CONSULTA PUERPERAL DE ENFERMAGEM : PREVENÇÃO DE COMPLICAÇÕES MAMÁRIAS Suellen

The present study aimed to identify breast disorders of postpartum women admitted to a maternity ward at a teaching hospital in the city of Ponta Grossa, Paraná. Quantitative exploratory study based on data collection performed from March to November 2015. The results obtained allowed to identify the obstetric profile of those women, breast complications such as cracked nipples, engorgement and mastitis. It is concluded that the Prenatal and Postpartum Nursing Consultation Project provided an opportunity to identify important breast complications, through health education in the postpartum period. DESCRIPTORS: Breastfeeding; Postpartum period; Health education; Nursing. Autor Correspondente: Recebido: 13/01/2016 Suellen Vienscoski Skupien Finalizado: 01/06/2016 Universidade Estadual de Ponta Grossa Av. Gen. Carlos Cavalcanti, 4748 84030-900 Ponta Grossa, PR, Brasil E-mail: suvienscoski@gmail.com http://revistas.ufpr.br/cogitare/ Artigo original 1Enfermeira. Mestre em Tecnologia em Saúde. Docente de Enfermagem e Saúde Pública da Universidade Estadual de Ponta Grossa. Ponta Grossa, PR, Brasil. 2Enfermeira Obstétrica. Mestre em Enfermagem. Docente de Enfermagem e Saúde Pública da Universidade Estadual de Ponta Grossa. Ponta Grossa, PR, Brasil. 3Enfermeira. Mestre em Enfermagem. Docente de Enfermagem e Saúde Pública da Universidade Estadual de Ponta Grossa. Ponta Grossa, PR, Brasil. Cogitare Enferm. 2016 Abr/jun; 21(2): 01-06 CONSULTA PUERPERAL DE ENFERMERÍA: PREVENCIÓN DE COMPLICACIONES DE LA MAMA RESUMEN: Estudio cuya finalidad fue identificar los problemas de la mama de puérperas en atendimiento de una maternidad escuela en el municipio de Ponta Grossa, Paraná. Investigación exploratoria cuantitativa por medio de datos obtenidos en el periodo de marzo a noviembre de 2015. Con los resultados, fue posible identificar el perfil obstétrico de las puérperas, problemas de mama como la fisura del pezón, congestión y mastitis. Se concluyó que el Proyecto Consulta de Enfermería en el Prenatal y Posparto posibilitó el descubrimiento de problemas mamarios relevantes, fornecendo subsidios para prevenir las complicaciones mamarias por medio de la educación en salud en el posparto. DESCRIPTORES: Amamantamiento materno; Periodo posparto; Educación en salud; Enfermería.


INTRODUCTION
The postpartum period is characterized by gradual physiological changes in the maternal body.Therefore, special care and information (for example, on breastfeeding) are needed (1) .In this context, postpartum nursing consultations aim to detect and assess the physiological factors of postpartum women and provide guidance on breastfeeding, in order to prevent breast complications and early weaning (2) .
The Brazilian Ministry of Health and the World Health Organization recommend exclusive breastfeeding up to 6 months of age because of the benefits of this practice in maternal and child health; however, these recommendations are far from the current reality (3) .
According to a study on breastfeeding conducted in the Southern region of Brazil (4) in the first month of life, 60% of the children were under exclusive breastfeeding and 10% had already been weaned.In the third month of life, 29% had been weaned and 39% were under exclusive breastfeeding.In another study (5) conducted in the city of Londrina, of the 72.5% children breastfed within one hour after delivery, only 33.8% continued receiving exclusive breastfeeding for six months.The average duration of exclusive breastfeeding in this study was 4 months and 27 days.This practice is common in the region where the study took place.Asking postpartum women about the reasons for early weaning of their infants involves the identification of the determining factors in this practice.These include lack of information on the bio-psychological function of breastfeeding and unpreparedness of health professionals (6) .
Thus, the state of Paraná, through "Rede Mãe Paranaense" (7) .This network, set as a government priority, based on analysis of child and maternal mortality indicators and aimed to lower these mortality levels further, disseminates actions targeted to the encouragement of breastfeeding e.g. , even to infants at risk.The Brazilian Ministry of Health set nationwide programs and policies correlated to the other breastfeeding support, promotion and protection proposals.One program is called "Iniciativa Hospital Amigo da Criança" (Baby Friendly Hospital Initiative) (8) , aimed to support breastfeeding in hospitals based on the "Dez Passos para o Incentivo do Aleitamento Materno" (Ten Steps to Breastfeeding) proposing changes in routines and practices.
Another program that deserves mention is "Rede Amamenta Brasil" (9) , also an initiative aimed to encourage breastfeeding in primary care.Nurses are trained and prepared to provide guidance and support in an interactive way, based on critical thinking.Thus, when appropriate guidance on breastfeeding is provided, mothers are more likely to breastfeed for longer, with proper baby's latch and adequate suction in the nipple and areola, preventing nipple soreness and early weaning.
In order to achieve the objectives of the State Department of Paraná and of the Ministry of Health, we stress the importance of the prevention of nipple sores, which can be caused by latch-on problems, especially during the first postpartum week.Nipple sores are very painful and can be prevented with health education, and nurses play a key role in this regard (10) .
The justification for the present study is in that it addresses the prevention of damage to postpartum women's health, once some postpartum-related complications are preventable.
Therefore, further studies are needed to emphasize the importance of nurse professionals as health educators in order to prevent postpartum complications through actions targeted to health promotion and prevention by scholars and professors.
In view of the aforementioned, the guiding hypotheses of this study is postpartum nursing consultation allows to identify and prevent breast complications in postpartum women based on health education.Thus, the present study aims to identify the breast problems of postpartum women admitted to a maternity ward at a teaching hospital in the city of Ponta Grossa, Paraná.

