Evaluation of Nursing Assistance to Women During Puerperium

Results: The study revealed that the sample consisted mostly of females (92.6%), aged between 32 and 34 years (44.4%), unmarried, between 10 and 15 years of training (37.0%), all with post-graduate degrees. All the professionals interviewed performed a puerperal consultation and reported that the most common complaints were related to difficulty with breastfeeding (92.6%). Most of the participants participated in training courses offered by management (66.7%), but the majority did not participate in scientific events in the area of women's health after graduation.


Introduction
The puerperium period is a variable and imprecise period in the life of women.In this period, several transformations occur and women face many new challenges.Thus, there is a need for support from trained professionals so women can be properly educated about the doubts that arise regarding how to take care of themselves and the baby, for example.In this initial postpartum phase, the relationship between mother and child is still not well established, so the caregiver should be careful not to focus all the attention on the baby and forget about the puerpera, because at this stage the woman needs physical and psychological attention, and must be treated with respect.
The puerperal consultation requires that the professional who attends the woman considers care in all its dimensions.When faced with the reality of being a mother, associated with domestic duties, caring for the child, doubts, fears and lack of knowledge arising from this new phase, the woman will inevitably need professional assistance to meet her needs.In this sense, the nurse, specifically the obstetrician nurse, has the technical conditions to meet this demand [8].
The puerperium is a chronologically variable period during which all the involutive modifications of the changes caused by pregnancy and childbirth are developed, also called the overpartum or postpartum period.These changes occur both in the maternal genitalia and in the organism in general, lasting until the return to pre-gravid conditions.At this stage, complications can occur, which, when unidentified or not taken care of, tend to result in morbidity and mortality from preventable causes.On this subject, studies show that diseases in pregnancy, childbirth and puerperium appear as one of the top 10 causes of death in women, however, 92% of these cases could be avoided [12].
The onset of the puerperium occurs soon after expulsion of most of the contents of the gravid uterus, lasting six weeks or more, divided into im-mediate, late, and remote puerperium.This is an important period for the return of the reproductive organs, as well as for the re-adaptation of the female organism, changed by pregnancy and delivery to the pre-gravid situation [6].
In addition, this period is characterised by the process of adjusting to a new maternal identity, learning a new role as mother, adapting to a new family element with its own identity (the child), and, above all, a restructuring of family and social relations [11].Thus, since the woman is tied to the experience of the physical puerperium, she experiences a psychic and social puerperium, commonly, longer than the first.
The construction of nursing knowledge in this area is significant, since in the context of care in the pregnancy-puerperal cycle, decisions about women's health have historically been based on paternalistic systems of health care, in which caregivers decide for the patients.In addition to this, a new direction of health actions is aimed towards a new paradigm of care, focused on the humanistic model [5].
Considering the priority given to women's health, and the importance of the nursing team's performance, knowing the qualification of the professionals responsible for the care of the puerperal women.Moreover, there is a need to know about the actions developed by them in this care as a way of understanding the institutional practice, as well as to highlight the need for strategies that favour the effective participation of the nurse professional in the care of the puerperal woman.
In view of the above, this research seeks to carry out a more detailed study of the nurses' performance regarding puerperal women in Family Health Units in the city of Patos, PB.What are the actions developed by nurses in the care of puerperal women?
In this context, this study will contribute to nursing professionals' awareness of the importance of the qualification of women's care in the puerperal period and their role as members of a health team.It will also provide inputs that can stimulate adequate quality care, focusing on strengthening strategies for puerperal care in search of greater satisfaction of women, relatives, health professionals and society in general, resulting in the improvement of the quality of human life.In this way, the study aimed to analyse the nursing care performed by nurses for women during the puerperium period.

Methods
This research is descriptive and exploratory, with a quantitative approach, carried out in the Family Health Units (FHU) of the municipality of Patos, PB, located in the Patos city, in the backwoods of Paraíba state.Located 307 km from João Pessoa, the headquarters are located in the centre of the state with roads interconnecting it with the whole of Paraíba and providing access to the states of Rio Grande do Norte, Pernambuco and Ceará.According to the Brazilian Institute of Geography and Statistics (IBGE), in the year 2014, the population was estimated at 105,531 inhabitants.
The research sample consisted of 27 nurses from FHU in the city of Patos, PB, representing 70% of the population of 38 nurses.Data collection was performed from August to October 2016.The nurses, who were in service for at least six months and agreed to sign the Informed Consent Form (ICF), were included in the survey.Nurses who were on vacation, maternity leave or with health problems during the period of data collection were excluded.
A questionnaire was distributed, containing objective, non-inductive questions, comprising two parts: the first related to the characterisation of the participants and the second concerned nursing care for the puerperal woman.The information was obtained after the project was approved by the Ethics Committee of the Integrated Colleges of Patos (FIP).The participants were interviewed for approximately 20 minutes in FHU, before or after their activities; the researchers explained the research, providing clarifications for adequate consent and questions regarding the language/nomenclature used in the questionnaire.Before data collection, the ICF was read aloud, giving the nurses the option to participate or not, as well as leave at any time.
Data were analysed in SPSS (version 21).Descriptive statistics of relative frequency, absolute frequency, means, standard deviations and medians were used.Mann Whitney and Chi-square with correlation test of Yates were used.Alpha was less than or equal to 0.05.
The research was carried out with the authorisation of the Health Secretary of the municipality, taking into account the ethical aspects in research involving human beings, as described in Resolution 466/2012 of the National Health Council, which regulates research involving human beings [4]

