POST PARTUM 1 Semester, S.Y. 2009-2010 Carissa Juliana J. R.

De Luzuriaga
st

1. Definition Postnatal (Latin for 'after birth', from post meaning "after" and natalis meaning "of birth") is the period beginning immediately after the birth of a child and extending for about six weeks. A more correct term would be postpartum period, as it refers to the mother (whereas postnatal refers to the infant). Less frequently used is puerperium. Biologically, it is the time after birth, a time in which the mother's body, including hormone levels and uterus size, returns to prepregnancy conditions. Lochia is postpartum vaginal discharge, containing blood, mucus, and placental tissue. 2. Specific body changes on the mother I. Puerperium: period of time during which the body adjusts and returns to a near pre-pregnancy state; usually lasts six weeks, can last up to one year. A. Uterus (Involution) a. The rapid reduction in size of the uterus and its return to a condition similar to its pre-pregnancy state. b. The uterus remains slightly larger than it was before the first pregnancy. c. Fundus is at umbilicus after delivery; 1 fingerbreadth above umbilicus 12 hours after delivery: decreases 1 fingerbreadth a day: by 10th day, is at symphysis pubis d. Fundus involutes faster if client breast feeds infant e. Process is complete at 3 weeks except at the placental site (6 to 7 weeks) f. Subinvolution may be caused by an infection or retained placenta fragments. B. Lochia: vaginal discharge following delivery a. Color i. Rubra (1-3 days); dark-red in color, consists of blood and cellular debris from decidua. ii. Serosa (4-10 days); pinkish-brownish, mostly serum, some blood, tissue debris iii. Alba (3-6 weeks); yellowish white, mostly leukocytes, with deciduas, epithelial cells, mucus. b. Odor If foul smelling, may indicate infection g. Amount Moderate at first, will increase with activity h. Afterpains due to involution of uterus; more severe with multiply births (example: twins), polyhydramnios; administration of oxytocin, breastfeeding i. Menstruation

resumes in about 6-8 weeks in non-nursing mothers: and can vary with nursing mothers. C. Cervical Changes a. Following birth it is spongy and flabby and formless and may appear bruised. b. Original form is regained in a few hours c. The shape is permanently changed by the first childbearing. d. Goes from dimple like to a lateral slit (fish mouth) D. Breasts a. Engorgement (3 days post delivery) i. Non breast feeding 1. ice 2. supportive bra 3. pain meds ii. Breast feeding 1. frequent hot showers 2. Frequent feedings 3. massage b. During pregnancy, the breasts develop in preparation for lactation as a result of both estrogen and progesterone. After birth, the interplay of maternal hormones leads to the establishment of milk production. E. Perineum a. May appear edematous with some bruising b. Episiotomy edges should be approximated c. Ecchymosis may occur and delay healing d. Episiotomy or Laceration i. Edema ii. Pain e. Nursing Interventions i. Sitz baths ii. Sprays or ointments iii. Kegel exercises F. Return of Ovulation and Menstruation a. Varies for each postpartum client b. Generally returns to non-nursing mothers between 7 and 9 weeks after birth c. The first cycle is non-ovulatory d. Breastfeeding clients may experience menustration and ovulation based on the amount of time nursingmay occur from 2nd to 18th month G. Gastrointestinal a. Sluggish bowel: constipation b. Episiotomy clients may delay bowel movement for fear of pain c. Cesarean birth clients may receive clear liquids and progress to a regular diet d. Increased appetite

