ࡱ> <>9:;q *bjbjt+t+ 0AA6]8888888LLLL8LL xx@2P P $ & 8 88x"88LL888888l  LL" COMPREHENSIVE PERINATAL SERVICES PROGRAM POSTPARTUM PROTOCOLS  Postpartum Assessment - PROTOCOLS The CPSP program is based on the concept that services will be provided in partnership with the woman and her family. The full scope of CPSP services is listed in the CPSP Provider Handbook (Handbook) on page 2-1. The Combined Postpartum Assessment tool permits the CPSP practitioner to assess the clients strengths, identify issues affecting the clients and her babys health, assess her readiness to take action, and select resources needed to address the issues. This information, along with the information from the medical postpartum assessment, is used, in consultation with the client, to develop a Plan. The combined assessment is ideal for those practice settings in which one CPSP practitioner is responsible for completing the clients postpartum assessment. It does not preclude discipline specialists from providing needed services to the client. PROCEDURES/PROCESS: The Combined Postpartum Assessment tool is designed to be administered by a qualified CPSP practitioner (CPHW or other). Refer to the CPSP Provider Handbook, pages 2-35 through 2-37 . Familiarize yourself with the assessment questions and the clients medical record before completing the assessment. The setting should allow for adequate privacy. Cultural customs and practices should be taken into consideration for each client. Inclusion of other family members must be evaluated on an individual basis, depending on the issues identified during the prenatal period. For example, domestic violence situations would indicate to the CPHW that the clients partner should be tactfully excluded from the assessment setting. Keep educational materials, visual aids, etc. readily available to promote a fluid exchange of information with the client. This also prevents wasted time looking for or copying materials. Before beginning, explain the purpose of the assessment and how the information will benefit the woman, her baby and her Primary Care Provider (PCP) in providing her with health care. Be certain to tell her that the assessment is intended to help her achieve her optimum health. Explain the confidentiality of the assessment process. State clearly to the woman that all child abuse/neglect must be reported to the proper authorities. Refer to reporting requirements related to domestic violence described in detail after question 103 in the Prenatal Assessment/Reassessment Protocol. Everything else is confidential and is shared only with her health care team or with her prior consent. Explain that you will be taking notes as you go along. You can offer to share the notes when the interview is complete if it would increase her comfort level. Try to maintain a conversational manner when asking the questions on the form. The first few times you use the assessment, you may want to read the questions as they are written on the form. As you become more comfortable with the content of the assessment, you can adopt a more conversational style. Questions should be asked in a manner that encourages dialogue and development of rapport. Sensitive questions should be asked in a straightforward, nonjudgmental manner. Most clients will be willing to provide you with the information, especially if they understand the reason for the question. Be aware of your body language, voice and attitudes. Explain that the clients answers are voluntary, and she may choose not to answer any question. Ask related, follow-up questions to explore further superficial or conflicting responses. If the client has limited English-speaking abilities and you are not comfortable speaking her preferred language, arrange, if possible, to have another staff member with those language capabilities complete the assessment. If such a person is not available, the CPSP practice should have the ability to make use of community interpreting services on an as-needed basis. As a last resort the client may be asked to bring someone with her to translate; it is not appropriate to use children to translate - a trusted female, rather than even her partner, may be more appropriate. Telephone translation services should only be considered as a last resort for very limited situations. Become familiar with the behaviors acceptable to the ethnic and cultural populations served in your CPSP practice. Make sure the assessment is offered in a culturally sensitive manner. When you are unsure, ask the client about ways you can help increase her comfort level with the process. For example: Is there anything I can do to make this more comfortable for you? Adolescents possess different cognitive