Public Health Nursing: Postpartum Nursing Care Pathway
2019 Provincial Standards For Prenatal, Postpartum And Early Childhood: Province of Manitoba
Public Health Nursing: Postpartum Nursing Care Pathway 2019
Table of Contents
INTRODUCTION 1 About the Postpartum Nursing Care Pathway...... 1 Postpartum Assessment...... 1 General Guidelines...... 1 PHYSIOLOGICAL HEALTH 3 Abdomen / Fundus...... 3 Pain...... 4 Abdominal Incision...... 5 Breasts...... 6 Breastfeeding...... 10 Hand Expression / Pumping...... 10 Informed Decision / Feeding...... 10 Skin-to-skin...... 10 Elimination Bowel Function...... 12 Bladder Function...... 13 Lochia...... 14 Perineum...... 15 Communicable Diseases (Infections) Hepatitis B...... 16 Hepatitis C (HCV)...... 17 Herpes Simplex (HSV)...... 18 Human Immunodeficiency Virus (HIV)...... 18 Rubella (German Measles)...... 19 Varicella Zoster (Chicken Pox)...... 19 Influenza and Influenza Like Illness (ILI)...... 20
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RH Factor...... 20 Vital Signs...... 21 PSYCHOSOCIAL HEALTH 22 Bonding and Attachment...... 22 Emotional Status and Mental Health...... 23 Support Systems / Resources...... 24 FAMILY STRENGTHS AND CHALLENGES 25 Family Function / Dynamic...... 25 Health Follow-up in Community...... 26 LIFESTYLE 27 Activities / Rest...... 27 Family Planning / Sexuality...... 29 Healthy Eating...... 31 Commercial Tobacco / Drug / Substance Use...... 32 Safe Home Environment...... 34 REFERENCES 35 ACKNOWLEDGEMENTS 39
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Introduction About the Postpartum Nursing Care Pathway The Postpartum Nursing Care Pathway identifies the goals and needs of postpartum clients and their families and is the foundation for documentation on the Public Health Nursing (PHN) Postpartum Assessment form. To ensure all of the assessment criteria are captured, they have been organized in alphabetical order into four main sections: • Physiological Health • Psychosocial Health • Family Strengths and Challenges • Lifestyle
While the postpartum assessment criteria are presented as discrete topics it is not intended that they be viewed in isolation. To assist with this, there is cross referencing to the Newborn Care Pathway throughout. The parent and newborn are considered to be an inseparable dyad with the care of one influencing the care of the other.
In this document, assessments are entered into specific periods from immediately after birth to 7 days postpartum and beyond. For the ease of PHN practice however, the documentation form reflects days postpartum rather than hours.
Postpartum Assessment The performance of a postpartum physical, psychosocial, family, lifestyle and safety assessment is referred to as a Nursing Assessment. Once the client is in their own surroundings, assessments will be performed based on individual nursing judgment in consultation with the family. To obtain pertinent information: • Confirm assessment data with the client. • Review the information provided on the Postpartum Referral Form (PPRF). For any identified variances or pertinent observations: • Document in the Progress Notes prior to entry into the electronic information system where applicable.
Item Description
Client Surname -- The surname of the client
Given Name -- The given (first) name of the client
Date of Birth (DOB) -- Client’s date of birth (MONTH/DD/YYYY)
Personal Health -- Client’s nine digit Manitoba personal health identification number (PHIN) or Identification Number Nunavut Health Care Plan number (PHIN), Nunavut Number
Gestational Age -- Infant gestational age indicated on postpartum assessment form
Manitoba Family -- Client’s six digit family registration number Registration Number (MFRN)
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Contact Date and Time Indicate date(s), and time of contact as Month, DD, YYYY (for example Jul 31, 2018, @ 11:15 am), type(s) of contact:
Contact Type
Initials Name Description
DC Direct contact In person meeting that may occur at any variety of locations
IC Indirect contact Communication with the client that is not in person - it may be via phone, social media, etc.
General Guidelines Documentation will be completed on the assessment forms using a charting by exception process. The Prenatal, Newborn and Postpartum Care Pathways contain information on normal, normal variations, variances, interventions, education, and anticipatory guidance. PHNs will indicate their assessment as follows:
Spaces are not left blank. Documentation is completed using: Item Description
PHN initials Indicates PHN assessment is consistent with normal expectations contained in the care pathway
V (Variance) Indicates a key assessment finding that requires further explanation in the progress note
/ (Not Assessed) PHN has not assessed that area Note: Bracketing and initialing sections is acceptable.
Item Description
Time from birth in number -- Postpartum Day 1 = 0 (birth) to 24 hours of days postpartum -- Postpartum Day 2 = 24 to 48 hours -- Postpartum Day 3 = 48 to 72 hours -- Postpartum Day 4 = 72 to 96 hours -- Postpartum Day 5 = 96 to 120 hours etc
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Physiological Health Abdomen / Fundus
Physiological Assessment 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
ABDOMEN / FUNDUS
Assess Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal --Fundus for normal involution --Fundus firm, central +/- 1 finger above/ Variations Variations Variations below umbilicus --Refer to POS --Fundus firm, central, --Fundus central, firm UptoDate1 --Rectus muscle intact 1 – 2 fingers below and 2 – 3 fingers below --Refer to UptoDate for detailed Client Education / Anticipatory umbilicus-goes down ~ umbilicus postpartum assessment data Guidance Client Education / 1 finger (1cm) breadth/ --Involuting and to correspond with information --Palpate fundus with 2nd hand supporting Anticipatory Guidance day descending ~1 contained in the carepathway uterus just above symphysis (client in --Refer to POS fingerbreadth 1cm/day supine position with knees flexed). Client Education / (not palpable at 7 – 10 Suggested frequency for vaginal --Advise to empty bladder and aware of Variance – Fundus and Anticipatory Guidance days postpartum, pre birth: need to empty frequently. Infection --Refer to 0 – 24 hr pregnant state at 6 wks) --q 15 min for 1 hour --Able to demonstrate palpation (if desired) --Refer to POS --at 2 hours Variance Client Education / --once per shift until discharge from Variance – Fundus Intervention – Fundus --Refer to 0 – 24 hr Anticipatory Guidance hospital --Uterus – boggy, soft, deviated to one and Infection --Refer to 0 – 24 hr --then as required by nursing side (due to retained products, distended --Refer to POS Intervention judgment and/or self report bladder, uterine atony, bleeding) --Refer to 0 – 24 hr Variance Variance – Diastasis --Refer to 0 – 24 hr Assess client’s understanding of: Intervention – Fundus recti abdominis --Normal involution progression --Massage uterus (if boggy) – advise to --Diastasis recti Intervention empty bladder abdominis as evidenced --Refer to 0 – 24 hr Assess client’s capacity to: --May require further interventions – e.g. by bulging or gaping in --Self check her involution intravenous, oxytocin (or other uterotonic the midline of abdomen progression medications), in and out catheterization --Identify variances that may require of bladder Intervention – further medical assessment --Nursing Assessment Diastasis recti --Refer to appropriate PCP prn abdominis Refer to: --Educate that this will --Lochia Variance – Infection become less apparent --Infection S & S: T>38,P, chills, anorexia, with time nausea, fatigue, lethargy, pelvic pain, foul smelling and/or profuse lochia
Intervention – Infection --Monitor for increased uterine tenderness and --Monitor S & S of infection --Refer to Lochia --Refer to PCP
Maternal Physiological Stability The Postpartum Nursing Care Pathway 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
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Pain
Physiological Assessment 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
PAIN
Use of a visual/verbal analogue Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal pain scale (VAS) and/or pain --Pain is tolerable with/without analgesia Variations Variations Variations assessment questions and/or non pharmacological pain relief --Refer to POS --Refer to 0 – 24 hr --Refer to 0 – 24 hr 1. Location: Where is the pain? measures --Afterpains may be more 2. Quality: What does your pain feel --Pain does not impact daily living, such as severe in multiparous Client Education / Client Education / like? walking, mood, sleep, interactions with clients when Anticipatory Guidance Anticipatory Guidance 3. Onset: When did your pain start? others and ability to concentrate breastfeeding --Refer to POS --Refer to 0 – 24 hr 4. Intensity: Using the scale 0 (no --Afterpains begin to pain) and 10 (worst pain possible) Client Education / Anticipatory Client Education / Variance subside after about where would your pain be? Guidance Anticipatory Guidance --Refer to POS 72 hr 5. What makes the pain better? --Using VAS questions to assess pain level --Refer to POS 6. What makes the pain worse? and when to consult PCP --Effect of breastfeeding Intervention Variance --Client aware of recommendation for on involution of uterus --Refer to POS --Refer to POS Effectiveness of comfort nursing mothers to take precautions measures/analgesia with the use of Codeine (Refer to Variance Intervention breastfeeding) --Refer to POS --Refer to POS Assess awareness of comfort --Confer with PCP RE: use of alternate measures and/or analgesia – medication. Intervention include doses, frequency and --Refer to POS effectiveness Variance --Client with increased pain are more --Pain does impact daily living, such as apt to develop chronic pain and/or walking, mood, sleep, interactions with depression others and ability to concentrate --Pain not relieved by current analgesia and/or non pharmacological pain relief measures
Intervention --Pain requires further evaluation and management --Nursing Assessment including pain assessment --Refer to appropriate PCP prn
Postpartum Pain and the Visual/Verbal Analogue Scale (VAS) Acute post partum pain is a strong predictor of persistent The following questions should be part of the maternal pain pain and depression after childbirth. assessment: 1. Location: Where is the pain? If interested in accessing a VAS scale, instructions and 2. Quality: What does the pain feel like? downloadable scales can be accessed via the following 3. Onset: When did your pain start? article. Adaptive Visual Analog Scales (AVAS): A Modifiable 4. Intensity: On a scale of 0 to 10 (with 0=no pain and Software Program for the Creation, Administration, and 10=worst pain possible) where would your pain be? Scoring of Visual Analog Scales: (Pain Scale is used on Postpartum Clinical Care Path) www.ncbi.nlm.nih.gov/pmc/articles/PMC2635491/ 5. What makes the pain better? 6. What makes the pain worse?
