Narm Test Specifications Vi. Postpartum Period

Front 1

B. Performs postpartum reevaluation of
mother and baby at:
1. day-one to day-two

Back 1

- begin by appraising the environment for order and cleanliness
- see to it that if dishes are piled up, chores undone, or fridge is bare that these things are tended to
- see what the mother has been eating and drinking, she should have water by her bed at all times and food should be readily available
- the bedroom should be comfortably warm and baby things readily available
- tend to her personal hygeine (help mother shower, if she hasn't yet)
- Assess her general condition by asking how she has been doing
- It is critical to stress the need for her to have a full ten days of absolute rest-- the more she rests and lets her body recover (with continual nourishment and breastfeeding/oxytocin and involution), the sooner she will look and feel her best-- repeat this for clarity and understanding.
- Walking several times a day even just around the house can help prevent thrombophlebitis

CHECK-UP on following:
(always wash your hands thoroughly upon arrival at house, before examining the mother)
1. Nipple for soreness and cracking: if soreness is developing, evaluate the baby's latch and feeding positioning. Suggest vit E oil between nusring sessions and stress importance of continuing to breastfeed. Have her begin with least affected breast then switch to sore side once let-down has occurred.

2. Uterus for NML involution: should be just below mothers umbilicus and should be firm, not tender, massage briefly to expel any clots.

3. Lochia, for color, amount and odor: should be lochia rubra (red-brown), flow in amounts like heave period, and odor should befleshy, like menstrual period (not fishy)

4. Perineum, especially if there has been swelling, tearing or suturing: all swelling should be gone--if not suggest alternating cool and warm compresses. Make sure she is rising her peri at least twice per day with warm water with a bit of betadine in it. If swelling increases and she complains of pain check for hematoma.
- Can check for cystocele or rectocele, if it is present suggest kegels and reassess at 7 day visits
- If she has stitches, check to make sure they have held, edges should be pulling together and should be clean and dry (if not she can apply fresh aloe vera). Signs of infection include inflammation, pain, and discharge--physician should be consulted if these are present.
- If she only reports tenderness w/out any s/s of infection suggest sitz bath 3-4 times daily.
- Check to see if there has been any pain with urination, have her pour warm water over perineum when she urinates if this is happening. Check her temp to rule out UTI
- See if she has had a BM, if not recommend fiber-rich foods, if she has had stitches, have her use counterpressure on peri with warm rag.

5. Mothers Temp record: if elevated she may be dehydrated, could indicate systemic, urinary or uterine infection. Rule these out one by one and if there is peri pain, check for hematoma

6. Pulse: if elevated see above

7. Mother's BP: particularly if it rose during or after labor.
- If elevated, check for signs of preeclampsia and consult with physician

8. Baby's cord stump: should look clean around the base, not red or swollen. Remove the cord clamp only if the stumo is completely dry.

9. Baby's skin color, inpecting for jaundice: depress flesh on baby's chest and extremities, checking fir yellow undertone. Jaundice is unusual on day one and should be immediately referred to physician.

10. Baby's skin consistency, for dehydration: if baby's wrists and ankles look cracked and wrinkly, it needs to nurse more often.

11. The baby's elimination pattern: should have passed mec by now and should be urinating frequently. If a BM has not occurred by 48 hrs consult pediatrician.

12. Baby's nursing pattern and behavior: Sleepiness is NML fir first day.
- Lethargy (characterized by drowsiness, disinterest in nursing, and lack of muscle tone) is of concern and should be checked by a pediat. immediately (particularly if mothers temp is elevated or if neonatal jaundice is noted).
- if parent report a high-pitched, cat-like wail, particularly in conjunction with jaundice, it is urgent that baby be seen immediately by pediat.--intercranial bleeding/damage??--

13. Anything unusual from the NB exam (at birth) reevaluate and refer to pediat. if necessary.

- See to it that the mother has adequate PP support according to how her labor and birth went (ie. complications). Evaluate her emotion well-being, consider doing a rebozo treatment ("bringing the bones back together")

