POSTPARTUM test #3 study guide Flashcards
- Review the evidence for breastfeeding
Infant: Higher infant morbidity and mortality in formula-fed infants as they do not receive antibodies from breast milk. Risk of contamination of the formula during manufacturing. Risk of malnutrition or GI problems due to over- or under- dilution when mother prepares the formula.
- Compare the risk and costs of using manufactured infant milk compared to human breast milk to the infant and the family.
Mother: higher risk of osteoporosis, premenopausal breast cancer, and ovarian cancer. More likely to develop type 2 diabetes than breastfeeding mothers. Less rapid weight loss.
Costs: approximately 150 cans of ready-to-feed in the first 6 months of full artificial feeding (a lot of money!!). Higher healthcare costs as child is sick more often, more days of missed work for mother/family.
- Define the Healthy People 2020 objectives for breastfeeding.
Increase the proportion of infants who are breastfed to 81.9%
Increase the proportion of infants who are breastfed at 6 months to 60.6%
Increase the proportion of infants who are breastfed at 1 year to 34.1%
Increase the proportion of infants who are breastfed exclusively through 3 months to 46.2%
Increase the proportion of infants who are breastfed exclusively through 3 months to 25.5%
- Review the Baby Friendly Hospital Initiative.
1) Written breast feeding policy routinely communicated to staff
2) Train all staff in skills necessary to implement this policy
3) Inform all pregnant woman about the benefits and management of breast feeding
4) Help mother’s initiate breastfeeding within 30 minutes of birth
5) show mothers how to breastfeed even if separated from infant
6) Give infants no food or drink other than breastmilk unless medically indicated
7) practice rooming in 24 hours a day
8) Encourage breastfeeding on demand
9) No pacifiers
10) Foster Breastfeeding support groups
Lactogenesis:
transition from pregnancy to lactation. lactogenesis I (mid-pregnancy to day 2PP): initiation of milk synthesis, differentiation of alveolar cells from secretory cells, prolactin stimulates mammary secretory cells to produce milk. Lactogenesis II (day 3 to 8 PP): triggered by rapid drop in mother’s progesterone levels, onset of copious secretion of milk, fullness and warmth in breasts, switch from endocrine to autocrine control. Significant fall in breastmilk levels of sodium, chloride, and protein, and a rise in lactose and milk lipids.
Galactopoiesis:
maintenance of the established milk production. Based on the supply-demand response. (emptying of breast)
Progesterone
Progesterone can cause delay of the effects of prolactin f placental fragments retained after birth Prolactin initiating and maintaining milk production.
breast changes
during pregnancy increased breast mass and cell differentiation (peptides: angiotensin 11 gonadotropin-releasing hormone (GnRH) and vasopressin all stimulate prolactin.
Anterior Pituitary
releases prolactin 7-20 x in 24 hours peak 200-400ng/ml at term-secreted in greater amounts during sleep following circadian rhythms
lactogenesis II
mild secretions shifts from endocrine to autocrine control controlled by the hypothalmus: infant suckles-hypothalmus inhibits release of dopamine (a prolactin-inhibiting factor), this drop in dopamine stimulates the release of prolactin (surge-doubles)=milk production.
prolactin
Need at least 8 feedings a day to prevent decrease in prolactin before the next feeding. Prolactin levels will remain elevated for as long as the mother breastfeeds even if it is years. Prolactin is present in breast milk and thought to benefit the infant. Prolactin enhances development of B & T lymphocytes
Posterior pituitary/oxytocin-milk ejection, uterine involution
Cortisol-main glucocorticoid-
synergisitc with prolactin secreeted by adrenal glands help regulate water transport across the cell membrane during lactation-a High cortisol level will delay lactogenesis
Thyroid Stimulating Hormorne-permissive-promotion of mammary growth and lactation increases on 3-5 postpartum days.
- Review the immune and anti-allergic properties in breast milk.
Breastfeeding promotes intestinal ecosystem-bifidobacteria and lactobacilli (pro and prebiotics)
- Review the key concepts at the end of chapter 5 discussing drug therapy and breastfeeding.