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Abdominal Incision
Physiological Assessment 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
ABDOMINAL INCISION
--Abdominal incision – progression --Abdominal incision dressing dry and Norm and Normal Norm and Normal Norm and Normal of healing intact with minimal oozing Variations Variations Variations --Well approximated and --Fundus may be tender --Refer to 0 – 24 hr Assess understanding of: Client Education / free of inflammation, but improving --Normal healing from caesarean Anticipatory Guidance little or no drainage, --Incision swelling Client Education / birth abdominal incision --Marked areas of oozing dressing dry and intact, decreasing Anticipatory Guidance --Encourage to splint abdomen with pillow staples present, may --Refer to 0 – 24 hr Suggested assessment frequency when coughing, moving or feeding have subcuticular suture Client Education / --Afterpains begin to for caesarean birth: --Use of good body mechanics when covered with steri-strip Anticipatory Guidance subside after about --q 15 min for 1 hour changing positions (getting up from bed/ pressure dressing --Traditional dressing 72 hr --at 2 hours chair) removed – may shower, --q 4 h X 24 hours Client Education / cover incision Variance --once per shift until d/c from hospital Variance Anticipatory Guidance --Steristrips to come off --Refer to POS --then as required by nursing --Increased bleeding on dressing, incision --Refer to POS on own judgment and/or self report gaping, swelling and bruising --For steri-strip pressure Intervention Variance dressing leave intact --Refer to POS Intervention --Refer to POS until removed by PCP --Apply pressure dressing --Incision gaping, edema, --Ensure arrangements --Nursing Assessment inflamed, ecchymosis, for removal of staples/ --Refer to PCP prn discharge sutures or steri-strip pressure dressing (as Variance – Infection Intervention per hospital/agency --S & S such as T>38, increased pulse, chills, --Refer to POS policy/PCP preference) anorexia, nausea, fatigue, lethargy, pelvic --Advise of correct lifting pain, foul smelling and/or profuse lochia technique – abdominal tightening with Intervention – Infection exhalation when lifting, --Nursing Assessment lift within comfort zone --Monitor for increased uterine tenderness (e.g. baby, toddler) and further signs and symptoms of --Advise to use good infection body mechanics and --Refer to PCP prn avoid the Valsalva when lifting --Recommend refraining from tub bath until dressings, sutures, staples removed
Variance --Refer to POS --Drainage/infection Intervention --Refer to POS
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Breasts
Physiological Assessment 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
BREASTS AND NIPPLES
Assess:2-9 Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal Variations --Breasts and nipples --Breasts soft, colostrum may be Variations Variations --After about 72 hours, breasts may --Breast comfort and function expressed --Refer to POS --Refer to >2 – 24h be softer after feedings --Conditions that may affect milk --Nipples are intact, may appear --Breast soft, minimal nipple --Breasts may be --Breast fullness supply: flat or inverted but protrude tenderness beginning to fill, firmer --Lack of breast enlargement with baby’s feeding attempt and colostrum more Client Education / during pregnancy and are minimally tender Client Education / easily expressed Anticipatory Guidance --Some breast traumas or Anticipatory Guidance --May have some nipple --Refer to >2 – 72 hr malformations Client Education / --Hand expression – if tenderness --Breast augmentation or Anticipatory Guidance colostrum or milk --Breast fullness Variance reduction surgery --Uninterrupted skin-to-skin expressed feed to baby --Refer to 0 – 72 hr --Some medical conditions contact until completion of the or rub drops into nipple Client Education / --If nipples were previously --Postpartum hemorrhage first feeding or longer tissue Anticipatory Guidance damaged – pain that does not --Clients with more than one --Breastfeeding your baby2: --Refer to >2 – 24 hr subside after initial latch Assess understanding of: hour of skin-to-skin contact www.gov.mb.ca/ --Frequent breastfeeding --Adequate breast stimulation during the first three hours healthychild/healthybaby/ helps to prevent Intervention following birth, increased hb_breastfeedingyourbaby. engorgement --Refer to 0 – 72 hr Assess: likelihood of breastfeeding pdf --If bra used it should fit --Breastfeeding confidence to exclusively --Support the client/infant to comfortably and not Variance – Engorgement produce adequate milk supply work together in achieving restrict breast --Tenderness, warmth, throbbing for baby an effective latch - most (may extend to armpits) important factor in --Skin on breast may be taut, shiny, Assess capacity to hand decreasing incidence of and transparent express nipple pain2 --Nipples flat, usually bilateral --Refer to Infant Feeding --Breast(s) hard, swollen, painful Section and Latch R tool --Healthy Eating (Refer to Intervention – Engorgement Lifestyle-Nutrition) --Massage breast gently and --Manitoba/RHA Guideline manually express breast milk Breastfeeding the Healthy to soften the areola before Term Infant breastfeeding, facilitating infant latch --Anti-inflammatory agents --Application of warm compresses, shower or breast soak before breastfeeding --Application of cold treatments, such as gel packs, cold packs or some cold cabbage leaves after breastfeeding (Clients’ report the use of cold cabbage leaves as helpful)5
Latch Score 0 1 2 L - Latch Too sleepy or reluctant; Repeated attempts; Hold nipple in mouth; Grasps breast; Tongue down; Lips flanged; No Latch achieved Simulate to suck Rhythmic sucking A - Audible swallowing None A few with stimulation Spontaneous and frequent > 24 hours old T - Type of nipple Inverted Flat Everted (after stimulation) C - Comfort (Breast/Nipple) Engorged; Cracked, bleeding, large blisters Filling; Reddened/small blisters or bruises; Soft; Tender or bruises; Severe discomfort Mild/moderate discomfort H - Hold (Positioning) Full assist (PHN holds infant at breast) Minimal assist (i.e., place pillows for No assist; Able to position/hold infant support); Teach one side; client does other; PHN holds - parent takes over R - Responsiveness to cues, confidence to Does not respond to feeding cues; Does not Requires help to interpret feeding cues; Responds appropriately to feeding cues; breastfeed feel confident about ability to breastfeed Requires confidence building Feels confident about ability to breastfeed
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Breasts
Physiological Assessment 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
BREASTS AND NIPPLES
(Continued) Variance Variance – Nipple(s) Variance Variance – Lump in Axilla --Nipple inversion, nipples that --Refer to POS --Refer to 0 – 24 hr and --Extra breast tissue in the Refer to infant feeding and Latch R tool3 invert with gentle compression --Nipple pain >72 hr and beyond axilla or do not evert with stimulation --Nipple damage – --Normal variation, medical sufficient for baby to latch (bleeding/ cracked, bruised Intervention intervention not required --Baby not latching nipples) --Refer to 0 – 24 hr and --Baby separate from mother --Nipple distortion after >72 hr and beyond Intervention – --Refer to >2 – 24 hr feeds Engorgement of Lumps --Inadequate breast Variance – in Axilla Intervention stimulation Nipple trauma --Anti-inflammatory agents --Refer to >2 – 24 hr --Not initiating hand --Nipple trauma (beginning --Comfort Measure – --Hand expression if baby expression within six hours signs of skin breakdown) application of cold separated from mother if baby separated --Nursing Assessment --Baby is unable to latch (flat Intervention – Variance – --Refer to Manitoba/RHA or inverted nipple) Nipple trauma Plugged Duct breastfeeding guideline --Assess infant feeding --Usually 1 breast Intervention – Nipple(s) --Ask client to rate her --Localized hot, tender spot --Refer to POS and > 24 – 72 nipple pain (using VAS – --May be white spot on hours and beyond see Pain) nipple --Assess infant feeding --Encourage client to --May be a palpable lump (especially for position and look at nipple as baby (plugged duct) latch) releases it, if nipple looks --Assess and support rounded rather than Intervention – strategies for infant creased or flattened the Plugged Duct feeding pain is probably related --Shower or warm --If baby unable to feed to previous damage. This compress to breast before effectively, initiate regular ‘reference feeding’ can breastfeeding hand expression in the first help determine latch --Frequent feeding 24 hours and expression effectiveness --Massage behind the plug and pumping thereafter --Refer to individual toward the nipple, prior to (refer to Newborn Nursing knowledgeable in current and during feeding Care Pathway) breastfeeding practices --Vary positions for feeding --Apply expressed breast or lactation consultant --Comfort measures may milk to nipple (LC) include ice and anti- --Start feeding with least --Can call for inflammatory agents affected nipple (if nipple Breastfeeding support --Avoid missing feedings pain) toll free 1-888-315-9257 --Only interrupt --After 24 hours use a breastfeeding if feeding combination of hand and intolerable – assist client pump expression with hand expression --Refer to RHA --Teach hand expression by breastfeeding guideline 6 hours --Information on managing engorgement (refer to 72 hr – 7 days and beyond – Engorgement) --Comfortable bra – if required --Refer to breastfeeding (variance not exclusively breastfeeding)
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Breasts
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
BREASTS AND NIPPLES
(Continued) Variance – Client conditions Variance – Mastitis --Conditions that may affect --Sudden onset of intense pain newborn feeding: --Usually in 1 breast (may be both) --Acute psychiatric condition --Breast may feel hot, appear red or have red streaks --Emotional stress and/or be swollen --Substance use --Client may experience flu like symptoms, fever of --Refer to Breast Assessment 38.5°C – conditions that may affect milk supply Intervention – Mastitis --Support Intervention – Client --Continue frequent breastfeeding – milk from Conditions affected breast is safe for infant --Careful observation of infant --Rest including feeding behavior --Express if too painful to breastfeed with support to maximize --Adequate fluids and healthy eating(refer to breast stimulation Lifestyle – Healthy Eating) --If there is a firm area, gently massage affected area (massage through feed) --Shower or warm compresses to affected area prior to feeds --After feeds – cool compresses --Analgesic --If symptoms do not resolve >24hr refer to PCP --Antibiotics may be indicated if not resolved in 24 hours
Variance – Nipple Candida (Fungus Infection) Yeast6 --Sore burning nipples --Sore all the time but worse when feeding --Deep burning/shooting pain --Itchy, flaky nipples --Tiny blisters --Deep pink/bright red nipples/areola --Client may have recently been on antibiotics or has a yeast infection (infant may have signs of Candida in mouth or perineal area)
Intervention – Nipple Candida (Fungus Infection) Yeast --Differentiate from poor latch --Frequent hand washing and washing of all items that touch breast and infants mouth --Antifungal treatment for both mother and infant may be prescribed --If using breast pads change when they become wet --Avoid use of soother
Interventions for all Variances --Assess infant feeding --Refer to primary care providers and/or individual knowledgeable in current breastfeeding practices or lactation consultant (LC)
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Breasts
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
BREASTS AND NIPPLES
The Non- Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations breastfeeding --Breasts soft, colostrum may be --Breasts soft, colostrum may be --Breasts beginning to fill, become --Breasts will start to become client present present firm and warm softer as lactation is suppressed --Small amounts of milk can Focus of Client Education / Client Education / continue to be produced for up Assessment: Anticipatory Guidance Anticipatory Guidance to one month postpartum Breast comfort --Wear supportive bra --Refer to >2 – 24 hr Intervention continuously until lactation is --Refer to >2 – 24 hr Client Education / suppressed, about 5 – 10 days --Supportive bra Anticipatory Guidance --Use of anti-inflammatory agents --Anti-inflammatory agents --Refer to >2 – 24 hr Intervention --Application of cold treatments, --Cold treatments such as gel --Refer to >24 – 72 hr such as gel packs, cold packs or packs, cold packs or cold cold cabbage leaves for comfort cabbage leaves for comfort for Variance --Avoid stimulation of the breasts 20 minutes q 1 – 4 hr --Mastitis such as heat, pumping, and sexual breast contact until Variance Intervention lacation is suppressed --Engorgement --Apply cool compresses --Small amounts of milk may be --Analgesics produced for up to a month Intervention – Engorgement in --Refer to PCP postpartum nonbreastfeeding client --Resumption of menstrual periods --Express small amounts for – as soon as 6 – 8 weeks comfort --Contraception use --Anti-inflammatory agents --Cold treatments as above Interventions --Wear supportive, well-fitting bra within 6 hours of birth --Anti-inflammatory agents --Cold treatments, such as gel packs, cold packs or cold cabbage leaves for comfort --PCP may prescribe medication to aid suppression
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Breastfeeding
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
BREASTFEEDING
Assess understanding Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal of:10-17 --Skin-to-skin contact, not --Breast offered 6 or more times in the first 24 hour Variations Variations --Breastfeeding wrapped in blanket, baby to period --Frequent cluster --Increase parental recommendations abdomen/chest right after birth --Able to latch baby to breast with minimal assistance feeding (more at confidence – importance --Maintain skin-to-skin contact --Sensitively responds to newborn feeding cues night) --Breasts soften with of exclusive until completion of the first --Client and partner/significant other aware of the --Feeds 8 or more feeding, free from breastfeeding for feeding or longer benefits of exclusive breastfeeding(no supplements times/day infection, tenderness 6 months followed --Warm blanket over mother and or use of artificial teats) and risks of human --Signs of breasts decreases by the introduction infant substitutes filling --Nipples: intact, of nutritious solids --Aware of various tenderness decreases at about 6 months Client Education / Client Education / Anticipatory Guidance newborn feeding --Complete an initial with continued Anticipatory Guidance --Refer to POS positions assessment, including breastfeeding for up --Support mother to respond to --Refer to Baby’s Best Chance --Refer to >2 – breastfeeding, within to 2 years and beyond newborn’s breast searching --Breastfeeding Practice Guidelines for Healthy Term 24 hr 48 hours of discharge --Informed decision behaviors infant12: to identify strengths making re infant --Assist with initial feed – baby’s www.wrha.mb.ca/healthinfo/prohealth/files/ Client Education / and risks, and to feeding attempt to latch and suckle at BF_Guidelines.pdf Anticipatory determine the need and --Infant feeding breast as soon as possible or --Breastfeeding your Baby2: Guidance timing of public health frequency over the 24 within 1st hour after delivery www.gov.mb.ca/healthychild/healthybaby/hb_ --Refer to >2 – 24 hr nursing and other hour period breastfeedingyourbaby.pdf --Offer both breasts community follow-up.14 --Appropriate position Variance --Medications and drugs while breastfeeding13: each feed --Refer to >2 – 72 hr and latch --Baby not placed skin-to- skin www.sogc.org/en/public-resources/en/content/public- --Correct position, --The importance of on abdomen/chest right after resources/public-resources.aspx?hkey=51a4ead6- latch, nipple shape Client Education / having support with birth c5c6-4bc4-8657-346aaeeee6cd post feed Anticipatory Guidance feeding --Baby not latching --Ensure the family understands what constitutes an --Methods of burping --Refer to 0 – 72 hr --Psychological and --Baby separated from mother effective feed --Strategies to --Breasts are full before environmental factors --Provide support: meet baby’s feeding and softer after affecting relaxation Intervention --written, verbal, visuals nighttime feeds feeding --Contraindications for --When baby stable place skin- --consistent feeding information to enable family to (without needing --After several weeks it breastfeeding – HIV, to-skin on abdomen/ chest determine if baby is feeding well – position, latch, to supplement is normal to have soft drug use, certain --Assist with latch – refer to feeding cues, unless medically breasts all the time and medications >2 – 12 hr Client Education/ --linking intake with output necessary) still have sufficient milk --Refer to: Anticipatory Guidance --Both breasts offered at each feed --Importance of human www.cps.ca/ --Discuss importance of breast --Review position, deep latch and active feeding: Variance milk: exclusive en/documents/ milk and support hand --Client comfortable-cradle, modified cradle or --Refer to 0 – 24 hr breastfeeding for position/maternal- expression if baby separated football hold, laid back nursing, lying-bring infant to --Delayed 6 months followed infectious-diseases- from parent the breast, use of pillows, and position of hands12 lactogenesis by the introduction breastfeeding11 --Encourage skin-to-skin, tummy to tummy --Explore underlying of nutritious solids --Baby’s body is aligned close to and facing mother cause such as at about 6 months Assess capacity to: --Hand holds and supports the upper back and SSRI, SNRI use with continued --Determine how shoulders, cradling the neck/base of the skull breastfeeding for up to well baby is feeding --If breast large, support breast (fingers from back of Intervention 2 years and beyond (includes feeding cues areola) --Refer to 0 – 24 hr --Breastmilk is the most and baby’s response) --Touch baby’s lips with nipple, wait until mouth open important food in the --Feed and calm baby wide first year --Identify common --Aim nipple towards the roof of infant’s mouth-the --Provide support to feeding issues and bottom lip/jaw touching the lower areolar under parents to manage concerns/ variances breast common breastfeeding that may require --More areola above the baby’s top lip than below, difficulties further support and mouth open wide, lower lip turned out, and chin --Revised Baby-friendly assessment touching breast Hospital initiative --Access resources --The baby takes slow deep sucks 201715: (e.g.- breastfeeding --You can see or hear the baby swallowing www.who.int/nutrition/ clinics, peer support --The baby’s cheeks are full and not drawn inward events/consultation- programs, drop-in during a feed protection-promotion- groups), --The baby finishes the feed and releases the breast support-breastfeeding/ --Follow-up with and looks contented. en/ primary care provider --The nipples not distorted after feeding or alternate care.
