5
Postpartum Visits

Checklist

This checklist covers the mother's nutrition and breastfeeding.

In the Hospital
Gathering Information
  • Review the medical record: Medications? Evidence of substance use? Twins? Infant with complications?

  • Need for birth control?

  • Support at home?

  • If breastfeeding, need for special assistance?

Basic Guidance

All Women

  • Dietary Guidelines

  • Appropriate weight change

  • Discharge advice: follow-up, avoidance of harmful substances, adequate rest

  • Breastfeeding Women

  • Assistance with initiating breastfeeding

  • Additional nutrient, fluid, and energy needs

  • Cautions concerning potentially harmful substances

  • Guidance for successful breastfeeding



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5 Postpartum Visits Checklist This checklist covers the mother's nutrition and breastfeeding. In the Hospital Gathering Information Review the medical record: Medications? Evidence of substance use? Twins? Infant with complications? Need for birth control? Support at home? If breastfeeding, need for special assistance? Basic Guidance All Women Dietary Guidelines Appropriate weight change Discharge advice: follow-up, avoidance of harmful substances, adequate rest Breastfeeding Women Assistance with initiating breastfeeding Additional nutrient, fluid, and energy needs Cautions concerning potentially harmful substances Guidance for successful breastfeeding

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Addressing Problems Facilitate improved access to food Treat anemia: For iron deficiency—60 to 120 mg of elemental iron daily; also 15 mg of zinc and 2 mg of copper given as part of a vitamin/mineral supplement Provide support for breastfeeding under challenging circumstances (neonatal complications, multiple gestation, etc.) Early Pediatric Visit—Maternal Issues Gathering Information General: Rest? Eating? Taking liquids? Breastfeeding experience? Future plans? Basic Guidance Support for breastfeeding Healthful diet with ample fluids to prevent thirst Visit at 4 to 6 Weeks Post Partum Gathering Information Diet and weight Breastfeeding Basic Guidance Dietary Guidelines with increased intake of milk products, fluids, and foods rich in vitamin A if breastfeeding Support for breastfeeding Encouragement of physical activity Addressing Problems Counsel how to correct inappropriate weight gain or loss Discourage restrictive food practices during lactation Follow-up on gestational diabetes mellitus Combat the use of harmful substances

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Postpartum Visits This section is organized by the timing of the contact with the health care provider and by the woman's lactation status (whether she is breastfeeding or not). It focuses on the woman, not the baby. Ideally, contacts with the mother occur during hospitalization after delivery, within a few days after discharge (a telephone or home visit), at early pediatric visits, and at the visit 4 to 6 weeks post partum. It is highly desirable for all women, regardless of their breastfeeding status, to strive for a healthful diet to replenish nutrient stores and maintain health. Breastfeeding is the recommended feeding method for infants under ordinary circumstances. Therefore, the establishment of lactation and maintenance of successful breastfeeding are nutritionally relevant to both the mother and her infant. This section includes basic information about breastfeeding. For more detailed sources of information, see Tab 10. Beginning at delivery and during the first 2 weeks afterward, the nutritional focus of the visits is to establish successful breastfeeding and provide dietary guidance. Support services for breastfeeding mothers should be provided in the hospital. (Short, well-targeted videotapes can be effective and efficient as a part of such an effort.) An early office visit, a visit to the home by a trained health professional, or telephone counseling is often advisable for breastfeeding women. Later, more attention is directed toward the mother's concerns about the adequacy of her milk supply, healthful weight loss strategies, her return to work or school, and birth control. During follow-up health maintenance visits for the infant and at the postpartum visit for the mother, the health care provider can help to maintain or improve the breastfeeding experience.

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Postpartum Nutritional Care in the Hospital Gathering Information Check the medical record to identify relevant questions and avoid unnecessary repetition. Was the delivery by cesarean section? Was it a multiple birth? History—Sample Questions General How will your family, friends, or others help you when you go home? Do you need birth control? Breastfeeding Does the mother wish to breastfeed? If yes, determine the following by reviewing the mother's history and by physical examination: Is the infant able to latch on to the nipple and areola and suckle vigorously? Are the nipples [still] inverted or flat? Has she been using any medication or drug that is contraindicated when breastfeeding? Does the baby have anomalies or medical complications that may interfere with feeding?

