The Birth Place at St. Rita's "Guide for new mothers" by Amy Howell Hirt

The Birth Place at St. Ritaâ&#x20AC;&#x2122;s

Guide for new mothers

Welcome to The Birth Place at St. Rita’s! The big day has arrived! All the months of preparation are over and now it’s time to deliver and hold your baby in your arms. We’re going to take great care of you both and provide the support and information you need to make this the best experience it can be. We will involve you in our shift report at your bedside to make sure we understand your wishes, and will work with you to keep you as comfortable as possible throughout your labor, delivery and recovery. If there is anything you need during your stay, please don’t hesitate to ask. Warmly, The manager and nursing staff of The Birth Place at St. Rita’s

General Information BIRTHING SUITES • You will stay in a private room for labor and delivery. Then you and your baby will be transferred to a comfortable and private postpartum room, where there’s plenty of space for guests. • Your baby stays with you, receiving the care he or she needs right in your room. • Your mother-baby nurse will care for your baby at your bedside. She will teach you how best to care for yourself and your baby.

VISITORS • Visitation is anytime since we realize babies are born at all hours of the day and night. • We welcome up to three support people during labor and delivery, but there may be times when we need to further limit your visitors. • To create the safest environment, no children under the age of 12 are permitted to visit, unless they are a sibling. Our comfortable lobby is available so that visitors may take turns coming into your birthing suite. • For non-emergency cesarean births, one person over age 18 may go to the surgery suite as long as the patient is not going to be “put to sleep” using general anesthesia. • Due to fire codes, safety and patient confidentiality, visitors are not permitted to stand in the hallways. • During certain times of the year, such as flu season, we may restrict young visitors.

BABY’S FIRST PHOTOS Mercy Health partners with Fresh Imprints, a photography company, to provide first photos of your baby. To learn more, please visit fresh-imprints.com.

WIRELESS SERVICE We offer free Wi-Fi service to patients and guests. To connect via a smartphone, tablet or laptop: 1. Go to your wireless network connection icon (Mac users – see your top right tool bar; Windows users – see the bottom right of your screen). 2. Click on the wireless icon and accept the screen using “MercyGuest”. 3. Next you will be requested to accept a wireless network that isn’t secure. After agreeing to these terms, launch your web browser. 4. The “Mercy Health” connection screen will appear. Review the “Terms of use” agreement on the welcome page and click “Accept” to confirm. This will connect you to the Internet.

DISCHARGE We understand the excitement of going home and want to make that transition as smooth as possible. Here is a list of everything that needs to be completed for you to take your baby home. Please tell your nurse what time you’d like to leave. This will allow us to plan for discharge orders to be written and for items on this list to be completed. Birth certificate worksheet: Please give all colored copies to your nurse.

CAMERA AND VIDEO POLICIES

Newborn metabolic screen blood test: This test is completed on most newborns 24 hours after birth.

Our policies on media coverage, photography and videotaping are designed for the safety of you and your baby.

Hearing screening: This screening must be completed on all newborns.

• Guests may use cameras and video cameras in your birthing suite. During the birth, however, your doctor or midwife may restrict their use.

Vaccines: Any vaccines ordered by your doctor or pediatrician must be given.

• Filming or videotaping of medical procedures or births for public broadcast or educational use is not permitted. This includes live Internet hookups. • Reporters may not film or record medical care delivery, procedures or births. They may not cover these events live, including by phone.

QUIET TIME Resting is healing, so we offer quiet time from 2-4 p.m. every day in our private postpartum rooms. At 2 p.m., we ask visitors to wait in the waiting room and all doors will be shut and hallway lights will be dimmed. No one will come into your room at this time so that you and your support person can rest.

Prescriptions: If the doctor or midwife has prescribed medication for you or your baby, please make sure you’ve been given the medicine or the prescription. Circumcision: If circumcised, newborn boys must stay in the hospital for at least one hour after circumcision. To discharge you and your baby from the hospital, your nurse will: • Complete discharge orders and instructions for you and your newborn • Help you sign all necessary paperwork • Check that your identification bands match your newborn’s • Remove the security tag on your baby

Labor, delivery and recovery

“Birth is not only about making babies.

Birth is about making mothers — strong,

competent, capable mothers

who trust themselves and

know their inner strength.” — Barbara Katz Rothman, sociologist and author

Labor, delivery and recovery This section will help you prepare for the delivery of your baby and what to expect during your stay at The Birth Place at St. Ritaâ&#x20AC;&#x2122;s. We want to make this special experience comfortable for you and your loved ones. If you have questions, please ask your nurse, physician or midwife.

INFORMATION IN THIS SECTION A3 Admission A3 IV fluids A3 Urinary catheters A3 Group B strep A4 Labor stages A6 Labor monitoring A7 Induced labor A7 Cesarean birth A8 Pain management A12 Newborn testing and treatment A14 Circumcision A15 Newborn medications and immunizations A22 Common discomforts after delivery A25 Common medications A30 Recovery and quiet time

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Admission Upon admission to labor and delivery, your nurse will familiarize you with the safety measures, call light, bed operations, visitation policy, television and telephone operation. In addition, a nurse will assess your baby’s heart rate and your contractions through an external fetal monitor. We provide care to meet your specific needs, including a number of routine procedures: • Assessing your baby’s heart rate • Monitoring your contractions • Controlling your pain and providing comfort measures • Periodically checking your cervix for progression of labor • Collecting a urine specimen • Drawing blood for laboratory analysis • Placing an IV or saline drip in your arm • Providing ice chips

IV FLUIDS You need IV fluids if you receive an epidural, are induced or if you experience any complications or have an increased risk for complications.

URINARY CATHETERS You should empty your bladder frequently during labor. If you aren’t able to empty your bladder on your own, a urinary catheter may be used to help drain your bladder.

GROUP B STREP (GBS) If you tested positive for GBS during your pregnancy, you’ll be given IV antibiotics when your labor begins. Antibiotics may also be given if you have certain risk factors for GBS and your GBS status is unknown. Penicillin is the medication most often used to treat GBS. These precautions help prevent bacteria from spreading to your baby during birth. It’s very important to tell your doctor, nurse or midwife if you’re allergic to penicillin or any related medications. Please discuss any concerns you may have with your nurse or doctor.

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Labor stages The four stages of labor include early labor to after-delivery.

FIRST STAGE This stage is divided into three phases. Phase 1: Early labor • Mild contractions begin 15 to 20 minutes apart, then increase to five minutes apart. • Passing of the mucus plug (also called “bloody show”) may happen. This can occur anywhere from two weeks to 24 hours before delivery. • Your amniotic sac (or “water”) may break. This can be a gush or slow trickle. • You may have an increase in lower back pain or abdominal cramping. • By the end of early labor, your cervix will have dilated 4 to 5 centimeters (cm). • This phase can last up to 24 hours with a first pregnancy. Phase 2: Active labor • Contractions are generally three to five minutes apart. • Vaginal discharge increases. • Your amniotic sac may break, if it did not break in early labor. • You may have increased fatigue between contractions. • With a first baby, the cervix dilates approximately 1 cm per hour. • By the end of active labor, your cervix will have dilated to approximately 8 cm. Phase 3: Transition • Contractions are generally two to three minutes apart. • You may feel an urge to push, but shouldn’t push unless directed by your healthcare team. • You may feel nausea and experience vomiting, leg cramps, chills, sweating or uncontrollable shaking. • By the end of the transition phase, your cervix will be fully dilated to 10 cm.

SECOND STAGE This stage begins when your cervix is fully dilated and ends with the birth of your baby. It may last as little as 15 minutes or continue for several hours. • Contractions slow down and are now two to five minutes apart. • Your uterus bears down with each contraction, creating an overwhelming desire to push the baby out.

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• You allow your body to push the baby down into the birth canal without physically bearing down. This is called “laboring down.” It allows you to rest and conserve your energy before delivery. It also decreases your chances of having a vaginal laceration. • You may labor down for an hour or more, as long as there are no complications. You can use laboring down whether or not you receive an epidural block. • When your baby reaches a particular place in your vagina, you’ll experience an urge to push. This is called “spontaneous bearing-down reflex.” This reflex may occur at approximately +2 station, which is about halfway down the birth canal. If you wait to push, your body does some of the early work of bringing the baby down lower while you conserve your energy. • Your baby moves down the birth canal until the top of the head appears in the vagina. • A few final pushes deliver your baby. Sometimes it’s necessary for the doctor to make a small cut (called an “episiotomy”) or use forceps or a vacuum to help with the delivery of your baby.

THIRD STAGE This stage begins after your baby is born and ends when the placenta is delivered. • Contractions become less painful and the placenta is delivered. • You may experience some chills and/or shaking. • Your provider will repair any episiotomy or tearing of the vagina. • You’ll hold your baby skin-to-skin and be given the opportunity to breastfeed.

FOURTH STAGE This stage is the immediate recovery period, from delivery of the placenta until two hours after delivery. • You may experience some afterpains as your uterus remains firm to decrease bleeding. Your nurse will check the firmness of your uterus every 15 minutes during the recovery period. • Pain should be mild. Tell your nurse if the pain is severe. • You and your baby will be monitored closely. • This is an important time to bond with your baby and begin breastfeeding.

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Labor monitoring FETAL MONITORING • External: A device is placed on your abdomen to monitor your contractions and your baby’s heart rate. • Internal: A small wire (known as a scalp electrode) is attached to your baby’s scalp to record his or her heart rate. This can only be done after your water has broken. • Telemetry: A cordless device can be used for fetal and contraction monitoring. This allows you more freedom of movement during labor. • Intermittent monitoring: A handheld Doppler, like the one used during your prenatal office visits, can be used to listen to your baby’s heartbeat during labor.

CONTRACTION MONITORING • External: A device is placed on your abdomen to monitor your baby’s heart rate and the duration and frequency of your contractions. • Intrauterine pressure catheter (IUPC): A small fluid-filled catheter is placed between the baby and the wall of the uterus and is used to record the pressure of each contraction.

PELVIC EXAMS A pelvic exam determines the status of your cervix and the position of the baby’s head. The frequency of these exams depends on your individual labor and your doctor. During a pelvic exam, the following are assessed: • Dilation: This is the amount the cervix has opened in preparation for the delivery of your baby, measured in centimeters, from 0 cm to 10 cm. It is time to begin pushing your baby out when your cervix is fully dilated to 10 cm and you feel an urge to push. • Effacement: As your cervix prepares for the delivery of your baby, it “thins out,” measured in percentages from 0 percent to 100 percent. When your cervix is 100 percent effaced and you are fully dilated, you are ready to begin pushing. • Station: This is a measurement of your baby’s position in the birth canal, from -3 to +3 station. When the baby has descended to the bony landmarks of the pelvis, the baby is said to be at “0 station” or “fully engaged.” As the baby descends further, the station numbers become positive.

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Induced labor Your doctor may induce labor if your baby is overdue or if it is medically necessary for the safety of you or your baby. Typically, induction/ augmentation does not occur until you’ve reached 39 weeks gestation. Labor can be induced/augmented through one or more of the following methods: • Applying a prostaglandin gel on the cervix to ripen (soften) it • Infusing oxytocin, a hormone that triggers contractions • Rupturing your amniotic sac, which is also called “breaking your water” • Foley Catheter Induction – cervical ripening by inserting a foley catheter through the cervix and inflating the bulb on the end to slowly soften and dilate the cervix Your doctor also may assist with the rupturing of the amniotic sac if your water does not break on its own. This may be performed to place an internal fetal monitor and/or IUPC. This also allows the doctor to check your amniotic fluid. If the fluid is found to be “meconium-stained,” it means your baby has passed its first stool while still in your uterus. This can cause your baby to have breathing problems after delivery, so he or she may need special attention.

Cesarean birth A cesarean birth (also known as a C-section) may be planned or unplanned. In a C-section, a surgical incision is made in the mother’s abdomen and uterus to deliver the baby. C-sections are performed when a vaginal delivery is not possible or when there is a concern for the well-being of the mother and/or the baby. To ensure safety during a C-section, you’ll be asked to state your name, date of birth and what procedure is being performed. The doctor, anesthesia provider, nursing staff and surgical staff will also review equipment needs and issues regarding your care.

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Pain management Just as each woman’s labor is unique, the intensity of pain experienced in labor varies. Many factors contribute to the pain you’ll experience during labor. These include: • Contractions that dilate your cervix • Stretching of your vagina and perineum • Pressure from your baby’s head as he or she moves down the birth canal • The size and position of your baby • Your own fears and anxieties

PAIN SCALE You’ll use this pain chart to rate your pain. This helps your doctor and nurse manage your pain. It’s important to understand your options for controlling pain during labor and realize that your decision to use or not use pain medication may change during labor. Your doctor and nurse can help you choose the best techniques for you and your baby.

Activity Examples

10 Hurts Worst

Hurts Whole Lot

Hurts Even More

Hurts Little More

Hurts Little Bit

Unable to do any activities because of pain.

INTENSE, DREADFUL, HORRIBLE

Unable to do most activities because of pain.

MISERABLE, DISTRESSING

Unable to do some activities because of pain.

NAGGING PAIN, UNCOMFORTABLE, TROUBLESOME

Can do most activities with rest periods.

MILD PAIN, ANNOYING

Pain is present but does not limit activity.

0 No Hurt A8

WORST PAIN POSSIBLE, UNBEARABLE

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NO PAIN

• Can’t turn in bed • Flinches when touched • Hard to take a deep breath

• Can watch TV • Cannot stand/walk

• Can eat, get up to go to bathroom, talk with family in the room • Can’t sleep

• Uncomfortable when walking w/therapy, talking on phone • Sleep, bathe self • Increased pain w/activity, subsides w/rest • Slight discomfort • Able to make eye contact • Relaxed facial expressions • Sleeps well • Eats well

• Able to perform all normal daily activity without discomfort • Normal body positioning • No moaning, grimacing or restlessness noted

BREATHING TECHNIQUES Cleansing breath: Take a long, slow, deep breath as your contraction begins, then slowly blow it out, allowing your body to completely relax. Patterned paced breathing: This technique begins with a cleansing breath and then breathing with your own pattern and rhythm. It can be modified for each individual. Women often make noises to release tension as they are breathing out. It’s important to keep breathing and not hold your breath. Focal point: A focal point is an external focus during labor. It can be a picture or something specific in the room. You may also find it comforting to focus on the eyes of your partner or support person. A visual focal point is not necessary. Some women prefer a more internal approach, closing their eyes and focusing inward.

RELAXATION TECHNIQUES Calm environment: Create a relaxing environment with dim lighting, a reduced noise level and, if you choose, fewer support people in the room. Music: Music can be soothing and relaxing. You can choose to listen to music that helps you de-stress. Aromatherapy: Aromatherapy is an effective way to relax the nervous system and ease the aches and pains of labor. Guided imagery: Mental images or thoughts can help guide you to a more relaxed and focused state. These can be special memories or calming scenes. Massage: Gentle pressure and relaxation massage over specific muscle groups may reduce your pain. Circular strokes that are light or firm to the touch may help relax you. Laboring positions: You can use position and movement to keep yourself comfortable. There are several positions to choose from and it often helps to change positions. Some positions include: • Sitting in a rocking chair Sitting on a birthing ball: A birthing ball facilitates position changes. It can be used to decrease perineal pressure by sitting on it and rocking or bouncing lightly. It is useful in decreasing back pain or back labor. • Walking: Light walking or movement during labor reduces tension and promotes relaxation. • Sitting cross-legged • Lying on your side • Being on your hands and knees

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For back labor: This occurs when contractions are almost entirely felt in the lower back due to how the infant is positioned in the uterus. Frequent changes in labor positions can help, especially using the hands-and-knees position. Applying counter-pressure on your tailbone region also can help alleviate some of the pressure you feel. Cold/warm therapy: A heating pad, ice pack, shower or bath also can help alleviate back discomfort.

