: • undertake regular physical activity throughout the postpartum period; • do at least 150 minutes of physical activity throughout the week for substantial health benefits; and • incorporate a variety of physical and muscle-strengthening activities; adding gentle stretching may also be beneficial.	To guide the practice of physical activties,¹,⁵ breathing, posture and muscle strengthening exercises, including exercises for the pelvic floor.⁵
Newborn Care
Recommended	25. The following signs should be assessed during each postnatal care contact, and the newborn should be referred for further evaluation if any of the signs is present: not feeding well; history of convulsions; fast breathing (breathing rate >60 per minute); severe chest in-drawing; no spontaneous movement; fever (temperature >37.5°C); low body temperature (temperature< 35.5°C); any jaundice in the first 24 hours after birth, or yellow palms and soles at any age. The parents and family should be encourage to seek health care early if they identify any of the above danger signs between postnatal care visits.⁸	To assess and orient parents about danger signs in the children under 2 months and the need for seek health care.⁴ To observe danger signs to the health of children in all HV.⁴ Children under 2 months may get sick and die fast.⁴ It is necessary the urgent referral to a health care service for babies that demonstrate signs such as: food rejection (does not drink water or cannot be breastfed), important vomits, convulsions or apnea, heart rate under 100 bpm, lethargy or unconsciousness, fast breathing (higher than 60 breaths per minute), diminished activity, presence of subcostal retractions, nose flaring, fever (from 37.5°C), hypothermia (under 35.5°C), visible jaundice below the belly or in the first 24 hours of life, among other signs
Recommended	32a. Clean, dry umbilical cord care is recommended.⁸	To guide about care with umbilical cord that should be maintained clean and dry and fall within two weeks.⁴ To observe characteristics of the umbilical stump.¹,⁵ Daily clean with 0.5% chlorhexhidine or 70% ethyl alcohol should be maintained up to the fall.¹ To guide about care.⁵
Context-specific recommendation	32b. Daily application of 4% chlorhexidine (7.1% chlorhexidine digluconate aqueous solution or gel, delivering 4% chlorhexidine) to the umbilical cord stump in the first week after birth is recommended only in settings where harmful traditional substances (e.g. animal dung) are commonly used on the umbilical cord.⁸	No specification of the population that will use chlorhexidine, the same recommendation for the general population.
Recommended	33. Putting the baby to sleep in the supine position during the first year is recommended to prevent sudden infant death syndrome (SIDS) and sudden unexpected death in infancy (SUDI).⁸	Guiding parents and caregivers for putting the baby to sleep in supine position and its relation with the protection to the nursling against sudden death.⁴ Alerting about risk of sudden death within the first year of life, especially in the first six months.
Context-specific recommendation	36. Vitamin D supplementation in breastfed, term infants is recommended for improving infant health outcomes only in the context of rigorous research.	Indicated in case of prematurity, dark skin, inadequate sunlight exposure and children of strict vegetarian mothers being breastfed.⁴ There is no recommendation concerning universalsupplementation.⁴
Recommended	42. All babies should be exclusively breastfed from birth until 6 months of age. Mothers should be counseled and provided with support for exclusive breastfeeding at each postnatal contact⁸.	Guiding exclusive breastfeeding up to six months,¹,⁴,⁵ without need for teas, water or other food¹ and without unnecessary prescription of other milks.⁴ To encourage and help the family with barriers in breastfeeding⁴,⁵ emphasizing its benefits and importance.⁵
Health Systems and Health Promotion Intervention
Recommended	44. A minimum of four postnatal care contacts is recommended. If birth is in a health facility, healthy women and newborns should receive postnatal care in the facility for at least 24 hours after birth. If birth is at home, the first postnatal contact should be as early as possible within 24 hours of birth. At least three additional postnatal contacts are recommended for healthy women and newborns, between 48 and 72 hours, between 7 and 14 days, and during week six after birth.⁸	HV in the first week after birth.¹,⁴ HV in the first week after baby hospital discharge.¹,⁵ HV and return of the mother and NB to the healthcare service within seven and ten days after birth¹ Puerperal consultation in up to 42 days after birth.¹,⁵
Recommended with targeted monitoring and evaluation	52. Interventions to promote the involvement of men during pregnancy, childbirth and after birth are recommended to facilitate and support improved self-care of women, home care practices for women and newborns, and use of skilled care for women and newborns during pregnancy, childbirth and the postnatal period, and to increase the timely use of facility care for obstetric and newborn complications. These interventions are recommended, provided they are implemented in a way that respects, promotes and facilitates women’s choices and their autonomy in decision-making, and that supports women in taking care of themselves and their newborns.⁸	The eSF professionals who work in prenatal and postpartum care play an important role in including the father (or partner) and the family^* in the care during these periods.¹ The partner and people close to the mother and baby are important in the development of the trust relationship.¹ The support of the partner, family and friends acts preventively against mental suffering in the postpartum period.¹ The support of the family and the health team contributes to a more satisfactory postpartum period.¹ Care for the postpartum woman should include the father, the family (in its various configurations) and the entire related social network.⁵ Pregnant women are referred for prenatal care with a specialist if they present gestational risk factors or risk situations, also in case of obstetric emergency.¹,⁵ The child is also referred to a specialist, according to the signs presented.⁴ ^*The terms family, partner and father in this text are considered broadly, considering several existing configurations of family organization.¹
Recommended	53. The use of home-based records, as a complement to facility-based records, is recommended for the care of pregnant and postpartum women, newborns and children, to improve care-seeking behavior, men’s involvement and support in the household, maternal and child home care practices, infant and child feeding, and communication between health workers and women, parents and caregivers.⁸	There is no specific guidance with regard to the registry of consultations that occurred by means of home visitation.