skills than their adult counterparts. It is important to understand the normal developmental tasks of adolescence and relate to your clients based on their individual developmental stage. Early adolescents are concrete thinkers. If they dont see it, feel it, or touch it, for them it does not exist. Middle adolescents start to develop abstract thinking. They have the ability to link two separate events. Cause and Effect. If I do this, that will happen. Late adolescents can link past experiences to present situations to predict future outcomes and influence their present behaviors. Two years ago I did this, that happened; if I do the same thing today, what happened two years ago will happen again. A teens ability to think, reason and understand will influence her health education needs. When the assessment is completed, pay particular attention to the answers that are shaded in the Postpartum Protocols; they are the ones most likely to need interventions and/or be included on the Plan. Generally they will require follow-up questions by the practitioner to determine the actual need and most appropriate intervention(s). Answers to unshaded responses and/or open-ended questions are important in that they provide additional information about the clients strengths, living situation and resources that will be important to consider when developing a Plan. At the completion of the interview, summarize the needs that have been identified and assist the client in prioritizing them. Work with her to set reasonable goals and document them on the Plan. Goals included in the Plan should begin with statements such as, The client will ..., or The client agrees to.... When applicable, the name of the staff member responsible for providing additional assessments, interventions or referrals, as well as the timeline for completion, should be included. DOCUMENTATION: Refer to STT Guidelines: First Steps - Documentation, page 11. Make sure there is some documentation for every question. If the question does not apply, indicate that by writing N/A. If the client chooses not to answer a question, note that: declines to answer. All notes and answers on the assessment should be legible and in English. The completed assessment tool must be included as a part of the clients medical record. All problems identified during the assessment should indicate some level of follow-up. Follow-up may range from a problem and planned interventions noted on the Plan, to notations on the assessment form and/or brief narrative that indicates immediate intervention was provided or that the issue is not one the client chooses to address at this time. Written protocols should be followed for intervention and referral. For clients with numerous and/or complex problems/needs, be sure to indicate the priority of each problem listed on the Plan. Problems which are particularly complex and/or will require the immediate attention of the clients PCP should be communicated by telephone conversation between the obstetric provider and the PCP. All assessments should be dated and signed with at least the first initial, last name, and title of the person completing the assessment. Use only those abbreviations your facility has approved. Indicate resolution of issues/problems identified prenatally, as appropriate, on the Individualized Care Plan (ICP). Time spent in minutes should be noted at the end of the assessment; indicate only time spent face-to-face with the client. Be sure to complete any billing or encounter data forms required. Photocopy the Combined Postpartum Assessment when all information is available. Send the copy to the clients PCP. If the record is sent by FAX, it is important to have specific instructions from the PCPs office in order to safeguard the clients right to confidentiality. Name: DOB: Date: _____________ I.D. No. Health Plan: _______________ _______ Provider: ______________________ Delivery Facility: ____________________________ Every attempt should be made to obtain the delivery record from the hospital, birth center, or other source. Review the delivery record for relevant information prior to conducting the postpartum assessment. Anthropometric: 1. Height2. Desirable Body Wt. HeightAges 19-34 (in pounds)Ages > 35 (in pounds)41092-12141195-1245098-128108-13851101-132111-14352104-137115-14853107-141119-15254111-146122-15755114-150126-16256118-155130-16757121-160134-17258125-164138-17859129-169142-183510132-174146-188511136-179151-19360140-184155-19961144-189159-20562148-195164-21063152-200168-21664156-205173-222 Source: United States Department of Agriculture and United States Department of Health and Human Resources, 1985 and 1990.  