Rev. Enferm. UFSM - REUFSM

Santa Maria, RS, v. 10, e50, p. 1-19, 2020

DOI: 10.5902/2179769237087

ISSN 2179-7692


Submission: 02/26/2019    Acceptance: 05/06/2020    Publication: 02/07/2020

Original Article


Puerperal care practices developed by nurses in the Family Health Strategies

Práticas de cuidado no puerpério desenvolvidas por enfermeiras em Estratégias de Saúde da Família

Prácticas de cuidado en el puerperio desarrolladas por las enfermeras en las Estrategias de Salud Familiar


Críslen Malavolta CastiglioniI

Luiza CremoneseII

Lisie Alende PratesIII

Maria Denise SchimithIV

 Graciela Dutra SehnemV

Laís Antunes WilhelmVI


I Obstetric Nurse, MSc in Nursing from the Postgraduate Program in Nursing of the Federal University of Santa Maria (PPGEnf/UFSM). Santiago, RS, Brazil. E-mail: ORCID:

II Nurse. Professor. PhD student in Nursing. Lutheran University of Brazil, Cachoeira do Sul, RS, Brazil. E-mail: ORCID:

III Nurse. Professor. PhD in Nursing. Federal University of Pampa, Uruguaiana, RS, Brazil. E-mail: ORCID:

IV Nurse. Professor. PhD in Nursing. Federal University of Santa Maria, Santa Maria, RS, Brazil. E-mail: ORCID:

V Nurse. Professor. PhD in Nursing. Federal University of Santa Maria, Santa Maria, RS, Brazil. E-mail: ORCID:

VI Nurse. Professor. PhD in Nursing. Federal University of Santa Catarina, Florianópolis, SC, Brazil, E-mail: ORCID:




Abstract: Objective: to know the care practices developed by nurses from the Family Health Strategies for women in the puerperium. Method: qualitative research conducted between December 2016 and January 2017 through interviews with nine nurses. The data were analyzed according to the operative proposal. Results: The puerperal appointments occur around one to two times within 30 days and are performed mostly by nurses through obstetric physical examination, care with the cesarean or episiotomy incision, evaluation of emotional aspects and guidelines on sexuality, reproductive planning, breastfeeding, newborn care and the bond between mother and baby. Conclusion: the nurses perceive the relevance of the care practices and their main characteristics, because they recognize the hormonal, emotional and social changes of the period and the importance of the work of professionals in this stage surrounded by changes, adaptations and vulnerability.

Descriptors: Postpartum Period; Family Health Strategy; Postnatal Care; Nursing Care; Nursing


Resumo: Objetivo: conhecer as práticas de cuidado desenvolvidas por enfermeiras de Estratégias de Saúde da Família para mulheres no puerpério. Método: pesquisa qualitativa realizada entre dezembro de 2016 e janeiro de 2017 por meio de entrevista semiestruturada com nove enfermeiras. Os dados foram analisados conforme a proposta operativa. Resultados: as consultas puerperais acontecem em torno de uma a duas vezes dentro de 30 dias e são realizadas, majoritariamente, pelas enfermeiras por meio do exame físico obstétrico, cuidados com a incisão da cesariana ou episiotomia, avaliação de aspectos emocionais e orientações sobre sexualidade, planejamento reprodutivo, amamentação, cuidados com o recém-nascido e vínculo entre mãe e bebê. Conclusão: as enfermeiras percebem a relevância das práticas do cuidado e suas principais características, pois reconhecem as alterações hormonais, emocionais e sociais do período e a importância da atuação de profissionais nessa fase cercada por transformações, adaptações e vulnerabilidade.

Descritores: Período Pós-Parto; Estratégia Saúde da Família; Cuidado Pós-Natal; Cuidados de Enfermagem; Enfermagem


Resumen: Objetivo: conocer las prácticas de atención desarrolladas por enfermeras de Estrategias de Salud Familiar a las mujeres en el puerperio. Método: investigación cualitativa realizada entre diciembre de 2016 y enero de 2017 mediante entrevistas con nueve enfermeras. Se analizaron los datos de acuerdo con la propuesta operativa. Resultados: las consultas puerperales ocurren alrededor de una a dos veces en un plazo de 30 días y son ejecutadas principalmente por enfermeras a través de un examen físico obstétrico, cuidados con la incisión de la cesárea o episiotomía, evaluación de aspectos emocionales y directrices sobre la sexualidad, la planificación reproductiva, lactancia materna, neonatal y el vínculo entre la madre y el bebé. Conclusión: las enfermeras perciben la relevancia de las prácticas de atención y sus características principales, ya que reconocen los cambios hormonales, emocionales y sociales del periodo y la importancia de la actuación de los profesionales en este escenario, rodeado por los cambios, adaptaciones y vulnerabilidad.