NOTE: Specific indications for a prompt reexamination/check-up at 48 hrs include:
- problems with perineal repair
- elevated maternal pulse or temp
- excessive blood loss
- difficulties with breastfeeding
- signs of neonatal jaundice or dehydration
(if everything is NML on day 1 visit a phone call is sufficient for day 2)
(Davis 191-94)

Front 2

B. Performs postpartum reevaluation of
mother and baby at:
2. day-three to day-four

Back 2

DAY 3 VISIT:
- emotional melt-down is common at this time fromt he challenge of integrating NB care with daily life and hormonal surges that initiate lactation can cause instability. The baby must also make an adjustment to breast milk and may experience fussiness or crying spells. The partner may be close to break-down also if he has been handling all household responsibilities. Discussing these issues and trying to help encourage them to find solutions is best. The mother may enjoy a ritual/herbal sitz bath at this time.

CHECK-UP:
1. Breasts: check for engorgement, by feeling for lumps at the sides of the breasts and in armpits, look for reddened areas, ask mother if she feels engorged. If engorgement is a problem, make sure mother is nursing on demand w/proper positioning, have her soak breast (or whole body) in warm water, she can express milk, apply cold cabbage leaves or steamed comfrey leaves to the breasts left in place for 20 mins and repeat periodically throughout the day. For lingering engorgement try hot ginger compresses under the arms or in the upper, outer quadrants of breasts.
- If nipples are cracked, check positioning and baby's latch, rule out short frenulum, vit E and cold cabbage leaves tucked against nipples may provide relief.

2. Uterus, lochia, perineum etc:
- Recheck peri thoroughly using guidelines from day one.
- Ask mother if her flow has been consistent--any clots, heavy bleeding or dark-re blood? Her flow should be lighter than before from rubra to pinker lochia serosa.
- Palpate uterus for enlargment and note any tenderness that may indicate infection. Fundus should be 1-2 FB below navel. Check odor on her pad to rule out any infection
- Recheck cystocele/rectocele and if evident remind her to do exercises.
- Ask if she feels any vaginal pressure or draggingsensation when out of bed (hematoma?)

3. Mother's temp:
elevation to 101 is NML when milk comes in, nevertheless rule out UTI and anything above this is ABNL.

4. Cord stump: clamp can definitely be removed by this time.

5. Baby, for jaundice: bit of yellow tinge is NML in face and down the nipple line, but unusual in the extremeties. If baby is yellow have mother place him or her in s unny window

6. Baby for dehydration: particularly important id jaundice is present or if it was noted on day 1. Make sure baby is nursing long, and frequently and on demand, and check again the following day.

7. Baby's bahavior, nursing pattern, crying pattern and so on: see #'s 5, 6 and 8

8. Mom's relationship to nursing: make sure she is not trying to get the baby on a schedule or limit time at the breast. Try to promote a positive feeling around letting go with the baby. Baby should be nursing often (every 2-3 hrs), long (10-20 mins) and on-demand (not scheduling).

9. Sleeping arrangements: check to see what has evolved, how does the partner feel about the arrangements? How does the mother feel about getting up if baby is in crib? Discuss options with them.
(Davis 194-96)

Front 3

B. Performs postpartum reevaluation of
mother and baby at:
3. one to two weeks

Back 3

1 WEEK VISIT:
- It is common for the mother to feel suddenly depressed and forgotton, her partner will prob be back at work, friends and relatives may be busy once again with their own concerns. A definite sign of overactivity isincreased lochia flow or change from serosa to rubra. This mother needs help a friend or close relative should help with cleaning, laundry, shopping, running errands, or someone can be hired for this purpose. The mother may want to discuss her birth experience, it is important to listen at this time and respond without being defensive paying tribute to her strengths and down-playing her shortcomings. It is important at this time to differentiate PP blues from PPD. PP blues diminish as time goes by, PPD is characterized by increasing withdrawal and inability to cope, it gets worse and worse. Important to realize when professional intervention is indicated.

