GMP

BSN II

Nursing Interventions for the following concerns:

Prevent or Relieve Engorgement
• The primary method for relieving engorgement is emptying the breast of milk by having the infant suck
more often, or at least continue to suck as much as before.
• Manual expression or the use of a breast pump to complete emptying of the breasts after the baby has
nursed can help maintain or promote a good milk supply during a period of engorgement.
• Good breast support from a firm-fitting bra helps prevent a pulling, heavy feeling.
• If an infant cannot grasp a nipple to suck strongly because of engorgement, warm packs applied to both
breast or standing under a warm shower for a few minutes before feeding, combined with massage to
begin milk flow, often promotes breast softness so an infant can suck.
• Assure a mother that symptoms of engorgement are healthy; it is an announcement her breast are
producing milk.
•Assure a mother that engorgement is only temporary and should begin to subside 24 hours after it first
becomes apparent.
Promote Healing of Sore Nipples
• Encourage a mother to position her baby slightly differently for each feeding. This helps prevent the
same area of the nipple from receiving the majority of pressure.
• Advise her to expose her nipples to air by leaving her bra unsnapped for 10 to 15 minutes after feeding.
• Discourage the use of plastic liners that come with nursing bras; it is preferable to have air always
circulating around the breasts.
• Applying vitamin E lotion after air exposure may toughen the nipples and prevent further irritation.
• Applying a few drops of breast milk to the nipples after feeding and gently massaging it into the areola
is also recommended.
• Advise women not to use a hand pump with sore nipples, because the pressure may cause fissures to
worsen. An electric or battery-operated pump (standard equipment in most maternity or pediatric
hospitals) usually can be used; these devices exert less pressure on the nipples.
Provide Pain Relief for afterpains
• Assure a mother that this type of discomfort is normal and rarely last longer than 3 days.
• If necessary, either ibuprofen (such as Motrin), which has anti-inflammatory properties or a common
analgesic such as acetaminophen (such as Tylenol) is effective for pain relief.
• A backrub is effective for relieving an aching back or shoulders.
• Carefully assess a woman who states that she has pain on standing.
• Applying an ice or cold pack to the perineum during the first 24 hours reduces perineal edema and the
possibility of hematoma formation, thereby reducing pain and promoting healing and comfort. Do not
place ice or plastic directly on the woman's perineum.
• Ice to the perineum after the first 24 hours is no longer therapeutic. Dry heat in the form of a perineal
hot pack or moist heat with a sitz bath is an effective way to increase circulation to the perineum, provide
comfort, reduce edema, and promote healing.
Postpartum care of the Perineum and Episiotomy Care
• Promote perineal exercises. The exercise consists of contracting and relaxing the muscles of the
perineum 5 to 10 times in succession. This aids comfort by improving circulation to the area and
decreasing edema.
• Provide Perineal Care. Postpartal women are particularly prone to perineal infection because lochia, if
allowed to dry and harden on the vulva and perineum, furnishes a rich bed for bacterial growth, which
then can spread to the uterus.
• Give Episiotomy Care. Many physicians and nurse-midwives order a soothing cream or anesthetic spray
to be applied to the suture line to reduce discomfort. A cortisone-based cream or sitz bath helps to
decrease inflammation and relieve tension in the area.
• A woman may worry that she will experience additional discomfort when the episiotomy sutures are
removed. Explain that these sutures are made of an absorbable material so will not need to be removed.
Sutures usually dissolve within 10 days.
• Because the perineal area heals rapidly, you can assure a woman that this discomfort is normal and does
not usually last longer than 5 or 6 days.
• A sitz bath is a portable basin that fits on a toilet seat. A reservoir filled with water provides a constant
supply of swirling water to the basin. The movement of water soothes healing tissue, decreases
inflammation by causing vasodilation in the area, and thereby effectively reduces discomfort and
promotes healing.
• Provide Pain Management. Several topical medications with lidocaine (Xylocaine) bases, such as gels or
sprays, are available to relieve perineal pain. In addition to local perineum creams or sprays, many
women require an oral or parenteral analgesic to relieve their episiotomy discomfort.
Perilight Treatment
Application of dry heat to perineal area in order to provide comfort and increase blood circulation and
hasten wound healing by means of perineal lamp. 20-50 centimeters or 18-24 inches away from the body
to be exposed.
Therapeutic uses of heat
1. SEDATIVE EFFECT- Heat is generally considered to produce a relaxation effect and increase the
contractility of muscles.
2. RELIEVES PAIN- Heat relieves pain by promoting muscle relaxation, increasing circulation, and
promoting psychological relaxation and a feeling of comfort.
3. REDUCES CONTRACTURE AND INCREASES RANGE OF MOTION- This effect is achieved by
allowing greater distention of muscles and connective tissue.
4. REDUCES JOINT STIFFNESS- Heat reduces joint stiffness by decreasing viscosity of synovial fluid
and increasing tissue distensibility.
5. PROVIDES WARMTH AND COMFORT
Importance of perilight treatment
1. Relief of pain and muscular spasm
-provides comfort by relief pain
-it relaxes muscles and capillaries making pain tolerable
2. Increases blood circulation
3. Hastens wound healing following an episiotomy repair
-increases circulation of blood
-increases supply of oxygen and nutrient which promotes wound healing
4. Reduces edema and soreness
-it releases dry heat and thus help reduce edema and soreness
-alleviated by relax muscles and capillaries
Nursing Responsibilities in Perilight Treatment
BEFORE:
• Check the client’s condition before applying the procedure.
