I.1. Demonstrate postpartum maternal physical assessment, compares data with norms and reports abnormal findings to physician or certified nurse midwife for the following areas:

general health (vital signs, nutrition, weight, sleep/activity level & resources)

breasts/nipples

uterus

lochia

perineum

c-section

elimination

circulatory

discomforts

affect

Refer to Guide for Postpartum Maternal Physical Assessment, Anticipatory Guidance and Health Teaching

I.2. List 3 signs and symptoms as well as client education for the following:

uterine infection

deep vein thrombosis

hemorrhage

Deep vein thrombosis: ankle or leg edema, initial low grade fever often followed by high fever with chills, pain in popliteal and lateral tibial areas, pain in entire lower leg or foot, inguinal tenderness, or pain in lower abdomen, positive Homan’s sign, pain with calf pressure, pale and cool skin Client teaching: call MD/CNM if experiencing any of these symptoms: prevention: avoid trauma to legs, encourage early ambulation, leg exercises; avoid: prolonged standing, crossing legs

Hemorrhage: excessive (saturation of more than 1 pad/hour) or bright red bleeding, a boggy uterus that does not respond to massage, abnormal clots, any unusual pelvic or rectal discomfort or backache, persistent bleeding in the presence of a firmly contracted uterus, rise in the level of the fundus of the uterus, increased pulse of decrease blood pressure, hematoma formation or bulging/shiny skin in the perineal area, decreased level of consciousness, high temperature. Client teaching: empty bladder (to allow for efficient uterine contractions,) gently massage uterus, call MD/CNM if experiencing any of these symptoms

Olds et. al, p 1119-1123, 1128.

Olds et. al, p 1139-40 and Guide for Postpartum Maternal Physical Assessment, Anticipatory Guidance and Health Teaching

Mother is attracted to her newborn, mother is inclined to nurture her infant, mother acts consistently, mother seeks information as needed, mother is sensitive to newborn’s needs, and mother seems pleased with her baby’s appearance and sex.

Olds et. al, p 452, 1049, 1107, 1126; Compendium of Postpartum Care, p. 1.14, 1.17

Vermont state statute mandates that professionals in the fields of education, child care, mental health, social services, medicine (this includes registered nurses) and law enforcement report all suspected cases of child abuse and neglect. SRS is the State agency designated by the statute to receive reports of child abuse and neglect. Child abuse and neglect takes many forms: abuse -- physical injury; emotional maltreatment; sexual abuse; neglect -- inadequate clothing, food, shelter; or health care; abandonment; and risk of harm -- substantial risk or serious physical injury or emotional maltreatment. Vermont’s child abuse statute states that mandated reporters must give an oral or written report to SRS within 24 hours if they have reasonable cause to believe that any child has been abused or neglected.

Reporting Child Abuse Helps Prevent It: Information for Professionals About Reporting Suspected Cases of Child Abuse and Neglect, Vermont Agency of Human Services, 1993

II.4. List one community resource for each of the following:

parent education

treatment of substance abuse

mental health

domestic violence

Answer depends on community.

Postpartum nursing client

The breastfeeding mother should follow the same food groups and servings as recommended while pregnant: 2-4 servings of fruit group: 3 -5 servings of vegetable group; 6 - 11 servings of bread, cereal, rice & pasta group; 3 servings of meat, fish, poultry, beans or nuts; 4 servings of milk, yogurt and cheese group; and 6 - 8 cups of liquids

suggest the mother "eat to hunger." It is recommended that lactating women consume 2700 calories per day (about 500 calories a day more than a non-pregnant, non-nursing woman), however, many nursing mothers take in closer to 220 calories per day or less

encourage mother to trust her appetite and choose nutritious foods that will help her feel energetic

the nursing mother should be encouraged to "drink to thirst." Drinking more than that is not beneficial and will not increase her milk supply

Olds et. al, p 415 and Mohrbacher & Stock, chapter 19, pages 372-373, 379

Postpartum nonnursing client

After birth the nonnursing mother’s dietary requirements return to prepregnancy levels: 2-4 servings of the fruit group; 3-5 servings of the vegetable group; ; 6-11 servings of the bread, cereal, rice and pasta group; 2-3 servings of the meat, poultry, fish, dry beans, eggs and nuts group; and 2 -3 servings milk, yogurt and cheese group