- Signs of physical recovery should be evident,
- if mother had peri repair, skin should be closed by now.
- Lochia flow should have decreased
- If mother has been doing her pelvic exercises her cyst/rectocele should be diminishing by now
- Breastfeeding should be fairly well established
- Assess the mothers emotional condition and provide referrals if indicated
- do your best to help with any difficulties as you will not see her several weeks unless she calls
- bring up the topic of sex, advise the mother to have nothing in her vagina until her lochia flow has stopped completely. Suggest that she wait to see you before continuing, perticularly if she had stitches. encourage her to listen to her body in making decisions when she is ready.
- Over next few weeks if she reports extreme fatigue, exhaustion, continued bleeding or sensations of pressure or dragging in her vag when she is up and about, see her at once. These are poor signs of healing that must be addressed promptly if she is to recover.
(Davis 196-7)

Front 4

B. Performs postpartum reevaluation of
mother and baby at:
4. three to four weeks
5. six to eight weeks

Back 4

3-6 WEEK VISIT:
- One big reason for this check-up is to give the okay for sexual activities involving penetration, along with how to make this comfortable. Suggest planty of lubrication, as breastfeeding causes dryness and fragility of tissues no matter how intense her desire is. If appropriate also raise the issue of birth control, ovulation can occur as early as 6 weeks (although rare with exclusive breastfeeding). If she is comfortable, she can (at home) wash her hands and insert two fingers into vag and check to see if the area is still sensitive to pressure.

- See her by 6 weeks, healing should have happened by now, some deep 2nd degree tears will take longer and in the absence of lochia and if she is feeling fine, that is not a worry.

- This may be the last time you see the mother for a while, depending on the size of your community. Look closely, noting her color, energy level and general demeanor.

CHECK-UP:
1. The uterus: should be out of palpation range, except bimanually. If it is enlarged she is prob still bleeding, indicating poor recovery. Prescribe rest, long relaxed nursing sessions (to bring oxytocin), optimal nutrition with plenty of calories, supplements as indicated and involuting tea or tincture of black haw and shepherd's purse.

2. Cervix: Should feel firm, closed and situated high in vaginal vault (like intial exam). Some women do not regain their prepregnant cervical position and tone until cutting back significantly on breastfeeding.

3. Internal muscle tone: Should be back to NML now if mother has been doing exercises. If not, explain the importance of strengthening the pelvic muscles to keep the uterus and other internal organs in their proper palce.

4. Lacerations or episiotomy: Healing should be complete, there may still be tenderness with labial splits as newly formed skin takes time to roughen up. This may cause some discomfort, w/sex, but adequate lube and creative positioning should help with this. If peri feels rigid with scar tissue, encourage mother to do peri massage with EPO.

5. Abdominal Muscle tone: with mother in supine position, place 2 fingers in juncture of ab muscles, and check for gaping--women typically have a 1/2 in. separation at this point-- If the separation is greater suggest abdominal exercises, starting with single leg lifts and progressing slowly to full sit-ups. Also can refer her to PP exercise or yoga class.

6. Breast for tenderness and lumps: It is said that hormones for pregnancy can accelerate abnl cell growth. Do a breast exam, and review SBE with her.

7. Cervix by PAP smear: for same reason as stated above

8. HGB and HTC: especially crucial if the mother appears weak or exhausted or has a hx of hemorrhage or anemia. If H/H is below 37 and 12 then treat for anemia.

10. Adjustment to parenting: Ask the mother how she ahs been sleeping, how she and her partner are getting along, and how she is coping with frustrations of mothering? Have the mothers partner present while discussing these matters if possible, unless there is reason to be private.
(Davis 197-8)

9. Diet: If mother coplains of chronic fatigue, nervous irritability, or upper resp infection, prescribe more protein, more calories, good sources of vit B and C and trace minerals.