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Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
BREASTFEEDING
(Continued) --Breastfeeding Your Baby, Healthy Variance Child Manitoba: --Refer to 0 – 24 hr Refer to Newborn Nursing Care www.gov.mb.ca/healthychild/ Guidelines: Feeding healthybaby/hb_ Intervention breastfeedingyourbaby.pdf --Refer to 0 – 24 hr --Breastfeeding2 Committee for Canada, The BFI 10 Steps and WHO Code, 2017 Outcome Indicators for Hospitals and Community Health Services9: breastfeedingcanada.ca/documents/ Indicators - complete June 2017.pdf --If necessary, break suction with finger before removing from breast --Methods of burping
Variance – Not exclusively breast feeding
Intervention – Not exclusively breast feeding16 --Makes informed decision to exclusively feed with human milk substitutes (refer to human milk substitute) --Provision of supplemental feedings for medical indications --Provide information on alternative nutrition (EBM, human donor milk, human milk substitutes) --Provide information on alternative feeding methods (cup, syringe, bottle, dropper, spoon) --Support breastfeeding and hand expression and pumping --Support parents to make informed decisions on use of pacifiers and bottle teats --Provision of supplemental feedings for nonmedical indications --Clarify concerns (to support informed decision) --Provide information as above --Refer to human milk substitute feeding re: preparation, feeding, and storage --Healthy eating for infants and children: www.gov.mb.ca/healthyliving/hlp/ nutrition/children.html --Breastfeeding Hotline 204-788-8667 (in Winnipeg) --Toll free 1-888-315-9257 (outside Winnipeg) --24 hours a day/7 days per week
Variance – Baby separated from parent
Intervention – Baby separated from parent --Begin hand expression by 6 hr --Teach pumping techniques --Combine hand expression with pump2 --Client to NICU (encourage skin-to-skin if possible)
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Elimination Bowel Function
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
BOWEL FUNCTION
Assess: Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal --Return to normal --Refer to >2 – 24 hr --May or may not have a bowel movement Variations Variations bowel movement --Hemorrhoids --Refer to > 2 – 24 hrs --Normal bowel pattern Client Education / movement pattern --Bowel sounds Anticipatory Guidance For Cesarean Birth For Caesarean Birth resumed after a Cesarean --Refer to >2 – 24 hr --Bowel sounds present --Minimal abdominal Birth --Clients who are recovering well and who do not have distention For Caesarean Birth Variance complications after cesarean birth can eat and drink --Active bowel sounds --Refer to >2 – 72 hr Assess: --Refer to >2 – 24 hr when they feel hungry or thirsty present --Understanding --Flatus passed Client Education / of normal bowel Intervention Client Education / Anticipatory Guidance Anticipatory Guidance functions --Refer to >2 – 24 hr --Hemorrhoid care Client Education / --Refer to >2 – 24 hr --Capacity to self --Prevention of constipation Anticipatory monitor bowel --Discuss meds that may constipate Guidance For Caesarean Birth functions --Return of normal bowel habits --Refer to >2 – 24 hr --Refer to >2 – 72 hr --Capacity to --Nutrition, fluids, ambulation, stool softeners, laxatives identify variances --Refer to Lifestyle – Healthy Eating Variance Variance that may require --Refer to >2 – 24 hr --Refer to >2 – 72 hr further medical For Cesarean Birth --Incontinent of stool --Normal bowel assessment --Start with fluids, hunger present movement pattern not --Ensure no nausea or vomiting present Intervention resumed --Nursing Assessment Variance – Hemorrhoids --Refer to appropriate For Caesarean Birth --Large, painful hemorrhoids PCP --Refer to >2 – 72 hr
Intervention – Hemorrhoids Intervention --Nursing Assessment --Refer to >2 – 72 hr --Comfort measures --Nursing Assessment --Pain control (Refer to Pain) --May require laxatives, --Refer to appropriate PCP stool softeners etc --Refer to appropriate Variance – Episiotomy PCP --Episiotomy / 3rd – 4th° tear that may affect bowel movement For Caesarean Birth --Refer to >2 – 72 hr Intervention – Episiotomy --Nursing Assessment --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 the client has had previous GI history that could interfere with bowel function
Intervention – Bowel Sounds Absent --Nursing Assessment --Refer to appropriate PCP
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Elimination Bladder Function
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
BLADDER FUNCTION
Assess: Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal --Voiding --Refer to >2 – 24 hr --Voids comfortably – voiding qs Variations Variations comfortably prn --Some extremity edema --Able to empty bladder --Refer to >2 – 24 hr --Refer to >2 – 24 hr --No feelings of pressure or fullness --Some extremity --Postpartum diuresis and Assess client’s: Client Education / --Dysuria following catheter removal edema diaphoresis common --Understanding of Anticipatory Guidance --Postpartum diuresis and diaphoresis until the end of first normal bladder --Refer to >2 – 24 hr Client Education / week function Client Education / Anticipatory Guidance Anticipatory --Extremity edema --Capacity to self Variance --Hygiene Guidance decreasing monitor bladder --Refer to >2 – 24 hr --Encourage to void approximately every 4 hours --Refer to >2 – 24 hr functions --Use of warm water – pour over perineum prior to/ Client Education / --Capacity to Intervention during voiding Variance Anticipatory Guidance identify variances --Refer to >2 – 24 hr --Sitz baths --Refer to >2 – 24 hr --Refer to >2 – 24 hr that may require --Kegel exercises to reestablish bladder control further medical Intervention Variance assessment Variance --Refer to >2 – 24 hr --Refer to >2 – 24 hr --Unable to void --Frequent voiding, small amounts Intervention --Burning on urination --Refer to >2 – 24 hr --Urinary tract infection (UTI) --Information re: future --Pressure/fullness after voiding incontinence problems --Elevated temperature --Refer to physiotherapy --Urgency prn --Loss of or difficulty controlling bladder function --Dysuria
Intervention --Nursing Assessment --Differentiate cause of variance – UTI, not emptying bladder, superficial tears, trauma --Use measures to help void: such as ambulation, oral analgesia, squeeze bottle with warm water, running water, hands in water, blow bubbles through a straw, sitz bath, shower, teach contraction and relaxation of pelvic floor --Refer to physiotherapy --Refer to appropriate PCP prn
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Lochia
Physiological Assessment 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
LOCHIA
Assess: Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal --Amount --Fleshy smelling --Refer to POS Variations Variations --Clots --Rubra colour --Increased flow on standing, --Fleshy smelling, --Day 3 – 5: Lochia --Colour --No trickling activity or breastfeeding rubra-serosa serosa (pink/brown) --Odour --Absence of or small clots --Should not exceed moderate --Amount decreases --Day 7 – 10: Temporary --Stage of involution (< size of a loonie) range daily increasing dark red discharge (shedding of Frequency of assessments to Range on peripad width vs length: Client Education / Client Education / old placenta site) follow organization’s policy Scant < 1 inch stain Anticipatory Guidance Anticipatory --Day 10 – 6 weeks: --Light < 4 inch stain --Refer to POS Guidance Lochia alba Suggested frequency for vaginal --Moderate < 6 inch stain --Change pads q 4 h --Refer to >2 – 24 hr --Gradually decreasing birth: --Hygiene: shower daily, keep --Discourage tampon – usually subsides by --q 15 min for 1 hour Client Education / perineum clean (peri care, wipe use 4 weeks --at 2 hours Anticipatory Guidance front to back, use of peri bottle) --once per shift until d/c from hospital --Normal pattern and amount/clots --Refer to Lifestyle/Activity/Rest Variance – PPH, Client Education / --then as required by nursing --Refer to Fundus and Elimination Infection Anticipatory Guidance judgment and/or self report Variance – – bladder function --Refer to 0 – 24 hr --Refer to >0 – 72 hr Postpartum Hemorrhage (PPH) (PPH, Infection) Suggested frequency for --Saturated pad within one hour Variance – PPH, Infection Variance – PPH, caesarean birth: --Numerous, large clots (>2 large --Refer to POS Intervention – PPH, Infection --q 15 min for 1 hour clots >loonie size per 24 hours) --Lochia volume increasing Infection --Refer to 0 – 24 hr (PPH, --at 2 hours --Refer to 0 – 24 hr Infection) --q 4 h X 24 hours Intervention – PPH Intervention – PPH, Infection (PPH, Infection) --Reoccurrence of --once per shift until d/c from --Nursing Assessment --Refer to POS continuous fresh --hospital --Check presence of --Decrease activity prn bleeding --then as required by nursing --Tissue/membrane --Nursing Assessment --Lochia rubra >4 days judgment and/or self report --Frequency of clots --Refer to appropriate PCP prn --Discharge >6 weeks --Increased amount (trickling) Assess: --Refer to appropriate PCP prn Intervention – PPH, --Understanding of normal lochia Infection progression Variance – Infection --Refer to 0 – 24 hr (PPH, --Capacity to self check --Foul smell Infection) --Capacity to identify variances --Increased temperature --Nursing Assessment that may require further medical --Pain --If bleeding not assessment --Flu like signs and symptoms decreased in 6 – 8 --Refer to Variance – Infection in hours call PCP and/or ** Refer to Fundus Fundus section go to emergency --Refer to PCP prn Intervention – Infection --Nursing assessment --Refer to Intervention – Infection in Fundus section
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Perineum
Physiological Assessment 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
PERINEUM
Assess: --Refer to appropriate PCP prn Norm and Normal Norm and Normal Norm and Normal --Integrity and progression of healing Variations Variations Variations --Effectiveness of comfort measures Norm and Normal Variations --Refer to POS --Refer to >0 – 24 hr --Refer to 0 - 24 hr --Mild to moderate discomfort --Discomfort decreasing --Discomfort decreasing Frequency of assessments to follow --Perineum intact or episiotomy/tear Client Education / --Decreased use of organization’s policy - well approximated with minimal Client Education / Anticipatory analgesics (if on swelling or bruising Anticipatory Guidance Guidance narcotic switch to non Suggested frequency for vaginal birth: --Small tear may be present and not --Offer to show how to --Refer to >0 – 24 hr narcotic) --q 15 min for 1 hour sutured inspect self with mirror --at 2 hours --Refer to POS Variance Client Education / --once per shift until d/c from hospital Client Education / --Warm water sitz baths --Refer to >0 – 24 hr Anticipatory Guidance --then as required by nursing judgment Anticipatory Guidance for comfort (for example --Refer to 0 – 24 hr and/or self report --Use of comfort measures and 2 – 3 per day for short Intervention --Discuss pain relief analgesics periods), longer periods --Refer to >0 – 24 hr options Suggested frequency for caesarean --Use of ice packs to decrease may interfere with suture birth: swelling adherence Variance --q 15 min for 1 hour --Pericare – peri bottle, fresh pads, --Discontinue ice packs >24 --Refer to 0 – 24 hr --at 2 hours wipe front to back hr to decrease swelling --Pain not decreasing --q 4 h X 24 hours --Using VAS questions to assess pain (some may choose to --once per shift until d/c from hospital level and when to consult PCP continue using for comfort) Intervention --then as required by nursing judgment --Refer to 0 – 24 hr and/or self report Variance Variance – Infection --Refer to appropriate --> 4 for VB or > 5 for CS on pain --Refer to Infection (lochia/ PCP Assess client’s understanding of normal scale (may be increased with fundus sections) perineal healing episiotomy, tear, instrumental delivery (cesarean section, forceps, Intervention – Infection Assess capacity to: vacuum), internal bleeding, --Refer to Infection (lochia/ --Self check for perineal healing hematoma) fundus sections) --Identify variances that may require further --Refer to POS medical assessment Intervention --Use of a visual/verbal analogue pain scale --Nursing Assessment (VAS) and pain assessment questions --Further evaluation and management of pain ** Refer to Pain --Refer to appropriate PCP prn
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Communicable Diseases (Infections) Hepatitis B
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
HEPATITIS B
Assess status at Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal initial assessment --HbsAg (Hepatitis B Surface Antigen) --Refer to POS Variations Variations negative --Refer to POS --Refer to POS Assess: --Client and/or household member(s) not Client Education / --Understanding of from an area when Hepatitis B is endemic Anticipatory Guidance Client Education / Client Education / Hepatitis B and --No risk factors for Hepatitis B infections --For client with Hep B / household contact Anticipatory Anticipatory Guidance the risks involved (such as IV drug use, sex trade worker) with Hep B: Guidance -->2 – 24 hr --Capacity to --Knowledge of client’s Hep B status --Disease transmission -->2 – 24 hr identify variances --Breastfeeding not contraindicated Variance that may Client Education / --Early identification of infant risk for Variance --Refer to POS require further Anticipatory Guidance exposure and infant prophylaxis --Refer to POS assessments and/ --Refer to >2 – 24 hr Intervention or treatments Variance Intervention --Refer to 0 – 24 hr Variance --Refer to POS --Refer to 0 – 24 hr --Hep B status is documented on Postpartum referral form as Intervention HbsAg (Hepatitis B Surface Antigen) --Support breastfeeding positive --Early identification of risks for early --Risk factors present or infectious status intervention unknown --Client and/or household member(s) from Refer to Manitoba/RHA policy18,19 an area where HbsAg is endemic