e. Hemorrhoids f. Nursing interventions i. Administer stool softeners ii. Instruct client to increase dietary fiber and fluids iii. Suggest sitz baths, witch hazel pads for comfort. H. Urinary Tract a. Lessened sensation of bladder fullness b. Urinary retention c. Difficulty urinating d. Urinary output increases 1rst 24 hours post delivery (puerperal diuresis) e. Urine specimens should be obtained as a catheterized specimen. I. Vital Signs a. Client should be afebrile after the first 24 hours. A temperature up to 100.4 may be due to dehydration and/or exertion in the first 24 hours. b. BP WNL, a decrease may occur. An BP may indicate toxemia, PIH. c. Pulse rate may decrease to 50-70. Tachycardia should alert the nurse to blood loss/difficult birth. J. Blood Loss a. Blood values should return to the prepregnant state by the end of the postpartum period. b. Predisposed to the development of thromboembolism c. Leukocytosis with white blood cell (WBC) counts up to 30,000 per mL may occur early postpartum. Treat the symptoms, not the lab work. d. Convenient rule of thumb is a 2 point drop in hematocrit equals a blood loss of 500 mL. K. Temperature a. First 24 hours, there can be an increase up to 100.40F due to dehydration; exhaustion b. WBC normally elevated L. Weight Loss a. An initial weight loss of 10 to 12 lbs occurs as a result of the birth of the infant, placenta and amniotic fluid. b. Puerperal diuresis accounts for loss of an additional 5 lbs during the early postpartum period. c. Normally return to pre-pregnant weight by 6 weeks postpartum. M. Postpartal chill and Skin Diaphoresis a. Diuresis b. Night sweats c. Increased output d. Most clients experience a shaking chill or tremor after delivery. Warm blankets usually relieve this tremor or chill. e. Chills and fever late in the postpartum period may indicate sepsis. f. Diaphoretic episodes may occur at night, a normal occurrence as the body rids itself of waste products.

g. Neurologic or vasomotor response to impending delivery h. Normal immediately following delivery N. Afterpains or Afterbirth Pains a. Occur more commonly in multiparas than the primiparas. b. Caused by intermittent contractions. c. May cause severe discomfort for the first 2-3 days. d. Breastfeeding may increase the severity. e. Oxytocins may increase severity. (Pitocin, Methergine, Ergotrate) f. Mild analgesic may be indicated for pain relief. O. Cardiac a. Puerperal brachycardia b. May occur in 1st 10 days of postpartum secondary to decreasing blood volume. 3. Psychological changes on the mother A. Self-Concept a. Body image b. Fatigue c. Discomfort B. Maternal Role: Reva Rubins stages ATTACHMENT: PSYCHOLOGICAL RESPONSE Phases: Taking-in phase 1. First few days after delivery. 2. Characterized by passiveness and dependency. 3. Mother is preoccupied with her own needs; food attention, and physical comforts and care. 4. Talkative Taking-hold phase 1. Occurs about 2-3 days after delivery; characterized by increase in physical well being. 2. Emphasis on the present; woman takes hold of the task of mothering; requires reassurance. 3. Very receptive to teaching. Letting go (Independent) Characteristics Usually evident by fifth or sixth weeks Show pattern of life style that includes new baby but still focuses on entire family as unit Reestablishment of husband wife Mother may still fell tired and overwhelmed by responsibility and conflicting demands on her time and energies Psychosocial Changes A. Adoption to Parenthood

Motor skills new parents must learn new physical skill to care for the infants feeding holding, burping, changing diapers, skin care) Attachment skills

(e.g.

a. Bonding -The development of a caring relationship with the baby, which includes: - Claiming- identifying the way in which the baby looks or acts like members of the family - Identification establishing the babys unique nature (assigning the baby his/her own name) - Attachment is facilitated by positive feedback between baby and caregivers b. Sensual Response Touch important communication with the baby Eye to eye contact forms a trusting relationship Voice baby respond to higher pitched voice that parent use in talking to the baby Odor baby quickly identify their own mothers breast milk and scent. Initial Attachment Behavior Progression of touching activities En face position dominates Relies heavily on senses of sight, touch, hearing in getting to know the baby Emotional distance may occur. The acquaintance phase, the phase of mutual regulation Some negative feelings may occur; be understanding not condescending Reciprocity is an interactional cycle that occurs simultaneously between mother and infant. (mutual cueing behaviors, expectancy, delight in each others company when synchronous Father-Infant Interactions Primary role has been supporting role Engrossment (the characteristic sense of absorption, preoccupation, and interest in the infant demonstrated by fathers during early contact with the newborn. C. Postpartum Depression 1. 2. 3. Mood swings, depression Usually peaks on 5th day, if lasts longer than 10 days, notify primary care provider Related to hormonal changes and fatigue: if continues, must seek professional help. 4. Postpartum Assessment: Monitoring of VS, uterine involution, amount and pattern of lochia, emotional responses, responses to drug therapy, episiotomy

