PUERPERIUM AND POSTPARTUM

The study was an exploratory, descriptive, qualitative approach that aimed to understand the meaning given by women about the postpartum and post-delivery review in the context of the Family Health Strategy. The study was conducted in Lajes, RN, Brazil, involving 15 mothers, after the consent of the Rio Grande do Norte Federal University Ethics Committee and the informed consent was signed by participants. Data were collected through semi-structured interviews, grounded on the basis of content analysis according to Bardin, and analyzed within the principles of Symbolic Interactionism as per Blumer. The women attributed a meaning to the puerperium and recognized the importance of rest after giving birth and the post delivery review to prevent complications. Within an interactional process, the puerperium acquired a meaning that leaned toward that of rest. It is necessary to address, discuss and reflect together with professionals, women and their families about the issues that permeate the post delivery review.


INTRODUCTION
The puerperium period, also called postpartum or postdelivery, is a chronologically variable period during which all involutive modifications of the changes caused by pregnancy and childbirth are developed.These occur both in the maternal genitalia as well as in the body in general, lasted until the return to pre-pregnancy conditions. 1 Complications can occur in this stage, which tend to result in morbidity and mortality from preventable causes, when they are not identified or appropriate action is not taken.On this subject, one study showed that disease during pregnancy, childbirth and the postpartum period were prominently featured as one of the ten leading causes of death in women; however, 92% of these cases could have been avoided. 2ven prior to the recognition of the increased vulnerability of women to certain diseases and disorders, the Ministry of Health, over the years, was concerned with the group health of this population.As such, in 1983, the National Program for Comprehensive Attention to Women's Health (NPIAWH) was implemented in order to include this in all levels of care. 3In addition to NPIAWH, other strategies were implemented, for example, the Program for the Humanization of Childbirth (PHCB) in 2002, which recognized quality care during pregnancy and childbirth, contemplating also the postpartum period.
During this period, it is essential to perform the postpartum review, which should occur in the Family Health Units (FHU) and at home, during home visits.For this, it is necessary to consider care in two phases: early and late puerperal review, which must occur, respectively, between the seventh and tenth days and up to 42 days after childbirth. 4 It is an opportune time to: provide cervical cancer prevention, investigate possible physical or psychological complications, and update the vaccination schedule. 5owever, it is observed that this type of care, despite the progress achieved through the PHCB, is not yet occurring satisfactorily at the basic level of health care.Research has revealed that during the years 2001 and 2002, of the women entered into SISPRENATAL who had six prenatal consultations, only 6.47 and 9.43% attended the postpartum review, respectively. 6This reality is in sharp contrast to our professional routine, since one cannot execute the postpartum care as was done with pregnant women during prenatal care.
One realizes the puerperium as a family and social phenomenon that brings with it a variety of meanings drawn from the interactions of the woman with her world of objects throughout her life.It is a period surrounded by taboos and beliefs passed from generation to generation, especially by grandmothers and mothers.Therefore, previous experiences of the women are decisive for considering whether or not the postpartum review is significant in their process of health / disease.Thus, this study aimed to understand the meaning assigned by puerperal women to the postpartum review, in the context of the Family Health Strategy (FHS).

METHODS
This was an exploratory, descriptive research study of a qualitative approach, conducted with 15 women attached to the catchment area of four FHS teams in a health unit in Lages, Rio Grande do Norte, Brazil.The participants received prenatal care and were enrolled in the SISPRE-NATAL in the institution concerned.The number of participants was determined by data saturation; in other words, when new testimony failed to provide any new information.
The way to achieve the goal was through the principle of symbolic interactionism, according to Blumer.For this theory, human beings act according to the meaning that things have for them.So, human beings interact, interpret, define and act within their context, in accordance with the meaning given to experienced situations.Thus, action is seen as a result formed by self-iteration; it is constructed by means of the indications that the person himself has, and the interpretation which indicates action. 7he inclusion of mothers in the study occurred using the following criteria: age greater than 18 years, enrolled in the catchment area of the four teams that comprised the FHS in the study county, entered in SISPRE-NATAL, having favorable cognitive abilities for participation in the interview, and being within 60 days of delivery.
Data collection was proceeded by the authorization from the Municipal Health Department of the study county, and was approved by the Rio Grande do Norte Federal University Ethics Committee, with a Presentation for Ethics Appreciation Certificate (PEAC) No. 00228.0.051.000-09 and opinion No. 443/2009.The participants acknowledged their willingness to participate through signature of the Terms of Free and Informed Consent.It is noted that, to guarantee anonymity of the participants, they were provided with fictitious names.Data were collected between April and May of 2010, through a semi-structured interview using a script prepared for this purpose.The statements, after being transcribed, were reviewed using content analysis according to Bardin. 8Thus, a categorization process was used based on the semantics of the words spoken, resulting in the following categories: importance of rest in the postpartum period, and the importance of postpartum review.