METHOD
Descriptive, exploratory study with quantitative approach conducted in a referral maternity ward at a teaching hospital in the city of Ponta Grossa -Paraná, from March to November 2015.
Primary data were obtained at the "Projeto de Pesquisa e Extensão Consulta de Enfermagem no Prénatal e Pós-parto" (Prenatal and Postpartum Nursing Consultation Research and Extension Project).The study population was composed by women that experienced the immediate postpartum period (first to tenth day after delivery) and were hospitalized in the maternity ward (inclusion criteria).The exclusion criteria were women outside the immediate postpartum period, not hospitalized and who refused to participate in the study.Convenience sampling was used, and 252 postpartum women participated in the study.
Data collection was performed with a structured questionnaire with 30 closed questions concerning identification, gynecologic, obstetric and family history and nutritional status and current pregnancy.The questionnaires were completed by nursing students of the 4th grade trained for this activity, in private rooms, in the study site, during a nursing consultation (around 40 minutes).The information was typed in a database of EPI INFO, version 3.3.1.For data analysis, the software Statistical Package for Social Sciences (SPSS), version 13, was used.
The project was approved by the Research Ethics Committee of Universidade Estadual de Ponta Grossa, under no 1.055.927/2015.The participants signed the Free Informed Consent form.The study complied with the national and international ethical standards of research involving humans.
In order to elucidate the study, we provide a brief obstetric and socio-demographic profile of the postpartum women: 124 (49.1%) are primiparous and 128 (50.9%) are multiparous.Regarding age assessment, an age group classification was used, as follows: 134 (53%) were aged 21-30 years.Regarding education and employment bond, 68 (27%) had completed secondary education and 166 (66%) had no employment bond.
Another finding related to the nursing consultation concerned the participation of the respondents in a group of pregnant women with a professional nurse: 121 (48.1%) participated in the group and 131 (51.9%) did not participate in any group during pregnancy.In turn, asked about guidance/information on breastfeeding, 168 (66.5%) mothers reported receiving guidance on the importance of breastfeeding for the health of their infants in the first six months of life and, especially, for the care of breasts.However, 84 (33.5%) said they did not receive any type of guidance regarding breastfeeding.
In nursing consultations, breast engorgement was a frequently reported breast complication, with 24 (9.2%) of the postpartum women reporting engorgement on both breasts.
The onset of nipple cracks occurred in 135 (53.5%) postpartum women; of these, 59 (23.5%) had nipple crack son the right breast and 76 (30%) on the left breast.Regarding the cracks observed in the right breast, 59 (23.5%), 42 (71%) postpartum women showed small nipple cracks, four (8%) had medium cracks, 11 (19%) large cracks and two (2%) nipple with vesicular eruptions.As for the left breast, 76 (30%), 12 (16%) postpartum women had small nipple cracks, 60 (79%), large cracks, three (4%) large cracks, and one (1%) nipple with vesicular eruptions.The study also revealed that of the 121 (48.1%) postpartum women who participated in groups of pregnant women, 25 (10%) had nipple cracks on the right breast, 30 (12%) on the left breast and 66 (26.1%) said they did not feel any discomfort while breastfeeding and did not have any nipple cracks, reinforcing the importance of health education in the prenatal period promoted by nurses.
Finally, it was found that 15 (6%) postpartum women had mastitis, breast inflammation, and four (1.6%) of them reported pain, as well as warmth and redness on the right breast and 11 (4.4%) on the left breast.