Vital signs: BP should remain consistent with baseline BP during pregnancy. Pulse 50 -90, respirations 16-24, temp 98-100.4 Breasts: Smooth, even pigmentation, soft, filling, full, engorged Abdomen: soft, fundus firm, midline and at/or below umbilicus, may be tender on palpation Lochia: rubra, scant to moderate, no clots, rubra to serosa to alba Perineum: Slight edema, no bruising, episiotomy without redness, swelling or drainage, hemorrhoids (none or small) Lower extremities: No pain with palpation, negative Homans sign Elimination: voiding 4-6 hrs, no bladder distention noted, normal bowel movement by the 2nd to 3rd day post delivery Psychological adaptation: cultural assessment, bonding, holding en face, attachment behaviors

BUBBLEHE Breasts Uterus Bowels Bladder Lochia Episiotomy / Laceration / C section incision Homans Sign Emotional Status BreastAssess lactation status Inspect and palpate breast Condition: Soft, Filling, Full, Firm, Engorged, Red, Pain Nipples: Normal, Red, Pain, Cracked Inverted UterusAssess fundus Location: fingerbreadths or cm or the umbilicus (e.g., 2 FB U) Position: M=Midline, Right=R or L=Left of the umbilicus Consistency: Firm, Boggy Assess the bladder prior to voiding and then again after voiding (Indwelling Foley catheter)-assess color, quantity, quality, odor of urine, etc.) I & 0 (if not on accurate I&O, record # of voids)__________ BowelAuscultate bowel sounds: Absent, Hypoactive, Active, Hyperactive Palpate Abdomen: Soft, Distended LochiaDischarge from uterus following delivery Color: Rubra, Serosa, Alba Amount: None, Scant, Small, Moderate, Heavy, Clots: describe size

Odor: Present, Absent EpisotomyAssess Perineum Condition: Use REEDA Redness, Edema, Ecchymosis, Drainage, Approximation- to assess Hemorrhoids:+ = Present, Edematous, Thrombosed, Soft, Painful C/S Incision: Clean, Dry, Intact (CD &I), OPA(Open to air) Dressing: Clean, Dry & Intact, Changed, Homan'sHomans 0=Negative Plus (+) positive (indicate R or L) Calf pain might be normal due to stress of delivery. Clonus:: With the womans knee flexed and the leg supported, vigorously dorsiflex the foot, maintain the dorsiflexion momentarily, and then release. Normally no clonus is present. Record the number of beats: 0= no clonus 1=beat of clonus, 2 = 2 beats of clonus, 3=3 beats of clonus Edema-Assess edema by weight gain (more than 3.3 lbs in the 2nd trimester or more than 1.1 lbs in the 3rd trimester). Edema is assessed on a 1+ to 4+ scale Reflexes-Elicit at least one pair of reflexes Patellar reflex, Biceps reflex, Triceps reflex, Brachioradialis reflex Grade reflexes: 0-no response; abnormal 1+-Diminished response; low normal 2+-Average response; normal 3+-Brisker than average; may not be abnormal 4+-Hyperactive; very brisk, jerky, or clonic response; abnormal EmotionalMaternal-Infant Attachment The mother has direct face-to-face and eye-to-eye contact in the en face position Holds, cuddles, asks questions and cares for infant Bonding or not bonding with infant Postpartum blues 5. Possible complications during post partum: bleeding and infection A. Nursing Interventions Assess for signs of infection: check vital signs, pain, chills, lochia Administer antibiotic therapy Complications Pulmonary embolism Peritonitis Pelvic cellulitis 6. Appropriate Nursing Diagnosis a. Attachment, Risk for impaired parent/infant/child/parenting;

B.

b. c. d. e. f.

