| A | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | AA | AB | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | Numbers | Code | Postpartum concern | Omaha System Problem | Category | Target | Brief Care Description | Mother or Baby Impact | Care Description | Evidence | Reference | |||||||||||||
2 | MP-1 | SNOMED_CT Problem=249562008 (PB0031); SNOMED_CT Cat-Tar=225361002 (CG0002, TG0005) | Postpartum Constipation | Bowel function | Treatments and Procedures | bowel care | High fiber diet, increased fluid intake. Mild stool softener or bulk forming laxatives if issues. | Mother | Women are recommended a high fiber diet along with increased fluid intake to prevent constipation. Laxatives can also be utilized such as bulk forming laxatives, osmotic laxatives or stimulant laxatives. For women with deep lacerations, mild stool softener is encouraged however if stools become too soft or liquid, this should be stopped. Suppositories should be avoided when lacerations penetrate the anal sphincter or rectum. Magnesium carbonate can also be effective as a supplement. | Further large and randomized control trials need to be conducted regarding laxatives for constipation in postpartum period. Current evidence from small trials suggests no improvement in postnatal pain or straining on defecation postpartum with laxative use. | Turawa, E. B., Musekiwa, A., & Rohwer, A. C. (2015). Interventions for preventing postpartum constipation. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd011625.pub2 | |||||||||||||
3 | MP-2 | SNOMED_CT Problem=249562008 (PB0031); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Hemorrhoids | Bowel function | Treatments and Procedures | medical/dental care | Ice packs, with hazel, stool softener, anesthetic gel. | Mother | Patient can use Ice packs, sitz baths, witch hazel compresses, stool softeners, warm water compresses or analgesic or anesthetic spray. External hemorrhoids can be replaced inside rectum with lubricated finger and pushed back into the rectum. | Karsnitz, D. B. (2015). Postpartum Complications. In Varney's Midwifery (5th ed., pp. 1143-1155). Burlington, MA: Jones & Bartlett Learning. | ||||||||||||||
4 | MP-3 | SNOMED_CT Problem=106063007 (PB0029); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Thrombophlebitis, Deep Vein Thrombosis and Pulmonary Embolism | Circulation | Treatments and Procedures | medical/dental care | Diagnostic Ultrasound, Homan's sign check. Consult medical team. | Mother | Pain in left lower extremity along with edema and increase in circumference unilaterally that comes on suddenly are signs for potential embolism. For pulmonary embolism, tachypnea, chest pain and dyspnea that occur suddenly are signs of embolism, consult physician immediately. Diagnostic ultrasound is recommended along with Homan's sign check. Anticoagulants and bedrest are recommended treatment. Ambulation resumes gradually once symptoms have resolved. Warfarin is typically continued for 6 months or longer as it is considered safe during lactation. | During pregnancy and postpartum period, women have increased risk (5-7 times higher) for venous thrombosis and embolism compared to nonpregnancy women. Incidence of venous thromboembolism from immediately after birth until 6 weeks postpartum ranges from 0.14-3.24 per 1000 births with highest risk in the immediate postpartum period. DVT is more common in left lower extremity due to compression of left iliac vein from the gravid uterus. | Karsnitz, D. B. (2015). Postpartum Complications. In Varney's Midwifery (5th ed., pp. 1143-1155). Burlington, MA: Jones & Bartlett Learning. | |||||||||||||
5 | MP-4 | SNOMED_CT Problem=106063007 (PB0029); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Hypertension | Circulation | Treatments and Procedures | medical/dental care | If oral and IV meds fail, consult critical care team. | Mother | If IV labetalol, hydralazine or immediate release oral nifedipine fails to relieve acute onset severe hypertension, emergent consultation of anesthesiologist, maternal fetal medicine or critical care should be implemented. Second line alternatives include nicardipine or esmolol by infusion pump. | Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. ACOG Committee Opinion No. 767. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e174–80. | ||||||||||||||
6 | MP-5 | SNOMED_CT Problem=106063007 (PB0029); SNOMED_CT Cat-Tar=18629005 (CG0002, TG0033) | Postpartum Hypertension | Circulation | Treatments and Procedures | medication administration | IV labetalol or hydralazine. Immediate release oral nifedipine can be used. | Mother | First line therapy is IV labetalol or hydralazine for management of acute onset, severe hypertension in women in the postpartum period. Immediate release oral nifedipine can be used if IV access is not available. Monitor maternal vital signs for heart rate and blood pressure. | Current research indicates that IV labetalol should be used as first line medications in severe hypertension in pregnant women. If IV access is not available, oral nifedipine can be utilized,. Studies show that women who received "immediate release oral nifedipine had their BP lowered more quickly than with either IV labetalol or hydralazine and had a significant increase in urine output." Severe hypotension with use of nifedipine and magnesium sulfate were not substantiated in review studies. Monitoring vital signs however is still recommended as both drugs are calcium antagonists. | Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. ACOG Committee Opinion No. 767. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e174–80. | |||||||||||||
7 | MP-6 | SNOMED_CT Problem=106063007 (PB0029); SNOMED_CT Cat-Tar=18629005 (CG0002, TG0033) | Postpartum Hypertension | Circulation | Treatments and Procedures | medication administration | Magnesium sulfate can be used for seizure prophylaxis with hypertension. | Mother | Magnesium sulfate is not recommended as an antihypertensive agent but it is the drug of choice for seizure prophylaxis for women with acute-onset severe hypertension during pregnancy and postpartum period. Once BP is stabilized, other measures such as magnesium sulfate for seizure prophylaxis should be implemented. Monitor vital signs. | Magnesium sulfate is recommended in setting of acute severe hypertension regardless if the patient has gestational hypertension with severe features, preeclampsia with severe features or eclampsia. | Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. ACOG Committee Opinion No. 767. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e174–80. | |||||||||||||