Front 5

C. Assess and provides counseling and education as needed, for:
1. postpartum-subjective history

Back 5

- depressive illnesses at previous time's in life
(Myles 692)
- how she perceived her previous births going from her point of view (ie. complications or issues necessitating intervention)

Front 6

C. Assess and provides counseling and education as needed, for:
2. lochia vs abnormal bleeding

Back 6

LOCHIA:
- Rubra: (red-brown), flow in amounts like heave period, and odor should befleshy, like menstrual period (not fishy)

- Serosa: occurrs at 3-10 days, flow is lighter than rubra, with a pink/brown color

- Alba: 10days to 2-4 weeks maybe longer, creamy white (leukocytes and decidual cells)

ABNL BLEEDING:
- Anything more than stated above, or lasting longer than stated (ie. rubra after 1-2 wks) could indicate over-activity of mother.

- Secondary PP hemorrhage (excessive/abnl bleeding between 24 hrs and 12 weeks PP) is usually due to retained placental fragments (occurring most commonly between 10-24 days PP) or the presence of a large uterine blood clot.Lochia will change from lochia serosa to a bright red blood loss and may have an offensive odor if infection is present. Subinvolution, pyrexia (), and tachycardia are usually present

MANAGE:
- Notify physician and transport
- Rub up UC/massage uterus
- express any clots
- encourage woman to empty her baldder
- keep note of EBL
- an IM injection of uterotonic drug can be given
(Myles 552)

Front 7

C. Assess and provides counseling and education as needed, for:
3. return of menses

Back 7

- Depends on how often the mother is breastfeeding and if she is exclusively BF.
- EBF (day and night) mothers generally won't start their periods until later (up to a year or longer, but possibly less).
- Non-breastfeeding mothers can startg menstruating as soon as one month after birth

NOTE: ovulation can and often does resume before the first return of menses, keep this in mind for edu/family planning purposes.

Front 8

C. Assess and provides counseling and education as needed, for:
4. vital signs, digestion, elimination patterns

Back 8

VITALS:
- BP may rise immediately following birth for many women and resolve spontaneously over several days to prepreg baseline. Midwife should assess for risk of PP preeclampsia, which is relatively rare

- Temp: Should return to NML (from slight elevation during intrapartum period) and stabilize within first 24 hrs PP. (High may indicate a PP infection--uterine, breast, urinary, laceration-- Low may be hypothermia)

- Pulse: elevates during labor, but should resolve over 1st few hrs PP to NML level (hemorrhage, fever during labor or persistent pain may affect this process). Any pulse >100 in PP period is ABNLand could indicate infection or late PPH.

Resp: Should resolve to NML within 1st few PP hrs. Shortness of breath, rapid resps, or other changes warrant evaluations for conditions ranging from fluid overload, asthma exacerbation, to pulmonary embolus.
(Varneys 1044)

DIGESTION/ELIMINATION:
- In the first few days PP minor disorders in urinary and bowel function are common. These may be associated with retention or incontinence of urine or constipation, or both. The woman may be practicing self-restraint because she lacks knowledge and is afraid of ripping or tearing out her stitches when she has a BM.
- The midwife should determine if these problems will resolve spontaneously or if furthered investigation is required. Rule out any infections or obstructions/injury from birth.
- Warm water, counter pressure with a warm rag and a fiber-rich diet can help with BM difficulties.
(Myles 660) (Varneys 1044)

Front 9

C. Assess and provides counseling and education as needed, for:
5. breastfeeding, condition of breasts and nipples

Back 9

NIPPLES:
Check nipples for soreness and cracking: if soreness is developing, evaluate the baby's latch and feeding positioning (educate and help correct any positioning or latching issues). Suggest vit E oil between nusring sessions and stress importance of continuing to breastfeed. Have her begin with least affected breast then switch to sore side once let-down has occurred.
- If nipples are cracked, check positioning and baby's latch, rule out short frenulum, vit E and cold cabbage leaves tucked against nipples may provide relief.


BREASTS:
Breasts: check for engorgement, by feeling for lumps at the sides of the breasts and in armpits, look for reddened areas, ask mother if she feels engorged. If engorgement is a problem, make sure mother is nursing on demand w/proper positioning, have her soak breast (or whole body) in warm water, she can express milk, apply cold cabbage leaves or steamed comfrey leaves to the breasts left in place for 20 mins and repeat periodically throughout the day. For lingering engorgement try hot ginger compresses under the arms or in the upper, outer quadrants of breasts.
- Breast for tenderness and lumps: It is said that hormones for pregnancy can accelerate abnl cell growth. Do a breast exam, and review SBE with her.