3. Total Pregnancy Wt. GainSee prepregnant weight at question 59 of the Prenatal Combined Assessment/Reassessment. Subtract this prepregnant weight from the last recorded weight measurement prior to delivery. Enter that number as the total pregnancy weight gain. 4. Weight this visit: 5. Prepregnant weight: 6. Postpartum Wt. GoalAssist the client in determining a reasonable one year weight goal based on her height and weight using the table above, and a recommended weight loss of no more than 1-2 pounds per week. Enter that weight goal at question 6. 7. Weeks Postpartum this Visit ________ Biochemical Blood:Date Collected:8. Hemoglobin:(<10.5)9. Hematocrit:(<32)Other: Blood tests are used to screen for problems such as anemia. Anemia can contribute to feeling fatigued and not able to manage the demands of parenting a newborn. Clients who are anemic are considered a priority for WIC, and receive additional nutrition counseling. Intervention: Abnormal values need to be brought to the attention of the provider. The Plan (at the end of the Combined Postpartum Assessment tool) must describe the interventions intended to address these needs. Urine:Date Collected: 10. Glucose:+-11. Ketones: +-12. Protein: + -Other: A client who developed diabetes during her pregnancy must have a 2-hour 75-gram oral glucose tolerance test 6 weeks or more after the baby is born and every year after that to make certain her diabetes has gone away and has not recurred. These clients are at risk for developing Type 2 diabetes later in life and should also receive preconceptional counseling related to their diabetes prior to becoming pregnant again. Intervention: Bring all abnormal values to the attention of the medical/obstetrical provider. Provide the client who has had gestational diabetes with a copy of STT Guidelines: Gestational Diabetes: Handout E: Now That Your Baby Is Here. Stress the importance of obtaining a checkup and preconceptional counseling prior to becoming pregnant again. 13. Blood Pressure: /Comments:Normal blood pressure values are: Systolic: <130 mm Hg Diastolic: < 85 mm Hg Intervention: Call all abnormal values to the attention of the medical/obstetrical provider. The Plan must describe the interventions intended to ameliorate or resolve hypertension. Clinical - Outcome of Pregnancy 14. Date of Birth:15. Gestational Age:16. Pregnancy/Delivery 17. Birth Weight:(gms) 18. Birth Length: (cm) Complications:19. Current Weight: (gms)20. Current Length: (cm)Apgar Scores: 1 min: 5 min: 21. Type of Delivery: (circle) NSVD VBAC Vacuum Forceps C-Section ( Primary or Repeat ) ( LTCS or Classical ) Information to complete questions 14-18 and 21 should be readily available from the delivery record. For questions 19 and 20, if pediatric record is not readily available, ask the client for this information based on the babys most recent visit to the pediatric provider. If the information is obtained through asking the client, indicate this: by mothers report. If the baby has not yet been to a CHDP provider or the mother cannot recall, document this as well: not available. Intervention: Any infant more than two weeks old who does not weigh more than she/he did at birth should be referred to a pediatric provider if follow-up care is not in place. Clients who delivered their infants prematurely (less than 36 weeks gestational age) should be referred to the provider or health educator for preconceptional counseling/anticipatory guidance prior to becoming pregnant again. Clients who delivered by primary (first) c-section should be referred to the provider or health educator for counseling related to VBAC prior to becoming pregnant again, depending on the reason for c-section and type of incision. Maternal:Infant:22. Have you had your postpartum check up?( Yes Date: 24. Has infant had a newborn check-up? ( If No,when scheduled? ( If No,when scheduled? 23. Any health problems since delivery? ( If Yes, any Problems? ( No( If Yes,please explain:25.Number of NICU Days: 26.Infant exposure to: (circle all that apply) Tobacco Alcohol Drugs This grouping of questions offers an opportunity to discuss the clients delivery experience and the questions or concerns she has related to her perceptions of her labor and delivery. Discrepancies between the clinical information and the clients perception may indicate a health education need to assist her in establishing realistic connections between actions and outcomes. For example: A new mother who believes her babys cleft palate was caused by drinking one alcoholic beverage during her pregnancy needs to be reassured that this cause-effect relationship is very unlikely. A new mother who drank alcoholic beverages excessively during pregnancy and does not believe her babys fetal