Descriptores: Período Posparto; Estrategia de Salud Familiar; Atención Posnatal; Atención de Enfermería; Enfermería




The puerperium is the period of the pregnancy-puerperal cycle that corresponds to the physical pregnancy regression and the beginning of exercise of motherhood. It starts immediately after placenta delivery and ends around six weeks after the birth, a period marked by many bodily and emotional changes, which can result in challenges that undermine the mother-child relationship.1-2

In puerperium, women, newborns (NB) and families present health needs. Although it is expected to be a period of healthy experiences, there may arise physical, subjective, relational and social problems.3 The profound transformations experienced in this cycle can expose women to specific complications of maternal morbidity.2-4

Thus, the puerperal women deserve special attention from services and health professionals, who need to be involved in the assessment and care dispensed to the woman, the RN and the family.5 This phase is surrounded by unique experiences, and the care practices developed by health professionals need to contemplate actions towards the NB and the puerperal woman, who needs to be evaluated regarding the presence and severity of physical and emotional changes.6-7

Health professionals from primary health care (PHC) teams need to be able to provide an early embracement of puerperal women and the family, in order to prevent the emergence of problems and difficulties related to the experience of this period.8 The care practices, in the Family Health Strategy (FHS) context, must include, in addition to the embracement: bond of the woman, man and the family with the local service; clinical-educational attention of follow-up of women’s organic changes; reproductive planning, prevention of breast cancer, cervical cancer and sexually transmitted infections; continued support to breastfeeding and newborn care; psychological-emotional support to motherhood and fatherhood; information and education focused on postpartum health; social activities for the promotion of reproductive health.9

The care practices to women in the postpartum period, in the PHC network, have not been implemented.10 However, according to the recommendations from the Ministry of Health (MH), their implementation is important to develop educational and preventive measures, early detection of risk puerperal situations, establishing a bond between the hospital and the FHS and operationalization of the access of puerperal women and NB to quality health services.9

In the Brazilian panorama, actions are deemed to be unsatisfactory, among other reasons, due to problems in the organization of the network of services, in education and health promotion, in the bond between the women and the FHS health team and the focus of professionals’ care practices on the child’s needs.3 The reproductive and motherhood experiences commonly result in new conditions of existence for families, in both personal as relational changes and adjustments that need to be considered by the health service.2

From this perspective, in FHS, the puerperal consultations and home visits (HV) have not been constituted as spaces to embrace women’s anxieties, fears, desires and needs.3-11 Although the puerperal appointment is one of the actions that are part of women’s health care, the frequency of appointments in the PHC is low and, when they occur, they merely focus on the contraception issue.3 Among the reasons for the low frequency of puerperal consultations, authors in the area cite the absence of calls in the health service, lack of scheduling of specific appointments for puerperal women, disorganization in scheduling, loss of records, users’ difficulty in obtaining information and women’s resistance in the nurse’s consultation, requiring the presence or execution of the care by a physician.3

Regarding the HV, although its implementation is essential in the puerperium to assess the health conditions of the mother and newborn, as well as to provide guidelines on health promotion and identify problems and complications to adopt behaviors,3 its planning is non-existent, as shown by the studies in PHC.3,11 In this way, the FHS professionals do not accomplish the HV and await the puerperal woman’s presence in the unit to perform the consultation or delegate the activity to the community health workers (CHW).3

There is little availability and implementation of care practices in the puerperal attention, which devalues the period while care qualifier and health promoter. The visibility of this issue leads to the production of privileged spaces for listening in the relationship between professionals, mothers and families, signaling to urgent investments in the relational component of care.

