Promoting Healthy Behaviors

Promoting Healthy Behaviors Healthy behaviors in the postpartum period include: • Breast care and optimal breastfeeding practices, including correct attachment and positioning—early (within one hour after birth), exclusive, and on-demand • Healthy nutrition, including an iron-rich diet • Prevention of infection, including: o Handwashing and perineal hygiene o Prevention of malaria, including sleeping under insecticide-treated bed nets o Tetanus toxoid immunization if a woman has not previously completed the series • Touching, handling, and bonding with the infant • Social and emotional support from family, including child care to enable extra rest.

Breast Care: Breast engorgement in women who aren’t breast-feeding typically occurs 3 days postpartum and may be treated with techniques such as breast binders, icepacks, and avoiding nipple stimulation. Can use oral analgesics. If mastitis, can treat with PenG or PCN-ase resistant drug (dicloxacillan) and keep breast-feeding from both sides with smaller more frequent feedings. The nipples should be washed with water and exposed to the air for 15-20 minutes after each feeding. A water-based cream such as lanolin or vitamin A or D ointment may be applied if the nipples are tender. Engorgement, mastitis, and plugged duct (galactocele) are three causes of enlarged, tender breast postpartum. Drugs in the breast milk are a common concern for the breast-feeding mother. Less that 1% of the total dosage of any medication is seen in breast milk. This should be considered when any medication is prescribed by a physician or when any over-the-counter medications are contemplated by the patient.

BREASTS Assess the fit and support provided by the bra. Instruct the patient on reasons for wearing supportive bra if patient does not have one. Examine and palpate the breasts, including the axilla and upper chest. Note the size and shape. Assess for abnormalities, reddened areas and engorgement. Palpate the breasts--check for softness; firmness associated with filling and engorgement. Assess for heat, edema, swelling of the lobules, and tenderness. Assess the nipples for fissures, cracks, redness, soreness and inversion if breastfeeding. ABDOMEN AND FUNDUS Ask patient to void prior to this assessment. Assess fundal height by palpating the fundus and noting its relationship to the umbilicus (i.e. above or below umbilicus.) Note whether the fundus is midline or displaced to

either side of the abdomen. Assess for complaints of excessive tenderness when the uterus is palpated. If the uterus is not firm, gently massage the fundus while supporting the lower uterine segment, and assess results. Assess the amount of lochial flow with massage if massage is necessary. If a boggy uterus does not respond to light massage, massage more vigorously while observing lochial flow. If uterine atony occurs: (a) reevaluate for full bladder; (b) if breastfeeding, put newborn to breast; (c) reassess the uterus, if still boggy, notify physician or nurse-midwife. Assess for diastasis recti abdominis. Evaluate separation according to length and width. Ask patient to lift her head to contract the rectus muscles and more clearly define their edges if necessary. If a C-Section was done, additionally palpate the uterus gently on each side of the abdomen. Inspect the incision for redness, edema, ecchymosis, drainage, and approximation of edges (REEDA scale.) Some physicians do not want the fundus checked if the patient had a Bilateral Tubal Ligation. Check on this before assessing the fundus on these patients. ELIMINATION Inspect and palpate the bladder simultaneously while checking the height of the fundus. Bladder distention should not be present after recent emptying. When it does occur, a pouch over the bladder area is observed, resistance is felt upon palpation, while at the same time, the woman usually feels a need to urinate. Assess frequency and amount of voids for the first three voids. Each void should exceed 250 ml. Assess for fundal bogginess and displacement to the right or left. Ask the patient if she feels she is emptying her bladder completely when she voids. Ask the patient if she experiences any signs/symptoms of UTI with urination--urgency, frequency, dysuria. Assess bowel sound. Ask patient about passing of flatus. Assess if the patient has had a bowel movement since delivery and record. Teach methods for avoiding constipation and promoting bowel elimination. LOCHIA Assess lochia for character, amount, odor, and the presence of clots. LOCHIA RUBRA-1 to 3 days-- dark red, possibly a few small clots. LOCHIA SEROSA-3 to 7 days--pinkish-brown in color. LOCHIA ALBA-after 7 days-yellowish-whitish in color. Lochia serosa should occur sooner for breastfeeding women.

