Perinatal Services BC Guideline 20 Postpartum Care Pathway

March 2011 Introduction About the Maternal Postpartum Nursing Care Pathway . 2 Who updated the Maternal Postpartum Nursing Care Pathway. 2 Women-Centred Care . 2 Referring to a Primary Provider (PHCP). 3 Referrals to Other Resources. 3 Goals and Needs – Health Canada’s National Guidelines . 3 Needs – World Health Organization . 4 Timeframes. 4 Maternal Physiological Stability . 4 Postpartum Pain Scale (VAS) . 5 Sedation Scale . 5 Physiological Health Abdomen/Fundus . 7 Pain. 8 Abdominal Incision . 9 Breasts . 10 Communicable () . 15 Hepatitis C . 16 Herpes Simplex . 17 HIV . 18 . 19 Varicella Zoster. 20 Perinatal Services BC Influenza . 21 West Tower, 3rd Floor Elimination 555 West 12th Avenue Bowel Function. 22 Vancouver, BC Canada V5Z 3X7 Urinary Function . 24 Tel: (604) 877-2121 Lochia. 25 Perineum . 26 www.perinatalservicesbc.ca Rh Negative. 27 Vital Signs. 28 Psychosocial Health Bonding and Attachment. 29 Emotional Status and . 31 Support Systems/Resources. 33 Changes: Family Strengths And Challenges Family Function. 34 While every attempt has been /Sexuality . 35 made to ensure that the information Health Follow-up in Community. 37 contained herein is clinically accurate and current, Perinatal Services BC Feeding – . 39 acknowledges that many issues remain Infant Feeding – Formula Feeding. 42 controversial, and therefore may be subject to practice interpretation. Lifestyle Activities/Rest. 43 Healthy Eating . 45 Smoking and Use of Drugs/Substances . 46 Safe Home Environment . 48 Glossary of Abbreviations. 49 References & Endnotes . 49 Revision Committee . 53 © Perinatal Services BC, 2011 Introduction About the Maternal Postpartum Nursing Care Pathway

The Maternal Postpartum Nursing Care Pathway identifies the goals and needs of postpartum women and is the foundation for documentation on the British Columbia Postpartum Clinical Care Path (for Vaginal and Caesarean Delivery). To ensure all of the assessment criteria are captured, they have been organized in alphabetical order into three main sections:

• Physiological Health • Psychosocial Health • Changes: Family Strengths and Challenges While the maternal assessment criteria are presented as discrete topic entities it is not intended that they be viewed as separate from one another. For example, the maternal physiological changes affect her psychosocial health. To assist with this, cross referencing is used throughout the document. This is also evident when referencing to newborn criteria in the Newborn Nursing Care Pathway. The and newborn are considered to be an inseparable dyad with the care of one influencing the care of the other; for example breastfeeding affects the mother, her newborn, bonding and attachment.

In this document, assessments are entered into specific periods; from immediately after to 7 days postpartum and beyond. These are guidelines and are used to ensure that all assessment criteria have been captured. Once the is in her own surroundings, assessments will be performed based on individual nursing judgment in consultation with the mother.

Who updated the Maternal Postpartum Nursing Care Pathway

Perinatal Services BC (formerly BC Perinatal Health Program)1 coordinated the updating of this document. It represents a consensus opinion, based on best evidence, of an interdisciplinary team of health care professionals. The team included nurses from acute care and nursing representing each of the Health Authorities as well as rural and urban practice areas. Clinical consultation was provided by family , pediatricians, obstetricians, and other clinical experts as required.

Statement of Women-Centred Care

The Postpartum Nursing Care Pathway assumes that informed decision making is used when care is offered. As stated by CRNBC2 “nurses provide information that a reasonable person would require in order to make an informed decision about the proposed care, treatment or research. This includes information about the condition for which the care, treatment or research is proposed, the nature of the care, treatment or research, and its risks and benefits as well as any alternatives. Nurses provide sufficient, specific, evidence-based information in a timely and appropriate manner, advocating for clients to acquire desired information from others and assisting clients to understand the information provided.”3

The United Nations4 states that gender is a primary determinant of health. Health Canada5 recognizes the potential biases women experience in health care where “women's health is determined not only by their reproductive functions, but also by biological characteristics that differ from those of men (sex), and by socially determined roles and relationships (gender)”.6

The BC Provincial Women’s Health Strategy7 uses the framework of Women-Centred Care which respects women’s diversity, supports the way women provide for their health needs in the social, cultural and spiritual context of their experience, addresses the barriers to access services, and places the woman and her newborn at the centre of care. It also assures that women, their partners and families are treated with kindness, respect and dignity. Services are planned and provided to meet their needs, respecting the woman’s preferences and decisions, even if they differ from the caregiver’s recommendations.8,9 In certain circumstances (such as maternal mental health or child maltreatment) nursing judgment and/or reporting requirements may override a woman’s decision.

2 Perinatal Services BC Introduction Referring to a Primary Health Care Provider (PHCP)

Prior to referring to a Primary Health Care Provider (PHCP) an appropriate postpartum nursing assessment will be performed. This may need to be specific or global (physical, emotional, & psychosocial health, learning needs for self care as well as care of her infant)10 in nature. In the intervention sections the nursing process will be referred to as Nursing Assessment.

Referrals to Other Resources

To support nursing practice the following resources are available. Links for many specific resources are included throughout the document. Key resources for parents are:

• Best Chance Website – This website is filled with up-to-date and practical information, useful tools and resources for women, expectant parents, and families with babies and toddlers up to 3 years of age. http://www.bestchance.gov.bc.ca/ • Baby’s Best Chance Parents’ Handbook of and Baby Care (second revision sixth edition) www.bestchance.gov.bc.ca In Key Resources Tab • Baby Best Chance Video www.bestchance.gov.bc.ca In Key Resources Tab • HealthLink BC – www.healthlinkbc.ca/kbaltindex.asp • HealthLink BC – Telephone number accessed by dialing 8-1-1 (Services available – health services representatives, nurses pharmacists, dietitians, translation services and hearing impaired services)

Goals and Needs - Health Canada’s National Guidelines

As indicated by Health Canada in the document Family-Centred Maternity and Newborn Care: National Guidelines,11 the is a significant time for the mother, baby, and family as there are vast maternal and newborn physiological adjustments and important psychosocial and emotional adaptations for all family members or support people.

From the National Guidelines, the BCPHP has adapted the goals, fundamental needs, and basic services for postpartum women to:

• Assess the physiological, psychosocial and emotional adaptations of the mother and baby • Promote the physical well-being of both mother and baby • Promote maternal rest and recovery from the physical demands of pregnancy and the birth experience • Support the developing relationship between the baby and his or her mother, and support(s)/family • Support the development of infant feeding skills • Support the development of skills • Encourage support of the mother, baby, and family during the period of adjustment (support may be from other family members, social contacts, and/or the community) • Provide education resources and services to the mother and support(s) in aspects relative to personal and baby care • Support and strengthen the mother’s knowledge, as well as her confidence in herself and in her baby’s health and well-being, thus enabling her to fulfill her mothering role within her particular family and cultural beliefs • Encourage and assist the completion of specific prophylactic or screening procedures organized through the different programs of maternal and newborn care, such as: Vitamin K administration and eye prophylaxis,

Obstetrics Guideline 20: Postpartum Nursing Care Pathway 3 Introduction

immunization (rubella, Hepatitis B), prevention of Rh isoimmunization and newborn screening (blood spot screening, newborn hearing screening) • Assess the safety and security of postpartum women and their newborns (families) (e.g. potentially violent home situations, substance use, car seats) • Identify and participate in implementing appropriate interventions for postpartum maternal and variances/ concerns • Assist the woman in the prevention of postpartum variances/concerns

Needs – World Health Organization (WHO)

The WHO12 states that “ should respond to the special needs of the mother and baby during this special phase and should include the prevention and early detection and treatment of complications and , the provision of advice and services on breastfeeding, , immunization and maternal nutrition.”13

The eight specific WHO maternal postpartum needs are identified as:

• Information and counselling on care of the baby and breastfeeding, what happens with and in their bodies, self care, sexual life, contraception and nutrition • Support from health care providers and family/partner • Health care for suspect or manifest complications • Time to care for the baby • Help with domestic tasks • Maternity leave • Social integration into her family and community • Protection from abuse/violence

Timeframes

The first 2 hours following the third stage of birth (delivery of ) is the Period of Stability. The Consensus Symposium14 defined ‘The Period of Stability’ as “maternal stability is generally attained within two hours following birth”.15 Other important timeframes identified by the development committee are: >2 – 24 hours, >24 – 72 hours, and >72 hours – 7 days and beyond and are the reference points used in this document.

NOTE: In order to capture key parent teaching / anticipatory guidance concepts, they will be located in the >2 – 24 hour timeframe. It is the at the individual nurse’s discretion to provide this information and or support earlier or later.

Maternal Physiological Stability

The Postpartum Nursing Care Pathway has adapted Consensus Statement #1, in the BC Postpartum Consensus Symposium16 and recommends that the 5 following criteria define postpartum physiologic stability for vaginal delivery at term.

• Vital signs stable (T, P, R, BP) • Perineum intact or repaired as needed • No postpartum complications requiring ongoing observation (e.g.: hemorrhage) • Bladder function adequate (e.g.: has voided) • Skin-to-skin (STS) contact with baby

4 Perinatal Services BC Introduction

Postpartum Pain and the Visual/ Verbal Analogue Scale (VAS)

Acute post partum pain is a strong predictor of persistent pain and after .17 Severity of acute post partum pain, not mode of delivery, is independently related to the risk of postpartum pain (2.5 fold increased risk) and depression (3.0 fold increased risk).18 In order to assess post partum pain and to improve maternal outcomes, the standardized method of using the Visual/Verbal Analogue Scale (VAS) is recommended.19 The pain assessment incorporates a visual or verbal pain scale plus 4 pain assessment questions.

For the purpose of these guidelines a verbal pain assessment will be incorporated.

The following questions should be part of the maternal pain assessment

1. Location: Where is the pain? 2. Quality: What does the pain feel like? 3. Onset: When did your pain start? 4. Intensity: On a scale of 0 to 10 (with 0=no pain and 10=worst pain possible) where would your pain be? (Pain Scale is used on Postpartum Clinical Care Path) 5. What makes the pain better? 6. What makes the pain worse?

Sedation Scale

To investigate the effects of differing degrees of intraoperative sedation during regional on intra and postoperative outcomes, a reliable and valid system for measuring the level of sedation is required.20 The Wilson Sedation Scale is a simple, evidence-based sedation scale and will be used to assess sedation in women experiencing a regional anesthetic.

The following parameters are used for the sedation scale assessment

1. Fully awake and oriented 2. Drowsy 3. Eyes closed but rousable to command 4. Eyes closed but rousable to mild physical stimulation (earlobe tug) 5. Eyes closed but unrousable to mild physical stimulation

Obstetrics Guideline 20: Postpartum Nursing Care Pathway 5

0 – 2 hours >72 hours – 7 days Physiological Assessment >2 – 24 hours >24 – 72 hours Period of Stability (POS) and beyond

Abdomen/fundus Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal Assess • Fundus firm, central +/- 1 finger above/below Variations Variations Variations • Fundus for normal umbilicus • Refer to POS • Fundus firm, central, • Fundus central, firm 1 – 2 fingers below and 2 – 3 fingers involution Client Education/ Anticipatory Guidance • Rectus muscle intact umbilicus-goes below umbilicus • Frequency of assessment • Palpate fundus with 2nd hand supporting just following organization’s down ~ 1 finger (1cm) • Involuting and

Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics above symphysis (woman in supine with Client Education/ breadth/day descending ~1 finger- policy: knees flexed).21 Anticipatory Guidance breadth 1cm/day Suggested frequency for • Advise to empty bladder and aware of need to • Refer to POS (not palpable at 7 – Client Education/ vaginal birth: empty frequently. 10 days postpartum, Anticipatory Guidance • q 15 min for 1 hour • Woman able to demonstrate palpation (if she Variance – pre pregnant state at desires) • Refer to 0 – 24 hr • at 2 hours Fundus and 6 wks) • once per shift until Variance – Fundus • Refer to POS discharge from • Uterus – boggy, soft, deviated to one side (due to Variance Client Education/ • then as required by nursing retained products, distended bladder, , Intervention – • Refer to 0 – 24 hr Anticipatory Guidance judgment and/or self report ) Fundus and Infection • Refer to 0 – 24 hr Intervention – Fundus • Refer to POS Assess woman’s Intervention understanding of: • Massage uterus (if boggy) – advise to empty bladder • Refer to 0 – 24 hr Variance – Variance • May require further interventions – e.g. intravenous, • Normal involution Diastasis recti abdominis • Refer to 0 – 24 hr progression (or other uterotonic medications), in and out catheterization of bladder • Diastasis recti abdominis Assess woman’s capacity to: • Nursing Assessment as evidenced by bulging Intervention or gaping in the midline • Self check her involution • Refer to appropriate PHCP prn • Refer to 0 – 24 hr of abdomen progression Variance – Infection • Identify variances that may • Infection S & S: T>38, P, chills, anorexia, nausea, Intervention – require further medical fatigue, lethargy, pelvic pain, foul smelling and/or Diastasis recti abdominis assessment profuse lochia • Educate that this will Intervention-Infection become less apparent Refer to: with time • Monitor for increased uterine tenderness and • Lochia • Monitor S & S of infection • Refer to Lochia • Refer to PHCP

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 7 Physiological Health: Abdomen/Fundus

Refer to 0 – 24 hr Refer to 0 Refer to 0 – 24 hr Afterpains begin to subside after about 72 hr Refer to POS Refer to POS >72 hours – 7 days >72 hours and beyond Normal Norm and Variations • Client Education/ Anticipatory Guidance • • Variance • Intervention • Refer to 0 – 24 hr Refer to 0 Refer to POS Refer to POS Refer to POS >24 – 72 hours Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance • Intervention • www.bestchance.gov.bc.ca multiparous women multiparous when breastfeeding Refer to POS of breastfeeding Effect on involution of uterus Refer to POS Refer to POS Refer to POS Afterpains may in severe be more Client Education/ Anticipatory Guidance • • Variance • Intervention • >2 – 24 hours Normal Norm and Variations • •

Best Chance Website – Best Chance Website and the narcotic effects effects and the narcotic 23 and not relieved by current by current and not relieved 24

22 use of alternate Confer with PHCP re medication. measures further Pain scale >4 for VB and >5 for CB requires evaluation and management of pain Nursing Assessment including pain assessment PHCP prn Refer to appropriate to take precautions with the use of Codeine mothers to take precautions Canada to identify ultra rapid (test not available in metabolizers of Codeine on the newborn. Refer to breastfeeding) Pain does impact daily living, such as walking, ability mood, sleep, interactions with others and to concentrate >5 for Pain scale >4 for vaginal birth (VB) and birth (CB) Cesarean pain relief analgesia and/or non pharmacological Pain is tolerable with/without analgesia and/or non analgesia and/or non with/without Pain is tolerable measures pain relief pharmacological daily living, such as walking, Pain does not impact with others and ability to mood, sleep, interactions concentrate and when questions to assess pain level Using VAS to consult PHCP for nursing of recommendation aware Women Intervention • • • Variance Variance • • Period of Stability (POS) Period of Normal Variations Norm and • • Guidance Client Education/ Anticipatory • • 0 – 2 hours 0 – 2 hours Best Chance Baby’s develop chronic pain and/or develop chronic depression Women with increased with increased Women apt to more pain are pain be? Intensity: Using the scale 0 pain (no pain) and 10 (worst would your possible) where feel like? start? ain frequency and effectiveness frequency • Assess woman’s awareness awareness Assess woman’s and/ of comfort measures or analgesia – include doses, Effectiveness of comfort Effectiveness measures/analgesia the pain better? makes 5. What the pain worse? makes 6. What 4. When did your pain 3. Onset: assessment questions is the pain? Where 1. Location: What does your pain 2. Quality: P analogue Use of a visual/verbal and pain (VAS) pain scale Physiological Assessment Physiological Physiological Health: Pain Refer to:

8 Perinatal Services BC 0 – 2 hours >72 hours – 7 days Physiological Assessment >2 – 24 hours >24 – 72 hours Period of Stability (POS) and beyond 0 – 2 hours >72 hours – 7 days Physiological Assessment >2 – 24 hours >24 – 72 hours Pain Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal Period of Stability (POS) and beyond Use of a visual/verbal analogue • Pain is tolerable with/without analgesia and/or non Variations Variations Variations Abdominal Incision • Abdominal incision dressing Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations pain scale (VAS) and pain pharmacological pain relief measures • Refer to POS • Refer to 0 – 24 hr • Refer to 0 – 24 hr dry and intact with minimal • Well approximated and free • Fundus may be tender but • Refer to 0 – 24 hr assessment questions • Pain does not impact daily living, such as walking, • Afterpains may • Abdominal incision – oozing of inflammation, little or no improving • May experience numbness 1. Location: Where is the pain? mood, sleep, interactions with others and ability to be more severe in drainage, dressing dry and • Incision swelling decreasing surrounding incision concentrate22 multiparous women Client Education/ Client Education/ progression of healing 2. Quality: What does your pain Client Education/Anticipatory intact, staples present, may when breastfeeding Anticipatory Guidance Anticipatory Guidance • Incision healing with little or feel like? have subcuticular suture • Refer to POS • Refer to 0 – 24 hr Assess woman’s understanding Guidance Client Education/ Anticipatory no drainage 3. Onset: When did your pain Client Education/ Anticipatory Guidance Pathway Care Nursing 20: Postpartum Guideline Obstetrics covered with steri-strip • Afterpains begin to of • Marked areas of oozing Guidance start? • Using VAS questions to assess pain level and when Client Education/ pressure dressing Anticipatory Guidance subside after about • Normal healing from • Encourage to splint abdomen • Traditional dressing removed Client Education/Anticipatory 4. Intensity: Using the scale 0 to consult PHCP Variance 72 hr caesarean birth abdominal with pillow when coughing, – may shower, cover incision Guidance (no pain) and 10 (worst pain • Women aware of recommendation for nursing • Refer to POS Client Education/ Anticipatory • Refer to POS incision moving or feeding • Steristrips to come off on own • Refer to >24 hr – 72 hr possible) where would your mothers to take precautions with the use of Codeine • Effect of breastfeeding Guidance Variance • Use of good body mechanics • For sterstrip pressure pain be? (test not available in Canada to identify ultra rapid on involution of uterus Intervention Suggested assessment when changing positions, • Refer to POS 23 • Refer to POS dressing leave intact until Variance 5. What makes the pain better? metabolizers of Codeine and the narcotic effects • Refer to POS frequency for caesarean birth: (getting up from bed/chair) removed by PHCP on the newborn. Refer to breastfeeding) Variance • Refer to 0 – 72 hr 6. What makes the pain worse? • q 15 min for 1 hour Variance • Ensure arrangements for Confer with PHCP re use of alternate medication. • Refer to POS Intervention • at 2 hours Variance • Refer to POS • Refer to POS removal of staples/sutures or Intervention Effectiveness of comfort Intervention • Increased bleeding on • Incision gaping, edema, Steri Strip pressure dressing Variance • q 4 h X 24 hours • Refer to POS measures/analgesia • Refer to POS • once per shift until d/c from dressing, incision gaping, inflamed, ecchymosis, (as per hospital/ agency • Pain does impact daily living, such as walking, hospital swelling and bruising discharge policy/ PHCP preference) mood, sleep, interactions with others and ability • Advise of correct lifting Assess woman’s awareness to concentrate • then as required by nursing judgment and/or self report Intervention Intervention technique – abdominal of comfort measures and/ • Pain scale >4 for vaginal birth (VB) and >5 for • Refer to POS tightening with exhalation or analgesia – include doses, Cesarean birth (CB)24 and not relieved by current • Apply pressure dressing when lifting, lift within the frequency and effectiveness analgesia and/or non pharmacological pain relief • Nursing Assessment woman's comfort zone (e.g. • Women with increased measures • Refer to PHCP prn pain are more apt to baby, toddler) Advise to use good body develop chronic pain and/or Intervention Variance – Infection depression mechanics and avoiding • Pain scale >4 for VB and >5 for CB requires further • S & S such as T>38, the Valsalva when lifting evaluation and management of pain increased pulse, chills, • Recommend refraining from • Nursing Assessment including pain assessment anorexia, nausea, fatigue, tub bath until dressings, • Refer to appropriate PHCP prn lethargy, pelvic pain, foul sutures, staples removed smelling and/or profuse lochia Variance Intervention – Infection • Refer to POS • Nursing Assessment • Drainage/infection • Monitor for increased uterine tenderness and further signs Intervention and symptoms of infection • Refer to POS • Refer to PHCP prn 9 Physiological Health: Abdominal Incision 30

(may extend to warmth, throbbing Tenderness, armpits) and transparent may be taut, shiny, Skin on breast Nipples flat, usually bilateral swollen, painful hard, Breast(s) breast gently and manually express Massage breast breastfeeding, before milk to soften the areola facilitating infant latch Anti-inflammatory agents shower or breast Application of warm compresses, breastfeeding soak before such as gel packs, Application of cold treatments, after cold packs or some cold cabbage leaves the use of cold cabbage (women report breastfeeding based) leaves as helpful although not evidenced softer after may be 72 hours, breasts After about feedings fullness Breast Refer to >2 – 72 hr Refer to 0 – 72 hr – pain that does damaged previously If nipples were latch not subside after initial Refer to 0 – 72 hr • • • • Intervention – Engorgement • • • • >72 hours – 7 days >72 hours and beyond Normal Variations Norm and • • Guidance Client Education/ Anticipatory • Variance • • Intervention • – Engorgement Variance 29 www.bestchance.gov.bc.ca If bra used it should fit comfortably and not breast restrict and colostrum more and colostrum more easily expressed May have some nipple tenderness fullness Breast Refer to >2 – 24 hr breastfeeding Frequent helps to prevent engorgement Refer to >2 – 24h Refer to >2 may be Breasts beginning to fill, firmer • • • Client Education/ Anticipatory Guidance • • >24 – 72 hours Normal Norm and Variations • •

Best Chance Website – Best Chance Website 27 28 – if Hand expression colostrum or milk feed to baby expressed into nipple or rub drops tissue Support the woman/ infant to work together in achieving an effective latch - most important factor in decreasing incidence of nipple pain Refer to Infant Feeding Section Healthy Eating (Refer to Lifestyle-Nutrition) PSBC (2011) Guideline the Breastfeeding Infant Healthy Term Refer to POS soft, minimal Breast nipple tenderness Client Education/ Anticipatory Guidance • • • • • >2 – 24 hours Normal Norm and Variations • •

26 Uninterrupted skin- to-skin contact until completion of the first feeding or longer Mothers with more than one hour of skin-to-skin contact during the first three hours following birth, likelihood increased of breastfeeding exclusively soft, colostrum Breasts may be expressed intact, may Nipples are appear flat or inverted with baby’s but protrude are feeding attempt and minimally tender reasts Anticipatory Guidance • • Period of Stability (POS) Period of Normal Norm and Variations • • Client Education/ 0 – 2 hours 0 – 2 hours s Baby’s Best Chance Baby’s t Some medical conditions Postpartum hemorrhage enlargement during enlargement pregnancy traumas Some breast or malformations augmentation Breast or reduction Lack of breast Lack of breast as e confidence to produce adequate milk supply for her baby stimulation breastfeeding Adequate breast Adequate breast affect milk supply affect Breast comfort and Breast function Conditions that may Breasts and nipples and nipples Breasts Assess woman’s capacity Assess woman’s to hand express Assess woman’s • Assess woman’s Assess woman’s understanding of • • • Br Assess • Physiological Physiological Assessment Physiological Health: B Refer to:

10 Perinatal Services BC 0 – 2 hours Physiological >72 hours – 7 days Period of Stability >2 – 24 hours >24 – 72 hours Assessment and beyond (POS)

Breasts Variance Variance – Nipple(s) Variance Variance – Lump in Axilla (Continued) • Nipple inversion, • Refer to POS • Refer to 0 – 24 hr and >72 hr and • Extra breast tissue in the axilla nipples that • Nipple pain beyond • Normal variation, medical invert with gentle • Nipple damage – (bleeding/ cracked, bruised intervention not required compression or nipples) Intervention

Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics do not evert with • Nipple distortion after feeds • Refer to 0 – 24 hr and >72 hr and Intervention – Engorgement of stimulation sufficient • Inadequate breast stimulation beyond Lumps in Axilla for baby to latch • Not initiating hand expression within six hours • Anti-inflammatory agents • Baby not latching if baby separated Variance – Nipple trauma • Comfort Measure – application • Baby separate from • Baby is unable to latch (flat or inverted nipple) • Nipple trauma (beginning signs of of cold mother skin breakdown) • Refer to >2 – 24 hr Intervention – Nipple(s) Variance – Plugged Duct • Refer to POS and > 24 – 72 hours and beyond Intervention – Nipple trauma • Usually 1 breast Intervention • Assess infant feeding (especially for position • Assess infant feeding • Localized hot, tender spot • Refer to >2 – 24 hr and latch) • Ask mother to rate her nipple pain • May be white spot on nipple • Hand expression if • Assess and support strategies for infant (using VAS-see Pain) • May be a palpable lump (plugged baby separated from feeding • Encourage mother to look at nipple duct) mother • If baby unable to feed effectively, initiate as baby releases it, if nipple looks • Nursing Assessment regular hand expression in the first 24hours rounded rather than creased or Intervention – Plugged Duct • Refer to PSBC and expression and pumping thereafter (refer flattened the pain is probably • Shower or warm compress to (2011) Guideline related to previous damage. to Newborn Nursing Care Pathway) breast before breastfeeding Breastfeeding the This ‘reference feeding’ can help • Apply expressed breast milk to nipple • Frequent feeding Healthy Term Infant determine latch effectiveness • Start feeding with least affected nipple (if • Massage behind the plug toward • Refer to individual knowledgeable nipple pain) the nipple, prior to and during in current breastfeeding practices • Only interrupt breastfeeding if feeding feeding or consultant (LC) intolerable – assist woman with hand • Vary positions for feeding25 expression • After 24 hours use a combination of hand and pump expression • Comfort measures may include • Teach hand expression by 6 hours31 ice and anti-inflammatory agents • Refer to PSBC (2011) • Information on managing engorgement (refer Breastfeeding the Healthy Term • Avoid missing feedings to 72 hr – 7 days and beyond – Engorgement) Infant • Comfortable bra – if required • Refer to breastfeeding (variance not exclusively breastfeeding)

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 11 Physiological Health: Breasts

33 gently massage affected a firm area, is If there feed) through (massage area area to affected Shower or warm compresses preference prior to feeds based on woman’s After feeds – cool compresses Analgesic to >24hr refer If symptoms do not resolve PHCP in Antibiotics may be indicated if not resolved 24 hours Sudden onset of intense pain Sudden onset both) (may be Usually in 1 breast red or have red may feel hot, appear Breast and/or be swollen streaks like symptoms, may experience flu Woman fever of 38.5 °C Support from – milk breastfeeding Continue frequent is safe for infant breast affected Rest if too painful to breastfeed Express to Adequate fluids and healthy eating (refer Lifestyle – Healthy Eating) • • • • • • >72 hours – 7 days >72 hours and beyond – Mastitis Variance • • • • Intervention – Mastitis • • • • • >24 – 72 hours www.bestchance.gov.bc.ca Best Chance Website – Best Chance Website 32 Acute psychiatric condition* Emotional stress* Substance use* *may affect ability to care for baby and make for baby and ability to care *may affect informed decisions Careful observation of infant including feeding observation of infant Careful stimulation behavior with support to maximize breast Maternal conditions that may affect newbornMaternal feeding may affect conditions that – conditions that may Assessment Refer to Breast milk supply affect Intervention – Maternal Conditions • >2 – 24 hours – Maternal conditions Variance • • reasts 0 – 2 hours 0 – 2 hours Period of Stability (POS) s Best Chance Baby’s t as e Br (Continued) Physiological Physiological Assessment Physiological Health: B Refer to:

12 Perinatal Services BC 0 – 2 hours Physiological >72 hours – 7 days Period of Stability >2 – 24 hours >24 – 72 hours Assessment and beyond (POS)

Breasts Variance – Nipple Candida (Fungus Infection) Yeast (Continued) • Sore burning nipples • Sore all the time but worse when feeding • Deep burning/shooting pain • Itchy, flaky nipples

Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics • Tiny blisters • Deep pink/bright red nipples/areola • Mother may have recently been on antibiotics or has a yeast infection (infant may have signs of Candida in mouth or perineal area)34

Intervention – Nipple Candida (Fungus Infection) Yeast • Differentiate from poor latch • Frequent hand washing and washing of all items that touch breast and mouth • Antifungal treatment for both mother and infant may be prescribed • If using breast pads change when they become wet35 • Avoid use of soother36

Interventions for all Variances • Assess infant feeding • Refer to individual knowledgeable in current breastfeeding practices or LC)

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 13 Physiological Health: Breasts

Mastitis Apply cool compresses Analgesics Refer to PHCP Breasts will start to will start to Breasts become softer as lactation is suppressed Small amounts of milk can continue to be for up to one produced month postpartum Refer to >2 – 24 hr Refer to >24 – 72 hr Variance • Intervention • • • >72 hours – 7 days >72 hours and beyond Normal Norm and Variations • • Client Education/ Anticipatory Guidance • Intervention •

agents agents q 1 – 4 hr Engorgement small amounts Express for comfort Anti-inflammatory as Cold treatments above to fill, beginning Breasts become firm and warm Refer to >2 – 24 hr Refer to >2 – 24 hr Supportive bra Anti-inflammatory such as Cold treatments gel packs, cold packs or cold cabbage leaves for comfort for 20 minutes Variance • Intervention – Engorgement in non- women breastfeeding • • • >24 – 72 hours Normal Norm and Variations • Client Education/ Anticipatory Guidance • Intervention • • • • www.bestchance.gov.bc.ca Best Chance Website – Best Chance Website Contraception use about 5 – 10 days suppressed, agents Use of anti-inflammatory such as gel packs, treatments, Application of cold leaves for comfort cold packs or cold cabbage as heat, such stimulation of the breasts Avoid contact until lacation is breast pumping, and sexual suppressed for up to a may be produced Small amounts of milk month postpartum soon as 6 – 8 Resumption of menstrual periods – as weeks well-fitting bra within 6 hours of supportive, Wear birth Anti-inflammatory agents such as gel packs, cold packs or Cold treatments, cold cabbage leaves for comfort medication to aid suppression PHCP may prescribe may be present soft, colostrum Breasts until lactation is supportive bra continuously Wear • • • • • Interventions • • • • >2 – 24 hours Normal Variations Norm and • Guidance Client Education/Anticipatory • soft, colostrum Breasts may be present reasts Period of Stability (POS) Period of Normal Norm and Variations • 0 – 2 hours 0 – 2 hours s Best Chance Baby’s t as e Focus of Assessment: Focus of Assessment: comfort Breast Br The Non-breastfeeding Woman Physiological Physiological Assessment Physiological Health: B Refer to:

14 Perinatal Services BC Physiological 0 – 2 hours >72 hours – 7 days >2 – 24 hours >24 – 72 hours Assessment Period of Stability (POS) and beyond

Communicable Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal Diseases • HbsAg (Hepatitis B Surface Antigen) • Refer to POS Variations Variations (Infections) negative • Refer to POS • Refer to POS Hepatitis B • Woman and/or household member(s) not Client Education/Anticipatory Guidance Assess status at initial from an area when Hepatitis B is endemic • For women with Hep B/ household contact Client Education/ Client Education/ assessment • No risk factors for Hepatitis B infections with Hep B: Anticipatory Anticipatory Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics (such as IV drug use, sex trade worker) Disease transmission Guidance Guidance • Knowledge of woman’s Hep B status • >2 – 24 hr • >2 – 24 hr Review status (from Breastfeeding not contraindicated Antenatal Record) Early identification of infant risk for Client Education/Anticipatory Guidance exposure and infant prophylaxis Variance Variance • Refer to >2 – 24 hr • Refer to POS • Refer to POS Assess woman’s Variance • Understanding of Variance • Refer to POS Intervention Intervention Hepatitis B and the risks • Refer to 0 – 24 hr • Refer to 0 – 24 hr involved • Hep B status is documented on the Antenatal Record Part 2 and Newborn Intervention • Capacity to identify Record Part 2 variances that may • Support breastfeeding require further • HbsAg (Hepatitis B Surface Antigen) • Early identification of risks for early assessments and/or positive intervention treatments • Risk factors present or infectious status unknown www.healthlinkbc.ca/kbase/topic/major/ • Woman and/or household member(s) from hw40968/descrip.htm an area where HbsAg is endemic www.bccdc.org/downloads/pdf/epid/ Intervention reports/CDC_HepBControl_June04.pdf • Follow-up as per BCCDC policy • Recommend woman to see PHCP for www.phac-aspc.gc.ca/im/vpd-mev/ testing and follow-up hepatitis-b-eng.php • Recommend household member(s) for testing and immunizations www.who.int/mediacentre/factsheets/fs204/ en/

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 15 Physiological Health: Communicable Diseases – Hepatitis B

Refer to POS >0 – 24 hr Refer to POS Refer to 0 – 24 hr >72 hours – 7 days >72 hours and beyond Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance • Intervention • Refer to POS >0 – 24 hr Refer to POS Refer to 0 – 24 hr >24 – 72 hours Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance • Intervention • or

masks gloves, of

use the www.bestchance.gov.bc.ca and routines Refer to POS www.phac-aspc.gc.ca/hepc/pubs/ gdwmn-dcfmms/viii-pregnant-eng.php Refer to POS disposal of potentially Basic hygiene and the with infected material should be discussed the patient. child No need for the mother to alter normal care extra is unnecessary Follow-up as per BCCDC policy Refer to PSBC Guideline for Hepatitis C www.perinatalservicesbc.ca Refer to SOGC Guideline E- www.sogc.org/guidelines/public/96 CPG-October2000.pdf Recommend woman to see PHCP for testing Refer to POS • • Variance • Intervention • • • • • • >2 – 24 hours Normal Variations Norm and • Guidance Client Education/Anticipatory Best Chance Website – Best Chance Website 39 iseasesHepatitis – C 37,38 mother to child may reach 36 percent in 36 percent mother to child may reach quantity of the mothers who have a larger hepatitis C virus in their blood and in those also infected with HIV). who are Refer to >2 – 24 hrs Support breastfeeding (breastfeeding is not (breastfeeding Support breastfeeding contraindicated) cracked or bleeding, discard If nipples are during this time as HCV milk breast blood transmitted through HCV is a blood borne pathogen and is not transmitted by urine or stool HCV evident or risk factors present have who 100 of out women 7 – 4 (between HCV might pass it to their babies at the time of birth. The risk of transmission from No maternal risk factors for HCV are No maternal for HCV are risk factors evident antibodies have HCV RNA and anti-HCV and breast been detected in colostrum no case of milk. In multiple studies has breastfeeding transmission through been documented Intervention • • • • Variance • Period of Stability (POS) Period of Normal Variations Norm and • Guidance Client Education/Anticipatory C: For women with Hep • 0 – 2 hours 0 – 2 hours ble ica s Best Chance Baby’s e as e mmun require further require assessments and/or treatments Hepatitis C and the risks risks the and C Hepatitis involved Capacity to identify variances that may Assess woman’s Assess woman’s Understanding of o • • assessment Review status (from Antenatal Record) Hepatitis C (HCV) Assess status at initial C Dis ns) (Infectio Physiological Physiological Assessment Physiological Health: Communicable D Refer to:

16 Perinatal Services BC 0 – 2 hours >72 hours – 7 days Physiological Assessment >2 – 24 hours >24 – 72 hours Period of Stability (POS) and beyond

Communicable Diseases Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal (Infections) • No HSV lesions • Refer to POS Variations Variations Herpes Simplex in Pregnancy (HSV) • Refer to POS • Refer to POS Client Education/Anticipatory Client Education/Anticipatory Assess status at initial assessment Guidance Guidance Client Education/ Client Education/ • Refer to 2 – 24 hrs • For women with HSV: Anticipatory Anticipatory Guidance

Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics Review status (from Antenatal Support breastfeeding Guidance • Refer to >2 – 24 hrs Record) Variance Breastfeeding is contraindicated • >2 – 24 hr • Sexual Activity Assess woman’s • Lesions present and/or history of only when there are open Avoid intercourse if HSV lesions on the breast40 Variance lesion present • Understanding of HSV and the • Refer to POS risks involved • HSV lesions not detected when Avoid oral sex if partner there is an infection Variance has cold sore • Capacity to identify variances that help but not may require further assessments • Woman may not know she is • Refer to POS Intervention guaranteed to prevent and/or treatments carrying the virus • Refer to 0 – 24 hr Intervention transmission Intervention • SOGC Guidelines Variance • May require culture of lesions • www.sogc.org/guidelines/ • Refer to 2 – 24 hrs documents/gui208CPG0806.pdf • Refer to POS ...Any HSV lesions that appear in the mother post partum should Intervention be managed with proper hand • Refer to 0 – 24 hrs washing and contact precautions41 • May use antiviral drugs • Refer to PHCP

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 17 Physiological Health: Communicable Diseases – Herpes Simplex

Refer to POS Refer to 0 – 24 hr Refer to POS Refer to POS >72 hours – 7 days >72 hours and beyond Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance • Intervention • Refer to POS >0 – 24 hr Refer to POS Refer to POS >24 – 72 hours Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance • Intervention • reeClinic/

www.bestchance.gov.bc.ca Refer to POS Oak Tree www.bcwomens.ca/Services/ T HealthServices/Oak default.htm Refer to POS Refer to POS Refer to POS • • Variance • Intervention • >2 – 24 hours Normal Variations Norm and • Client Education/Anticipatory Guidance

Best Chance Website – Best Chance Website iseasesHIV – infections (wound, ) Advise not to breastfeed (in (in Advise not to breastfeed Canada) in may be transferred Virus breastmilk Higher rate for postpartum HIV present HIV present or infectious Risk factors present status unknown Follow-up as per PSBC and Oak Clinic Guidelines for HIV Tree www.perinatalservicesbc.ca No HIV present HIV positive: For women who are Variance • • Intervention • Period of Stability (POS) Period of Normal Variations Norm and • Client Education/Anticipatory Guidance • 0 – 2 hours 0 – 2 hours

Best Chance Baby’s current treatment current Capacity to identify variances that further assessments may require and/or treatments Understanding of HIV and the risks Understanding of HIV involved any with Capacity to follow through Record) Assess status at initial assessment Assess status at initial Antenatal Review status (from • • • Assess woman’s Assess woman’s (HIV) • • es icable Diseas Commun ns) (Infectio Virus Immunodeficiency Physiological Assessment Physiological Physiological Health: Communicable D Refer to:

18 Perinatal Services BC 0 – 2 hours >72 hours – 7 days Physiological Assessment >2 – 24 hours >24 – 72 hours Period of Stability (POS) and beyond

Communicable Diseases Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal (Infections) • Immune (refer to Antenatal Record) • Refer to POS Variations Variations Rubella (German Measles) • Immune to Rubella IgG antibody • Refer to >2 – 24 hr • Refer to >2 – 24 hr Client Education/Anticipatory titre >10 IU42 Assess immune status at initial Guidance Client Education/ Client Education/ assessment • Refer to 2 – 24 hr Client Education/Anticipatory Anticipatory Anticipatory Guidance

Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics Guidance Guidance • Refer to >2 – 24 hr Assess woman’s Variance • For women who are non-immune • Refer to >2 – 24 h • If MMR is given • Understanding of Rubella and the • Refer to 2 – 24 hr or status unknown: concurrently with RhIg, risks involved Disease transmission Variance rubella status needs to be • Capacity to identify variances that Intervention Immunization • Refer to >2 – 24 hr checked at 2 months may require further assessments • www.healthlinkbc.ca/kbase/list/ and/or treatments • Refer to 2 – 24 hr msindex/search.asp?searchterm Intervention Variance =rubella&filter=all • Refer to >2 – 24 h • Refer to >2 – 24 hr • When MMR and Rh Variance immune globulin given • Non-immune concurrently, rubella • Immune status unknown status at 2 months is negative – need to be revaccinated with MMR Intervention No serologic testing • Counsel re rubella vaccine required after the • Confer with PHCP re immunization second dose of MMR prior to discharge vaccine43 • Give rubella vaccine upon care provider’s order Intervention • If mother requires RhIg and • Refer to >2 – 24 hr rubella vaccine, they may be given • Refer to adult concurrently immunization clinic prn • www.who.int/topics/rubella/ entopic.php?item=90 • www.phac-aspc.gc.ca/im/vpd- mev/rubella-eng.php

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 19 Physiological Health: Communicable Diseases – Rubella

Refer to POS Refer to 0 – 24 hrs Refer to POS Refer to 0 – 24 hrs >72 hours – 7 days >72 hours and beyond Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance • Intervention • Refer to POS Refer to 0 – 24 hrs Refer to POS Refer to 0 – 24 hrs >24 – 72 hours Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance • Intervention •

www.bestchance.gov.bc.ca Refer to POS Disease transmission if Recommend immunization non immune Refer to POS to Discuss immunization – refer varicella (Immunization guide) Recommend woman follow-up with PHCP for testing and results Refer to POS • • • Variance • Intervention • • NR/ www.bccdc.ca/ F4AD-0EEC-430F- rdonlyres/0065 B1B5-9634115528D4/0/Epid_GF_ VaricellaZoster_July04.pdf www.phac-aspc.gc.ca/im/vpd- mev/varicella-eng.php >2 – 24 hours Normal Variations Norm and • Client Education/Anticipatory Guidance Best Chance Website – Best Chance Website iseasesVaricella – Zoster immunized – indicates present Varicella newborn be at high risk to Refer to agency infection control manual for isolation (respiratory isolation) Immune Support breastfeeding is not (breastfeeding contraindicated) is not or Not immune to Varicella • Intervention • Period of Stability (POS) Period of Normal Variations Norm and • Client Education/Anticipatory Guidance • Variance • 0 – 2 hours 0 – 2 hours

Best Chance Baby’s may require further assessments may require and/or treatments Understanding of Varicella and the Understanding of Varicella risks involved variances that Capacity to identify • • Assess status at initial assessment Assess status at initial Assess woman’s es icable Diseas Commun ns) (Infectio (Chicken Pox) Zoster Varicella Physiological Assessment Physiological Physiological Health: Communicable D Refer to:

20 Perinatal Services BC 0 – 2 hours >72 hours – 7 days Physiological Assessment >2 – 24 hours >24 – 72 hours Period of Stability (POS) and beyond

Communicable Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal Diseases (Infections) • No of • Refer to POS Variations Variations Influenza and Influenza Like influenza and ILI • Refer to POS • Refer to POS Illness (ILI) Client Education/ Anticipatory Guidance Client Education/ For women with flu or influenza-like symptoms: Client Education/ Client Education/ Assess status at initial Anticipatory Guidance • Wash hands thoroughly with soap and water, Anticipatory Guidance Anticipatory Guidance assessment Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics • Refer to >2 – 24 hr especially after coughing or sneezing and before • Refer to > 2 – 24 hrs • Refer to 2 – 24 hrs eating Assess woman’s Variance • Cover nose and mouth with tissue when cough or Variance Variance • Understanding of Influenza • Signs and symptoms of sneezing – discard tissue in trash • Refer to 0 – 24 hrs • Refer to 0 – 24 hrs and the risks involved influenza • Cough and sneeze into sleeve • Capacity to identify • Fever, respiratory tract • Avoid touching eyes, nose or mouth (infection Intervention Intervention variances that may require infection spreads that way) further assessments and/ • Refer to 0 – 24 hrs • Refer to 0 – 24 hrs or treatments • Review flu vaccine availability during fall/winter Intervention months • May require isolation, refer to infection control Variance • Refer to > 2 – 24 hr • Refer to POS

Intervention • Refer to PHCP prn • Seasonal Flu/ H1N1 – respiratory hygiene/cough etiquette in health care settings • www.cdc.gov/flu/professionals/infectioncontrol/ resphygiene.htm

Nursing assessment • Refer to PHCP re follow-up vaccine orders prn

H1N1: www.perinatalservicesbc.ca www.fightflu.ca

Avian flu www.cdc.gov/flu/avian/

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 21 Physiological Health: Communicable Diseases – Influenza and ILI

pattern not resumed Refer to >2 – 72 hr Refer to >2 – 72 hr Nursing Assessment laxatives, May require stool softeners etc Refer to appropriate PHCP Refer to >2 – 72 hr Normal bowel movement movement bowel Normal pattern resumed Refer to >2 – 72 hr Refer to >2 – 24 hr Refer to >2 – 72 hr Refer to >2 – 72 hr movement bowel Normal or Caesarean Birth For Caesarean • Intervention • • • • Birth For Caesarean • >72 hours – 7 days >72 hours and beyond Normal Norm and Variations • Birth For Caesarean • Client Education/ Anticipatory Guidance • Birth For Caesarean • Variance • • Incontinent of stool Nursing Assessment Refer to appropriate PHCP Refer to >2 – 24 hr Minimal abdominal distention Active bowel sounds present Flatus passed Refer to >2 – 24 hr Refer to >2 – 24 hr • Intervention • • >24 – 72 hours Normal Norm and Variations • Birth For Caesarean • • • Client Education/ Anticipatory Guidance • Variance • www.bestchance.gov.bc.ca

44 Best Chance Website – Best Chance Website Bowel sounds present Bowel sounds present not have well and who do recovering who are Women birth can eat and drink cesarean complications after or thirsty. when they feel hungry Hemorrhoid care of constipation Prevention constipate Discuss meds that may Return of normal bowel habits laxatives Nutrition, fluids, ambulation, stool softeners, Refer to Lifestyle – Healthy Eating Start with fluids, hunger present nausea or vomiting present no Ensure painful hemorrhoids Large, Nursing Assessment Comfort measures – (Refer to Pain) Pain control PHCP Refer to appropriate May or may not have a bowel movement not have a bowel May or may Hemorrhoids or Cesarean Birth For Cesarean • • Guidance Client Education/ Anticipatory • • • • • • Birth For Cesarean • • - Hemorrhoids Variance • Intervention - Hemorrhoids • • • • >2 – 24 hours Normal Variations Norm and • • unction owel F owel Refer to >2 – 72 hr Refer to >2 – 24 hr Refer to >2 – 24 hr Refer to >2 – 72 hr Intervention • Period of Stability Period of (POS) Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance • 0 – 2 hours 0 – 2 liminationB – tion – Baby’s Best Chance Baby’s require further medical require assessment Capacity to self check her Capacity to self check bowel functions Capacity to identify variances that may Understanding of normal Understanding of normal bowel functions Bowel sounds after a Bowel sounds after Birth Cesarean Return bowel to normal movement pattern • • Assess woman’s Assess woman’s • • Assess • Elimina ction Bowel fun Physiological Assessment Physiological Physiological Health: E Refer to:

22 Perinatal Services BC 0 – 2 hours >72 hours – 7 days Physiological Assessment >2 – 24 hours >24 – 72 hours Period of Stability (POS) and beyond

Elimination Variance – Bowel function • Episiotomy/3rd – 4tho tear that may affect bowel movement (Continued)

Intervention – Episiotomy • Nursing Assessment

Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics • Prevention of constipation • Advise against use of enemas or suppositories

For Cesarean Birth • Variance – Bowel Sounds Absent • Bowel sounds absent after Cesarean Birth and if woman has had previous GI history that could interfere with bowel function

Intervention – Bowel Sounds Absent • Nursing Assessment • Refer to appropriate PHCP

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 23 Physiological Health: Elimination – Bowel Function

Refer to >2 – 24 hr Refer to >2 – 24 hr Information re: incontinence future problems Refer to physiotherapy prn Refer to >2 – 24 hr Refer to >2 Postpartum and diaphoresis common until the end of first week PP edema Extremity decreasing Refer to >2 – 24 hr Variance • Intervention • • • >72 hours – 7 days >72 hours and beyond Normal Norm and Variations • • • Client Education/ Anticipatory Guidance • • Refer to >2 – 24 hr Refer to >2 Some extremity edema Refer to >2 – 24 h4 Refer to >2 – 24 hr Refer to >2 – 24 hr >24 – 72 hours Normal Norm and Variations • • Client Education/ Anticipatory Guidance • Variance • Intervention •

45 www.bestchance.gov.bc.ca Best Chance Website – Best Chance Website to help void: such as ambulation, oral Use measures running water, analgesia, squeeze bottle with warm water, sitz bath, a straw, blow bubbles through hands in water, of pelvic floor teach contraction and relaxation shower, Refer to physiotherapy PHCP prnRefer to appropriate Dysuria following catheter removal Dysuria following catheter and diaphoresis Postpartum diuresis Hygiene every 4 hours Encourage to void approximately – pour over perineum prior to/during Use of warm water voiding Sitz baths bladder control to reestablish Kegel exercises Unable to void voiding, small amounts Frequent Burning on urination (UTI) after voiding Pressure/fullness Elevated temperature Urgency bladder function Loss of or difficulty controlling Dysuria Nursing Assessment cause of variance – UTI, not emptying bladder, Differentiate superficial tears, trauma Voids comfortably – voiding qs comfortably Voids bladder Able to empty or fullness No feelings of pressure unction • • • • • Guidance Client Education/ Anticipatory • • • • • Variance • • • • • • • • • Intervention • • >2 – 24 hours Normal Variations Norm and • • • rinary F Refer to >2 – 24 hr Refer to >2 – 24 hr Refer to >2 edema Some extremity Refer to >2 – 24 hr Refer to >2 – 24 hr liminationU – Intervention • Period of Stability (POS) Period of Normal Norm and Variations • • Client Education/ Anticipatory Guidance • Variance • 0 – 2 hours 0 – 2 hours tion – Baby’s Best Chance Baby’s require further medical require assessment her urinary functions Capacity to identify variances that may Understanding of normal Understanding of normal urinary function Capacity to self check Voiding comfortably prn Voiding • • • Assess • Assess woman’s Elimina function Urinary Physiological Assessment Physiological Physiological Health: E Refer to:

24 Perinatal Services BC 0 – 2 hours >72 hours – 7 days Physiological Assessment >2 – 24 hours >24 – 72 hours Period of Stability (POS) and beyond

Lochia Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal Assess: • Fleshy smelling Variations Variations Variations • Amount • Rubra colour • Refer to POS • Fleshy smelling, • Day 3 – 5: Lochia serosa • Clots • No trickling • Increased flow on rubra-serosa (pink/brown) • Colour • Absence of or small clots(< size of a loonie) standing, activity or • Amount decreases • Day 7 – 10: Temporary breastfeeding daily increasing dark red • Odour Range on peripad Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics • Should not exceed discharge (shedding of • Stage of involution • Scant < 1 inch stain moderate range Client Education/ old placenta site) Frequency of assessments to • Light < 4 inch stain Anticipatory • Day 10 – 6 weeks: follow organization’s policy: • Moderate < 6 inch stain Client Education/ Guidance Lochia alba Suggested frequency for vaginal • Gradually decreasing – Client Education/ Anticipatory Guidance Anticipatory Guidance • Refer to >2 – 24 hr birth: usually subsides by • Normal pattern and amount/clots • Refer to POS • Discourage • q 15 min for 1 hour • Change pads q 4 h use 4 weeks Variance – Postpartum Hemorrhage (PPH) • at 2 hours • Hygiene: shower daily, • once per shift until d/c from • Saturated pad within one hour keep perineum clean Variance – PPH, Client Education/ hospital • Numerous, large clots (>2 large clots >loonie size (peri care, wipe front to Infection Anticipatory Guidance • then as required by nursing per 24 hours) back, use of peri bottle) • Refer to 0 – 24 hr • Refer to >0 – 72 hr judgment and/or self report • Refer to Lifestyle/Activity/ (PPH, Infection) Intervention – PPH Rest Variance– PPH, Infection Suggested frequency for • Refer to Decision Support Tool No. 7 PPH (BCPHP, 2009) • Refer to Fundus and Intervention – PPH, • Refer to 0 – 24 hr (PPH, caesarean birth: Elimination – Urinary Infection Infection) • Nursing Assessment • q 15 min for 1 hour function • Refer to 0 – 24 hr • Reoccurrence of • Weigh peripad (1g=1ml) • at 2 hours (PPH, Infection) continuous fresh bleeding Check presence of • q 4 h X 24 hours Variance – PPH, Infection • Lochia rubra >4 days Tissue/membrane • once per shift until d/c from • Refer to POS • Discharge >6 weeks Frequency of clots hospital • Lochia volume increasing Increased amount (trickling) then as required by nursing Intervention – PPH, • Refer to appropriate PHCP prn judgment and/or self report Intervention – PPH, Infection Variance – Infection Infection • Refer to 0 – 24 hr (PPH, Assess woman’s • Foul smell • Refer to POS Infection) • Understanding of normal • Increased temperature • Nursing Assessment lochia progression • Decrease activity prn • Pain • If bleeding not decreased • Capacity to self check • Nursing Assessment • Flu like signs and symptoms in 6 – 8 hours call PHCP • Capacity to identify variances • Refer to appropriate and/or go to emergency that may require further • Refer to Variance – Infection in Fundus section PHCP prn • Refer to PHCP prn medical assessment Intervention – Infection • Nursing assessment ** Refer to Fundus • Refer to Intervention – Infection in Fundus section 25 Physiological Health: Lochia

Refer to 0 – 24 hr Pain not decreasing Refer to 0 – 24 hr Refer to appropriate PHCP - 24 hr Refer to 0 Discomfort decreasing use of Decreased analgesics (if on switch to narcotic non narcotic) Refer to 0 – 24 hr Discuss pain relief options • • Intervention • • >72 hours – 7 days >72 hours and beyond Normal Norm and Variations • • • Client Education/ Anticipatory Guidance • • Variance Refer to >0 – 24 hr Refer to >0 Refer to >0 – 24 hr Refer to >0 – 24 hr Refer to >0 – 24 hr >24 – 72 hours Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance • Intervention • Offer to show how to inspect to show how to inspect Offer self with mirror Refer to POS for water sitz baths Warm 2 – 3 comfort (for example per day for short periods), interfere longer periods may adherence with suture Discontinue ice packs >24 swelling hr to decrease (some women may choose to continue using for comfort) Refer to Infection Refer to Infection Refer to POS Refer to POS decreasing Discomfort ducation/Anticipatory Client Education/Anticipatory Guidance • • • • – Infection Variance • Intervention – Infection • • >2 – 24 hours Normal Variations Norm and • • vacuum), internal section, forceps, bleeding, hematoma) Nursing Assessment Further evaluation and management of pain PHCP prn Refer to appropriate Use of comfort measures and and Use of comfort measures analgesics swelling Use of ice packs to decrease pads, wipe – peri bottle, fresh Pericare to back front to assess pain questions Using VAS level and when to consult PHCP > 4 for VB or > 5 for CS on pain scale with episiotomy, (may be increased instrumental delivery (cesarean tear, Refer to appropriate PHCP prn Refer to appropriate Mild to moderate discomfort Perineum intact or episiotomy/tear with minimal - well approximated swelling or bruising not and Small tear may be present sutured Intervention • • • • • • • Variance • Period of Stability (POS) Period of • Normal Variations Norm and • • • Client Education/ Anticipatory Guidance 0 – 2 hours 0 – 2 hours

Pain questions further medical assessment Use of a visual/verbal analogue pain and pain assessment scale (VAS) Self check for perineal healing Identify variances that may require once per shift until d/c from hospital once per shift until d/c from by nursing judgment then as required and/or self report q 15 min for 1 hour at 2 hours q 4 h X 24 hours and/or self report at 2 hours hospital from once per shift until d/c by nursing judgment then as required q 15 min for 1 hour Effectiveness of comfort measures Effectiveness Integrity and progression of healing of progression Integrity and • Refer to: • Assess woman’s capacity to Assess woman’s • • Assess woman’s understanding of understanding of Assess woman’s normal perineal healing • • • • • Suggested frequency for caesarean birth: for caesarean Suggested frequency • • • organization’s policy: organization’s birth: for vaginal Suggested frequency • • to follow of assessments Frequency Perineum Assess • Physiological Assessment Physiological Physiological Health: Perineum

26 Perinatal Services BC 0 – 2 hours >72 hours – 7 days Physiological Assessment >2 – 24 hours >24 – 72 hours Period of Stability (POS) and beyond

Rh Factor Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations • Woman is Rh positive • Refer to POS • Refer to POS • Refer to POS Assess • Woman is Rh negative with Rh • Rh factor from Client Education / Anticipatory negative infant Client Education / Anticipatory Client Education / Anticipatory Guidance documentation on the Guidance Guidance Antenatal Record • Refer to >2 – 24 hr Client Education / Anticipatory • Aware of need for testing infant • Refer to >2 – 24 hr • If RhIg given concurrently, Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics Guidance and administration of Rh- rubella status to be checked at immune globulin • Refer to >2 – 24 hr Variance 2 months • Implications for future • Refer to POS pregnancy Variance Variance • Rh negative woman with Rh Intervention • Refer to POS positive infant Variance • Aware of infant’s • When Rh immune globulin and • Refer to POS Rh factor MMR given concurrently and Intervention • Refer to >2 – 24 hr rubella status is negative at • Refer to >2 – 24 hr Intervention 2 months check,, need to be • Aware of infant’s Rh factor revaccinated with MMR • Administer Rh immune globulin No serologic testing required IM as per PHCP orders after the second dose of • If mother has non-immune MMR vaccine46 rubella status and MMR vaccine is ordered by the Intervention PHCP RhIg and MMR • Refer to >2 – 24 hr vaccine may be administered concurrently

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 27 Physiological Health: RH Factor

Refer to 0 – 72 hr Refer to 0 – 24 hr Normal vital signs Normal vital by as reported woman Refer to 0 – 72 hr May experience in increase with temperature milk coming down, engorgement • Intervention • >72 hours – 7 days >72 hours and beyond Normal Norm and Variations • Client Education/ Anticipatory Guidance • • Variance

Refer to 0 – 24 hr Refer to POS Able to self report Refer to POS Refer to 0 – 24 hr T >38°C on any 2 days T >39°C any time • Normal Norm and Variations • Client Education / Anticipatory Guidance • • Variance • • • Intervention >24 – 72 hours

50

49 www.bestchance.gov.bc.ca VAS and questions VAS Nursing assessment including Further evaluation and to management of pain – refer anesthesiologist Refer to POS Refer to POS sensory and/or motor Decreased extremities power to the lower (from after the epidural block on the 2 – 5 hours depending epidural agent) ≥ 5 on the Sedation Scale Epidural headache Nursing assessment PHCP prn Refer to appropriate Walking Mood Sleep Interactions with others Ability to concentrate Refer to POS Intervention – Impairment • • • Signs – Vital Variance • • • • Signs Intervention – Vital • • – Impairment of daily Variance living such as • • • • • >2 – 24 hours Normal Variations Norm and • Client Education / Anticipatory Guidance

palpitations,

Best Chance Website – Best Chance Website BP: S= 90 – 140 D= 50 – 90 Resp: 12 – 24, unlabored Pulse: 55 – 100 bpm PO Temp: PO Temp: 36.7°C – 37.9°C Normal vital signs and who to contact if variances Chills, febrile, headache, labored vision, blurred light respirations, headedness, edema, vital signs outside the norm Nursing assessment Refer to appropriate PHCP prn Asymptomatic Client Education/ Anticipatory Guidance • Variance • Intervention • • 0 – 2 hours 0 – 2 hours Stability (POS) Period of Normal Norm and Variations • anesthesia orders) to (refer

47 48 Baby’s Best Chance Baby’s al Signs Pain Identify variances and report if she requires further if she requires Identify variances and report medical assessment(s) Check self once per shift until discharge from hospital from once per shift until discharge by nursing judgment and/or self report then as required q 1 h x 12 hours rate: resp at 2 hours q 4 h X 24 hours q 15 min for 1 hour temp: x 1 in 1st hour at 2 hours hospital from once per shift until discharge and/or self report by nursing judgment then as required q 15 min for 1 hour temp x 1 in 1st hour to vital signs related woman is feeling Self report-how policy follow organization’s of assessment to Frequency Vital signs and include history and risks signs and include Vital • • Refer to: Assess woman’s understanding of her normal vitals signs understanding of Assess woman’s capacity to Assess woman’s • and pain (VAS) Use of a visual verbal analogue pain scale assessment questions May want to use a separate graphic chart to document May want to use a separate graphic chart maternal vital signs as per the Maternal Early Obstetrical System (MEOWS). Warning • • • • • Suggested frequency for caesarean birth: for caesarean Suggested frequency • • • • • Suggested frequency for vaginal birth: for vaginal Suggested frequency • • • • Vit Assess • Physiological Assessment Physiological Physiological Health: Vital Signs Refer to:

28 Perinatal Services BC Psychosocial 0 – 2 hours >2 – 24 hours >24 – 72 hours >72 hours – 7 days and beyond Assessment Period of Stability (POS)