Fluid volume, risk for deficient Pain acute/[Discomfort] Urinary Elimination, impaired Constipation Sleep Pattern, disturbed

7. Nursing care of mothers during post partum a. Safety measures: limitations in movement, protection from falls, provision of adequate clothing, wound care e.g. episiotomy b. Comfort measures: exercises, initiation of lactation, relief of discomforts like breast engorgement and nipple sores, hygienic measures, maintaining adequate nutrition. c. Measures to prevent complication: ensuring adequate uterine contraction to prevent bleeding, adequate monitoring, early ambulation, prompt referral for complications. d. Support for the psychosocial adjustment of the mother. e. Health teaching needs of mother, newborn, family f. Accurate documentation and reporting as needed 8. Health beliefs and practices of different cultures in pregnancy, labor, delivery, puerperium. a. Maternal Role i. Time of readjustment and adaptation ii. During the first day or two, the client tends to be passive and somewhat dependent iii. Hesitant about making decisions iv. Food or sleep are of major importance, May feel a great need to talk v. Taking In phase according to Rubin vi. By second or third day, client is ready to resume control. Taking Hold phase occurs during this time. vii. Todays client adjust more rapidly as LOS has shortened. viii. Maternal role attainment: process by which a woman learns mothering behaviors. (anticipatory, formal, informal, and personal) b. Postpartum Blues i. Describes a transient period of depression that occurs in most women during the first week or two after birth. ii. May be manifested by mood swings, anger, weepiness, anorexia, difficulty sleeping, and a feeling of letdown. iii. Hormonal changes and psychological adjustments are thought to be main causes. iv. Usually resolve naturally in 2 to 3 weeks with support and reassurance. If symptoms persist, the client should be evaluated for postpartum depression. c. Development of Parent-Infant attachment i. Level of trust ii. Level of self-esteem iii. Capacity for enjoying herself

iv. Interest in and adequacy of knowledge about childbearing and childrearing v. Clients prevailing mood or usual feeling tone vi. Reactions to the present pregnancy d. Initial attachment behavior i. Progression of touching activities ii. En face position dominates iii. Relies heavily on senses of sight, touch, hearing in getting to know the baby iv. Emotional distance may be occur. v. The acquaintance phase, the phase of mutual regulation vi. Some negative feelings may occur; be understanding not condescending vii. Reciprocity is an interactional cycle that occurs simultaneously between mother and infant. (mutual cueing behaviors, expectancy, delight in each others company when synchronous) e. Father-infant interactions i. Primary role has been supporting role ii. Engrossment (the characteristic sense of absorption, preoccupation, and interest in the infant demonstrated by fathers during early contact with the newborn. 9. Cultural Influences Prenatal Beliefs Wearing a necklace can cause the umbilical cord to wrap around the babys neck. Eating dark colored foods (ex. Chocolates) can cause the baby to have dark skin. Eating twin bananas can result in having twins. Admiring flowers is not advisable because the petals resemble cleft lip and palate. The pregnant woman should not pick fruits from the tree because it is believed that the baby can steal the tree's spirit and cause it to die. Eating spicy foods can cause a hot-tempered baby. Dont hang your underwear outside because the evil spirit will cause deformities to baby. Dont sit in the dark because the evil spirit will take away the baby through miscarriage. Dont sit on the stairs because it can cause a long labor. Labor and Delivery beliefs During labor dont let anyone stand by the door because it delays the labor process. The baby will not come out if the father is not present. What to do with the Placenta:

Hang it on the tree so the baby will be able to climb trees when she/he grows up Put it in the water so the baby will be a good swimmer when she/he grows up Wrap it with a newspaper or pages from a book so the baby will be smart

Post Partum beliefs: Colostrums is expressed and discarded because it is thought to be dirty. Give baby papaya leaf juice as a first food to help meconium pass easily. The new mother should not drink cold beverages. It can cause epigastric discomforts and the uterus will not shrink. The new mother should not read or watch TV because it can harm her vision. The woman should stay home for at least 10 days after delivery. Use cloth belt firmly around the woman's waist to get the pre-pregnancy figure back. Eat vegetable soup to help with lactation. Dont eat taro or squash while breastfeeding. It causes the baby to be itchy. No shower, no breastfeeding for the first three days, hot and cold foods Do not make generalizations Extended family may play an important role in care 10. Current trends in maternal and child care. The teen-birth rate (births to women aged 15-19 as a share of total births) The low birth-weight birth rate (births of babies weighing less than 2,500 grams as apercent of total births) The prenatal care rate (births to women who received prenatal care in the first trimesteras a share of total births) Fertility is not far short of its biological maximum and, as it can hardly increase, any change will tend to favor maternal and child health. Urbanization is rapidly increasing. Female literacy and education level is increasing sharply. Expectations of child survival, knowledge of hygiene and nutrition will improve, and fertility regulation will accelerate. Oral rehydration, obstetric care, and immunization levels will improve. 11. Family Planning Family Planning A national mandated priority public health program to attain the country's national health development: a health intervention program and an important tool for the improvement of the health and welfare of mothers, children and other members of the family.