Lochia should never exceed moderate amount. Ask the patient how long the perineal pad has been in place prior to assessing amount of lochia. Ask the patient if she has passed clots while ambulating or voiding. If unsure of amount, put on clean pad and assess in 1 hour. SCANT-less than a 1 inch stain on pad. LIGHT-less than 4 inch stain on pad in 1 hour. MODERATE-less than 6 inch stain on pad in 1 hour. HEAVYsaturated pad within 1 hour. Assess lochia for odor--should be nonoffensive and never foul. Women with C-Sections should have less lochial flow after the first 24 hours than women with vaginal deliveries. PERINEUM While in lithotomy position, assess the labia for edema. Observe for vaginal or labial hematomas. Inspect the perineum with the woman lying in a Sim's position. Lift the buttocks to expose the perineum and anus. Assess the episiotomy using the REEDA scale. Palpate the sides of the suture line for occult hematomas and complaints of excessive pain. Inspect the rectal area for hemorrhoids. Assess the size and number of hemorrhoids, and the amount of pain. LOWER EXTREMITIES Assess the Homan's sign. Report a positive Homan's sign and do not retest. Assess the legs for edema, redness, tenderness, and areas of increased temperature. Assess for pedal edema. Assess degree of edema (+1, +2, +3, +4) and parts of the lower extremities involved. Assess dorsal tendon reflexes--knee jerk. Use 0 to 4+ scale. 0=no reflex elicited. +1=slightly depressed. +2=normal response. +3=slightly hyperreflexic. +4=hyperreflexic. REST AND SLEEP Evaluate the amount of rest the woman is getting. Ask about any difficulty sleeping. Assess causes of interferences with sleep and rest and implement corrective actions. PSYCHOLOGIC ADJUSTMENT Assess the woman's general attitude, feelings of competence, available support systems, and care-giving skills. Evaluate her fatigue level, sense of satisfaction with her L&D experience and newborn interactions and her ability to accomplish for developmental tasks. Listen to her description of her L&D experience. Problem clues might include continued fatigue, marked depression, excessive preoccupation with physical status and/or discomfort, evidence of low self-esteem, lack of support systems, marital problems, inability to care for or nurture the newborn, and current family crises. Assess for normal progression through the taking-in and taking-hold phases of the restorative process.

ATTACHMENT Observe the parent-infant interaction. Assess for signs of positive attachment (cuddling, talking to the newborn, feeding, responding to the needs/cues of the baby, expressing positive feelings and descriptions of the newborn, eye contact, expressing concern for the newborn's well-being and safety, etc.) Assess for problems with attachment (lack of cuddling, slow or hesitant response to needs of the baby, repetitive negative statements about the baby, hesitancy or refusal to perform caretaking tasks, etc.) CULTURE Assess cultural/ethnic background. Ask questions about preferences about food and fluids. Ask questions about childrearing and caretaking tasks that she learned from her mother, grandmother, etc. Assess feelings about breastfeeding/bottlefeeding. Assess desires for privacy.

1. http://faculty.washington.edu/alexbert/MEDEX/Winter/MCHPostpartumCare.ht m

pitocin What is the most important information I should know about oxytocin? Oxytocin should be administered as an injection into a muscle or intravenously by a healthcare provider. It should be administered in a clinical setting where a healthcare provider can monitor uterine contractions and other vital signs (blood pressure, heart rates) and where an emergency situation can be handled properly. What is oxytocin? Oxytocin is a natural hormone that causes the uterus to contract. Oxytocin is used to induce labor, strengthen labor contractions during childbirth, control bleeding after childbirth, or to induce an abortion. Oxytocin may also be used for purposes other than those listed in this medication guide. Do not take oxytocin without first talking to your doctor if you

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have or have had cervical cancer;

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have an allergy to oxytocin, other medications, dyes, foods, or preservatives;

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have eclampsia;

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have herpes;

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have had more than 7 pregnancies;

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are experiencing premature labor;

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have had a caesarean section (C-section);

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have had any surgery on the cervix or uterus;

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have a prolapsed uterus; or

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have a breech, placenta previa or any other issues with the fetus or umbilical cord. You may not be able to use oxytocin, or you may require a dosage adjustment or special monitoring during treatment if you have any of the conditions listed above. Tell your doctor about all prescription or over-the-counter medicines including vitamins, minerals, and herbal products that your are taking. Tell your doctor if you drink alcohol or caffeine drinks regularly, if you are a smoker or if you use illegal drugs. These factors can affect the way oxytocin works in your body. There are no known indications for the use of oxytocin in the first or second trimester of pregnancy other than in relation to spontaneous or induced abortion. Based on the wide experience with this drug and its properties, it would not be expected to present a risk of harm to the baby when used as indicated under the supervision of a trained healthcare professional. Ask your doctor to answer any questions you have about the use of oxytocin and your pregnancy. Do not use oxytocin without first talking to your doctor if you are breastfeeding a baby. How should I use oxytocin? Oxytocin should be administered as an injection into a muscle or intravenously by a healthcare provider. It should be administered in a clinical setting where a healthcare provider can monitor uterine contractions and other vital signs (blood pressure, heart rates) and where an emergency situation can be handled properly. Your healthcare provider will store oxytocin as directed by the manufacturer.

What happens if I miss a dose? Since the medication will be administered by a healthcare provider, missing a dose should not occur. What happens if I overdose? If an overdose of oxytocin is suspected, seek emergency medical attention or contact your healthcare provider immediately.