8 | MP-7 | SNOMED_CT Problem=191415002 (PB0050); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Mastitis | Communicable/infectious condition | Treatments and Procedures | medical/dental care | Change breastfeeding technique, antibiotics against Staph aureus, continue breastfeeding. | Mother | Diagnosing mastitis is clinical, patients present with focal tenderness in one breast, fever and malaise. Treatment includes changing breastfeeding technique, antibiotics effective against Staphylococcus aureus (dicloxacillin or cephalexin). Continued breastfeeding is encouraged and does not pose a risk to infant. If breast abscess develops, surgical drainage or needle aspiration is needed. | Mastitis occurs in 10% of US mothers who are breastfeeding and can lead to the cessation of breastfeeding. Risk of mastitis can be reduced by emptying the breast and optimizing breastfeeding techniques. Sore nipples can precipitate mastitis. Assess infant for tongue tie. | Spencer, J. (2008). Management of mastitis in breastfeeding women. American Family Physician, 78(6), 727-731. | |||||||||||||
9 | MP-8 | SNOMED_CT Problem=191415002 (PB0050); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Infections | Communicable/infectious condition | Treatments and Procedures | medical/dental care | CBC, blood culture, urine cultures. Consult with medical team if severe infection. | Mother | Postpartum fever is an oral temperature greater than 100.4F on more than two occasions during the first 10 days postpartum. Differential diagnoses include endometritis, mastitis, wound infections or UTIs. Conduct CBC, blood culture and urine culture. Consultation with physician may be warranted depending on etiology and severity of infection. | Puerperal fever and infection is a leading cause of hospital readmission following giving birth. In a study conducted in Denmark (2008), 24% of women reported an infection within 4 weeks postpartum. Breast infections (12%) were most common followed by wound, vaginal, urinary, and respiratory infections, endometritis and other infections. | Karsnitz, D. B. (2015). Postpartum Complications. In Varney's Midwifery (5th ed., pp. 1143-1155). Burlington, MA: Jones & Bartlett Learning. | |||||||||||||
10 | MP-9 | SNOMED_CT Problem=191415002 (PB0050); SNOMED_CT Cat-Tar=18629005 (CG0002, TG0033) | Neonatal Immunizations | Communicable/infectious condition | Treatments and Procedures | medication administration | Administer Hep B vaccine within 24 hrs of birth. | Baby | If mother is HBsAg-negative, administer first dose within 24 hrs for ALL medically stable infants > 2000 g. If mother is HBsAg-positive, administer HepB vaccine and hepatitis B immune globulin (in separate limbs) within 12 hrs of birth regardless of birth weight (administer 3 additional doses beginning at 1 month). If mother's HBsAg is unknown, administer Hep B vaccine within 12 hrs of birth regardless of birth weight, if infants are less than 2000 g, administer HBIG in addition to Hep B vaccine. | Hepatitis B vaccine (first dose) should be administered at birth. Second dose between 1-2 months and third dose between 6 months to 12 months. Routine series are 3 dose series unless combination vaccine was used, then it is 4 series. See CDC website for further child and adolescent immunization schedule. | Birth-18 Years Immunization Schedule. (2020, February 03). Retrieved November 13, 2020, from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html | |||||||||||||
11 | MP-10 | SNOMED_CT Problem=129908006 (PB0030); SNOMED_CT Cat-Tar=20135006 (CG0002, TG0047) | Postpartum Gestational Diabetes | Digestion-hydration | Treatments and Procedures | screening procedures | Glucose tolerance test 2 hrs 6-12 weeks postpartum. | Mother | Follow up tests to assess for type II diabetes including glucose tolerance test at 6-12 weeks postpartum is recommended. Physician consultation is recommended. | Karsnitz, D. B. (2015). Postpartum Complications. In Varney's Midwifery (5th ed., pp. 1143-1155). Burlington, MA: Jones & Bartlett Learning. | ||||||||||||||
12 | MP-11 | SNOMED_CT Problem=13197004 (PB0040); SNOMED_CT Cat-Tar=410290005 (CG0001, TG0020) | Postpartum Sexual Health | Family planning | Teaching, Guidance and Counseling | family planning care | Counsel about contraceptive use prior to birth otherwise earlier than 6 weeks postpartum. | Mother | Counseling regarding sexual health and postpartum contraception should meet normative behavior of the patient, contraception plans should be established during prenatal care and postpartum visit should occur earlier than 6 weeks postpartum. Education regarding return to sexual activity. | By 6 weeks postpartum, studies show that 4 in 10 women have already resumed vaginal intercourse with only half of those individuals using actual contraception. It is therefore recommended that contraceptive plans should be established prenatally and the postpartum visit should be occurring earlier than 6 weeks. | Sok, C., Sanders, J. N., Saltzman, H. M., & Turok, D. K. (2016). Sexual Behavior, Satisfaction, and Contraceptive Use Among Postpartum Women. Journal of Midwifery & Women's Health, 61(2), 158-165. doi:10.1111/jmwh.12409 | |||||||||||||
13 | MP-12 | SNOMED_CT Problem=105726004 (PB0017); SNOMED_CT Cat-Tar=410410006 (CG0004, TG0047) | Neonatal Screening | Growth and development | Surveillance | screening procedures | Screen all newborns for hemoglobinopathies, phenylketonuria, hypothyroidism. | Baby | All newborns must be screened for hemoglobinopathies, phenylketonuria, hypothyroidism in the first week of life. Appropriate follow up services must be provided if positives occur. | Early identification of newborn metabolic disorders are vital in detecting serious health conditions that can originally be asymptomatic. There is strong evidence suggesting support for screening for hemoglobinopathies, phenylketonuria and hypothyroidism. There is fair evidence that suggests that false positive results are not a burden to parents and that screening is cost effective. | Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, McKeon K, Milteer L, Owens J, Rothe P, Snellman L, Solberg L, Vincent P. Institute for Clinical Systems Improvement. Preventive Services for Children and Adolescents. Updated September 2013 | |||||||||||||