Key concepts:
Avoid medications that are not absolutely necessary
Choose drugs with less toxicity and those commonly used in infants
Maternal plasma levels of the drug at time of breastfeeding: Choose drugs with published studies
Molecular weight of the medication
Oral bioavailability of the medication in mother and infant: choose ones with poor oral bioavailability to reduce oral absorption in infants
Evaluate the infant’s medications, to see if there are drug interactions-evaluate the infant: age, stability, condition-can they handle exposure to this medication (pre-term infants have impaired clearance mechanism so they are at risk)
If a drug enters CNS-crosses blood/brain barrier-it will likely enter breastmilk
medications & breastfeeding
protein-binding of the medication
passive diffusion of drugs into milk
First 2-3 das of life breast tissue is porous-meds cross easily by passive diffusion, but after intercellular junction closes this decreases.
Must take into consideration-the absolute amount of colostrum ingested by infant is low 50-60 ml/day thus clinical dose of medication is low
<10 meds that are selectively transported into human milk are best.
Avoid Breastfeeding during peaks of medication, effective for drugs with short half-lives. Choose drugs with shorter half-lives over those with longer half-lives
Drugs that may inhibit milk production-progestins, estrogens, ethanol, bromocriptin, ergotamine, cabergoline, pseudoephedrine(even nasal). Especially prior to establishment of milk supply. Advise mother to watch for changes in breast milk production
No ASA in Breastfeeding women d/t Reye’s syndrome
Risk vs benefit assessment before prescribing
only a few medications are unsafe under any circumstances
A relative dose of less than 10 percent is generally considered compatible with breastfeeding
HIV & Breastfeeding
Use of anti-retroviral drugs and avoiding breastfeeding reduced risk of trasmission of HIV to less than 2%. CDC recommends against breastfeeding by HIV-infected women living in developed countries. New studies show that exclusive breastfeeding by women in 3rd world countries has improved survival rates, reduces transmission of HIV by keeping gut flora intact-decreased diarrhea and should be encouraged over formula-introduces bacteria and other contaminants which causes inflammatory responses and damages the mucosa-HIV penetrates GI mucosa-once the decision to not exclusively breastfed, woman must stop as it is no longer protective.
HBV & Breastfeeding
virus is present in breastmilk, but also antibodies so Safe to breastfeed. Transmission of HBV would occur during delivery, 5-15% before birth, not BF-unless acute infection with no antibodies, potential risk with bleeding nipples. Infant should receive Hep B Immunoglobulin within 12 hours of birth and be tested after completion of the series. Lack of BF places infant at greater risk of contracting the disease.
HCV & Breastfeeding
virus is present in breast milk, but infant May breastfeed-unless acute infection with no antibodies. potential risk with cracked, bleeding nipples. Perinatal transmission 6%
HSV & Breastfeeding
: Mother’s milk may be free of virus, ocasionally HSV-1 can be cultured from breastmilk (rare). If mother has herpetic lesions on breasts, do not breastfeed. Active lesions should be covered to prevent contact with infant. Advise about hand-washing before breastfeeding. (see table in p.203) If primary infection during pregnancy-50% transmission only 1-3% if recurrent. Congential infection most serious infections in neonates.
CMV & Breastfeeding
CMV virus can be found in breastmilk, but no serious illness or clinical symptoms in neonates secondary to breastfeeding. Breastfeeding will confer passive immunity. Danger of CMV infection is in potential transmission to the fetus or newborn of woman who has a primary infection during pregnancy. Pasteurization of milk appears to inactivate CMV
• Varicella
Can breastfeed. If mother contracts varicella while breastfeeding, continue BF - will give baby passive immunity-antibodies develop in 48 hours and will decrease the severity of illness in infant. However, If mother contracts varicella in 1st trimester=neurological problems, if within days of delivery can be life threatening-manage with airborne and contact infection control precautions-it says isolate the infant from the mother if the infant doesn’t have lesions and protect the infant from the mother’s lesions. Mother is to pump-not clear about feeding or dumping until antibodies present at 48 hours. However if the infant has lesions it says isolate couplet together and continue breastfeeding.
• Rubella-
OK to breastfeed. Greatest risk is during 1st trimester= congenital defects. If mother is immunized to rubella postpartum the breast feeding infant will develop antibodies to rubella.
