MATERNAL AND INFANT CARE: 
A POSTPARTUM DISCHARGE MANUAL 
by 
Donna Mae Bristow 
A professional project submitted in partial fulfillment 
of the requirements for the degree 
of 
Master of Nursing 
MONTANA STATE UNIVERSITY 
Bozeman, Montana 
April 1996 
© COPYRIGHT 
by 
Donna Mae Bristow 
1996 
All Rights Reserved 
ii 
APPROVAL 
of a professional project submitted by 
Donna Mae Bristow 
This professional paper has been read by each member of 
the committee and has been found to be satisfactory 
regarding content, English usage, format, citations, 
bibliographic style, and consistency, and is ready for 
submission to the College of Graduate Studies. 
Approved for the Department of Nursing 
Kathleen Chafey iM 
Approved for the College of Graduate Studies 
Robert Brown 
Ill 
STATEMENT OF PERMISSION TO USE 
In presenting this paper in partial fulfillment of the 
requirements for a master's degree at Montana State 
University-Bozeman, I agree that the Library shall make it 
available to borrowers under rules of the Library, 
If I have indicated my intention to copyright this 
paper by including a copyright notice page, copying is 
allowable only for scholarly purposes, consistent with "fair 
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iv 
TABLE OF CONTENTS 
Page 
ABSTRACT  vi 
1. INTRODUCTION   1 
Statement of the problem  1 
Background    1 
Purpose   4 
2. LITERATURE REVIEW  5 
History of Early Postpartum Discharge  5 
Educational Needs for Early Postpartum Discharge... 6 
Reva Rubin's Theory of Maternal Identity  9 
Conceptual Framework.   11 
Overview  11 
Roy's Adaptation Model  12 
Person  13 
Environment  15 
Health   16 
Nursing  16 
Nursing Process  16 
Rural ity  18 
Process of Patient Education   19 
Assessment   20 
Learning Needs  20 
Goals   20 
Teaching  21 
Written Materials  21 
Format  21 
Evaluation   23 
Summary   24 
3. METHODOLOGY   25 
Step 1: Review of Literature  25 
Step 2: Contact Five Community Hospitals  26 
Step 3: Follow-Up Telephone Calls  26 
Step 4: Design of Postpartum Discharge Manual  26 
Step 5: Review and Approval  27 
V 
TABLE OF CONTENTS—continued 
4. PROJECT OUTCOME   28 
Results  28 
Step Is Review of Literature  28 
Step 2 s Contact Five Community Hospitals  29 
Step 3 s Follow-Up Telephone Calls  29 
Step 4s Design of Postpartum Discharge Manual. 30 
Step 5 s Review and Approval  31 
Implications and Recommendations for Further Study. 32 
REFERENCES CITED  34 
APPENDICES  37 
Appendix A - Letter of Request   38 
Appendix B - The Postpartum Discharge Manual  40 
vi 
ABSTRACT 
The length of hospital stay following an uncomplicated 
vaginal delivery has been steadily decreasing over the past 
30 years. Currently new mothers and their infants are being 
discharged from the hospital within 12 to 48 hours of 
delivery. This presents a problem for postpartum nurses as 
they attempt to provide discharge teaching to these families 
at a time they may not be ready to learn. The purpose of 
this professional project was to design a postpartum 
discharge manual for a community hospital located in a south 
central Montana city with a population of approximately 
25,000. The conceptual framework on which the manual was 
designed, consisted of principles from Roy's Theory of 
Adaptation, Rural Nursing Theory, and the process of patient 
education. The methodology for this project consists of a 
review of the literature to identify the history of early 
postpartum discharge in the United States, the educational 
needs of patients experiencing early postpartum discharge, a 
review of Reva Rubin's classic theory of maternal identity 
from a 1996 perspective, and examination of instructional 
design. In addition, three community hospitals located in 
Montana cities with populations of at least 12,000 sent 
copies of their discharge materials by request to be 
reviewed for content and format. Follow-up telephone calls 
were made to staff at the hospitals to determine perceptions 
of strengths and weaknesses of the materials. The initial 
draft of the manual was evaluated by expert reviewers and 
two learners from the target audience who provided feedback 
on content and format. The major findings of the project 
were that early postpartum patients are concerned about 
receiving specific information about care of themselves and 
their infants. In addition, written materials are one method 
of providing this information to these patients when they 
are most able to access and comprehend it. 
1 
CHAPTER 1 
INTRODUCTION 
Statement of the Problem 
Many postpartum women, and their infants, are being 
discharged within 24 to 48 hours of an uncomplicated, 
vaginal delivery (Riser, 1991; Stover & Marnejon, 1995? 
Harrison, 1990; & Shell, et al, 1995). This phenomenon 
appears to be occurring on a national level, in both urban 
and rural areas. The characteristics of rural life, 
including the distance to services and the independent 
lifestyles of rural residents, make it difficult to provide 
follow up for these families (Bushy, 1991b). Knowledge of 
the trends, and the lack of a written discharge manual for 
postpartum families in a community hospital in south central 
Montana, established the rationale for this study. 
Background 
From the classic work of Reva Rubin (1961), it is known 
that there are two distinct periods of adjustment in the 
immediate postpartum period. The first, the "taking-in" 
phase, is said to last two to three days and is described as 
a period of maternal passivity and dependence. The new 
mother is preoccupied with food and sleep and hesitant to 
2 
make decisions or resume control of her life. She is very 
dependent on the staff and her family to assume control for 
her. The second phase, the "taking-hold" phase, begins some 
time during the next two to three days. In this phase, the 
new mother is able to begin to resume control of her life 
and make decisions for her new infant and her self. Also, 
this period is more conducive to learning how to care for 
herself and her infant. She is less dependent on staff and 
family for her care. 
In 1984, Kartell and Mitchell reexamined Rubin's (1961) 
research to see whether her tenants were still applicable. 
They looked at the timing and characteristics of both the 
"taking-in" and "taking-hold" phases. They found little 
evidence of a strong "taking-in" phase, but did discover 
strong evidence for the "taking-hold" phase. However, the 
"taking-hold" phase appeared to occur between the first and 
second post postpartum day rather than the second or third 
days as previously described by Rubin. Kartell and Mitchell 
(1984) believed that the decrease in time between delivery 
and the "taking-hold" phase was related to both medical and 
societal changes that had taken effect during the 23 year 
interim. The authors believed mothers had less sedation for 
labor and so were more alert and tuned into their babies. 
The feminist movement has decreased dependent behaviors of 
women in general. The expansion in prenatal education better 
prepares women for what to expect in the postpartum period. 
In addition, new mothers have "earlier, more frequent, and 
longer contact with their infants than did mothers in the 
3 
1960s" (Martell & Mitchell, 1984, p. 146), This emphasis on 
early contact may have an impact on why women become focused 
on their infants earlier in the postpartum period (Martell & 
Mitchell, 1984). 
With today's length of stay decreased even further than 
in 1984, the mother is discharged during the "taking-hold" 
phase and may be unable to assimilate the information being 
presented prior to discharge (Ament, 1990). This presents a 
challenge to the postpartum nurse who is responsible for 
assessing the need for, and providing, necessary information 
to this new family. A need exists for alternative methods of 
making the information available to the new family, when 
they are ready for it. Many alternative methods are 
considered for providing this information. These include 
having the families attend a prenatal course designed to 
provide this information prior to delivery or having them 
return for a postpartum class after delivery. These 
alternatives are difficult for rural families with limited 
time and resources. The distance from the health care 
facility may be a barrier to returning for education 
numerous times. Like many other groups, postpartum families 
may not be motivated to learn until they perceive the need 
for specific information to care for themselves or their 
infants (Redman, 1993). 
Another method of providing discharge information is 
print form. In this way the families control the speed at 
which they read and comprehended the information. "Print 
partially relaxes time requirements and is more efficient 
4 
than oral language ..." (Redman, 1993, p. 140). Additional 
advantages of printed materials include: (1) they are 
readily available; (2) they provide consistent information; 
and (3) parents can read them multiple times to promote 
increased comprehension levels. They can be used any time, 
any place, and by relatives, friends and neighbors (Kramer 
and Perin, 1985). 
Purpose 
The purpose of this project was to develop a discharge 
manual for low risk, vaginally delivered, postpartum 
patients. The manual is directed at the needs of first time 
parents during the first two weeks postpartum and also 
serves as a review for all parents, regardless of parity. 
5 
CHAPTER 2 
LITERATURE REVIEW 
The review of the literature focused on three areas: 
the history of early postpartum discharge in the United 
States; the educational needs of families that are 
discharged earlier than the traditional 24-72 hours 
postpartum; and a review of Reva Rubin's (1961) classic 
theory of maternal identity. In additionf literature 
reviewed for the conceptual framework includes Roy's (1983) 
Adaptation Model, rurality and the process of patient 
education. 
History of Early Postpartum Discharge 
During the past 40 years, the length of stay following 
a vaginal delivery has steadily decreased (Beck, 1991). As 
early as 1943, early discharge was reported to be between 
two and five days, while the average length of stay, 
following a vaginal discharge, was 10 days (Beck, 1991). In 
1962, the traditional postpartum stay, after a vaginal 
delivery, was five to six days. During this time, the need 
to relieve the overcrowding caused by the increased birth 
rate of the 'baby-boomers' increased the number of early 
discharges. These discharges occurred after a 72 hour stay 
(Rhodes, 1994). While the original reason for early 
discharge was to alleviate the hospital bed shortage, more 
6 
recent reasons are increasing costs for hospital care, 
consumer demand and family-centered maternity care (Beck, 
1991). 