EPIDURAL BLOCK An epidural numbs your body from the waist down. It is the most commonly applied form of regional anesthesia for childbirth. Epidurals are used for both vaginal and cesarean section (C-section) deliveries. • The anesthesia provider will discuss the procedure with you and review the risks and benefits of the epidural. • A “time out” will take place as the anesthesia provider prepares the supplies for epidural placement. • To ensure your safety, visitation will be limited during the insertion of the epidural. • You’ll be asked to sit or lie on your side with your back curved outward. You’ll remain in this position until the procedure is complete. • Before the block is performed, your skin will be cleaned and local anesthesia will be used to numb an area of your lower back. • After the epidural needle is placed, a catheter is inserted through it and the needle is withdrawn. • Pain-numbing medication is injected through a small piece of flexible tubing inserted into the lower back. • The medication can be given or re-dosed without another injection. • Pain relief begins 10 to 20 minutes after the medication is given. • The epidural effectively eases pain from contractions as well as vaginal and perineal pain as your baby moves down the birth canal. • The epidural may not relieve all your pain, but it should make the pain more manageable.

SPINAL BLOCK • A spinal block, like an epidural block, is an injection in the lower back to numb the lower half of the body. • This pain management provides stronger and faster pain relief, but it lasts only an hour or two. • It’s commonly used for C-section births. • A spinal block is generally given only once during labor and is best suited for pain relief during delivery.

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LOCAL ANESTHESIA • This form of anesthesia is used to relieve pain in a small area. • It’s administered in the vaginal or rectal areas. • Local anesthesia is helpful in reducing the pain of an episiotomy incision or vaginal tearing. • This form of pain management does not lessen the pain of contractions.

GENERAL ANESTHESIA • General anesthesia is a state of unconsciousness. You are not awake to feel pain. • It can be started quickly and causes a rapid loss of consciousness. • General anesthetics are often used when an emergency C-section is needed or if general anesthesia is medically necessary. • After general anesthesia, you may feel groggy and disoriented. You may have a sore throat from the tube inserted in your mouth to help you breathe.

TIPS FOR YOUR PARTNER OR SUPPORT PERSON • Remain calm and support your partner no matter what she wants. • Encourage your partner by telling her that you are there to support and help her, and that soon you’ll both have a beautiful baby to hold and love. • Tell her how proud you are of her and that she is doing great. • Provide ice chips. • Provide massages, back rubs and counter pressure. • Make eye contact to help her maintain focus. • Breathe with her to help keep her breathing steady and rhythmic. • Time her contractions. • Know where the emesis basin is in case of nausea or vomiting. • Remember to eat and hydrate yourself during the labor process. Take short breaks when you need them to keep your strength up.

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Newborn testing and treatments APGAR SCORE The APGAR score helps your baby’s doctor estimate your baby’s general condition at birth. The score is assigned at one minute and five minutes of life. Your baby is evaluated in five areas: heart rate, color, breathing, muscle tone and reflexes. In each of these areas, your baby is assigned a score of 0, 1 or 2 based on certain criteria. The highest total score is a 10, which very few babies receive. The APGAR score can’t predict how healthy your baby will be as he or she grows up or how he or she will develop. It doesn’t indicate your baby’s intelligence or personality. It does alert the hospital staff if a baby is sleepier or slower to respond than normal and may need assistance adapting to the world outside the womb.

VITAMIN K Because babies are born with a low production of vitamin K, an injection is given within two hours of birth. This helps with blood clotting and helps prevent a rare but serious bleeding disorder.

EYE PROPHYLAXIS All babies born in the U.S. are required to have a treatment that protects them from blindness due to gonorrhea. An antibiotic ointment, such as erythromycin, is applied to infants’ eyes after delivery.

HEPATITIS B VACCINE The hepatitis B vaccine is recommended. If you give your consent, your baby will receive the vaccine at 12-24 hours of age. This is the first of the three recommended vaccine doses. The second is given at 1 to 2 months of age, and the third between 6 and 18 months. A vaccine information sheet will be provided to you with more information about the vaccine.

HEARING SCREENS At 12 to 24 hours of age, your baby will receive one or possibly two hearing screens. It is common for babies to have amniotic fluid or blood in their ear canals, which makes it difficult to pass the screen. This does not mean your baby cannot hear. If your baby does not pass the hearing screens, you will need to take your baby to a hearing specialist for further testing.

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CONGENITAL HEART DISEASE (CHD) SCREENING After 24 hours of age, your baby will receive a screen for potential heart complications. This requires checking the amount of oxygen in one of your baby’s hands and feet. If your baby does not pass this screening, it does not mean that your baby has heart complications. Further testing will be completed in the hospital.

NEWBORN METABOLIC SCREENING After 24 hours of age, a newborn metabolic screen will be completed. This consists of pricking your baby’s heel to collect blood on a special piece of paper. To help with your baby’s comfort, he or she will be offered either a pacifier or a gloved finger dipped in sugar water during the procedure. Once the form is completed, it will be sent to the state of Ohio and tested for many different diseases. The results will be sent to your baby’s doctors.

CARSEAT CHALLENGE TEST Due to their size, some babies can’t tolerate being in a car seat beyond a certain amount of time. If your baby is small for his or her gestational age, or under a certain weight, he or she will be tested by being securely fastened in his or her car seat. Our staff will monitor your baby’s heart rate, breathing and oxygen saturation. This test is given in the nursery and you are welcome to stay with your baby.

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Circumcision Some parents decide to have their baby boy circumcised. Circumcision is the removal of the foreskin around the head of the penis. If you decide on a circumcision, it will be done in the nursery by your doctor. Your baby will need to weigh more than four pounds. If he’s small or has a medical problem, the circumcision will be postponed. Your baby will be circumcised only with your permission. The doctor will have you sign a permit before the circumcision is done. Your baby’s comfort is important to us. We help minimize his pain in several ways: • The doctor uses a numbing medicine before the circumcision. • During the circumcision, your baby will be offered a gloved finger or pacifier dipped in sugar water. This is proven to reduce pain in infants. • Vaseline will be placed around the head of the penis to prevent it from sticking to the diaper.

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Newborn medications Newborns often receive these medications and immunizations during their stay in the hospital. If you have any questions, please ask your nurse, doctor or pharmacist

VITAMIN K Uses: Assists in clotting of blood Dose: 0.5-1 mg injection Frequency: Once within two hours of birth Common side effects: Irritation at the injection site

ERYTHROMYCIN Uses: Prevention of eye infection Dose: 0.5-percent ointment in each eye Frequency: Once, following delivery Common side effects: Swelling and slight redness around the eyes Special considerations: Ask a doctor or nurse before wiping away excess ointment

SWEET EASE Uses: Short-term pain relief during painful procedures Dose: Varies; given orally Frequency: As needed before/during a painful procedure Common side effects: Drowsiness Special considerations: Can affect blood sugar levels if given in multiple doses

HEPATITIS B VACCINE Uses: Immunization again hepatitis B virus Dose: Injection of 10 micrograms/0.5mL Frequency: Series of three vaccines Common side effects: Pain at the injection site; flu-like symptoms

LIDOCAINE Uses: Numbing a localized area, such as before circumcision Dose: Varies depending on the procedure; given as an injection Frequency: Varies with procedure Common side effects: Irritation at the injection site; numbness; tingling

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VACCINE INFORMATION STATEMENT

Hepatitis B Vaccine

Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis

What You Need to Know 1

Why get vaccinated?

Hepatitis B is a serious disease that affects the liver. It is caused by the hepatitis B virus. Hepatitis B can cause mild illness lasting a few weeks, or it can lead to a serious, lifelong illness. Hepatitis B virus infection can be either acute or chronic. Acute hepatitis B virus infection is a short-term illness that occurs within the first 6 months after someone is exposed to the hepatitis B virus. This can lead to: • fever, fatigue, loss of appetite, nausea, and/or vomiting • jaundice (yellow skin or eyes, dark urine, clay-colored bowel movements) • pain in muscles, joints, and stomach Chronic hepatitis B virus infection is a long-term illness that occurs when the hepatitis B virus remains in a person’s body. Most people who go on to develop chronic hepatitis B do not have symptoms, but it is still very serious and can lead to: • liver damage (cirrhosis) • liver cancer • death Chronically-infected people can spread hepatitis B virus to others, even if they do not feel or look sick themselves. Up to 1.4 million people in the United States may have chronic hepatitis B infection. About 90% of infants who get hepatitis B become chronically infected and about 1 out of 4 of them dies. Hepatitis B is spread when blood, semen, or other body fluid infected with the Hepatitis B virus enters the body of a person who is not infected. People can become infected with the virus through: • Birth (a baby whose mother is infected can be infected at or after birth) • Sharing items such as razors or toothbrushes with an infected person • Contact with the blood or open sores of an infected person • Sex with an infected partner • Sharing needles, syringes, or other drug-injection equipment • Exposure to blood from needlesticks or other sharp instruments

Hojas de información sobre vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis

Hepatitis B vaccine can prevent hepatitis B and its consequences, including liver cancer and cirrhosis.

Hepatitis B vaccine is made from parts of the hepatitis B virus. It cannot cause hepatitis B infection. The vaccine is usually given as 3 or 4 shots over a 6-month period. Infants should get their first dose of hepatitis B vaccine at birth and will usually complete the series at 6 months of age. All children and adolescents younger than 19 years of age who have not yet gotten the vaccine should also be vaccinated. Hepatitis B vaccine is recommended for unvaccinated adults who are at risk for hepatitis B virus infection, including: • People whose sex partners have hepatitis B • Sexually active persons who are not in a long-term monogamous relationship • Persons seeking evaluation or treatment for a sexually transmitted disease • Men who have sexual contact with other men • People who share needles, syringes, or other druginjection equipment • People who have household contact with someone infected with the hepatitis B virus • Health care and public safety workers at risk for exposure to blood or body fluids • Residents and staff of facilities for developmentally disabled persons • Persons in correctional facilities • Victims of sexual assault or abuse • Travelers to regions with increased rates of hepatitis B • People with chronic liver disease, kidney disease, HIV infection, or diabetes • Anyone who wants to be protected from hepatitis B There are no known risks to getting hepatitis B vaccine at the same time as other vaccines.

Each year about 2,000 people in the United States die from hepatitis B-related liver disease.

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Hepatitis B vaccine

G U I D E F O R N E W M OT H E R S | T H E B I R T H P L AC E AT S T. R I TA’ S

U.S. Department of Health and Human Services Centers for Disease Control and Prevention

Some people should not get this vaccine

Tell the person who is giving the vaccine: • If the person getting the vaccine has any severe, lifethreatening allergies. If you ever had a life-threatening allergic reaction after a dose of hepatitis B vaccine, or have a severe allergy to any part of this vaccine, you may be advised not to get vaccinated. Ask your health care provider if you want information about vaccine components. • If the person getting the vaccine is not feeling well. If you have a mild illness, such as a cold, you can probably get the vaccine today. If you are moderately or severely ill, you should probably wait until you recover. Your doctor can advise you.

Risks of a vaccine reaction

With any medicine, including vaccines, there is a chance of side effects. These are usually mild and go away on their own, but serious reactions are also possible. Most people who get hepatitis B vaccine do not have any problems with it. Minor problems following hepatitis B vaccine include: • soreness where the shot was given • temperature of 99.9°F or higher If these problems occur, they usually begin soon after the shot and last 1 or 2 days. Your doctor can tell you more about these reactions. Other problems that could happen after this vaccine: • People sometimes faint after a medical procedure, including vaccination. Sitting or lying down for about 15 minutes can help prevent fainting and injuries caused by a fall. Tell your provider if you feel dizzy, or have vision changes or ringing in the ears. • Some people get shoulder pain that can be more severe and longer-lasting than the more routine soreness that can follow injections. This happens very rarely. • Any medication can cause a severe allergic reaction. Such reactions from a vaccine are very rare, estimated at about 1 in a million doses, and would happen within a few minutes to a few hours after the vaccination.

What if there is a serious problem?

What should I look for? • Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or unusual behavior. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination.

What should I do? • If you think it is a severe allergic reaction or other emergency that can’t wait, call 9-1-1 or get to the nearest hospital. Otherwise, call your clinic. Afterward, the reaction should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor should file this report, or you can do it yourself through the VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967. VAERS does not give medical advice.

The National Vaccine Injury Compensation Program

The National Vaccine Injury Compensation Program (VICP) is a federal program that was created to compensate people who may have been injured by certain vaccines. Persons who believe they may have been injured by a vaccine can learn about the program and about filing a claim by calling 1-800-338-2382 or visiting the VICP website at www.hrsa.gov/vaccinecompensation. There is a time limit to file a claim for compensation.

How can I learn more?

• Ask your healthcare provider. He or she can give you the vaccine package insert or suggest other sources of information. • Call your local or state health department. • Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 (1-800-CDC-INFO) or - Visit CDC’s website at www.cdc.gov/vaccines

As with any medicine, there is a very remote chance of a vaccine causing a serious injury or death. The safety of vaccines is always being monitored. For more information, visit: www.cdc.gov/vaccinesafety/

Vaccine Information Statement

Hepatitis B Vaccine

Office Use Only

7/20/2016 42 U.S.C. § 300aa-26

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VACCINE INFORMATION STATEMENT

MMR Vaccine

(Measles, Mumps and Rubella)

What You Need to Know 1

Why get vaccinated?

Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis Hojas de información Sobre Vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis

Who should get MMR vaccine and when?

Measles, mumps, and rubella are serious diseases. Before vaccines they were very common, especially among children.

Children should get 2 doses of MMR vaccine:

Measles • Measles virus causes rash, cough, runny nose, eye irritation, and fever.

• Second Dose: 4–6 years of age (may be given earlier, if at least 28 days after the 1st dose)

• It can lead to ear infection, pneumonia, seizures (jerking and staring), brain damage, and death. Mumps • Mumps virus causes fever, headache, muscle pain, loss of appetite, and swollen glands. • It can lead to deafness, meningitis (infection of the brain and spinal cord covering), painful swelling of the testicles or ovaries, and rarely sterility. Rubella (German Measles) • Rubella virus causes rash, arthritis (mostly in women), and mild fever. • If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects. These diseases spread from person to person through the air. You can easily catch them by being around someone who is already infected. Measles, mumps, and rubella (MMR) vaccine can protect children (and adults) from all three of these diseases. Thanks to successful vaccination programs these diseases are much less common in the U.S. than they used to be. But if we stopped vaccinating they would return.

• First Dose: 12–15 months of age

Some infants younger than 12 months should get a dose of MMR if they are traveling out of the country. (This dose will not count toward their routine series.) Some adults should also get MMR vaccine: Generally, anyone 18 years of age or older who was born after 1956 should get at least one dose of MMR vaccine, unless they can show that they have either been vaccinated or had all three diseases. MMR vaccine may be given at the same time as other vaccines. Children between 1 and 12 years of age can get a “combination” vaccine called MMRV, which contains both MMR and varicella (chickenpox) vaccines. There is a separate Vaccine Information Statement for MMRV.

Some people should not get MMR vaccine or should wait.

• Anyone who has ever had a life-threatening allergic reaction to the antibiotic neomycin, or any other component of MMR vaccine, should not get the vaccine. Tell your doctor if you have any severe allergies. • Anyone who had a life-threatening allergic reaction to a previous dose of MMR or MMRV vaccine should not get another dose. • Some people who are sick at the time the shot is scheduled may be advised to wait until they recover before getting MMR vaccine. • Pregnant women should not get MMR vaccine. Pregnant women who need the vaccine should wait until after giving birth. Women should avoid getting pregnant for 4 weeks after vaccination with MMR vaccine.

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• Tell your doctor if the person getting the vaccine: - Has HIV/AIDS, or another disease that affects the immune system - Is being treated with drugs that affect the immune system, such as steroids - Has any kind of cancer - Is being treated for cancer with radiation or drugs - Has ever had a low platelet count (a blood disorder) - Has gotten another vaccine within the past 4 weeks - Has recently had a transfusion or received other blood products Any of these might be a reason to not get the vaccine, or delay vaccination until later.

What are the risks from MMR vaccine?