Intervention --Refer to Manitoba Health policy
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Communicable Diseases (Infections) Hepatitis C (HCV)
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
HEPATITIS C (HCV)
Assess status at Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal initial assessment --No client risk factors for HCV are evident --Refer to POS Variations Variations --Refer to POS --Refer to POS Review status Client Education / Anticipatory Client Education / Anticipatory Guidance (from Antenatal Guidance --Refer to POS: Client Education Client Education / Record) For clients with Hep C:20 www.phac-aspc.gc.ca/hepc/pubs/gdwmn- / Anticipatory Anticipatory Guidance --HCV RNA and anti-HCV antibodies have dcfmms/viii-pregnant-eng.php Guidance -->0 – 24 hr Assess client’s: been detected in colostrum and breast --www.caringforkids.cps.ca/handouts/ -->0 – 24 hr --Understanding of milk. In multiple studies no case of hepatitis_c_in_pregnancy Variance Hepatitis C and transmission through breastfeeding has Variance --Refer to POS the risks involved been documented Variance --Refer to POS --Capacity to --Support breastfeeding (breastfeeding is --Refer to POS Intervention identify variances not contraindicated) Intervention --Refer to 0 – 24 hr that may --If nipples are cracked or bleeding, discard Intervention --Refer to 0 – 24 hr require further breast milk during this time as HCV --Basic hygiene and the disposal of potentially assessments transmitted through blood infected material should be discussed with --HCV is a blood borne pathogen and is not the patient. transmitted by urine or stool --No need for the client to alter normal child care routines and the use of gloves, masks or Variance extra sterilization is unnecessary20 --HCV evident or risk factors present --Refer to Manitoba Guideline for Hepatitis C20: www.gov.mb.ca/health/publichealth/diseases/ Intervention hepatitisc.html --Refer to >2 – 24 hrs --Refer to CPS Guideline: www.cps.ca/en/documents/position/vertical- transmission-of-hepatitis-C --Recommend client to see PCP for testing20
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Communicable Diseases (Infections) Herpes Simplex (HSV)
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
HERPES SIMPLEX (HSV)
Herpes Simplex Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal in Pregnancy --No HSV lesions --Refer to POS Variations Variations (HSV)23, 24 --Refer to POS --Refer to POS Client Education / Anticipatory Client Education / Anticipatory Guidance Assess status at Guidance --For clients with HSV: Client Education Client Education / initial assessment --Refer to 2 – 24 hrs --Support breastfeeding / Anticipatory Anticipatory Guidance --Breastfeeding is contraindicated only when Guidance --Refer to >2 – 24 hrs Review status Variance there are open lesions on the breast40 -->0 – 24 hr --Sexual Activity (from Antenatal --Lesions present and/or history of HSV --Avoid intercourse if Record) --HSV lesions not detected when there is Variance Variance lesion present an infection --Refer to POS --Refer to POS --Avoid oral sex if Assess: --Client may not know they are carrying partner has cold sore --Understanding of the virus Intervention Intervention --Condoms help but not HSV and the risks --CPS Guidelines23: --Refer to 0 – 24 hr guaranteed to prevent involved Intervention www.cps.ca/en/documents/position/ transmission --Capacity to --May require culture of lesions prevention-management-neonatal-herpes- identify variances --Refer to 2 – 24 hrs simplex-virus-infections Variance that may --Manitoba Health, Seniors, and Active Living: --Refer to POS require further Genital Herpes24: assessments and/ www.gov.mb.ca/health/publichealth/diseases/ Intervention or treatments genital_herpes.html --Refer to 0 – 24 hr --...Any HSV lesions that appear in the parent post partum should be managed with proper hand washing and contact precautions --May use antiviral drugs --Refer to PCP
Human Immunodeficiency Virus (HIV)
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
Assess status Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal at initial --No HIV present --Refer to POS Variations Variations assessment25-28 --Refer to POS --Refer to POS Client Education / Anticipatory Client Education / Anticipatory Guidance Assess client’s: Guidance --Refer to POS Client Education Client Education / --Understanding of --For clients who are HIV positive: --Nine Circlies26: / Anticipatory Anticipatory Guidance HIV and the risks --Advise not to breastfeed (in Canada) www.ninecircles.ca Guidance --Refer to 0 – 24 hr involved --Virus may be transferred in breastmilk --SERC: -->0 – 24 hr --Capacity to follow --Higher rate for postpartum infections www.serc.mb.ca/sexual-health/stis-and-hiv/ Variance through with any (wound, endometritis) hiv-aids Variance --Refer to POS current treatment --CPS: --Refer to POS --Capacity to Variance www.caringforkids.cps.ca/handouts/ Intervention identify variances --HIV present pregnant_women_who_have_hiv Intervention --Refer to POS that may --Risk factors present or infectious status --Refer to POS require further unknown Variance assessments and/ --Refer to POS or treatments Intervention --Manitoba Health, Seniors, Intervention and Active Living: --Refer to POS www.gov.mb.ca/health/publichealth/ diseases/hiv.html
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Communicable Diseases (Infections) Rubella (German Measles)
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
RUBELLA (GERMAN MEASLES)
Assess immune Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal Variations status at initial --Immune --Refer to POS Variations --Refer to >2 – 24 hr assessment29-31 --Immune to Rubella IgG antibody titre >10 IU --Refer to >2 – 24 hr Client Education / Client Education / Assess client’s: Anticipatory Guidance Client Education / Anticipatory Guidance Client Education Anticipatory Guidance --Understanding of --Refer to 2 – 24 hr --For clients who are non-immune or status / Anticipatory --Refer to >2 – 24 hr Rubella and the unknown: Guidance --If MMR is given concurrently risks involved Variance --Disease transmission --Refer to >2 – 24 hr with RhIg, rubella status needs --Capacity to --Refer to 2 – 24 hr --Immunization29: to be checked at 2 months identify variances www.gov.mb.ca/health/publichealth/ Variance that may Intervention factsheets/mmrv.pdf --Refer to >2 – 24 hr Variance require further --Refer to 2 – 24 hr --Rubella in Pregnancy31: --Refer to >2 – 24 hr assessments and/ www.caringforkids.cps.ca/handouts/rubella_ Intervention --When MMR and Rh immune or treatments in_pregnancy --Refer to >2 – 24 hr globulin given concurrently, rubella status at 2 months Variance is negative – need to be --Non-immune revaccinated with MMR --Immune status unknown --No serologic testing required after the second dose of MMR Intervention vaccine --Counsel regarding rubella vaccine --Give rubella vaccine upon care provider’s order Intervention --If mother requires RhIg and rubella vaccine, --Refer to >2 – 24 hr they may be given concurrently --Refer to adult immunization --Vaccination and Pregnancy30: clinic prn www.canada.ca/en/public-health/services/ vaccination-pregnancy.html
Varicella Zoster (Chicken Pox)
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
VARICELLA ZOSTER (CHICKEN POX)
Assess status Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal at initial --Immune --Refer to POS Variations Variations assessment30,32 --Refer to POS --Refer to POS Client Education / Client Education / Anticipatory Guidance Assess client’s: Anticipatory Guidance --Refer to POS Client Education Client Education / --Understanding of --Support breastfeeding --Disease transmission / Anticipatory Anticipatory Guidance Varicella and the (breastfeeding is not --Recommend immunization if non immune Guidance --Refer to 0 – 24 hr risks involved contraindicated) --Refer to 0 – 24 hrs --Capacity to Variance Variance identify variances Variance --Refer to POS Variance --Refer to POS that may --Not immune to Varicella or is --Refer to POS require further not immunized Intervention Intervention assessments and/ --Varicella present – indicates --Discuss immunization – refer to varicella (Immunization Intervention --Refer to 0 – 24 hrs or treatments newborn to be at high risk guide) --Refer to 0 – 24 hrs --Recommend follow-up with PCP for testing and results Intervention --Varicella30,32: --Refer to agency infection www.gov.mb.ca/health/publichealth/cdc/protocol/ control manual for isolation varicella.pdf (respiratory isolation)
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Communicable Diseases (Infections) Influenza and Influenza Like Illness (ILI)
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
INFLUENZA AND INFLUENZA LIKE ILLNESS (ILI)
Assess status Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal at initial --No signs and symptoms of --Refer to POS Variations Variations assessment33 influenza and ILI --Refer to POS --Refer to POS Client Education / Anticipatory Guidance Assess client’s: Client Education / --For clients with flu or influenza-like symptoms: Client Education / Client Education / --Understanding of Anticipatory Guidance --Wash hands thoroughly with soap and water, especially Anticipatory Anticipatory Guidance Influenza and the --Refer to >2 – 24 hr after coughing or sneezing and before eating Guidance --Refer to 0 – 24 hr risks involved --Cover nose and mouth with tissue when cough or --Refer to > 2 – 24 hrs --Capacity to Variance sneezing – discard tissue in trash Variance identify variances --Signs and symptoms of --Cough and sneeze into sleeve Variance --Refer to 0 – 24 hrs that may influenza --Avoid touching eyes, nose or mouth (infection spreads --Refer to 0 – 24 hrs require further --Fever, respiratory tract infection that way) Intervention assessments and/ --Review flu vaccine availability during fall/winter Intervention --Refer to 0 – 24 hrs or treatments Intervention months --Refer to 0 – 24 hrs --May require isolation, refer to --Seasonal influenza factsheet33: infection control www.gov.mb.ca/health/publichealth/factsheets/ --Refer to > 2 – 24 hr flu_vaccine.pdf
Variance --Refer to POS
Intervention --Refer to PCP prn --Seasonal Flu/H1N1 – respiratory hygiene/cough etiquette in health care settings33: www.gov.mb.ca/health/flu/index.html
Nursing assessment --Refer to PCP re follow-up vaccine orders prn
RH Factor
Physiological 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
RH FACTOR
Review: Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal Variations --Rh factor --Client is Rh positive --Refer to POS Variations --Refer to POS --Client is Rh negative with Rh --Refer to POS negative infant Client Education / Client Education / Anticipatory Guidance Client Education / Anticipatory Guidance Client Education / --Aware of need for testing infant and Anticipatory --Refer to >2 – 24 hr Anticipatory Guidance administration of Rhimmune globulin Guidance --If RhIg given concurrently, rubella status --Refer to >2 – 24 hr --Implications for future pregnancy --Refer to >2 – 24 hr to be checked at 2 months
Variance Variance Variance Variance --Rh negative client with Rh --Refer to POS --Refer to POS --Refer to POS positive infant --When Rh immune globulin and MMR Intervention Intervention given concurrently and rubella status is Intervention --Aware of infant’s Rh factor --Aware of infant’s Rh negative at 2 months check, need to be --Refer to >2 – 24 hr --Administer Rh immune globulin IM as factor revaccinated with MMR per PCP orders --Refer to >2 – 24 hr --No serologic testing required after the --If client has non-immune rubella status second dose of MMR vaccine29,30 and MMR vaccine is ordered by the PCP RhIg and MMR vaccine may be Intervention administered concurrently --Refer to >2 – 24 hr
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Vital Signs
Physiological Assessment 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
VITAL SIGNS
Assess: Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal --Vital signs and include history and risks --Asymptomatic --Refer to POS Variations Variations --Self report-how client is feeling related to --PO Temp: 36.7°C – 37.9°C --Refer to POS --Normal vital signs as vital signs --BP: S = 90 – 140, D = 50 – 90 Client Education / reported by client --Frequency of assessment to follow --Resp: 12 – 24, unlabored Anticipatory Guidance Client Education / organization’s policy --Pulse: 55 – 100 bpm --Refer to POS Anticipatory Client Education / Guidance Anticipatory Guidance Suggested frequency for vaginal birth: Client Education / Variance – Vital Signs --Able to self report --Refer to 0 – 72 hr --q 15 min for 1 hour Anticipatory Guidance --Refer to POS --Refer to POS --May experience --temp x 1 in 1st hour --Normal vital signs and who to --Decreased sensory and/or increase in temperature --at 2 hours contact if variances motor power to the lower Variance with milk coming --once per shift until discharge from extremities after the epidural --Refer to 0 – 24 hr down, engorgement hospital Variance block (from 2 – 5 hours --T >38°C on any --then as required by nursing judgment and/ --Chills, febrile, headache, blurred depending on the epidural 2 days Variance or self report vision, labored respirations, agent) --T >39°C any time --Refer to 0 – 72 hr light headedness, palpitations, --Epidural headache Suggested frequency for caesarean edema, vital signs outside the Intervention Intervention birth: norm Intervention – Vital Signs --Refer to 0 – 24 hr --Refer to 0 – 24 hr --q 15 min for 1 hour --Nursing assessment --temp: x 1 in 1st hour Intervention --Refer to appropriate PCP prn --resp rate: q 1 h x 12 hours (refer to --Nursing assessment anesthesia orders) --Refer to appropriate PCP prn Variance – Impairment of --at 2 hours daily living such as: --q 4 h X 24 hours --Walking --once per shift until discharge from --Mood hospital --Sleep --then as required by nursing judgment and/ --Interactions with others or self report --Ability to concentrate