14 | MP-13 | SNOMED_CT Problem=105726004 (PB0017); SNOMED_CT Cat-Tar=410410006 (CG0004, TG0047) | Hyperbilirubinemia Screening | Growth and development | Surveillance | screening procedures | Screen all newborns for hyperbilirubinemia. | Baby | Clinicians should screen for hyperbilirubinemia in newborn infants to prevent severe complications such as kernicterus. | Kernicterus happens very rarely in 1.5/100,000 full term infants and 4/100,000 pre-term infants. Following screening guidelines have been shown to decrease the incidence of kernicterus. Screening is effective in detecting the condition and current evidence is not conclusive enough to recommend for or against screening. | Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, McKeon K, Milteer L, Owens J, Rothe P, Snellman L, Solberg L, Vincent P. Institute for Clinical Systems Improvement. Preventive Services for Children and Adolescents. Updated September 2013 | |||||||||||||
15 | MP-14 | SNOMED_CT Problem=105726004 (PB0017); SNOMED_CT Cat-Tar=410410006 (CG0004, TG0047) | Dysplasia of Hip Screening | Growth and development | Surveillance | screening procedures | Ortolani and Barlow tests. | Baby | Screening for for disorders of the hip could be recommended by physical examination or radiologic tests. Individuals clinicians can determine if hip dysplasia screening is necessary. Ortolani and Barlow tests are recommended if that is the case. If abnormalities are found, further evaluation by orthopedic surgeon is recommended. | Current evidence of screening is not of the best quality in order to recommend universal screening. | Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, McKeon K, Milteer L, Owens J, Rothe P, Snellman L, Solberg L, Vincent P. Institute for Clinical Systems Improvement. Preventive Services for Children and Adolescents. Updated September 2015 | |||||||||||||
16 | MP-15 | SNOMED_CT Problem=105726004 (PB0017); SNOMED_CT Cat-Tar=410263001 (CG0001, TG0031) | Neonatal Circumcision | Growth and development | Teaching, Guidance and Counseling | medical/dental care | Shared decision making process. | Baby | Present evidence based information to parents and families regarding risk and benefits and alternatives in a shared decision making process. | Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, McKeon K, Milteer L, Owens J, Rothe P, Snellman L, Solberg L, Vincent P. Institute for Clinical Systems Improvement. Preventive Services for Children and Adolescents. Updated September 2013 | ||||||||||||||
17 | MP-16 | SNOMED_CT Problem=105726004 (PB0017); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Hyperbilirubinemia | Growth and development | Treatment and Procedures | medical/dental care | Phototherapy, exchange transfusion possible but high risk. | Baby | Phototherapy is the most commonly used intervention. Exchange transfusion is also possible but a lot less used due to high risk of complications. | There have been no studies that analyze the impact of the use of phototherapy for kernicterus however exchange transfusion has been associated with significant risk and has declined significantly since 1988 without change in incidence of kernicterus. | Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, McKeon K, Milteer L, Owens J, Rothe P, Snellman L, Solberg L, Vincent P. Institute for Clinical Systems Improvement. Preventive Services for Children and Adolescents. Updated September 2014 | |||||||||||||
18 | MP-17 | SNOMED_CT Problem=118230007 (PB0019); SNOMED_CT Cat-Tar=410410006 (CG0004, TG0047) | Hearing Screening | Hearing | Surveillance | screening procedures | Screen for congenital hearing loss. | Baby | Screen for congenital hearing loss before 1 month of age. | There is evidence that recommends newborn screening prior to one month of age. "The testing methodology of a one- or two-step validated protocol showed high sensitivity (0.92) and specificity (0.98) for the two-step protocol (otoacoustic emissions followed by auditory brainstem response for those who failed otoacoustic emissions)." | Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, McKeon K, Milteer L, Owens J, Rothe P, Snellman L, Solberg L, Vincent P. Institute for Clinical Systems Improvement. Preventive Services for Children and Adolescents. Updated September 2016 | |||||||||||||
19 | MP-18 | SNOMED_CT Problem=36456004 (PB0012); SNOMED_CT Cat-Tar=410328009 (CG0003, TG0011) | Postpartum Depression | Mental health | Case Management | coping skills | Screen for postpartum depression. Follow up 2 and 6 weeks postparutm. | Mother | It is recommended that obstetric clinicians complete a full assessment of mood and emotional well being that screens for both postpartum depression and anxiety using a validated instrument during the postpartum visit. Ensure referral to mental health provider and follow-up diagnosis and treatment. Follow up should occur at 2 weeks and 6 weeks. | Evidence suggests that screening alone can have benefits however initiation of treatment along with referral to mental health providers shows greatest benefits. | Screening for perinatal depression. ACOG Committee Opinion No. 757. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e208–12. | |||||||||||||
20 | MP-19 | SNOMED_CT Problem=36456004 (PB0012); SNOMED_CT Cat-Tar=410410006 (CG0004, TG0047) | Postpartum Depression | Mental health | Surveillance | screening procedures | Use EPDS when screening for depression. | Mother | Edinburgh Postnatal Depression Scale (EPDS) is the most commonly used screening tool. Patient Health Questionnaire 9 can also be utilized. | Edinburgh Postnatal Depression Scale has a sensitivity of 59%-100% and specificity 49%-100%. Patient Health Questionnaire 9 has sensitivity of 75% and Specificity of 90%.Postnatal depression is very common in the postpartum period, affecting 1 in 9 women. There is great benefit surrounding screening and initiation of treatment for women. | Screening for perinatal depression. ACOG Committee Opinion No. 757. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e208–12. | |||||||||||||