A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of MMR vaccine causing serious harm, or death, is extremely small. Getting MMR vaccine is much safer than getting measles, mumps or rubella. Most people who get MMR vaccine do not have any serious problems with it. Mild problems • Fever (up to 1 person out of 6) • Mild rash (about 1 person out of 20) • Swelling of glands in the cheeks or neck (about 1 person out of 75) If these problems occur, it is usually within 6-14 days after the shot. They occur less often after the second dose. Moderate problems • Seizure (jerking or staring) caused by fever (about 1 out of 3,000 doses) • Temporary pain and stiffness in the joints, mostly in teenage or adult women (up to 1 out of 4) • Temporary low platelet count, which can cause a bleeding disorder (about 1 out of 30,000 doses) Severe problems (very rare) • Serious allergic reaction (less than 1 out of a million doses) • Several other severe problems have been reported after a child gets MMR vaccine, including: - Deafness - Long-term seizures, coma, or lowered consciousness - Permanent brain damage These are so rare that it is hard to tell whether they are caused by the vaccine.

What if there is a serious reaction?

What should I look for? • Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or behavior changes. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination. What should I do? • If you think it is a severe allergic reaction or other emergency that can’t wait, call 9-1-1 or get the person to the nearest hospital. Otherwise, call your doctor. • Afterward, the reaction should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor might file this report, or you can do it yourself through the VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967. VAERS is only for reporting reactions. They do not give medical advice.

The National Vaccine Injury Compensation Program

How can I learn more?

• Ask your doctor. • Call your local or state health department. • Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 (1-800-CDC-INFO) or - Visit CDC’s website at www.cdc.gov/vaccines

Vaccine Information Statement (Interim)

MMR Vaccine

Office Use Only

4/20/2012 42 U.S.C. § 300aa-26

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VACCINE INFORMATION STATEMENT

Tdap Vaccine

What You Need to Know 1

Why get vaccinated?

Tetanus, diphtheria and pertussis are very serious diseases. Tdap vaccine can protect us from these diseases. And, Tdap vaccine given to pregnant women can protect newborn babies against pertussis.. TETANUS (Lockjaw) is rare in the United States today. It causes painful muscle tightening and stiffness, usually all over the body. • It can lead to tightening of muscles in the head and neck so you can’t open your mouth, swallow, or sometimes even breathe. Tetanus kills about 1 out of 10 people who are infected even after receiving the best medical care. DIPHTHERIA is also rare in the United States today. It can cause a thick coating to form in the back of the throat. • It can lead to breathing problems, heart failure, paralysis, and death. PERTUSSIS (Whooping Cough) causes severe coughing spells, which can cause difficulty breathing, vomiting and disturbed sleep. • It can also lead to weight loss, incontinence, and rib fractures. Up to 2 in 100 adolescents and 5 in 100 adults with pertussis are hospitalized or have complications, which could include pneumonia or death. These diseases are caused by bacteria. Diphtheria and pertussis are spread from person to person through secretions from coughing or sneezing. Tetanus enters the body through cuts, scratches, or wounds. Before vaccines, as many as 200,000 cases of diphtheria, 200,000 cases of pertussis, and hundreds of cases of tetanus, were reported in the United States each year. Since vaccination began, reports of cases for tetanus and diphtheria have dropped by about 99% and for pertussis by about 80%.

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(Tetanus, Diphtheria and Pertussis)

Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis Hojas de información sobre vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis

Tdap vaccine

Tdap vaccine can protect adolescents and adults from tetanus, diphtheria, and pertussis. One dose of Tdap is routinely given at age 11 or 12. People who did not get Tdap at that age should get it as soon as possible. Tdap is especially important for healthcare professionals and anyone having close contact with a baby younger than 12 months. Pregnant women should get a dose of Tdap during every pregnancy, to protect the newborn from pertussis. Infants are most at risk for severe, life-threatening complications from pertussis. Another vaccine, called Td, protects against tetanus and diphtheria, but not pertussis. A Td booster should be given every 10 years. Tdap may be given as one of these boosters if you have never gotten Tdap before. Tdap may also be given after a severe cut or burn to prevent tetanus infection. Your doctor or the person giving you the vaccine can give you more information. Tdap may safely be given at the same time as other vaccines.

Some people should not get this vaccine

• A person who has ever had a life-threatening allergic reaction after a previous dose of any diphtheria, tetanus or pertussis containing vaccine, OR has a severe allergy to any part of this vaccine, should not get Tdap vaccine. Tell the person giving the vaccine about any severe allergies. • Anyone who had coma or long repeated seizures within 7 days after a childhood dose of DTP or DTaP, or a previous dose of Tdap, should not get Tdap, unless a cause other than the vaccine was found. They can still get Td. • Talk to your doctor if you: - have seizures or another nervous system problem, - had severe pain or swelling after any vaccine containing diphtheria, tetanus or pertussis, - ever had a conditioned called Guillain-Barré Syndrome (GBS), - aren’t feeling well on the day the shot is scheduled.

G U I D E F O R N E W M OT H E R S | T H E B I R T H P L AC E AT S T. R I TA’ S

Risks

With any medicine, including vaccines, there is a chance of side effects. These are usually mild and go away on their own. Serious reactions are also possible but are rare. Most people who get Tdap vaccine do not have any problems with it. Mild problems following Tdap (Did not interfere with activities) • Pain where the shot was given (about 3 in 4 adolescents or 2 in 3 adults) • Redness or swelling where the shot was given (about 1 person in 5) • Mild fever of at least 100.4°F (up to about 1 in 25 adolescents or 1 in 100 adults) • Headache (about 3 or 4 people in 10) • Tiredness (about 1 person in 3 or 4) • Nausea, vomiting, diarrhea, stomach ache (up to 1 in 4 adolescents or 1 in 10 adults) • Chills, sore joints (about 1 person in 10) • Body aches (about 1 person in 3 or 4) • Rash, swollen glands (uncommon) Moderate problems following Tdap (Interfered with activities, but did not require medical attention) • Pain where the shot was given (up to 1 in 5 or 6) • Redness or swelling where the shot was given (up to about 1 in 16 adolescents or 1 in 12 adults) • Fever over 102°F (about 1 in 100 adolescents or 1 in 250 adults) • Headache (about 1 in 7 adolescents or 1 in 10 adults) • Nausea, vomiting, diarrhea, stomach ache (up to 1 or 3 people in 100) • Swelling of the entire arm where the shot was given (up to about 1 in 500). Severe problems following Tdap (Unable to perform usual activities; required medical attention) • Swelling, severe pain, bleeding and redness in the arm where the shot was given (rare). Problems that could happen after any vaccine: • People sometimes faint after a medical procedure, including vaccination. Sitting or lying down for about 15 minutes can help prevent fainting, and injuries caused by a fall. Tell your doctor if you feel dizzy, or have vision changes or ringing in the ears. • Some people get severe pain in the shoulder and have difficulty moving the arm where a shot was given. This happens very rarely. • Any medication can cause a severe allergic reaction. Such reactions from a vaccine are very rare, estimated at fewer than 1 in a million doses, and would happen within a few minutes to a few hours after the vaccination.

What if there is a serious problem?

What should I look for? • Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or unusual behavior. • Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would usually start a few minutes to a few hours after the vaccination. What should I do? • If you think it is a severe allergic reaction or other emergency that can’t wait, call 9-1-1 or get the person to the nearest hospital. Otherwise, call your doctor. • Afterward, the reaction should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor might file this report, or you can do it yourself through the VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967. VAERS does not give medical advice.

The National Vaccine Injury Compensation Program

How can I learn more?

• Ask your doctor. He or she can give you the vaccine package insert or suggest other sources of information. • Call your local or state health department. • Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 (1-800-CDC-INFO) or - Visit CDC’s website at www.cdc.gov/vaccines

Vaccine Information Statement

Tdap Vaccine 2/24/2015

Office Use Only

42 U.S.C. § 300aa-26

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Common discomforts after delivery Some discomforts are common after a vaginal or cesarean delivery, and some may continue after you leave the hospital. Your doctor, nurse or midwife can provide more information on how to reduce the pain or discomfort.

SHAKING AND CHILLS Soon after delivery, you may have shaking and chills. Your nurse will check your temperature. If you don’t have a fever, the shaking and chills will go away within an hour. You can also ask your nurse for extra warm blankets and hot liquids.

AFTERBIRTH PAINS After the placenta delivers, your uterus tightens firmly to the size of a grapefruit. Over the next four to six weeks, your uterus will continue to shrink to its non-pregnant size. This is called involution. As your uterus tightens, you may feel cramping in your lower stomach or back. This discomfort is known as afterbirth pains and may last for several days after delivery. These pains may increase with breastfeeding. To manage your afterbirth pain: • Take your pain medicine as prescribed. • Take frequent warm showers. • Put a warm pack to your lower stomach or lower back. • Empty your bladder often. A full bladder puts pressure on the uterus, causing it to cramp.

PERINEAL DISCOMFORT The perineum is the area around the birth canal or vagina. Some perineal discomfort is normal after a vaginal delivery. This discomfort is from stretching and swelling of the muscles during delivery. In addition, you may have stitches from the repair of an episiotomy or tear. To manage your perineal discomfort: • Take your pain medicine as prescribed. • Use an ice pack for the first 24 hours. Ice helps reduce discomfort and swelling. • Use a medicated spray or witch hazel pads, such as Tucks medicated pads. • Take a warm sitz bath several times a day. You can buy a sitz bath, which is a plastic bowl that fits over the toilet, or simply fill the bathtub with warm water up to your hips. You may add Epsom salt to the bath if your doctor recommends it. • Stitches dissolve on their own in 7 to 10 days. Until then, you may notice or feel them. Every time you use the restroom, rinse the area with the water from your “peri bottle.” • See page D8 for additional tips on perineal care.

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ABDOMINAL PAIN If you had a cesarean delivery, abdominal pain is normal. The pain is usually from your incision, which is often tender after delivery. Another source of abdominal discomfort after a cesarean delivery is gas pain. This discomfort is common for the first day or two after delivery. To manage your abdominal pain: • Take your pain medicine as prescribed. Your nurse will give you information about the type of pain medicines ordered by your doctor or midwife. • Move around in bed. Change positions frequently. • Walk around the hallways at least three times a day, once you are allowed to get out of bed. • Avoid carbonated drinks (such as soda) and very cold drinks, or eating foods that cause gas for you. If gas pains become a problem, your nurse can show you ways to help relieve the discomfort.

SWEATING Your body may get rid of some extra fluids by sweating. If you experience excessive sweating, shower and change your clothing often.

VAGINAL BLEEDING OR LOCHIA Healing of the uterus, cervix and vagina (birth canal) takes place during the first four to six weeks after delivery. During this time, you may have vaginal discharge, also called lochia. Lochia will be bright red the first few days, then turn pink to brown and then become white/clear over the next two to four weeks. Call your doctor or midwife if: • The lochia turns from pink or brown back to bright red • You are changing your pad more than once every hour • The lochia has a foul odor • You pass a blood clot bigger than the size of a lemon

FATIGUE OR FEELING TIRED Physical changes, hormone changes, emotional adjustments and lack of sleep can all lead to fatigue. To feel less tired: • Get plenty of rest. • Accept offers of help. • Eat a well-balanced diet. • Limit telephone calls and visitors if you need more rest.

DIFFICULTY PASSING URINE After a vaginal delivery, the area around your bladder may be swollen. This can lead to difficulty passing urine for some women. Don’t wait for your bladder to become too full before emptying it. Try to urinate often. A few days after delivery, you may notice that you’re passing urine in large amounts. Your kidneys help rid your body of the extra fluid retained during pregnancy.

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During this time, try to: • Drink eight to 10 glasses of water each day. • Take slow, deep breaths. • Run tap water. The sound of water may relax the bladder. • Pour warm water over your perineum. Call your doctor, nurse or midwife if you experience any of these signs of infection: • Pain and/or burning while urinating • Passing very small amounts of urine • Chills and/or fever • Pain in your back, near your kidneys

CONSTIPATION Constipation can be caused by hemorrhoids, surgery, stitches or the loss of abdominal muscle tone. It is normal not to have a bowel movement the first two to three days after delivery. To manage your constipation: • Eat a diet high in fiber, including whole grains, fruits and vegetables. • Drink eight to 10 glasses of water daily. • Take slow, frequent walks. • Take a stool softener or laxative if instructed by your doctor or midwife. If you don’t have a bowel movement within seven days after delivery, tell your doctor.

HEMORRHOIDS Hemorrhoids are dilated veins in the rectum. They are caused by the extra weight of pregnancy and by pushing during delivery. Hemorrhoids may make it uncomfortable for you to sit. They usually shrink in six weeks. To manage hemorrhoid discomfort: • Place an ice pack to this area to help decrease swelling. • Use medicated spray or witch hazel pads. • Take warm sitz baths two to three times a day. • Sit on a soft cushion or rubber ring. • Follow the above suggestions to reduce constipation and keep your bowel movements soft.

SWELLING Swelling of your hands or feet may become worse after delivery. This normally resolves within two weeks after delivery. Drink plenty of water to help reduce swelling.

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Common medications Your doctor may provide these medications during your labor, delivery or recovery.

PAIN MEDICATIONS TYLENOL (ACETAMINOPHEN) Uses: Mild pain; fever of 100.5Â°F or more; headache Dose: 650 mg orally Frequency: Every four hours as needed Common side effects: Upset stomach; rash Special considerations: Do not take more than 4,000 mg in a 24-hour period due to effects on the liver; can alternate with ibuprofen MOTRIN (IBUPROFEN) Uses: Mild pain; swelling; fever; uterine cramping Dose: 800 mg orally Frequency: Every eight hours as needed Common side effects: Stomach pain; nausea; vomiting Special considerations: Take with food; can take with acetaminophen or Percocet NORCO (ACETAMINOPHEN/HYDROCODONE) Uses: Moderate to severe pain Dose: One tablet for moderate pain (4-6 on the pain scale); two tablets for severe pain (7-10 on the pain scale) Frequency: Every four hours as needed Common side effects: Stomach upset; constipation PERCOCET (ACETAMINOPHEN/OXYCODONE) Uses: Moderate to severe pain Dose: One tablet for moderate pain (4-6 on the pain scale); two tablets for severe pain (7-10 on the pain scale) Frequency: Every four hours as needed Common side effects: Dizziness; drowsiness; upset stomach; constipation Special considerations: Drink plenty of water; take with food; avoid driving TORADOL (KETOROLAC) Uses: Moderate to severe pain (comparable to Motrin); given in addition to pain medications after a cesarean section Dose: 30 mg via IV Frequency: Every six hours as needed Common side effects: Headache; upset stomach; nausea; loose stool MORPHINE Uses: Moderate to severe pain Dose: 2 mg via IV for moderate pain (4-6 on the pain scale); 4 mg for severe pain (7-10 on the pain scale) Frequency: Every two hours as needed Common side effects: Itching; constipation; dizziness; tiredness

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SLEEPING AIDS AMBIEN (ZOLPIDEM) Uses: Falling asleep and staying asleep Dose: 10 mg orally Frequency: Once at bedtime Common side effects: Shortness of breath; rash; hives; altered thinking

CONSTIPATION AIDS/STOOL SOFTENERS COLACE (DOCUSATE SODIUM) Uses: Stool softener Dose: 100 mg orally Frequency: Once in morning; once at bedtime Common side effects: Diarrhea; abdominal cramping Special instructions: Drink plenty of water; avoid straining while having a bowel movement DULCOLAX SUPPOSITORY (BISACODYL) Uses: Constipation relief by causing a bowel movement or passing gas; works in 15 minutes to one hour Dose: 10 mg daily, given via rectum Frequency: As needed Common side effects: Mild abdominal discomfort; cramps; nausea

ANTI-NAUSEA DRUGS REGLAN (METOCLOPRAMIDE) Uses: Nausea and indigestion Dose: 10-20 mg, given by IV Frequency: Every six hours or before surgery Common side effects: Headache; diarrhea; dizziness ZOFRAN (ONDANSETRON) Uses: Nausea; vomiting Dose: 4 mg given by IV; 8 mg orally Frequency: Every six hours as needed via IV; every eight hours as needed by mouth Common side effects: Hives; wheezing Special considerations: Will not cause drowsiness