Lactational Amenorrhea Method (LAM)

Is the use of breastfeeding as temporary introductory postpartum method of postponing pregnancy based on physiological infertility experienced by breastfeeding women. 3 criteria for LAM use Amenorrhea (i.e., menses have not yet returned) Fully or nearly fully breastfeeding her infant Infant is less than 6 months old

How does LAM work? The normal physiology of breastfeeding and the hormonal response of a womans body to her infants suckling at her breast suppresses ovulation Advantages LAM is universally available to all postpartum breastfeeding women Using LAM does not require a physical examination With LAM, protection from an unplanned pregnancy begins immediately postpartum No other family planning commodities are required while a client is using LAM The use of LAM contributes to improved maternal and child health and nutrition LAM counseling encourages optimal breastfeeding and weaning practices LAM serves as a bridge to the use of other family planning methods The use of LAM during immediate postpartum allows a woman to consider which longer-term method is best for her. LAM counseling encourages the use of another complementary FP method when any of the three criteria is not met Disadvantages LAM is considered as an introductory short-term FP method which is effective only for a maximum 6 months postpartum If a mother and child are separated for extended periods of time because the mother works outside of the home, or for whatever other reason, the effectiveness of LAM may decrease Full or nearly full breastfeeding may be difficult to maintain for up to 6 months due to a variety of social circumstances

Who can use this method? LAM is a good introductory FP method for lactating women for up to 6 months postpartum if the client remains amenorrheic and fully or nearly fully breastfeeding

Who can not use this method? Women who do not pass any of the three criteria to practice LAM cannot use the method.

How effective?

Perfect use: 99.5% Typical use: 98%

Billings-Ovulation Method Also known as cervical mucus method This is the observation of wet and dry sensations in the vulva

Advantages Effective when used correctly and consistently No physical side effects No prescription required Inexpensive; no medication involved No follow-up medical appointments required Better understanding of the couple about their sexual physiology and reproductive function Encourage shared responsibility for family planning Foster better communication between spouses, thereby strengthening the marriage and family. Disadvantages May inhibit sexual spontaneity Except for SDM, need extensive training takes about two to three cycles to learn to accurately identify the fertile period and how to effectively use it Require a high level of diligence from both partners Require periods of abstinence from sexual intercourse, which may be difficult for some couples Require rigid adherence to daily routine of awakening at a fixed time, without enduring any disturbance before taking the temperature (BBT/Symptothermal) May be difficult to practice for women with multiple partners (Ovulation method) Can be used only by women whose cycles are within 26-32 days (SDM) Offer no protection against STI/HIV/AIDS Fertile Feeling of wetness Mucus secretion is wet, slippery and clear Unfertile Feeling of dryness No secretion (nothing is seen or felt) Presence of pasty, non-stretchy mucus Unchanging mucus pattern a day after menstruation

Who can use this method?

Any woman of reproductive age as long as she is not suffering from an unusual disease or condition that results in extraordinary vaginal discharge that makes observation difficult

Who can not use this method? Women with: Medical conditions that would make pregnancy especially dangerous Irregular menstrual cycles, vaginal bleeding between periods, heavy or long monthly bleeding Recently gave birth or had a miscarriage Women with: Exclusive breastfeeding Other conditions that affect the ovaries or menstrual bleeding such as stroke, serious liver disease, hyperthyroid, hypothyroid, or cervical cancer Women with: Infections or diseases that may change mucus such as STIs or PID in the last 3 months, or vaginal infection Taking drugs that affect cervical mucus, such as mood-altering drugs, lithium, TCAs or antianxiety therapies Standard Days Method Is a new methods of natural family planning in which all users with menstrual cycles between 26 and 32 days are counseled to abstrain from sexual intercourse on days 8-19 to avoid pregnancy Uses a color-coded cycle beads to mark fertile and infertile days of the menstrual cycle