alcohol syndrome (FAS) was caused by her alcohol consumption needs to be educated about the direct relationship between consuming alcohol during pregnancy and FAS as preconceptional counseling. Interventions: All health problems should be brought to the attention of the provider. If no postpartum checkup appointment has been scheduled at the time of the postpartum CPSP support services assessment, schedule one for the client before she leaves. Encourage the client to ensure her baby receives all checkups and immunizations as recommended by the pediatric provider. If the baby has not been seen by a pediatric provider and no appointment is scheduled at the time of the postpartum CPSP support services assessment, schedule one for the baby before the client leaves. Provide the client with referrals and/or resources appropriate to her needs and those of her baby. Anyone can refer children with special medical needs to California Children Services. All infants born to HIV+ women should be referred. Contact the appropriate health plan for assistance with making the referral: Health Nets Provider Inquiry Line:(800) 675-6110L.A. Care Provider Inquiry Line:(800) 452-2273 Refer managed care members to the appropriate Member Service Department for assistance in locating a pediatric provider and establishing a medical home for her baby. Client should be directed to discuss public and community resources (such as Early Start, California Children Services, Regional Centers, High Risk Infant Follow-up, Healthy Infant Program) available to assist her with meeting the needs of any infant with physical disabilities or developmental delays. Resources: Health Net Member Service Department:(800) 675-6110L.A. Care Member Service Line:(800) 452-2273 Nutrition Maternal Dietary Assessment 27. Nutrition Assessment Summary For ___ Day(s) Servings/ Suggested Food Group Points ChangeDietary Goals: _______________ Protein+ -Client agrees to:Milk Products+ -Breads/Cereals/Grains+ -Vit. C-rich fruit/veg+ -Vit. A-rich fruit/veg+ -REFERRALS:(WICOther fruit/veg+ - Date Enrolled:Fats/Sweets+ -( Food Stamps ( Emergency Food ( AFDCb.)Diet adequate as assessed:( Yes( No ( Referred to Registered Dietitian The purpose of question 27 is to summarize the data on the dietary intake form (PFFQ or 24-hour recall). Administer the Perinatal Food Frequency Questionnaire (a 24 hour recall is also an acceptable dietary assessment technique, but requires that the assessor be adequately trained in the amounts of each food/food group that constitute a serving, and is not the recommended assessment unless the assessor has received such training). Section A, Nutrition Assessment Summary: Add up the total for foods eaten daily and multiply that total by 7. This gives the total of points for foods eaten daily. Add up the numbers for foods eaten from the weekly column (foods eaten on 1 to 6 days per week). Add this number to the weekly foods number for each food group and write this total in the Servings/Points column next to the appropriate food group in the Nutrition Summary box. Circle the word points if the Perinatal Food Frequency Questionnaire was used and the word servings if a 24 hour recall was the assessment technique used. Compare the clients totals to those listed in the table below. Section B, Diet Adequate: After completing Nutrition Assessment Summary - Section A: Diet is low in total protein only if the combined points of groups 1 and 2 are less than 35 for breastfeeding women and 22 for bottle feeding women. A star (*) next to a food (on the PFFQ) indicates that it is high in folic acid. The clients diet may be low in folic acid If the total for all starred foods is less than 7. A triangle next to a food indicates that the food is high in unsaturated fats. The clients diet may be low in unsaturated fat if the total for all triangle foods is less than 3. Intervention: Provide the client with a copy of STT Guidelines: Nutrition -The Daily Food Guide for Pregnancy, page 28. Make suggestions to the client to increase servings from any food group of which she is eating less than the recommended servings. Advise the client to eat the recommended number of servings from any food group of which she is eating more or less than the recommended number of servings. For other foods on the PFFQ, encourage intake in moderation. Circle the (+) or (-) and enter the number of additional or fewer servings of each food group you have recommended to the client. If the client is high risk nutritionally (lacking the minimum number of servings from 2 or more food groups after nutrition education has been offered), refer her to a registered dietitian or other appropriate nutrition counselor and check the appropriate