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Explanations All mothers have increased nutritional needs related to pregnancy and childbirth. Women are more likely to be successful at breastfeeding if they receive assistance with breastfeeding basics, relieving engorgement, appropriate birth control methods, and special situations. Combined estrogen and progestin pills may reduce milk volume and the duration of breastfeeding; progestin-only pills have not been found to have this effect.2 For the Lactating Woman: Special Recommendations for Lactating Women  Avoid diets and medications that promise rapid weight loss.  Eat a wide variety of breads and cereal grains, fruits, vegetables, milk products, and meats or meat alternates each day.  Take three or more servings of milk products daily.  Make a greater effort to eat vitamin-A-rich vegetables or fruit often. Examples of vitamin-A-rich foods include carrots, spinach or other cooked greens, sweet potatoes, and cantaloupe.  Be sure to drink when you are thirsty· You will need more fluid than usual.  If you drink coffee or other caffeinated beverages, such as cola, do so in moderation. Two servings daily are unlikely to harm the infant. Caffeine passes into the milk.

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Basic Guidance All Women Diet Encourage a healthful diet based on the Dietary Guidelines and suggest eating meals and snacks that are easy to prepare. Provide information on the usual pattern of postpartum weight loss. Discharge Advice Arrange for telephone follow-up or a home visit within a few days after hospital discharge to offer support and answer questions. Try to avoid or drastically reduce the use of potentially harmful substances. Try to rest as much as possible during the day when the baby is sleeping. Schedule the first pediatric visit for the mother and baby 7 to 14 days after delivery, or earlier if discharge from the hospital occurs within 48 hours of delivery. Provide guidance for resuming physical activity that considers the mother's current health status. Breastfeeding Women Initiating Breastfeeding Assist with the initiation of breastfeeding immediately or as soon as possible after delivery. Advise the mother as to positioning, breastfeeding techniques, and removing the infant from the breast. Breastfeed your infant when there are signs of hunger. Feed until at least one breast softens. It is okay to feed on both breasts for as long and as

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often as your baby wants, provided that attachment has been checked to avoid sore nipples. Sometimes feedings will be only about 11/2 hours apart. Foster a rooming-in situation in the hospital. Discourage the hospital staff from giving any supplemental feedings or water. Reassure: Your diet does not have to be “perfect" to nourish your baby well. The more your baby nurses, the more milk you will produce. Diet Take enough fluids (especially milk, juice, water, and soup)to keep from getting thirsty. You need enough food (at least 1,800 kcal/day)to help maintain milk production and to provide the nutrients that you and your baby need. For the first 6 weeks, the best guide to how much you should be eating is your own appetite. Try to keep your intake of coffee, cola, or other sources of caffeine to 2 servings or less per day. Advise against alcohol consumption, and inform the mother that drinking beer does not aid lactation. For those who choose to take alcoholic beverages, advise: It is best to avoid drinking alcoholic beverages, but certainly have no more than 2 to 2.5 oz of liquor, 8 oz of table wine, or 2 cans of beer on any one day (less for small women). If environmental contaminants (e.g., heavy metals such as mercury and organic chemicals such as pesticides) are a potential problem in the area, be on the alert for official advisories concerning foods or areas to avoid. If the mother wishes to use beverages containing sugar substitutes, suggest moderation and discourage her from using these to replace important sources of nutrients.