Who can use this method? Works well for women who usually have menstrual cycles between 26 to 32 days long Who can not use this method? Women with cycles not within 26-32 days cannot use the method Two-day Method Is a simple FAB method that involves: Cervical secretions as an indicator of fertility; and Women checking the presence of secretions every day If a woman notices any secretions today or yesterday, she should consider herself fertile and avoid intercourse today It has been known for several decades that secretions are a very reliable indicator of fertility (this is also what the Billings Ovulation Method is based on). Who can use this method? Women with cycles of any length Women with normal secretions Women willing to check their secretions

Couples who can avoid intercourse for several consecutive days each cycle

Basal Body Temperature Identifying the fertile and infertile period of a womans cycle by daily taking and recording of the rise in body temperature during and after ovulation BBT is taking the temperature of the body at rest and after at least 3 hours of continuous sleeping before taking temperature A womans BBT rises during her ovulation period and stays high until the next menstruation due to a rise in progesterone level Who can use this method? The method can be used by any woman of reproductive age who is willing to take and chart her BBT daily and practice abstinence during fertile periods Who can not use this method? There are no medical precautions against the use of BBT. However, the following conditions may affect BBT: Sore throat, colds and flu, fever, toothache, vomiting, diarrhea, anxiety, sunburn, medication, travel, sleep disturbance, and alcoholic beverages

Advantages Free Safe Acceptable to many whose religious beliefs prohibit other methods Provide an increased awareness of the body Involve no artificial substances or devices Encourage communication Useful in planning a pregnancy Symptothermal Method Identifying the fertile and infertile days of the menstrual cycle as determined through a combination of observations made on the cervical mucus, basal body temperature recording, and other signs of ovulation

Who can use this method? any woman of reproductive age who is willing to take and chart her BBT daily, has the patience and diligence to make daily observations of her cervical mucus and chart all these on a daily basis, and is willing to practice abstinence during the fertile period

Who can not use this method? Same as Ovulation and BBT methods Require extensive initial counseling to be effective May interfere with sexual spontaneity Require a couple to keep records for several cycles before beginning to use them

May be difficult or impossible for women with irregular cycles May not be reliable in preventing pregnancy a. Natural methods- Standard Days Method (SDM) with cycle beads, Billings Method, sympto-thermal method, lactation amenorrhea method (LAM) b. Artificial methods- use of hormones, intra-uterine device, barrier methods, tubal ligation, vasectomy

Oral Contraceptive Pill (a.k.a. the Pill) About 100 million women all over the world rely on the Pill. It's one of the world's most prescribed medications. Contraceptive Patch (Evra) A small contraceptive patch that sticks to a woman's skin and releases hormones into her bloodstream. Injection (Depo-Provera) An injectable contraceptive containing the hormone progestin that interferes with a woman's menstrual cycle. Vaginal Ring (NuvaRing) The vaginal ring is a new and highly effective birth control method that is now available in Canada. Intra-uterine System (Mirena) The IUS provides contraception for up to five years and is 99% effective in preventing pregnancy. Intra-uterine Device (Copper IUD) Inserted into the uterus, this small T-shaped device changes the chemistry in the uterus, destroying sperm. Male Condom The male condom is made of latex and is rolled over a guy's penis to block sperm from entering the vagina. Female Condom The female condom works just like a male condom, and is worn inside a girl's vagina during sex. These other contraception methods are either less effective or permanent, so they may not be right for teens. But they are something you might want to consider if you think