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ANTI-ITCH MEDICINE BENADRYL (DIPHENHYDRAMINE) Uses: Itching Dose: 25 mg by mouth or IV Frequency: Every four hours as needed Common side effects: Drowsiness; dizziness; dry mouth Special considerations: Use caution when walking DERMOPLAST SPRAY (BENZOCAINE) Uses: Soreness, discomfort and itching from stitches Dose: Spray on peri pads and/or the affected area Frequency: As needed Common side effects: Skin irritation; redness Special considerations: If irritation persists, discontinue use

ANTACIDS PEPCID (FAMOTIDINE) Uses: Acid reflux Dose: 20 mg orally Frequency: Two times daily as needed Common side effects: Dizziness; headache MYLICON (SIMETHICONE) Uses: Gas pain; indigestion Dose: 80 mg orally Frequency: Every six hours as needed Common side effects: Belching; flatulence; loose stool Special instructions: Chew; do not swallow whole

HEMORRHOID RELIEF ANUSOL CREAM (HYDROCORTISONE) Uses: Hemorrhoid swelling, itching and discomfort Dose: Apply as directed Frequency: As needed Common side effects: Irritation; redness ANUSOL SUPPOSITORY (HYDROCORTISONE ACETATE) Uses: Hemorrhoid swelling, itching and discomfort Dose: 25 mg as directed, given via rectum Frequency: As needed Common side effects: Stinging; irritation; skin rash WITCH HAZEL (TUCKS) PADS Uses: Discomfort of hemorrhoids and episiotomies Dose: Apply pad to perineum/rectal area; may be applied to peripads as well Frequency: As needed Common side effects: Skin irritation Special considerations: If irritation becomes intolerable, discontinue use

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EXCESSIVE VAGINAL BLEEDING METHERGINE (METHYLERGONOVINE) Uses: Excessive bleeding Dose: 0.2 mg given as injection in thigh or hip Frequency: As directed by doctor Common side effects: Shortness of breath; chest pain; ringing in the ears HEMABATE (CARBOPROST) Uses: Excessive bleeding; usually given if Methergine does not work or if you have high blood pressure Dose: 250 mcg/ml given as injection in thigh or hip Frequency: As directed by doctor Common side effects: Shortness of breath; hives; loose stool CYTOTEC (MISOPROSTOL) Uses: Excessive bleeding; usually given if Methergine or Hemabate does not work Dose: 800-1000 mcg given via rectum Frequency: As directed by doctor Common side effects: Headache; loose stool; abdominal pain; vomiting

ANTIBIOTICS ANCEF (CEFAZOLIN) Uses: Prevent infection after surgery Dose: 1-3 grams via IV Frequency: Two doses every eight hours Common side effects: Rash; hives; wheezing; upset stomach CLEOCIN (CLINDAMYCIN) Uses: Prevent infection after surgery; usually given if there is an allergy to Ancef Dose: 900 mg via IV Frequency: Two doses every eight hours Common side effects: Diarrhea; upset stomach; rash

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OTHER MEDICATIONS FERROUS SULFATE Uses: Hemoglobin levels less than 9 g/dL (iron-deficiency anemia) Dose: 325 mg by mouth Frequency: Daily with breakfast or as directed by doctor Common side effects: Constipation; upset stomach; black stool LANOLIN OINTMENT Uses: Nipple soreness Dose: Apply as directed Frequency: Every hour as needed Common side effects: Burning; redness; irritation Special considerations: Safe for baby; no need to wipe off before breastfeeding LIDOCAINE Uses: Numbing a localized area Dose: Varies depending on the procedure; given as an injection Frequency: Varies with procedure Common side effects: Irritation at the injection site; numbness; tingling Special considerations: Be cautious applying cold or heat therapy to the treated area PITOCIN (OXYTOCIN) Uses: induction of labor; contraction of uterus after delivery to prevent excess bleeding Dose: For labor: titrated IV medication, slowly increased until adequate contraction pattern is achieved For bleeding: 10-40 units; may be given by IV or injection Frequency: For labor: no sooner than every 30 minutes For bleeding: once following delivery Common side effects: Uterine cramping; headache; upset stomach; high blood pressure Special instructions: Nurse will adjust as needed

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Recovery and quiet time We believe in keeping mothers and their babies together at all times as long as they’re both healthy. This time together allows for increased bonding and enhances a mother’s understanding of how to care for her baby. During your stay with us, your nurse will assist you with caring for your baby in your room.

KANGAROO CARE DURING THE GOLDEN HOUR We believe in the importance of skin-to-skin contact with you and baby immediately following their birth. This is called kangaroo care. Kangaroo care offers many benefits for both you and your new baby or babies. The method will help your baby regulate temperature, heart rate, breathing and growth. This process helps the infant feel safe, calms quicker, decreases the stress of the infant and you. Not to mention the great bonding experience. As long as you and your infant are stable, we recommend staying skin-to-skin for the first hour of the baby’s life if not longer. To help promote this time of bonding we only allow the support person to be in the room with you and your baby. This time is called the “Golden Hour”. During this time you can continue skin-to-skin with the baby and begin to breastfeed the infant with assistance from the nurses or your support person if needed. The nurses will continue to assess you and your baby throughout this time to make sure your needs are met and that you both remain in a stable condition. We ask that all other visitors return to the lobby during this “golden hour” and may return when you are done with this initial bonding time, and you are ready for visitors. Resting is healing, so we offer quiet time from 2-4 p.m. every day in our private postpartum rooms. At 2 p.m. we ask visitors to wait in the waiting room and all doors will be shut and hallway lights will be dimmed. No one will come into your room during this time so that you and your support person can rest. During the recovery period, we will monitor you and your baby closely. Your care will include: • Frequent checks of your uterus and bleeding • Applying ice packs to your perineum, as needed to relieve pain and swelling • Assessing the healing of your perineum/vaginal area, including any episiotomy incision or tearing • Helping you to the bathroom, if necessary, or caring for your catheter and/or abdominal incision site • Helping with breastfeeding concerns • Assessing the overall health of you and your baby

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Feeding your newborn

“It isn’t the

size of the family,

it’s the interactions of the members inside.” — Michele Borba, educational psychologist and author

Feeding your newborn For the first few months of your babyâ&#x20AC;&#x2122;s life, much of their daily routine will revolve around feeding and diapers. This information will help you recognize your babyâ&#x20AC;&#x2122;s hunger signs and signs of any problems. Your nurse, doctor, lactation consultant or midwife are here to answer any questions you may have. In addition, we encourage you to watch the Newborn Channel during your stay with us. There is a guide in your binder with program times.

INFORMATION IN THIS SECTION B3

Quick tips for feeding

B4 Urine and stool patterns B5

Feeding and diaper log

B10 How to burp your baby B11 Breastfeeding B17 Bottle feeding

Quick tips for feeding SIGNS OF HUNGER Your baby may show any of these signs when he or she is hungry: • Moving hand to mouth • Turning head from side to side • Sticking out tongue • Licking lips • Sucking on thumb • Hands closed/tight to face • Stirring in sleep close to feeding time • Crying or becoming fussy

SIGNS YOUR BABY IS GETTING FULL Watch for these signs that let you know your baby has had enough to eat: • Sucking less often or playing with your breast or bottle • Releasing the nipple after feeding • Becoming sleepy or not interested in feeding • Body getting more open and relaxed

SIGNS YOUR BABY IS GETTING ENOUGH TO EAT • Producing at least the minimum number of wet diapers daily • Producing at least one bowel movement every day • Steady weight gain after the first week of life: From birth to 3 months, typical weight gain is four to eight ounces per week. • Pale yellow urine: Your baby’s urine should not be deep yellow or orange. • Sleeping well: Your baby should sleep well but be alert and look healthy when awake.

SIGNS OF DEHYDRATION • Your baby is more than three days old and has fewer than six soaking wet diapers in 24 hours • Dry mouth • Sunken eyes • Sunken soft spot on head • Extreme irritability • Decreased activity

F E E D I N G YO U R N E W B O R N

Urine and stool patterns Normal urine and stool patterns vary from baby to baby and can even change in the same baby from day to day. • For the first few days after birth, most babies have one to several bowel movements each day. • Stools of a constipated baby are usually firm and hard and may be pebble-like and difficult to pass. • Stools may change color. • Babies may pass stools easily, or may fuss, grunt, strain and turn red in the face while having a bowel movement. This is not usually a sign of constipation. • Breastfed babies may have more frequent stools and less constipation than bottle-fed babies. • Diarrhea stools are frequent (more than one an hour) and may be loose/watery. Urine and stool patterns for the first week and beyond Baby’s age

Wet diapers

Dirty diapers*, color and texture

Day 1 (birth)

Thick, tarry, and black

Day 2

Thick, tarry, and black

Day 3

Loose; greenish or yellow brown; seedy

Day 4

6 or more

Loose; greenish or yellow brown; seedy

Day 5

If breastfed: pasty/seedy; golden yellow

and beyond

If formula fed: soft/pasty; yellow brown

* This is a minimum number of diapers for most babies. It is fine if your baby has more.

Call your baby’s doctor if you observe any of the following urine or stool patterns. Do not use home remedies: • No stool within 48 hours after birth • Black, tarry stools beyond 48 hours of life • Change in urine/stool pattern with vomiting and/or a fever (over 100.4°F) • Fewer feedings than usual • Blood in stool • Stools that are hard and difficult to pass • Three or more days with no stools • Loose stools more often than one an hour

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Your baby’s feeding and diaper log You can tell your baby is getting enough milk by keeping track of the number of wet and dirty diapers. When your baby has a feeding, urine or stool, find the box for your baby’s age and the hour of day. For feedings, write the start time and the number of minutes if breastfeeding or the amount of ounces or milliliters if bottle feeding. For urine or stool, make a check mark. At the end of each day, write your baby’s totals and compare them to the minimum goals (see page B3).

AGE OF BABY

DAY 0 FEEDINGS

URINE

DAY 1 STOOL

FEEDINGS

URINE

DAY 2 STOOL

FEEDINGS

URINE

STOOL

Midnight 1 a.m. 2 a.m. 3 a.m. 4 a.m. 5 a.m. 6 a.m. 7 a.m. 8 a.m. 9 a.m. 10 a.m. 11 a.m. Noon 1 p.m. 2 p.m. 3 p.m. 4 p.m. 5 p.m. 6 p.m. 7 p.m. 8 p.m. 9 p.m. 10 p.m. 11 p.m. TOTALS MINIMUM GOALS

F E E D I N G YO U R N E W B O R N

AGE OF BABY

DAY 3 FEEDINGS

URINE

DAY 4 STOOL

FEEDINGS

URINE

Midnight 1 a.m. 2 a.m. 3 a.m. 4 a.m. 5 a.m. 6 a.m. 7 a.m. 8 a.m. 9 a.m. 10 a.m. 11 a.m. Noon 1 p.m. 2 p.m. 3 p.m. 4 p.m. 5 p.m. 6 p.m. 7 p.m. 8 p.m. 9 p.m. 10 p.m. 11 p.m. TOTALS MINIMUM GOALS

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DAY 5 STOOL

FEEDINGS

URINE

STOOL

AGE OF BABY

DAY 6 FEEDINGS

URINE

DAY 7 STOOL

FEEDINGS

URINE

DAY 8 STOOL

FEEDINGS

URINE

STOOL

Midnight 1 a.m. 2 a.m. 3 a.m. 4 a.m. 5 a.m. 6 a.m. 7 a.m. 8 a.m. 9 a.m. 10 a.m. 11 a.m. Noon 1 p.m. 2 p.m. 3 p.m. 4 p.m. 5 p.m. 6 p.m. 7 p.m. 8 p.m. 9 p.m. 10 p.m. 11 p.m. TOTALS MINIMUM GOALS

F E E D I N G YO U R N E W B O R N

AGE OF BABY

DAY 9 FEEDINGS

URINE

DAY 10 STOOL

FEEDINGS

URINE

Midnight 1 a.m. 2 a.m. 3 a.m. 4 a.m. 5 a.m. 6 a.m. 7 a.m. 8 a.m. 9 a.m. 10 a.m. 11 a.m. Noon 1 p.m. 2 p.m. 3 p.m. 4 p.m. 5 p.m. 6 p.m. 7 p.m. 8 p.m. 9 p.m. 10 p.m. 11 p.m. TOTALS MINIMUM GOALS

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DAY 11 STOOL

FEEDINGS

URINE

STOOL

AGE OF BABY

DAY 12 FEEDINGS

URINE

DAY 13 STOOL

FEEDINGS

URINE

DAY 14 STOOL

FEEDINGS

URINE

STOOL

Midnight 1 a.m. 2 a.m. 3 a.m. 4 a.m. 5 a.m. 6 a.m. 7 a.m. 8 a.m. 9 a.m. 10 a.m. 11 a.m. Noon 1 p.m. 2 p.m. 3 p.m. 4 p.m. 5 p.m. 6 p.m. 7 p.m. 8 p.m. 9 p.m. 10 p.m. 11 p.m. TOTALS MINIMUM GOALS

F E E D I N G YO U R N E W B O R N

How to burp your baby During feedings, newborn babies swallow milk or formula and air. Air in the stomach can make your baby feel full and uncomfortable. This can cause your baby to not want to eat, or to stop feeding too soon. That’s why it’s important to burp your baby before, during and after feeding. Burping will release excess air to keep your baby comfortable. • Burp your baby before breastfeeding or bottle feeding. • If you are breastfeeding, burp your baby after the first breast. • If you are bottle feeding, burp the baby after every half ounce, or every ounce if your baby spits up. • To burp your baby well, position him or her so there is some pressure on the stomach, and pat, rub or apply gentle pressure to his back with your hand. • Drape a burp cloth over your clothing when burping. Spitting up a small amount is common after a feeding. • If getting a burp takes longer than five minutes, continue to feed or stop as your baby desires. • Try each of the positions below until you determine the one that works best for your baby. Babies burp better in one position than another. • As your baby gets older, there is less of a need to burp at feedings.

POSITIONS FOR BURPING YOUR BABY Over your shoulder Hold your baby firmly against your shoulder and rub or pat your baby’s back with your hand. Provide support for your baby’s bottom and lower back with the other arm. Face down on your lap Place your baby face down on your lap with the head resting on one leg and the stomach area over the other leg. Support your baby with one hand while patting, rubbing or applying gentle pressure on his or her back with the other hand. Sitting up Sit your baby in your lap with his or her body leaning forward. Support the chest and head with one hand while patting your baby’s back with your other hand. If there is no burp after two to three minutes, lean your baby back slightly with the chest as upright as possible. Then pat, rub or gently put pressure on the back.

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Breastfeeding There is so much to learn when becoming a new mother. The following tips are designed to help you have the most positive, successful breastfeeding experience possible.

WHAT TO EXPECT DURING THE FIRST 24 HOURS • The first feeding is usually the easiest. Most babies have about six or more full feedings within the first 24 hours of life. • It is normal for your baby to take up to a six-hour nap after the first feeding, a shorter nap after circumcision, and one four-hour nap daily. • It is normal for your baby to be sleepy for the first 24 hours. It is also normal for your baby to want to eat often when he or she is about 24 hours old, so nurse as often as your baby wants, for a minimum of 10 minutes or longer each time. This will help you and your baby practice breastfeeding and bring in a good milk supply. • At first you’ll be feeding your baby colostrum, your first milk that is thick and yellowish. Even though it looks like only a small amount, this is the only food your baby needs.

BREASTFEEDING TIPS Breastfeeding can be a wonderful experience for you and your baby. Don’t get frustrated if you’re having problems. What works for one mother and baby may not work for another. Just focus on finding a comfortable routine and positions that work for both of you. Here are some tips for success: Get an early start. You should start nursing as early as you can after delivery (within an hour if possible), when your baby is awake and the sucking instinct is strong. Watch for cues. Early hunger cues include sucking movements and sounds, hand-to-mouth movements, stirring in sleep and rapid-eye movements. Crying is actually a late hunger cue. When you see early hunger cues, awaken your baby by removing blankets, undressing, changing his or her diaper, giving skin-to-skin contact or massaging his or her back, arms and legs. Nurse frequently. Newborns need to nurse often. You should nurse when your baby shows hunger cues. In addition, in the early weeks after birth, you should wake your baby to feed every two to three hours, even if he or she isn’t showing signs of hunger or if it’s overnight. If you’re having a hard time waking your baby, you can try taking his or her clothes off, changing the diaper or massaging with brisk upward strokes. After 24 hours of life, the normal frequency is eight to 12 times in 24 hours.