DISCUSSION
Considered a basic physiological act, breastfeeding is not always instinctive in humans and must be learnt by women.Thus, some postpartum women may feel insecure and need professional advice on this practice (5) .According to the results obtained, most respondents were multiparous (have had previous pregnancies), at a biological ideal childbearing age, but had a low educational level.It is known that a low educational level may contribute to poor understanding and adherence to breastfeeding promotion actions by postpartum women with lower educational level may find it more difficult to understand and adhere to breastfeeding promotion actions, which affects their decision on shorter or longer breastfeeding (6) .
The educational actions promoted during the pregnancy and postpartum period are very important and should start as soon as possible, to reduce the probability of postpartum complications and ensure a successful (11) .
Thus, women should be given professional advice on breastfeeding in the prenatal period, in order to experience this cycle in a pleasant and positive way.A minimum of six nursing consultations are recommended as follows: one in the first quarter, two in the second quarter and three in the last quarter, as well as one consultation in the postpartum period, up to 42 days after delivery (11)(12) .Regarding attendance of prenatal consultations, the study showed (100%) adherence of the postpartum women, but they still need to be encouraged to attend the six consultations.
In order to be ensure a high-quality prenatal care, nursing professionals should be continuously trained to perform care and educational activities, either individually or in groups, to ensure that the pregnant women know and understand the gestational process.Group training has been used as an educational strategy, a space of knowledge, for exchanging experiences, clarifying doubts, establishing bonds and sharing their distress (13) .Despite the importance of such groups, most postpartum women said they did not participate in any group, but were given information on breastfeeding practice in the prenatal consultations.
Prenatal care is aimed to the early detection of complications in the pregnant woman and her fetus.It also provides an opportunity for the nurse to assess the level of understanding of pregnant women of the breastfeeding practice, to promote its adoption and maintenance (7) .During this period, women should be advised on how to prepare their breasts for breastfeeding, in order to prevent cracks and more serious complications such as mastitis, breast abscesses and milk retention (14) .
It should be stressed that prenatal nursing guidance has been found to have a positive impact on breastfeeding, but many women usually do not attend the six nursing consultations recommended by the Ministry of Health (11) .
Health professionals play a key role in turning breastfeeding into a pleasant practice, providing valuable advice and clarifying doubts.However, lack of information on breastfeeding may lead to nipple cracks and engorgement (15) .The present study corroborates these findings, since most postpartum women reported nipple cracks and engorgement as the main breast complications.
According to the literature (6,16) breast problems have been reported as the main factors that lead to early weaning.Nipple soreness, fissures and engorgement are the most common.
Health education promoted through the Prenatal and Postpartum Nursing Consultation project is aimed to prevent breast complications.Since breast complications are extremely painful, nurses should immediately intervene to promote the healing of the sores (10) .
The referred project promotes educational activities by means of informative leaflets that emphasize the importance of breastfeeding and the main care to be provided to the breasts to prevent breast complications.

CONCLUSION
The study provided a brief socio-demographic and obstetric profile of the postpartum women, shedding light on the population assisted by nurses, professor and scholars, which may contribute to disseminate health education as a key strategy on the prevention of breast complications.
The study detected poor adherence of postpartum women to the program established by the Brazilian Ministry of Health (42.9%), which gives rise to concerns about the effectiveness of the health education provided by nurses in prenatal care.Adherence to recommended prenatal care content is essential for the mother/infant dyad, and for the control of relevant parameters and the monitoring of health indicators during the pregnancy and postpartum periods.
Activities targeted to improve the quality of educational actions are needed to strengthen the relationships between postpartum women and nurses, and consequently improve the physical and mental health of the newborn.
Based on the data obtained from the nursing consultations in this study, we found that the most common breast complications are cracks and engorgement, and that the prenatal and postpartum health education program from the "Projeto Consulta de Enfermagem no Pré-Natal e Pós-Parto" (Prenatal and Postpartum Nursing Consultation Project) is essential to prevent such complications in mothers/postpartum women.The educational approach that provides information on the lactation process, infant demand, stimulation of milk production, breastfeeding positions, milking process, conservation and validity of human milk, care of the breasts and other actions targeted to the health of the mother and the infant, contribute to the promotion of maternal physical and emotional health, stimulating the breastfeeding practice, as recommended by the Ministry of Health.
One limitation of this study is that it did not investigate the quality of health education delivered in group activities of pregnant women, postpartum women and nurses.