Therefore, the research question that guides this work emerges as follows: what are the care practices developed in the puerperal period by nurses in the Family Health Strategy (FHS)? To answer the question, the objective is to understand the care practices developed by nurses from Family Health Strategies for women in the puerperium.




This is a qualitative, field and descriptive study, carried out in a FHS in a city in the countryside of Rio Grande do Sul. The local PHC is composed of 32 health services, being 11 urban FHS, three of these health units have two FHS teams and two are located in rural areas, in addition to 19 Basic Health Units (BHU), resulting in a FHS coverage of around 22%. The nine simple teams have one nurse per unit, whereas the three double teams have two nurses per unit, totaling 14 professionals distributed in 11 services. The city is divided into eight health regions and one District unit.

The scenario of study included all health regions of the city with FHS. The scenario of study was chosen because of the recommendation of the puerperal appointments by the MH.9

The research ended once the objective was achieved and when there were no contributions different from those found in the course of the interviews.12 Moreover, the analysis occurred concurrently with data collection, which allowed considering the criterion of data saturation.12

The participants were nine nurses from seven FHS in the urban area of the city of study, of which two are health units with two FHS teams. The criteria for selection were: working in the FHS in the urban area of the city and time working in the service of more than six months. Regarding the latter criterion, the professional was expected to present adaptation to service and knowledge about the reality of the community.

The data were collected between December 2016 and January 2017 through a semi-structured interview, lasting an average of 45 minutes each. Only the researcher and the participant were present, aiming to promote the approach and fluidity.

The guide presented the following questions: Do you perform pre-natal consultations? How do you guide women’s return to the health unit after the delivery for puerperal consultation? Tell me how puerperal consultations tend to happen? How do you proceed in case of absent puerperal women in consultations? What do you consider most important in the puerperal care? Tell me about the Rede Cegonha and its practice in this regard. What do you know about the puerperium in general?

Prior to data collection, the FHS nurses were phone contacted to present the project and question about the interest to participate in the research. In that moment, one day was scheduled in health services, after the work shift, according to the participants’ availability for clarifications and execution of the interviews, which were recorded after the acceptance and approval, through the Informed Consent Form. Subsequently, the recordings were transcribed, analyzed and interpreted according to the operative proposal.12 For this purpose, there was a pre-analysis with floating reading, highlighting the data collected in color, then exploring the analysis material, organizing them into categories.

The commitment with the secrecy and anonymity was guaranteed by the signing of the Confidentiality Form by the researcher and her advisor and by the use of the letter “N” (representing nurses) followed by the number of the order of interviews (N1, N2, N3...) for the identification of the participants in the study. The research was approved on December 15, 2016, by the Ethics Committee of the Federal University of Santa Maria, under opinion number 1.867430, CAAE 62063216.9.0000.5346, and complied with the ethical precepts described in Resolution n. 466 of December 12, 2012.



Results and discussion


The nurses saw the puerperium as a period marked by physiological, emotional and social changes, which represent a female “rebirth”. They also symbolized it as a transformation, adaptation and vulnerability phase, which demand sensitivity from health professionals.


I think it is a period of adaptation. If I had to choose a word: adaptation. Everybody’s adaptation, of the family with the child, the child with the world, and needs a lot of assistance. (N1)


It is a sudden change of life. It is something that deals with many feelings, emotions, and that influences the emotional state [...] it is a period of adaptation of processes, it changes everything, in mind, in thought, life, it messes everything up. Transformation and adaptation, especially for those who are primigravida. (N2)



I think that the puerperium is a period of rebirth for women, which is all new to them [...] there are hormonal, physiological changes, it is a period in which we also have to have the sensitivity to understand what they are going through and the difficulties they are experiencing. (N4)


The reports reveal that the nurses understand the changes stemming from the puerperium and recognize the importance of care practices to women in this phase. For them, in this time, women are more sensitized and vulnerable, experiencing a new life stage, permeated by doubts, which can result in emotional changes, especially when primigravida.

It is essential for nurses understand the puerperium as a moment of weakness, in which the care with the NB, the family readjustments and their own self-care can generate insecurity, anxiety and doubts in women.5 When recognizing that this period is usually surrounded by uncertainties, regardless of being the first experience or not, health professionals can prioritize the individual needs of each puerperal woman13 and develop care practices, which go beyond the physical aspects, also covering emotional and relational issues, thus allowing a woman to live with safety and fullness.