Use of a visual verbal analogue pain Intervention – Impairment scale (VAS) and/or pain assessment --Nursing assessment including questions --VAS and/or questions --Further evaluation and Assess client’s understanding of her management of pain – refer to normal vitals signs anesthesiologist
Assess capacity to: --Check self/monitor --Identify variances and report if she requires further medical assessment(s)
Refer to Pain
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Psychosocial Health Bonding and Attachment
Psychosocial 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
BONDING AND ATTACHMENT
Assess: Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal --Parental supports --Parent-newborn skin-to-skin --Refer to POS Variations Variations --Parental responses contact immediately after birth --Sensitive response to newborn’s needs and --Refer to 0 – 24 hr --Refer to 0 – 24 hr to infant feeding and until completion of the first behavior cues (feeding, settling, diapering) behavior cues feed or longer --Effective consoling techniques (skin-to-skin, Client Education / Client Education / --Parental response to --Parent responds to infant cues showing face to infant, talking to infant in a steady Anticipatory Anticipatory Guidance infant crying --Parent interacts with newborn voice, soft voice, holding, rocking, feeding) Guidance --Refer to 0 – 24 hr --Parental, family and by holding (face-to-face), --Responds to early infant feeding cues (restlessness, --Refer to 0 – 24 hr --Signs of later attachment baby interaction talking, cuddling, making eye beginning to wake, hand to mouth, searching for behaviors --Risk factors for contact nipples) Variance poor bonding and --Partner/significant person --Responds to infant’s needs in a warm, loving, --Refer to 0 – 24 hr Variance attachment presence and involvement sensitive way, emotionally and physically available, --Refer to 0 – 72 hr demonstrates affection toward newborn, appears Intervention --Lack of or inconsistent Assess client’s Client Education / to enjoy interacting with newborn --Refer to 0 – 24 hr responses to newborn understanding of: Anticipatory Guidance --Partner/significant other/family interactions with feeding and behavior --Infant attachment --Bonding is a gradual process newborn and mother cues behaviors that may develop over the first --Positive relation with others (partner, support(s), --Lack of response to --Responses to infant month family members) discomfort and distress feeding and behavior --Refer to >2 – 24 hr --Refer to crying section in Newborn Nursing Care (with crying, parent may cues Pathway believe baby is crying for Variance no reason, is just spoiled Assess capacity to: Parent newborn separation Client Education / Anticipatory Guidance or is manipulating) --identify factors that --Limited parent interaction with --Parent involved in all decision making --Inappropriate or abusive enhance or interfere newborn --Activities that enhance attachment (breastfeeding, interactions with infant with attachment and --Some parents may appear skin-to-skin, involved in assessment, care, bathing, --Eye contact minimal the resources for to have less interest in infant massage, talking, singing to newborn) or lacking when infant support the newborn in the first --Positive reinforcement re parenting skills; there awake 24 hours – consider labor is growing evidence that role of parent as Refer to Newborn medication(s), exhaustion, pain, attachment figure is most influential in first few Intervention Nursing Care Pathway: intervention(s) during labor and years of infant’s life --Refer to 0 – 24 hr Crying birth and personal expectations --Involve partner/significant other as appropriate --Ways to increase – requires further assessment --Review methods of dealing with infant crying parental positive --Minimal or support(s) not --See Lifestyle-Activity and Rest, (the importance of responses available rest and night time needs of baby) --Position infant so parent --Limited interaction with and infant can see each newborn from support(s) Variance other --Minimal or no planning for --Minimal or no interaction with baby --Make eye contact taking baby home (diapers, --Lack of or inconsistent responses to newborn --Imitate the baby baby clothes, car seat) feeding and behavior cues --Refer to community --Inappropriate or abusive --Lack of response for discomfort or distress (with supports/agencies interactions with infant infant crying, parent may believe baby is crying for as appropriate and --Family history of trauma and/or no reason, is just spoiled or is manipulating) available, such as family lack of positive relationships resources, parenting --Conflictual, violent intimate Intervention programs, peer support, partner relationships --Find a parenting strength to build on as a way to public health programs reassure parents that they are doing something --Maintain open Intervention right when trying to comfort baby (even if baby relationship with family --Refer to Client Education doesn’t always calm down) >2 – 24 hr --Ways to increase parents sensitivity (cue based --Assist client to hand express interaction, discuss normal newborn growth and colostrum if separated from development) newborn --Ask parent about what they think the baby is --Encourage visiting and feeling and why skin-to-skin contact as soon as --Suggest specific comfort measures such as able if separated from newborn snuggling, rocking, soft talking, walking, singing --Refer to appropriate PCP prn --Refer to appropriate PCP, counselor, or social worker prn
22 Public Health Nursing: Postpartum Nursing Care Pathway 2019
Emotional Status and Mental Health
Psychosocial 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
EMOTIONAL STATUS AND MENTAL HEALTH
Assess:34-40 Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal Variations --Emotional response to --Support(s) present Variations Variations --Refer to 0 – 72 hr delivery and postpartum --No personal history of PPD or --Client indicates they feel --Refer to 0 – 24 hr --More knowledgeable about caring for infant and period (current and other mental illness supported --Responds to eager to learn past) --Increasing parental newborn’s needs --Assimilating infant into family life --Adjustment to Client Education / confidence and and behavior/cues --Feels supported by partner/significant other/ parenthood and Anticipatory Guidance competence in providing for feeding, crying, family friends emotional status of --Refer to >2 – 24 hr infant care settling, cuddling, --Tearful moments and mood swings up to about 2 partner/significant other --Increasing partner/ diapering weeks postpartum --Medication use for Variance significant other --Verbalizes --May feel ’blue’ mental health concerns --Excessive anxiety, fear, confidence and understanding of --NB: about 2 – 6 weeks PP begins to see infant --Predisposing/risk depression, exhaustion competence in providing PP adjustment – PP as an individual, starts to focus on issues greater factors to postpartum --Minimal or no parent/ infant care blues than those associated directly with self/infant depression (PPD) such client interaction with baby, --Moving to actively as previous prenatal, separation of client and baby Client Education / seeking help with Client Education / postpartum or other --Limited/ no support(s) Anticipatory Guidance self care; connecting Anticipatory Guidance episodes of depression, --Current symptoms or history --Encourage verbalization with and caring for --Refer to 0 – 72 hr history of anxiety with of mental illness including: of feelings and needs newborn; willing --Provide opportunity to verbalize feelings current pregnancy, depression, anxiety disorders, --Explore feelings and to learn; expresses (parenting, self esteem) family history of eating disorders, personality expectations of partner/ anxiety with --Encourage connecting with peers, new families depression, previous disorders or suicidal ideation significant other and parenting abilities and community resources35: use of antidepressants, ways of promoting www.postpartum.org significant medical or Intervention support Postpartum support International: obstetrical challenges --Assist in recognizing problems --Discuss normal www.postpartum.net --For current signs of PPD --Refer to Bonding and postpartum adjustments Best Practice Guidelines for Mental Health --For other mental health Attachment section and challenges Disorders in the Perinatal Period37: conditions such as: --Refer to appropriate PCP prn (appetite, sleep, energy, www.perinatalservicesbc.ca/Documents/ postpartum psychosis, body image, emotional Guidelines-Standards/Maternal/ schizophrenia, anxiety Variance state) MentalHealthDisordersGuideline.pdf disorders, personality --Perinatal Loss, traumatic --Discuss mood swings, Winnipeg Regional Health Authority. Perinatal disorders or suicidal labor and delivery, perinatal some are normal mental health: Quick reference for health-care ideation complications for mom and/or --Explore ways to and social service providers38: baby, illness in baby maximize rest – refer to www.wrha.mb.ca/healthinfo/prohealth/files/ Assess client’s Lifestyle – Rest Activity PerinatalMHGuide (2).pdf understanding of: Intervention Section --Discuss risk factors and signs and symptoms of --Normal postpartum --Nursing assessment and --Discuss risk factors and postpartum depression and importance of talking emotional responses emotional support signs of PPD to someone --Adjustment to --Refer to appropriate PCP prn --Provide opportunity to Mood Disorders Association of Manitoba parenthood review birth experience (MDAM)39: --Mental health www.mooddisordersmanitoba.ca/services/ conditions (see above) Variance postpartum/ --As for POS Assess capacity to: --Continued Variance --Identify variances that dissatisfaction with birth --Refer to 0 – 24 hr may require support experience --Excessive anxiety, fear, depression, infanticide and/or further medical --Negative perception of ideation assessment infant --Access support and/ Intervention or medical assessment Intervention --Refer to 0 – 24 hr and care --Refer to Bonding and --Discuss signs and symptoms of PPD and Attachment section importance of talking to someone about this. --Nursing Assessment Common symptoms during the perinatal period --Refer to appropriate include excessive worry about the wellbeing/ PCP prn safety of baby, excessive checking and --National Institute reassurance-seeking about baby, panic attacks, for Health and Care excessive worry about ability to be a good parent Excellence Antenatal Refer to www.anxietybc.com and postnatal mental --PPD assessment and use of a tool for screening health overview34: and education such as the Edinburgh Postpartum www.nice.org.uk/ Screening Tool between 6 – 8 weeks (PRN)40: guidance/cg192 www.perinatalservicesbc.ca/health-professionals/ professional-resources/health-promo/edinburgh- postnatal-depression-scale-(epds)
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Psychosocial 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
EMOTIONAL STATUS AND MENTAL HEALTH
--RNAO Best Practice Guideline (2018): Assessment and interventions for perinatal depression: rnao.ca/bpg/guidelines/assessment-and- interventions-perinatal-depression --Dr. Furer suggested another screening tool: The Perinatal Anxiety Stress Scale (PASS): www.kemh.health.wa.gov.au/~/ media/Files/Hospitals/WNHS/Our%20 Services/State-wide%20Services/WHSP/ PASSAdministrationandScoringGuidelines.pdf --SA Maternal, Neonatal & Gynaecology Community of Practice Perinatal Practice Clinical Guideline: www.sahealth.sa.gov.au/wps/wcm/con nect/3efd79004ee5509ca827add150ce4f37/Perin atal+Anxiety+and+Depressive+Disorders_PPG_ v3.0.pdf?MOD=AJPERES&CACHEID=ROOTWOR KSPACE-3efd79004ee5509ca827add150ce4f37- lNSaHYq --SA Maternal & Neonatal Clinical Network: Screening for Perinatal Anxiety and Depression Clinical Guideline: www.sahealth.sa.gov.au/ wps/wcm/connect/9050aa004eedd75ab40b b76a7ac0d6e4/Screening+for+Perinatal+A nxiety+and+Depression_Sept2015.pdf?MO D=AJPERES&CACHEID=ROOTWORKSPACE- 9050aa004eedd75ab40bb76a7ac0d6e4-moBL9Cj
Support Systems / Resources
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
SUPPORT SYSTEMS / RESOURCES
Assess:41-43 Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal --Parent’s support(s) --Refer to >2 – 24 hr --Maternal support system evident Variations Variations – partner, family, --Refer to >2 – 24 hr --Refer to >2 – 24 hr friends and Client Education / Client Education / Anticipatory Guidance community Anticipatory Guidance --Resources and supports available in Manitoba: Client Education / Client Education / --Client’s --Refer to >2 – 24 hr www.gov.mb.ca/fs/fvpp/resources.html Anticipatory Anticipatory Guidance understanding of --Resources and supports available in Manitoba: Are you Guidance --Refer to >2 – 24 hr the available family Variance in a Healthy Relationship?41: --Refer to >2 – 24 hr and community --Refer to >2 – 24 hr www.gov.mb.ca/msw/fvpp/index.html Variance resources --Families Home Page42: Variance --Refer to >2 – 24 hr Intervention www.gov.mb.ca/fs/index.html --Refer to >2 – 24 hr Assess capacity to: --Refer to >2 – 24 hr Intervention --Access family Variance Intervention --Refer to >2 – 24 hr and community --Lack of support and resources (social determinants of --Refer to >2 – 24 hr resources health) to meet needs (isolation, cultural, language) --Identify variances --Client/support(s) not aware of community resources that may require and follow up further assessment Intervention --Nursing Assessment --Review community resources with client partner/ significant other --Refer to social worker or available community resources --Refer to appropriate PCP prn