21 | MP-20 | SNOMED_CT Problem=106088004 (PB0035); SNOMED_CT Cat-Tar=424753004 (CG0001, TG0067) | Breastfeeding | Nutrition | Teaching, Guidance and Counseling | dietary management | Breastfeed exclusively for first 6 months and up to a year. 500 calories extra per day for mother. Iron fortified cereal at 6 months. | Baby | Providers should encourage and promote breastfeeding in mothers. Breastfeeding exclusively for the first 6 months and up to a year is encouraged. Supplementing breast fed infants with iron no later than 6 months along with iron fortified cereal. Supplementing with 400 IU/day vitamin D within 2 months for infants is also recommended. Pacifiers can be used by parents. 500 calories extra per day for mother. | Breastfeeding has been shown to decrease ear and gastrointestinal infections as well as lower the incidence of asthma, Type II Diabetes and obesity. Studies have also shown that maternal maltreatment decreases as breastfeeding duration increases. "Pacifier use as not shown to affect breastfeeding duration or exclusivity." | Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, McKeon K, Milteer L, Owens J, Rothe P, Snellman L, Solberg L, Vincent P. Institute for Clinical Systems Improvement. Preventive Services for Children and Adolescents. Updated September 2013 | |||||||||||||
22 | MP-21 | SNOMED_CT Problem=106088004 (PB0035); SNOMED_CT Cat-Tar=20135006 (CG0002, TG0047) | Postpartum Anemia | Nutrition | Treatments and Procedures | screening procedures | Screen for anemia if risk factors. Iron replacement therapy. | Mother | If women have risk factors such as prenatal anemia, postpartum hemorrhage and Cesarean birth, screen for anemia. Wait 24 hrs after birth to test for anemia. Treatment includes iron rich foods, iron therapy. | It is not recommended to screen for anemia unless patient has risk factors . | Karsnitz, D. B. (2015). Postpartum Complications. In Varney's Midwifery (5th ed., pp. 1143-1155). Burlington, MA: Jones & Bartlett Learning. | |||||||||||||
23 | MP-22 | SNOMED_CT Problem=22253000 (PB0024); SNOMED_CT Cat-Tar=409058006 (CG0002, TG0032) | Pain Management | Pain | Treatments and Procedures | medication action/side effects | NSAIDs, oral ketorolac for breastfeeding pain. No tramadol or codeine with breastfeeding. | Mother | Pain management breast feeding considerations, use NSAIDs (Ibuprofen should be first line for pain control). Oral or IV ketorolac can be utilized for moderate pain. Opioids should be used with caution as they can cause significant CNS depression in infants who are breastfeeding. Tramadol and codeine are not recommended if woman is breastfeeding. | The relevant infant dose (weight adjusted maximum percentage of maternal dose in milligrams per kilogram) is used to assess drug safety during lactation. An infant dose greater than 10% of maternal dose is concerning. Orally administered NSAIDs are excreted into breast milk at lower concentrations. "Ibuprofen has a short half-life with a relative infant dose that ranges from 0.6% in colostrum to less than 0.38% in mature milk, equivalent to approximately 0.2% of the pediatric dose." Used as first line agent for postpartum pain. Safe to use when breast feeding. Injectable and oral ketorolac to treat moderate pain, studies show that it has little concentration in breast milk and can be used for lactating breastfeeding woman. Opioids are lipophilic and are easily transferrable into breast milk. Codeine has the active metabolite morphine causing CNS depression. Several studies and reports have shown excessive sedation as well as infant deaths with use of maternal codeine. Breastfeeding is not recommended if patient is on tramadol or codeine as they use the CYP2D6 pathway to produce excessive analgesic effects. Use non-opioid analgesics once a woman's breast milk comes in. Neonatal sedation was reported in less than 2.1% of infants when these guidelines were used. | Postpartum pain management. ACOG Committee Opinion No. 742. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132. DOI: 10.1097/AOG.0000000000002683. Epub 2018 May 18. | |||||||||||||
24 | MP-23 | SNOMED_CT Problem=22253000 (PB0024); SNOMED_CT Cat-Tar=18629005 (CG0002, TG0033) | Pain Management | Pain | Treatments and Procedures | medication administration | Consult specialist for chronic pain postpartum. | Mother | Pain management for women with chronic pain, consult appropriate specialist to manage opioid use. | Management of women with chronic pain, especially those utilizing opioids on a regular basis are a unique population that should be handled by a pain specialist that should follows the CDC's Guidelines for Prescribing opioids for chronic pain. | CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. (2016, March 18). Retrieved November 13, 2020, from https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm | |||||||||||||
25 | MP-24 | SNOMED_CT Problem=22253000 (PB0024); SNOMED_CT Cat-Tar=18629005 (CG0002, TG0033) | Pain Management | Pain | Treatments and Procedures | medication administration | NSAIDs, avoid opioids unless necessary. Stepwise approach. | Mother | Pain management in postpartum period, use NSAIDs and other antiinflammatory drugs, only reserve use of opioids when other adjuncts are inadequate. If prescribing codeine, patient should be educated about signs of newborn toxicity and risks of CNS depression. | "For postpartum cesarean pain, oral and parenteral analgesics adjuvants including Acetaminophen, Nonsteroidal antiinflammatory drugs, opioids and opioids that are in combination with acetaminophen or NSAIDs. Parenteral or oral opioids should be reserved for treating breakthrough pain when analgesia from neuraxial opioids and nonopioids adjuncts become inadequate. If codeine-containing medications are selected, patient education regarding newborn signs of toxicity, should be reviewed with family. Counsel women who are prescribed opioid analgesics about the risk of CNS depression in woman and breastfed infant, duration of prescription should be limited to shortest reasonable course for treating acute pain." | Postpartum pain management. ACOG Committee Opinion No. 742. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132. DOI: 10.1097/AOG.0000000000002683. Epub 2018 May 18. | |||||||||||||