Front 10

C. Assess and provides counseling and education as needed, for:
6. muscle prolapse of vagina and rectum (cystocele, rectocele)

Back 10

ASSESS:
a) cystocele: Insert fingers into vagina and press down posteriorly, ask the woman to bear down and assess for evidence of a cystocele by feeling for a bulge of the anterior vaginal wall. 1st degre=bulging of anterior vag wall; 2nd degree= bulging reaches vaginal orifice or introitus; 3rd degree=bulging extends betond the introitus

b) rectocele: (Doing the same thing as for cystocele) Spread your finger and ask woman to bear down again. Asses for evidence of rectocele by feeling foe bulging upward into vagina and outward toward the introitus. Rectoceles are graded in same degrees as cystoceles.


EDUCATE/COUNSEL:
- If cyst/rectocele is present suggest kegels and reassess at 7 day visits, a reminder at the 3 days visit to do exercises can be helpful. If she is doing her exercises faithfully, the cyst/rectocele should be diminishing by 1 week PP.

Front 11

C. Assess and provides counseling and education as needed, for:
7. strength of pelvic floor

Back 11

Internal muscle tone: Should be back to NML by 3-6wks PP, if mother has been doing exercises. If not, explain the importance of strengthening the pelvic muscles to keep the uterus and other internal organs in their proper palce.

Front 12

C. Assess and provides counseling and education as needed, for:
8. condition of the uterus (size and involution), ovaries and cervix

Back 12

UTERUS:
- Immediate PP should be below the navel and firm
- Day1 PP might be at or below navel and firm
- Day 3 PP should be 1-2 FB below navel, firm (not tender or enlarged, or malordorous which could indicate hemorrrhage, or infection at any time)
- Week 1-2, fundus should be a few FB above PS and firm
- Week 4-6, fundus should be out of range by palpation, except for bimanually. If it is enlarged she is prob still bleeding, indicating poor recovery. Prescribe rest, long relaxed nursing sessions (to bring oxytocin), optimal nutrition with plenty of calories, supplements as indicated and involuting tea or tincture of black haw and shepherd's purse.

OVARIES/CERVIX:
- By 4-6 weeks the Cervix: Should feel firm, closed and situated high in vaginal vault (like intial exam). Some women do not regain their prepregnant cervical position and tone until cutting back significantly on breastfeeding.
Ovaries should be back to prepregnant norm, out of palpation range except for on bimanual exam (and not even then sometimes). Enlarged ovaries would be ABNL and in need of furthered investigation.

Front 13

C. Assess and provides counseling and education as needed, for:
9. condition of the vulva, vagina, perineum and anus

Back 13

PERI/VAG/VULVA/ANUS:
- DAY 1:
Perineum, especially if there has been swelling, tearing or suturing: all swelling should be gone--if not suggest alternating cool and warm compresses. Make sure she is rising her peri at least twice per day with warm water with a bit of betadine in it. If swelling increases and she complains of pain check for hematoma.
- Can check for cystocele or rectocele, if it is present suggest kegels and reassess at 7 day visits
- If she has stitches, check to make sure they have held, edges should be pulling together and should be clean and dry (if not she can apply fresh aloe vera). Signs of infection include inflammation, pain, and discharge--physician should be consulted if these are present.
- If she only reports tenderness w/out any s/s of infection suggest sitz bath 3-4 times daily.
- Check to see if there has been any pain with urination, have her pour warm water over perineum when she urinates if this is happening. Check her temp to rule out UTI
- See if she has had a BM, if not recommend fiber-rich foods, if she has had stitches, have her use counterpressure on peri with warm rag.

DAY 2: (recheck with guidelines from day one)
- Recheck cystocele/rectocele and if evident remind her to do exercises.
- Ask if she feels any vaginal pressure or draggingsensation when out of bed (hematoma?)