• Human Lymphotropic Virus HTLV-1
No breastfeeding Endemic in Caribbean islands, parts of Japan and Africa-linked with adult T-cell leukemia and lymphoma. The longer they breastfeed the larger the risk.
• Implications for practice
rarely requires terminating breastfeeding-infant usually already expose, breastfeeding only antibody protection, concern should not be towards mother’s with known infection but those with unknown infectious status.
- Compare and contrast breast fullness vs. engorgement.
Fullness: non-patho
Engorgement: has become pathologic; results from mis-management
Lochia
4-8wks in length, rubra, serosa, alba. Soaking greater than 1 pad per hour is an urgent reason to call Obgyn.
Afterbirth pains:
Uterus contracts and relaxes after birth. The greater the parity the greater the after birth pains. Also breastfeeding increases after birth pains. The uterus is trying to return to pre-pregnant size.
Diuresis/diaphoresis:
Day 2-5 has greatest diuresis and diaphoresis; this is body’s way of getting rid of excess fluids.
Sexuality
No reason to recommend 6 weeks, but instead is based on when patient feels ready. Birth control important to discuss
Perineal healing/pain
Pain: Witch hazel pads for comfort (hemorrhoids and lacerations), Ice packs: best used within the first 24 hours, cover ice pack with soft covering for comfort, apply to perineum. Topical pain relief: Dermoplast (benzocaine spray) can be sprayed to entire perineum for pain relief including hemorrhoids. Sitz baths: soaking bottom up to 3X daily in bath or using disposable sitz bath. Can use warm or cool water, whichever is comforting for the woman.
Constipation/hemorrhoids:
1st bowel movement usually within 2-3 days with normal bowel function returning by 2 weeks. Important to eat and drink regularly. Stool softeners helpful especially if mother has hemorrhoids or is taking narcotics for pain relief.
. Uterus
Weights ≈ 1000g after birth. Starts contracting and rotating 100-180 degrees along the axis of the internal os, assumes upright position by day 7 PP. Weighs ≈500g by the end of first week PP, and still palpable above the symphysis pubis. Usually back to nonpregant anatomic position by week 2 PP, no longer palpated abdominally
Cervix
Reconstituted in the first few days PP. By the end of first week, endocervical canal reappears and os is only about 1cm dilated. External cervical os does not return to dimple form of prepregnancy, but takes the form of a slit.
Vagina
Edematous and bruised after birth. Vaginal rugae return at about 3-4 weeks PP, prepregnant vaginal tone may never be completely restored. Vaginal epithelium usually heals by 6-10 weeks PP.
Lochia
Lochia may persist for up to 4 to 8 weeks after delivery. Median duration - 33 days.
Lochia rubra: primarily blood (red or brownish). Lasts 3-5 days.
Lochia serosa: Has a pinkish brown color. Contains some blood, but mainly wound exudate and leukocytes. Lasts approximately 22 days.
Lochia alba: Composed of leukocytes and some decidual cells. White or yellowish white color.
. Breasts
Mammary involution depends on breastfeeding status. If not BF, prolactin will decrease in the first week PP, then milk stasis, mammary epithelium cell apoptosis and mammary involution will occur. Mammary involution will take months of lactating. Regardless of BF status, breasts will nver return to prepregnant state.
GI system
Gastric tone and motility remain decreased for 2-3 days PP. Bowel movements resume 2-3 days PP, normal GI function and bowel patterns return 1-2 weeks PP.
Renal system
Gradual return to nonpregnant values of GFR, renal plasma flow, plasma creatinine, BUN, and creatinine clearance (2-3 months PP). Mild proteinuria may develop in the first few days PP (return to normal 3-5 days PP). Sodium excretion and diuresis lead to ↓ in blood volume to nonpregnant levels (return to nonpregnant state - 3 weeks or less). Urine production in days 2-5 PP can reach 3000ml and is caused by decrease in oxytocin.
Gradual return of bladder tone, size and function of bladder, ureters, and renal pelvis - 6-8 weeks or longer.
Hematological system
RBC, hematocrit, hemoglobin → return to prepregnancy levels 4-6 weeks PP
White blood cells → 4-7 days PP
Platelets → remain stable during pregnancy and postpartum
Breast feeding influences by
- culture
- ethnicity
- level of education
- family support
- economic status
- advertising come in contact with
- additional support from caregiver
who is more likely to breast feed
→ 30 y.o
higher of education
higher income
Black Spanish or White == Spanish is more likely to INITIATE breastfeeding but
White women continue breastfeeding.