26 | MP-25 | SNOMED_CT Problem=22253000 (PB0024); SNOMED_CT Cat-Tar=18629005 (CG0002, TG0033) | Pain Management | Pain | Treatments and Procedures | medication administration | Cold packs, Witch Hazel pads. Warm packs for uterine involution discomfort. | Mother | Pain management vaginal birth, use cold packs, Witch Hazel pads and NSAIDs (more effective than acetaminophen per EBP). For breast trauma, utilize breast shield and application of breast milk instead of lanolin. For hemorrhoids, topical steroid cream. Stronger opioid analgesics are reserved for women with inadequate pain control using NSAIDs and milder opioids, use step-wise approach. Warm packs for uterine involution discomfort. | Most common sources of pain are breast engorgement, uterine contractions and perineal lacerations so cold packs and increasing the frequency of breastfeeding are sufficient for breast pain, mild antiinflammatory effect can be used if needed. For perineal pain, cold packs achieve most analgesia compared to numbing agents. For hemorrhoids, topical application of astringent, steroid, or anesthetic creams is recommended but not for long term as it can cause atrophic effects. Nipple pain can be controlled with expressing milk, controlling the fit of the pump flanges and assessment/readjustment of infact latch. "Of note, a recent randomized controlled trial found that application of breast milk with the additional protection from a breast shield is more effective in healing trauma and mitigating pain than is application of lanolin, which must be wiped away before breastfeeding." NSAIDs appear to be more beneficial than acetaminophen 4 hrs after birth for postpartum pain, however at 6 hrs, there is no difference. "Stronger opioid analgesics are best reserved for women with inadequate pain control after a reasonable trial of a standard dosage of a multimodal regimen of NSAIDs combined with milder opioids. Stronger opioids should be used only as long as absolutely needed for adequate analgesia." | Postpartum pain management. ACOG Committee Opinion No. 742. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132. DOI: 10.1097/AOG.0000000000002683. Epub 2018 May 18. | |||||||||||||
27 | MP-26 | SNOMED_CT Problem=22253000 (PB0024); SNOMED_CT Cat-Tar=18629005 (CG0002, TG0033) | Pain Management | Pain | Treatments and Procedures | medication administration | Can use dexamethasone to relieve nausea and pain perioperatively. No gabapentin. | Mother | Pain management cesarean birth, use neuraxial opioids for analgesia as well as acetaminophen, NSAIDs and opioids that are in combination with either acetaminophen or NSAID. Dexamethasone can be used in the perioperative period to relieve nausea and improve pain in the first postoperative day. Parenteral or oral opioids should be used for breakthrough pain. Pain block can be beneficial. Gabapentin should not be used. | Use stepwise, multimodal approach to analgesia. Neuraxial opioids provide greatest relief in postpartum period but most women require additional analgesia as the effects of them diminish. Acetaminophen, NSAIDs and combination opioids are standard oral and parenteral analgesics that are used. Parenteral or oral opioids should be reserved for breakthrough pain. "Dexamethasone has been used in the perioperative period; a single preoperative dose of dexamethasone has been found to improve analgesia and decrease nausea and vomiting on the first postoperative day. Gabapentin is not recommended for routine post cesarean pain control given the lack of strong evidence for significantly improved cesarean postoperative pain as well as potential adverse effects and limited data on the neonatal safety profile. However, gabapentin may be considered as part of a multimodal analgesic regimen in patients with a history of chronic pain or pain not relieved by standard treatment protocols." | Postpartum pain management. ACOG Committee Opinion No. 742. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132. DOI: 10.1097/AOG.0000000000002683. Epub 2018 May 18. | |||||||||||||
28 | MP-27 | SNOMED_CT Problem=22253000 (PB0024); SNOMED_CT Cat-Tar=18629005 (CG0002, TG0033) | Pain Management | Pain | Treatments and Procedures | medication administration | Prescription drug monitoring prior to discharge for opioids. | Mother | Pain management discharge medications, therapy should be individualized per patient. Look up prescription drug monitoring programs if prescribing opioids upon discharge. | Studies show that amount of opioid prescribed after cesarean section exceeds the amount used or consumed after discharged. "The median number of dispensed opioid tablets was 40 (interquartile range, 30–40), the median number consumed was 20 (interquartile range, 8–30), and leftover was 15 (interquartile range, 3–26)." No number has been identified for a good amount of opioids therefore therapy should be individualized per patient condition. | Postpartum pain management. ACOG Committee Opinion No. 742. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132. DOI: 10.1097/AOG.0000000000002683. Epub 2018 May 18. | |||||||||||||
29 | MP-28 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=410291009 (CG0001, TG0021) | Breastfeeding | Postpartum | Teaching, Guidance and Counseling | feeding procedures | Breastfeed infants on demand. Initiate within 1 hr postpartum. | Baby | Infants should be breastfed on demand (as often as the child wants, day and night), can use bottles and pacifiers. Breastfeeding should be initiated within 1 hour of birth. | WHO and UNICEF recommend children imitation breastfeeding within the first hour of birth and exclusively breast fed for the first 6 months of life. CDC reports benefits to mother (lower risk of breast cancer, ovarian cancer, type 2 diabetes and hypertension) and benefits to babies (lower risk of asthma, obesity, type 1 diabetes, SIDS, ear infections and gastrointestinal infections). | Recommendations and Benefits for Infant and Toddler Nutrition. (2019, November 04). Retrieved November 13, 2020, from https://www.cdc.gov/nutrition/infantandtoddlernutrition/breastfeeding/recommendations-benefits.html | |||||||||||||