Two recent solutions have been associated with the 
early postpartum discharge programs: an increased postpartum 
follow up period, in which home visits or telephone calls 
are provided to the short stay families; and the inclusion 
of postpartum teaching in prenatal education programs (Beck, 
1991). Planning for early discharge includes antepartum 
classes and follow up home care to facilitate a safe and 
comprehensive transition from the hospital to home. This 
follow up home care can be extended to the third week 
postpartum (Beck, 1991). 
Recent studies, in both the private and military 
sectors, have found early postpartum discharge to be safe 
and effective (Carty & Bradley, 1990; Berryman & Rhodes, 
1991; Gonzalves & Hardin, 1993; Rhodes, 1994). In the 
majority of contemporary studies, early discharge is defined 
as discharge after 24 hours of observation following a 
vaginal delivery (Rhodes, 1994; Carty,1990; Berryman & 
Rhodes, 1991), while others define early discharge as up to 
48 hours post delivery (Gonzalves & Hardin, 1993). 
Educational Needs for Early Postpartum Discharge 
All early discharge programs, with successful outcomes, 
identify three common factors for program participants. 
Factors include: (1) meeting definitive inclusion criteria. 
7 
Factors include: (1) meeting definitive inclusion criteria, 
such as having a vaginal delivery with no adverse 
complications during labor, delivery, or postpartum; (2) 
participating in antepartal education with a postpartal 
component; and (3) agreeing to participate in postpartal 
follow-up, either by telephone call or home visit (Beck, 
1991; Rhodes, 1994; Carty & Bradley, 1990; Berryman & 
Rhodes, 1991; Gonzalves & Hardin, 1993). According to 
Harrison (1990), assessment is necessary to provide 
individualized teaching. Common problems identified during 
home visits were "elevated bilirubin levels, questions about 
infant care and feeding, and breast engorgement" (p. 39). 
Hiser (1991) found in her study, using card-sort and 
questionnaire tools, that maternal concerns could be grouped 
into three categories. Items included the 'worry' category, 
the 'interest' category, and the 'no concern' category 
(Hiser, 1991). 
Items most frequently sorted into the worry 
category were family finances/having enough money, 
meeting the needs of everyone at home, and being a 
good mother. Items sorted most frequently into the 
interest category were knowing how babies grow and 
develop, knowing how babies act, and blood tests 
taken on the baby. Items of no concern to 
participants were my urinating, my sweating and my 
hemorrhoids (Hiser, 1991, p. 169) 
According to Williams and Cooper (1993) "nursing care 
that historically included a focus on the adaptation of the 
mother, newborn and family no longer can be accomplished 
because of the decreased length of hospitalization" (p. 25). 
Further "mothers and newborns are being discharged from the 
8 
hospital without the majority of their post delivery health¬ 
care needs being met" (p* 25). A postpartum home care 
program was developed by Williams and Cooper, and nursing 
diagnoses monitored on 1,616 clients. The following concerns 
were identified by at least 10% of their clients: 
-episiotomy/laceration pain (36%) 
-ineffective breastfeeding (21%) 
-diet concerns (21%) 
-breast engorgement (19%) 
-backache (16%) 
-uterine cramping (14%) 
-hyperbilirubinemia (14%) 
-constipation (10%) 
-bottle feeding problems (10%) 
It is the responsibility of postpartum nurses to make 
accurate assessments of families' needs for follow-up and 
respond to the identified needs. With the growing number of 
women opting for early postpartum discharge, it is necessary 
to provide education for the families outside of the 
hospital. These educational needs may include a phone call 
or intensive in-home education (Hampson, 1989). 
Lemmer (1987) states that with early discharge, 
conditions which normally do not manifest themselves until 
the second or third day of life may go unnoticed. She 
advises that postpartum teaching should include "written 
information on signs of illness, community resources, and 
care provider phone numbers" (p. 235). The written 
information should effectively provide instruction to the 
9 
audience for which it is being designed (Smith & Ragan, 
1993). 
Reva Rubin's Theory of Maternal Identity 
In the late 1960's, Reva Rubin conducted her classic 
study of the needs of postpartum women. She identified two 
phases, "taking-in" and "taking-hold". "Taking-in" began at 
delivery and lasted for two to three days. During this 
period the mother was dependent on others to make decisions 
for her and to care for her and her infant. "Taking-hold" 
began after the second or third day after delivery. During 
this period the mother assumed more control for her self and 
her infant and was able to begin making independent 
decisions regarding their care. 
In the last twelve years, several studies have tested 
Rubin's theories to determine if they are relevant to 
current maternity practice and care. The first of these 
studies was one by Kartell and Mitchell (1984) that sought 
to answer two questions: "1) Do the subjects show 'Taking- 
in' and 'Taking-hold' behaviors and attitudes as described 
by Rubin? and 2) Do these behaviors and attitudes change 
during the course of hospitalization?"(p. 146). Using a 
similar population and setting, they determined that the 
traditional taking-in phase has decreased in time and the 
taking-hold phase occurs sooner (Kartell & Mitchell, 1984). 
The second study, conducted by Gay, Edgel & Douglas 
(1988), found that "much of the information on which Rubin 
10 
based her observations is obsolete today" (p. 398), Though 
the specific tenets may not be true. Gay and others credit 
Rubin with stimulating obstetric nurses "to look beyond the 
physical aspects of women who delivered infants"( p. 397). 
They caution that "classical writing of yesterday should not 
be discarded but should be viewed in the light of changes 
that may have an effect on what is known today" (Gay, Edgel 
& Douglas, 1988, p. 398). When a discrepancy exists between 
a study and current practice, further research is warranted. 
Ament (1990) strived to evaluate how recent trends in 
maternity care impact Rubin's (1961) original theory of 
maternal identity. She found strong support for Rubin's 
theory based on the findings that behaviors and attitudes 
associated with "taking-in" and "taking-hold" do indeed 
change during the course of hospitalization. Her data 
supports "...Rubin's classic work in all respects, except 
that the time frames in which the changes are thought to 
occur must be altered" (p. 333). Ament's (1990) study found 
a strong taking-in phase lasted only 24 hours instead of the 
two to three days identified by Rubin. Ament (1990) is 
concerned about the current practice of encouraging women to 
be independent on their first postpartum day. She notes that 
"women are not ready to absorb the vast amount of 
information presented to them at that time because they are 
highly involved in the taking-in phenomenon" (p. 334). The 
independence expected of postpartum patients is unrealistic. 
Postpartum nurses need to reexamine their teaching role. 
Ament (1990) recommends that "instead of attempting to teach 
11 
these women in one day everything they need to know about 
caring for their newborns, perhaps outlining the necessary 
highlights may be more practical" (p. 334). She believes 
that follow up instruction 24 to 48 hours after discharge; 
in the 'taking-hold' phase; is more effective than providing 
necessary information to the families prior to an early 
discharge (Ament, 1990). 
Conceptual Framework 
Overview 
During this time of decreased length of hospitalization 
after childbirth, the postpartum nurse's goal is to provide 
increased services to families within the constraints of 
decreased time and resources. One way of attaining this goal 
is by using an organizational framework (Logan, 1990). 
"Implementation of a conceptual framework in practice offers 
an opportunity for designing a structured, organized 
approach to patient care delivery, with the potential for 
increased efficiency and effectiveness" (Weiss, Hastings, 
Holly & Craig, 1994, p. 80). 
The conceptual framework for this project encompassed 
principles from Sister Calista Roy's Adaptation Model, the 
concept of rurality, and the process of patient education. 
Selected principles are described in the following 
paragraphs, giving special attention to the significance of 
each principle to postpartum families. The adaptation, 
education, and rurality principles provide the foundation 
12 
for development of a postpartum manual to provide 
information to postpartum patients on caring for themselves 
and their infants following discharge from the hospital. 
Roy's Adaptation Model 
The family is the system that most influences an 
individual's thoughts, beliefs, and attitudes. This 
relationship is reciprocal with the individual helping to 
shape and define the family. Any changes within the family 
can cause disruption of the system and adaptation is 
necessary for the survival of the family. Roy defined a 
system as "a set of parts connected to function as a whole 
for some purpose, and it does so by virtue of the 
interdependence of its parts" (Andrews & Roy, 1991, p. 7). 
This definition is very close to the definition of family 
found in Friedman (1992) that states a family is "a small 
open social system composed of a set of highly 
interdependent parts and affected by both its internal 
structure and external systems" (p.8). Roy's (1983) 
Adaptation Model was chosen as a component of the conceptual 
framework for developing a postpartum manual for families, 
because it focuses on "responses of the adaptive system in a 
constantly changing environment" (Fawcett, 1995, p. 445) 
with adaptation being "the central feature and a core 
concept of the model" (p. 445). 
"Nursing interventions are the enhancing of stimuli 
[focal, contextual, and residual] to promote adaptation 
within the family system" (Roy, 1983, p. 275). The 
13 
integration of Roy with family is demonstrated in the 
following comment by Friedman (1992). 
Whereas Roy suggests that nursing problems 
involve ineffective coping mechanismsf which cause 
ineffective responses, disrupting the integrity 
of the person, this notion could easily be 
broadened to the family unit, where ineffective 
family coping patterns lead to family functioning 
problems (p. 61). 
Providing information to postpartum families at a time 
when they are best able to comprehend, enhances coping in a 
new situation. 
Roy's Adaptation Model, as outlined by Jacqueline 
Fawcett (1995), is expanded in the following paragraphs by 
describing the model's relationship to family as client. 