United States or Foreign born
Dual parent family
AAP recommendations
Breastfeeding exclusively for approximately 6 months and support to first year & beyond if desire by mother & child
WHO recommendations
Breastfeeding exclusively for 6 months and continue for at least 2 years with adding weaning food at about 6 months
What is the culture norms for extending breastfeeding?
30% make it til 6 months
one year is the greatest extend here in the United States
What are the risk of NOT breastbreast feeding
Breastfeeding is sterile.
Bottle is not (manufacturing, preparation : kitchen not cleanse)
Prepare formular incorrectly : dilute with H2O or rice cereal
Risks: Poor nutrition, electrolyte imbalance- water intoxication (hyponatremia ) ← life threatening
Poor weight gain
Infant risk for not breastfeeding
→ RSV, coloritis, necrosis, ***otitist media, insulin dependent diabetes, inflammatory bowel disease, pneumonia, lephoma, lower tract infection.
Mom risk for not breastfeeding
increase risk of osteoporosis because time period after breastfeeding the body will lay down calcium and aborption most in time of her life…tissue …increase breast cancer, diabetes (store abdominal fat –need to be motibilize by breast feeding)
Cost of formula
20-30-40 (depend on specialize formula)
2 billion on all family
500 million fund buying formula from WIC
WHO – baby friendly initiatives
The code for breastmilk substitute is recommending for country to adopt for standard to advertisting because of medical financial and universal risk of it use
→ there should be no advertising to the public, no free sample to mother, no sample of products in health care facility, no gifts to health care workers, no word or picture idealize artificial feeding !!!
Baby friendly initiative is a program that certified hospital as baby friendly if they include these 10 steps in labor & delivery unit: 20 thousand worldwide —143 in u.s. (1 year ago, probably more now)
* lot of centralize nursery care
* restrict advertising
* promote of breast feeding
HOspital breastfriendly policy
(1) written policy that is routinely communicate with staff about breastfeeding support
(2) all staffs trained in policy & skill in support breast feeding
(3) all pregnant patient are well inform about benefit & management of breastfeeding
(4) mother assistant to breast feeding within 30 minutes
(5) demonstration breastfeeding even during separation: NICU care
(6) no food/drink other than breast milk if not medical indicated
(7) rooming in 24 hour a day
(8) breastfeeding on demand
(9) no artificial nipple /pacifier
(10) refer mom to support group if needed.
facilitate breastfeeding by :
Skin to skin contact best intervention to support breast-feeding
Earlier initiation and longer duration skin to skin are the most beneficial so the so the soon you can get mom & baby together the better !!!
Baby who have at least 30 minutes skin to skin on chest after birth improve duration of breastfeeding
Baby on mom’s chest stimulate oxytocin –
later recognize mom’s milk
root to the smell after day 3
how much breast feeding competent when that initial contact would do
lactogenesis
stage 1 → occur during pregnancy –milk present after 16 weeks
stage II → three to two days postpartum or sometimes up to 8 days it is drop of progesterone level following by the delivery of the placenta …also result from release of prolactin from anterior pituitary gland → knowing this if mom have great milk supply at 3 days old and breast feeding very well :
what do we know about the placenta ????
it completely deliver
in the other hand if mom struggle from breastfeeding & milk has come in by 3-4 days that’s mean we should concern about → retain placenta fragments.
Prolacproesis
Suckling stimulate oxytocin produce by anterior pituitary gland →Milk rejection reflex from epithelia cell result in → release milk
Prolacproesis : control by newborn : supply & demand
→ oxytocin
produce by the result of suckling …continue to rise over time if supplement is not use ← 90mg/mL !!!
flat & invert nipple →
no problem !
treat during antepartum
Thing to watch regarding milk coming in (factor cause milk from come in)
lack of breastfeeding can impaired by mom that receive pain medication or epidural during labor
obesity –ovarian syndrome –diabetes
mom return to work →
most formula fed baby look like they have more milk to bring in than mom who breast feed so you need to let her know that the volume is smaller because it’s more efficient
she also need to know that her breast size doesn’t determine ability to breast milk … just the capacity to hold milk…. So small breast mean more feedings
baby have favorite breast –
70mL first day size of marble.