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Discharge Advice Encourage breastfeeding exclusively for 4 to 6 months. The amount of milk you produce depends directly on how often and how long your baby nurses. A reasonable goal is to nurse the baby whenever he or she is hungry. This may occur 10 or more times per 24 hours during the first few weeks after birth. Newborns who sleep for more than 3 to 4 hours may need to be awakened for feeding if they are not gaining weight and have little urine and stool output. You know your baby is getting milk if milk leaks from the alternate breast when you're nursing, you hear your baby swallow, or the baby has six to eight wet diapers and at least one dirty diaper a day. Relax and find a comfortable place to feed, and enjoy your baby. Avoid supplemental feedings of formula or water. Discuss strategies for maintaining healthy breasts: frequent nursing, proper positioning, using a finger to break suction before removing the infant from the breast, and identification of early signs of mastitis to permit rapid treatment. Explain that some nipple tenderness may occur at the beginning of the feed during the first 2 weeks but that it is usually not long lasting. Teach all breastfeeding mothers how to express milk manually Demonstrate the use of pumps if indicated. Reaffirm that the mother is doing something really important for her baby. If a multivitamin/mineral supplement was prescribed during pregnancy consider continued use of it during lactation. (See supplement chart, Tab 1.) Check the mother's understanding of instructions about getting help with breastfeeding if questions or problems arise.

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Addressing Problems All Women Suspected Difficulty in Obtaining Adequate Food Refer mother to food assistance programs such as WIC and food stamps. (See Tab 10.) Postpartum Anemia Check for postpartum anemia if there was unusually heavy blood loss at delivery. If detected, start a therapeutic dose of iron of 60 to 120 mg/day. At a different time of day, give 15 mg of zinc and 2 mg of copper as part of a vitamin/mineral supplement. Recheck hemoglobin or hematocrit at the mother's 6-week postpartum visit. Special Support for Mothers of Twins or Triplets Provide assistance with strategies for nursing two infants. Provide practical suggestions for achieving high nutrient and energy intake with the resources available. Refer the mother to a support group* Assist the mother in enlisting support from others. Arrange for a home visitor. *   National Organization of Mothers of Twins Clubs, Inc., 402 Amberwood Lane, Rockville, MD 20853; The Triplet Connection, P.O. Box 99571, Stockton, CA 95209.

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Breastfeeding Women Lack of Support for Breastfeeding Provide support and/or refer to a local support resource. Low Birth Weight Baby or Other Neonatal Complications • Consult with the team member who is an expert in breastfeeding management for advice and information about special care, such as: — Establishing and maintaining lactation. — Safe storage of mother's milk. — Support and encouragement for the mother. Cesarean Delivery Help the mother find comfortable positions (e.g., lying down, using pillows) for breastfeeding. Initiate breastfeeding as soon as the mother and infant are ready. Minimize interrupting the mother's sleep for reasons other than breastfeeding. Assist the mother in enlisting support from family, friends, or support groups such as La Leche League. Breast Surgery or Anatomical Variants If an anatomical variation was not corrected prenatally, consult an experienced clinician for observation and assessment of breastfeeding and for guidance in using a breast pump or breast shells to evert the nipples. Facilitate nursing after delivery. Encourage women with previous breast augmentation or reduction to monitor the infant's weight gain regularly.

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Smoking and Use of Contraindicated Drugs Encourage mothers who smoke to stop smoking and help them to do so. Be sure not to smoke while nursing the baby. If the mother has been using illicit mood-altering drugs, recommendations concerning breastfeeding should be made, on a case-by-case basis, by the health care team. Drugs that are contraindicated during breastfeeding include bromocriptine, cocaine, cyclophosphamide, cyclosporine, doxorubicin, ergotamine, lithium, methotrexate, phencyclidine (PCP), and phenindione (not used in the United States).16 Radiopharmaceuticals that require temporary cessation of breastfeeding include gallium-67, indium-111, iodine-125, iodine-131, radioactive sodium, and technetium-99m.16 If the mother wishes to breastfeed after treatment with a contraindicated drug is discontinued, assist her with pumping her breasts to maintain lactation and explain why the milk must be discarded. Request consultation concerning safe medically indicated drugs for use when breastfeeding. (See Study Group on Human Lactation and Breastfeeding, under "Examples of Breastfeeding Projects to Assist Health Professionals," Tab 10.)

