How to Care for Pregnant and Lactating Patients in Non-Obstetric Departments with Dr. Michelle Solone

Pregnant and breastfeeding patients aren’t always hospitalized for obstetric reasons and can be placed throughout the hospital. Dr. Michelle Solone, OBGYN talks to us about how we can assess these patients, what to look out for, and how nurses can promote pumping and breast feeding during a hospitalization.

Care of the pregnant patient NOT experiencing a obstetric related illness

Common reasons for non-OBGYN related hospitalization for pregnant patients:

• Medical: kidney stones, chemo, pyelonephritis, cardiac conditions
• Surgical: cholecystitis, appendicitis
• Trauma

Which floor does the Pregnant Patient receive care on?

• Less than 20 weeks → regular medical floor
• 20 weeks & up → labor & delivery floor
• Situational Examples: 
  • L&D Nurses don’t interpret EKGs, which will influence which floor a patient can be assigned → CCU/ICU
  • ED for astma exacerbation, traumas
  • Respiratory distress/IV drip monitoring →need ICU nurse with L&D Nurse present to monitor baby

Physiologic Differences of Pregnant Patients

• Increased Blood Volume
  • which can lead to dilutional anemia (ex: Hct 34), due to plasma>RBCs
• Increased Cardiac Output and decreased vascular resistance (↓BP) 
• CPR:
  • Left lateral decubitus positioning or left uterine displacement for CPR over 20 weeks →have mom supine, and have a coworker push the uterus about 2 inches over to the left side for circulation return
• Increased WBCs
• Decreased lung capacity, but increased tidal volume (RR should be same)
• Increased R/F VTE
  • Nursing interventions: SCD’s, mobilization, sleep on left side
  • Medical intervention: Lovenox
• Increased GFR →some medications may need adjustments/labs
• DVT/PE Treatment:
  • Anticoagulation for the rest of pregnancy. (Heparin and Lovenox are safe options-NO Coumadin)
  • Blood Thinners would need to be held prior to any hospitalization with Anesthesia (such as C-sections)

Assessment ABC’s 

• A. Amniotic Fluid
• B. Bleeding (never normal, need OBGYN at bedside)
• C. Contractions/Abdominal Pain
• D. Dysuria
• E. Edema (DVT or Pre-Eclampsia)
• F. Fetal Movement

Dr. Solone’s best advice for assessment and care: “Keep mom healthy and happy.” Many Non-OB healthcare workers are anxious about potentially harming the fetus. “I think my main takeaway is that the best thing you can do for a fetus and a mom is keep the mom healthy. Do not feel like you have to withhold care that is going to help…Most meds and imaging is totally fine.” 

Medications and Imaging

• There is a fear of giving moms pain medications, but most narcotics are safe in short term, such as with kidney stones. Chronic use would be of concern. 
• Antibiotics such as Vancomycin and Ampicillin are very common for the treatment of infection in pregnant patients
• Imaging is safe
  • Preference →ultrasound to avoid radiation, followed by MRI (no gadolinium) if needed
  • CT (with or without contrast) is also safe

Examples of Compatible Medications https://my.clevelandclinic.org/health/drugs/4396-medicine-guidelines-during-pregnancy

Care of the Postpartum and Lactating Patient

• Important: Advocate for breastfeeding and Pumping!
  • Get a Pump in the room early on!
  • Save ALL milk → DON’T DUMP Unnecessarily
    • Label milk to later review with MD if safe for baby
    • Great Northwestern Medicine article supporting this https://www.nm.org/healthbeat/healthy-tips/pumping-and-dumping-myths
• What meds are compatible with breastfeeding?
  • Almost all medications are compatible with breastfeeding
    • One notable exception is Codeine/Tramadol (such as Tylenol with Codeine)
  • Regular Tylenol and Motrin safe for Postpartum Patients
• Be aware: Mothers may still be breastfeeding their toddler
  • Important to establish rapport with your patient in order to receive this information!
• Physiological Changes in Postpartum
  • Fluid Shifts: all blood from uterus rush and return back to heart → flash pulmonary edema, fluid overload within 24 hrs after delivery
  • Preeclampsia may present after delivery
  • Anemia →PP mom may need blood transfusions/iron