Bonding and Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal Variations Attachment • Maternal-newborn skin-to-skin contact • Refer to POS Variations • Refer to 0 – 24 hr Assess immediately after birth until completion • Refer to 0 – 24 hr • Sensitive response to Client Education/Anticipatory of the first feed or longer • Maternal supports newborn’s needs and Guidance • Mother responds to infant cues behavior cues (feeding, Client Education/ • Maternal responses • Refer to 0 – 24 hr • Maternal interactions with newborn by settling, diapering) Anticipatory to infant feeding and • Signs of later attachment behaviors behavior cues holding (face-to-face), talking, cuddling, • Effective consoling Guidance Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics • Maternal response to making eye contact techniques (skin-to-skin, • Refer to 0 – 24 hr Variance infant crying • Partner/ significant person presence showing face to infant, • Refer to 0 – 72 hr • Maternal, family and and involvement talking to infant in a steady Variance • Lack of or inconsistent responses to voice, soft voice, holding, baby interaction • Refer to 0 – 24 hr newborn feeding and behavior cues rocking, feeding) • Risk factors for poor Client Education/ Anticipatory Guidance • Feeding • Lack of response to discomfort and • Responds to early infant bonding and attachment • Bonding is a gradual process that may difficulties distress (with crying, mother may feeding cues (restlessness, believe baby is crying for no reason, develop over the first month • Adjusting to new Assess woman’s beginning to wake, hand to is just spoiled or is manipulating her) • Refer to >2 – 24 hr person in the understanding of: mouth, searching for nipples) family • Inappropriate or abusive interactions • Responds to infant’s with infant • Infant attachment Variance behaviors needs in a warm, loving, • Eye contact minimal or lacking when • Maternal newborn separation Intervention • Responses to infant sensitive way, emotionally infant awake • Limited maternal interaction with • Refer to 0 – 24 hr feeding and behavior and physically available, newborn Intervention cues demonstrates affection • Some mothers may appear to have less toward newborn, appears • Refer to 0 – 24 hr Assess woman’s capacity to interest in the newborn in the first 24 to enjoy interacting with • Ways to increase parental positive responses • identify factors that hours – consider labor medication(s), newborn enhance or interfere exhaustion, pain, intervention(s) • Partner/significant other/ • Position infant so mother and infant with attachment and the during labor and birth and personal family interactions with can see each other resources for support expectations – requires further newborn and mother • Make eye contact assessment • Positive relation with others • Imitate the baby Refer to: • Minimal or support(s) not available (partner, support(s), family • Resource kit on infant attachment – • Limited interaction with newborn from First Connections • Newborn Nursing Care members) support(s) Pathway: Crying • Refer to crying section in • www.phac-aspc.gc.ca/mh-sm/mhp- • Minimal or no planning for taking baby Newborn Nursing Care psm/pub/fc-pc/index-eng.php home (diapers, baby clothes, car seat) Pathway • Refer to community supports/ • Inappropriate or abusive interactions agencies as appropriate and available, with infant such as family resources, parenting • Family history of trauma and/or lack of programs, peer support, public health positive relationships programs • Conflictual, violent intimate partner • Maintain open relationship with family relationships 29 Psychosocial Health: Bonding and Attachment >72 hours – 7 days >72 hours and beyond >24 – 72 hours 51 www.bestchance.gov.bc.ca such as snuggling, Suggest specific comfort measures soft talking, walking, singing rocking, or social worker prn counselor, PHCP, Refer to appropriate talking, singing to newborn) is growing skills; there parenting re Positive reinforcement is most figure as attachment of parent evidence that role life years of infant’s influential in first few other as appropriate Involve partner/significant dealing with infant crying (Review Review methods of Period of PURPLE crying) resource and and Rest, (the importance of rest See Lifestyle-Activity baby) night time needs of Minimal or no interaction with baby to newborn feeding and Lack of or inconsistent responses behavior cues (with infant for discomfort or distress Lack of response is for no reason, crying mother may believe baby is crying just spoiled or is manipulating her) to build on as a way to reassure strength Find a parenting to doing something right when trying they are that parents always calm down) comfort baby (even if baby doesn’t sensitivity (cue based interaction, parents to increase Ways discuss normal newborn and development) growth is feeling and Ask mother about what she thinks the baby why Mother involved in all decision making (refer to Statement of to Statement making (refer in all decision Mother involved Care) Women-Centred skin-to- attachment (breastfeeding, Activities that enhance bathing, infant massage, care, skin, involved in assessment, Best Chance Website – Best Chance Website • • • • • • Variance • • • Intervention • • • >2 – 24 hours Anticipatory Guidance Client Education/ • • PHCP prn Refer to Client Education Refer to Client >2 – 24 hr Assist mother to hand colostrum if express newbornseparated from Encourage visiting and as skin-to-skin contact soon as able if separated newbornfrom Refer to appropriate Period of Stability (POS) Period of Intervention • • • • 0 – 2 hours 0 – 2 hours onding and Attachment ment ach

nd Att a

g Baby’s Best Chance Baby’s n i nd Bo (Continued) Psychosocial Psychosocial Assessment PsychosocialHealth: B Refer to:

30 Perinatal Services BC Psychosocial 0 – 2 hours >2 – 24 hours >24 – 72 hours >72 hours – 7 days and beyond Assessment Period of Stability (POS)

Emotional Status and Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal Variations Mental Health • Support(s) present Variations Variations • Refer to 0 – 72 hr Assess • No personal history of PPD or • Woman indicates she • Refer to 0 – 24 hr • More knowledgeable about caring • Emotional response to delivery and other mental illness feels supported • Responds to for infant and eager to learn postpartum period (current and past) • Increasing maternal newborn’s needs • Assimilating infant into family life Client Education/ Anticipatory confidence and and behavior/cues • Adjustment to parenthood and Guidance • Feels supported by partner/ emotional status of partner/significant competence in providing for feeding, crying, significant other/ family friends Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics • Refer to >2 – 24 hr other infant care settling, cuddling, • Tearful moments and mood swings • Medication use for mental health Variance • Increasing partner/ diapering up to about 2 weeks postpartum concerns • Excessive , fear, significant other • Verbalizes • May feel ’blue’ • Predisposing/risk factors to depression, exhaustion confidence and understanding of • NB: about 2 – 6 weeks PP ‘Letting postpartum depression (PPD) such • Minimal or no maternal competence in providing PP adjustment – Go’ psychological state – begins to as previous prenatal, postpartum or interaction with baby, infant care PP blues see infant as an individual, starts to other episodes of depression, family separation of mother and Client Education/ • Moving to ‘Taking focus on issues greater than those history of depression, previous use of baby Anticipatory Guidance Hold’ psychological associated directly with self/infant stage; actively antidepressants, significant medical or • Limited/ no support(s) • Encourage verbalization seeking help with obstetrical challenges • Current symptoms or history of feelings and needs Client Education/ Anticipatory self care; connecting • For current signs of PPD of mental illness including: Guidance • Explore feelings and with and cares for • For other mental health conditions depression, anxiety disorders, • Refer to 0 – 72 hr expectations of partner/ newborn and willing such as: postpartum psychosis, eating disorders, personality • Provide opportunity to verbalize significant other and ways to learn; expresses schizophrenia, anxiety disorders, disorders or suicidal ideation feelings (parenting, self esteem) of promoting support anxiety with personality disorders or suicidal • Encourage connecting with peers, Intervention • Discuss normal mothering abilities ideation new families and community • Assist in recognizing problems postpartum adjustments and challenges (appetite, resources such as Reproductive *Refer to Antenatal Record • Refer to Bonding and sleep, energy, body Mental Health, Pacific Post Partum (in hospital) – EPDS Score Attachment section image, emotional state) Support Society • Refer to appropriate PHCP Assess woman’s understanding of • Discuss mood swings, prn www.postpartum.org • Normal postpartum emotional some are normal • Discuss risk factors and signs responses Variance • Explore ways to maximize and symptoms of postpartum • Adjustment to parenthood • Perinatal Loss rest – refer to Lifestyle – depression and importance of • Mental health conditions (see above) Rest Activity Section Intervention talking to someone • Discuss risk factors and • Nursing assessment and Assess woman’s capacity to signs of PPD with woman emotional support • Identify variances that may require and families support and/or further medical • Refer to appropriate assessment PHCP prn • Access support and/or medical assessment and care

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 31 Psychosocial Health: Emotional Status and Mental Health

Refer to 0 – 24 hr Refer to 0 fear, Excessive anxiety, infanticide ideation depression, Refer to 0 – 24 hr use of a PPD assessment and and education tool for screening such as the Edinburgh Tool Postpartum Screening between 6 – 8 weeks PHN as (by , , per local protocol) >72 hours – 7 days >72 hours and beyond Variance • • Intervention • • >24 – 72 hours www.bestchance.gov.bc.ca

psychological stage; In the ‘Taking-In’ Best Chance Website – Best Chance Website birth experience opportunity to review Provide As for POS with birth experience Continued dissatisfaction of infant Negative perception Refer to Bonding and Attachment section Nursing Assessment PHCP prn Refer to appropriate ental Health and/or anxiety/confusion. Often elation, excitement the labour and birth verbally and mentally, relive, experience • Variance • • • Intervention • • • >2 – 24 hours www.bcwomens.ca ental Health) M – Reproductive (Search Note: and/or emotional dependence, experiences physical Period of Stability Period of (POS) 0 – 2 hours 0 – 2 hours motional Status andM nd tus and a

Best Chance Baby’s h al Healt PsychosocialHealth: E (Continued) al St Emotion Ment Psychosocial Psychosocial Assessment Refer to:

32 Perinatal Services BC Family 0 – 2 hours >72 hours – 7 days >2 – 24 hours >24 – 72 hours Assessment Period of Stability (POS) and beyond

Support Systems/ Resources Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal Assess • Refer to >2 – 24 hr • Maternal support system evident Variations Variations • Mother’s support(s) – partner, family, • Refer to >2 – 24 hr • Refer to >2 – 24 hr friends and community Client Education/ Client Education/ Anticipatory • Woman’s understanding of the Anticipatory Guidance Guidance Client Education/ Client Education/ available family and community • Refer to >2 – 24 hr • BC Association of Family Resource Anticipatory Guidance Anticipatory Guidance

Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics resources Programs • Refer to >2 – 24 hr • Refer to >2 – 24 hr Variance www.frpbc.ca Assess woman’s capacity to: • Refer to >2 – 24 hr Variance Variance • Access family and community Variance • Refer to >2 – 24 hr • Refer to >2 – 24 hr resources Intervention • Lack of support and resources (social • Identify variances that may require • Refer to >2 – 24 hr determinants of health) to meet needs Intervention Intervention further assessment (isolation, cultural, language) • Refer to >2 – 24 hr • Refer to >2 – 24 hr • Woman/support(s) not aware of community resources and follow up

Intervention • Nursing Assessment • Review community resources with woman and her partner/ significant other • Refer to social worker or available community resources • Refer to appropriate PHCP prn

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 33 Psychosocial Health: Support Systems / Resources #92h #92c

#92f Play and Your Baby Play and Your Time Out for Parents Bringing Home the Second Baby – – – – – – Social integration into community supports and resources Available – Healthfile resources Changes that occur to Changes that occur relationships child Expectations re development, infant crying, behavior and feeding Infant care Domestic tasks Refer to >2 – 72 hr Family does not adjust well to new infant (see above) Refer to >2 – 72 hr Refer to >2 – 72 hr Refer to >2 Refer to >2 – 72 hr to new Family gradually adjusts infant Review Variance Variance • • Intervention • >72 hours – 7 days >72 hours and beyond Normal Variations Norm and • Client Education/ Anticipatory Guidance • • • positive coping skills positive coping skills – able to express concerns ways and conflict to resolve Some siblings may have difficulty adjusting to the birth of a new baby Refer to >2 – 24 hr Sibling rivalry – ways to include siblings into activities Refer to >2 – 24 hr Refer to >2 – 24 hr Refer to >2 – 24 hr Family exhibits • Client Education/ Anticipatory Guidance • • Variance • Intervention • >24 – 72 hours Normal Norm and Variations • • www.bestchance.gov.bc.ca unction family dynamics Nursing Assessment resources Refer to appropriate and/or PHCP other Include partner/ significant to learn to support in care ways mother individualized support, Provide as information and resources needed time management Discuss stress, Refer to Emotional Status – Mental Health Section Refer to Lifestyle–Activity and Rest Section Refer to Support Systems/ Resources Period of PURPLE crying resources Family identified as being vulnerable or at risk – increased risk for increased family stress, violence in family breakdown, lack of strategies and family, supports to deal with changing changes in family Wide-ranging dynamics and interrelationships Best Chance Website – Best Chance Website Intervention • • ducation/ Anticipatory Client Education/ Anticipatory Guidance • • • • • • • Variance • >2 – 24 hours Normal Variations Norm and • amily F Refer to >2 – 48 hr Refer to >2 – 48 hr Refer to >2 – 24 hr Refer to >2 – 48 hr • Intervention • Period of Stability Period of (POS) Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance 0 – 2 hours 0 – 2 hours amily Strengths andChallenges – F Baby’s Best Chance Baby’s ion y Funct Identify variances that may require Identify variances that may require further assessment and support Identify positive/effective coping Identify positive/effective strategies (for family and crying infant) your baby?” of intimate For history and/or signs partner violence/abuse strategies with crying infant Strategies for coping of personal safety, Maternal perception safe for you and such as “Is your home Interactions between family members Interactions between family coping Positive/effective Follow agency policy for identification of high risk clients Tool) (E.g. Nursing Priority Screening • Assess woman’s capacity to: Assess woman’s • Assess woman’s understanding of family understanding of Assess woman’s dynamics and interrelationships • • • Assess • • mil Fa Family Assessment Changes: F Refer to:

34 Perinatal Services BC Family 0 – 2 hours >72 hours – 7 days >2 – 24 hours >24 – 72 hours Assessment Period of Stability (POS) and beyond

Family Planning/ Norm and Normal Norm and Normal Norm and Normal Norm and Normal Variations Sexuality Variations Variations Variations • Resumption of sexual activity is variable and is when • May have had tubal • Refer to >72 hr – 7 days • Refer to >72 hr – 7 days woman is ready/comfortable (Refer to Statement of Assess woman’s ligation (TL) with and beyond (discussion and beyond (discussion Woman-Centred Care) understanding of: C-section may not be appropriate may not be appropriate • May have vaginal discomfort due to decreased • Family planning at this time) at this time) hormonal levels, thinning of vaginal walls, decreased methods Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics Client Education/ lubrication, sutures • Resumption of Anticipatory Guidance Client Education/ Client Education/ • May have decreased libido due to role overload, intercourse • Refer to >72 hr – 7 days Anticipatory Guidance Anticipatory Guidance psychological, social changes, lack of sleep, and beyond (discussion • Refer to >72 hr – 7 days • Refer to >72 hr – 7 days hormonal changes Assess for mothers may not be appropriate and beyond (discussion and beyond (discussion capacity to access / obtain at this time) may not be appropriate may not be appropriate contraception prn Ovulation may occur before menses begins: at this time) at this time) • Lactating Women – Breastfeeding exclusively Variance regularly throughout the 24-hour period. • Refer to >72 hr – 7 days Variance Variance Affected by frequency of breastfeeding, use of and beyond (discussion • Refer to >72 hr – 7 days • Refer to >72 hr – 7 days formula, other fluids, weaning, pacifier use may not be appropriate and beyond (discussion and beyond (discussion • Non Lactating Women – Menses may start in at this time) may not be appropriate may not be appropriate 6 – 8 weeks at this time) at this time) Intervention • Refer to >72 hr – 7 days Intervention Intervention and beyond (discussion • Refer to >72 hr – 7 days • Refer to >72 hr – 7 days may not be appropriate and beyond (discussion and beyond (discussion at this time) may not be appropriate may not be appropriate at this time) at this time)