box. Review STT Guidelines: Nutrition - The Daily Food Guide for Pregnancy, page 28, with the client. Provide the client with a copy and review with her STT Guidelines: Nutrition-Handout C: Choose Healthy Foods to Eat. DIETARY INTAKE EVALUATION (Assessment of the Perinatal Food Frequency Questionnaire) Breastfeeding: GROUPFOODPOINTS NEEDEDSERVINGS/DAYMAJOR NUTRIENTS1PROTEINS213PROTEIN, IRON, ZINC2MILK213CALCIUM, PROTEIN, VITAMIN D3BREADS, GRAINS497CARBOHYDRATES, B VITAMINS, IRON4FRUITS/VEGETABLES71VITAMIN C, FOLIC ACID5FRUITS/VEGETABLES71VITAMIN A, FOLIC ACID6FRUITS/VEGETABLES213CONTRIBUTES TO INTAKE OF VITAMINS A & COTHERFATS AND SWEETSN/A3VITAMIN E Bottle Feeding: GROUPFOODPOINTS NEEDEDSERVINGS/DAYMAJOR NUTRIENTS1PROTEINS142PROTEIN, IRON, ZINC2MILK142CALCIUM, PROTEIN, VITAMIN D3BREADS, GRAINS426CARBOHYDRATES, B VITAMINS, IRON4FRUITS/VEGETABLES71VITAMIN C, FOLIC ACID5FRUITS/VEGETABLES71VITAMIN A, FOLIC ACID6FRUITS/VEGETABLES213CONTRIBUTES TO INTAKE OF VITAMINS A & COTHERFATS AND SWEETSN/A3VITAMIN E 28. Infant Method of Feeding:( Breast( Bottle(Breast & Bottle# Wet diapers/day? ___ Type of Formula: With iron?( Yes( No _____oz.. _____times/day Breast and bottle feeding are discussed in detail in the Health Education section at question 35. Psychosocial 29.Do you feel comfortable in your relationship with your baby?(Yes(NoAny special concerns? 30.Are you experiencing postpartum blues?(No (Yes 31. Have your household members adjusted to your baby?(Yes(No 32. Has your relationship with the babys father changed?(Yes(No Questions 29-32 provide the assessor with information about the clients feelings related to her new baby, her support system, her ability to cope with sleep deprivation and the demands of parenting a newborn, her own assessment of her parenting abilities, and other stressors that may be present at this time. Both responses to question 32 are shaded. Either a change or lack of change in a relationship may be positive or negative depending on the circumstances. Refer to STT Guidelines: Psychosocial - Parenting Stress, pages 44-48; Spousal/Partner Abuse, pages 53-59; Emotional or Mental Health Concerns, pages 73-76; and Depression, pages 77-81. Additional information is also available in the Prenatal Combined Assessment/Reassessment Protocols. Interventions: If appropriate, provide and review with client a copy of STT Guidelines: Psychosocial - Handout I: How Bad Are Your Blues?. Inform the provider about any client who may be clinically depressed. She may need a thorough medical and psychiatric evaluation to determine an accurate diagnosis and the best possible course of treatment. Immediate referral to a clinical supervisor or medical/obstetric provider is required for any client who expresses directly or indirectly a wish to die or concern that she may hurt herself or her baby. Other referrals as appropriate. Referral: Psychosocial professional for assessment Religious community In-home support, such as Public Health Nursing Resources: Psychosocial Consultant:National Institute of Mental Health: 800-421-4211Domestic Violence Hotline: 800-799-7233  33. Do you have the resources to assist in maximizing the health of you and your baby?(Yes( If No,indicate where need exists: (circle all that apply)HousingFinancialFoodFamilyThe status of the clients resources may have changed since the birth of her baby. This question allows the assessor to determine the clients need for and knowledge of available resources for housing, food, medical care, and family support. Refer to STT First Steps: Making Successful Referrals, page 7, Women, Infants and Children (WIC) Supplemental Nutrition Program, pages 9-10; and STT Guidelines: Psychosocial- Financial Concerns, pages 28-34. Intervention: When making referrals, ask the client if she thinks she will have any difficulty in following through. Explain the benefit, describe the process of the referral and praise the client for taking care of herself. Anticipate barriers to follow-through - can she take notes?. . . does she have a map?. . . a bus schedule?. . . a calendar? . . . a clock? . . . Provide anticipatory guidance. Do your best to make appropriate referrals and encourage her to accept them. Referral: Local WIC program if client is breastfeeding. Other items need to be evaluated individually. Resources: Public Assistance: Food Stamps, CalWORKS and General Assistance: Los Angeles County Department of Public Social Services: 12860 Crossroads Parkway South, City of Industry 91746 (562) 908-8333 SSI:GAIN: Community Resources: Emergency Food:Nonemergency Food:Emergency Housing:Local WICOther: 34. Outstanding issues from Prenatal Assessment/Reassessment: Refer to the ICP for any psychosocial issues that were unresolved prior to delivery and note them here. Be sure to include all outstanding issues on the Plan, along with the interventions proposed to ameliorate or resolve them. Assess behavioral changes made during pregnancy and whether client continutes to maintain healthy habits postpartum (ie.: smoking, drug, alcohol cessation) Health Education 35.If breastfeeding:Do you have enough milk?