If the client has a good understanding of nutritional principles, it is sufficient to advise her to reduce her daily caloric intake by about 300 kcal . If the client has a poor understanding of nutrition, this is an opportunity to teach her the basic principles and the importance of a well-balanced diet. If the client has gained excessive weight during pregnancy (or perhaps was overweight before pregnancy) referral to a nutritionist/dietitian is appropriate.

Olds et. al, p 417 and 430

III.A.2. List at least 2 adaptations of the diet for each of the following:

breastfeeding

anemia

constipation

Olds et. al, p 415, 429 and Mohrbacher & Stock, chapter 19, pages 372-373, 379

III.A.3. Identify at least 1 community resource for each of the following:

nutrition information

food supplementation

breastfeeding support

Answer depends on community.

III.B.1. List 2 prevention or self care measures for each of the following discomforts associated with postpartum:

engorgement

uterine cramping

perineal discomfort

hemorrhoids

Uterine Cramping: lie prone with small pillow under abdomen, warm shower or sitz baths; walking

Perineal discomfort: peri-care, sitz baths, topical analgesics, ice pack

Hemorrhoids: sitz baths, topical analgesics, rectal suppositories, witch hazel pads applied directly to anal area, avoid prolonged sitting, side lying position when possible, tighten her buttocks when sitting

Olds et. al., p1073-1077 and Compendium of Postpartum Care p 1.26

A new mother should begin simple exercises such as abdominal breathing and pelvic rocking (day 1), chin to chest, and arm raises (day 2), knee rolls and buttocks lifts(day 4), abdominal tighteners and knee to abdomen (day 6). After 2-3 weeks more strenuous exercises such as sit-ups and side leg raises may be added as tolerated. Kegel exercises should be done many times daily during postpartum. A new mother should avoid heavy lifting, excessive stair climbing and strenuous exercise.

Olds et. al. p. 1077-1079

lochia flow

perineal discomfort, discomfort from episitomy or laceration, discomfort from c-s incision

dryness of the vagina

baby’s crying may spoil the mood

woman or partner may be uncomfortable with woman’s changed body

maternal sleep deprivation, fatigue decreased libido or other changes in the woman’s physiologic response to sexual stimulation

escape of milk during sexual activity

breast engorgement and tenderness

Sexually Transmitted Diseases

Hepatitis B

HIV/AIDS

Syphilis

Gonorrhea

Chlamydia

Genital Herpes

Genital Warts (Human Papilloma Virus)

Methods of Prevention

Limit the number of sexual partners, preferably to one

Use condoms and spermicide with a new partner or any partner who has multiple sexual contacts

Avoid intercourse when you or your partner has lesions (genital herpes)

If infection (such as gonorrhea, syphilis or chlamydia) is present, complete antibiotic therapy and return to health care provider for follow-up

Blood borne pathogens such as Hepatitis B and HIV can also be spread through contact with infected blood so avoid practices such as sharing needles and use universal precautions if working in jobs that place you at higher risk of coming in contact with blood or body fluids

Obtain vaccination against Hepatitis B

IV.A.1. Demonstrates newborn physical assessment, compares data with norms, and reports abnormal findings to physician or certified nurse midwife for the following areas:

general health (sleep, feeding, elimination, cry, alertness, respirations, temperature, apical pulse)

newborn screening

movement (muscle tone, symmetry)

jaundice

hydration

umbilicus

circumcision

Refer to Guide for Newborn Physical Assessment, Anticipatory Guidance and Health Teaching, August 1997.

36.5 C - 37.5 C or 97.8 F - 99.5 F

Guide for Newborn Physical Assessment, Anticipatory Guidance and Health Teaching, August 1997, p 7

10% weight loss for first 3 days.