the Pill, patch, ring, or injection aren't the right choices for you. Some of them also make a great second type of birth control to use with condoms. Contraceptive Sponge The disposable sponge containing spermicide is placed at the cervix and absorbs and destroys sperm. Diaphragm A latex cap that covers a girl's cervix and stops sperm from getting inside. Cervical Cap A deep latex cap that fits against a girl's cervix and prevents sperm and bacteria from entering. Lea Contraceptive A soft, silicone device is inserted into the vagina in front of the cervix, to prevent sperm from entering. Tubal Ligation Permanent surgery to disconnect the fallopian tubes, which transport the eggs from the ovaries to the uterus. Vasectomy Permanent surgery to block a man's sperm duct and prevents sperm from entering the ejaculate. Withdrawal In this method, a guy withdraws his penis from a girl's vagina before ejaculation. Natural Birth Control Methods A woman can keep track of her monthly cycle, and determine when she's most likely to get pregnant. Spermicide A chemical called nonoxynol-9 comes in many forms and can destroy sperm on contact. Lactational Most breastfeeding women have a period of infertility after the birth of their child. The lactational amenorrhea method, or LAM, gives guidelines for determining the length of a woman's period of breastfeeding infertility. Breastfeeding must be the infants only (or almost only) source of nutrition. Feeding formula, pumping instead of nursing[2], and feeding solids all reduce the effectiveness of LAM. The infant must breastfeed at least every four hours during the day and at least every six hours at night.

The infant must be less than six months old. The mother must not have had a period after 56 days post-partum (when determining fertility, bleeding prior to 56 days post-partum can be ignored).

Standard Days Method

To use the SDM you will need to count the days of your menstrual cycle, starting with the first day your period begins. 1. Count the first day of your period as day 1. 2. On days 1 to 7 you are not fertile and can have unprotected intercourse. (Provided neither partner has an STD, it is medically safe to have sex even while menstruating!) 3. On days 8 to 19 you must avoid sex or use a barrier method if you do not want to get pregnant. 4. From day 20 until your period starts you can have unprotected sex. The Billings ovulation method (BOM) is a method which women use to monitor their fertility, by identifying when they are fertile and when they are infertile during each menstrual cycle. Contraception: Fertility Awareness Methods Basal Body Temperature (BBT) Calendar or Rhythm Method The Cervical Mucous Method Symptothermal Method Advantages and Disadvantages Free Safe Acceptable to many whose religious beliefs prohibit other methods Provide an increased awareness of the body Involve no artificial substances or devices Encourage communication Useful in planning a pregnancy Require extensive initial counseling to be effective May interfere with sexual spontaneity Require a couple to keep records for several cycles before beginning to use them May be difficult or impossible for women with irregular cycles May not be reliable in preventing pregnancy Contraception: Situational Contraceptives Abstinence Coitius Interruptus Douching after intercourse Contraception: Spermicides Creams, jellies, foams, vaginal film, and suppositories Minimally effective when used alone Major advantage is wide availability and low toxicity

Contraception: Mechanical Contraceptives Condoms (male and female) Diaphragm The cervical Cap The Intrauterine Device (IUD) Contraception: Oral Contraceptives The use of hormones, specifically the combination of estrogen and progesterone, is a very successful birth control method. Work by inhibiting the release of an ovum, by creating an atrophic endometrium, and by maintaining cervical mucus that is hostile to sperm. Contraception: Long-Acting Progestin Contraceptives Norplant Depo-Provera Emergency Postcoital Contraception Actually takes two pills as soon after intercourse as possible and two more 12 hours later. Must be initiated within 72 hours after unprotected intercourse. Operative Sterilization Vasectomy: 1) Involves surgical severing of the vans deferens in both sides of the scrotum, 2) It takes 4-6 weeks or 6-36 ejaculations to clear remaining sperm, 3) Must be rechecked at 6 to 12 months to insure fertility has not been restored. Tubal Ligation: The fallopian tubes are ligated, clipped, electrocoagulated, banded or plugged. This interrupts the patency of the fallopian tune, thus preventing the ovum and sperm from meeting. Reversal may be accomplished surgically with both procedures. Reversal may also occur naturally.

Surgical and Medical Interruption of Pregnancy Methotrexate can be used alone or in conjunction with misoprostil to terminate pregnancy up to approximately 50 days from the last menstrual period. Mifepristone (RU 486) blocks progesterone, altering the endometrium and making it unsuitable for implantation (currently not made in the US). Surgical intervention D&C, D&S

Prepared by: Carissa Juliana J. R. De Luzuriaga, RN Level II