(Yes(NoDo you supplement with formula?(Yes(NoDoes your baby take the breast easily?(Yes(NoAre your nipples cracked and/or sore?(Yes(NoDo you have any questions about breast feeding?(Yes(NoBreastfeeding is the best way to feed a baby in most circumstances. Breast milk supply is determined by how often the baby breastfeeds. A woman who tries to breast- and formula feed her baby may have problems maintaining her breast milk supply. About half the mothers who start breastfeeding will still be nursing at 6 weeks postpartum. This is the time to help clients picture breastfeeding working for them over the long term. Refer to STT Guidelines: Nutrition - Breastfeeding, pages 122-131. Interventions: If the client is breastfeeding, ask her about her breastfeeding experience. What does she like? With what is she having difficulty? Use her responses as a guide for what to discuss further. Cracked, sore nipples are most commonly a result of improper positioning of the babys mouth on the mothers breast. Utilize educational materials which specifically address positioning if the client complains of sore or cracked nipples. Respect the clients infant feeding choices. Offer needed support and direction for the method the client chooses. As appropriate, provide and review with the client copies of STT Guidelines: Health Education - Infant Feeding - Decision-Making, pages 99-100 and Nutrition - Handout EE: Going Back to Work or School. Assessment and Management of Persistent Breast Soreness Cracked NipplesPlugged DuctsMastitisCandidal InfectionAggravating FactorsUse of soaps, oils, ointments; incorrect positioningEngorgement; poor letdown: decreased nursing; tight clothing, stress, fatigue, caked secretionsCracked nipples, plugged ducts, incomplete emptying, and stress and fatigue leading to decreased resistanceMaternal antibiotics; maternal vaginal moniliasis, infant thrush, candidal diaper dermatitisSymptoms/ Physical FindingsPainful cracks (subepithelial petechiae may be first sign)Swelling, redness, or painful lump in one area of the breastLocalized tenderness, flu-like symptoms: fever, malaise, nausea and vomitingIntense, sharp burning pain when nursing; nipple may look normalTreatmentGeneral measures for sore nipples: emphasis on heat treatment; if not effective, use of a nipple shield temporarily; referral to lactation consultant or clinician; acetaminophen or short-acting codeine prior to nursing; as a last resort, hydrocortisone ointment to nipple after feeding; if nursing stopped, encourage pumping or expressingApplication of hot compresses; breast massage; frequent change of infant position; soaking nipple of affected breast in warm waterBed rest; nurse infant; use both breasts; nurse from unaffected side first to allow letdown to occur; reassurance that infant can nurse from affected breast unless it has an abscess; application of heat/cold; increase fluid intake; supportive bra; antibiotics: 10-day course dicloxacillin, erythromycin or a cephalosporinNystatin cream or Mycolog with cortisone to nipple after feedings; oral Nystatin for infant; for less severe cases: 1 tbsp. baking soda or vinegar/1 cup water: swab nipples and infant mouth after each feeding General Measures for Sore Nipples (Breast is B-E-S-T) Breast measures: Nurse on least sore side first Manual expression before infant begins to nurse Makes nipple softer; easier for infant to latch on Start flow of milk so infant does not have to suck as hard Use water only to clean breast; avoid soaps that may be irritating Let breastmilk dry on nipples Frequent changes of nursing pad/ avoid plastic-lined pads Moisten nipple if stuck to pad or bra before removing Encouragement to keep breastfeeding Suckling measures Frequent nursing; nursing on demand Ensure proper positioning of infant; change with each feeding Ensure that infant is grasping areola and not just nipple Treatment measures Ice/heat application for related engorgement, whichever gives most comfort Let flaps down on maternity bra and expose nipples to air and sun Blow dryer set on warm, held 6-8 in. from breasts X 20 min. four times/day 60 watt light bulb 6-8 in. from breasts X 20 min. four times/day Referral: Local Breastfeeding classes/support groups:Local Nursing Mothers Council:La Leche League International: 1-800-LA LECHE Mon. - Fri. 8 