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Be patient. Allow unlimited time to feed on your first breast, then burp your baby and offer your second breast if your baby shows hunger cues. Gently touch and talk to your baby while at your breast. Per feeding, you should give your baby a minimum of 15 to 20 minutes of active sucking and swallowing. If your baby won’t nurse, try expressing drops of colostrum (your first milk) into your baby’s mouth. If your baby is healthy and doesn’t have any medical problems, this may be all your baby needs on his or her first day of life. Use more skin-to-skin time to help baby rest and get ready to eat. Wait for the next time your baby shows early hunger cues and try again. If your baby is unable to latch properly, please ask your lactation consultant or nurse for help. Feed your baby only breast milk. Nursing babies don’t need water, sugar water or formula. Breastfeed exclusively for about the first six months. Giving other liquids will reduce the amount of breast milk the baby takes. To keep up your supply, pump when your baby gets a bottle of breast milk. Breastfeed your sick baby during and after illness. Oftentimes, sick babies will refuse to eat but will continue to breastfeed. Breast milk will give your baby needed nutrients and prevent dehydration. Keep sore nipples moist. Use a natural moisturizer such as lanolin to avoid dryness, which can lead to cracking and infection. If your nipples do crack, keep them coated with a natural moisturizer to help them heal. It isn’t necessary to use soap on your nipples, and it may remove helpful natural oils secreted by glands in the areola. Soap can cause drying and cracking and make the nipple more prone to soreness. Watch for infection. Signs of breast infection include fever, irritation and painful lumps and redness in the breast. You need to see a doctor right away if you have any of these symptoms. Treat engorgement right away. It’s normal for your breasts to become larger, heavier and a little tender when they begin making greater quantities of milk on days 2 to 6 after birth. This normal breast fullness may turn into engorgement. When this happens, you should feed your baby often. Your body will, over time, adjust and produce only

B 12

G U I D E F O R N E W M OT H E R S | T H E B I R T H P L AC E AT S T. R I TA’ S

the amount of milk your baby needs. To relieve engorgement, before breastfeeding you can put cold, wet washcloths on your breasts, massage your breasts toward the nipples or shower, letting the water massage your breasts. If the engorgement is severe, placing cold packs on your breasts between feedings may help. Eat right and get enough rest. You may be thirstier and have a bigger appetite while you are breastfeeding. Making milk will use about 500 extra calories a day. Drink plenty of water and non-caffeinated beverages and maintain a healthy diet. Continue taking your prenatal vitamin while you are breastfeeding and get as much rest as you can. This will help prevent breast infections, which are worsened by fatigue.

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HOW TO BREASTFEED • Gently stroke under your baby’s nose. • When his or her lips are open wide, bring your baby to your breast so his or her lips are around both the nipple and areola and your baby’s tummy is facing your tummy.

• When your baby is latched on well, his or her nose and chin touch your breast. Your baby’s lips should be turned out or “flanged,” not tucked in.

BREASTFEEDING POSITIONS Here are several positions in which you can hold your baby while breastfeeding. You can try all of them and choose whichever feels most comfortable. No matter which position you choose, make sure your infant’s tummy is facing your tummy. This helps him or her properly “latch on” to the nipple. For support, try using pillows under your arms, elbows, neck or back or under your baby. A. Cradle: This is an easy and commonly used position B

B. Cross cradle, modified clutch or transitional: This position gives your baby extra head support. It may also help him or her stay on the breast. This position is good for premature babies, babies with a weak suck and those who are having problems latching on. C. Clutch or “football”: This position allows you to better see and control your baby’s head. It’s the best position for moms who have had a C-section, as well as those with large breasts or inverted nipples, which sink in instead of protruding or lying flat.

B 14

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Breastfeeding questions and answers WHY SHOULD I BREASTFEED? The following are just some of the good reasons why you should breastfeed your baby: • Breast milk is the most complete form of nutrition for infants. Breast milk has just the right amount of fat, sugar, water and protein needed for your baby’s growth and development. • Most babies find it easier to digest breast milk than they do formula. • Breast milk has agents (called antibodies) in it that help protect your baby from bacteria and viruses. Babies who aren’t exclusively breastfed for the first six months are more likely to develop a wide range of infectious diseases including ear infections, diarrhea and respiratory illnesses. They are sick more often and have more doctor visits. • Breastfed babies score higher on IQ tests in childhood. Breastfeeding has benefits for you, too. • It burns extra calories, making it easier to lose the pounds you gained during pregnancy. • It helps your uterus get back to its original size, and lessens any bleeding you may have after giving birth. • It lowers the risk of breast and ovarian cancers and possibly the risk of hip fractures and osteoporosis after menopause. • It helps you bond with your baby. Physical contact is important to newborns and can help them feel more secure, warm and comforted. • It reduces the risk of childhood obesity and the risk of diabetes in both mother and child.

HOW LONG SHOULD I BREASTFEED? Babies should be fed with breast milk only — no formula — for the first six months of life. Ideally, your baby should receive breast milk through the first year of life, or longer as both you and your baby wish. During this time, your baby won’t need supplements of water, juice or other fluids. These can interfere with your milk supply if they are introduced during this time. When your baby is 6 months old, solid foods can be added to your baby’s diet while you continue to breastfeed.

WHEN SHOULD SUPPLEMENTS BE USED? • If you choose to supplement, supplemental options for a breastfeeding baby include hand-expressed mother’s milk, donor milk, if available, IV fluids and formula.

• If you use formula as a supplement, you should pump your breasts for 15 to 20 minutes to keep your milk supply up and avoid engorgement.

IS IT SAFE TO TAKE MEDICATIONS WHILE BREASTFEEDING? Always talk with your doctor before taking any medications. Some medications pass into your milk and may not be safe for your baby. If you take medication for a chronic condition such as high blood pressure, diabetes or asthma, your medication may already have been studied in breastfeeding women. You should be able to find information to help you make an informed decision with the help of your doctor. Newer medications and medications for rare disorders may have less information available. Resources for more information include: • American Academy of Pediatrics: aap.org • National Institutes of Health Drugs and Lactation Database: toxnet.nlm.nih.gov • InfantRisk Center: 806-352-2519 or infantrisk.com

Breastfeeding Q&A

• It helps reduce the risk of postpartum depression.

• The nurse will watch your baby for signs of low blood sugar or other medical problems. If your baby’s blood sugar is low, your nurse will follow our policy for feeding and continue to check his or her blood sugar levels.

• Medications and Mothers’ Milk, Thomas W. Hale, PhD.: medsmilk.com

IS THERE ANY TIME WHEN I SHOULDN’T BREASTFEED? There are very few times when a mother should not breastfeed her baby. These may include: • Mothers with human immunodeficiency virus (HIV) • Mothers with active, untreated tuberculosis • Mothers receiving chemotherapy • Mothers who are abusing drugs or alcohol • Babies with galactosemia Some women think that when they’re sick, they shouldn’t breastfeed. But most common illnesses like the cold or flu can’t be passed through breast milk. In fact, if you’re sick, your breast milk will have antibodies in it. These antibodies will help protect your baby from getting the same sickness. Sometimes a baby may have a reaction to something you eat, but this doesn’t mean your baby is allergic to your milk. Usually, if you’ve eaten a food throughout pregnancy, your baby has already become used to the flavor of this food. If you stop eating whatever is F E E D I N G YO U R N E W B O R N

B 15

bothering your baby, the problem usually goes away on its own. If you’re breastfeeding, you should not take illegal drugs. Drugs including cocaine, marijuana and PCP can make your baby high and cause irritability, poor sleeping patterns, tremors and vomiting. Babies also can become addicted to these drugs. If you’re having a hard time quitting, ask your doctor for help.

CAN I DRINK ALCOHOL IF I AM BREASTFEEDING? If you want an occasional alcoholic drink, wait at least two hours after a single drink before you breastfeed. The alcohol will leave your milk as it leaves your bloodstream. You do not need to hand-express and discard your milk. Drinking more than two drinks a day regularly, however, can be harmful to your baby. This can cause drowsiness, weakness and abnormal weight gain.

Breastfeeding Q&A

WHEN AND HOW SHOULD I INTRODUCE A BOTTLE? If you plan to have your baby take a bottle of expressed breast milk while you’re at work, you can introduce your baby to a bottle when he or she is around 4 weeks old or older. Once your baby is comfortable taking a bottle, it’s a good idea to have your partner or another family member offer a bottle of pumped breast milk on a regular basis so the baby stays in practice.

CAN I BREASTFEED IF MY BREASTS ARE SMALL?

CAN I GIVE MY BABY A PACIFIER IF I BREASTFEED?

Of course! Breast size is not related to your ability to produce milk for your baby. Breast size is determined by the amount of fatty tissue in the breast, not by the amount of milk. Most women, with all sizes of breasts, can make enough milk for their babies.

Most lactation consultants recommend avoiding bottle nipples or pacifiers for about the first month because they may interfere with your baby’s ability to learn to breastfeed. The American Academy of Pediatrics recommends that parents of breastfed babies wait a month before introducing a pacifier to ensure the infant’s nursing habits have been established. After the first month, the academy recommends parents offer a pacifier to their babies at nap and bed times for the first year, as studies associate pacifier use with a reduced risk of sudden infant death syndrome (SIDS). Pacifiers should not be forced upon babies who protest and should never be used instead of or to delay a feeding.

WILL BREASTFEEDING KEEP ME FROM GETTING PREGNANT? When you breastfeed, your ovaries can stop releasing eggs, making it harder for you to get pregnant. Your periods can also stop. But, there are no guarantees that you won’t get pregnant while you’re nursing.

DO I HAVE TO STAY AT HOME IF I BREASTFEED? Not at all. Breastfeeding can be convenient no matter where you are because you don’t have to bring along feeding equipment like bottles, water or formula. Your baby is all you need. Even if you want to breastfeed in private, you usually can find a women’s lounge or fitting room. If you want to go out without your baby, you can pump your milk beforehand and leave it for someone else to give your baby while you’re gone.

CAN I STILL BREASTFEED WHEN I GO BACK TO WORK? Breastfeeding keeps you connected to your baby, even when you’re away. Employers and co-workers benefit because breastfeeding moms often need less time off

B 16

for sick babies. Your health insurance company may provide a breast pump at no charge to you. More and more women are breastfeeding when they return to work, and many employers are willing to set up special rooms for mothers who pump. After you have your baby, try to take as much time off as possible, since it will help you get breastfeeding well established and also reduce the number of months you may need to pump your milk while you’re at work.

BREASTFEEDING HELP The Birth Place at St. Rita’s lactation consultants: 419-996-5807 Food and Drug Administration: fda.gov National Institute of Child Health and Human Development: nichd.nih.gov Women, Infants and Children (WIC) Program, USDA: fns.usda.gov/wic La Leche League International: 877-452-5324 or LLLI.org Center for Breastfeeding Medicine at Cincinnati Children’s Hospital Medical Center: 513-636-2326

G U I D E F O R N E W M OT H E R S | T H E B I R T H P L AC E AT S T. R I TA’ S

Bottle feeding your baby The American Academy of Pediatrics recommends feeding your baby breast milk or an iron-fortified commercial infant formula during your baby’s first year of life. You may choose to bottle feed or use a formula supplement while you are breastfeeding. Regardless of your feeding choice, your infant will benefit most if mealtimes are full of cuddling and love.

BOTTLE FEEDING TIPS • Wash your hands well with soap and water for 20 seconds or use an alcohol-based hand sanitizer before feeding your child or handling formula. • Feed your baby when he or she shows signs of hunger. This may be every three to four hours. If your baby sleeps for longer than a fourhour period during the day, then wake your baby for feedings. Plan to feed your baby at least six to eight times in 24 hours. • Don’t worry if your baby takes only 1 ounce of formula at each feeding during the first few days. Your baby will slowly take more formula as he or she grows. By the end of the first week, your baby should eat at least 1 to 3 ounces at each feeding. • Relax, sit down and make yourself comfortable. Hold your baby in a semi-upright position while feeding. • Get your baby’s attention by stroking his or her cheek with your finger or with the tip of the bottle’s nipple. Your baby’s head will turn and his or her mouth will open in response to the stroking. When you place the nipple in your baby’s mouth, your baby should begin sucking. • Hold the bottle at an incline so the nipple fills completely with formula. This will help prevent your baby from swallowing air. • When feeding your baby, watch for signs that he needs a break. This may include constant gulping without breaks. • If the baby is working too hard to suck in the formula or breast milk, tires easily or becomes frustrated, the milk flow may be too slow. If your baby gulps air or formula leaks out of the corners of his or her mouth, the milk flow may be too fast. To test the nipple, turn the bottle upside down. Breast milk or formula should drip about one drop per second. • Stop and burp your baby about halfway through each feeding. See page B10 for more information about burping. • Allow your baby to decide when he or she has had enough to eat. Don’t force your baby to finish a bottle. Toward the end of a feeding, your baby may fall into a light sleep. You may still notice some sucking movements. This is just a reflex and does not mean that he or she is still hungry. Let your baby suck on your finger or a pacifier. • Hold your baby close and talk softly during the feeding. Skin-to-skin contact also will help you feel closer to your baby. This can be done by wearing short sleeves or partially undressing yourself and your baby. Your baby will enjoy the warmth and feel of your skin.

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COMMON QUESTIONS ABOUT FORMULA How long will my baby need formula? Usually babies need to drink formula for the first year of life. Avoid adding anything to the formula, including honey, sugar, cow’s milk or cereal. Your baby’s doctor will give you information about when to start solid foods and cow’s milk. What kind of formula should I give my baby? Talk to your baby’s doctor about which formula is best for your baby. Formula comes in three different forms. • Ready-to-use: This type of formula comes in ready-to-feed 4-ounce bottles or cans of different sizes. If you buy cans, pour the formula into a sterilized bottle. Place a sterilized nipple on the bottle after filling. Ready-to-use bottles don’t come with a nipple. You’ll need to use your own nipple. This type of formula is the most expensive. • Concentrate: Concentrate costs less than ready-to-use formula. To prepare concentrate formula, follow the directions on the label. Mix the concentrate with equal amounts of water. For example, if you want 4 ounces of formula, use 2 ounces of concentrate and 2 ounces of water. You’ll need bottles ready to fill after mixing the formula. • Powder: The least expensive type of formula is powder. To prepare powder formula, mix one scoop of powder with every 2 ounces of water. For example, if you need to make 4 ounces of formula, use 4 ounces of water and add two scoops of formula. You’ll need bottles ready to fill after mixing the formula. This kind of ready-to-mix formula comes in cans or single-serve packets. Regardless of which formula you choose, you should always check the expiration date because expired formula could be harmful to your baby Can I use tap water to mix formula? Yes, most pediatricians agree that you can use city tap water. To be sure, ask your doctor if boiling the water is necessary. How long should I refrigerate formula after mixing it? Use refrigerated formula within 24 to 48 hours of mixing. For your baby’s safety, throw away unused formula after 48 hours. Can I change formula if my baby does not like it? Treat formula like a medicine. Call your baby’s doctor for advice on changing the brand or type (cow, soy, etc.). Do not change the formula because you have seen an advertisement or have a coupon for a different brand. If you think your baby does not like the formula or your baby has problems digesting it, call his or her doctor.