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 35 Changes: Family Strengths and Challenges – Family Planning/Sexuality

had return

not

>4 hr during the day and 6 hr at night >4 hr during the day comfort (Mutually agreeable) and sense of control Woman’s Lochia no longer red (follow-up with pelvic floor problems Perineum healed – ongoing PHCP) C/B) healing and comfortable Incision (from – lubricant, positions Comfort measures 2. Mother has 3. Infant exclusively breastfeeding 4. NOT nurse period when infant does No prolonged 1. Infant under 6 months www.bestchance.gov.bc.ca Unaware of contraception choices Unaware Nursing Assessment Refer to Client Education above PHCP prnRefer to appropriate Resumption of vaginal intercourse: Resumption of vaginal milk feeding (potential of breast Review normal sexuality PP – effects to suckling infant) sensual responses ejection reflex, of contraception choices Awareness site SOGC resource www.sexualityandu.ca/adults/index.aspx options) Options for Sexual Health site ( www.optionsforsexualhealth.org after perineum healed Pain with vaginal intercourse prior to healing of perineum/ partner expectations of intercourse Voiced mutual agreement than one partner or partner has multiple sex partners STI risk if more Review Lactational Method for Birth Control as per client Control Method for Birth Amenorrhea Review Lactational must be met choice – all conditions • Intervention • • • • • • • • Variance • • • >72 hours – 7 days >72 hours and beyond Anticipatory Guidance Client Education/ • >24 – 72 hours Best Chance Website – Best Chance Website amily Planning/Sexuality >2 – 24 hours Period of Stability Period of (POS) 0 – 2 hours 0 – 2 hours amily Strengths andChallenges – F / g Baby’s Best Chance Baby’s n

i

y nn a Sexuality (Continued) mil Fa Pl Family Assessment Changes: F Refer to:

36 Perinatal Services BC 0 – 2 hours Family >72 hours – 7 days Period of Stability >2 – 24 hours >24 – 72 hours Assessment and beyond (POS)

Health Follow-Up in Norm and Normal Norm and Normal Variations Norm and Normal Norm and Normal Variations Community Variations • Prior to discharge appropriate arrangements Variations • Care provider responsible for • Refer to >2 – 24 hr are made for ongoing care • If discharged <48 hr continuing care is identified Services accessible 7 days per week • If discharged <48 hr of birth, arrangements of birth: with arrangements made by Assess woman’s Client Education/ made for evaluation within 48 hours of Refer to >2 – 24 mother for follow-up within 7 52 54 Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics • Readiness for discharge Anticipatory discharge by a Health Care Professional hrs days of discharge • Ability to breastfeed her infant – Guidance position, latch, milk transfer • Refer to >2 – 24 hr Client Education/ Anticipatory Guidance Client Education/ Client Education/Anticipatory • Ability to formula feed her infant • Knowledge of self care53 Anticipatory Guidance Guidance (if not exclusively breast feeding) Variance Mobile with adequate food / fluid intake • Refer to >2 – 24 hr • Refer to >2 – 24 hr • Refer to >2 – 24 hr Recognizes normal postpartum changes Refer to: (physical, psychosocial) and informs Variance Variance • Newborn Nursing Care Pathway Intervention PHCP of abnormal findings • Refer to >2 – 24 hr • Refer to >2 – 24 hr • Refer to >2 – 24 hr Responds to newborn’s needs • Woman does not have PHCP Assess woman’s understanding of Support system in place Intervention • Self care • Provision of community resources in writing • Refer to >2 – 24 hr Intervention • Newborn feeding including • Use of Pregnancy Passport, common care • Refer to >2 – 24 hr feeding cues paths, feeding guidelines • Assist in finding appropriate • Newborn care • Discussion and mutual decision making PHCP • Reporting about ongoing contact Assess woman’s capacity to: Variance – no PHCP • Self report • Family doesn’t have a PHCP • Breastfeed her infant, identify and respond to infant feeding cues (position, latch, milk transfer) Intervention– no PHCP • Formula feed her infant (if not • Nursing Assessment exclusively breast feeding) • Care Provider who provides ongoing care is • Identify variances that may identified require further medical assessment • Access resources or follow-up with primary care provider or alternate medical care.

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 37 Changes: Family Strengths and Challenges – Follow-up in Community

(PHN, resources Community Early Maternity Discharge) week at unavailable 7 days per community level follow- Family does not seek up as needed cannot be contacted Woman or declines a visit (when identified vulnerabilities/needs providers) by care Assist in obtaining supports further Family may require assessment and referrals, such as a social worker >72 hours – 7 days >72 hours and beyond Variance • • • Intervention • • >24 – 72 hours www.bestchance.gov.bc.ca Follow-up Infant Care Follow-up Best Chance Website – Best Chance Website No discussion and or mutual decision making No discussion and or about ongoing contact services prnNotify PHCP or social due to newborn care Mother not able to provide maternal illness, death, or infant placed in care or for Intervention – Infant Care Support mother prn to appropriate and refer HCP prn prn caregiver Support the infant’s as needed not seek follow-up Family does or woman be contacted (woman cannot when contact/visit is declines PHN services recommended) ollow-up inCommunity • Intervention – • – Variance • • • • >2 – 24 hours – Variance • Period of Stability (POS) Period of 0 – 2 hours 0 – 2 hours n i

Up - ow amily Strengths andChallenges – F ll Fo

Best Chance Baby’s h

lt a He ity Commun (Continued) Family Assessment Changes: F Refer to:

38 Perinatal Services BC Family 0 – 2 hours >72 hours – 7 days >2 – 24 hours >24 – 72 hours Assessment Period of Stability (POS) and beyond

Breastfeeding Assess: Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations Woman’s understanding of: • Skin-to-skin contact, not • Breast offered 5 or more times • Frequent cluster feeding • Increase maternal confidence • Breastfeeding wrapped in blanket, baby to in this 24 hour period61 (more at night) • Breasts soften with recommendations55, 56, 57, 58, abdomen/chest right after • Able to latch baby to breast • Feeds 8 or more times/day feeding, free from infection, 59, 60 – importance of exclusive birth with minimal assistance • Signs of breasts filling tenderness decreases Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics breastfeeding for 6 months • Maintain skin-to-skin contact • Sensitively responds to • Aware of various newborn • Nipples: intact, tenderness followed by the introduction until completion of the first newborn feeding cues feeding positions decreases of nutritious solids at about feeding or longer • Mother and partner/ • Refer to >2 – 24 hr • Breastfeeding assessments: 6 months with continued • Warm blanket over mother significant other aware of 3 – 4 days postpartum and at breastfeeding for up to 2 years and infant 68,69 the benefits of exclusive Client Education/ Anticipatory 7 – 10 days postpartum and beyond breastfeeding (no Guidance • Refer to >2 – 72 hr • Informed decision making re Client Education/ Anticipatory supplements or use of • Refer to >2 – 24 hr Client Education/Anticipatory infant feeding Guidance artificial teats) and risks • Offer both breasts each feed Guidance • Infant feeding frequency over • Support mother to respond to of breastmilk substitutes • Correct position, latch, nipple • Refer to 0 – 72 hr the 24 hour period newborn’s breast searching (formula) shape post feed • Appropriate position and latch behaviors • Within 24 hours of birth, 2 • Breasts are full before feeding • Methods of burping and softer after feeding • The importance of having • Assist mother with initial feed independent assessments of support with feeding – baby’s attempt to latch and effectively latching at breast • Strategies to meet baby’s • After several weeks it is 62 nighttime feeds (without • Psychological and suckle at breast as soon as are observed normal to have soft breasts needing to supplement unless environmental factors affecting possible or within 1 – 2 hours • 2 effective feeds achieved all the time and still have medically necessary) relaxation (without assistance) prior to sufficient milk 63 • Contraindications for Variance moving to self care • Importance of human milk: Variance exclusive breastfeeding for breastfeeding – HIV, drug use, • Baby not placed skin-to- skin 6 months followed by the certain medications on abdomen/chest right after • Refer to 0 – 24 hr introduction of nutritious birth • Delayed lactogenesis solids at about 6 months with Explore underlying cause • Baby not latching continued breastfeeding for such as SSRI, SNRI use67 • Baby separated from mother up to 2 years and beyond Intervention • Breastmilk is the most important food in the first year • Refer to 0 – 24 hr

Variance • Refer to 0 – 24 hr

Intervention • Refer to 0 – 24 hr Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 39 Changes: Family Strengths and Challenges: Infant Feeding – Breastfeeding >72 hours – >72 hours 7 days and beyond >24 – 72 hours

64

65 www.bestchance.gov.bc.ca reastfeeding written, verbal, visuals information to enable family to consistent feeding feeding well – position, latch, determine if baby is feeding cues, linking intake with output cradle, or Mother comfortable – cradle, modified use of football hold, lying - bring infant to breast, pillows, position of hands Encourage skin-to-skin, tummy to tummy and Hand holds and supports the upper back skull shoulders, cradling the neck/base of the areola) (fingers back from breast support large, If breast lips with nipple, wait until mouth open baby’s Touch wide mouth – the of infant’s the roof Aim nipple towards under breast bottom lip/jaw on the lower areola be easily Baby begins to actively suck and cannot the breast pulled off Methods of burping removing suction with finger before break If necessary, breast from Ensure the woman understands what constitutes an the woman understands Ensure feed effective support Provide at each feed offered Both breasts Review position and latch Refer to POS Best Chance Refer to Baby’s Guidelines Feeding BCPHP (2010) Breast • • • • • • >2 – 24 hours Anticipatory Guidance Client Education/ • • • eeding– B Best Chance Website – Best Chance Website stable place skin- When baby chest to-skin on abdomen/ to Assist with latch – refer >2 – 12 hr Client Education/ Anticipatory Guidance of breast Discuss importance milk and support hand if baby separated expression mother from Period of Stability (POS) Period of Intervention • • • 0 – 2 hours 0 – 2 hours amily Strengths andChallenges: Infant F Best Chance Baby’s

Guidelines: Feeding or alternate provider care. Newborn Nursing Care , peer support breastfeeding groups), drop-in programs, Follow-up with primary care and concerns/ variances that further support and may require assessment (e.g.- Access resources response) baby’s baby Feed and calm her issues Identify common feeding Determine how well her baby is Determine how well cues and feeding (includes feeding Refer to: • • • • • Assess woman’s capacity to Assess woman’s • ing Breastfeed (Continued) Family Assessment Changes: F Refer to:

40 Perinatal Services BC Family 0 – 2 hours >72 hours – 7 days >2 – 24 hours >24 – 72 hours Assessment Period of Stability (POS) and beyond

Breastfeeding Variance – Not exclusively breast feeding (Continued) Intervention – Not exclusively breast feeding • Makes informed decision to exclusively feed with breastmilk substitutes (refer to breastmlk substitute) • Provision of supplemental feedings for medical Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics indications Provide information on alternative nutrition (EBM, human donor milk, breastmilk substitutes) Provide information on alternative feeding methods (cup, syringe, bottle, dropper, spoon) Support breastfeeding and hand expression and pumping • Provision of supplemental feedings for non- medical indications Clarify concerns (to support informed decision) Provide information as above • Refer to formula feeding re: preparation and storage • Refer woman to www.healthlinkbc.ca (search – Formula Feeding Your Baby Getting Started; Formula Feeding Your Baby: Safely Preparing and Storing Formula) HealthLinkBC telephone: dial 8-1-1 Variance – Baby separated from mother Intervention – Baby separated from mother • Begin hand expression by 6 hr • Teach pumping techniques66 Combine hand expression with pump • Mother to NICU (encourage skin-to-skin if possible)

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 41 Changes: Family Strengths and Challenges: Infant Feeding – Breastfeeding

Refer to POS Refer to >2 – 72 hours Refer to >2 Refer to 0 – 72 hr preparation, Careful storage and use of formula commercial of appropriate Introduction solids at about 6 months Refer to POS • >72 hours – 7 days – 7 >72 hours and beyond Normal Norm and Variations • Client Education/ Anticipatory Guidance • • • Variance • Intervention ormula) Only F Refer to >2 – 24 hours Refer to >2 Refer to 0 – 24 hr Refer to POS Refer to >2 – 24 hours >24 – 72 hours Normal Norm and Variations • Client Education/ Anticipatory Guidance • Variance • Intervention • ilk Substitutes ( www.bestchance.gov.bc.ca Aware of newborn Aware feeding positions Responds (stops feeding) when baby shows signs of satiation Refer to POS Review formula and preparation storage with the to prior parents discharge Refer to 0 – 2 hours Refer to POS Refer to POS Feeds baby when Feeds baby baby shows signs of hunger • • Client Education/ Anticipatory Guidance • • • Variance • Intervention • >2 – 24 hours Normal Norm and Variations • reast M

eeding– B Best Chance Website – Best Chance Website readiness to feed readiness small amounts Provide to of formula (note: ready use bottles of 120 ml (4 ounces) could contribute to overfeeding) information Provide amount to feed, regarding feeding cues, positioning, of overfeeding prevention Lack of formula feeding knowledge Nursing assessment formulas Use of appropriate immediately Skin-to-skin after birth formula Begin offering of when baby shows signs Client Education/ Anticipatory Guidance • • Variance • Intervention • • 0 – 2 hours 0 – 2 Stability (POS) Period of Normal Variations Norm and • •

y amily Strengths andChallenges: Infant F Best Chance Baby’s

(clinics, peer support programs, Access resources groups), drop-in or alternate provider Follow-up with primary care provider care Identify common feeding issues and concerns/ further support and variances that may require assessment Tell how well her baby is feeding (infant’s feeding how well her baby is feeding (infant’s Tell response) cues and baby’s Feed and calm her baby relaxation concerns about infant feeding in order to make an concerns infant feeding in order about informed decision?) support with feeding The importance of having factors affecting Psychological and environmental infant feeding WHO, re: Informed decision making yourself – has the woman had CPS Guidelines (ask and opportunity to discuss her sufficient information ursing Care Pathway Newbornursing Care N • • • • • Assess woman’s capacity to Assess woman’s • • • • understanding of: Assess woman’s s (Formula) Onl ilk Substitute Breast m Refer to: Family Assessment Changes: F Refer to:

42 Perinatal Services BC 0 – 2 hours Family >72 hours – 7 days Period of Stability >2 – 24 hours >24 – 72 hours Assessment and beyond (POS)

Lifestyle – Norm and Normal Norm and Normal Variations Norm and Normal Norm and Normal Activities / Rest Variations • Vaginal birth: Ambulates independently and able to Variations Variations Assess • Refer to >2 – 24 hr rest • Refer to >2 – 24 hr • Refer to >2 – 72 hr • Ability to manage activities • Caesarean birth: Dangles and ambulates with • Caesarean • Fatigue gradually for daily living (ADL) Client Education/ assistance birth, ambulates improving

Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics • Ability to rest/sleep Anticipatory independently • Safe resumption of physical Guidance Client Education/ Anticipatory Guidance Client Education/ activity program • Refer >2 – 24 hr • Rest – when baby sleeping, managing visitors Client Education/ Anticipatory Guidance • Early ambulation, safe body mechanics Anticipatory Guidance • Refer to >2 – 72 hr Assess woman’s Variance • Normal postpartum recovery including body • Refer >2 – 24 hr • Relationship between understanding of • Refer >2 – 24 hr mechanics healthy eating and activity • Night time needs of baby • Support(s) at home and in community Variance level – especially iron requirements, refer to • Her normal activity and rest Intervention • Refer >2 – 24 hr Healthy Eating requirements • Refer >2 – 24 hr www.healthypregnancybc.ca • Unable to perform activities of daily living • Balance between activity Assess woman’s capacity to Variance – Sleep (ADL) due to pain, and rest identify • Unable to sleep, not ambulating fatigue • Care for self and meeting • Night time needs of baby • Uncontrolled pain needs of baby • Her rest requirements as Intervention • Gradual resumption of sleep interrupted during the Intervention – Sleep • Refer >2 – 24 hr physical activity (safe & appropriate exercises) night • Assess comfort level and need for analgesia or • Nursing Assessment • Problem solving re coping • Variances that may require relaxation exercises • Discuss options for with visitors and tending further medical assessment • Nursing Assessment support to tasks • Refer to PHCP prn • Refer to PHCP prn Use of visual verbal analogue • Organizing household to pain scale (VAS) and pain minimize stair climbing, Variance – Calf Discomfort assessment questions reaching, lifting • Calf discomfort, redness, swelling, decreased mobility – possible deep vein (DVT) Refer to: Variance • Pain • Refer to >2 – 48 hr Intervention – Calf Discomfort • Screening for DVT via Homan’s sign not recommended • Intervention as is not reliable • Refer to >2 – 48 hr • Risk of thrombosis due to activation of blood clotting factors, increased platelet adhesiveness, traumatic/ operative delivery, smoking, inactivity, • Refer to PHCP prn 43 Changes: Family Strengths and Challenges: Lifestyle – Activities/Rest