Gradually by day 5 it is 500mL to 800mL
Baby is biological not going by the clock !!!
How can we tell if baby getting enough
→ number of diapers (1 per day—- 6-8 start days #6) weight gain
→ stool one per day.
Look for hydration of baby !!! → skin turgor, mucous membrane , moist eyes, nice fontanel that is not sunk in
Why important to have human milk
just one breast feeding can protect baby from diseases
human milk contain lymphocyte( destroy cell wall of pathogenesis) & phagocytes (engulf & absorp pathogen and release immunoglobulin)
-→ immunoglobulin present in breast milk (not just colostrum) & remain constant throughout the period of lactation no matter how long mom breast feed (one week or 8 years she still pass immunoglobulin to her baby)
→ tell mom about benefit of breast milk
you go to the grocery store & u exposed to a virus and u give your baby antibody for that virus – you may get sick but your baby never will or both of you may never will !!!
the more milk the baby ingest the greater the immunity !!!!
PAIN ??
Engorgement is a normal process: fullness—minor or severe (red tight skin slight fever d/t baby have trouble latching on to the breast)
Stasis: inadequate milk removal— feeling of fullness — will cause distention of alveoli which milk synthesis –deactivate phatocyte → set her up for bacteria invasion & infection ⇒ mastitist (breast abscess )
Improper latch ? why ?
it is NB anatomy? present of yeast ? bacteria ? allergen ?
→ Evaluate mom & baby
pain is not to delay breast feeding…. Milk is so important
consider any comfort measure or medication to treat infection if necessary …
consider:
Reassurance
Referral IBLC or support group
Plugged duct :
tenderness or heat in one area to the breast w/o fever but with palpable lump. Related to inadequate milk removal particular area of the duct. → intervention: massage warm compress, change position of baby so it will compressed that area of the body , no wear tight bra especially underwire because constriction cause the flow of milk
Mastitist:
bacterial infection accompanied with fever
Is there such thing as normal nipple pain ?
YES –transient pain with initial latch but it should subsided !!
How many day will it be subside : ~ 3-6 days
→ So if more than 5-6 days then we should be concern !!!!
MEDICATIONS to avoid
Call OTIS (if medication are safe)
Only few such as radiopharmaceutical rumerone lithium
→ consider these factors :
if the molecular wt is more than 1000 m cannot enter the milk
it have to be lipophilic to enter the milk
consider blood brain barrier:
if it can pass BBB then it can pass the breast milk
alcohol
in blood is the same in milk
nicotine
can pass the breast milk
smoking coat or jacket off & smoke outside….
sick mom
still breastfeed
HIV —
if the water quality too bad to mix formula
In US no HIV mom to breastfeed but other country yes because water quality is bad. (breast milk is protective for 6 months)
HSV Varicella
we want baby to avoid direct contact with active lesion
Rubella
Rubella if mom immunize postpartum the baby will develop antibody through the breastmilk
With HTLV1
mom should not breast feed
If mom with influenza immediately post partum
AAP said: CDC does not have any evident to keep mom away from baby & not breast feed & that mom should not be separate after birth !!! baby need to get those antibodies.
Preterm mom milk (late preterm)
mom produce high anti-infective properties : protein sodium iron fat calories
Premies are higher risk at
hyperbilirubinemia & hyperglycemia & breathing difficulty & weight loss→ likely to admit to hospital twice as much
Because → low muscle tone excessive sleepiness & weak suck
Difficulty time for mom to get the premie to latch — mom need a lots of help & connect to support groups
Encourage mom to breastfeed their premies to prevent
increase chance of getting out of the hospital earlier by provide breastmilk & reduce infection , interlectural development and breastmilk is like medicine for premies …..especially with tiny baby it could mean make a different between life vs death !!!
position
Cross cradle hold , many many ways ….can be confusion sooooo
Easiest way is telling mom to be in the comfortable position support with lots of pillow & get baby to the breast where it naturally falls…
Baby can get the breast at any angle !!!