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What are signs that my baby may have problems with formula? • Vomiting right after feedings • Recurring diarrhea or constipation • Frequent bouts of crying after feedings • Signs of colic with a firm, enlarged and tender tummy right after a feeding • Fussy behavior and/or waking frequently overnight • A rough rash on the face and around the rectum (the opening for bowel movements) • Frequent colds and/or ear infections Do I need to sterilize bottles and nipples? If you have city water, you do not have to sterilize bottles and nipples. Most doctors recommend hand-washing bottles and nipples or placing them on the top rack of your dishwasher. Should I give my baby water or other fluids? If your baby is getting enough to eat, you don’t need to give your baby any other fluids like water or juice unless advised by his or her doctor. Extra water may be needed during warm summer months or when your baby gets older and begins eating solid food. How will I know my baby is getting enough to eat? If you answer yes to these questions, you can be sure your baby is getting enough to eat. If not, talk to your baby’s doctor right away. • Does my baby suck and swallow without gagging or choking during feeding? • Does my baby have six or more wet diapers over a 24-hour period? • Does my baby have a bowel movement or dirty diaper every day? • Is my baby sleeping between feedings? • Is my baby gaining weight and filling out his or her baby clothes? What is the safest way to heat a bottle of formula? • The safest way to heat a bottle of formula is to run warm water over it or to place it in a pan of warm water. Use the formula right after heating it. • Do not place a bottle in boiling water. This destroys the protein in the formula and makes it too hot for your baby to drink. • Do not microwave formula. Microwaving causes uneven heating. The bottle may feel cool to you, but the formula inside can be very hot and burn your baby. • Always check the temperature first before giving a bottle to your baby. Shake a few drops on your inner arm. The formula is ready when it no longer feels cold.

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BOTTLE FEEDING SAFETY • Do not let your baby take a bottle of formula when lying flat. Feeding a baby in this position increases the chance of ear infections and choking. Tooth decay and jaw problems are also common if you feed in this position. • Learn how to use a bulb syringe. Sometimes babies choke when you are feeding them. Your nurse will show how to use the bulb syringe to suction your baby’s mouth and/or nose. • If your baby does not finish formula within one hour, throw it away. Formula spoils easily once bacteria from a baby’s mouth backwashes into the bottle. • Do not give your baby homemade formula. Formula made from cow’s milk (fresh or evaporated) does not have the same nutrients as commercially made formula. Babies cannot digest cow’s milk.

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G U I D E F O R N E W M OT H E R S | T H E B I R T H P L AC E AT S T. R I TA’ S

Basic newborn care

“A baby is born with

Basic newborn care

a need to be loved —

and never outgrows it.” — Frank Howard Clark, screenwriter

Basic newborn care Thereâ&#x20AC;&#x2122;s a lot to learn about caring for your new baby. This information will help you quickly master the basics youâ&#x20AC;&#x2122;ll need to provide gentle loving care.

INFORMATION IN THIS SECTION C3

Quick tips for newborn care

C4 When to call the doctor C5

Umbilical cord care

Circumcision care

Care of the uncircumcised penis

Skin-to-skin contact

Holding your newborn

Caring for a crying baby

C10 Bathing your newborn C12 Safe sleeping C13 Car and booster seat safety C15 Common newborn conditions C17 Smoking and your baby C19 Local doctors for your newborn

Quick tips for newborn care These guidelines will help keep your newborn safe and healthy. • Avoid taking your baby into large crowds of people until he or she is 1 month old. This helps protect your baby from germs and viruses that may cause illness. • While riding in a vehicle, place your baby in an approved infant car seat. Ohio law requires children under 4 years old or 40 pounds to be in a car seat. Never leave your baby unattended at home or in a vehicle. • Wash your hands with soap and water for 20 seconds or use alcoholbased hand sanitizer before picking up and holding your baby. Tell visitors they must wash their hands before handling your baby. • Ask people not to visit you and your baby if they have cold or flu symptoms. Your baby may not be able to fight off germs or viruses from others. • Take your baby’s temperature under the arm, in the armpit. Do not take your baby’s temperature rectally unless directed to do so by your doctor. Place the tip of the thermometer high up in the armpit. Hold your baby’s arm snugly yet gently against his or her body. • Give your baby a sponge bath until the umbilical cord falls off. After the cord has fallen off and the area heals, you may bathe your baby in a tub. Use mild soaps and baby shampoo. To avoid getting soap in your baby’s eyes, use only warm water on his or her face. • Schedule an appointment with your baby’s healthcare provider soon after leaving the hospital. Most will want to see your baby within the first week.

BASIC NEWBORN CARE

When to call the doctor Getting to know your new baby takes time, but there are certain signs and symptoms that need immediate medical attention. Call your baby’s doctor if any of the following signs occur. • Temperature above 99.8 degrees Fahrenheit (37.6 degrees Celsius) or below 97.6 degrees Fahrenheit (36.4 degrees Celsius) • Fewer than six wet diapers in 24 hours when your baby is more than 3 days old • Diarrhea (defined as two or more green, loose, watery bowel movements over a 24-hour period) • Yellowish color to the skin or in the white areas of the eyes • Vomiting after two or more feedings over a 24-hour period • Lack of interest in feeding, or skipping two feedings in a row • Poor muscle tone or feeling floppy when held • Difficulty keeping your baby awake • Convulsions (seizures) • Rash on any part of your baby’s body • Redness or discharge around the eyes, umbilical cord or circumcision site • High-pitched crying for three or more hours, which isn’t helped by attempts to soothe or calm your baby • Patches of white in his or her mouth If your baby seems ill, take your baby’s temperature and write it down. Do not give your baby any medicine. The doctor will tell you what to do. Call 911 if your baby has: • Difficulty breathing • Blue or pale-colored skin • Blue lips

G U I D E F O R N E W M OT H E R S | T H E B I R T H P L AC E AT S T. R I TA’ S

Umbilical cord care Leave the umbilical cord open to air when possible. Fold the baby’s diaper down so the cord is not covered. If the cord is soiled by urine or stool, clean with warm water and towel dry. • Healing has occurred when the cord is hard, dry and shriveled and the base is pink and dry. This takes one to two weeks. • When the stump falls off, there may be a few drops of blood. This is normal. • If bleeding continues or if the cord area becomes red or has pus-like drainage, call your baby’s doctor. • Do not put objects, such as corks or silver dollars, into your baby’s navel. There are germs on these objects that could harm your baby.

Circumcision care • Offer to snuggle and hold your baby more for the first 24-48 hours after the procedure. • Keep the circumcision area clean and dry. • Keep your baby off his stomach as much as possible. • Wash your hands before and after changing the diaper. • Watch for signs of infection such as redness, swelling or foul odor. • Put a small amount of Vaseline on the raw area of the penis. Do this each time you change the diaper for five to seven days. This helps the penis heal and keeps it from sticking to the diaper. • The baby can have a tub bath only after the circumcision is healed. This is usually in 10 to 14 days.

NORMAL CHANGES • Your baby may be fussy and not eat well. This should last for about a day. • There may be a small amount of bleeding for the first 48 hours. • Some swelling may occur. • You may notice a yellow material where the foreskin was removed. Don’t try to wipe the yellow material off. It will go away as the circumcision heals. Call your baby’s doctor if you notice: • Increased redness or swelling • A foul odor • More than a trace of blood from the penis or on the diaper

Care of the uncircumcised penis The uncircumcised penis should be washed with soap and water, just as the rest of the body is washed. It is not necessary to pull back the foreskin for cleansing. Doing so forcibly could be harmful BASIC NEWBORN CARE

Skin-to-skin contact After your baby is born, he or she will be placed on your chest, touching you skin-to-skin. The nurse will check that the baby is doing well, and will only remove the baby if more care is needed. This skin-to-skin contact (SSC) gives your baby warmth. It is calming as your baby will hear you, feel you, nurse from you and be loved by you. This is important immediately after birth, but also throughout your baby’s first weeks.

HOW TO PRACTICE SSC • You may want to lie on your back or side, or sit up in a chair. Do not sleep when doing SSC. It is not safe for your baby. • Your baby may wear a diaper and head cover or not wear anything. • Place a blanket over his or her back for more warmth or nest your baby inside of your clothing. • Place your baby on your chest or between your breasts so that his or her stomach is toward your chest. • Support your baby’s head and body with your arms. Tuck your baby’s legs and feet under his or her body. As your baby gets older, he or she may want to stretch out but will still enjoy SSC.

BENEFITS OF SSC During the first few weeks of life, SSC may provide many benefits. Your partner can also practice SSC, providing the same benefits for baby and enjoying the same bonding and stress-relieving benefits. For baby: • Better temperature: Your baby is less likely to be cold or hot. • Better breathing: Your baby has more relaxed and regular breathing. • Better breastfeeding: Babies are most alert during SSC, providing a better start on breastfeeding. SSC may help your baby latch onto your breast and develop interest in feeding. • Pain relief: With SSC, your baby may cry less and be comforted during heel sticks or other tests. • Better sleep: Your baby sleeps longer and has better sleep. • Blood sugar levels: With SSC, your baby’s blood sugar levels stay normal longer. For you: • Better bonding: Touching and cuddling with your baby helps you bond with him or her. SSC is important for partners, too. • Better recovery from delivery: SSC helps control postpartum bleeding and allows your uterus to return to normal size more quickly. • Milk production: SSC helps with milk production for breastfeeding. • Less stress: Mothers report more relaxation when their babies feel secure during SSC. • Pain relief: You may feel less pain from stitches and from procedures such as episiotomy repair. C6

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Holding your newborn HOW TO PICK UP YOUR BABY Your baby’s neck muscles will be weak for the first few months of life. Use both hands to support your baby’s head and neck when you lift your child. One way of picking up your baby is to place the palm of one hand under the baby’s head and neck. Slide the palm of the other hand under his or her bottom and gently lift. This technique is useful when picking your baby up from a flat surface, such as a changing table or crib. Another way to pick up your baby is to slide both hands under your baby’s back, using your fingers to support his or her head and neck. Your thumbs should be across your baby’s chest, holding firmly. This method is useful when lifting your baby from a semi-upright position. The semi-upright position is common when a baby is in an infant seat or swing.

HOW TO HOLD YOUR BABY There are three basic positions used for holding a newborn: • Cradle: Place your baby in your forearm, nestling his or her head in the bend of your elbow. Use your wrist and hand to support your baby’s bottom and lower spine. • Football: This position allows you to hold your baby with one arm while the other arm can move freely. Place one hand under your baby’s head and neck. Slide his or her bottom between your elbow and hip in a tucked position. • Over-the-shoulder: This is also known as the burping position. Place your baby high enough so his or her chest rests on your shoulder. Use one hand to support the baby’s head and neck and place the other under your baby’s bottom to support the body.

BASIC NEWBORN CARE

Caring for a crying baby When your baby starts crying, try to soothe him or her. By responding quickly, you may prevent your baby from becoming too upset. If your baby is fussy or crying, look for a reason why he or she is uncomfortable. Ask yourself these questions: • Does your baby have a wet or dirty diaper? A clean diaper decreases skin irritation and may help your baby feel better. • Is your baby hungry? Does he or she need to feed for a longer period of time? Does your baby need to feed more often, but in smaller amounts? • Does your baby need to burp? • Is he or she in an uncomfortable position? • Could your baby be having a reaction to a recent immunization shot? • Are there bright lights, loud noises or too many people around? This stimulation might upset your baby.

WAYS TO CALM YOUR BABY Sometimes it’s difficult to know how to comfort your baby. Here are some suggestions: • Feed and/or burp your baby. • Offer a pacifier. This may help satisfy your baby’s need to suck. If breastfeeding, wait until your baby is older than four weeks to offer a pacifier. Never put the pacifier on a string or cord around the baby’s neck. Never use a bottle nipple for a pacifier. • Change your baby’s diaper. • Check your baby for warmth or coolness. Add or remove blankets and clothing as needed. • Cuddle your baby close to you. He or she may feel your calmness and become quiet or be soothed by the sound of your heartbeat. • Lay your baby next to your skin and gently rub his or her back. • Put your baby in a soft carrier, close to your body. • Swaddle or wrap your baby tightly in a soft blanket. This may help him or her feel more secure. Never put your baby to bed with loose blankets, as they may increase the risk of sudden infant death syndrome (SIDS). • Rhythmic motion may help calm your baby. Rock, walk or dance with your baby, or place him in a baby swing. • Take your baby for a ride in the stroller or car. • Massage your baby’s body and limbs gently using warm lotion (avoid the face). • Give your baby a warm bath. • Play soft, soothing music or sing quietly to your baby.

G U I D E F O R N E W M OT H E R S | T H E B I R T H P L AC E AT S T. R I TA’ S

• Lay your baby down across your lap and gently rub or pat his or her back. • If your baby has trouble passing gas, apply light pressure over his or her stomach. You can also try placing your baby over your shoulder, across your lap or across your arm. Balancing your baby across a beach ball may also help. • Expose your baby to white noise such as the noise from a vacuum, dryer, dishwasher or fan. • Offer your baby a noisy toy. Shake or rattle it.

WHEN IT’S TIME FOR A TIME-OUT Parents can feel overwhelmed when they can’t get their baby to stop crying. While crying won’t hurt your baby, shaking your baby can damage your baby’s brain and even cause death. If you start to feel overly stressed, like you might lose control, take a time out. • Gently place your baby in his or her crib for 10 to 15 minutes and allow yourself to do something else. This will not hurt your baby. • Let someone else try to comfort your baby for a while. • Do something relaxing or let yourself have a good cry. • Sit or lie down, close your eyes and take several deep breaths. Call your doctor if your baby is crying and: • Vomiting or has diarrhea • Does not meet the daily goal for urine and/or stool • Has a fever over 100.4 degrees Fahrenheit when taken under the arm • Cries constantly for more than three hours • His or her cry changes from fussy to painful • The constant crying continues after 3 months of age (when signs of colic begin to decrease) • You can’t soothe your baby, no matter what you try • You are afraid you might hurt your baby

BASIC NEWBORN CARE

Bathing your newborn Bath time can be a happy time that allows your baby to play without the restriction of clothing. It’s also a time for you and your baby to get to know each other, to touch and have eye contact. • A nurse will show you how to give your baby a bath. • Until the umbilical cord falls off and the area is healed, which takes one to two weeks, only give your baby a sponge bath on a folded towel. After that, you may give your baby baths in a tub, sink or infant tub. • Use only water to wash your baby’s face. • The bath can be a morning routine or just before bedtime. • It’s best not to bathe your baby right after a feeding, as he or she may vomit. • You won’t need to wash your baby every day. A soap bath of the whole body can be given two to three times a week. Bath supplies • Mild soap, without alcohol or perfumes • Soft washcloth • Towels (regular or hooded) • Container of water if tub is not near the sink • Diaper • Clothes • Blanket • Comb and hair brush • Manicure scissors or clippers Bath safety • The temperature of the water should be about 100 degrees Fahrenheit to prevent chilling or burning. If you don’t have a bath thermometer, use your wrist to test the water. It should feel warm, not hot. • The room should be free of drafts, such as open windows or fans. • Never leave your baby alone! Not for a second. If the telephone rings or someone knocks on the door, ignore it and finish the bath. Accidents can occur quickly. • Always support your baby’s head during the bath. • Always keep a firm grip on your baby. A soapy baby can be very slippery.

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HOW TO BATHE A NEWBORN 1. Arrange all your supplies within easy reach. 2. Wash your hands. Use a clean cloth. 3. Fill the basin or infant tub with warm water. 4. Test the water for a comfortable temperature. 5. Undress your baby and place him or her in the basin of water or, if giving a sponge bath, on the folded towel. 6. Wash the eyes, using only water and a clean washcloth. Begin at the inside of the eye and wash toward the ear. Use a clean part of the washcloth to wash the other eye. 7. Wash your baby’s face, using only water. 8. Place your little finger inside a wet wash cloth and gently clean just inside your baby’s ears. Never use cotton swabs to clean your baby’s ears. 9. Reach under your baby’s back and lift his or her back and head up with your arm. Use your hand to cradle his head, and support his back with your forearm. Wet your baby’s head with water. Apply mild soap or shampoo to the washcloth and gently rub the lather over his head, from front to back. Make sure to keep soap out of his eyes. Rinse his head with clean water and gently pat dry with the towel. 10. Use mild soap and work up a lather on the washcloth. Start with your baby’s neck and wash his or her back, tummy, arms and fingers. Rinse the wash cloth, then gently rinse the soap off this area. Lather then rinse your baby’s legs and feet in the same way. 11. Use this same process to clean your baby’s diaper area, beginning at the front and moving to the buttocks. Remember to clean between the folds of genitals as well. This prevents stool from getting into the opening leading to the bladder, which can cause urinary tract infections. 12. Rinse and dry your baby with a clean, soft towel.