• Check all electrical equipment for defects or try to switch it on and off.
• Always handle equipment with dry hands.
• Check physicians order for each area to be treated and duration of therapy.
• Do perineal flushing.
DURING:
• Position client comfortably with only area where heat is to be applied.
• Position lamp at a safe distance from where it is to be applied.
• Inspect skin and see to it that its clean and dry before applying heat.
• Place bed cover over lamp but not allowing bed sheet to touch the light bulb.
• Check skin every 5 minutes interval throughout duration of procedure.
• Monitor any untoward response.
• Perilight exposure should be given 24 hours after delivery.
• Place bed cover after pulling lamp and provide privacy.
• Position lamp at 18-24 inches away from the body part to be exposed.
AFTER:
• Assist the client.
• Do after care.
• Monitor clients response.
• Do recording; record on patients chart - time when it started- patients reaction- condition of perineum-
inspect sutures and episiotomy after procedure.
• Inspect condition of part being treated.
Promotion and Establishing of Breastfeeding
It is universally agreed that breast milk is the preferred method of feeding a newborn, because it
provides numerous health benefits to both a mother and an infant; it remains the ideal nutritional source
for infants through the first year of life (American College of Obstetricians & Gynecologists [ACOG],
2007).
Create an atmosphere conducive to breastfeeding success in health care facilities by implementing steps
such as:
• Educating all pregnant women about the benefits and management of breastfeeding.
• Helping women initiate breastfeeding within half an hour after birth.
• Assisting mothers to breastfeed and maintain lactation even if they should be separated from their infant.
• Not giving newborns food or drink other than breast milk unless medically indicated, so they are hungry
to breastfeed.
• Supporting rooming-in (such as allowing mothers and infants to remain together) 24 hours a day.
• Encouraging breastfeeding on demand.
• Fostering the establishment of breastfeeding support groups and referring mothers to them on discharge
from the birthing center or hospital.
Considering breastfeeding in specific circumstances:
Contraindications
• An infant with galactosemia (such infants cannot digest the lactose in milk).
• Herpes lesions on a mother’s nipples.
• Maternal diet is nutrient restricted, preventing quality milk production.
• Maternal exposure to radioactive compounds (e.g., during thyroid testing).
• Breast cancer
• Maternal active, untreated tuberculosis, hepatitis B or C, cytomegalovirus, or human immunodeficiency
syndrome.
• Maternal active, untreated varicella. Once the infant has been given varicella zoster immunoglobulin,
the infant can receive expressed breast milk if there are no lesions on the breast. Within 5 days of the
appearance of the rash, maternal antibodies are produced, and thus breastfeeding could be beneficial in
providing passive immunity against varicella.
• Mothers receiving antimetabolites or chemotherapeutic agents.
• Mothers receiving prescribed medications that would be harmful to an infant such as lithium or
methotrexate.
• A mother lives in an area where environmental contaminants can be carried via breast milk to the infant.
• A mother or an infant too ill for breastfeeding.
• A mother who has undergone breast-reduction surgery where the nipples were detached during surgery.
Advantages for a Mother
• Breastfeeding may serve a protective function in preventing breast cancer.
• The release of oxytocin from the posterior pituitary gland aids in uterine involution.
• Successful breastfeeding can have an empowering effect, because it is a skill only a woman can master.
• Breastfeeding reduces the cost of feeding and preparation time.
• Breastfeeding provides an excellent opportunity to enhance a true symbiotic bond between mother and
child. Although this does occur readily with breastfeeding, a woman who holds her baby to formula feed
can form this bond as well.
Advantages for an Infant
• Breast milk contains secretory immunoglobulin A (IgA), which binds large molecules of foreign
proteins, including viruses and bacteria, keeping them from being absorbed from the gastrointestinal tract
into the infant.
• Lactoferrin is an iron-binding protein in breast milk that interferes with the growth of pathogenic
bacteria.
• The enzyme lysozyme in breast milk apparently actively destroys bacteria by lysing (dissolving) their
cell membranes, possibly increasing the effectiveness of antibodies.
• Leukocytes in breast milk provide protection against common respiratory infectious invaders.
• Macrophages, responsible for producing interferon (a protein that protects against viruses), help
interfere with virus growth.
• The presence of L. bifidus in breast milk interferes with the colonization of pathogenic bacteria in the
gastrointestinal tract, reducing the incidence of diarrhea.
• Breast milk contains the ideal electrolyte and mineral composition for human infant growth.
 • Breast milk is high in lactose, an easily digested sugar that provides ready glucose for rapid brain
growth.
• Breast milk contains nitrogen in compounds other than protein, so that an infant can receive cell-
building materials from sources other than just protein.
• Breast milk contains more linoleic acid, an essential fatty acid for skin integrity.
• Breastfeeding may also help prevent excessive weight gain in infants.
• Infants make breastfeeding the best preparation for forming common speech sounds.
Skin-to-skin contact
Skin-to-skin contact following birth involves placing the naked infant prone on the mother’s bare chest at
birth or within a few minutes of birth. All mothers should be encouraged to place their infants in skin-to-
skin contact, regardless of mode of birth, unless prevented by a medical reason such as illness or
significant prematurity.
Beginning Breastfeeding
Breastfeeding should begin as soon after birth as possible, ideally while the woman is still in the birthing
room and while the infant is in the first reactivity period.
Getting your baby to latch