***always ask before touch the mom & document it **
Hand express milk even better than pump
Express every 3 hours
- **aware of the law of your state
- employer have to allow employee to breastfeed up to 1 year
- not share/use breast milk pump
how long breast milk to be store ?
6 hours room temperature
6 days in the fridge
6 month in the freezer
once it thaw u must use it w/in 24 hour !!!
African American mom breastfeeding based on
rely on experience of grandmother
Hispanic
supplement w/ formula or rice cereal ….discuss malnutrition & delusion with them
**find out why she doesn’t want breast feed
**sexuality & expose of breast ?
lot of time it is because of partner concern with breastfeeding !
We Cannot control ethnicity & cultural practices, her social geomenic status & her age & breast surgery
But we can change→ education (benefit & risk)
get her skin to skin, her perception , her exposure : medications whether or not they safe, cont back to work, strategies, breast feeding in public.
→ give strategies←
Placenta delivery
Progesterone & estrogen is now being removed
FSH & LH
at bay quiest not in pulsatile fashion (which getting egg ready for action)
Now (postpartum) the progesterone & estrogen are gone → FSH & LH are free to be secrete again
What we know is the FSH will reach follicular level by about 4- 8 week postpartum
So it is not the FSH that help with lactation amenorrhea it is the disruption of LH …… ***lactation amenorrhea begin with letter “L” major hormone is LH ) is not allow to release by pulsatile fashion & so that is why keep her from ovulation
when the baby suckle that will stimulate the prolactin & gonadotropin releasing hormone….
The prolactin which help with milk production which inhibit ovulation but it is not the major inhibitor of ovulation …It is the gnadotropin releasing hormone affect on the LH , that disrupt the LH that is needed for follicle stimulation….
That is how lactation amenorrhea work !!
Postpartum contraception should be discuss
antepartumally that women have sometimes think about it … how it impact decision …
Many women resume intercourse before they get to their 6 weeks appointment !!!
so antepartum or right before she leave the birth center…..
NON lactating women
expect that 4-6 weeks she will have her first
this can be tricky for provider because it is lochia or first menses ?? so ask her to jot down note when is her lochia stop will help you and her determine
CDC recommendation
women should not start combined contraceptive for full 3 week postpartum d/t increase of thrombophebitis , thromboembolism with being pregnant !!!!
→ after 42 days postpartum there is no problem/ restriction = the hypercoagulate state of being pregnant no longer play big of a role.
You can only talk to her about CoC : implanon, progestin only method, depaprovea ….
Immediate postpartum funky bleeding pattern
Minipill (progestin only pill)
not to give person NOT LACTATING why or why not
→ very merticulous about taking this cannot be one hour late !!
Merina ?
timing ! always use condoms :o)
Permanent sterilization :
pay by Medicaid but have to be done while in the hospital… no easy to reverse…pretty darn sure not want to have anymore children !!!
Lactating women Or women with little breastfeeding alternate with formula →
hormone will be out of wack
*** LAM :
efficacy 98% ! but still need to use another method , it a good method for people who want to space baby but not overly concern getting pregnant sooner or rather later
follow this to be effective within the first 6 months :
** cannot resume menses. (the more you get closer to 6 months the more likely to be ovulatory )
** more frequently & longer duration (shorter interval in between include night feed will help suppressed the LH more —LAM will be more efficacious)
**baby cannot be supplemented or eating any foods
** less than 6 months postpartum
**suckling …not just stimulation of the breast ! so pumping or hand expressing is not enough to suppress ovulation ***
CONDOMS:
put in drawer & in purse
DIAPHRAGM :
wait until no more lochia flow d/t sepsis → refit at 6 weeks visit … if she lost more than 10lbs need to be refit …
Contraceptive sponge : ok to use after 6 weeks → decrease efficacy in parous women ( when you are nullip is work better than when you are multip )
Paragaurd :
this IUD is w/o hormone, can insert after 6 weeks but here talk about timing !!!
→ insert immediate postpartum very soon after the baby is born (w/in 10 minutes) or after 4-6 weeks the time in between that is the highest risk for infection & expulsion
progestine only method:
it pass through milk !!!
first 2-3 days postpartum that when the crucial lactogenesis occur so if we can prevent given women extrogenous hormones during that time then we can do the least we can to disrupt the establish of breastmilk (don’t want to disrupt her breast feeding at all !!!)