Guide for Newborn Physical Assessment, Anticipatory Guidance and Health Teaching, August 1997, p 7

IV.B.1. List 3 signs and symptoms for each of the following newborn problems:

sepsis

hypoglycemia

respiratory distress

dehydration

Hypoglycemia: Lethargy, jitteriness, poor feeding, vomiting, pallor, apnea, irregular respirations, respiratory distress, cyanosis, hypotonia, possible loss of swallowing reflex, tremors, jerkiness, seizure activity, high-pitched cry. (Olds, p 1013)

Respiratory distress: Tachypnea, grunting respirations, retractions, nasal flaring, cyanosis (Guide, p. 16)

Dehydration: Abnormal elimination pattern, weight loss, skin turgor dry and non-elastic (tenting of skin), depressed fontanel, sunken eyes (Guide, p 6, 9

IV.B.2. Describe the physical findings of neonatal jaundice that would indicate a pediatric health care provider referral as it relates to:

onset

progression/course

behavioral symptoms

Onset: jaundice appearing during the first 24 hours of life.

Progression/course: jaundice progressing from head, downward to trunk and extremities and sclera of eyes. Intensity persists or increases.

Behavior: poor suck, eating less, irritability, vomiting, decreased activity, sleep for long periods

Guide for Newborn Physical Assessment, Anticipatory Guidance and Health Teaching, August 1997, p 8

Guide for Newborn Physical Assessment, Anticipatory Guidance and Health Teaching, August 1997, p 5

V.B.1. List 3 cues of overstimulation of the newborn.

V.B.2. List 3 techniques of supporting an infant in quieting and coming into an alert state.

V.B.3. Lists 3 factors that promote healthy brain development in the first 3 years of life.

V.C.1. List at least 1 preventive measure for each of the following:

car safety

environmental tobacco smoke

shaking or other inappropriate handling

sleep safety (positioning, bedding, and crib)

How to Protect Your New Baby in the Car, National Highway Traffic Safety Administration, 4/97 and Children are Depending on You to Buckle’Em Up Properly! Governor’s Highway Safety Commission, Vt

Environmental tobacco smoke

Suggest the family create a smoke-free zone around the baby (home, car, child car, relatives & friends, etc.)

If the mom or other family member smokes, encourage them to quit

Encourage the family to choose baby-sitters that don’t smoke and won’t allow others to smoke in the home or around the baby

Encourage family to avoid crowded smoky places

Environmental Tobacco Smoke: A Danger to Children, American Academy of Pediatrics

Shaking or other inappropriate handling

Provide parents and other caregivers with tips on how to deal with "feeling out of control" when nothing seems to comfort their child such as leave the baby in a safe, secure place, take deep breaths and count to 10.

For parents of babies that cry alot, encourage them to get help from family , friends, or neighbors

Encourage parents to use community resources such as the Parents Assistance Line for help

Never Shake a Baby, Prevent Child Abuse-Vermont

Sleep safety

Place baby on back to sleep unless the baby has a health condition that requires sleeping on the tummy

Crib slats are spaced no more than 2 3/8 inches apart

Mattress fits snugly - less than two fingers width between edge of mattress and crib side

Remove pillows, quilts, comforters, sheepskins, stuffed toys and other soft products from the crib

Do not place baby on a waterbed, sofa, soft mattress, pillow or other soft surface to sleep

Consider using a sleeper as an alternative to blankets, with no other covering. If using a blanket, put baby with its feet at the foot of the crib. Tuck a thin blanket around the crib mattress, only as far as the baby’s chest. Make sure your baby’s head remains uncovered during sleep.

Corner posts are no higher than 1/16 inch to prevent entanglement of clothing, etc.

Do not place a crib near draperies or blinds where a child could become entangled and strangle on cords

Back to Sleep Campaign, 6/98 ; Tips for Your Baby’s Safety, Consumer Product Safety Commission and CPSC April 1999 Recommendations Revised to prevent Infant Deaths from Soft Bedding

V.D.1. List recommended immunizations for a 2 month old using the Department of Health Immunization Schedule.

Refer to Vermont Department of Health Immunization Schedule 6/98

Refer to Vermont Department of Health Periodicity Schedule 10/98