Important Last Note

• As a nurse, let your patient (pregnant or PP) know that she should not feel guilt taking care of herself with pain medication during her short hospital stay. It is totally fine to take the pain meds to heal and get out of the hospital even sooner. She does not have to dump her milk from her stay, as long as her OBGYN approves that it is safe for the baby. As Dr. Solone stated, “Don’t think twice and feel so guilty about it!” 
• We must advocate for a healthy and happy mom for a healthy fetus!

References:

Pregnant and breastfeeding patients aren't always hospitalized for obstetric reasons and can be placed throughout the hospital. Dr. Michelle Solone, OBGYN talks to us about how we can assess these patients, what to look out for, and how nurses can promote pumping and breastfeeding during a hospitalization.

Common reasons for non-OBGYN related hospitalization for pregnant patients:

• Medical: Kidney Stones, Chemo, Pyelonephritis, Cardiac Conditions
• Surgical: Cholecystitis, Appendicitis
• Trauma

Which floor does the Pregnant Patient receive care on?

• Less than 20 weeks → regular medical floor
• 20 weeks & up → Labor & Delivery Floor
• Situational Examples:  
  • L&D Nurses don't interpret EKG's, which will influence which floor a patient can be assigned → CCU/ICU
  • ED for asthma exacerbation, traumas
  • Respiratory Distress/IV Drip Monitoring →need ICU nurse with L&D Nurse present to monitor baby

Physiologic Differences of Pregnant Patients

• Increased Blood Volume 
  • which can lead to dilutional anemia (ex: Hct 34), due to plasma>RBCs
• Increased Cardiac Output and decreased vascular resistance (↓BP) 
• CPR: 
  • Left lateral decubitus positioning or Left Uterine displacement for CPR over 20 weeks →Have mom supine, and have a coworker push the uterus about 2 inches over to the Left side for circulation return
• Increased WBCs
• Decreased lung capacity, but increased tidal volume (RR should be same)
• Increased risk for VTE 
  • Nursing Interventions: SCD's, mobilization, sleep on left side
  • Medical Intervention: Lovenox, Heparin
• Increased GFR →some medications may need adjustments/labs

Assessment ABC's of Pregnancy

• A. Amniotic Fluid
• B. Bleeding (never normal, need OBGYN at bedside)
• C. Contractions/Abdominal Pain
• D. Dysuria
• E. Edema (DVT or Pre-Eclampsia)
• F. Fetal Movement

Medications and Imaging in Pregnancy

• There is a fear of giving moms pain medications, but most narcotics are safe in short term, such as with kidney stones. Chronic use would be of concern. 
• Antibiotics such as Vancomycin and Ampicillin are very common for the treatment of infection in pregnant patients
• Imaging is safe 
  • Preference →ultrasound to avoid radiation, followed by MRI (no gadolinium) if needed
  • CT (with or without contrast) is also safe

Care of the Postpartum and Lactating Patient

• Important: Advocate for breastfeeding and Pumping! 
  • Get a Pump in the room early on!
  • Save ALL milk → DON'T DUMP Unnecessarily 
    • Label milk to later review with MD if safe for baby
• What meds are compatible with breastfeeding? 
  • Almost all medications are compatible with breastfeeding
    • Notable exception: Codeine/Tramadol (such as Tylenol with Codeine)
  • Regular Tylenol and Motrin safe for Postpartum Patients
• Physiological Changes in Postpartum 
  • Fluid Shifts: all blood from uterus rush and return back to heart → flash pulmonary edema, fluid overload within 24 hrs after delivery
  • Preeclampsia may present after delivery
  • Anemia →PP mom may need blood transfusions/iron