24 Public Health Nursing: Postpartum Nursing Care Pathway 2019
Family Strengths and Challenges Family Function / Dynamic
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
FAMILY FUNCTION / DYNAMIC
Assess:41-43 Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal --Interactions between family --Refer to >2 – 24 hr --Wide-ranging changes in family Variations Variations members dynamics and interrelationships --Refer to >2 – 24 hr --Refer to >2 – 72 hr --Positive/effective family Client Education / --Family exhibits positive coping strategies Anticipatory Guidance Client Education / coping skills – able to Client Education / --Strategies for coping with --Refer to >2 – 48 hr Anticipatory Guidance express concerns and ways Anticipatory Guidance crying infant --Include partner/significant other to resolve conflict --Refer to >2 – 72 hr --Perception of personal safety, Variance in care to learn ways to be --Some siblings may have --Family gradually adjusts to ask client “Is your home safe --Refer to >2 – 48 hr supportive difficulty adjusting to the new infant for you and your baby?” --Provide individualized support, birth of a new baby --Review: --History and/or signs of Intervention information and resources as --Changes that occur to intimate partner violence/ --Refer to >2 – 48 hr needed Client Education / relationships abuse --Discuss stress, time management Anticipatory Guidance --Expectations re child --Refer to Emotional Status – --Refer to >2 – 24 hr development, infant Assess client’s Mental Health Section --Sibling rivalry – ways crying, behavior understanding of --Refer to Lifestyle – Activity and to include siblings into --Infant care and feeding family dynamics and Rest Section activities --Domestic tasks interrelationships --Refer to Support Systems/ --Government of Manitoba: --Social integration into Resources Stop the Violence43: community Assess client’s capacity to: www.gov.mb.ca/ --Available supports and --Identify positive/effective Variance stoptheviolence/index.html resources coping strategies (for family --Family identified as being --For confidential help and crying infant) vulnerable or at risk – increased Variance and information on --Identify variances that may family stress, increased risk for --Refer to >2 – 24 hr domestic violence, call require further assessment family breakdown, violence in 1-877-977-0007 or TTY and support family, lack of strategies and Intervention 1-888-987-2829 supports to deal with changing --Refer to >2 – 24 hr family dynamics Variance --Refer to >2 – 72 hr Intervention --Family does not adjust well --Nursing Assessment to new infant (see above) --Refer to appropriate resources and/or PCP Intervention --Refer to >2 – 72 hr
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Follow-up in Community
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
HEALTH FOLLOW-UP IN COMMUNITY
Services accessible 7 days per Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal week --Refer to >2 – 24 hr --Prior to discharge appropriate Variations Variations arrangements are made for ongoing --If discharged <48 hr --Care provider responsible Assess client’s: Client Education / care of birth: for continuing care --Readiness for discharge Anticipatory Guidance --Complete an initial assessment, --Refer to >2 – 24 hrs is identified with --Ability to breastfeed infant – --Refer to >2 – 24 hr including breastfeeding, within 48 arrangements made by position, latch, milk transfer hours of discharge to identify strengths Client Education / mother for follow-up --Ability to feed infant human Variance and risks to determine the need and Anticipatory milk substitutes (if not --Refer to >2 – 24 hr timing of public health nursing and Guidance Client Education / exclusively breast feeding) community follow-up.14 --Refer to >2 – 24 hr Anticipatory Guidance Intervention --Refer to >2 – 24 hr Refer to: --Refer to >2 – 24 hr Client Education / Variance --Newborn Nursing Care Anticipatory Guidance --Refer to >2 – 24 hr Variance Pathway --Pregnancy, childbirth, postpartum and --Refer to >2 – 24 hr newborn care: A guide for essential Intervention --Client does not have PCP Assess understanding of: practice47 --Refer to >2 – 24 hr --Self care --Knowledge of self care Intervention --Newborn feeding including --Mobile with adequate food/fluid --Refer to >2 – 24 hr feeding cues intake --Assist in finding --Newborn care --Recognizes normal postpartum appropriate PCP changes (physical, psychosocial) and --Refer to Dr. Finder: Assess capacity to: informs PCP of abnormal findings www.gov.mb.ca/health/ --Self report --Responds to newborn’s needs familydoctorfinder/ --Breastfeed infant, identify and --Support system in place respond to infant feeding cues --Provision of community resources in Variance (position, latch, milk transfer) writing --Community resources --Feed infant human milk --Use of common resources and care unavailable 7 days per substitutes (if not exclusively paths, feeding guidelines2,47 week at community level breast feeding) --Discussion and mutual decision --Family does not seek --Identify variances that may making about ongoing contact followup as needed require further medical --Client cannot be contacted assessment Variance – no PCP or declines a visit --Access resources or follow-up --Family doesn’t have a PCP (when vulnerabilities/ with primary care provider or needs identified by care alternate medical care Intervention – no PCP providers) --Nursing Assessment --Care Provider who provides ongoing Intervention care is identified --Assist in obtaining supports Variance – Follow-up --Family may require further --Family does not seek follow-up as assessment and referrals, needed (client cannot be contacted or such as a social worker declines PHN services when contact/ visit is recommended) --No discussion and or mutual decision making about ongoing contact
Intervention – Follow-up --Notify PCP or social services prn
Variance – Infant Care --Client not able to provide newborn care due to illness, death, or infant placed in care or for adoption
Intervention – Infant Care --Support client prn and refer to appropriate HCP prn --Support the infant’s caregiver prn
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Lifestyle Activity / Rest
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
ACTIVITY / REST
Assess: Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal --Ability to manage --Refer to >2 – 24 hr --Vaginal birth: Ambulates Variations Variations instrumental activities for independently and able to rest --Refer to >2 – 24 hr --Refer to >2 – 72 hr daily living (IADL’s) Client Education / --Caesarean birth: Dangles and --Caesarean --Fatigue gradually --Ability to rest/sleep Anticipatory Guidance ambulates with assistance birth, ambulates improving --Safe resumption of physical --Refer to >2 – 24 hr independently activity program Client Education / Client Education / Variance Anticipatory Guidance Client Education / Anticipatory Guidance Assess understanding of: --Refer to >2 – 24 hr --Rest – when baby sleeping, Anticipatory Guidance --Refer to >2 – 72 hr --Night time needs of baby managing visitors --Refer >2 – 24 hr --Relationship between --Normal activity and rest Intervention --Early ambulation, safe body healthy eating and activity requirements --Refer to >2 – 24 hr mechanics Variance level – especially iron --Normal postpartum recovery --Refer >2 – 24 hr requirements, refer to Assess capacity to identify: including body mechanics --Unable to perform Healthy Eating --Night time needs of baby --Support(s) at home and in community activities of daily living --Balance between activity --Rest requirements as sleep (ADL) due to pain, and rest interrupted during the night Variance – Sleep fatigue --Care for self and meeting --Variances that may require --Unable to sleep, not ambulating needs of baby further medical assessment --Uncontrolled pain Intervention --Gradual resumption of --Refer >2 – 24 hr physical activity (safe & Use of visual verbal Intervention – Sleep --Nursing Assessment appropriate exercises) analogue pain scale (VAS) --Assess comfort level and need for --Discuss options for --Problem solving re coping and/or pain assessment analgesia or relaxation exercises support with visitors and tending questions --Nursing Assessment --Refer to PCP prn to tasks --Refer to PCP prn --Organizing household to minimize stair climbing, Variance – Calf Discomfort reaching, lifting --Calf discomfort, redness, swelling, decreased mobility – possible deep Variance vein thrombosis (DVT) --Refer to >2 – 48 hr
Intervention – Calf Discomfort Intervention --Screening for DVT via Homan’s sign --Refer to >2 – 48 hr not recommended as is not reliable --Risk of thrombosis due to activation of blood clotting factors, increased platelet adhesiveness, traumatic/ operative delivery, smoking, inactivity, medical history --Refer to PCP prn
27 Public Health Nursing: Postpartum Nursing Care Pathway 2019
Activity / Rest
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
ACTIVITY / REST
(Continued) Variance – Separated Symphysis Pubis
Intervention – Separated Symphysis Pubis --Nursing Assessment --Refer to Physiotherapy or PCP --Assist client to identify additional supports to assist with ADL and infant care --Support family --Refer to community agencies prn
Pain affecting ADL --VAS and/or questions
Norm and Normal Variations --Pain is tolerable with/ without analgesia and/or non pharmacological pain relief measures --Pain does not impact daily living such as walking, mood, sleep, interactions with others and ability to concentrate
Client Education / Anticipatory Guidance --Using VAS and/or questions to assess pain level and when to consult PCP --Client aware of comfort measures and/or analgesia including dose, frequency and effectiveness --Clients with increased pain are more apt to develop chronic pain and/or depression
Variance --Pain does impact daily living such as walking, mood, sleep, interactions with others and ability to concentrate --Pain not relieved by current analgesia and/or non pharmacological pain relief measures --Back pain (if post epidural), localized redness/ tenderness over epidural insertion site
Intervention --Pain requires further evaluation and management of pain --Nursing Assessment --Refer to appropriate PCP prn
28 Public Health Nursing: Postpartum Nursing Care Pathway 2019
Family Planning / Sexuality
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
FAMILY PLANNING / SEXUALITY
Assess client’s Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal Variations understanding --May have had tubal ligation Variations Variations --Resumption of sexual activity is variable and is when of:44-46 (TL) with C-section --Refer to >72 hr – 7 --Refer to >72 hr – 7 client is ready/comfortable --Family planning days and beyond days and beyond --May have vaginal discomfort due to decreased hormonal methods Client Education / (discussion may not (discussion may not levels, thinning of vaginal walls, decreased lubrication, --Resumption of Anticipatory Guidance be appropriate at be appropriate at sutures intercourse --Refer to >72 hr – 7 days and this time) this time) --May have decreased libido due to role overload, beyond (discussion may not be psychological, social changes, lack of sleep, hormonal Assess for client’s appropriate at this time) Client Education / Client Education / changes capacity to Anticipatory Anticipatory access/obtain Variance Guidance Guidance Ovulation may occur before menses begins: contraception prn --Refer to >72 hr – 7 days and --Refer to >72 hr – 7 --Refer to >72 hr – 7 --Lactating Clients – Breastfeeding exclusively regularly beyond (discussion may not be days and beyond days and beyond throughout the 24-hour period. appropriate at this time) (discussion may not (discussion may not --Affected by frequency of breastfeeding, use of human milk be appropriate at be appropriate at substitutes, other fluids, weaning, pacifier use Intervention this time) this time) --Non Lactating Clients – Menses may start in 6 – 8 weeks --Refer to >72 hr – 7 days and beyond (discussion may not be Variance Variance Client Education / Anticipatory Guidance appropriate at this time) --Refer to >72 hr – 7 --Refer to >72 hr – 7 --Family gradually adjusts to new infant days and beyond days and beyond --Review: (discussion may not (discussion may not --Changes that occur to relationships be appropriate at be appropriate at --Expectations re child development, infant crying, this time) this time) behavior --Infant care and feeding Intervention Intervention --Domestic tasks --Refer to >72 hr – 7 --Refer to >72 hr – 7 --Social integration into community days and beyond days and beyond --Available supports and resources (discussion may not (discussion may not be appropriate at be appropriate at Client Education / Anticipatory Guidance this time) this time) --Review Lactational Amenorrhea Method for Birth Control as per client choice – all conditions must be met 1. Infant under 6 months 2. Mother has not had menstruation return 3. Infant exclusively breastfeeding 4. No prolonged period when infant does NOT nurse >4 hr during the day and 6 hr at night --Resumption of vaginal intercourse: --Client’s sense of control and comfort (Mutually agreeable) --Lochia no longer red --Perineum healed – ongoing pelvic floor problems (follow-up with PCP) --Incision (from Cesarean) healing and comfortable --Comfort measures – lubricant, positions --Review normal sexuality PP – effects of breast feeding (potential milk ejection reflex, sensual responses to suckling infant) --Awareness of contraception choices --SOGC Sex & U44: www.sexualityandu.ca/adults/index.aspx --SERC: Sexual Health Through Education: www.serc.mb.ca/sexuality-and-relationships --Getsomecondoms.com: www.getsomecondoms.com/birth-control-and-pregnancy/ birth-control-pills/