WEEK 1:
- Signs of physical recovery should be evident,
- if mother had peri repair, skin should be closed by now.
- If mother has been doing her pelvic exercises her cyst/rectocele should be diminishing by now
- bring up the topic of sex, advise the mother to have nothing in her vagina until her lochia flow has stopped completely. Suggest that she wait to see you before continuing, perticularly if she had stitches. encourage her to listen to her body in making decisions when she is ready.
- Over next few weeks if she reports extreme fatigue, exhaustion, continued bleeding or sensations of pressure or dragging in her vag when she is up and about, see her at once. These are poor signs of healing that must be addressed promptly if she is to recover.

WEEK 4-6:
- Lacerations or episiotomy: Healing should be complete, there may still be tenderness with labial splits as newly formed skin takes time to roughen up. This may cause some discomfort, w/sex, but adequate lube and creative positioning should help with this. If peri feels rigid with scar tissue, encourage mother to do peri massage with EPO.
- If she is comfortable, she can (at home) wash her hands and insert two fingers into vag and check to see if the area is still sensitive to pressure.
-healing should have happened by now, some deep 2nd degree tears will take longer and in the absence of lochia and if she is feeling fine, that is not a worry.

Front 14

D. Educates regarding adverse factors affecting breastfeeding:
1. environmental
2. biological
3. occupational
4. pharmacological

Back 14

1/2/3:
- Stay away from lead and mercury products (fish and shellfish) also always check any skin-products, lotions or soaps, these have been known to carry mercury as an ingredient at times (rare in US)

4. Pharmacological:
- Most drugs will pass into breast milk in greater or lesser concentrations. A mother taking a larger fat-soluble drug will pass more to an infiant that feeds for prolonged periods (more hindmilk) that to one who feeds little and often because of the relative amounts of the hindmilk consumed.
- Some drugs that may adversely affect milk production that are most commonly encountered are:
- estrogen: the combined contraceptive pill therefore contraindicated
- bromocriptine and cabergoline
- large doses of thiazide diuretics, NML doses may be safe
- ergotamine (used in treatment of migraine)
(Myles 955)

Front 15

E. Provides contraceptive/family planning
education and counseling

Back 15

Card-- I.K.14. -- discusses all different types of contraception.

- Before sexual activity resumes, couples must discuss/address contraception and come to a conclusion made from evidence based knowledge (received from care-giver and additional resources) and their own desires. This decision is important to be made together as a couple.

- Birth control pills are not very suitable, estrogen suppresses milk production and the progesterone mini pills are not as effective on there own.
- Copper IUD is another option, many women find thisless desirable because of adverse side effects like chronic bleeding and low-grade infection
- Fertility awareness method is difficult to implement PP, as lactation causes erratic basal body temp andcervical mucus (LAM or ovulens may prove better results?--NOT NARM--)
- Norplant and Depo-Provera cause heavy bleeding and can delay the resumption of menses when discontinued.
- This leaves barrier methods: condom, diaphragm and cervical cap
(Davis 216)

Front 16

H. Knows signs and symptoms, differential
diagnosis, and appropriate midwifery management or referral for:
1. uterine infection

Back 16

S/S: uterine tenderness or pain, foul smelling lochia, high pulse, high temp, achy/flu-like symptoms

- Diff diag: other PP infections, vaginal tear/incision, peri/vaginal, breast, general flu etc.

- Load up on Vit. C, herbs (eccinachea), increase fluid intake, rest

- Consult physician

Front 17

H. Knows signs and symptoms, differential
diagnosis, and appropriate midwifery management or referral for:
3. infection of vaginal tear or incision

Back 17

S/S: peri pain, high pulse, high temp, swelling inflammation, discharge, flu-like s/s

- Diff Diag: other PP infections, uterine, breast etc.

- Manag: clean peri everytime she uses toilet, cold/hot compresses, sitz baths

- Consult Phys.