AFTER THE BATH • Dry your baby well. • Dress your baby. • Comb or brush your baby’s hair. • Clean your baby’s fingernails and toenails with a wash cloth. Use baby clippers to clip the nails, when needed. It is important to keep the nails short, so your baby doesn’t scratch himself. • If you’d like, put lotion on your baby’s body, but not on the face. Baby powder is not recommended as it can get into your baby’s lungs and cause breathing problems.

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Safe sleeping • Place your infant on his or her back when sleeping. This reduces the risk of sudden infant death syndrome (SIDS). As your baby gets older, tummy time will be recommended to develop neck and stomach muscles. • Use infant sleep sacks or blanket sleepers, not blankets, to keep your baby warm. Your baby may pull a blanket over his or her head, making it difficult to breathe. • Don’t over-bundle your baby in clothing when sleeping. Light clothing is best. • The temperature in the room should be comfortable for a lightly clothed adult.

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G U I D E F O R N E W M OT H E R S | T H E B I R T H P L AC E AT S T. R I TA’ S

Car and booster seat safety Car crashes are the main cause of accidental death and serious injury of children. Correctly using a car seat or booster seat can save your child’s life.

TYPES AND POSITIONS Infant car seats: Infants up to age 2 should ride facing the rear in an infant-only seat (A) or convertible seat (B). Young-child car seats: Most children over age 2 and between 20 and 40 pounds can ride facing forward (C). Child booster seats: Children who are under 80 pounds, are 4 to 8 years old or under 4 feet, 9 inches tall must ride in booster seats (D).

INSTALLATION • Not all car seats fit in all vehicles. When installed correctly, the car seat should not move more than one inch from side to side. • To install a car or booster seat properly, carefully follow the instructions provided with the seat as well as directions in your vehicle’s owner’s manual. • Schedule a free check with a certified technician, who will inspect the seat and show you how to correctly install and use it. Go to seatcheck.org or call 866 SEAT CHECK (866-732-8243) to find one in your neighborhood.

USE • Children under age 12 should always ride in the backseat. This is the safest place. • Never place a car seat in the front seat. Car seats do not protect infants and children from passenger air bags, which can be dangerous when they are deployed. • If an older child must ride in the front seat, secure the child properly in the correct restraints, and move the front seat as far back as possible from the dashboard. • Laws for car and booster seats vary by state. Make sure to follow the laws of the state you’re traveling in.

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CAR SEAT SAFETY TIPS For rear-facing (infant or convertible) seats: • Keep the harness straps snug and fasten the harness clip at armpit level. Harness straps should be at or below shoulder level. • Place the car seat at a 45-degree angle to keep your baby’s head from dropping forward. • Put the carrying handle for the infant car seat in the down position. • For additional support, place rolled towels or rolled receiving blankets along the sides of your child. Never place padding under or behind a baby. For forward-facing (convertible) seats: • Harness straps should be in the upper slots, at or above the shoulders. • Place the car seat in the upright position. Fasten the harness clip at armpit level and keep the straps snug.

BOOSTER SEAT SAFETY TIPS • Use a booster seat until your child weighs 80 pounds or more and is at least 8 years old. • Make sure your child’s legs are long enough to bend naturally at the end of the seat. • The seat belt should fit across your child’s lap and hips and not rest on his or her stomach. • Many booster seats have a shoulder grip to pull the seat belt comfortably across the upper chest. Use this grip to improve the fit for your child.

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Common newborn conditions JAUNDICE • Jaundice is yellowing of the skin. It is common in newborns and is often harmless. Normal jaundice may go away about a week or so after birth. Sometimes, treatment may be needed. • Jaundice occurs when a normal body chemical, called bilirubin (pronounced “Billy Reuben”), builds up in a baby’s blood. The buildup often occurs because the liver of a newborn may be too immature to keep up with bilirubin removal. Treatment may be needed when this level gets too high. • Normal bilirubin levels increase after 24 hours of life. • Jaundice usually appears first in the baby’s face, then progresses to the chest, abdomen, arms and legs as the bilirubin level increases. • For full-term babies, newborn jaundice peaks on day 3 or 4 and usually clears by 7 days of age. • For pre-term babies, newborn jaundice peaks on day 5 or 6 and then clears by 9 or 10 days of age. • Newborn jaundice occurs both in breastfed and bottle-fed babies, and may happen when the baby does not get enough fluids. • Jaundice may be more common in premature babies. • Jaundice may occur for a variety of reasons. Your baby’s doctor will provide testing and treatment. What you can do: • Have your baby checked for jaundice in the hospital. • If you are breastfeeding, make sure your baby is getting enough breast milk. Please let us know if you would like help from one of our lactation consultants. • Make sure your baby meets the goal for wet diapers each day (see page B4). Call your doctor if your baby has any of the following signs: • His or her skin turns yellower after release from the hospital. • Your baby’s arms, abdomen or legs are turning yellow. • The whites of your baby’s eyes are yellow. • Your baby is hard to wake, fussy or not feeding well.

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CRADLE CAP Your baby’s head may appear dry, scaly or dirty-looking. It’s not due to infection or inadequate washing. This condition, called cradle cap, is thought to be caused by exposure to increased hormones before birth. It won’t harm your baby and will go away. To treat cradle cap: • Apply a small amount of baby oil and leave it on your baby’s head overnight or for at least eight hours. • To keep oil off sheets and clothing, cover your baby’s head with a soft knit hat or buy a “mattress saver” at a baby store. Be sure to safely attach it to the crib, following the instructions. • Comb your baby’s hair with a fine-toothed comb and shampoo. • Always wash and dry your baby’s brush after each use. This process may need to be repeated until the scalp looks clean and normal. If your baby’s scalp does not improve after several days, call his doctor.

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G U I D E F O R N E W M OT H E R S | T H E B I R T H P L AC E AT S T. R I TA’ S

Smoking and your baby Smoking is harmful to your baby before and after birth.

WHAT IS SECONDHAND SMOKE? Secondhand smoke comes from the burning end of a cigarette. This smoke is filled with more tar, poisonous gases and nicotine than the smoke inhaled by the smoker. People in the same room as a smoker, including babies, breathe in secondhand smoke.

WHAT HAPPENS WHEN PEOPLE SMOKE AROUND BABIES? • Babies have tiny lungs and airways. Breathing air filled with smoke causes their tiny airways to get even smaller. This can make it harder for babies to breathe. • Babies and young children breathe much faster than adults. This means they breathe in more smoke than adults. • Babies of parents who smoke develop more colds, allergies and other lung problems in their first year. This can lead to more visits to the doctor and more doctor bills. • Children have more ear infections and sore throats if their parents smoke. These problems make babies cry and fuss more. • Babies may have frequent bouts of colic or stomach upset when they are around secondhand smoke. • Secondhand smoke makes asthma worse. • More babies die of sudden infant death syndrome (SIDS) when they are around secondhand smoke. • Babies of parents who smoke are at risk for burns. Burns often happen from ashes falling from the end of a cigarette. More serious burn injuries and death may occur from house fires caused by cigarette smoking or lighters.

HOW DOES SMOKING AFFECT BREAST MILK? • If you smoke tobacco, it’s best for everyone if you try to quit as soon as possible. Ask your doctor for help. • Tobacco from cigarettes contains a drug called nicotine, which transfers to breast milk and may even affect the amount of milk you produce.

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WHAT ARE THE EFFECTS OF SMOKING ON OLDER CHILDREN? • Children of smokers may be shorter and smaller than nonsmokers. • Children’s lungs grow more slowly if their parents smoke. • Children are twice as likely to become smokers when they get older if their parents smoke.

WHAT CAN I DO? • Don’t allow people to smoke near your baby. That includes inside a car. Tell them they must smoke outside so your baby doesn’t breathe smoke-filled air. • If you smoke, STOP. Ask your doctor or nurse about how to get help, or contact one of these resources: – Ohio Tobacco Quit Line: 800-784-8669 – Smoke-Free Families: tobacco-cessation.org/sf – Smokefree.gov – American Cancer Society Quit Line: 800-227-2345, extension 3, or visit cancer.org – American Lung Association Hotline: 800-LUNG-USA (800-5864872), extension 1, or visit ffsonline.org

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Local doctors for your newborn Itâ&#x20AC;&#x2122;s best to find a pediatrician for your baby before you deliver. The doctors below are accepting new patients: Pediatrics of Lima 830 W. High St., Suite 102 Lima, OH 45801 419-222-4045 Rajbir Bajwa, MD * Sheila McNeal, MD * Teresa Byrne, MD * Michelle Tegenkamp, PNP Teri Grothaus, PNP Kidz Paradise Pediatrics 1220 E. Elm St., Suite 240 Lima, OH 45804 419-999-9004 Tilly Duncan-Sampson, MD West Market Street Family Physicians 915 W. Market St. Lima, OH 45805 419-229-4747 Madeline Agosto, MD * David Neidhardt, MD * Edward Tremoulis, MD * Manuel Patricio, MD * Health Partners of Western Ohio Dr. Gene Wright Community Health Center 441 E. 8th St. Lima, OH 45804 419-221-3072 Karen Martin, PNP Sara Kavalauskas, PNP Klass Family Medicine 601 U.S. 224 Glandorf, OH 45848 419-538-7330 Mandy Klass, MD Jacinta Eickholt, MD Brendon Hovest, CNP

Martin & Martz Family Practice 825 W. Market St., Suite 205 Lima, OH 45805 419-996-5780 Jay Martin, MD Michael Martz, MD Eric Armstutz, CNP Matthew Jose, MD * 1015 S. Blackhoof St. P.O. Box 39 Wapakoneta, OH 45895 419-738-5952 Jennifer Maag, MD 102 Putnam Pkwy. Ottawa, OH 45875 419-523-9632 Lima Pediatrics 1005 Bellefontaine Ave., Suite 245 Lima, OH 45804 419-998-8230 Melody Cyrus, MD Ufuoma Onyemachi, MD Linda Kerr, CNP Gina Marquis, CNP Christina Rodriguez, CNP Family Physicians of Lima 285 W. Elm St. Lima, OH 45805 419-991-7805 Karri Krendl, MD * Tracy Sharp, MD * Elise Clark, FNP

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Family Medicine Associates 582 N. Cable Road Lima, OH 45805 419-996-2500 Mark Mueller, MD Eric Stallkamp, MD Chritine Gaynier, MD * Jamie Reindel, CNP Brenda Keller, FNP St. Rita’s Family Medicine at University of Northwestern Ohio (UNOH) 3224 Jarvis Drive Lima, OH 45807 419-996-5757 Mark Kahle, MD Kent Brandeberry, MD April Garner, CNP St. Rita’s Family Medicine at Columbus Grove 100 Progressive Drive Columbus Grove, OH 45830 419-659-6010 Alisa Marzec, MD J.R. Niese, CNP

Wishing Well Pediatrics 154 W. 3rd St. Delphos, OH 45833 419-692-9355 Celeste Lopez, MD Delphos Medical Associates 1800 E. Fifth St., Suite 1 Delphos, OH 45833 419-692-5611 Danielle Westrick, MD Spencerville Physicians 107 N. Canal St. Spencerville, OH 45887 419-647-4188 Ron Ringwald, MD Auglaize Family Practice Center, LLC 1007 W. Auglaize St. Wapakoneta, OH 45895 419-738-9601 Deron Horman, MD Jamie Szelagowski, MD

Mercy Health — Ada Family Medicine 604 W. North Ave. Ada, OH 45810 419-634-0431 Janelle Niese, CNP * Doctor will visit newborns in the hospital. For a complete list of doctors who are accepting new patients, call St. Rita’s Call-A-Nurse at 419-226-9000. If you doctor does not have privileges at St. Rita’s, our in-house pediatricians from Nationwide Children’s Hospital will care for your baby during your stay. This staff includes neonatologists Vicento Romero, MD, and Magdalino Tatad, MD, and nurse practitioners Val Moniaci, Debbie Krendl, Lisa Shelly, Ginny Synder, Steven Lacey and Annie Yahl.

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Caring for yourself

“If you raise your children to feel that

they can accomplish any goal or task they decide upon,

you will have succeeded as a parent and you will have given your children

the greatest of all blessings.”

Caring for yourself

— Brian Tracy, author and development coach

Caring for yourself It takes time for your body to recover and heal after pregnancy and delivery. The following information will help you care for yourself after leaving the hospital. Your doctor, nurse or midwife will also give you specific information as part of your discharge instructions.

INFORMATION IN THIS SECTION D3 When to call your doctor D4 Activity and rest D4 Postpartum checkup D5 Breast care D8 Incision care D8 Perineal care D9 Other considerations D10 Handwashing D11 Emotional changes D13 Sexual activity D15 Domestic violence

When to call your doctor Your body will need time to heal after you deliver your baby. Watch your body for anything that may signal a problem with recovery. If you have any of these signs, contact your doctor, nurse or midwife right away: • Heavy bleeding like a menstrual period or blood clots larger than a lemon: Heavy bleeding is not normal. Your bleeding is heavy if you need to change your pad more often than every hour. Vaginal bleeding should decrease every day, changing in color from bright red to pink and then to white or clear discharge. The discharge may continue up to six weeks as part of the healing process. Your period may begin a month or more after the birth of your baby. • Fever greater than 100.4 degrees Fahrenheit • Pain that becomes worse in your abdominal or vaginal area • Pain, redness, warmth or firmness in the lower leg or calf area • Trouble breathing, dizziness or fainting • Burning, painful urination or trouble when urinating • Fluid leaking from an abdominal incision or opening of an incision • Breasts that are painful (may be swollen, hot, itchy, lumpy, look red or shiny) • Feeling like you have signs of the flu, such as body aches, vomiting or nausea • Feeling like you can’t cope with caring for yourself: Excessive crying, anger, mood swings that feel out of control or feeling overwhelmed may all be signs of postpartum depression or postpartum mood disorder. Call your doctor or midwife right away.

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Activity and rest • Read your discharge instructions for information about activity. You may be told not to lift anything heavier than your baby for several weeks to allow your body time to heal from delivery. • Rest as much as possible and accept help from others. • Do not drive for two weeks or if you are still taking narcotic pain medications. • Gradually increase your daily activity until you are back to normal activity levels. • When possible, sit down to do work. If you are too active, you may notice an increase in the amount of your vaginal discharge. • Brief walks of five to 10 minutes will help restore your body to its normal state. • Kegels (or pelvic-floor tightening) and pelvic tilts are good toning exercises after leaving the hospital.

Postpartum checkup It’s important to see your doctor four to six weeks after delivery to make sure your body has healed properly

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Breast care Your breasts experience many changes as they begin producing milk for your baby. This can cause some women pain and discomfort, whether they are breastfeeding or not. Wearing a well-fitted support bra (without underwire) during the day and at night, if needed, can help. Most problems can be overcome with a little help and support, but some may require you to see your doctor.

SORE NIPPLES Breastfeeding shouldn’t hurt. There may be some tenderness at first, but it should gradually go away as the days go by. Poor latch-on and positioning are the major causes of sore nipples because the baby is probably not getting enough of the areola into his or her mouth and is sucking mostly on the nipple. If you have sore nipples, you’re more likely to postpone feedings because of the pain. However, this can lead to your breasts becoming overly full or engorged, which can then lead to plugged milk ducts. If your baby is latched on correctly and sucking effectively, he or she should be able to nurse as long as he or she likes without causing any pain. Remember: if it hurts, take your baby off your breast and try again. Ask for help if nursing is still painful for you. Solutions • Check the positioning of your baby’s body and the way he or she latches on and sucks. To minimize soreness, your baby’s mouth should be open wide with as much of the areola in his or her mouth as possible. You should find that it feels better right away once the baby is positioned correctly. (For more information, see “How to breastfeed,” page B14.). • Don’t delay feedings, and try to relax so your let-down reflex comes easily. You also can hand-express a little milk before beginning the feeding so your baby does not clamp down harder, waiting for the milk to come. • If your nipples are very sore, it can help to change positions each time you nurse. This puts the pressure on a different part of the nipple. • Avoid wearing bras or clothes that are too tight and put pressure on your nipples. Change nursing pads often to avoid trapping in moisture. • Avoid using soap or ointments on your nipples that contain astringents or other chemicals. Make sure to avoid products that must be removed before nursing. Washing with clean water is all that’s necessary to keep your nipples and breasts clean. • Making sure you get enough rest, eat healthy foods and get enough fluids. This can help the healing process.