This model follows nursing's metaparadigm as it contains the 
same basic components of person, environment, health, and 
nursing. 
Person. The person in Roy's model, defined as the 
recipient of nursing care, can include an individual, a 
community, or as in this case, a postpartum family. The 
person is an adaptive system and has two major internal 
control processes, the regulator subsystem and the cognator 
subsystem. The regulator subsystem responds automatically 
through neural, chemical and endocrine pathways which 
produced automatic, unconscious effects on the family. The 
cognator subsystem responds to psychological, social, 
physical, and physiological factors that are then processed 
through four cognitive-emotive channels: 
(a) perceptual/information processing, (b) learning, 
14 
(c) judgmentf and (d) emotion (Fawcett, 1995). 
The postpartum manual can have the most impact in the 
perceptual/information processing and learning channels. 
Regulator and cognator activity is demonstrated through 
coping behaviors in four adaptive, or response, modes: the 
physiological mode, the self-concept mode, the role function 
mode, and the interdependence mode (Fawcett, 1995). 
Meeting the physiological needs is the primary function 
of families. The adaptive family provides for these needs at 
the most basic and most effective level. The family can not, 
and often does not, survive if these needs are not met. 
The postpartum manual can be designed to provide 
information on how families can provide for the basic needs 
of newly delivered mothers and newborns. 
The self-esteem of the family is inherent in each 
component of the self-concept mode. The family's level of 
self-esteem is a reflection of their self-concept and their 
related behaviors provide insight as to their adaptation in 
this mode (Fawcett, 1995). The postpartum manual provides 
factual information to the family, bringing the ideal self 
and reality closer together. 
The role function mode is based on the need for social 
integrity. This mode contains both instrumental and 
expressive components. The instrumental component is goal- 
oriented and involves demonstrating role behaviors that meet 
societal expectations. The postpartum manual can provide 
insight into role behaviors associated with being a new 
parent. The expressive component deals with the feelings. 
15 
likes, dislikes and attitudes that the family has about the 
role or the performance of the role (Fawcett, 1995). The 
postpartum manual can provide information on feelings 
related to parenting and infant care. Resources can be 
included for parents to contact, should they need 
information and support. 
The interdependence mode is based on the need for 
social integrity and the primary focus is on affectional 
adequacy. Families not only need affection from within their 
boundaries, but also from others outside the identified 
family unit. The postpartum manual can identify available 
community resources. 
Environment. Roy (1983) describes environment as 
anything that has an effect on the development and behavior 
of the family. The environment is in a constant state of 
change and there are internal and external components. The 
model contains three classes of stimuli: (a) focal stimuli, 
the stimuli that most immediately attracts the family's 
attention, (b) contextual stimuli, all other stimuli that 
have an effect on the focal stimuli and impact how the 
family deals with the focal stimuli, and (c) residual 
stimuli, other environmental elements that may have unclear 
effects on the focal stimuli. The family may not be aware of 
these stimuli and the observer may not know that they were 
having an effect on the family (Fawcett, 1995). The 
postpartum manual can be written in a manner that focuses 
16 
primarily on focal stimuli, which is defined as the mother 
and infant's immediate needs. 
Health. Within Roy's (1983) model, health is a 
dichotomy of adaptive and ineffective responses to the 
stimuli at hand, a state of being and a process of becoming 
integrated and whole. Adaptive responses promote the 
integrity of the family and ineffective responses do not 
promote the integrity of the family (Fawcett, 1995). The 
postpartum manual can assist the family in adjusting to 
their new roles in an adaptive, rather than a maladaptive 
manner. 
Nursing. Nursing is a scientific body of knowledge that 
prescribes a process of assessment and interventions 
relating to ill or potentially ill families (Fawcett, 1995). 
Roy (1983) indicates that a nurse is necessary when the 
family is unable to cope effectively with, or adapt to, the 
ever changing environment, because of new or unusual 
stressors and/or weakened coping mechanisms. The goal of 
nursing is to increase adaptive responses and decrease 
ineffective responses by the family through promotion of 
adaptation in the physiological, self-concept, role 
function, and interdependent modes (Fawcett, 1995). The 
postpartum manual could address adaptive responses in the 
four modes. 
Nursing Process. Roy's (1983) model includes a detailed 
nursing process consisting of six steps: 
17 
1. Assessment of behavior: Observable and non 
observable behaviors in each of the four adaptive modes. 
2. Assessment of stimuli: Identification of internal 
and external stimuli influencing the behaviors of the 
family. 
3. Nursing diagnoses: Three approaches to diagnosis 
with this model are: (a) the statement of behaviors within 
one mode with the most prominent influencing stimulir (b) a 
summary label for behaviors in one mode with relevant 
stimuli, and (c) a label that summarizes behavioral patterns 
when more than one mode is being affected by the same 
stimuli. 
4. Goal setting: Actively involving the family in 
identifying clear statements of the behavioral outcomes of 
nursing care of the family. Short term and long term 
behavioral outcomes are thought to promote adaptation by the 
family. 
5. Intervention: Management of relevant focal and 
contextual stimuli to achieve stated goals for nursing care. 
Primarily, the focal stimuli are selected for management. If 
the focal stimuli can not be managed or changed, then 
management of the contextual stimuli is chosen as a way to 
increase the adaptation level of the family. 
6. Evaluation: Effectiveness of nursing interventions 
are reviewed with the family, and defined by whether 
adaptation is occurring, through stimuli modification or by 
enhanced coping strategies. 
18 
The postpartum manual could be written using the 
nursing process to identify, and respond to, commonly 
identified needs of the families during the immediate 
postpartum period. Therefore, the discharge manual, 
according to Roy's (1983) model, would be a nursing 
intervention. 
Ruralitv 
Rurality, from the postpartum families perspective, is 
important to understand. Rurality impacts how parents view 
health and how and when they access health care services. 
When considering the needs of rural families, the issues of 
access to care and the characteristics of self-reliance and 
independence of rural dwellers are important (Bushy, 1991b). 
Access to care is complicated by isolation as a result 
of distance and decreased population (Magilvy, Congdon, & 
Martinez, 1994), difficult terrain, inadequate or 
nonexistent public transportation, poor roads (Bushy, 
1991a), extremes in weather, rural economy, long distances 
and paucity of services (Dietz, 1991). Postpartum families 
often find it difficult to obtain care and to have answers 
to their questions in a timely fashion, because of these 
constraints. While rural people do have a variety of health 
care resources available to them, (e.g., family, friends, 
neighbors and possibly nurses, physicians, nurse 
practitioners, physician's assistants, and others), they may 
be reluctant to use them (Doede, 1993). The physical 
barriers may lead to psychological barriers, perhaps 
19 
lowering health expectations (Doede, 1993). Bringing health 
care to them, in the form of a postpartum manual, could 
enhance adaptation and coping. 
Self-reliance and independence, part of the 
theoretical dimension of person, have been 
demonstrated to be strong rural characteristics of 
rural dwellers in relation to health care. Rural 
persons have been found to manage on their own or 
turn to family and friends for assistance rather 
than formal agencies (Weinert and Long, 1991,p.29). 
Bushy (1991b) concurs, stating that rural clients are 
more self-reliant and perform more services for themselves, 
rather than relying on health care providers. These 
characteristics support the need for postpartum families to 
be able to obtain health care information after they are 
discharged from the hospital. The postpartum manual needs to 
provide information in a manner congruent with their 
lifestyle and beliefs. Parents would not have to travel, 
make long distance calls for information, or seek 
information from others, if they had access to instructional 
materials in their homes. 
Process of Patient Education 
Redman (1993) describes a process model of patient 
education that closely follows the nursing process. The 
steps include assessment of patient needs and the readiness 
to learn, identification of learning needs and goals, and 
evaluation of the learning. Each of these steps are applied 
to postpartum families in the following section. 
20 
Assessment. Motivation is required for learning to 
occur (Redman, 1993). Motivation of postpartum patients may 
be their ability to care for themselves and their new 
infant. Readiness is described as "evidence of motivation at 
a particular time" (p. 16). Thus, parents asking questions 
regarding their infant or themselves demonstrate motivation 
to learn. Newly delivered mothers are in a "taking-in" mode 
(requiring assistance with care for themselves and their 
infants), and may not be as motivated to learn as mothers in 
the "taking-hold" phase. 
Learning needs. The common learning needs of the 
postpartum patient are identified as specific skills 
necessary to care for themselves and their infants. From the 
review of the literature, it is known that postpartum 
patients are concerned with topics such as pain, 
engorgement, backache, cramping, diet, constipation, breast 
and bottle feeding, safety, and infant care (Williams & 
Cooper, 1993). 
Goals. Redman (1993) describes individual and family 
development as one of the major goals of patient education. 
Within this domain, the focus of patient education is 
identified as "supporting and enhancing normal development" 
(p. 47). As noted in the nursing process, individual goals 
are developed in collaboration with the patient and can be 
stated as behavioral objectives. These objectives then 
determine what interventions are necessary in order to teach 
the postpartum patient to care for themselves and their 
21 
infants. The goals of postpartum patients, as identified in 
the literature, can be used when designing the postpartum 
discharge manual. 
Teaching. Teaching encompasses interventions that 
promote learning for the postpartum family. Providing 
instruction involves trying to produce a change in behavior, 
"including change in thoughts, in feeling, and in the 
meaning of experience that will eventually yield observable 
behavior change" (Redman, 1993, p. 118). 