Puerperal Woman Assessment
Category of recommendation	World Health Organization	Ministry of Health
Not Recommended	7. For postpartum women, starting routine pelvic floor muscle training (PFMT) after childbirth for the prevention of postpartum urinary and fecal incontinence is not recommended.⁸	Recommending in the late puerperium frequent and gradual pelvic floor muscle training, in order to promote awareness and strengthening.⁵
Context-specific recommendation	17. Oral pre-exposure prophylaxis (PrEP) containing tenofovirdisoproxil fumarate (TDF) should be started or continued as an additional prevention choice for postpartum and/or lactating women at substantial risk of HIV infection as part of combination HIV prevention approaches.⁸	Does not mention pre-exposure prophylaxis (PrEP).
Recommended	18. Screening for postpartum depression and anxiety using a validated instrument is recommended and should be accompanied by diagnostic and management services for women who screen positive.⁸	Asking all women about issues concerning humor alteration, sleep, appetite, pleasure and feelings related to their babies.¹ Referral of women with high-risk of postpartum depression to specialized treatment¹,⁵ or when portray several mental suffering.⁵
Not Recommended	21. Vitamin A supplementation in postpartum women for the prevention of maternal and infant morbidity and mortality is not recommended.⁸	All puerperal women residing in locations considered endemic for vitamin A deficiency, should receive, in the immediate postpartum, a megadose (200,000 IU, an oral route capsule) of vitamin A in the maternity hospital¹,⁴,⁵.
Newborn Care
Recommended	30. The first bath of a term, healthy newborn should be delayed for at least 24 hours after birth.⁸	Guiding about the bath of a child, water temperature around 37ºC, not using talcum powder and not letting the child alone even with little water.⁴
Not Recommended	35a. Routine neonatal vitamin A supplementation is not recommended to reduce neonatal and infant mortality.⁸	Oral route administration of a megadose of vitamin A for residents of settings considered of risk.
Context-specific recommendation	35b. In settings with recent (within the last five years) and reliable data that indicate a high infant mortality rate (greater than 50 per 1000 live births) and a high prevalence of maternal vitamin A deficiency (≥10% of pregnant women with serum retinol concentrations.⁸	Vitamin A megadose is recommended for children within six and 59 months, who reside in settings considered of risk⁴: Children within 6 and 11 months - 1 megadose of 100,000 IU. Children within 12 and 59 months - 1 megadose of 200,000 IU each six months.
Recommended	38. All infants and children should receive responsive care between 0 and 3 years of age; parents and other caregivers should be supported to provide responsive care.⁸	We could not find any content concerning responsive care.
Recommended	39. All infants and children should have early learning activities with their parents and other caregivers between 0 and 3 years of age; parents and other caregivers should be supported to engage in early learning with their infants and children.⁸	Early learning activities are not mentioned.
Recommended	40. Support for responsive care and early learning should be included as part of interventions for optimal nutrition of newborns, infants and young children.⁸	No content regarding responsive care and early learning being used as a strategy for optimal nutrition.
Recommended	43a. Facilities providing maternity and newborn services should have a clearly written breastfeeding policy that is routinely communicated to staff and parents.⁸	No recommendation for Basic Health Units to have a clearly written breastfeeding policy.
Context-specific recommendation	54. WHO recommends digital targeted client communication for behavior change regarding sexual, reproductive, maternal, newborn and child health, under the condition that concerns about sensitive content and data privacy are adequately addressed.⁸	No recommendation regarding digital targeted client communication.

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