a.m. to 5 p.m. (Central Time) for volunteers in your area Resources: Client pamphlets available through the California WIC Program: State Department of Health ServicesChildbirth Graphics Catalogue:WIC WarehouseOR1-800-299-3366, ext. 2873901 Lennane DriveSacramento, CA 95834 Titles include: Breastfeeding: Getting Started in 5 Easy Steps (English or Spanish) 20 Great Reasons to Breastfeed Your Baby (English or Spanish) Helpful Hints on Breastfeeding (English or Spanish) Counseling the Nursing Mother, a referenced handbook for health care providers and lay counselors by Judith Lauwers and Candance Woessner. Avery Publishing Group, Garden City Park, New York, 1990. The Breastfeeding Answer Book by Nancy Mohrbacher and Julie Stock, La Leche League Publications, Schaumburg, Illinois, 1997. Breastfeeding Resource Directory 1998, a free service of the Breastfeeding Task Force of Greater Los Angeles. Call (626) 856-6650 to obtain a copy of the Directory and/or to become a subscriber. Breastfeeding Resource Handbook for the Healthcare Professional, published by the San Diego County Breastfeeding Coalition. Order from and make check out to: San Diego County Breastfeeding Coalition, c/o Childrens Health Hospital and Health Center, 3020 Childrens Way, MC 5058, San Diego, CA 92123-4282. Cost: $39.95 For more information call: (858) 576-5981. Breastfeeding Provider Resource Packet available to Health Net providers from Health Nets Provider Education Department (800) 977-2203. 36.Do you have any questions about mixing or feeding formula?(Yes(No General bottle feeding education: Clean bottles well. Use clean, hot, sudsy water to wash bottles, nipples, rings and caps. Use a bottle brush. Squeeze water through the nipple holes. Rinse everything well. If the client uses a dishwasher, bottles should be placed in the top rack and nipples should still be hand washed. If the client has well water, a sample should be taken to the county/city health department to be tested. They can tell the client if it is safe to use for mixing with formula powder or concentrate. Use fresh, properly stored formula. Check the formula for the use by date. Throw any unused formula away after that date. Dont buy damaged packages or dented cans. Never use formula known to have been frozen or stored above 95(F. Cans of liquid formula must be shaken and the lids washed and dried before opening. Opened liquid formula and mixed bottles of formula not used immediately must be covered and stored in the refrigerator. Any unused liquid formula must be thrown out 48 hours after opening or mixing. Stress the importance of following the directions on the formula labels. Improper mixing of formula can result in inadequate nutrition and/or electrolyte imbalances which, if undetected, can be life threatening. Formula provides much better nourishment than cows milk, which should not be used until recommended by the babys pediatric provider. Formula can be fed at any temperature - straight from the refrigerator, at room temperature, or warm (never hot!). A microwave oven should NEVER be used to heat formula. Microwaves heat unevenly, and hot spots in the formula can burn an infants mouth. Instead, warm tap water can be run over the bottle, or the bottle can be placed it in a bowl of warm water for a few minutes. NEVER prop a bottle for feedings. The baby may swallow air, and choke or spit up. Additionally, babies need to be held closely and eye contact made to promote normal development. NEVER put a baby to bed with a bottle. In addition to the risk of choking, baby bottle tooth decay can occur. A client who has any questions about whether her baby is getting the right formula should be referred to the babys pediatric provider. Interventions: Provide the client with information regarding safe and appropriate bottle feeding techniques as indicated by her questions and responses. Handouts that describe the correct procedures for formula feeding are typically available from formula companies. Handouts produced by formula manufacturers are NOT recommended for distribution to breastfeeding mothers. 37.Do you have any questions about your babys health?(Yes(NoIf Yes, please explain:38.Do you have any questions about your babys safety?