Written materials. Written materials are the most 
common method for providing patient education. Advantages 
include their low cost to produce and duplicate , ease of 
distribution, ease of use and portability (Smith & Ragan, 
1993). Written information has both strengths and 
weaknesses. Strengths are constant availability and 
efficiency. Weaknesses are that written materials are 
selective and discourage feedback (Redman, 1993). In order 
for written materials to be effective, it is important that 
reading comprehension and learning objectives be considered. 
The postpartum manual can be developed using consumer 
language to meet the previously identified learning needs of 
the postpartum family. 
Format. When designing the postpartum discharge manual, 
many decisions need to be made regarding the format of the 
manual. Smith and Ragan (1993) recommend a systematic method 
in which written materials are developed using a "process 
22 
approach" (p. 362). The process consists of generating, 
critically evaluating, and revising the text. 
The first step is to determine the "text structure" 
(Smith & Ragan, 1993, p. 362). Text structures are selected 
based on the type of learning outcome. When the goal of 
learning is concept oriented, the type of "text structure" 
used is description, whereas when the learning outcome is 
problem solving, the "text structure" is problem-solution 
(Smith & Ragan, 1993). 
Guidelines for written materials recommended by Smith 
and Ragan (1993), include: keep the sentences short, simple, 
and concrete; make pronoun references direct and clear? and 
use the pronoun 'you' to direct the information to the 
learners. In addition use headings to break the text into 
sections, use transition words as appropriate (e.g., then, 
now, next, first, second, finally); and avoid gender bias 
(Smith & Ragan, 1993). 
To ensure that the information presented in the manual 
is at approximately the sixth grade level, the SMOG formula 
can be used (Redman, 1993). To apply this formula, 30 
sentences are identified from the written material, and the 
number of words containing three or more syllables are 
counted. A mathematical formula is then applied and the 
grade-level difficulty of the written material calculated. 
Smith and Ragan's (1993) "text specifications" (p. 365) 
are important when designing written materials. They include 
consideration of font selection (style of type), leading 
(space between lines), and page breaks. "For instructional 
23 
texts, one should select a conservative and fairly common 
font, with an emphasis on clarity and legibility" (Smith & 
Ragan, 1993, p. 365). When determining the line spacing, 
recommendations from Montana State University College of 
Graduate Studies (1995) and the American Psychological 
Association (1994) were used. When establishing the "page 
breaks" for the sake of clarity, it is important not to 
•> 
separate a text unit into two separate pages (Smith & Ragan, 
1993). 
Evaluation. During the design process, evaluation of 
the instructional material is critical to identify 
weaknesses and the need for revisions. Smith & Ragan (1993) 
identified four evaluation phases. The first is the review 
by the author. During this phase, the author evaluates the 
information as it is written. The next phase consists of 
review by the experts. This phase involves examining the 
manual for accuracy, appropriateness, and completeness, by 
content and instructional design experts. The third phase 
consists of review by the learners. The best method of 
determining whether the instruction is effective is trying 
out the instructional materials with two or three members of 
the target audience. "Materials that have been tried out 
with only one or two representative students and then 
revised based upon the information gained are substantially 
more effective than the original instruction" (Smith & 
Ragan, 1993, p. 388). The purpose of having learner 
reviewers is to identify and revise gross problems with the 
24 
instructional materials (Smith & Ragan, 1993). The final 
phase involves ongoing evaluation of the written materials 
once they became available to the target population. This 
final phase is beyond the scope of this study. 
Summary 
The literature review indicates that early postpartum 
discharge (defined as within 24 to 48 hours of delivery) is 
occurring with increasing frequency in the United States. 
However, due to the recovery phase of the mother at the time 
of discharge, a need exists for additional instruction 
material for use in the home setting. Written materials can 
be provided either antepartally or postpartally. 
Roy's Theory of Adaptation (1983), the concept of 
rurality, and the process of patient education were 
presented in the conceptual framework. Four important 
factors need consideration in the development of a 
postpartum manual: 
(a) postpartum families need timely assistance in adapting 
to new roles, (b) postpartum families need access to 
information to assist them in adapting to new roles, 
(c) rural postpartum families need support for self-reliance 
and independence in health seeking behaviors, and 
(d) written materials need to be appropriate to the learner 
in both content and format. 
25 
CHAPTER 3 
METHODOLOGY 
Design of the postpartum manual included a general 
review of the literaturef contact with community hospitals, 
follow up telephone calls to staff, development of the 
manual, and evaluation of initial and final drafts by staff 
and postpartum families. 
Step 1: Review of Literature 
First, a literature search was conducted. This was 
completed by using the Montana State University computer 
system to log into the library and search in Cumulative 
Index of Nursing and Allied Health Literature and 
Carl/Uncover for the following terms: postpartum, 
infant/newborn care, patient education, home care services, 
length of stay, and Reva Rubin. Additionally, the community 
hospital medical librarian was contacted. Medline and/or 
other data base searches were requested for the same terms 
and conducted by the librarian. 
Articles appropriate for the project were located, 
requested, and thoroughly reviewed for content. The 
reference list from each article was reviewed for resources, 
and additional articles requested, and reviewed for 
inclusion. 
26 
Step 2: Contact Five Community Hospitals 
Five hospitals located in communities in Montana with 
populations of 12,000 or more were contacted by letter (See 
Appendix B) and asked to provide a copy of postpartum 
teaching manuals, or other information they sent home with 
patients. Hospitals that provided copies of their discharge 
information were offered a completed copy of the manual 
being designed. 
Step 3; Follow-Up Telephone Calls 
After reviewing the literature, and the postpartum 
information from other institutions, telephone calls were 
made to a staff member from each of the institutions 
returning information. Staff were asked two questions: What 
do you like about your hospital's discharge information? and 
What don't you like about your hospital's discharge 
information? The answers were incorporated into the design 
of the postpartum manual. 
Step 4: Design of the Postpartum Discharge Manual 
Information obtained using steps one through three was 
used to design the postpartum discharge manual. The 
literature review determined the outline for content. 
Educational materials from the community hospitals were used 
to identify format. 
27 
Step 5: Review and Approval of Manual 
Once an initial draft of the manual was completed it 
was taken to a community hospital. Two staff members were 
invited to review the manual for content and format. In 
addition, two postpartum inpatients were asked to review the 
manual and provide feedback to the author. Based on their 
suggestions, as well as other maternal-infant experts, the 
final draft of the manual was completed. 
The finished manual was submitted to a department head 
of obstetrics and approval was requested to have it printed 
in the graphics department and to make the manual available 
for distribution to postpartum patients. The manual will be 
used for patient teaching during their stay, and be 
available as a reference after they have been discharged 
from the hospital. 
28 
CHAPTER 4 
PROJECT OUTCOME 
Results 
Step 1; Review of Literature 
Since the 1960s, the postpartum stay, following an 
uncomplicated vaginal delivery, has been decreasing at a 
steady rate to its current length of 24 to 48 hours. Reva 
Rubin's concepts on the "taking-in" and "taking-hold" phase 
remain true today, however, the time frame in which the 
phases occur have decreased. This information indicates a 
need for alternative methods of providing postpartum 
education to families discharged within 24 to 48 hours of 
delivery. 
Next, the literature was reviewed to determine the 
educational needs of families. Families are concerned with 
day to day care of themselves and their infants. Maternal 
concerns were identified, including such items as breast 
care and what to do for discomfort. Identified infant 
concerns included bathing, safety issues, and how to know 
when the baby is ill (Lemmer, 1987; Hiser, 1991; Williams & 
Cooper, 1993). 
A review of the literature on written materials was 
conducted to examine formatting recommendations. The 
29 
formatting suggestions include using the appropriate "text 
structure" for the identified learning needs; keeping 
sentences short and simple; using the pronoun 'you' to 
direct the information to the reader; avoiding gender bias; 
using transition words; and using expert and learner 
reviewers to evaluate the written materials (Smith & Ragan, 
1993). 
Step 2: Contact Five Community Hospitals 
Letters were sent to five community hospitals in * 
Montana requesting copies of postpartum discharge materials. 
Three hospitals responded and sent information. 
Step 3: Follow-Up Telephone Calls 
Phone calls were made to the three hospitals that 
provided information. A registered nurse at each of the 
institutions was asked what she liked/disliked about the 
manual used by that institution. One of the nurses indicated 
that while the manual was easy to understand, it contained 
only information on care of the mother, not the infant. That 
facility is currently working on a separate booklet for 
infant care. Another nurse at the second institution felt 
their manual was thorough and provided easy to understand 
information, but felt that illustrations would enhance the 
understanding, especially for those with low literacy 
levels. The nurse from the third institution, stated their 
manual was very comprehensive and well indexed. She could 
not think of anything she did not like about it. 
30 
Step 4: Design of the Postpartum Discharge Manual 
The "You and Your Baby" postpartum discharge manual was 
constructed using information obtained from the review of 
the literature, from written information received from the 
three responding community hospitals, and from information 
received from the staff in follow-up telephone calls. (See 
Appendix B - The Manual). Revisions were made based on 
feedback in four categories: maternal care, infant care, 
community resources, and references. This feedback was 
obtained from masters prepared maternal-infant nurses, staff 
nurses and postpartum inpatients at the community hospital 
in south central Montana. 
The staff nurses at the community hospital provided 
editorial comments, and clarified some of the information. 
Due to conflicting information in the literature, the author 
and the masters prepared maternal-infant nurses selected 
information that was congruent with the current instruction 
at the hospital. Examples of conflicting information 
included length of breastfeeding sessions and care of 
plastibell circumcisions. 