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Early Pediatric Visit The first baby visit provides an opportunity to ask the mother about her diet and home situation and about how breastfeeding is going. Gathering Information Physical Examination Measure the infant's weight and length, and record measurements on the growth chart as a means of evaluating the infant's nutrition. Observe the mother nursing the baby, if applicable, noting the method of holding the infant, the infant's ability to latch on and suckle, the removal of the infant from the breast, signs that the mother is comfortable, and her responses. History—Sample Questions General How are things going at home? Are you enjoying your baby? How much sleep (rest) are you getting? Do you have trouble finding time to eat? To drink enough liquids? How often are you eating and drinking? Any snacks? What liquids are you drinking? If she is eating fewer than three meals per day, get more details. How are you feeding your baby? Breastfeeding Experience If the woman is breastfeeding, ask: How often are you breastfeeding your baby? How are you doing with breastfeeding?

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Are your breasts comfortable now? Your nipples? What, if anything , are you feeding your baby besides your milk? Why? How often? When? About how much has your weight changed since you left the hospital? Future Plans How long do you plan to breastfeed? Do you plan to go to work or school? If so, when? Tell me how you will combine work and breastfeeding. Perhaps I can make some suggestions about feeding your baby while you're at work, expressing milk, storing milk, and managing on days off from work. Explanations Physical Examination Slow infant growth may be a sign that the mother needs assistance with breastfeeding or with formula feeding. Early identification and correction of positioning problems may promote continuation of breastfeeding. General Support and care for the primary caretaker and family will assist in optimal care of the infant. The mother benefits from help to meet her own needs for rest and a healthful diet. Breastfeeding Experience Most problems with breastfeeding the neonate can be resolved through relatively simple measures such as feeding on demand, proper positioning, breastfeeding exclusively (without feeding formula or other supple

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ments), pumping the breasts if absences are unavoidable, alternating the breasts, and releasing suction when removing the infant from the breast. Basic Guidance Reassure the mother, as appropriate, and reinforce her successes, such as the infant's growth or the feeding relationship. You can expect your baby to want to nurse more often if he or she starts to have a growth spurt. This will increase your milk supply. Discuss strategies and provide materials to assist in coping with the demands of the newborn and other family members. If applicable, provide tips for eating well with fewer calories (see ideas on page 108 and "Boosting Your Nutrient Intake," page 103. Encourage the mother to consume a healthful diet based mainly on the Dietary Guidelines (see "Basic Dietary Guidance," Tab 2). Discourage her from trying diets and drugs that promise quick weight loss. Provide information for the mother or primary meal preparer concerning practical strategies for healthful family meals. Assist the mother in finding valid answers to her breastfeeding questions. Addressing Problems Check on the mother's need for physician referral to a breastfeeding specialist. For problem resolution for breastfeeding mothers, see Tab 10 for sources of information.

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Visit at 4 to 6 Weeks Post Partum The customary postpartum visit with the obstetric care provider offers a valuable opportunity to assess problems relating to the mother's nutritional status and breastfeeding experience. Gathering Information History—Sample Questions General How many hours of sleep are you able to get? Have you gone to work outside your home or to school? If not, Are you planning to do so? Diet and Weight How many times a day do you eat? About how many glasses or cups of fluids are you drinking every day? How do you feel about your weight now? If the mother is concerned about excessive weight, ask: Are you trying to lose weight? How? What is your weight loss goal? Breastfeeding Are you continuing to breastfeed your baby? If mother is breastfeeding with or without supplementary formula, ask: How many times a day do you breastfeed your baby? When do you alternate your breasts? How is breastfeeding going for you?