Furthermore, the care practices in the puerperal period lack a humanized relationship, with active and sensitive listening and with the establishment of bonds between health professionals, family members, and puerperal women, prioritizing them as the real protagonists in the decision-making process of their care.14 The healthy puerperal experience must be contemplated in the professionals’ actions, and the well-being and the minimization of maternal and neonatal morbidity and mortality need to be one of the priorities of their care practices.13 Importantly, the nurse has a key role and, in this sense, the care needs to encompass the puerperal woman multidimensionally and meets her health needs.

In relation to the care in the puerperium in the FHS, the participants mentioned how the schedules in the PHC occur, in addition to the frequency and the number of consultations at this phase. One of them even mentioned that the puerperal consultation occurs concomitantly with childcare or the Guthrie test.


Oh, after the birth, we schedule it right away, we do not wait many time, but I cannot tell you how many days exactly, but up to thirty days she will already have been met. (N3)


In puerperium, there is only one [...] we do not usually schedule two puerperal appointments. We try in the first week, but in up to two weeks. (N6)


On average two because, in fact, it includes the child’s appointment. We already make the first puerperal consultation with the Guthrie test and with thirty days. (N7)


The responses ranged between one and two appointments, and the moment when they occurred was around 30 days, mainly in the women’s return to the unit for the Guthrie test.

Given the above, the puerperal care has received attention and been happening, at any time, in the units, and, sometimes, as recommended by the MH, which recommends two appointments. The first needs to happen seven through ten days after hospital discharge through a HV or in the unit itself, and the second, within 42 days, scheduled as a return of the puerperal women to the health service.9

The findings here covered can be seen, considerably, as positive if compared to a survey15 developed in Bahia with 17 puerperal women enrolled in a FHS, in which most of them did not attend the puerperal consultation within 30 days. Furthermore, a study3 conducted in Recife in 2017 points out that the puerperal care occurred through HV. Nevertheless, the care practices to puerperal women were offered only once and by CHW.

The puerperal consultation is a right of all women in the postpartum period, and the health professionals, especially nurses, are responsible for the direct and integral care with the puerperal women,16-17 reflecting about the care practices to this clientele, seeking to ensure the promotion of health and well-being.17 In this sense, according to a study conducted with FHS nurses, actions related to staff training, continuing and permanent education and organization of protocols for the puerperal assistance are strategies that may contribute to the care qualification during the puerperal period.¹

Notably, both the nurse as the physician are capable of carrying out the puerperal consultation. Nonetheless, in the health services of the participants in this study, there were some variations in the organization and accomplishment of this service.


The nursing is usually responsible for the puerperal consultation. In case of some need, we pass on to the doctor. (N3)


Normally us. We have a NASF pediatrician, who makes the inter-consultations with us, from childcare, so they can help us, for example, if we schedule the 30-day return, then the pediatrician is also in the consultation, the nursing consultation with the pediatrician. (N4)


Both of us [physician and nurse]! We can both make the first consultation. (N8)


He [physician] is responsible for the consultation, because he had time availability, by demand, but, in general, other questions are usually answered by the nurse. (N9)



According to the statements, consultations are carried out predominantly by nurses, but also appear as physicians’ responsibility, or still interspersed by both professionals. Even when the physicians carry out the puerperal consultations, nurses are still reference to clarify women’s doubts.

The predominance of nurses’ work in the development of puerperal consultations was also found in a study3 conducted in a FHS in Recife, in the year 2017, which sought to understand the perceptions and practices relating to the embracement in the puerperal care with women. Concerning the multidisciplinary care in the postpartum period, the medical consultation does not replace the nursing consultation, because they are complementary and both play a fundamental role in care.3

            The care practices to women’s health, at all life stages, must be one of the priorities of all professionals who work in the FHS. In this sense, the health team, in services, needs to understand the importance of a quality puerperal care, which happens integrally, beyond the limits of technical procedures, and providing qualified listening and attention to the biopsychosocial needs of puerperal women.18 The support in the puerperium is essential and, when properly done, towards the mother-baby dyad, with the opportunity of manifestation of maternal concerns and complaints, as well as clarifying her questions, promotes the satisfaction of puerperal women, once the support of a person able to clarify the doubts and transmit self-confidence is indispensable for the maternal performance and the experience of the period without complications.18-19