The first postpartum inpatient to review the manual for 
content and clarity was a second time mother. She validated 
the information in the manual as congruent with her first 
postpartum experience. The mother indicated she had been 
told different things by different staff members and had 
become confused. The mother felt the draft of the postpartum 
discharge manual provided valuable information that she 
would have liked to have had available to her after 
31 
discharge following her first delivery. She did not feel the 
manual was as imperative with the second child, but did 
agree it would be a good review. 
The second postpartum inpatient to review the manual 
was a new mother with her first baby. The mother reviewed 
the information and commented positively about the 
readability and format of the manual. The mother felt the 
text was easy to understand and was in an easy to use 
format. The mother especially appreciated the table of 
contents so she could look up the specific information she 
needed it. When asked about the content, she indicated it 
was all new to her and she appreciated any amount of 
instruction and information. 
Step 5: Review and Approval of Manual 
The last step involved submitting the manual to a 
supervisor of an obstetrics department. The supervisor is 
also the lactation specialist for the institution and 
provided additional feedback on the breastfeeding portion of 
the manual. Her comments were incorporated during further 
revision. Once approved, the manual will go to the graphics 
department of the hospital for printing. A copy will then be 
made available to the patients as part of their postpartum 
teaching. They can take the postpartum discharge manual home 
to be used as a resource during their first few weeks 
postpartum. In addition, a copy will be provided to each of 
the institutions that provided their postpartum discharge 
information to this author. 
32 
Implications and Recommendations for Further Study 
Written information in the form of a postpartum 
discharge teaching manual is just one of an array of 
educational strategies that can be implemented to facilitate 
early postpartum discharge. Postpartum parents should have 
additional follow-up during the first few days after 
discharge. There are many ways of providing this service. 
They could receive follow up phone calls or visits from 
nurses. Parents could schedule visits with their health care 
providers within the first few days of discharge, rather 
than during the two to six week time span as is common 
today. Educational classes, both antenatally and 
postpartally, should be made available for these patients. 
Patients planning to go home soon after delivery may be 
ready for the information prenatally, as they will realize 
the postpartum stay may not be long enough to learn 
everything (Lemmer, 1986). 
Another advantage of the postpartum discharge manual is 
it provides a framework. All health care providers, who come 
in contact with postpartum women, can use the manual to 
provide consistent information regarding the care of mothers 
and newborns during the postpartum period. 
Nurses need to become involved with legislation which 
promotes the family. Currently, there is legislation pending 
in several states to require insurance companies to pay for 
a two day postpartum stay. Perhaps it would be more 
beneficial for nurses to encourage legislation that will pay 
33 
for some type of after hospital care, whether it be home 
visits, telephone calls, or some type of postpartum clinic 
service, where women can be seen within two or three days of 
discharge. Lemmer (1986) indicates that follow up contact 
needs to occur on the second day after discharge "as this is 
the time when maternal physical discomforts are greatest and 
when first responsibility for total care of the infant rests 
with the parents (p. 235). If women remain in the hospital 
until this period they may not experience full 
responsibility for infant care, as the hospital staff will 
continue to fulfill this role. 
Recommendations for further study are to assess the 
needs of the clients in this rural community to see if the 
postpartum discharge manual actually meets their needs. It 
would be beneficial to research the impact of a discharge 
manual verses early postpartum visits (home or clinic 
based), postpartum telephone calls, or other combination of 
strategies. 
34 
References Cited 
Ament, L.A. (1990). Maternal tasks of the puerperium 
reidentified. Journal of Obstetric, Gynecologic and Neonatal 
Nursingr 19(4), 330-335. 
American Psychological Association. (1994). Publication 
Manual of the American Psychological Association (4th ed.). 
Washington DC: American Psychological Association. 
Andrews, H.A., & Roy, C. (1991). Essentials of the Roy 
adaptation model. In C. Roy & H. Andrews (Eds.), The Roy 
adaptation model: The definitive statement (pp. 3 - 25). 
Norwalk, CT: Appleton & Lange. 
Beck, C.T. (1991). Early postpartum discharge programs 
in the United States: A literature review and critique. 
Women & Health, 17m. 125-138. 
Berryman, G.K., SE Rhodes, M.K. (1991). Early discharge 
of mothers and infants following vaginal childbirth. 
Military Medicine. 156. 583-584. 
Bushy, A. (1991a). Background, definitions, theory. In 
A. Bushy (Ed.) Rural Nursing, Volume 1 (pp. 1-6). Newbury, 
CA: Sage. 
Bushy, A. (1991b). Rural determinants in family health: 
Considerations for community nurses. In A. Bushy (Ed.) Rural 
Nursing, Volume 1 (pp. 133-145). Newbury, CA: Sage. 
Carty, E.M., & Bradley, C.F. (1990). A randomized, 
controlled evaluation of early postpartum hospital 
discharge. Birth, 17(4), 199-204. 
Dietz, M. (1991). Stressors and coping mechanisms of 
older rural women. In A. Bushy (Ed.), Rural Nursing, Volume 
1. (pp* 267-280). Newbury Park, CA: Sage. 
Doede, L.M. (1993). Dimensions of health and rural 
residents' health care resources. Unpublished master's 
thesis, Montana State University, Bozeman, MT. 
Fawcett, J. (1995). Analysis and evaluation of 
conceptual models of nursing (3rd ed.). Philadelphia: F.A. 
Davis. 
Freidman, M.M. (1992). Family nursing: Theory and 
practice (3rd ed.). Norwalk, CT: Appleton & Lange. 
35 
Gay, J.T., Edgil, A.E,, & Douglas, A.B. (1988). Reva 
Rubin revisited. Journal of Obstetric# Gynecologic and 
Neonatal Nursinq, 17(6), 394-399. 
Gonzalves, P.E., & Hardin, J.J. (1993). Coordinated 
care early discharge of postpartum patients at Irwin Army 
Community Hospital. Military Medicine, 158, 820-822. 
Hampson, S.J. (1989). Nursing interventions for the 
first three postpartum months. Journal of Obstetric, 
Gynecologic and Neonatal Nursingy 18, 116-122. 
Harrison, L.L. (1990). Patient education in early 
postpartum discharge programs. Maternal Child Nursing, 15f 
39. 
Hiser, P.L. (1991). Maternal concerns during the early 
postpartum. Journal of the American Academy of Nurse 
Practitioners, 3(4), 166-172. 
Kramer, R.F., & Perin, G. (1985). Patient^education and 
pediatric oncology. Nursing Clinics of North America/ 20(1), 
31-48. 
Lemmer, C.M. (1987). Early discharge: Outcomes of 
primiparas and their infants. Journal of Obstetricr 
Gynecologic and Neonatal Nursing, 16, 230-236. 
Logan, M. (1990). The Roy adaptation model: Are nursing 
diagnosis amenable to independent nurse functions? Journal 
of Advanced Nursing, 15, 468-470. 
Magilvy, J.K., Congdon, J.G., & Martinez, R. (1994). 
Circles of care: Home care and community support for rural 
older adults. Advanced Nursing Science, 16(3), 22-33. 
Martell, L.K., & Mitchell, S.K. (1984). Rubin's 
"Puerperal Change" reconsidered. Journal of Obstetricy 
Gynecologic and Neonatal Nursing, 13, 145-149. 
Montana State University College of Graduate Studies. 
(1995). Guide for Preparation of Theses and Professional 
Papers. Bozeman, MT: Montana State University. 
Redman, B.K. (1993). The process of patient education. 
St. Louis: Mosby. 
36 
Rhodes, M.K. (1994). Early discharge of mothers and 
infants following vaginal childbirth at the United States 
Air Force Academy: A three-year study. Military Medicine, 
159, 227-230. 
Roy, C. (1983). Roy adaptation model. In I.W. Clements 
andF.B. Roberts (Eds.). Family Health: A theoretical 
approach to nursing care (pp. 255-278). New York: John Wiley 
and Sons. 
Rubin, R. (1961). Puerperal chance. Nursine Outlook, 
9(12), 743-755. 
Schafer, P.J. (1987). Philosophic analysis of a theory 
of clinical nursing. Maternal-Child Nursing Journal, 19(2), 
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Shell, E.P., Bull, M.J., Moxon, B.E., Muehl, P.A., 
Kroening, K.L., Peterson-Palmberg, G., & Kelber, S. (1995). 
Concerns of childbearing women: A maternal concerns 
questionnaire as an assessment tool. Journal of Obstetric, 
Gynecologic and Neonatal Nursing, 24(2), 149-155. 
Smith, P.L., & Ragan, T.J. (1993). Instructional 
Design. New York: Macmillan 
Stover, A.M., & Marnejon, D.O. (1995). Postpartum care. 
American Family Physician, 52f5). 1465-1472. 
Weinert, C., & Long, K.A. (1991). The theory and 
research base for rural nursing practice. In A. Bushy (Ed.) 
Rural Nursing, Volume 1 (pp. 21-38). Newbury Park, CA: Sage. 
Weiss, M.E., Haskins, W.J., Holly, D.C., & Craig, D.I. 
(1994). Using Roy's adaptation model in practice: Nurses 
perspective. Nursing Science Quarterly, 7(2), 80-86. 
Williams, L.R., & Cooper, M.K. (1993). Nurse-managed 
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Neonatal Nursing, 22(1), 25-31. 