Pull your baby close so that the Watch the lower lip and aim it as far
Tickle the baby’s lips to encourage
him or her to open wide. chin and lower jaw moves into from base of nipple as possible so
your breast first. the baby takes a large mouthful of
breast.
Breastfeeding holds
Clutch or “football” hold: useful if you have had a C-section, or if you have large
breasts, flat or inverted nipples, or a strong let-down reflex. This hold is also
helpful for babies who like to be in a more upright position when they feed. Hold
your baby at your side with the baby lying on his or her back and with his or her
head at the level of your nipple. Support your baby’s head by placing the palm of
your hand at the base of his or her head.

Cross-cradle or transitional hold: useful for premature babies or babies with a

weak suck because this hold gives extra head support and may help the baby stay
latched. Hold your baby along the area opposite from the breast you are using. Support your baby’s head
at the base of his or her neck with the palm of your hand.

Cradle hold: an easy, common hold that is comfortable for most mothers and
babies. Hold your baby with his or her head on your forearm and his or her body
facing yours.

Laid-back hold (straddle hold): a more relaxed, baby-led approach. Lie back on a
pillow. Lay your baby against your body with your baby’s head just above and
between your breasts. Gravity and an instinct to nurse will guide your baby to
your breast. As your baby searches for your breast, support your baby’s head and
shoulders but don’t force the latch.

Side-lying position: useful if you have had a C-section, but also allows you to
rest while the baby breastfeeds. Lie on your side with your baby facing you.
Pull your baby close so your baby faces your body.

Latch Breastfeeding Charting System

0 1 2
L Latch Too sleepy or reluctant;
no latch achieved
Repeated attempts; hold
nipple in mouth; stimulate
Grasps breast; tongue down;
lips flanged; rhythmic
to suck sucking
Spontaneous and intermittent
A Audible None A few with stimulation
under 24 hr old; spontaneous
Swallowing and frequent over 24 hr old
Everted (after stimulation)
Inverted Flat
T Type of Nipple Filling; reddened/small
Soft, nontender
Engorged; cracked,
blisters or bruises;
C Comfort bleeding, large blisters or
bruises; severe mild/moderate discomfort
(Breast/Nipple)
discomfort

Full assists (staff holds
H Hold (Positioning) infant at breast)
Minimal assist (i.e.,place No assist from staff; mother
pillows for support,
elevate head of bed); teach
able to position/hold baby by
self
one side, mother does
other; staff holds and then
mother takes over

Theories of Development
A. Freud’s Psychoanalytic Theory
B. Erikson’s Theory of Psychosocial Development
C. Piaget’s Theory of Cognitive Development
D. Kohlberg’s Theory of Moral Development
Concepts of Growth and Development: Normal Infant Growth and Development Milestones