The nurse plays an important role in the postpartum care in relation to the nursing puerperal consultation, a moment that enables guidelines, interventions and actions of prevention and care that minimize risks and contribute to the maternal and child well-being.1 In this sense, as a fundamental part of the care practices to puerperal women in PHC16,19, these professionals need to provide assistance aiming to contribute significantly to reducing the indices of maternal and perinatal mortality. The nurse’s important actions that stand out are the provision of care guidelines and the assessment of maternal psychological state, care with the NB and embracement and clarification of anxieties, fears, desires and needs of each woman.1-6

In this perspective, the nurses reported the information addressed during the puerperal consultation. Essentially, the guidelines begin with the birth of the NB and extend to the moment of the consultation.


When the childbirth occurred, the type of delivery, if there was any complication, any medication, when the discharge occurred, how long was the labor, if it was fast or slow, if the cesarean section was the first option, if it was induced. We normally ask the mother to breastfeed in front of us, so that we can see it. Who cares for the baby, if there is anyone to help, the stitches pain issue, whether it is a C-section or episio, how the care is going. Orientation of the of the breastfeeding, feeding free demand. The adaptation of a woman’s life to continue being a woman. The relationship of [the baby’s] brothers, if there is an elder brother, the issue of not abandoning the other little brothers and see how they are reacting [in relation to the baby] to try to stimulate this issue of family ties. And the mother’s vaccines. (N1)


[...] in case of C-section, we assess the postoperative scar, we talk to her, try to see how she is breastfeeding, we ask her to breastfeed to see if the latch is correct, if she is well, how the lochia is, to check if everything is normal. We assess her and the baby, we evaluate the weight, blood pressure, talk to see how she is feeling, contraceptive methods [...] (N2)


Sexual activity, the use of contraception, breastfeeding, eating, hydration and loss control. (N5)



            According to the participants’ statements, they tend to address the issues recommended by the MH while meeting the puerperal women. However, some reported more complete care practices, while others were straightforward. The most frequent types of care were in relation to the type of delivery, observation of lochia, uterine involution, signs of infection, such as pain and fever, care with the C-section or episiotomy incision, evaluation of blood pressure, breastfeeding, eating, hygiene, sexual activity, contraception methods, family planning, social support to care for the baby, feelings expressed by the puerperal woman, postpartum depression and care with the NB. In addition to these, the participants also cited the guidelines encompassing the labor, hydration, mother’s contact with the baby, brothers’ relationship with the new member, family ties and doubts of the puerperal women themselves.

Given the above, the findings of the study are positive and significant, since, in Brazil, the puerperal assistance, in addition to happening just in the period shortly after childbirth, is often limited and directed to child care, with a focus on breastfeeding.6 The puerperium can be experienced without complications or even with significant problems that can extend for weeks, months or years. In this sense, it must receive attention and longitudinal care.6

The actions and guidelines performed by nurses to puerperal women need to contemplate the peculiarities of the period featured by physical, social and emotional changes, the care with hygiene, eating, breastfeeding, iron supplementation, reproductive planning, postpartum complications, return to the routine appointment and the care related to the child’s health, growth and development conditions.13 However, a space should be offered for women to express their specific health needs, explaining concerns and anxieties, since this is considered a care deficiency and may represent a differential in the assistance.3

The breastfeeding, which represents one of the most explained themes in the postpartum period, must encompass guidelines that involve since breast stimulation until the appearance of possible breast complications.18 Thus, the support for women that desire to breastfeed needs to start from the pre-natal care, so that the experience of this phase elapse positively later, once the mother’s understanding about the benefits of this practice and the preparation for the difficulties that may be presented strengthen its maintenance.20

Regarding sexual intercourse, there is no specific period for the woman to resume sexual activity, which can happen once her intimacy is restored and she feels prepared, being the partner’s support essential.21-22 The health team has a fundamental role in the clarification of doubts about sexuality and sexual practice, providing guidelines about the experience of this process and addressing the issues that involve the reproductive planning and contraceptive methods.17