30 | MP-29 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=385715006 (CG0002, TG0007) | Postpartum Hemorrhage | Postpartum | Treatments and Procedures | cardiac care | Monitor in aftermath, debrief with patient and staff. | Mother | Aftercare: monitor for ongoing blood loss and vital signs, assess of signs of anemia (fatigue, chest pain, shortness of breath, lactation problems), debrief with and listen to patients and staff. | Evensen, A., Fontaine, P., & Anderson, J. M. (2017). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician, 95(7), 442-449. | ||||||||||||||
31 | MP-30 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Hemorrhage | Postpartum | Treatments and Procedures | medical/dental care | Oxytocin after delivery for prevention of hemorrhage. | Mother | Prevention of postpartum hemorrhage is active management of the third stage of labor. Administer oxytocin (Pitocin) soon after delivery of anterior shoulder, controlled cord traction to deliver placenta and uterine massage after the delivery of the placenta. Oxytocin (Pitocin) for prevention is 10 IU IM or 5-10 IU IV bolus, for treatment, 20-40 IU in 1L normal saline, infuse over 500 mL over 10 minutes then 250 mL per hour. Second line agents include Carboprost (Hemabate), Tranexamic acid, Methylergonovine, Misoprostol. | Based on current evidence, administration of oxytocin is the most important component in preventing postpartum hemorrhage. "The number needed to treat to prevent one case of hemorrhage 500 mL or greater is 7 for oxytocin administered after delivery of the fetal anterior shoulder or after delivery of the neonate compared with placebo." Alternative to oxytocin is misoprostol (Cytotec), it's inexpensive and does not require injection however current studies show that oxytocin is more effective than misoprostol and has less side effects. Controlled cord traction hasn't been shown to prevent severe postpartum hemorrhage however it reduces the incidence of less severe blood loss (500 to 1000 mL) and shows a decreased need for manual extraction of the placenta. | Evensen, A., Fontaine, P., & Anderson, J. M. (2017). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician, 95(7), 442-449. | |||||||||||||
32 | MP-31 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Hemorrhage | Postpartum | Treatments and Procedures | medical/dental care | Measure blood loss. Monitor for hypovolemia. Four Ts mnemonic. | Mother | Diagnosis and management, quantitative measurement occurs immediately after the birth of the infant. Measure cumulative blood loss with calibrated under buttocks drape, weighing blood soaked pads, sponges and clots. Tachycardia is earliest symptom of hemorrhage. Orthostasis, hypotension, nausea, dyspnea, oliguria and chest pain can indicate hypovolemia. If excess bleeding is diagnosed, " the Four T's mnemonic (uterine atony [Tone]; laceration, hematoma, inversion, rupture [Trauma]; retained tissue or invasive placenta [Tissue]; and coagulopathy [Thrombin]) can be used to identify specific causes." Additional personnel should be called in to initiate emergency hemorrhage protocols. | Evensen, A., Fontaine, P., & Anderson, J. M. (2017). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician, 95(7), 442-449. | ||||||||||||||
33 | MP-32 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Hemorrhage | Postpartum | Treatments and Procedures | medical/dental care | If hypotensive and EBL>500mL, bimanual uterine massage, oxytocin and fluid bolus. | Mother | If despite active management, bleeding still occurs (EBL >500mL) and signs of hypotension are observed, call for help, perform bimanual uterine massage, institute labor unit hemorrhage protocol, deliver oxytocin 20 IU in 1L normal saline, infuse 500 mL over 10 minutes then 250 mL per hour, ensure there are 2 large bore IVs placed, provide O2 by mask, monitor BP, HR and urine output, lab testing such as type and crossmatch, CBC tests. | Evensen, A., Fontaine, P., & Anderson, J. M. (2017). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician, 95(7), 442-449. | ||||||||||||||
34 | MP-33 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Hemorrhage | Postpartum | Treatments and Procedures | medical/dental care | If still hemorrhaging, oxytocin, carboprost, methylergonovine or misoprostol should be used. | Mother | Determine cause and treat using the Four T's mnemonic: Soft, boggy uterus (Tone). Oxytocin: 20 to 40 IU in 1L NS, infuse 500 mL over 10 minutes then 250 mL/hr. Carboprost (Hemabate): 250 mcg IM or into the myometrium every 15 to 90 minutes (2 mg total). Methylergonovine (Methergine): 0.2 mg IM every two to four hours. Misoprostol (Cytotec): 800 to 1000 mcg rectally or 600 to 800 much sublingually or orally. | Uterine atony is most common cause of postpartum hemorrhage, if brisk blood flow after delivery of the placenta is unresponsive to transabdominal massage, bimanual compression is recommended along with uterotonic agents . Oxytocin is most effective treatment of postpartum hemorrhage. Second line should be base don patient specific factors taking into consideration hypertension, asthma or use of protease inhibitors. | Evensen, A., Fontaine, P., & Anderson, J. M. (2017). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician, 95(7), 442-449. | |||||||||||||
35 | MP-34 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Hemorrhage | Postpartum | Treatments and Procedures | medical/dental care | Inspect lacerations, hematoma or observe for inverted uterus. | Mother | Determine cause and treat using the Four T's mnemonic: Laceration of uterine inversion (Trauma). Suture lacerations, drain expanding hematoma, replace inverted uterus. | Episiotomies increase risk of blood loss and anal sphincter tears so it should be avoided unless urgent delivery is needed. Uterine inversion is rare and impacts 0.04% deliveries and could be a potential cause of postpartum hemorrhage. "If placenta is attached, it should be left in place until after reduction to limit hemorrhage. "Uterine rupture can also cause intrapartum and postpartum hemorrhage, clinically significant rupture occurs in 0.8% of vaginal births after cesarean delivery. Induction and augmentation also increase risk of uterine rupture. "Before delivery, primary sign of uterine rupture is fetal bradycardia." | Evensen, A., Fontaine, P., & Anderson, J. M. (2017). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician, 95(7), 442-449. | |||||||||||||