37 
APPENDICES 
38 
APPENDIX A 
LETTER OF REQUEST 
39 
Donna M. Bristow 
c/o Montana State University 
College of Nursing 
Bozeman, MT 59717 
July 25, 1995 
Nurse Manager, RN 
Obstetrics Department 
Community Hospital 
Address 
City, State, Zip Code 
Dear RN: 
I am a graduate student in Montana State University's 
Family Nurse Practitioner program and am currently beginning 
work on my professional project. The purpose of my project 
is to research and construct a booklet to be given to 
patients at the community hospital at which I am currently 
employed. With the recent development of short stay 
maternity programs, I am concerned that the families are not 
ready to take in all of the information that the staff has 
to give them prior to discharge. I am planning to write a 
booklet that will be organized and indexed so that the 
patients can easily find the information they need once they 
are at home. It will focus on the care of newly delivered 
women and infants in the first two weeks post partum. At 
this time, I am interested in gathering samples of 
information that facilities in Montana are currently sending 
home with their patients and would be interested in finding 
out if your organization has any type of booklet you send 
home at discharge. If possible I would like to obtain a copy 
of it. In this day of short stays, it seems to be most 
important that patients have some way to access information 
when they need it, not just when we are able to provide it 
for them. 
In return for your assistance, I will be happy to 
supply you with a copy of my finished product in the spring. 
I can be reached at 406-449-7628 (home). Bobbi Derwinski- 
robinson, MSN, RNC, chair of my professional project 
committee can be reached at 406-657-2912 after August 15th. 
Thank you for your assistance with this matter and I look 
forward to hearing from you in the near future. 
Sincerely, 
Donna M. Bristow, BSN, RNC 
FNP Graduate Student 
40 
APPENDIX B 
THE MANUAL 
41 
YOU AND YOUR BABY 
by 
Donna M. Bristow, BSN, RNC 
42 
Table of Contents 
Page 
YOUR CARE  44 
Uterine Cramping 44 
Vaginal Discharge  45 
Peri Care/Episiotomy 45 
Breast & Nipple Care 46 
Breast Feeding 46 
Formula Feeding 47 
Diet & Activity 48 
Elimination  48 
Resumption of Intercourse/Contraception 49 
Sleep/Rest   
Feelings   
Warning Signs ..51 
BABY CARE   
Feeding   
Breast   
Formula   
Bathing   
Tub Bath,   55 
Umbilical Cord Care 56 
Cradle Cap.   
Diapering   
Voiding & Stooling 57 
Circumcision   
Gomco   
Plastibell   
Dressing   
Safety   
Bulb Syringe 60 
Car Seats 60 
Temperature Taking 61 
Jaundice 61 
Immunizations  62 
Feelings 62 
Siblings 63 
Warning Signs 64 
43 
TABLE OF CONTENTS - continued 
COMMUNITY RESOURCES 65 
La Leche League 65 
Ask A Nurse 65 
WIC 65 
St. Peter's Community Hospital Obstetric's Dept 66 
Cooperative Health Center 66 
Mother's Health Care Provider  66 
Baby's Health Care Provider  66 
REFERENCES 67 
J 
44 
Congratulations on the birth of your child! With this 
new addition to your family, you may find yourselves with 
many questions and concerns about yourself and your infant. 
This manual is not designed to replace your regular health 
care provider, but rather is to be a resource for you during 
the first two weeks after your delivery. 
YOUR CARE 
Uterine Cramping 
At first your uterus can be felt as a hard round ball 
with the top near your navel. It will get smaller over the 
next few weeks until you are no longer able to feel it. 
There may be some cramping as the uterus gets smaller in 
size. This means that it is returning to its normal size and 
is nothing to be alarmed about. If the discomfort from the 
cramping prevents you from doing the things you need to do, 
you may want to take something for the pain, such as Tylenol 
or Ibuprofen, to help ease your discomfort. The cramping may 
increase when you are breast feeding. If you discover that 
the cramping is uncomfortable while breastfeeding, you may 
find it helpful to take medication prior to nursing your 
baby. The cramping should gradually decrease over the first 
two or three days. If your cramping worsens you should 
contact your health care provider, as this may be a sign of 
infection. 
45 
Vaginal Discharge 
You will notice a vaginal discharge, similar to a 
menstrual period, for the first two to six weeks after 
delivery. It will be a bright red at first, possibly 
containing some small (grape size) clots, and then should 
decrease in amount and turn to a pink and finally a white 
color. If you notice that the bright red discharge is 
increasing in amount, becoming bright red again after it has 
been the pink or white color, or you are passing larger 
(plum size) clots, these are signs you may be doing too 
much. You should immediately sit down, put your feet up and 
massage the top of your uterus. If this does not slow the 
discharge you should call your health care provider 
immediately. 
Peri Care/Episiotomv 
You are encouraged to continue to use your peri-bottle, 
filled with warm water, each time you void (urinate), until 
your flow has stopped. This will cleanse the irritated 
tissue around your vagina and help prevent infection, if you 
had a tear or episiotomy. You should also wipe from front to 
back after voiding and apply your peri-pad in a front-to- 
back motion to prevent infections. You can make your own 
sitz bath, by filling a clean tub with four to six inches of 
warm water, and sitting in it for 20 minutes. You may do 
this several times a day for comfort. If necessary, you may 
46 
take Tylenol or some other pain reliever prescribed by your 
health care provider for the discomfort. 
Breast and Nipple Care 
Breast Feeding 
It is important that you wear a good supportive bra 
while you are breastfeeding. This will support the weight of 
the breasts as they fill with milk. Your bra does not have 
to be worn at night unless you feel the need. 
Though you may find your nipples are slightly tender 
during the first 30 seconds of nursing, sore breasts and 
nipples are not a normal finding early in the postpartum 
period. If your baby is correctly latched onto your breast, 
nursing should not be painful. The entire nipple and most of 
the areola (the dark area surrounding your nipple) should be 
in the baby's mouth. It is important to break the suction by 
placing your fingertip in the corner of the baby's mouth 
before taking the baby off the breast. If your nipples do 
become sore, you can leave some breast milk on your nipples 
and expose them to air after the feeding to let them dry. 
You may also apply some purified lanolin to your nipples, if 
they become too dry and start cracking or bleeding. Some 
women find that using regular (not herbal) tea bags will 
help sore nipples. They steep them in warm water and apply 
them to the sore nipples until the tea bags have cooled. It 
is felt this will toughen the nipples, and the warmth is 
soothing and promotes healing. Another comfort measure is to 
47 
dry your nipples with your blow dryer, placing it on low 
heat and only using it for a couple of minutes. 
Your breasts may become engorged as you begin to 
produce more milk on the second or third day after delivery. 
One way to alleviate the discomfort, associated with 
engorgement, is to put the baby to breast frequently to 
promote emptying the breasts. If this does not help, you may 
want to express some of the milk until you feel more 
comfortable, apply warm compresses to your breasts before 
nursing, or take a warm shower to decrease the discomfort. 
Formula Feeding 
You should also wear a good supportive bra, day and 
night. This will be more comfortable for you. You may 
experience engorgement as you begin to produce breast milk 
on the second or third day after delivery. If you are not 
planning to breast feed, it will be important to avoid 
stimulating your breasts by your baby, yourself, or your 
partner. Stimulation and warmth, as from a shower, will 
increase milk production. One way to ease the discomfort is 
to place ice packs on your breasts for ten minutes, three or 
four times per day. This will decrease the swelling 
associated with the increase in milk. Another option is to 
take Tylenol or Ibuprofen for the discomfort. 
48 
Diet and Activity 
A well balanced diet should be followed whether you are 
formula feeding or breast feeding. A well balanced diet 
consists of at least two servings of meat or meat 
alternatives, two servings of dairy products, six servings 
of breads and cereals, and five servings of fruits or 
vegetables. If you are breast feeding you should continue 
your prenatal vitamins and always drink at least eight 
glasses of non-caffeinated beverages per day. 
You should avoid excessive activity in the first couple 
of weeks. This includes stair climbing, lifting heavy 
objects, heavy housework, and vigorous exercise. You may 
want to do some stretching type exercise, or take long 
walks, but you should wait until after your first visit with 
your health care provider before starting more vigorous 
exercise programs. If at any time you notice that your flow 
or afterpains are increasing with activity, you should stop 
the activity until these symptoms disappear. 
Elimination 
You may notice increased voiding during the first 12 to 
24 hours after delivery. This is because your body is 
eliminating the extra fluid from the pregnancy. 
Many women are afraid that the first bowel movement 
after delivery will be painful. You should eat high fiber 
foods (whole grains, fruits and vegetables) and drink at 
least eight glasses of fluids per day to keep your stool 
49 
soft and decrease the discomfort associated with bowel 
movements. If you should become constipated, you should use 
natural type laxatives, such as prunes, prune juice or 
Metamucil, and support the area with tissue when attempting 
to have a bowel movement. Many medications used for 
constipation can be passed to your baby through breast milk. 
If you have worsening constipation despite the extra fluids 
and fiber, you should consult your health care provider. 
Resumption of Intercourse/Contraception 
Most health care providers advise waiting for three to 
four weeks after delivery before resuming intercourse as it 
can take up to six weeks for the inside of the uterus to 
heal, and this will help prevent infection. You should 
consider using some type of birth control method unless you 
are planning to become pregnant right away. If you feel 
comfortable and choose to have intercourse before the 
recommended waiting period, your partner should use a 
condom. Some new mothers report a lower sex drive after 
delivery and while breast feeding because of hormonal 
changes, fatigue, and vaginal discomfort. Because some women 
have vaginal dryness while breastfeeding, you may wish to 
use some type of water soluble lubricant, such as KY Jelly 
or Astroglide, during the first few months. Be patient and 
remember you will not feel this way forever. If intercourse 
remains uncomfortable after six months, you should contact 
your health care provider. 