After the child’s birth, a woman may experience undermining situations in her new routine, and the knowledge deficit about the moment, coupled with the daily burden of household chores and the dependence of the NB on her care, can lead her to a psychic suffering.23 In this context, an Australian study pointed to the importance of clinical and public health investments in the establishment of a strong bond between mother and child in the early postpartum period as a measure to prevent postpartum stress and depression.24

            The health care professionals working in the care with puerperal women and their relatives need to identify the emotional instability and/or lability, directing care actions that will help the family to cope with and overcome the difficulties of this moment of transition of the vital cycle. The lack of support and guidance during the puerperium can jeopardize the care practices to puerperal women, offering potential risks to their health.14

During the puerperal consultation, the MH recommends assessing, on the pregnant woman’s card and/or by asking the puerperal woman, data relating to the process of pregnancy and puerperium as a way to qualify the care practices to puerperal women.9 To do this, one needs to know about the pregnancy conditions, delivery care and the NB, date of birth, route of birth and its indications, complications during pregnancy, delivery or post-partum, advice received, testing for syphilis and human immunodeficiency virus (HIV) during pregnancy and/or delivery and the use of medications.9

The planning during the puerperal assistance reflects in a care that meets the needs of the puerperal woman and the newborn, and contributes to the experience of a healthy postpartum for the new mother.25 In this sense, the family also plays an important role in the support to women and to the demands of the NB. Therefore, they must be oriented since the pre-natal about their responsibility as a support network,23 including the father in the new care routine required by the period.1

The postpartum period can be a moment in the woman’s life in which the happiness of becoming mother spreads with the various feelings and physiological changes, which, when deviated from its natural course, can jeopardize the woman’s health. Thus, nurses, chiefly responsible for this care in the PHC, need to understand the meaning of this period, women’s emerging needs in this phase and the importance of care practices qualified and developed from an integral approach, in order to modify their methods and perform a puerperal assistance to identify and prevent potential complications, in addition to contributing in the exercise of motherhood and the health of the mother and the child.



The nurses realize the puerperium as a period of adjustments, changes and physiological and hormonal changes that may suffer complications. Moreover, they also understand that, in the course of this process, women become more sensitized and vulnerable because they experience a new phase permeated by doubts that cause emotional lability, especially when primigravida.

The nurses in this study perceive the relevance of care practices in the puerperium and their main characteristics once they recognize the hormonal, emotional and social changes of the period and the importance of professionals’ actions in this phase to understand it as surrounded by changes, adaptations and vulnerability. Furthermore, the majority manages to highlight the needs and the main points to be worked and emphasized in this process. Although some professionals provide a more objective care than the others do, and the commitment to implementing the puerperal consultation is different in each location, the care in the puerperium is happening in accordance with the recommendations of the MH.

Nonetheless, the city of study has a low FHS coverage, which may represent a limitation to this research, since, in that moment, many puerperal women could have been assisted differently, not allowing knowing the care provided during the puerperium across the PHC.




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Corresponding author

Name: Críslen Malavolta Castiglioni


Address: Rua Neri Gomes Peixoto, 1700. Edifício Maranata, ap 203, centro. Santiago/RS.

CEP: 97700-000


Authors’ Constributions

1 – Críslen Malavolta Castiglioni

Planning of the research project, acquisition, analysis and interpretation of data and writing of the manuscript and critical review.


2 – Luiza Cremonese

Contributions: analysis and interpretation of data and writing of the manuscript.


3 Lisie Alende Prates

Analysis and interpretation of data and writing of the manuscript.


4 Maria Denise Schimith

Writing of the manuscript and critical review.


5 Graciela Dutra Sehnem

Writing of the manuscript and critical review.


6 Laís Antunes Wilhelm

Planning of the research project, acquisition, analysis and interpretation of data and writing of the manuscript and critical review.




How to cite this article

Castiglioni CM, Cremonese L, Prates LA, Schimith MD, Sehnem GD, Wilhelm LA. Puerperal care practices developed by nurses in the Family Health Strategies. Rev. Enferm. UFSM. 2020 [cited: Year Month Day]; vol.10 e50: 1-18. DOI:

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