29 Public Health Nursing: Postpartum Nursing Care Pathway 2019
Family Planning / Sexuality
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
FAMILY PLANNING / SEXUALITY
(Continued) Variance --Pain with vaginal intercourse after perineum healed --Voiced partner expectations of intercourse prior to healing of perineum/mutual agreement --STI risk if more than one partner or partner has multiple sex partners --Unaware of contraception choices
Intervention --Nursing Assessment --Refer to Client Education above --Refer to appropriate PCP prn
30 Public Health Nursing: Postpartum Nursing Care Pathway 2019
Healthy Eating
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
HEALTHY EATING
Assess:48-53 Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations --Adequate fluid and nutrient --Refer to >2 – 24 hr --Adequate fluid and nutritious --Refer to >2 – 24 hr --Refer to >2 – 24 hr intake food intake including vitamins --May require iron supplement, --Ability to consume nutritious Client Education / and folate Client Education / especially if Hgb is low food/adequate intake of Anticipatory Guidance Anticipatory Guidance vitamins with emphasis on --Refer to >2 – 48 hr Client Education / --Access to and ability to Client Education / Vitamin D and folate Anticipatory Guidance consume nutritious foods, Anticipatory Guidance Variance --Encourage small, frequent, vitamins, and folic acid to --Refer to >2 – 72 hr --Understanding of adequate --Refer to >2 – 24 hr nutritious meals meet needs and healthy eating including --Encourage to continue with --Sources of fibre include whole Variance vitamins and folate Intervention prenatal vitamins and folate grain bread, beans, lentils, --Refer to >2 – 24 hr --Capacity to access nutritious --Refer to >2 – 48 hr --Encourage to continue whole grain bread, high fibre --Not able to maintain foods (with support) vitamins with attention to cereals (100% bran) adequate fluid and nutritious --Health Canada recommends Vitamin D to maintain stores --Sources of iron include liver, food intake, may be unwell or 2-3 extra food guide during breastfeeding and red meat, deep green leafy lacking financial resources Eating well with Canada’s folate (both to optimize vegetables, legumes, dried food guides/Eating well with health for any future fruit and iron enriched foods Intervention Canada’s food guides - First pregnancies) (eating foods with Vitamin --Refer to >2 – 72 hr Nations, Inuit, Metis49,50: --Once complete prenatal C enhances iron absorption. --Refer to appropriate PCP www.canada.ca/en/health- vitamins, while breastfeeding This is especially important --Refer to community canada/services/canada- a multivitamin with 0.4mg if client is vegan or does not nutritionist food-guides.html folic acid is recommended. eat meat.) --Refer to social services and --If on iron may be constipated other community agencies Assess: Variance (refer to Elimination – Bowel providing assistance with --Ability to afford or continue --Inadequate fluid, food, Function) food security with multivitamins. I.e. A vitamins and/or folic --Continue with prenatal --Dial-a-Dietitian: multivitamin with 0.4 mg of acid intake due to lack supplements 1-877-830-2892 folic acid is recommended of knowledge, physical, --Not a time for dieting (outside Winnipeg) every day if you are: emotional or socio-economic --Impact of fatigue on appetite (204) 788-8248 --able to become pregnant factors --May be on special diet, such (in Winnipeg) --planning a pregnancy --Low Hgb as Diabetic diet --Food Security- Manitoba --pregnant or breastfeeding --Canada’s Food Guide For Government: --Folic Acid: Are you getting Intervention Healthy Eating49 Eating Well in your enough? (fact sheet)51: --Nursing Assessment --Healthy Eating - Manitoba Community52: www.canada.ca/en/ --If low Hgb consult with PCP Government: www.gov.mb.ca/health/ public-health/services/ re potential need for iron www.gov.mb.ca/healthyliving/ healthyeating/community/ publications/healthy-living/ supplement, recommend hlp/nutrition/index.html index.html folic-acid-are-you-getting- iron rich foods (eating foods --Eating Well with Canada’s enough-factsheet.html with Vitamin C enhances iron Variance Food Guide - First Nations, --Note: A prenatal absorption) --Refer to >2 – 24 hr Inuit and Métis49: vitamin isn’t needed for --Refer to appropriate PCP prn www.canada.ca/en/health- breastfeeding, a regular Intervention canada/services/food- multivitamin with 0.4mg --May require iron supplements nutrition/reports-publications/ folic acid is adequate. --If on iron may be constipated, eating-well-canada-food- refer to Elimination – Bowel guide-first-nations-inuit-metis. Function html --Refer to nutritionist or PCP --Rady Faculty of Health Sciences: Food & Housing53: umanitoba.ca/faculties/ health_sciences/medicine/ units/chs/benefits/ foodhousing.html
31 Public Health Nursing: Postpartum Nursing Care Pathway 2019
Commercial Tobacco / Drug / Substance Use
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
COMMERCIAL TOBACCO / DRUG / SUBSTANCE USE
Assess client and Norm and Normal Variations Norm and Normal Norm and Normal Variations Norm and Normal household members --Refer to >24 – 72 hr Variations --Non smoker tobacco user (as per history) Variations previous and current:54-62 --Refer to >24 – 72 hr --Client stays quit after pregnancy (if stopped --Refer to >24 – 72hr --Tobacco use history Client Education / prior to/during pregnancy) (smoking, chewing, vaping Anticipatory Guidance Client Education / --Home environment free of substances Client Education / etc status) --Refer to >24 – 72 hr and Anticipatory including second and third hand smoke Anticipatory Guidance --Use of drugs or substances smoking history and current Guidance --Refer to smoking status --Refer to >24 – 72 hr Client Education / history/status Assess understanding of: Anticipatory Guidance --Refer to >2 – 48 hr --The effects of alcohol, Variance Variance --Refer to history and current status tobacco, cannabis and other --Refer to >24 – 72 hr --Refer to >24 – 72 hr --Emphasize the importance of: Variance substances used including --Remaining substance free (or quitting) for --Refer to >24 – 72hr second and third-hand Intervention Intervention own health and that of children (smoke residue on indoor --Refer to >24 – 72 hr --Refer to >24 – 72 hr --Mantra Quit Resources54: Intervention surfaces, including clothing www.mantrainc.ca --Refer to >24 – 72hr and human skin of smokers) Smoking History/ --Smoking control and cessation: smoke prescription and non Status www.gov.mb.ca/health/tobacco/index.html prescription drugs --Manitoba Health – Smoking Control and Cessation55 Assess readiness to: --Centre for Addiction and Mental Health: --Stay quit after pregnancy (if www.pregnets.org stopped tobacco use prior to or during pregnancy) Variance – Use of Tobacco/cannabis61 --Quit smoking, tobacco use --Parent is currently using tobacco/cannabis (if a current smoker) --Parent reduced tobacco/cannabis use during pregnancy Assess capacity to: --Family is exposed to second or third hand --Identify warning signals/ smoke variances that may require --Exposure to residual nicotine from tobacco further assessment and or cannabis smoke, also called third hand action smoke presents a health hazard via dermal --Access support exposure, dust inhalation, ingestion
32 Public Health Nursing: Postpartum Nursing Care Pathway 2019
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
COMMERCIAL TOBACCO / DRUG / SUBSTANCE USE
(Continued) Intervention – Use of Tobacco Nursing Assessment --WRHA Tobacco Use and Dependence: www.wrha.mb.ca/staff/tobacco/index.php
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) and social services or PCP prn --Canadian Cancer Society P: (866) 366-3667 www.cancer.ca/en/?region=mb --MANTRA54 www.mantrainc.ca/mantra-resources.html --Cannabis --Canadian Nurses Association: CNA resources and implications for nursing care58 --The Canadian Nurses Protective Society. (2017). Cannabis for medical purposes: Legal implications for nurses. Canadian Nurse: Legal Matters, January/February. Retrieved from https://canadian-nurse. com/en/articles/issues/2017/january- february-2017/cannabis-for-medical- purposes-legal-implications-for-nurses --Smoking, vaping, cannabis, and breastfeeding – laleche league60: www.laleche.org.uk/smoking-vaping- cannabis-breastfeeding/ --Health effects of exposure to second- and third-hand marijuana smoke: a systematic review: cmajopen.ca/content/5/4/E814.full --Motherisk --Motherisk62 Helpline 1-877-439-2744 (Toll-free) 416-813-6780 (Toronto and GTA) --Alcohol and Substance 1-877-327-4636 www.motherisk.org/women/contactUs.jsp --Pregnancy & Breastfeeding Safety Guide --Motherisk Alcohol and Substance Use Helpline Pamphlet
33 Public Health Nursing: Postpartum Nursing Care Pathway 2019
Safe Home Environment
Family 0 – 2 hours >2 – 24 hours Days 2-3 Day 3 & beyond Assessment Period of Stability (POS) (>24-72 hours) (72 hours-7 days & beyond)
SAFE HOME ENVIRONMENT
Assess knowledge of:63 Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations --A safe home environment --Refer to >24 – 72 hr --Refer to >24 – 72 hr --Home environment is free --Refer to >24 – 72 hr --Safety hazards in the of environmental or safety environment Client Education / Client Education / hazards Client Education / Anticipatory Guidance Anticipatory Guidance --See CPS - Keeping kids safe: Anticipatory Guidance Assess capacity to: --Refer to >24 – 72 hr --Refer to >24 – 72 hr www.caringforkids.cps.ca/ --Refer to >24 – 72 hr --Identify variances that may handouts/kidssafe-index require action Variance Variance Variance --Address solution(s) prn --Refer to >24 – 72 hr --Refer to >24 – 72 hr Variance --Refer to >24 – 72 hr --Home contains safety hazards Intervention Intervention Intervention --Refer to >24 – 72 hr --Refer to >24 – 72 hr Intervention --Refer to >24 – 72 hr --Nursing assessment --Discuss alleviating safety hazards and refer prn
34 Public Health Nursing: Postpartum Nursing Care Pathway 2019
References 1. Berens P. Overview of the postpartum period: Physiology, complications, and maternal care. 2018 May 18, 2018. In: UptoDate [Internet]. Waltham, MA: Wolters Kluwer. last updated: May 08, 2018. Available from: https://www-uptodate-com.uml.idm.oclc.org/contents/overview- of-the-postpartum-period-physiology-complications-and-maternal-care?search=postpartum assessment&source=search_result&selectedTitle=1~150&usage_type=default&display_ rank=1#H37. 2. Healthy Child Manitoba. Breastfeeding your baby Winnipeg, MB: Healthy Child Manitoba, ; 2017 [Available from: https://www.gov.mb.ca/healthychild/healthybaby/hb_breastfeedingyourbaby.pdf. 3. Jensen D, Wallace S, Kelsay P. LATCH:A Breastfeeding charting system and documentation Tool. Journal of Obstetric, Gynecologic & Neonatal Nursing. 1994;23(1):27-32. 4. Mangesi L, Zakarija-Grkovic I. Treatments for breast engorgement during lactation. Cochrane Database of Systematic Reviews. 2016(6). 5. Wong BB, Chan YH, Leow MQH, Lu Y, Chong YS, Koh SSL, et al. Application of cabbage leaves compared to gel packs for mothers with breast engorgement: Randomised controlled trial. International Journal of Nursing Studies. 2017;76:92-9. 6. Goldfarb Breastfeeding Clinic. Candida or thrush of the nipple and breast Montreal, Quebec: The Canadian Breastfeeding Foundation 2009 [Handout]. Available from: https://www.canadianbreastfeedingfoundation.org/basics/candida_thrush.shtml. 7. World Health Organization, UNICEF. Breastfeeding policy brief Geneva: World Health Organization,; 2014 [Available from: http://apps.who.int/iris/bitstream/handle/10665/149022/WHO_NMH_NHD_14.7_eng.pdf;jsession id=110F87C988618776D28DC28AC0C46FF6?sequence=1. 8. Government of Manitoba. Getting help with breastfeeding Winnipeg, MB: Health, Seniors and Active Living; n.d., [Available from: https://www.gov.mb.ca/health/bfm/help.html. 9. Breastfeeding Committee for Canada. The BFI 10 steps and WHO code outcome indicators for hospitals and community health services Geneva: Breastfeeding Committee for Canada,; 2017 [Available from: http://breastfeedingcanada.ca/documents/Indicators - complete June 2017.pdf. 10. Government of Canada. Nutrition for healthy term infants: Recommendations from birth to six months Ottawa, ON: Health Canada,; 2013/2014 [updated 2015-08-18 Available from: https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/infant-feeding/ nutrition-healthy-term-infants-recommendations-birth-six-months.html. 11. MacDonald NE, Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Maternal infectious diseases, antimicrobial therapy or immunizations: Very few contraindications to breastfeeding Winnipeg, MB: Canadian Paediatric Society,; 2006 [updated Feb 28 2018. Available from: https://www.cps.ca/en/documents/position/maternal-infectious-diseases- breastfeeding. 12. Hamelin K, Corvino S, Dowse T, Mackay M, Kosie N. Breastfeeding practice guidelines for the healthy term infant2005 May 18, 2018. Available from: http://www.wrha.mb.ca/healthinfo/prohealth/files/BF_Guidelines.pdf. 13. The Society of Obstetricians and Gynaecologists of Canada. Medication and drugs while breastfeeding Ottawa, ON: The Society of Obstetricians and Gynaecologists of Canada,; 2018 [Available from: https://www.pregnancyinfo.ca/postpartum/postpartum/medication-and-drugs- while-breastfeeding/. 14. Manitoba Health. Provincial public health nursing standards: Prenatal, postpartum, and early childhood. Winnipeg, MB: Manitoba Health; 2015. Available from: https://www.gov.mb.ca/health/publichealth/phnursingstandards/index.html. 15. World Health Organization. Baby-friendly Hospital Initiative Geneva: World Health Organization,; n.d. [Available from: http://www.who.int/nutrition/bfhi/en/. 35 Public Health Nursing: Postpartum Nursing Care Pathway 2019