Results
Table 1 shows that the sample consisted mostly of females (92.6%), aged 32 to 34 years (44.4%),single, between 10 and 15 years of training (37.0%), and between 2 and 5 years of working time in the institution (37.0%).All had a postgraduate degree.Table 2 shows that all conducted consultation, mostly at home visits and reported that the most common complaints were related to the difficulty of breastfeeding (92.6%).Among the most reported difficulties regarding breastfeeding were fissures in the breasts (74.1%).The majority reported participating in management training courses (66.7%).Table 3 shows that most have not carried out updates on women's health care during puerperium.The three who reported performing updates described different hours and years working.Table 5 shows a statistically significant association between updating in the women's health care in the puerperium period and difficulties with breast engorgement (p = 0.04).All the professionals who performed the update in the area reported verifying these difficulties.
Table 6 does not present statistically significant associations between the difficulties of the puerperae in fissures of the breasts and the continuous formation of the professionals.Proportionally, the professionals who report continuous training in the area report fewer difficulties of the puerperas in fissures in the breasts.

Discussion
The data in Table 1 corroborate the findings of a Luz et col study [8] that interviewed 14 nurses who work in the team, with 13 females and 1 male.Regarding the age group, they were between 29 to 59 years of age.According to this research, the time of service of the subjects ranged from 2 to 16 years at the FHU.Lastly, two of the interviewees stated that they had participated in some training Table 4. Description of participation in scientific events in the area of women's health, after graduation.

Variables n %
Participation in scientific events   Table 4 shows that the majority did not participate in scientific events in the area of women's health, after graduation.Continuing education on the care of women during puerperium is essential for these nurses to provide quality care. in the area of women's health, and 12 said they did not have specific training.
According to [10], conducting a home visit is an activity of great importance for the detection and/or prevention of problems that affect pregnancy and puerperium, which are not always apparent in prenatal and puerperal consultations.During a home visit, it is possible to develop educational work with caregivers and family members, providing multidisciplinary intervention aimed at educating mothers about baby care using family members as a strategy.
Among the actions considered important by professionals involved in puerperal care are the identification of problems and difficulties, the examination of the mother and the baby with precise guidelines on care for the new born [7].It is also important to emphasise the importance of the evaluation of lochia which were not verified in the present study.
Even with information about breastfeeding provided by the media, prenatal care, pregnancy courses, posters and leaflets available in the health services, it is during puerperium that the nourisher needs guidance, support and assistance from a qualified professional [1].For [2], nursing activities in national public policies and programmes for women have been offered by international and national institutions and entities -for example, the Ministry of Health (MH), which has developed a continuing education programme with a strategy to improve the social commitment of the professionals and to value their work, since these workers comprise the majority.
The need for support during puerperium is pertinent, because this phase is marked by doubts, fear, insecurity, and assuming responsibilities such as being a mother and a puerpera, concomitantly.From this point of view, the participants' satisfaction with the care offered by the health professionals involved in this type of care was expressive, since they contributed a lot to the success of the puerperium [11].
Breast engorgement is a phenomenon that occurs through venous and lymphatic congestion of the breast and through milk stasis in any portion of the parenchyma.It may disappear 24 to 48 hours after onset.It is attributed to the incomplete emptying of the mammary gland, caused by deficient sucking or by the imbalance between the production and ejection of milk secretion.The breasts become swollen, in maximum tension, turgid, painful and hot.There may also be general malaise, headache and chills.In order to avoid this situation, it is necessary to guide correct positioning at the time of breastfeeding, in order to establish adequate sucking capacity, demonstrating how to place and remove the child from the breast and the correct positions to breastfeed, as well as guidance on breast alternation and frequencies of feedings [15].
Nursing is considered the art of caring, and should be based on scientific technical knowledge and human qualities so that care is given to those who need it, no matter how.A common point among authors of the articles researched is the need for continuing education, with discussions about the need for nursing professionals to receive updates and be trained to perform their duties better.

Conclusion
In this study, all nurses performed a puerperal consultation at the home visit, as a primordial instrument for nursing practice within the scope of the Family Health Unit and has a beneficial effect on the health of the mother and the new born, besides strengthening the family's link with the service.
The most frequent complaint was the difficulty of breastfeeding, in view of the fact that nursing provided guidance to the puerpera at the time of the consultation.The nursing team plays a key role in the follow-up of puerperal women.The actions taken are aimed at promoting health, providing assistance and providing quality services to prepare women for breastfeeding and in health education actions.
More than half of the nurses participate in training courses provided by the management, verifying that there has been an advance in the permanent education of the municipality under study.The results of this study are of great value because they offer support for quality prenatal care offered by the nursing professionals of the municipality as a whole and the differential performance of some who already seek professional qualification and care.
. The research project was sent to the Research Ethics Committee of the Integrated Colleges of Patos, located in the municipality of Patos, PB, obtaining a technical opinion number 1.769.676and Certificate of introduction to Ethics Assessment (CAAE) number 56635316.4.0000.5181.

Table 1 .
Demographics of sample.

Table 2 .
Description of data about puerperal care.

Table 3 .
Description of the completion of refresher courses in women's health care during puerperium.

Table 5 .
Association between difficulties of puerperae with breast engorgement and participation in continuing education.

Table 6 .
Association between difficulties of puerperae with fissures in the breasts and participation in continuous formation.