(Yes(NoIf Yes, please explain: Maintaining the health of babies involves knowing when health problems are serious, when to get medical help, and keeping babies protected from serious diseases. Safety issues for babies focus on car travel and safety at home. Refer to STT Guidelines: Health Education - Infant Safety and Health, pages 101-103. Intervention: Use the clients questions and concerns as a basis for education. Ask the client if she has used an infant safety seat, and if she can tell you how to use it. Provide and review with the client a copy of STT Guidelines: Health Education - Handout S: Keep Your New Baby Safe. Reinforce the importance of well child checkups and immunizations as a means of preventing illness and disability. Discuss sleeping positions - Back to Sleep. Provide and review with the client a copy of STT Guidelines: Health Education - Handout T: When Your New Baby is Ill, and U: Your Baby Needs to be Immunized. Referral: Refer client to pediatric provider for any special education related to her infants specific condition or medical needs. WIC. CHDP (Child Health and Disability Prevention) provider (pediatric), if needed. Resources: National Maternal and Child Health Clearinghouse, Publications Catalog 2070 Chain Bridge Road, Suite 450, Vienna, VA 22182-2536 (703) 356-1964 8:30 a.m.-5:00 p.m. EST, M-F FAX: (703) 821-2098 World Wide Web: http://www.circsol.com/mch U.S. Consumer Product Safety Commission Washington, DC 20207 (800) 638-2772 Child Safety pamphlet American Academy of Family Physicians 8880 Ward Parkway, Kansas City, MO 64114-2797 (800) 944-0000 Care For Your Baby California Department of Health Services publication available from Miller Litho: (800) 995-4714 or (408) 757-1179 39.Are you using, or planning to use, any method of birth control?(Yes(NoIf Yes, which one?If No, would you like more information?(Yes(No Offers an educational opportunity to discuss the importance of recovery time prior to a subsequent pregnancy. For most women, waiting at least 15 months after having a baby before becoming pregnant again is recommended. Adequate spacing of children helps parents cope with demands of childrearing and with finances. It provides parents with time to provide physical, emotional and intellectual nurturing for each child. Effective birth control helps sexually active women and couples who want no more children to achieve their life plans. Each client should have the opportunity to make a fully informed decision about what method, if any, she wants to use postpartum. The use of birth control is a personal choice influenced by many factors including cultural background, religion, family history, and personal choice. Refer to STT Guidelines: Health Education - Family Planning Choices, pages 95-98. Intervention: Refer to Prenatal Combined Assessment/Reassessment to determine if the client has a plan for contraception, review it with her, and determine if she is still satisfied with that plan. Inquire about the clients prior experience with birth control methods and her satisfaction with them. This frequently provides insight into what types of methods may work best for the client. Provide client with educational materials as appropriate. Emphasize the health benefits of pregnancy spacing. Medi-Cal beneficiaries who request sterilization have a mandatory 30-day waiting period after signing the appropriate consent. Your practice location should have policies and procedures related to informed consent for sterilization as well as all temporary contraceptive methods. Inform the Provider of the clients choice of whether and what contraceptive method she wishes to use. Include the clients infant feeding method (breast or bottle). CPHWs may provide information, but need specialized training to provide the information required for an informed consent for any contraceptive method. Resources: What is Right For You? Choosing a Birth Control Method pamphlet is available from: Education Programs Associates: (408) 374-3720. Birth Control Methods pamphlet available from National Maternal and Child Health Clearing house at address, phone and FAX listed at question 38. Available in Chinese, Korean, Tagalog, and Vietnamese. Teen Help Line: __________________________ Plan: Client Goals, Interventions and Timeline Client agrees to: Referrals Agency: Date: ____________ Agency : ______________ Date: Materials Given: (Birth Control(Infant Feeding(Infant Care(Infant Safety( (___________(______________(___________(___________(________________________Document written material provided to the client during the postpartum assessment here. Summary: Date: __ _____ Interviewer: ________________________ Title: Minutes Spent: Copy of this form sent to Clients PCP on: (date) __________ by: (name and title) __________________ If the medical/obstetrical provider and the clients PCP are not the same, a copy of this form must be sent to the clients PCP. Any outstanding issues must be addressed by the clients PCP, including coordination of any referrals made. It is, therefore, important for the PCP to be aware of the clients course during pregnancy and the postpartum period. 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