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• If you have very sore nipples, you can ask your doctor about using non-aspirin pain relievers. • If your sore nipples last or you suddenly get sore nipples after several weeks of nursing, you could have a condition called thrush, a fungal infection that can form on your nipples. Other signs of thrush include itching, flaking, drying, tender or pink skin. The infection also can form in your baby’s mouth. It appears as little white spots on the inside of the cheeks, gums or tongue. Thrush also can appear as a diaper rash on your baby that won’t go away by using regular diaper rash ointments. If you have any of these symptoms, call your doctor, your baby’s doctor or a lactation consultant. You can get medication for your nipples and for your baby. If you still have sore nipples after following the above tips, you may need to see someone who is trained in breastfeeding, like a lactation consultant. See “Breastfeeding tips” on page B11 for more information.

ENGORGEMENT It’s normal for your breasts to become larger, heavier and a little tender when they begin making greater quantities of milk on postpartum days 2 through 6. Sometimes this fullness may turn into engorgement, when your breasts feel very hard and painful. You also may have breast swelling, tenderness, warmth, redness, throbbing and flattening of the nipple. Engorgement sometimes also causes a low-grade fever and can be confused with a breast infection. Engorgement is the result of the milk building up, and usually happens during the third to fifth days after birth. This slows circulation, and when blood and lymph move through the breasts, fluid from the blood vessels can seep into the breast tissues. Engorgement can be caused by: • Poor latch-on or positioning • Trying to limit feeding times or infrequent feedings • Giving supplemental bottles of water, juice, formula or breast milk • Using a pacifier • Changing the breastfeeding schedule to return to work or school • Changing your nursing pattern as your baby begins to sleep through the night, or breastfeeding more often during one part of the day and less often at other times • A baby who has a weak suck and is not able to nurse effectively • Fatigue, stress or anemia in the mother • An overabundant milk supply • Nipple damage • Breast abnormalities or surgery Engorgement can lead to plugged ducts or a breast infection, so it is important to prevent it before this happens. If treated properly, engorgement should only last one to two days.

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Prevention • Minimize engorgement by making sure your baby is latched on and positioned correctly at the breast, and nurse frequently after birth. • Allow your baby to nurse as long as he or she likes, as long as he or she is latched on well and sucking effectively. In the early days when your milk is coming in, you should awaken a sleepy baby who breastfeeds less than eight times a day. Breastfeeding often on the affected side helps to remove the milk, keep it moving freely and prevents the breast from becoming overly full. • Avoid bottles and pacifiers. • Try hand-expressing or pumping a little milk to first soften the breast, areola and nipple before breastfeeding, or massage the breast and apply heat before feeding. • If you are returning to work, try to pump your milk on the same schedule that the baby breastfed at home. • Get enough rest and proper nutrition and fluids. If you choose to bottle feed, daily care of your breasts is important to avoid painful engorgement. There are no safe medicines to “dry up” the milk in your breasts. But you can avoid these activities that increase your milk supply: • Exposing your breasts to warm spray in the shower • Touching or massaging your breasts • Pumping or hand expressing milk To help relieve discomfort from engorged breasts: • Use ice packs under your armpits or on your breasts for 20 minutes at a time. • Take pain medicines as directed by your doctor. • Wear a well-fitted support bra day and night until engorgement goes away. • Try to wear a well-fitted, supportive bra that isn’t too tight. If your engorgement lasts for more than two days even after treating it, contact a lactation consultant.

BREAST INFECTION Call your doctor if you experience any of these signs of a breast infection, which requires immediate treatment: • Breasts that are painful or hard with red streaks • Flu-like symptoms • A temperature of 101 degrees Fahrenheit or greater

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Incision care If you have an episiotomy, any stitches usually will dissolve on their own. If you have a cesarean delivery, you will have staples or stitches with steristrips for your incision. Staples will be removed by your nurse before discharge or you may return to your doctor’s office for removal. Stitches will dissolve, and steristrips will fall off in about a week. Keep the incision area clean and dry. You may shower with staples or stitches. To clean your incision, drip plain or soapy water over it and gently pat dry with a clean towel. Do not rub the area.

Perineal care Perineal care (peri care) refers to cleaning your perineum. This includes your vagina, anus (rectum) and the area around these openings. You’ll need to wear a sanitary pad and do peri care each time you urinate or have a bowel movement. Proper perineal care helps to: • Prevent infection • Comfort sore muscles around your vagina and birth canal • Eliminate odor caused by vaginal discharge You should continue this routine until your bleeding stops or as instructed by your doctor: • Wash your hands before going to the bathroom and after perineal care. • Change your sanitary pad every two hours or as needed. • Do not douche or use tampons. • Place dirty pads in a small bag or wrap in toilet paper to control odor. Place in the trash. Do not flush pads down the toilet. • Use your peri bottle to spray water onto your perineal area after going to the bathroom. • Gently wipe or pat your perineal area from front to back with toilet paper. This will prevent spreading germs from your rectum to your bladder and vagina. • Apply sprays, ointments or ice packs as advised by your doctor. • Do not use any powders, oils or perfumes in the perineal area. • Call your doctor if you have any foul-smelling vaginal discharge or prolonged itching.

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Other considerations BATHING Take showers instead of baths until your postpartum checkup in four to six weeks. You may take a sitz bath two to three times daily to relieve the discomfort from stitches or hemorrhoids.

DIET • You may be told to continue taking your prenatal vitamin. Follow your doctor’s or midwife’s orders for medicine. • Drink plenty of water. This helps with breastfeeding and your body’s healing. • Eat foods high in fiber, such as whole grains (cereal, bread and pasta), fruits, vegetables and beans to reduce constipation. • Eat foods high in calcium, such as low-fat milk, yogurt and dark, leafy vegetables. • Eat small, frequent meals and snacks throughout the day rather than one or two big meals. This helps keep your energy level up.

MENSTRUATION (PERIODS) If you are not breastfeeding, your menstrual cycle can begin as early as six weeks after delivery. If breastfeeding, you may not have a period for 12 weeks to 18 months after delivery.

HAIR LOSS A few weeks after delivery, you may find that you are losing large amounts of hair. This is not unusual. Your hair will soon return to its normal growth.

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Handwashing Hand washing is easy to do and it’s one of the most effective ways to prevent the spread of many types of infection and illness in all settings— from your home and workplace to child care facilities and hospitals. When should you wash your hands? • Before, during and after preparing food • Before eating food • After using the toilet • After changing diapers or cleaning up a child who has used the toilet • Before and after caring for someone who is sick • After blowing your nose, coughing or sneezing • After touching an animal or animal waste • After touching garbage • Before and after treating a cut or wound

WHAT IS THE RIGHT WAY TO WASH YOUR HANDS? 1. Wet your hands with clean running water (warm or cold) and apply soap. 2. Rub your hands together to make a lather and scrub them well. Be sure to scrub the backs of your hands, between your fingers and under your nails. 3. Continue rubbing your hands for at least 20 seconds. Need an easy timer? Hum the “Happy Birthday” song from beginning to end twice. 4. Rinse your hands well under running water. 5. Dry your hands using a clean towel or air dry.

WHAT IS THE RIGHT WAY TO WASH YOUR HANDS? Washing hands with soap and water is the best way to reduce germs. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60 percent alcohol. Keep in mind that sanitizers don’t eliminate all types of germs, and are not effective if your hands are visibly dirty. To apply hand sanitizer correctly: • Dispense the recommended amount into the palm of one hand. • Rub your hands together. • Rub the product over all surfaces of your hands and fingers until your hands are dry.

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Emotional changes No amount of study or practice can truly prepare you for parenthood. The most significant change will be in your priorities and demands on your time. In the beginning at least, your universe will center on your baby. It’s normal to feel overwhelmed by all the changes. In addition, sleep deprivation can amplify feelings of anxiety and fear. • It’s common for women to feel inpatient, irritable or sad after giving birth. • These are not signs of weakness or inadequacy. • Many women experience perinatal mood and anxiety disorders. Symptoms can appear any time during pregnancy through the first 12 months of a baby’s life. Postpartum depression is the most wellknown of these conditions. • In fact, postpartum depression is the most common complication after childbearing. Depression can vary widely among new mothers, with some women not affected at all and others needing the support of their doctors. • Experts believe these disorders stem from the physical and emotional adjustments of pregnancy and birth. • These disorders are real, and treatment is available. • Call 911 right away if you think you may harm yourself or others due to depression.

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EDINBURGH POSTNATAL DEPRESSION SCALE We encourage you to take this test every two weeks and bring the results with you to your next office visit. Directions: Choose the answer that best describes how you’ve felt in the past seven days. Total your score when you finish. 1.

In the past seven days, I have been able to laugh

6. In the past seven days, I’ve felt overwhelmed by

and see the funny side of things.

things.

0 = As much as I always could

0 = No, I have been coping as well as ever

1 = Not quite as much now

1 = No, most of the time I have coped quite well

2 = Much less than usual

2 = Yes, sometimes I haven’t been coping as well

3 = Not at all

2. In the past seven days, I have anticipated the

as usual

3 = Yes, most of the time I haven’t been able to cope at all

activities of my day with enjoyment.

7. In the past seven days, I have felt so unhappy

0 = As much as I always could

1 = Not quite as much now

2 = Much less than usual

0 = No, not at all

3 = Not at all

1 = Not very often

2 = Yes, sometimes

unnecessarily when things went wrong.

3 = Yes, most of the time

0 = No, never

8. In the past seven days, I have felt sad or

1 = Not very often

2 = Yes, some of the time

0 = No, not at all

3 = Yes, most of the time

1 = Not very often

2 = Yes, sometimes

worried and cannot put my finger on why.

3 = Yes, most of the time

0 = No, not at all

9. In the past seven days, I have cried because I’ve

1 = Hardly ever

2 = Yes, sometimes

0 = No, never

3 = Yes, often

1 = Only occasionally

2 = Yes, quite often

panicky and cannot put my finger on why.

3 = Yes, most of the time

0 = No, not at all

10. In the past seven days, the thought of harming

1 = No, not much

2 = Yes, sometimes

0 = Not at all

3 = Yes, quite a lot

1 = Hardly ever

2 = Sometimes

3 = Yes, quite often

3. In the past seven days, I have blamed myself

4. In the past seven days, I have been anxious or

5. In the past seven days, I have felt scared or

that I have had difficulty sleeping.

miserable.

been so unhappy.

myself has occurred to me.

Scoring: If your score is 12 or higher, call your doctor today. If your score is less than 12, take this test every two weeks to see if your score changes.

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Sexual activity After the birth of your baby, you may have concerns about resuming sexual activity. You can still be a loving partner, but your body needs time to heal. • Wait four to six weeks after delivery before having sex so that your body can heal from the pregnancy and delivery. Also, it is possible to become pregnant during this period after delivery. Your doctor or midwife will talk with you at your postpartum checkup about resuming sexual activity. • Sex with your partner may be uncomfortable at first. Talk with your partner about your concerns. Until you and your partner are ready to resume sexual activity, there are other ways to feel intimate: • Try to have some alone time together, cuddle during baby’s naps or have a romantic dinner. • Talk with your partner about each of your needs for intimacy. Think creatively about ways you can both show affection, such as giving each other massages. • Join a support group with other women or with your partner if you have postpartum depression, have experienced a loss or are having trouble adjusting to your new parenting role. Having a baby is a lot of work for your body. In the first few weeks you’ll notice many of these postpartum signs which may affect your interest or enjoyment in sexual activity:

VAGINAL TENDERNESS AND DRYNESS You may have tenderness in your vagina (birth canal) and perineum (area around your vagina) from delivery. Try massage or gentle touching until this tenderness improves. When engaging in sexual activity, talk with your partner about what feels comfortable and encourage your partner to go slowly. Estrogen, a hormone in your body, helps to lubricate the vagina during sex. After delivery, your estrogen level decreases, which can cause dryness. The level of estrogen will also remain low in women who breastfeed. You can use a water-soluble lubricant, like K-Y Jelly, to help add moisture.

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BREAST TENDERNESS Let your partner know if your breasts are tender. If you are breastfeeding, breastfeed your baby about an hour before sex to reduce breast fullness, leaking and tenderness. If you are not breastfeeding and are drying up your milk supply, your partner should avoid touching your breasts.

WEAK PELVIC FLOOR MUSCLES Giving birth can change the strength of your pelvic floor muscles, which can affect how sexual intercourse feels. Kegel exercises can help with vaginal stimulation. To do Kegel exercises, tighten your pelvic muscles for three seconds. These are the same muscles you use to control the flow of urine. Then let the muscles relax for three seconds. Slowly build up to doing three sets of 10 Kegel exercises each day to strengthen the muscles.

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Domestic violence Domestic violence is a pattern of behaviors that includes: • Physical injury • Psychological/mental abuse • Sexual abuse • Social isolation • Stalking • Deprivation • Intimidation • Threats Things to know about domestic violence: • These behaviors are perpetrated by someone who is, was or wishes to be involved in an intimate relationship with an adult or adolescent. The behaviors are aimed at establishing control by one partner over the other. • Abuse affects people regardless of race, ethnicity, class, sexual and gender identity, religious affiliation, age, immigration status and ability. Abuse is a healthcare issue that has an impact on people of all ages. • Domestic violence contributes to a number of long-term consequences, physical, emotional and psychological. Many chronic physical conditions—along with mental health problems such as depression, anxiety, post-traumatic stress disorder, alcohol and drug abuse and suicide—may result. • Domestic abuse often escalates from threats and verbal abuse to violence. While physical injury may be the most obvious danger, the emotional and psychological consequences of domestic abuse are also severe. Emotionally abusive relationships can destroy a person’s self-worth, lead to anxiety and depression and cause feelings of helplessness and loneliness. No one should have to endure this kind of pain. • Your first step toward breaking free is recognizing that your situation is abusive. Once you acknowledge the reality of the abusive situation, you can get the help you need.

SIGNS OF AN ABUSIVE RELATIONSHIP To determine whether your relationship is abusive, answer the questions on the following page. The more “yes” answers you have, the more likely it is that you are in an abusive relationship.

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Your thoughts and feelings Do you: • Feel afraid of your partner most of the time? • Avoid certain topics out of fear of angering your partner? • Feel that you can’t do anything right for your partner? • Believe that you deserve to be hurt or mistreated? • Wonder if you are the one who is crazy? • Feel emotionally numb or helpless? Violent behavior or threats Does your partner: • Have a bad and unpredictable temper? • Hurt you, or threaten to hurt or kill you? • Threaten to take your children away or harm them? • Threaten to commit suicide if you leave? • Force you to have sex? • Destroy your belongings? Belittling behavior Does your partner: • Humiliate or yell at you? • Criticize you and put you down? • Treat you so badly that you are embarrassed for your friends or family to see? • Ignore or put down your opinions or accomplishments? • Blame you for his or her own abusive behavior? • See you as property or a sex object, rather than as a person? Controlling behavior Does your partner: • Act excessively jealous and possessive? • Control where you go or what you do? • Keep you from seeing your friends or family? • Limit your access to money, the phone or the car? • Constantly check up on you?

HELP IS AVAILABLE You deserve to feel valued, respected and safe. If you feel that you are a victim of domestic violence, talk to someone right away. These resources are here to help you and your baby: Women Helping Women, Cincinnati 513-381-5610 National Domestic Violence Hotline 800-799-SAFE (7233) If you or your children need immediate help, call 911.

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“A mother’s love is instinctual, unconditional,

and forever...” — author unknown

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Guide for new mothers