Front 18

H. Knows signs and symptoms, differential
diagnosis, and appropriate midwifery management or referral for:
6. late postpartum bleeding/hemorrhage

Back 18

S/S: any abnl/excessive bleeding between 24hrs-12wks PP. Lochia is heavy and turns bright red flow (from serosa), subinvolution, tachy pulse, pyrexia (fever)

- Cause: usually from retained membranes or clot

- Consult Phys and transport giving O2, massage uterus/express clots, EBL, give hemorrhage meds

Front 19

H. Knows signs and symptoms, differential
diagnosis, and appropriate midwifery management or referral for:
7. thrombophlebitis

Back 19

Thrombo: inflammation of superficial or deep vein of leg. Those with varicosities are at higher risk.

- Superficial Thrombo S/S: leg pain w/heat, tenderness, and redness at site--confirm by checking Homan's sign (straight leg, dorsiflex foot-pain=positive sign)

Deep Thromb S/S: high fever, severe pain, edema and tenderness along entire length of the leg

-- With either sontact phys. immediately-- lay mother flat, legs elevated HANDS OFF effected leg NO massage (it could dislodge clot and allow it to lodge in lungs causing a pulmonary embolism--serious/deathly condition)
- Davis

Front 20

I. Assesses for, and treats jaundice by: (4)

Back 20

1. encourage mother to breastfeed every
two hours

2. expose the front and back of newborn to sunlight through window glass (30 min 2x/day)

3. assess newborn lethargy and hydration(assess elimination pattern, type/color and amount)

4. consult or refer if signs worsen

Front 21

J. Provide direction for care of circumcised penis

Back 21

- After circ. keep penis wrapped in gauze that is dabbed in petrolium jelly/ointment and change this everytime you change diaper. Avoid getting penis wet (in bath), until healing is complete--typically 1wk after surgery--

- Call Dr. if there is: discoloration, bleeding (that doesn't stop in a few mins), discharge w/pus or redness, fever, not urinating, baby is unable to be comforted

- small amount of oozing, soreness (irritability), bleeding, swelling and yellow crust around incision is considered NML

-online

Front 22

K. Provide direction for care of uncircumcised penis

Back 22

- Foreskin adheres to glans for 1st 1-2 yrs at which point the boy will pull it back as he becomes aware of his genitals--Parents should NOT pull back foreskin before this for any reason, this could cause vicious cycle of bleeding and infection.

- When foreskin becomes moveable, teach him to pull it back and clean underneath when he showers.

Front 23

L. Treat thrush on nipples:

Back 23

1. dry nipples after nursing

2. non-allopathic remedies: calendula cream or probiotics on nipples (probiotics internally also)
- Gaskin says to wash nipples off with vineager then rinse that with water between nursing sessions

3. allopathic treatments:
- very good hygeine and cleaning after using bathroom/touching vagina
- topical acidophilus/probiotics (kefir?)

- If it continues and interferes with breastfeeding then consult Phys.

Front 24

M. Treat sore nipples with:

Back 24

1. expose to air: allow to dry after each session

2. suggest alternate nursing positions

3. evaluate baby’s sucking method: check frenulum under tongue for shortness, is tongue visible under nipple when nursing?, is there more of lower portion of areola in baby's mouth?

4. apply topical agents: vit E oil

5. apply expressed milk

Front 25

N. Treat mastitis by:

Back 25

1. provide immune system support including:

a) nutrition/hydration: do diet intake and discuss nutritional needs especially pertaining to immunity and strength against bacterial infection

b) non-allopathic remedies: vit. C and eccinachea

2. encourage multiple nursing positions

3. apply herbal/non-allopathic
compresses: cold cabbage leaves, steamed comfrey leaves, steamed ginger compresses

4. apply warmth, soaking in tub or by shower

5. encourage adequate rest/relaxation: also assess mothers relationship to b.feeding, is she relaxed, enjoying experience? Is she trying to get the baby onto a shedule with nursing

6. assess for signs and symptoms of infections

7. teach mother to empty breasts at each feeding: express

8. provide/teach gentle massage of sore spots

9. consult/refer to:
a) La Leche League
b) lactation counselor
c) other healthcare providers