RESULTS
The women attributed meaning to the postpartum period, and recognized the importance of rest and the postpartum review to prevent complications, in order to avoid maternal morbidity and mortality.
Accordingly, these impediments are necessary in order to avoid the appearance of alterations that could trigger illness and even death. 9t is considered that in the puerperal context, the beliefs and taboos pertaining to this phase are present in the daily lives of women during the postpartum period, because a study conducted with postpartum women showed that, in their view, illnesses acquired during this phase remain uncured until the end of life.Moreover, if, for some reason, the protection is broken and a change in health if this happens is present, it is necessary to heal it before puerperal quarantine, so that the body does not retain it.Thus, there are beliefs that a woman's body opens with childbirth, getting exposed to diseases, closing when the postpartum period ends, that is, 45 days after the child's birth. 10t is worth mentioning that the rules obeyed by the women in the postpartum period are based on the references of the people in their relative environment.This is because the knowledge acquired is linked to the transmission of experiences, making it such that daughters are supported by examples and teachings of their mothers, repeating their experiences as a model to be followed. 11ccording to the contributions of symbolic interactionism, it is understood that in the postpartum period the meanings emerged from the interaction between puerperal women and people who participated directly or indirectly in this moment -mother, mother-in-law, sister, neighbor, husband and health professionals.
Thus, the postpartum period is permeated by conceptions that safeguard knowledge and common sense, and within an interactionist process, acquire meaning focused on rest.Accordingly, with the interviewees, in addition to rest, the woman should be cared for by both the family and the healthcare team.

Importance of the postpartum review
Although they have certain theoretical knowledge about the subject, these mothers showed, during the interview, fear and anxiety when facing the uncertainty of what could come to pass in this stage.Thus, it is understood that they take care to maintain their physiological stability and, therefore, considered the puerperal consultation as a process that provided health.
The postpartum review was alluded to as a means for early diagnosis of disease and thus the avoidance of future problems.Therefore, it was understood that the respondents attributed meaning to the puerperal consultation, drawn from the interactions that they had with the world of objects throughout all their lives.This is, what they had heard from their mothers, relatives, the media, and health professionals, among others.
In experiencing the postpartum period, the woman had emotions arising from her interaction with reality, so that the mean-For the interviewees, the puerperium signified a tranquil and caring time.They expressed fear about complications and recognized that these could be avoided through rest, as well as the completion of postpartum consultation.
The interviewees demonstrated recognition of the need for a postpartum review, because they considered this to be relevant care for the maintenance of their health, especially when it came to preventing complications, as can be seen in the excerpts of their statements below:

[…] It is important to avoid complications that may arise after delivery (Clara).
[…] There are a lot of women who have a problem in the intimate part, in the cervix and stuff.If you had an illness, getting care early, the disease would not develop (Joan).

Importance of rest in the postpartum period
It is unveiled that the discussion above touches on the transitory character advocated by the ECA for permanence of children and adolescents in residential institutions.Despite new laws and glances cast forward to this issue, children and adolescents still remain for long periods in these institutions, because of the impossibility of returning to the family of origin or insertion in a foster family.Starting from the principle that the human being is based on his actions the symbols by he interpreted and defined, it can be said that the integration of the interviewees in the postpartum context occurred through the interpretation and definition of the postpartum.For them, this period predisposes the woman to irreversible damages, such as death, if the case existed that they did not have the necessary care during this phase, as evidenced in the following statement:

"[…] fear of having a complication and dying. For this reason I have to be relaxing" (Maria).
In this way, death comes be referred to as a consequence of complications, causing a woman to experience the feeling of fear.In this process, death symbolically represents the end of a journey, and consequently, the breakdown of a family structure.Thus, family members have adopted protective behaviors, preventing postpartum women from performing household chores as a way of preserving her health and her life.
Participants reported that they only began to perform household activities after 30 days, according to the following quote: "I was afraid of damaging something concerning my health" (Ana Luiza).
ing she assigned to this stage was seen as a complex and troubling moment, requiring specific care for the postpartum condition.The actions of the health professionals should be focused on the physical exam, paying attention to the psychological, social, cultural and religious beliefs aspects.Thus, considering the woman in the postpartum period, it is conceived that care for the postpartum women was essential for overcoming difficulties arising from this period.
However, the perceived importance of puerperal review did not guarantee full coverage of this procedure, as shown in the daily FHUs.Considering that, for different reasons, postpartum return occurs with a low frequency and, as a justification, two reasons are cited, namely: failure to record the data in the spreadsheet SISPRE-NATAL, and lack of structure of the primary level services for the performance of the review. 12nother factor mentioned was the argument that women did not return to FHU after delivery.However, data from the National Immunization Program (NIP) revealed a significant number of newborns who attended the clinics to be vaccinated with the second dose of hepatitis B, which is given with 30 days of life. 13It is noteworthy that, often, these children are brought by mothers, so, this time might be appropriate for conducting the postpartum consultation.
In this approach, it is appropriate remember that the followup of the pregnant woman terminates with the childbirth review consultation, which is to be held within 42 days after the child's birth.The PHCB considers this an essential activity for the care of women in the pregnancy-puerperal period. 14,15 owever, for the services and for some professionals, childbirth is the end of the obstetrical process, so, they do not value this return visit. 6hus, the gap in the planning and implementation of the care has triggered difficulties in the effective consolidation of the services in the postpartum period, because although they demonstrated the importance of recognizing postpartum review, only a small number of the participants of this study returned to the health service seeking such care.
Faced with this reality, health professionals, especially nurses, should consider the characteristics and peculiarities of the puerperal women, in the actions to be conducted for them, both at home and in the health services.Thus, they may contribute to the adaptation of the women in the process of motherhood in a quiet and uneventful way.
Another point to be emphasized is the fact that, theoretically, health services recognize puerperal consultation as necessary, but admit the absence of strategies for its achievement.Seen in this way, it is necessary that there is a political commitment to the philosophical assumptions of the UHS, and also with the women, in search of effecting care for postpartum women.For both, programs, care strategies and monitoring of results are auxiliary tools for this pathway, because when used with responsibility and commitment, they become funda-mental tools in planning actions aimed toward improving the health of the population. 12iven these considerations, it is understood that the puerperium signifies an event of great importance in the life cycle of women.However, what happens in the majority of the maternity services is that women are discharged without prior clarity about a referral to the public health system, or ensuring that the women will return to FHUs for the postpartum review. 16hus, health services should ensure efforts for offering quality services to women guided by humanized, individualized, culturally coherent and consistent care, respecting them as social beings.This population group should be understood from the perspective of social transformation and not just from the reductionist perspective of human procreation. 17n general, postpartum consultation is the instance of pregnancy and childbirth cycle which decouples the mother's health from that of the newborn.Therefore, it is a moment of care in the health as a woman, not as a mother.

CONCLUSION
Considering the postpartum review as one of the preventive measures for puerperal complications, and based on testimonials, it can be said that it is an action that guards possibilities to avoid risks and problems in the mother's physical and emotional state, with repercussions in the newborn.Therefore, for the respondents, the meanings relating to the prevention of complications were directly related to rest and the completion of the puerperal consultation.However, despite having demonstrated a recognition of the importance of the postpartum review, only a tiny number returned to the health services in search of this care.
The results indicated the need to address, discuss and reflect together with the professionals, women and their families, the issues related to the postpartum review.For this, it is necessary to provide spaces where people involved with the postpartum care of women can discuss issues of their everyday life with a view to a humanized relationship, fostered by active and sensitive listening, as well as the establishment of links between postpartum women, health professionals and family.
In general terms, the study sought answers based on a methodology that allowed understanding of the meaning ascribed by postpartum women to the postnatal review.Thus, it is concluded that this period was considered a phase of rest and that the postpartum review was a means of detecting abnormalities and acquiring knowledge.