36 | MP-35 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Hemorrhage | Postpartum | Treatments and Procedures | medical/dental care | Inspect placenta, uterus. | Mother | Determine cause and treat using the Four T's mnemonic: retained placenta or clot (Tissue). Inspect placenta, explore uterus, manual removal of placenta, curettage. | Longer intervals from delivery to placental expulsion are associated with increased risk of postpartum hemorrhage. Rates double after 10 minutes. Invasive placenta can cause life threatening postpartum hemorrhage. Incidence increases with time and with an increase in cesarean deliveries. Advanced maternal age, high parity and previous invasive placenta are all risk factors. | Evensen, A., Fontaine, P., & Anderson, J. M. (2017). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician, 95(7), 442-449. | |||||||||||||
37 | MP-36 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Hemorrhage | Postpartum | Treatments and Procedures | medical/dental care | Coagulation studies and observe clotting. | Mother | Determine cause and treat using the Four T's mnemonic: blood not clotting (Thrombin). Observe clotting, check coagulation studies, replace clotting factors, platelets, supply fresh frozen plasma. | Evensen, A., Fontaine, P., & Anderson, J. M. (2017). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician, 95(7), 442-449. | ||||||||||||||
38 | MP-37 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Hemorrhage | Postpartum | Treatments and Procedures | medical/dental care | Transfuse RBCs, platelets and clotting factors if massive hemorrhage. Consult medical team. | Mother | For severe postpartum hemorrhage, transfuse RBCs, platelets and clotting factors using massive transfusion. Consult anesthesia, surgery and intensivist, support blood pressure with vasopressors, consider uterine packing, balloon tamponade, vessel embolization, compression sutures, recombinant factor VIIa or hysterectomy (to be done by MD or DO). | Evensen, A., Fontaine, P., & Anderson, J. M. (2017). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician, 95(7), 442-449. | ||||||||||||||
39 | MP-38 | SNOMED_CT Problem=118213005 (PB0049); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Thyroiditis | Postpartum | Treatments and Procedures | medical/dental care | Obtain TSH level, test for thyroid peroxidase antibodies. Beta blockers and levothyroxine. Physician management. | Mother | Thyroiditis symptoms depend on whether it is hyperthyroidosis (fatigue, palpitations, anxiety, insomnia, weight loss, irritability and goiter) or hypothyroiditis (fatigue, impaired concentration, depression, dry skin, constipation, weight gain and goiter). Obtain TSH level and test for thyroid peroxidase antibodies. Beta blockers are treatment of choice for hyperthyroidosis or levothyroxine if hypothyroiditis. Physician management is indicated. | Postpartum thyroitis can occur anytime during the first year following birth (first 1 to 4 months is most common) with incidence varying fom 5-10%. Risk factors include Type 1 Diabetes, previous thyroid dysfunction and those with history of thyroid disorders. | Karsnitz, D. B. (2015). Postpartum Complications. In Varney's Midwifery (5th ed., pp. 1143-1155). Burlington, MA: Jones & Bartlett Learning. | |||||||||||||
40 | MP-39 | SNOMED_CT Problem=118232004 (PB0047); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Endometritis | Reproductive function | Treatments and Procedures | medical/dental care | Prophylactic antimicrobial therapy before C section. Consult medical team. CBC, blood cultures, CXR for rule out. Start antibiotics. | Mother | Endometritis usually occurs within 2-4 days postpartum or as late as 2-6 weeks postpartum. Symptoms include generalized malaise, fever, foul smelling lochia and uterine tenderness. Administer one dose of prophylactic antimicrobial therapy before C section. If endometritis occurs, complete CBC, chest XR to rule out pneumonia, blood cultures. Consultation with physician is encouraged as differential diagnoses include appendicitis, pyelonephritis and pneumonia. Start Clindamycin 900 mg + gentamicin 1.5 mg/kg every 8 hrs OR Clindamycin 900 mg every 8 hrs and ampicillin-sulbactam (Unasyn) 1.5 g every 6 hrs OR Ampicillin 2 g every 6 hrs and Gentamicin 1.5 mg/kg every 8 hrs. | Endometritis can occurs in 1-2% of all vaginal births, cesarean section increases the risk up to 27%. ACOG recommends using one dose of prophylactic antimicrobial therapy administered 60 minutes before cesarean section, standard practice. Risk factors include prolonged labor, improper management of retained placental fragments and cesarean section. | Karsnitz, D. B. (2015). Postpartum Complications. In Varney's Midwifery (5th ed., pp. 1143-1155). Burlington, MA: Jones & Bartlett Learning. | |||||||||||||
41 | MP-40 | SNOMED_CT Problem=106076001 (PB0026); SNOMED_CT Cat-Tar=77248004 (CG0002, TG0071) | Postpartum Incision Care | Skin | Treatments and Procedures | infection precautions | Handwashing, adminsitration of antibiotics prophylactically. | Mother | Hand washing and administration of antibiotics within 60 minutes of commencement of cesarean section of a repaired perineal laceration of episiotomy. Signs and symptoms of wound infections include low grade temperatures, dysuria, localized pain, exudate or dehiscence. Depending on type of infection, management includes daily debridement, wound packing, antibiotic management and drainage if necessary. Could consult physician if complications occur. | Vaginal infections can be the cause of puerperal fever, it is vital to prevent however if it occurs, treatment and management is recommended. | Karsnitz, D. B. (2015). Postpartum Complications. In Varney's Midwifery (5th ed., pp. 1143-1155). Burlington, MA: Jones & Bartlett Learning. | |||||||||||||