16. Manitoba Parent Zone. Eating, Winnipeg, MB: Government of Manitoba; n.d., [Available from: http://manitobaparentzone.ca/parent-or-caregiver/newborns/eating.html. 17. Government of Manitoba. Ages & stages Winnipeg, MB: Health, Seniors and Active Living; n.d. [Available from: https://www.gov.mb.ca/health/healthyeating/index.html. 18. Government of Canada. Hepatitis B: Get the facts. You can have it and not know it. Ottawa, ON: Public Health Agency of Canada; 2004 [Available from: https://www.canada.ca/en/public-health/services/surveillance/blood-safety-contribution-program/ bloodborne-pathogens-section/hepatitis.html#hepb. 19. Government of Manitoba. Hepatitis B (HBV) Winnipeg, MB: Health, Seniors and Active Living; n.d. [Available from: http://www.gov.mb.ca/health/publichealth/diseases/hepatitisb.html. 20. Robinson JL, Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Vertical transmission of the hepatitis C virus: Current knowledge and issues Ottawa, ON: Canadian Paediatric Society; 2008 [updated Feb 28 2018. 21. Government of Manitoba. Hepatitis C (HCV) Winnipeg, MB: Health, Seniors and Active Living; n.d. [Available from: https://www.gov.mb.ca/health/publichealth/diseases/hepatitisc.html. 22. Canadian Paediatric Society. Hepatitis C in pregnancy Ottawa, ON: Canadian Paediatric Society,; 2018 [Available from: https://www.caringforkids.cps.ca/handouts/hepatitis_c_in_pregnancy. 23. Allen UD, Robinson JL, Canadian Paediatric Society. Prevention and management of neonatal herpes simplex virus infections Ottawa, ON: Canadian Paediatric Society,; 2014 [updated Jan 30 2017. Available from: https://www.cps.ca/en/documents/position/prevention-management- neonatal-herpes-simplex-virus-infections. 24. Government of Manitoba. Genital Herpes (Herpes simplex) Winnipeg, MB: Manitoba Health, Seniors and Active Living; n.d., [Available from: https://www.gov.mb.ca/health/publichealth/ diseases/genital_herpes.html. 25. Government of Manitoba. Human Immunodeficiency Virus (HIV) Winnipeg, MB: Health, Seniors and Active Living; n.d., [Available from: https://www.gov.mb.ca/health/publichealth/diseases/hiv.html. 26. Nine Circles Community Health Centre. Home Page Winnipeg, MB: Nine Circles Community Health Clinic 2018 [Available from: http://ninecircles.ca/. 27. SERC. STIs and HIV Winnipeg, MB: Sexuality Education Resource Centre; 2018 [Available from: http://www.serc.mb.ca/. 28. Canadian Pediatric Society. Information for pregnant women who have HIV Ottawa, ON: Canadian Pediatric Society,; 2017 [Available from: https://www.caringforkids.cps.ca/handouts/ pregnant_women_who_have_hiv. 29. Government of Manitoba. Vaccine Factsheets and Resources Winnipeg, MB: Health, Seniors and Active Living; n.d., [Available from: https://www.gov.mb.ca/health/publichealth/cdc/div/vaccines. html. 30. Government of Canada. Vaccination and pregnancy Ottawa, ON: Public Health Agency of Canada; 2015 [Available from: https://www.canada.ca/en/public-health/services/vaccination- pregnancy.html. 31. Canadian Paediatric Society. Rubella (German measles) in pregnancy Ottawa, ON: Canadian Paediatric Society,; 2015 [Available from: https://www.caringforkids.cps.ca/handouts/rubella_in_ pregnancy. 32. Government of Manitoba. Varicella (Chickenpox) Winnipeg, MB: Health, Seniors and Active Living; n.d., [Available from: https://www.gov.mb.ca/health/publichealth/diseases/varicella.html. 33. Government of Manitoba. Seasonal Flu Winnipeg, MB: Health, Seniors and Active Living; n.d., [Available from: https://www.gov.mb.ca/health/flu/index.html. 34. National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance UK: NICE; 2014 [updated April 2018 Available from: https://www.nice.org.uk/guidance/cg192. 36 Public Health Nursing: Postpartum Nursing Care Pathway 2019
35. Pacific Post Partum Support Society. Home Burnaby, BC2018 [Available from: http://postpartum.org. 36. Postpartum Support International. Learn more Portland, Oregon Postpartum Support International; 2018 [Available from: http://www.postpartum.net/. 37. BC Reproductive Mental Health Program, Perinatal Services BC., BC Ministry of Health. Best practice guidelines for mental health disorders in the perinatal period. Vancouver, BC: BC Reproductive Mental Health Program,; 2014. Available from: http://www.perinatalservicesbc.ca/ Documents/Guidelines-Standards/Maternal/MentalHealthDisordersGuideline.pdf. 38. Winnipeg Regional Health Authority. Perinatal mental health: Quick reference for health-care and social service providers2016 May 18, 2018. Available from: http://www.wrha.mb.ca/healthinfo/prohealth/files/PerinatalMHGuide (2).pdf. 39. Mood Disorders Association of Manitoba. Postpartum Winnipeg, MB: Mood Disorders Association of Manitoba,; 2018 [Available from: http://www.mooddisordersmanitoba.ca/services/postpartum/. 40. Perinatal Services BC. Edinburgh postnatal depression scale (EPDS) Vancouver, BC: Perinatal Services BC,; 2018 [Available from: http://www.perinatalservicesbc.ca/health-professionals/ professional-resources/health-promo/edinburgh-postnatal-depression-scale-(epds). 41. Government of Manitoba. Are you in a healthy relationship? Winnipeg, MB: Status of Women; n.d. [Available from: http://www.gov.mb.ca/msw/fvpp/index.html. 42. Government of Manitoba. Families home page Winnipeg, MB: Families; n.d. [Available from: http://www.gov.mb.ca/fs/index.html. 43. Government of Manitoba. Stop the violence Winnipeg, Manitoba: Government of Manitoba,; n.d. [Available from: http://www.gov.mb.ca/stoptheviolence/index.html. 44. SOCG. Sex & U. Ottawa, ON: The Society of Obstetricians and Gynaecologists of Canada; 2018 [Available from: https://www.sexandu.ca/. 45. SERC. Sexuality & relationships Winnipeg, MB: Sexuality Education Resource Centre 2018 [Available from: http://www.serc.mb.ca/. 46. Winnipeg Regional Health Authority. Getsomecondoms.com Winnipeg, MB: Winnipeg Regional Health Authority; n.d. [Available from: http://www.getsomecondoms.com/clinic-and-condom- finder. 47. World Health Organization. Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice. Geneva, Switzerland: World Health Organization,; 2015. Available from: http://apps.who.int/iris/bitstream/handle/10665/249580/9789241549356-eng.pdf;jsessionid=40 45745E68D2EBC5D69E0EDC788B0CC6?sequence=1. 48. Healthy Child Manitoba. Making connections your first two years with baby: Formula feeding 2013 May 11, 2018. Available from: https://www.gov.mb.ca/healthychild/healthybaby/hb_ formulafeeding.pdf. 49. Government of Canada. Canada’s food guides Ottawa, ON: Health Canada; n.d. [updated 2016- 09-01. Available from: https://www.canada.ca/en/health-canada/services/canada-food-guides. html. 50. Government of Canada. The sensible guide to a healthy pregnancy Ottawa, ON: Public Health Agency of Canada n.d. [updated 2018-04-25. Available from: https://www.canada.ca/en/public- health/services/health-promotion/healthy-pregnancy/healthy-pregnancy-guide.html. 51. Government of Canada. Folic Acid: Are you getting enough? Healthy Living. Ottawa, ON: Health Canada; 2017. 52. Government of Manitoba. Healthy eating Winnipeg, MB: Health, Seniors and Active Living; n.d. [Available from: https://www.gov.mb.ca/health/healthyeating/index.html. 53. Get Your Benefits. Food & Housing Winnipeg, MB: Rady Faculty of Health Sciences; 2017 [Available from: http://umanitoba.ca/faculties/health_sciences/medicine/units/chs/benefits/ foodhousing.html. 37 Public Health Nursing: Postpartum Nursing Care Pathway 2019
54. Manitoba Tobacco Reduction Alliciance Inc. Quit resources Winnipeg, Manitoba: Mantra; 2017 [Available from: www.mantrainc.ca. 55. Government of manitoba. Quitting resources Winnipeg, MB: Health, Seniors and Active Living; n.d. [Available from: https://www.gov.mb.ca/health/tobacco/index.html. 56. Centre for Addiction and Mental Health. Pregnets Toronto, ON: CAMH; 2018 [Available from: http://www.pregnets.org/. 57. Winnipeg Regional Health Authority. Tobacco use and dependence Winnipeg, MB: Winnipeg Regional Health Authority,; n.d. [Available from: http://www.wrha.mb.ca/staff/tobacco/index. php. 58. Canadian Nurses Association. Cannabis Ottawa, ON: Canadian Nurses Association,; 2018 [Available from: https://cna-aiic.ca/en/policy-advocacy/cannabis. 59. Canadian Nurses Protective Society. Cannabis for medical purposes: Legal implications for nurses. Canadian Nurse [Internet]. 2017 May 28, 2018; January/February. Available from: https://canadian-nurse.com/en/articles/issues/2017/january-february-2017/cannabis-for-medical- purposes-legal-implications-for-nurses. 60. La Leche League GB. Smoking, vaping, cannabis, and breastfeeding W Bridgford, Nottingham: La Leche League GB,; 2018 [Available from: https://www.laleche.org.uk/smoking-vaping-cannabis- breastfeeding/. 61. Holitzki H, Dowsett LE, Spackman E, Noseworthy T, Clement F. Health effects of exposure to second- and third-hand marijuana smoke: a systematic review. CMAJ Open [Internet]. 2017 November 24, 2017; 5(4):[E814-E22 pp.]. Available from: http://cmajopen.ca/content/5/4/E814. abstract. 62. Sick Kids Hospital. Motherisk Toronto, ON: The Hospital for Sick Children; 2018 [Available from: http://www.motherisk.org/prof/index.jsp. 63. Canadian Pediatric Society. Keeping kids safe: At play, in the home, on the move, whatever the weather Ottawa, ON: Canadian Pediatric Society,; 2018 [Available from: https://www.caringforkids.cps.ca/handouts/kidssafe-index.
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Acknowledgements The development of postpartum documents has been a collaborative effort across the province.
Initial Author Perinatal Services BC developed the original documents, through the interdisciplinary consensus, and based on best evidence. From July 2017 to June 2018, the BC documents were reviewed, piloted, and adapted for PHN practice in Manitoba. The process involved the collaboration of PHNs, nursing leaders, and Manitoba Health, Seniors, and Active Living.
PHN Pilot and Sub-Group An initial meeting was convened in July 2017, as an orientation to promote consistency and understanding. Ongoing meetings were scheduled to support the pilot PHNs, to discuss use of the forms in practice, and to gather feedback for revisions. Initial revisions to the BC documents were completed by December 2017. From January to May, a sub-group of representatives from the pilot group met regularly by teleconference to continue to review and adapt the forms to the Manitoba context. This group consisted of April Gage, Alison Campbell, Crystal Nazareth, Jacqueline Brandt, and Jenna Furkalo. And Lorelei Pierce. The final review was completed during a face-to-face day long meeting on June 7, 2018. This work would not have been possible without the dedication and effort of the subcommittee. Thanks to the PHNs listed below who were instrumental in piloting these provincial tools and facilitating the process.
Name Healthy Authority Abbie Humby Northern Health Alison Campbell Winnipeg Regional Health Authority Amy Mink Northern Health Angela Bakos Northern Health April Gage InterLake Eastern Regional Health Authority April Pierre Pont Prairie Mountain Health Bonnie Watson Prairie Mountain Health Brenda Klassen Southern Health-Santé Sud Breanna Harms Prairie Mountain Health Brianne Rempel Southern Health-Santé Sud Bridigit (Erin) Murphy Northern Health Carrie McDuff Northern Health Charan Kaler Winnipeg Regional Health Authority Chelsea Giroux Prairie Mountain Health Crystal Nazarewich InterLake Eastern Regional Health Authority Heather Dowling Southern Health-Santé Sud
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Name Healthy Authority Heather Cheasley InterLake Eastern Regional Health Authority Helene Wiens Southern Health-Santé Sud Jacqueline Brandt Southern Health-Santé Sud Jeannie Marion Southern Health-Santé Sud Jenna Furkalo Prairie Mountain Health Jennifer Rank Prairie Mountain Health Jennifer Cochrane Prairie Mountain Health Jill Eggie Prairie Mountain Health Jill Klippenstein Southern Health-Santé Sud Jodi Unger Southern Health-Santé Sud Kathy Beavis Northern Health Kerry Lajambe Northern Health Kirsten Duguay Prairie Mountain Health Laurie Guilbert Prairie Mountain Health Loida Agpalza Northern Health Marcy Timchishen InterLake Eastern Regional Health Authority Maria Mackay Winnipeg Regional Health Authority Marlene Whitby InterLake Eastern Regional Health Authority M Bryant Prairie Mountain Health Melanie Foster Northern Health Michele Martel Southern Health-Santé Sud Michelle Johnson Prairie Mountain Health Monique Gauthier Southern Health-Santé Sud Lea Mutch Winnipeg Regional Health Authority Pam Noseworthy Northern Health Patricia Ladoucer InterLake Eastern Regional Health Authority Lorelei Pierce Winnipeg Regional Health Authority Ramona Doherty Northern Health Rita Watier Northern Health Ruth Unrau Northern Health Sara McNally Northern Health Sasha Conway Northern Health
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Name Healthy Authority Stacie Gardiner-Graham Prairie Mountain Health Teresa Olson Prairie Mountain Health Victoria Phillips Northern Health Zippy Shivachi Winnipeg Regional Health Authority
41 Public Health Nursing: Postpartum Nursing Care Pathway 2019