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Are you avoiding any foods because you are nursing? Which ones? May I offer some suggestions for combining work with breastfeeding? Are you using some kind of birth control? If yes, ask What method? If no, ask: Do you need birth control? Physical Examination Examine breasts. Measure weight. Explanations History General Some mothers need assistance to find practical strategies for getting adequate rest and resuming outside activities, especially if they are breastfeeding. Diet and Weight Some mothers benefit from concrete suggestions for achieving adequate intake in the face of increased family demands. The use of rapid weight-loss methods should be discouraged. Weight loss is usually gradual; it may take many months to achieve prepregnant weight. Some women resume smoking to lose weight more easily, but this poses long-term health risks for the mother, exposes the infant to smoke, and may interfere with the let-down reflex when nursing. Breastfeeding Infrequent or delayed feeding may lead to problems of reduced milk supply and engorgement. Problems with

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nipples may lead to reduced frequency of feeding. Avoidance of specific foods by the mother seldom benefits the baby Combined estrogen and progestin pills may reduce milk volume and the duration of breastfeeding; progestin-only pills have not been found to have this effect.2 Physical Examination Rapid weight loss often occurs over the first month post partum without restricting food intake, regardless of breastfeeding status. Engorged breasts and cracked nipples signal a need for support with breastfeeding. Basic Guidance All Women Encourage a healthful diet based on the Dietary Guidelines (see “Basic Dietary Guidance," Tab 2, page 27). Assist the mother or primary meal preparer with strategies for a healthful diet for the family. Clarify that (further) weight loss will occur only if energy intake is less than energy expenditure (plus the energy content of the milk produced). Discourage the use of harmful substances. Encourage physical activity. Breastfeeding Women Encourage generous intake of milk products, fluids, and foods rich in vitamin A. (See box "Special Recommendations for Lactating Women," page 73.) Explain that most women who breastfeed can eat more calories than they could before pregnancy without gaining weight. Answer questions concerning breastfeeding.

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For the Health Professional: Signals of Possible Weight-Related Problems During Lactation Consider diet counseling for women if any of the following applies: All Breastfeeding Women Abnormally slow infant growth despite frequent feedings and other appropriate breastfeeding techniques. Women with Normal Prepregnancy Weight-for-Height Weight loss in excess of 4.5 lb (approximately 2 kg)/month after the first month post partum. Weight falling below normal weight-for-height. Weight gain leading to high weight-for-height. Preoccupation with weight combined with major fluctuations in weight. (Look for additional signs of an eating disorder.) Women with Low Prepregnancy Weight-for-Height Any weight loss after weight-for-height returns to the low prepregnancy weight-for-height category (or after the weight returns to the prepregnancy weight). Weight loss in excess of 4.5 lb (approximately 2 kg)/month after the first month post partum. Women with High or Very High Prepregnancy Weight-for-Height Weight loss in excess of 6.5 lb (approximately 3 kg)/month after the first month post partum. Postpartum weight gain.

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Addressing Problems Weight Problems Determine possible causes of excessive postpartum weight loss, weight gain, or lack of any weight loss (see box); and check on the infant's growth. Counsel the woman about strategies to adjust her energy and nutrient intakes, alter her level of physical activity, or both. Recommend a low-dose multivitamin/mineral supplement (this can be the same as the prenatal supplement) if the mother has been curbing energy intake excessively and is unlikely to increase her nutrient intake. Restrictive Food Practices During Lactation If a breastfeeding mother is restricting her food intake to prevent colic, allergic reactions, or other problems in her infant, tell her that the evidence does not support routine elimination of milk or other basic foods to prevent these problems. If symptoms are serious, it may be advisable to demonstrate objectively whether food avoidance will help, as outlined below. Remove the suspected food allergen from the mother's diet. (This may require diet counseling.) Determine if the infant becomes asymptomatic. If yes, conduct an oral challenge under careful medical supervision to determine whether the symptoms recur. Treat provoked reactions appropriately. If the mother must eliminate a basic food from her diet for weeks to months, provide for diet counseling to promote adequate nutrient intake.

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Glucose Intolerance For those who developed gestational diabetes, follow-up on current glucose tolerance. Consider providing or refer for weight control counseling as appropriate to reduce the risk of developing type II diabetes mellitus. Use of Harmful Substances Assist women who smoke cigarettes, use smokeless tobacco, abuse alcohol, or use illegal drugs to quit. Include diet counseling to address their concerns about weight, as appropriate. Refer women to evaluation or treatment programs as needed.