>72 hours – 7 days >72 hours and beyond >24 – 72 hours

71

70 sleep, impact daily living such as walking, mood, not sleep, impact daily living such as walking, mood, ifestyle – Activities/Rest does tenderness over Back pain (if post epidural), localized redness/ epidural insertion site and further evaluation Pain scale >4 for VB and >5 for CB requires management of pain Nursing Assessment PHCP prnRefer to appropriate and not relieved by current analgesia and/or non pharmacological pain analgesia and/or non pharmacological by current and not relieved measures relief Assist client to identify additional supports to assist with ADL and and additional supports to assist with ADL Assist client to identify infant care Support family agencies prnRefer to community and questions VAS analgesia and/or non pharmacological Pain is tolerable with/without measures pain relief Pain does interactions with others and ability to concentrate to assess pain level and when to consult PHCP questions Using VAS and/or analgesia including dose, of comfort measures aware Woman and effectiveness frequency pain and/ apt to develop chronic more pain are with increased Women or depression Pain interactions with others and ability to concentrate birth (CB) >5 for Cesarean Pain scale >4 for vaginal birth (VB) and Nursing Assessment or PHCP Refer to Physiotherapy • Intervention • • • • • • ADL Pain affecting • Norm and Normal Variations • • Client Education/ Anticipatory Guidance • • • Variance • • >2 – 24 hours Pubis Symphysis – Separated Variance Pubis – Separated Symphysis Intervention • • Period of Stability (POS) Period of 0 – 2 hours 0 – 2 hours

amily Strengths andChallenges: L le – y

t s fe Li Re st / es Activiti (Continued) Family Assessment Changes: F

44 Perinatal Services BC 0 – 2 hours Family >72 hours – 7 days Period of Stability >2 – 24 hours >24 – 72 hours Assessment and beyond (POS)

Lifestyle – Norm and Normal Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations healthy Eating Variations • Adequate fluid and nutritious food • Refer to >2 – 24 hr • Refer to >2 – 24 hr Assess • Refer to >2 – 24 hr intake including vitamins and folate • May require iron • Adequate fluid and Client Education/Anticipatory Guidance supplement, especially if nutrient intake Client Education/ Client Education/ Anticipatory • Access to and ability to consume Hgb is low

Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics • Ability to consume Anticipatory Guidance Guidance nutritious foods, vitamins, and folic acid nutritious food/ • Refer to >2 – 48 hr • Encourage small, frequent, to meet needs Client Education/Anticipatory adequate intake of nutritious meals • Sources of fibre include whole grain Guidance vitamins with emphasis Variance • Encourage to continue with bread, beans, lentils, whole grain bread, • Refer to >2 – 48 hr on Vitamin D and folate • Refer to >2 – 24 hr prenatal vitamins and folate high fibre cereals (100% bran) • Sources of iron include liver, red meat, Variance Assess woman’s • Encourage to continue vitamins Intervention with attention to Vitamin D deep green leafy vegetables, legumes, • Refer to >2 – 24 hr • Understanding of to maintain stores during dried fruit and iron enriched foods (taking adequate and healthy • Refer to >2 – 48 hr • Not able to maintain breastfeeding and folate (both Vitamin C with iron enhnces absorption) eating including adequate fluid and nutritious to optimize health for any future • If on iron may be constipated (refer to vitamins and folate food intake, may be unwell )72, 73 Elimination – Bowel Function) or lacking financial resources • Capacity to access • Continue with prenatal supplements nutritious foods (with Variance • Not a time for dieting support) Intervention • Inadequate fluid, food, vitamins • Impact of fatigue on appetite • Refer to >2 – 72 hr and/or folic acid intake due to lack • May be on special diet, such as Diabetic • Refer to appropriate PHCP of knowledge, physical, emotional diet • Refer to community or socio-economic factors • Canada’s Food Guide For Healthy Eating nutritionist • Low Hgb www.healthypregnancybc.ca • Refer to social services and other community agencies Intervention Variance providing assistance with • Nursing Assessment • Refer to >2 – 24 hr food security • If low Hgb consult with PHCP re potential need for iron supplement, Intervention recommend iron rich foods (taking • May require iron supplements Vitamin C with iron enhances • If on iron may be constipated, refer to absorption) Elimination – Bowel Function • Refer to appropriate PHCP prn • Refer to nutritionist or PHCP

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 45 Changes: Family Strengths and Challenges: Lifestyle – Healthy Eating

Refer to >24 – 72hr Refer to >24 Refer to smoking history/ status Refer to >24 – 72hr Refer to >24 – 72hr Refer to >24 – 72hr >72 hours – 7 days – 7 >72 hours and beyond Normal Norm and Variations • Client Education/ Anticipatory Guidance • • Variance • Intervention •

75 obacco

76 for her (or quitting) Remaining smoke free of her children own health and that Remaining drug/ free substance rug/SubstanceUse including second hand smoke including second hand status and current Refer to smoking history of Emphasize the importance smoking Mother is currently smoking during pregnancy Mother reduced Family is exposed to second hand tobacco smoke nicotine from to residual Exposure hand tobacco smoke, also called third on indoor smoke (tobacco smoke residue surfaces, including clothing and human a health hazard skin of smokers) presents dust inhalation, via dermal exposure, ingestion Mother stays quit after pregnancy (if quit after pregnancy Mother stays to/during pregnancy) stopped smoking prior of tobacco smoke- free Home environment history) (as per smoking Non smoker ducation/Anticipatory Guidance Client Education/Anticipatory • • www.quitnow.ca – Use of T Variance • • • • • • >24 – 72 hours Normal Variations Norm and • No obacco D Use,

74 Never smoked Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 No (Adapted from PSBC (Adapted from Use in Guideline: Tobacco the Perinatal Period. 2006) Anticipatory Guidance • Variance • Intervention • Smoking History/ Status: >2 – 24 hours Normal Norm and Variations • Client Education/ Quit prior to pregnancy Quit during pregnancy When did you last smoke? • • ifestyle – T Have you ever smoked cigarettes? (>100 in lifetime) Yes Do you smoke now? Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 Refer to >24 – 72 hr and smoking history and current status Yes Variance Variance • Intervention • (POS) Normal Norm and Variations • Client Education/ Anticipatory Guidance • 0 – 2 hours 0 – 2 Stability Period of smoked/day? Number of cigarettes

e ance Us amily Strengths andChallenges: L

le: y

t s action Access support Identify warning signals/variances that further assessment and or may require Stay quit after pregnancy (if stopped Stay quit after pregnancy smoking prior to or during pregnancy) smoker) Quit smoking (if a current drugs tobacco smoke (tobacco smoke tobacco smoke (tobacco indoor surfaces including on reside clothing and human skin of smokers), and non prescription prescription of alcohol, tobacco, The effects smoke and (including second hand nictoine from to residual exposure Use of drugs or substances status) Smoking history (smoking fe • Assess woman’s capacity to: Assess woman’s • • • Assess the woman’s readiness to readiness Assess the woman’s • • understanding of: Assess woman’s Assess woman and household members Assess woman and and current previous • Li Use Tobacco st Drug/Sub amily Family Assessment Changes: F

46 Perinatal Services BC 0 – 2 hours Family >72 hours – Period of >2 – 24 hours >24 – 72 hours Assessment 7 days and beyond Stability (POS)

Lifestyle: Intervention – Use of Tobacco Tobacco Nursing Assessment Use Drug/ www.perinatalservicesbc.ca – Guidelines on Tobacco Substance • ASK: about smoking history/status and exposure to second hand Use Obstetrics Guideline 20: Postpartum Nursing Care Pathway Care Nursing 20: Postpartum Guideline Obstetrics • ADVISE: re importance of remaining smoke free (if quit before/during pregnancy) for her own (Continued) health and that of her children. • If a smoker, provide brief, clear personalized and respectful message re stopping.77 Smokes outside after breastfeeding • Discuss importance of keeping baby and self free from exposure to second hand smoke • Discuss the potential harm particularly to infants (and toddlers) from the residue of second hand smoke nicotine that lingers on surfaces that can react with another chemical in the air to form carcinogens – chemicals linked to various cancers78 • ASSESS: assess woman’s readiness to stay quit after pregnancy (to prevent relapse).79 If a current smoker – readiness to quit and knowledge of smoking and health • For women who have quit before/during pregnancy encourage to recognize and take action on the warning signals that may precede relapse, such as stress, depression, drinking alcohol/using other drugs, flagging motivation/ feeling deprived, lack of support for cessation, weight gain • ASSIST mother in planning actions prn • ARRANGE refer to appropriate follow-up prn • Include partner/ significant other and family in interventions whenever possible

Variance – Use of substances/drugs (excluding tobacco) • Mother is currently using drugs/substances, • Family is exposed to harmful substances, such as alcohol, drugs

Intervention – Use of substances/drugs (excluding tobacco) • Nursing Assessment • Use Ask/ Advise/ Assess/ Assist/ Arrange principles

• Refer to appropriate resources (such as addiction services/ appropriate services) and social services or PHCP prn

Refer to: Baby’s Best Chance Best Chance Website – www.bestchance.gov.bc.ca 47 Changes: Family Strengths and Challenges: Lifestyle – Tobacco Use, Drug/Substance Use

Refer to >24 – 72 hr Refer to >24 Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 – 72 hr >72 hours – 7 days – 7 >72 hours and beyond Normal Variations Norm and • Client Education/Anticipatory Guidance • Variance • Intervention • Home contains safety Home contains safety hazards Nursing assessment Discuss alleviating safety prn and refer hazards Home environment is free is free Home environment safety or of environmental hazards Variance • Intervention • • >24 – 72 hours Normal Variations Norm and • www.bestchance.gov.bc.ca nvironment Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 • Variance • Intervention • >2 – 24 hours Normal Variations Norm and • Client Education/Anticipatory Guidance Best Chance Website – Best Chance Website ifestyle – Safe Home E Refer to >24 – 72 hr Refer to >24 – 72 hr Refer to >24 Refer to >24 – 72 hr Refer to >24 – 72 hr • Period of Stability (POS) Period of Normal Variations Norm and • Client Education/ Anticipatory Guidance • Variance • Intervention 0 – 2 hours 0 – 2 amily Strengths andChallenges: L Best Chance Baby’s

solution(s) prnAddress Identify variances that may Identify variances that action require Safety hazards in the Safety hazards environment A safe home environment • Assess the woman’s capacity to Assess the woman’s • • me Environment Safe Ho of knowledge woman’s Assess the • Family Assessment Changes: F Refer to:

48 Perinatal Services BC Glossary of Abbreviations

ADL Activities of Daily Living Mm Millimetres BCCH British Columbia Children’s Hospital PO By Mouth Bpm Beats per minute POS Period of Stability BCCDC BC Centre for Disease Control PHCP Primary Health Care Provider BP Blood Pressure PHN Public Health Nurse CB Caesarean Birth PCR / RNA The best approach to confirm the diagnosis Cm Centimetres of hepatitis C is to test for HCV RNA CNS Central Nervous System (Ribonucleic acid) using a sensitive assay such as polymerase chain reaction (PCR) CPS Canadian Paediatric Society PSBC Perinatal Services BC D/C Discontinue PP Postpartum E.g. For example PPD Postpartum Depression EBM Expressed Breast milk PPH PPostpartum Haemorrhage GI Gastrointestinal prn As needed Gm Gram(s) P Pulse > Greater than RR Respiratory Rate ≥ Greater than or equal to ROM HbsAg Hepatitis B Surface Antigen SOGC Society of Obstetricians and Gynaecologists HIV Human Immunodeficiency Virus of Canada HCV Hepatitis C SSRI Selective Serotonin Reuptake Inhibitors HSV Herpes Simplex Virus SNRI Selective Norepenephrine Reuptake HBIG Hepatitis B Immune Globulin Inhibitors HR S&S Signs and Symptoms Hr Hours T Temperature i.e. That is TL Tubal Ligation IV Intravenous UTI Urinary Tract Infection LC Lactation Consultant VAS Visual/ Verbal Analogue Scale < Less than VB Vaginal Birth ≤ Less than or equal to vs Versus Min Minute WHO World Health Organization Ml Millilitre(s)

References

Barash, B., Cullen, R., Stoelting, R. ( 2001). Clinical BCCDC. (2005). Rubella (German measles). Health Topics. Anesthesia. Lippincott, Williams & Wilkins. New York. BCCDC www.bccdc.org Benoit, Diane. (2000). Attachment and parent-infant Breivik, H., Borchgrevink, P., Allen, S., Rosseland, L., relationships...a review of attachment theory and Romundstad, L., Breivik Hals.E., Kvarstein,G., Stubhaug, research. Ontario Association of Children's Aid A. (2008) Assessment of Pain. British Journal of Societies (OACAS), Journal, 44(1), 13-22. Anaesthesia 101(1), 17-24. British Columbia Centre for Disease Control (BCCDC). BC Women’s Hospital (BCW) and Health Centre and BC (2004). Hepatitis B. Communicable Disease Control Centre of Excellence for Women’s Health (2004). Chapter. BCCDC. www.bccdc.org Advancing the Health of Girls and Women in British Columbia: A Provincial Women’s Health Strategy. Author. BCCDC. (2004). Hepatitis C. Communicable Disease Control Chapter. BCCDC. www.bccdc.org BCW (2006). Newborn Weighing Policy, Fetal Maternal Newborn and Family Health Policy and Procedure BCCDC (2008). HIV/AIDS BCCDC www.bccdc.org Manual. BCWBCW. (2009). Oak Tree Clinic www. BCCDC (2008). Interpretation of Virology Serology Reports. bcwomens.ca/Services/HealthServices/OakTreeClinic/ Rubella Serology. Public Health Laboratory Services. BCW. (2008). Policy CU 0300 Appendix A. Postpartum PHSA Laboratories Programs and Services Urinary Retention Assessment. Fetal Maternal Newborn BCCDC. (2004).Varicella Zoster. Communicable Disease and Family Health Policy & Procedure Manual. Author. Control Chapter. BCCDC www.bccdc.org

Obstetrics Guideline 20: Postpartum Nursing Care Pathway 49 References, cont.