Oxytocin should be administered in a clinical setting where a healthcare provider can monitor uterine contractions and other vital signs (blood pressure, heart rates) and where an emergency situation can be handled immediately. What should I avoid while using oxytocin? Tell your doctor if you drink alcohol or caffeine drinks regularly, if you are a smoker or if you use illegal drugs. These factors can affect the way oxytocin works in your body. What are the possible side effects of oxytocin? Side effects with oxytocin are not common. Serious side effects include: 

an allergic reaction (shortness of breath; closing of the throat; hives; swelling of the lips, face, or tongue; rash; or fainting);

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difficulty urinating;

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chest pain or irregular heart beat;

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difficulty breathing;

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confusion;

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sudden weight gain or excessive swelling;

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severe headache;

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rash;

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excessive vaginal bleeding; or

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seizures. Other, less serious side effects may be more likely to occur. Talk to your doctor if you experience

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redness or irritation at the injection site;

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loss of appetite; or

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nausea or vomiting. Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome. What other drugs will affect oxytocin? Other drugs can interact with oxytocin resulting in dangerous side effects and/or decreased effectiveness. Do not take any other prescription or over-the-counter medicines, including vitamins, minerals, and herbal products, without first talking to your doctor during treatment with oxytocin. Where can I get more information? Your pharmacist has additional information about oxytocin written for health professionals that you may read. What does my medication look like? Oxytocin is available generically and under the brand names Pitocin and Syntocinon. Other brand or generic formulations may also be available. Ask your doctor or pharmacist any questions you have about this medication. http://health.yahoo.com/pregnancy-birth/oxytocin/healthwise-d00584a1.html

ergotrate ERGONOVINE/METHYLERGONOVINE (Systemic)

Some commonly used brand names are: In the U.S.— •

Ergotrate

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Methergine

In Canada—

1 2

•

Ergotrate Maleate

1

Other commonly used names are: Ergometrine Methylergometrine Note For quick reference, the following medicines are numbered to match the : corresponding brand names. This information applies to the following medicines 1.Ergonovine (er-goe-NOE-veen)§ 2.Methylergonovine (meth-ill-er-goe-NOEveen)† † Not commercially available in Canada § Generic name product may be available in Canada Category •

Diagnostic aid, coronary vasospasm— Ergonovine

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Uterine stimulant—Ergonovine; Methylergonovine Description

Ergonovine and methylergonovine belong to the group of medicines known as ergot alkaloids. These medicines are usually given to stop excessive bleeding that sometimes occurs after abortion or a baby is delivered. They work by causing the muscle of the uterus to contract. Ergonovine and methylergonovine may also be used for other conditions as determined by your doctor. These medicines are available only on prescription and are to be administered only by or under the supervision of your doctor. They are available in the following dosage forms: •

Oral

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Ergonovine ○

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Tablets (U.S. and Canada)

Methylergonovine ○

Tablets (U.S.)

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Parenteral

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Ergonovine ○

Injection (U.S. and Canada)

•

Methylergonovine ○

Injection (U.S.) Before Using This Medicine

In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For ergonovine and methylergonovine, the following should be considered: Allergies—Tell your doctor if you have ever had any unusual or allergic reaction to ergonovine, methylergonovine, or other ergot medicines. Also tell your health care professional if you are allergic to any other substances, such as foods, preservatives, or dyes. Breast-feeding—This medicine passes into the breast milk and may cause unwanted effects, such as vomiting; decreased circulation in the hands, lower legs, and feet; diarrhea; weak pulse; unstable blood pressure; or convulsions (seizures) in infants of mothers taking large doses. Children—Although there is no specific information comparing use of ergonovine or methylergonovine in children with use in other age groups, these medicines are not expected to cause different problems in children than they do in adults. Older adults—Many medicines have not been studied specifically in older people. Therefore, it may not be known whether they work exactly the same way they do in younger adults or if they cause different side effects or problems in older people. There is no specific information comparing use of ergonovine or methylergonovine in the elderly with use in other age groups. Other medicines—Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking ergonovine or methylergonovine it is especially important that your health care professional know if you are taking any of the following: •

Bromocriptine (e.g., Parlodel) or

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Other ergot alkaloids (dihydroergotamine [e.g., D.H.E. 45], ergoloid mesylates [e.g., Hydergine], ergotamine [e.g., Gynergen], methysergide [e.g., Sansert])—Use of these medicines with ergonovine or methylergonovine may increase the chance of side effects of these medicines.

•

Nitrates or

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Other medicines for angina—Use of these medicines with ergonovine or methylergonovine may keep these medicines from working properly

Other medical problems—The presence of other medical problems may affect the use of ergonovine or methylergonovine. Make sure you tell your doctor if you have any other medical problems, especially: •

Angina (chest pain) or other heart problems or

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Blood vessel disease or

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High blood pressure (or history of) or

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Stroke (history of)—These medicines may cause changes in how the heart works or blood pressure changes

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Infection—Infections may cause an increased sensitivity to the effect of these medicines

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Kidney disease

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Liver disease—The body may not remove these medicines from the bloodstream at the usual rate, which may make the medicine work longer or increase the chance for side effects

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Raynaud's phenomenon—Use of these medicines may cause worsening of the blood vessel narrowing that occurs with this disease