50 
Sleep/Rest 
It is important to get enough rest. You should take the 
time for at least two naps per day. Lay down when the baby 
does. Another suggestion is to remain in your gown and robe 
the first week home as a reminder to yourself to take it 
easy. This will also discourage visitors from staying too 
long and overtiring you. 
Feelings 
During the first few days after delivery, most new 
mothers are thrilled and excited about their new baby. 
However, some mothers respond to the hormonal changes, 
fatigue and the new responsibilities with mood swings. At 
one moment they may be very excited and the next they may be 
crying. This is termed the "baby blues" and is considered 
normal. These "baby blues" usually occur between the second 
day and fourth week after delivery. If these feelings last 
beyond this time or are accompanied by anxiety, inability to 
sleep, lack of appetite, feelings of hopelessness, or 
inability to care for yourself or your baby, you should 
contact your health care provider for assistance. These can 
be signs of postpartum depression. 
Some fathers will often have many of the same feelings 
as the mother. They may feel increased responsibility for 
their family and possibly some anxiety about finances, 
especially if the mother was also bringing in a salary prior 
to delivery. They may also feel left out of the 
51 
relationship between the infant and the mother. Since many 
fathers have taken an active role in providing care for 
their babies, they report fewer feelings of being left out 
of the relationship. They are getting involved in the day to 
day care of their babies, and the babies are coming to 
depend on both parents for comfort. Fathers are often more 
playful and physically active with their infants, which the 
babies seem to enjoy. 
Warning Signs 
You should call your health care provider if you have 
any of the following symptoms: 
temperature over 100.4 degrees F. 
foul smelling vaginal discharge 
bleeding heavier than a normal period 
bright red bleeding or passing large clots (larger 
than a plum),after the first two to three days 
breast pain or redness 
leg pain or swelling (especially if in one leg and 
not the other) 
pain or burning when voiding 
redness, warmth or drainage around your vagina 
Feeding 
Breast 
Breast milk is the most natural food for babies. It 
contains all the necessary nutrients for baby's early 
feedings and is easily digested. Breast milk is produced 
based on the law of supply and demand. This means that you 
will produce as much milk as your baby requires, based on 
the feeding patterns. For example, if your baby eats 
frequently, you will produce more milk. Feeding your baby a 
bottle of formula or water will disrupt this cycle and may 
cause you to have a decreased milk supply. Breast fed babies 
eat more often than formula fed babies, as the breast milk 
moves through the babies system more rapidly than formula. 
The early milk you produce after delivery is called 
colostrum. It is thicker and darker in color and contains 
many protective proteins to help your baby fight off 
infections. 
It is important that you be relaxed, both physically 
and emotionally, when you nurse your baby, as these 
conditions may affect your milk let down and production. 
Proper positioning is important. One common position is 
sitting up with several pillows to support your back and 
arms. Babies should be on their side with the entire body 
facing toward you and held at the level of your breast so 
you do not have to lean toward them. Alternate positions 
53 
include lying down to nurse, and the football hold, where 
you tuck the baby's legs under your arm and cradle the head 
in your hand, using pillows to keep the baby at the level of 
your breast. 
You should be sure that the baby is latched onto a good 
share of the areola (the dark area around the nipple) to 
help prevent soreness and promote adequate suckling. You 
should nurse at least 10 to 15 minutes per side as it often 
takes this long for your milk to let down. You should 
alternate which breast you start each feeding on, and 
encourage the baby to nurse on both breasts with each 
feeding. Many women use a safety pin on their bra strap to 
remind them on which side the baby should start feeding. If 
your baby does not release the nipple after feeding it is 
helpful to insert your little finger into the side of the 
baby/s mouth to break the suction prior to removing the baby 
from your breast. Changing positions and breaking the 
suction will help decrease sore nipples. You should try 
burping your baby when switching breasts and after a 
feeding. 
Many mothers are concerned as to whether their baby is 
getting enough to eat at the breast. Do not be concerned by 
the seemingly small amount of colostrum available during the 
first day or two. Your baby was born with fat and fluid 
stores to last until you are producing more milk. It is 
known that the more frequently the baby nurses, the sooner 
your milk will come in. Once your milk is in, you can count 
wet diapers. If your baby is having at least six to eight 
54 
wet diapers per day, you can be assured there is enough 
breast milk. 
If you plan to spend some time away from your baby, you 
can pump breast milk either manually or by using an electric 
breast pump. Several different types of breast pumps are 
available, and each will come with instructions for its use. 
You can store your breast milk in the refrigerator for two 
to three days, or freeze it. It can be stored in a 
refrigerator-freezer for up to two weeks or in a deep freeze 
for up to two years. Be sure to label the milk with the date 
so you can use the milk in the order that you pumped it. 
Once thawed, breast milk should not be refrozen. You should 
not thaw frozen breast milk in a microwave because it will 
break down the proteins in the milk. You should thaw the 
milk quickly by running warm water over the container, 
rather than letting it sit at room temperature. 
Formula 
Formula is the food of choice if choosing not to breast 
feed. It is best not to feed your baby regular milk for the 
first year of life, as it is not as completely digested as 
formula. The formulas have been developed to be easily 
digested by infants. There are essentially two types of 
formula, milk-based and soy-based. Milk based is generally 
used unless there is a family history of milk allergy. If 
your baby seems fussy, or spits up frequently on one type of 
formula, you should contact your baby's health care provider 
and discuss the possibility of changing to another formula 
55 
to see if the symptoms are alleviated. Once you have found a 
formula that is agreeable with your baby, it is best to 
stick to one brand. 
The baby should be held for each feeding in a position 
similar to a breast fed baby. Bottles should never be 
propped as your baby may choke during the feeding. Your baby 
will take the formula best, if it is at room temperature or 
just slightly warmed, but never hot. Once your baby has been 
fed from a bottle, the leftover formula should be discarded, 
within the next hour, to prevent germs from growing in the 
formula. 
Formula fed babies need to be burped. If your baby 
slows down when sucking, it is a good time to remove the 
bottle, and sit the baby up to burp. This will help get 
excess air out of the stomach, which will make the baby less 
likely to spit up. 
Bathing 
Babies do not require a daily bath. Giving a sponge 
bath with a mild soap and paying special attention to the 
diaper area and creases should be enough . However, at some 
time after the cord falls off and the circumcision is 
healed, you may want to begin giving your baby a tub bath. 
Tub Bath 
For a tub bath you will need the following supplies: 
washcloth, mild soap, baby shampoo, towels and clothing, 
diaper, baby tub or basin, and a soft brush for hair. It is 
56 
best to bathe the baby in a warm, non drafty area. One 
procedure for a tub bath is as follows: The first or last 
step is to wash the baby's hair and dry it while your baby 
is still in a diaper and covered with a light towel or 
blanket to prevent your baby from getting cold. Next, wash 
the face with plain warm water using a separate clean corner 
of the washcloth for each eye, wiping from inside to out. 
Then dry the face. Next remove the diaper and light towel or 
blanket and place the baby in the tub in two to three inches 
of warm water, keeping the head supported above the water by 
cradling it in your hand, or holding the baby under the 
arms. You can now use soap on the wash cloth and wash the 
rest of the baby. Finish by rinsing the baby in the tub 
water, and wiping with a dry towel. Finally, diaper and 
dress the baby. 
Umbilical Cord Care 
The umbilical cord will dry up and fall off over the 
next week to 10 days. To assist in helping it to dry, you 
should clean it, each time you change the diaper, with an 
alcohol soaked cotton tip applicator. You should apply the 
alcohol to the site where the skin and the cord meet. Once 
the cord falls off you should continue applying the alcohol 
to the site for the next two days. You can keep this area 
exposed to air by fastening the diaper below the cord. This 
will hasten the drying of the cord. If this area becomes 
57 
reddened, or has a foul smell, you should contact the baby's 
health care provider. 
Cradle Cap 
Cradle cap is a crusting noted on the baby's scalp. 
While it will not hurt the baby in any way, it is rather 
unattractive. To remove this crust you can apply some type 
of oil (baby oil, Keri oil) to the baby's scalp and leave it 
in place for 20 minutes. You can then remove the oil and the 
crust by shampooing the baby's hair. You may need to use a 
soft bristle brush to assist in gently removing the crust. 
Diapering 
The baby's diaper should be changed any time the baby 
has voided or stooled. After each void or stool you should 
clean the diaper area with a washcloth wet with water, prior 
to placing a new diaper on your baby. It is best to check 
your baby's diaper at least every couple of hours, whenever 
your baby is fussy, and before or after each feeding. 
Voiding and Stoolinq 
If you are breastfeeding, you may notice your baby only 
voids once or twice in the first 24 hours. Once your milk is 
in you should notice six to eight wet diapers per day. This 
will let you know the baby is getting enough fluids. Stools 
are more frequent in breast fed babies, often stooling 
occurs with each feeding. As your baby gets a little older, 
you may notice stools as rare as every three days. There is 
58 
a wide variation among babies. Formula fed babies should 
also have six to eight wet diapers per day, but may have 
fewer, more firm stools than breast fed infants. They are 
initially a black/green tarry substance called meconium and 
will gradually change over the next couple of days to a 
brown (if bottle feeding) or yellow (if breast feeding) 
color. If you notice blood in the stools or it is a bright 
green color, you should contact your baby's health care 
provider. 