**no study say that it decrease the milk production ** (most people say it does)
( depo or implanon ← higher level of hormone are likely to disrupt lactogenesis )
permenant method ?
sterilization tubal ligation
→ consider : probably should be done within the first 2 days (lactate or not) or after 4-6 weeks because risk of infection & access to the tube and you really want to make sure that they tight or cut or burn an actual tube instead of ligament down there because that not going to prevent her from getting pregnant
also anesthesia !! so have her breastfeed prior to surgery…. Usually by the time she come back up normal time frame the anesthesia will wean off so that she can breast feed again
she need to be prepare though that she may be bump if she need surgery ? what is the plan for her feeding the baby if she leave more longer than the expected period of time.
Decision → formula or donor breast milk → finger fed or what ??
Vasectomy ?
have to go back after surgery to check if sperm still available or not
Fertility awareness method (FAM)
also tricky ! when is hormone are going to be lining up back in order … on look out for everything…
Such as cervical mucus → can be hard to detect in lochia because it also prevalence & slippery too …especially if she pass tiny fragments (things like that can be mistaken)
Basal body temperature : she need 6 hours of interrupted sleep …. But how ? pump—then how effective is LAM because she is not truly stimulate
⇒ wait until 4-6 months (hormone are more inline like they were
combined hormonal contraceptive
that can affect the milk supply so keep that in mind it is the ESTROGEN component that can DECREASE DURATION of breast feeding
→ WHO stated CoC cannot use after 6 months postpartum (what we know is after 6 months of breast feeding she have a higher risk of ovulating )
→CDC stated that there is too many risk during the first month ! lactating women can get CoC because benefit outweight the risk (affect of milk supply)
Emergency contraception ?
→ what we know is that not need unless unprotective intercourse is happen w/in the first 3 weeks postpartum if she lactating ….. you can insert an IUD just like you can for gyn pt. but it have to be at 4-6 week range and you can use progestin only pill
if you use the progestin only pills
→ WHO stated: pump & dump 24 hours → store breast milk or formula
LAM
right after birth !
Add another method by 6 months
Depo
wait til 7 days so least effect lactogenesis (ideally wait until 6 week postpartum)
Merina ?
right after baby birth (10minutes) or 4-6 weeks
Same with paraguard
Minipill
after 6 weeks or after first week after lactogenesis is establish !
Let the patient initiate permanent methods
What she use in the mean time while watiting for these other methods : condoms
Sponge /diaphragm → cannot use after 6 weeks
What teaching is vital ?
Depo or Nepronon → they will be fine timing OCP earliest can start them is 42 for anybody ….no risk factor then 21 days !
Permanent sterilization ?
Immediately or after 6 weeks (visualization of the tube )
Lactogenesis :
: occur at day # 2 change in hormonal driven function to autocrine driven function → milk removal
How to minimize Nipple soreness ??
proper latch ! cotton bra
More fuzzy during afternoon
Moving head arm and leg →
swirming (Hungry sign) cooing lip smacking head poping rooting *crying is late sign of hunger !!
NB sleep 14 hours a day
Frequent feeding ? what is normal
eat frequently because stomach is small
educate on s/x satisfaction :
fall asleep on the breast, relaxing , arm away from mouth letting go of the nipple & stop suckling ….
Day 3:
diaper count 3 wet diaper & 1 stool (green and black then transition to yellow)
Jaundice expect to see on day 3→ physiological jaundice.
Jaundice expect to see on day 3
physiological jaundice.
Peak at days # 5-7 still jaundice ….below the waist ??
Evidence : evaluation of bilirubin transcutaneous bilirubin at 24 hours
***Measure at 24 hours is pretty predictive of Phototherapy **
baby personality @day #3 → baby naturally push off the breast see it as good not “eww gross they don’t like it “
Post partum blues
sadness, irritability mood swing anxiety trouble sleeping decrease concentrations
-→ ask for help, exercise, self care time
family support : attention to breast feed
if breast feeding going well with mom we also want to hear husband and other family member saying positive thing toward it as well .
husband find it challenging /difficulty
promote involvement & care of the infant
sibling adjustment
are the children want to be include at this time?
Mom should create a bonding experience for the other children as well by place playing area around breastfeeding place instead of separate them out !