BCW. (2009). Reproductive Mental Health www.bcwomens. National Collaborating Centre for Women’s and Children’s ca/Services/HealthServices/ReproductiveMentalHealth/ Health (2004). . Clinical Guideline. RCOG Press. (p.8) www.nice.org.uk/nicemedia/pdf/ British Ministry of Health Services (2008). Health Link BC CG013fullguideline.pdf www.healthlinkbc.ca/kbaltindex.asp Parkyn, JH. (1985). Identification of At-Risk Infants and British Columbia Reproductive Care Program (BCPHP). Preschool Children. In: Frenkenburg W., Emde R and (2009). Breastfeeding the Healthy Term Infant. BCPHP Sullivan J. Early Identification of Children at Risk: An BCPHP. (2009). Decision Support Tool No. 7. Postpartum International Perspective. New York, London: Plenham Hemorrhage. Author. Press, p. 203-209. BCPHP (BCRCP). (2003). Hepatitis C in the Perinatal Period. Poole, N. Urquart, C (2007). Healthy Choices in Pregnancy. Obstetrical Guideline No.18. Author. BC Centre of Excellence for Women’s Health, BCW, BCPHP www.hcip-bc.org/ BCPHP. (2003) HIV in the Perinatal Period. Obstetrical Guideline No.15. Author. Province of British Columbia. (2008). Pregnant Women. Act Now BC. www.actnowbc.ca BCPHP. (2002) Report on the Findings of the Postpartum Consensus Symposium. Author Public Health Agency of Canada. (2003). First Connections make all the difference. Infant Attachment-What College of Registered Nurses of British Columbia (CRNBC). Professionals Can Do. Author. (2005). Consent. Practice Standard for Registered www.phac-aspc.gc.ca Nurses and Nurse Practitioners Pub. No. 359. CRNBC. www.crnbc.ca/downloads/359.pdf Public Health Agency of Canada. (2006). Canadian Immunization Guide. (7th ed) Author. Eisenach, J., Pan, P., Smiley, R., Lavand’homme, P., www.phac-aspc.gc.ca/publicat/cig-gci/ Landau, R., Houle, T. (2008) Severity of acute pain after childbirth, but not type of delivery, predicts persistent Government of Ontario. (2005-2008). PP Mood Disorders. pain and postpartum depression. PAIN 140. 87-94 Best Start: Ontario's Maternal, Newborn and Early Child Development Resource Centre. Author. Hawe, C., McIlveney, F. (2006) Early-warning scoring in www.beststart.org/resources/ppmd/index.html obstetric patients. International Journal of Obstetric Anesthesia,15, S1-43. Sio, J., Minwall, F., George, R. Booth, I. (1987). Oral Candida: Is Dummy Carriage the Culprit? Arch Dis Child 62 (4): Health Canada. (2000). Early Postpartum Care of the Mother 406-8. and Infant and Transition to Home. Family Centred Maternity and Newborn Care: National Guidelines (4th SOGC. (2008). Guidelines for the Management of Herpes Edition). Chapter 6. Author. www.hc-sc.gc.ca/index- Simplex in Pregnancy. Clinical Practice Guideline. No. eng.php 208 SPGC. SOGC www.sogc.org/guidelines/documents/ Health Canada. (2000). Gender-based Analysis Policy. www. SOGC. (2000). The Reproductive Care of Women Living with hc-sc.gc.ca/hl-vs/women-femmes/gender-sexe/policy- Hepatitis C Infection. Clinical Practice Guideline. No. 96. politique_e.html SPGC. SOGC www.sogc.org/guidelines/documents/ Health Canada. (2008, October). Use of Codeine products . (1995). Report of the UN 4th World by Nursing Mothers, Advisory. Author. ww.hc-sc.gc.ca Conference on Women. Author, Beijing Health Nexus & Province of Ontario (2007). Best World Health Organization. (1998). Health Topics, Pregnancy, Start: Ontario's Maternal Newborn and Early Child Making Pregnancy Safer, All Publications, Postpartum Development Resource Centre www.beststart.org:80/ care, Postpartum Care of Mother and Newborn: A resources/breastfeeding Practical Guide. www.who.int/en/ Lowdermilk, D. L. & Perry, S. E. (2007). Maternity & Women’s Health Care (9th ed.). St. Louis, MI: Mosby. Ministry of Health (1998). Ministry of Health and Women’s Health Bureau and the Women-Centred Care Project (WCP), Author Ministry of Health. (2006). Baby’s Best Chance. (6th ed). Victoria, BC: Open School BC. www.publications.gov. bc.ca Morland-Schulz, K.& Hill, P. (2005). Prevention of and for Nipple Pain: A Systematic Review. JOGNN, (34) 4, 428-434.

50 Perinatal Services BC Endnotes

1. Perinatal Services BC (formerly BC Perinatal Health 29. PSBC. (2011). Breastfeeding the Healthy Term Infant. Program) is a program of the the Provincial Health Services 30. Ibid. Authority. 31. Ibid. 2. College of Registered Nurses. (2005). 32. BCW. (2006). Newborn Weighing Policy, Fetal Maternal 3. College of Registered Nurses. (2005). Newborn and Family Health Policy and Procedure Manual. 4. United Nations. (1995). Report of the UN 4th World BCW. Conference on Women. Beijing. 33. PSBC. (2011). Breastfeeding Healthy Term Infant. 5. Health Canada. (2000). Gender based Analysis Policy. 34. Ibid. 6. Health Canada. (2000). Gender based Analysis Policy. 35. Ibid. 7. BC Provincial Women’s Health Strategy. (2004). 36. Sio, J., Minwall, F., George, R. Booth, I. (1987). Oral 8. BC Excellence for Women’s Health. (2004). Candida: Is Dummy Carriage the Culprit? Arch Dis Child 62 9. Matenity Care Enhancement Project. (2004). (4): 406-8. 10. BCRCP Report on the Findings of the Postpartum 37. Public Health Agency of Canada www.phac-aspc.gc.ca/ Consensus Symposium (2002), hepc/pubs/gdwmn-dcfmms/viii-pregnant-eng.php 11. Health Canada. (2000) Chapter 6, Early Postpartum Care 38. Canadian Pediatric Society www.cps.ca/english/ of the Mother and Infant and Transition to the Community, statements/ID/id08-05.htm Family-Centred Maternity and Newborn Care: National 39. Public Health Agency of Canada Guidelines (4th Edition). 40. SOGC. (2008). Guidelines for the Management of Herpes 12. World Health Organization (WHO). (1998) “Postpartum Care Simplex Virus in Pregnancy. JOGC Clinical Practice of Mother and Newborn: A Practical Guide”. Guideline, No 208. p.518. 13. World Health Organization (WHO). (1998) “Postpartum Care 41. SOGC. (2008). Guidelines for the Management of Herpes of Mother and Newborn: A Practical Guide” p.2. Simplex Virus in Pregnancy. JOGC Clinical Practice 14. BCRCP Report on the Findings of the Postpartum Guideline, No 208. p.518. Consensus Symposium. (2002). 42. BCCDC. (2008). Interpretation of Virology Serology Reports. 15. Ibid. Rubella Serology. Public Health Laboratory Services. PHSA Laboratories Programs and Services, p. 91 16. Ibid. 43. BCCDC (2009). Communicable Disease Control Manual. 17. Eisenach, J et al. (2008) Severity of acute pain after Immunization Program Chapter IIA Immunization childbirth, but not type of delivery, predicts persistent pain Schedules. p.43. and postpartum depression. PAIN 140 p. 87. 44. National Collaborating Centre for Women’s and Children’s 18. Ibid. Health. (2004). 19. Breivik, H. et al. (2008). Assessment of pain. British Journal 45. BCW. (2008). Policy CU 0300 Appendix A. Postpartum of Anaesthesia. 101(1) p. 17. Urinary Retention Assessment 20. Ne’methy, M., Paroli, L., Williams-Russo, P., Blanck, T. 46. BCCDC (2009). Communicable Disease Control Manual. (2002). Assessing Sedation with Regional Anesthesia: Inter- Immunization Program Chapter IIA Immunization Rater Agreement on a Modified Wilson Sedation Scale. Schedules. p.43 Anesth Analg, p. 723. 47. American Society of anesthesiologists Task Force on 21. Lowdermilk & Perry. (2007) p.586. Neuraxial Opioids. Practice Guidelines for the Prevention, 22. Eisenach, J et al. (2008) Severity of acute pain after Detection, and Management of Respiratory Depression childbirth, but not type of delivery, predicts persistent pain Associated with Neuraxial Opioid Administration. and postpartum depression. PAIN 140 p. 91. , 2009;110(2):218-230. 23. Health Canada. (2008, October). Use of Codeine products 48. (MEOWS). Hawe, C., McIlveney, F. (2006) Early-warning by Nursing Mothers, Advisory. Author. scoring in obstetric patients. International Journal of 24. Eisenach, J et al. (2008) Severity of acute pain after Obstetric Anesthesia (2006). 15, S1-43. childbirth, but not type of delivery, predicts persistent pain 49. Barash, B., Cullen, R., Stoelting, R. ( 2001). Clinical and postpartum depression. PAIN 140 p. 91. Anesthesia. p.458. 25. Province of British Columbia. (2010). Baby’s Best Chance. 50. Eisenach, J et al (2008) Severity of acute pain after Second revision sixth edition. Queen’s Printer of British childbirth, but not type of delivery, predicts persistent pain Columbia, Canada. and postpartum depression. PAIN 140 p. 91 26. Bramson, L, Lee JW, Moore E et al (2010) Effect of Early 51. Benoit, D. (2000). Attachment and Parent-Infant Skin-to-Skin Mother-Infant Contact During the First 3 Relationships....A review of Attachment Theory and Hours Following Birth on Exclusive Breastfeeding During Research p.13 the Stay. J Hum Lact. 28 January 2010, 52. SOGC (2007). Postpartum Maternal and Newborn 10.1177/089033440935. Discharge. JOGC Clinical Practice Guideline No. 190 p. 357 27. PSBC. (2011). Breastfeeding the Healthy Term Infant. www.sogc.org/guidelines/documents/190E-PS-April2007. 28. Morland-Schulz, K. & Hill, P. (2005). Prevention of and pdf Therapies for Nipple Pain: A Systematic Review. JOGNN. 53. BCRCP (2002) Report on the Findings of the Postpartum (34) 4. 428-434. Consensus Symposium.

Obstetrics Guideline 20: Postpartum Nursing Care Pathway 51 Endnotes, cont.

54. SOGC (2007). Postpartum Maternal and Newborn 76. Sleiman M, Gujdel LA, Pankow JF, et al. Formation of Discharge. JOGC Clinical Practice Guideline No. 190 carinogens indoors by surface-mediated reactions of p. 357www.sogc.org/guidelines/documents/190E-PS- nicotine with nitrous acid, leading to potential thirdhand April2007.pdf smoke hazards. Proceedings of the National Academy 55. Health Canada. (2004). Exclusive breastfeeding duration – of . 2010; Sptil 107(15); 6576 – 6581. accessed 2004 Health Canada recommendation. www.hc-sc.gc.ca/ April 21, 2010 from www.pnas.org/cgi/doi/10.073/ fn-an/nutrition/child-enfant/infant-nourisson/excl_bf_dur- pnas.0912820107 . dur_am_excl-eng.php 77. www.perinatalservices.bc.ca 56. Canadian Pediatric Society, Dietitians fo Canada & Health 78. Sleiman M, Gujdel LA, Pankow JF, et al. Formation of Canada. (2005). Nutrition for healthy term infants. Minister carinogens indoors by surface-mediated reactions of of Public Works and Government Services. Ottawa: Author. nicotine with nitrous acid, leading to potential thirdhand 57. World Health Organization. (2001). The optimal duration of smoke hazards. Proceedings of the National Academy exclusive breastfeeding: Report of an expert consultation. of Sciences. 2010 ;Sptil 107(15); 6576 – 6581. accessed Department of Nutrition for Health and Development, April 21, 2010 from www.pnas.org/cgi/doi/10.073/ Department of Child and Adolescent Health and pnas.0912820107 Development, WHO, Geneva, Switzer4land: Author. www. 79. www.perinatalservices.bc.ca who.int/nutrition/publications/optimal_duration_of_exc_ bfeeding_report_eng.pdf 58. World Health Organization. (2003). Global strategy for infant and young child feeding. Geneva, Switzerland: Author. http://whqlibdoc.who.int/publications/2003/9241562218. pdf 59. College of Family Physicians of Canada. (2004). Infant feeding policy statement. www.cfpc.ca/local/files/ Communications/Health%20Policy/Final_04Infant_ Feeding_Policy_Statement.pdf 60. Breastfeeding Committee for Canada. (2002). Breastfeeding statement of the Breastfeeding Committee of Canada. http://breastfeedingcanada.ca/html/webdoc5.html 61. PSBC. (2011). Breastfeeding Healthy Term Infant. 62. BCRCP (2002) Consensus Statement #16. Report on the Findings of the Postpartum Consensus Symposium. 63. Ibid. 64. PSBC. (2011). Breastfeeding the Healthy Term Infant. 65. Ibid. 66. Ibid. 67. Aaron M, Marchall LA, Nommsen-Fivers LL et all. Serotonin Transport and Metabolism in the Mammary gland Modulates Secretory Activation and Involution. J Clin Endocrinol Metab 2010;95(2):1-10. 68. BCPHP (2002) Consensus Statement, Consensus Statement #12, Report on the Findings of the Postpartum Consensus Symposium. 69. PSBC. (2011). Breastfeeding the Healthy Term Infant. 70. Eisenach, J et al (2008) Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. PAIN 140 p. 91 71. Ibid. 72. www.cps.ca/english/statements/ii/fnim07-01.htm 73. www.sogc.org/media/pdf/advisories/JOGC-dec-07-FOLIC. pdf 74. www.perinatalservices.bc.ca 75. Ibid.

52 Perinatal Services BC Revision Committee

Members of the Postpartum Nursing Care Pathway Revision Committee Perinatal Services BC would like to acknowledge the working committee who revised the BC Postpartum Care Pathway. Committee members included:

Barbara Selwood Project Lead, Health Promotion and Prevention, PSBC Taslin Janmohamed-Velani Coordinator, Knowledge Translation, PSBC Laurie Seymour Project Consultant Jacqueline Koufie Clinical Nurse Educator, St. Paul’s Hospital Radhika Bhagat Clinical Nurse Specialist, 0-5 years, Vancouver Community Kathy Hydamaka Program Leader, Healthy Babies and Families, Richmond Joan Brown Clinical Educator for the Early Years Team, North Shore Health Yvonne Law Perinatal Clinical Educator – Postpartum, BC Women's Hospital Monica Carey Staff Nurse, BC Women's Hospital Marina Green Lactation Consultant, BC Women's Hospital Tammy MacDonald Educator, Surrey Memorial Hospital Kate McCulloch Regional Clinical Nurse Educator – Aboriginal Health, Fraser Health Public Health Tanya Jansen Clinical Nurse Educator Maternal Child Program, Ridge Meadows Hospital Pam Munro CNS Maternal, Infant, Child & Youth Program, Fraser Health Public Health Elaine Klassen Clinical Nurse Educator, Fraser Health Public Health Bev Grossler Patient Care Coordinator, Lillooet Hospital Anita Gauvin NICU Clinical Resource Coordinator, Kamloops Hospital Patty Hallam Public Health Nursing Program Consultant – ECD, Kamloops Jennifer Stubbings Team Leader, Thompson Cariboo Shuswap Public Health Christine Moffitt Clinical Practice Educator, Labour and Delivery, Royal Inland Hospital Lynn Popien Regional Perinatal Education Coordinator, Royal Inland Hospital Tamara Kropp Program Manager Medical & Maternity, Quesnel Hospital Sharron Sponton Community Health Nurse, Smithers Grace Dowker Maternity RN/Educator, Campbell River Hospital and Community Amber Thomas Public Health Nurse, Courtenay Grace Park Family Physician, White Rock Wilma Aruda Pediatrician, Nanaimo

Obstetrics Guideline 20: Postpartum Nursing Care Pathway 53

Perinatal Services BC West Tower, 3rd Floor 555 West 12th Avenue Vancouver, BC Canada V5Z 3X7 Tel: (604) 877-2121 www.perinatalservicesbc.ca

While every attempt has been made to ensure that the information contained herein is clinically accurate and current, Perinatal Services BC acknowledges that many issues remain controversial, and therefore may be subject to practice interpretation.

© Perinatal Services BC, 2011