Circumcision 
Gomco 
If your baby's health care provider performed a gomco 
type circumcision, you will notice a dressing of gauze with 
vaseline placed over the head of the penis. This dressing 
should be changed with each diaper change for 48 hours. For 
comfort, you should place the diaper loosely over the 
circumcision during this period. You may notice a thin layer 
of yellow covering the head of the penis as it starts to 
heal. This is normal and will disappear as it heals 
completely. If the baby gets stool on the circumcision, you 
can cleanse this area by lathering a washcloth with a mild 
soap and wringing it out over the penis. You then should 
rinse it in the same manner. If you notice the gauze is 
stuck to the penis, you can soak it off as above. 
Plastibell 
If you notice a plastic ring on your baby's penis, then 
59 
your baby's health care provider has performed a plastibell 
circumcision. This plastic ring should be left in place. It 
will fall off as the edge of the circumcision heals, usually 
in about seven to ten days. You do not need to care for this 
type of circumcision in any special manner, except keeping 
the penis free of urine or stool. 
Dressing 
Generally, your baby will need to dress in as many 
layers as you do. If the weather is very warm, a diaper may 
be enough. If the weather is cool, you may need to add an 
extra blanket or layer of clothing, as babies may not move 
as much as adults and may not keep themselves as warm. 
Safety 
While it may seem that there are few things that can 
occur with a newborn during the first few weeks after 
delivery, there are actually several safety measures you can 
take to prevent accidents. Newborns can be quite active and 
it is important not to leave them unattended on a changing 
table or a couch as they may roll or fall off. Crib slats 
should be no more than 2 3/8 inches apart and protected with 
a bumper pad to prevent the baby from getting caught between 
the slats. Always leave the rails in the up position, 
whenever leaving the baby unattended in the crib. The 
American Academy of Pediatrics recommends that healthy 
babies be placed on their back or side to sleep in an effort 
60 
to reduce the risk of Sudden Infant Death Syndrome (SIDS). 
The side lying position is preferred during the first 30 
minutes after eating, in case the baby should spit up. 
Bulb Syringe 
Because your baby may have increased mucous the first 
few days of life, it is important that you are able to clear 
this mucous out so your baby can breathe easily. Compress 
the bulb syringe and place the tip into the side of the 
baby's mouth. Then slowly release the bulb syringe and 
remove it from the baby's mouth. Repeat this process to 
clear the baby's nose by placing the tip of the bulb syringe 
into your baby's nose. This will draw up the excess mucous. 
You should avoid the roof of the baby's mouth and the back 
of the throat or you may cause the baby to gag. The bulb 
syringe should be washed after each use with warm soapy 
water. 
Car Seats 
State law requires that all infants under 20 pounds be 
placed in a rear facing car seat. They should be buckled 
into the carseat, and the carseat belted into your car. If 
you have front seat airbags, your carseat should be buckled 
into the back seat in the rear facing position. If the 
weather is cool it is preferred that extra blankets be 
placed over the infant once buckled into the car seat, 
rather than under the belts, as this may prevent the belts 
from being securely tightened. The baby's head should be 
supported by the car seat and it is best for newborns to be 
61 
in a reclining, rear-facing position to prevent injury in 
case of a car accident. Your baby should remain in a 
federally approved infant car set until reaching 40 pounds 
according to state law. This hospital rents infant and 
toddler car seats for a nominal fee. 
Temperature Taking 
There are several ways to check an infants temperature. 
One way to assess the temperature is under the arm. To do 
this, shake down the mercury in a glass thermometer and 
place the silver bulb into the baby's armpit and hold the 
arm securely to the chest. Hold the thermometer in place for 
five minutes. There are digital thermometers available for 
both axillary and ear temperatures. They are more costly 
than a glass thermometer, but work more rapidly. The ear 
thermometer works by scanning the temperature of the ear 
drum. Follow manufacturers instructions for their use. They 
will give you the baby's temperature within seconds. A 
normal temperature for a baby is 98.0 to 99.5 degrees F. 
Jaundice 
Jaundice is a term used to describe a yellow coloring 
of a baby's skin. This is normally caused by the immature 
liver of the baby. It often occurs after the second day of 
life and resolves after a week, often without treatment. You 
can help to speed the process by placing your baby near a 
sunny window, but out of direct sunlight, to protect against 
62 
sunburn* Providing frequent feedings will also improve the 
condition* If the jaundice lasts longer than a week, if the 
baby is too sleepy to eat, or if you notice the yellow color 
below the waist, you should notify your health care provider 
right away. If the jaundice becomes a problem, as identified 
with a simple lab test, it can be treated with specially 
designed lights. If the blood level is too high use of the 
lights may need to be done in the hospital. If the baby's 
health care provider feels it is at a safe level, the light 
treatment can be set up in your home. 
Immunizations 
Baby's are currently being immunized with the Hepatitis 
B vaccine while still in the hospital. It is a series of 
three shots that will prevent Hepatitis B infection in most 
people who are immunized. There are usually no side effects 
with the initial vaccine. The other two shots are given by 
your health care provider with the other childhood 
immunizations at two and six months of age. Your baby will 
not need any other immunizations until two months of age. 
Feelings 
Infants have unique personalities and behaviors from 
birth. You will come to know your baby best. Babies cannot 
talk to you or tell you their wants and needs. They 
communicate in other ways, such as crying when needing 
something, or snuggling into your arms when content or 
63 
comforted. If your baby is crying, it is often for one of 
the following reasons; wet diapers, gas, hunger, being 
uncomfortable, being overtired, or just bored and needing 
your attention. 
Babies may have a consistent fussy time of the day 
where they just need to cry. It is often in the afternoon or 
evening and at the same time each day. There are many ways 
to deal with a fussy baby. Sometimes all you have to do is 
hold the baby close. Other suggestions are to take the baby 
for a drive in the car, take the baby into the tub with you, 
or rocking the baby in a rocking chair, or even putting the 
baby into a carrier and place it on top of the dryer. It is 
also helpful to enlist the help of others, such as a spouse 
or friend, who can assist you in trying to calm the infant. 
You can take turns with the fussy baby to decrease your 
stress. If your baby continues to cry despite all of your 
efforts to calm the baby, you can place the baby in a safe 
place, such as a crib, and walk away. This is a good way to 
calm yourself down, as the baby can sense your stress. After 
five or ten minutes you should check on your baby, and if 
the crying continues you can try the calming efforts again. 
Siblings 
If this is not your first baby you may be wondering how 
your older child will react. Siblings react in many ways, 
depending on their age. Younger children often begin to take 
on the baby's role, reverting to wetting their pants or 
64 
taking the baby's bottle or toys. Older children may throw 
temper tantrums or display anger toward the new baby. You 
can help your older child adjust to the new baby by allowing 
your child to help with the baby's care and activities. It 
will also help if you or your partner can spend some time 
alone with the older child and do some of the things they 
prefer, rather than focusing entirely on the baby. 
Warnincr Signs 
If any of the following occur you should call your 
baby's health care provider immediately: 
fever of 100.5 degrees F or higher 
sleepier than usual 
decreased wet diapers (four or less in 24 hours) 
nonstop or high pitched crying 
prolonged or forceful vomiting 
too tired to eat, poor appetite 
diarrhea or constipation 
yellow skin below the waist 
any other concerns you may have 
65 
COMMUNITY RESOURCES 
La Leche League 
An international organization with trained volunteers 
in most areas who answer questions and provide practical 
information and instruction to breastfeeding mothers. 
Headquarters are located in Franklin Park, Illinois and the 
number to call is 1-708-455-7730 between 9 AM and 3 PM 
central time. They will be able to locate a local La Leche 
League leader in your community. 
Ask a Nurse 
A nurse is on duty in St. Peter's Community Hospital 
emergency room, from 7 AM to 11PM daily, to answer health 
care related questions. The number to call is 447-2666 or 
1-800-557-2666. 
WIC 
The Women, Infants & Children's program is located at 
the County Health Department. They offer nutritional 
counseling and food programs for pregnant and nursing women, 
infants and children who qualify for their program. 
Their number is 449-2935. 
66 
St. Peter's Community Hospital Obstetrics Dept. 
Nurses are on duty 24 hours every day to answer 
questions about you and your baby. The number to call is 
444-2208 or 444-2210. 
Cooperative Health Center 
The CHC is located in the County Health Department. 
They offer primary health care for all ages on a sliding fee 
scale. Their number is 443-2584. 
Mother's Health Care Provider 
Name & Number:  
Infant's Health Care Provider 
Name & Number: 
67 
References 
American Academy of Pediatrics Task Force on 
Positioning and SIDS (1992). Pediatrics, 89(6). 1120-1126. 
Bobak, I.M., & Jensen, M.D. (1993). Maternity and 
gynecologic care: The nurse and the family (5th ed.). St. 
Louis: Mosby. 
Fenlon, A.f Oakes, E., & Dorchak, L. (1986). Getting 
ready for childbirth: A guide for expectant parents. Boston 
Little, Brown, and Company. 
Holzman, G.B., & Rinehart, R.D. (Eds.). (1995). 
Planning for pregnancy, birth, and beyond (2nd ed.). 
Washington DC:The American College of Obstetricians and 
Gynecologists. 
Olds, S.B., London, M.L., & Ladewig, P.W. (1996). 
Maternal-newborn nursing: A family-centered approach (5th 
ed.). Menlo Park, CA: Addison-Wesley 
Torgus, J. (Ed.). (1987). The womanly art of 
breastfeeding (4th ed.). Franklin Park, IL: La Leche League 
International.