Sexuality & Fatigue
→ interfere with sexuality after childbirth included: dyspareunia, operative vaginal delivery , episiotomy , 3rd or 4th degree lacerations, lack of privacy, interruptions, & fatigue.
If you have laceration or episotomy is gonna be uncomfortable for a long period of time … d/t pain bleeding infections, care for baby, sleep & overwhelm…. Interruptions by family….and privacy !
Midwifery ?
Encourage time alone with partner & stretch the important of getting away from baby like in room watching TV together…..
Use lubrications may help with breast feeding because dryness of hormone from breastfeeding ….
→ reassure them than ½ of the women resume sexual relationship after 6 weeks postpartum …
When it is ok to resume ?? (sex)
6 weeks ? no set time for all women to heal at the same time ! base on healing & readiness … longer for people with C-section, epiostomy or lacerations forcep or vaccum during delivery these all can cause pain ….
Breastfeeding can cause hormonal changes that can affect —increase or DECREASE resume of sex …
FATIGUE
Affect women caring for her child or her childrens
Perform work tasks if she is going back to work
Negative effect her partner at home
How
interrupt sleep from breast feeding ….crying or cooing from diaper changes… baby sleep cycle is only 3 hours
Other such as Home cares: laundry disks family care : get other kids up to school & feed.
Self care : shower / bathroom
Midwifery care
Midwifery care
• 6 weeks / 40 days
recover ? many are more than that !
• postpartum from different culture have less support : feeling conflicted they may go through depression or role conflict if they don’t experience that …
• help women (foreign) get help resources.
• Postpartum fatigue – anticipate this ? is this thyroid or depression
Taking in:
period between birth and 3rd day postpartum … mother is fatigue & want to left alone …
Discuss her labor experience.
Self focus
Need directions
Hungry
Almost like a state of overwhelming experience …taking it all in)
Taking whole
day 3 to day 10 of postpartum
On day 3 the mom become more energetic & active ….or sleep deprive .. focus on the present : learning tasks …. remain bodily functions , relationship with other especially the newborn …. Forming new relationship & change relationship with other …etc. ect…
Anxious & impatient with self
Mood swing– less intense over time.
Risk factors for poor role attainment
birth experiences , lack of maternal involvement , lack of partner support & involvement , labor & birth experience , prenatal expectation , separate mother & baby.
Overwhelm by instructions from HCP during the hospital
Teenager mom
Social/eeconomic
Lack of self esteem self confidence
Not good relationship with mother
Same with dad …if he didn’t have good relationship with her dad then he have hard time to be dad as well
Maternal fatigue
2-3 days
Unfamiliar environment (hospital) difficulty resting..
Too many nursing care ?
All factors decrease competence !!!
Midwifery care:
start early –
- birth plan
- increase support – involve dad
- provide privacy
- early breast feeding
- *rooming in
→ touch touch look talk
→ talk about birth experience & concerns…
encourage self care
nursing staff help with the baby
not expect to know it all
coordinate things…..
familiar with baby – recognize baby cues (before they get into hungry cycle)
implications for midwifery care
mother & mother-in –law & grandmother have large influence of new mom cares, so you need to start early educate family & pt postpartum practices and potential harmful practices
satisfaction with breastfeeding
pattern of growth & weight gain in infant, normal feeding pattern , sign of adequate milk transfer , proper latch & positioning
sign of adequate milk transfer are : alert & sucking hands before feeding . 8-12 times per day, heard the swallowing sound, after breast feed the nipple is wet & no pain or
baby→ moist mucous membrane , frontanel not sunking …. No taunting skin
baby should :
baby should : pass 3 or more loose stool per day sleep 5--20 hours/day 8-12 feeding per days 2-6 -12 week growth spurt 6-8 inches (sight) preferred black & white pattern & red
baby gain weight back by
6 weeks
→ most women can resume exercise
about 6 weeks but meanwhile can walk with baby in the stroller …
car seat
car-seat until 20lb
SIBLING ADJUSTMENT
Expressed maturation Extreme behavior are uncommon Delayed response Why transition to siblinghood important Mom is more depressed & fatigue … The quality & quantity decrease in older sibling with the mom
Marital conflicts !
Regression
Parental characteristics.