42 | MP-41 | SNOMED_CT Problem=106076001 (PB0026); SNOMED_CT Cat-Tar=410324006 (CG0002, TG0031) | Postpartum Vaginal Hematomas | Skin | Treatments and Procedures | medical/dental care | CBC, start IV line. Monitor vitals. Administer pain medications. Vaginal packing. Blood replacement if necessary. | Mother | Small and moderate hematomas are typically absorbed spontaneously. If hematoma is large or growing, CBC should be collected and IV line should be started. Vital signs are monitored for signs of shock. Administer pain medications as needed. Monitor hematocrit level, vaginal packing to evacuate blood and blood clots and ensure closure of cavity. Blood replacement, antibiotics or interventional radiology might be needed (consult physician). | Hematomas are localized collection of blood that has been clotted. Incidence of postpartum hematoma 1/300-1/1500 births. Typically occurs due to trauma from instrumental birth or episiotomy. Risk factors include primiparity, multiple gestation, preeclampsia, coagulopathies, vulvovaginal varicosities and prolonged second stage labor along with instrumental birth and episiotomy. | Karsnitz, D. B. (2015). Postpartum Complications. In Varney's Midwifery (5th ed., pp. 1143-1155). Burlington, MA: Jones & Bartlett Learning. | |||||||||||||
43 | MP-42 | SNOMED_CT Problem=106021008 (PB0036); SNOMED_CT Cat-Tar=410305008 (CG0001, TG0045) | Infant Sleep Positioning | Sleep and rest patterns | Teaching, Guidance and Counseling | rest/sleep | Infants should sleep on their back for sleep. | Baby | Ask about the infant's environment, educate parents about placing infants on their back to sleep. | Stomach and side sleeping are major risk factors for sudden infant death syndrome in multiple studies. The frequency of stomach sleeping has decreased from 70% to 20% in the USA and since then SIDS has gone down by over 50%. Avoidance of sleep covering, loose soft objects around infants and offering of pacifiers are also recommended along with good ventilation as these have all had good evidence in decreasing rates of SIDS. | Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, McKeon K, Milteer L, Owens J, Rothe P, Snellman L, Solberg L, Vincent P. Institute for Clinical Systems Improvement. Preventive Services for Children and Adolescents. Updated September 2017 | |||||||||||||
44 | MP-43 | SNOMED_CT Problem=409069009 (PB0039); SNOMED_CT Cat-Tar=20135006 (CG0002, TG0047) | Pain Management | Substance use | Treatments and Procedures | screening procedures | Screen for opioid use disorder. Continue agonist therapy through pregnancy and postpartum | Mother | Pain management opioid use disorder, screen for substance use using the 4Ps, NIDA Quick Screen and CRAFFT. Women should continue opioid agonist pharmacotherapy throughout pregnancy and postpartum period. Patient education, family education about risk of opioid overdose. | ACOG recommends the utilization of validated screening tools 4Ps, NIDA Quick Screen and CRAFFT and should be done at first prenatal visit with pregnant woman. "Women with substance use disorder should continue their opioid agonist pharmacotherapy throughout pregnancy and the postpartum period, although the dosage might need to be adjusted." Women with opioid use disorders can be at a higher risk of substance use and overdose as well as other comorbid mental health conditions and should be screened if concern exists. | Postpartum pain management. ACOG Committee Opinion No. 742. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132. DOI: 10.1097/AOG.0000000000002683. Epub 2018 May 18. | |||||||||||||
45 | MP-44 | SNOMED_CT Problem=106098005 (PB0046); SNOMED_CT Cat-Tar=385961000 (CG0002, TG0003) | Postpartum Urinary Retention | Urinary function | Treatments and Procedures | bladder care | Scan bladder with ultrasound within 6 hrs of birth. If PVR 400 mL, indwelling catheter. | Mother | Routine scanning of bladder by ultrasound is recommended in the postpartum period if there is no voiding within 6 hours of birth. If there is not, catheterization should be performed. An indwelling catheter can be used 2-3 days if woman is unable to void and if post-void residual volume is consistently more than 400 mL. | Nulliparity, longer labor course, instrumental delivery, extensive vaginal and perineal lacerations along with use of epidural analgesia contributed to postpartum urinary retention in a study conducted by Ching-Chung et al (2002). Current evidence regarding Postpartum Urinary Retention being harmless is lacking and further studies need to be conducted to identify the potential consequences of PUR. Based on current studies, routine scanning in postpartum period may be beneficial however future studies regarding cost-effectiveness and advantages for routine postpartum bladder scanning are needed. | Ching-Chung, L., Shuenn-Dhy, C., Ling-Hong, T., Ching-Chang, H., Chao-Lun, C., & Po-Jen, C. (2003). Postpartum Urinary Retention: Assessment of Contributing Factors and Long-Term Clinical Impact. Obstetrical & Gynecological Survey, 58(5), 302-304. doi:10.1097/00006254-200305000-00008 | |||||||||||||
46 | MP-45 | SNOMED_CT Problem=106098005 (PB0046); SNOMED_CT Cat-Tar=385961000 (CG0002, TG0003) | Postpartum Urinary Tract Infections | Urinary function | Treatments and Procedures | bladder care | UTI screening, UA/culture, treat appropriately. | Mother | UTI symptoms include urgency, dysuria, frequency and/or lower abdominal pain. Obtain clean catch specimen to diagnose and treat with appropriate antibiotics depending on type of bacteria. | UTI is the most common cause of puerperal fever. Organisms that are typically responsible include Escherichia coli, Proteus mirabilis and Klebsiella pneumoniae. Pregnancy and postpartum women are predisposed to UTI due to decreased bladder tone and increased bladder volume along with incomplete bladder emptying. | Karsnitz, D. B. (2015). Postpartum Complications. In Varney's Midwifery (5th ed., pp. 1143-1155). Burlington, MA: Jones & Bartlett Learning. | |||||||||||||
47 | ||||||||||||||||||||||||
48 | ||||||||||||||||||||||||
49 | ||||||||||||||||||||||||
50 | ||||||||||||||||||||||||
51 | ||||||||||||||||||||||||
52 | ||||||||||||||||||||||||
53 | ||||||||||||||||||||||||
54 | ||||||||||||||||||||||||
55 | ||||||||||||||||||||||||
56 | ||||||||||||||||||||||||
57 | ||||||||||||||||||||||||
58 | ||||||||||||||||||||||||
59 | ||||||||||||||||||||||||
60 | ||||||||||||||||||||||||
61 | ||||||||||||||||||||||||
62 | ||||||||||||||||||||||||
63 | ||||||||||||||||||||||||
64 | ||||||||||||||||||||||||
65 | ||||||||||||||||||||||||
66 | ||||||||||||||||||||||||
67 | ||||||||||||||||||||||||
68 | ||||||||||||||||||||||||
69 | ||||||||||||||||||||||||
70 | ||||||||||||||||||||||||
71 | ||||||||||||||||||||||||
72 | ||||||||||||||||||||||||
73 | ||||||||||||||||||||||||
74 | ||||||||||||||||||||||||
75 | ||||||||||||||||||||||||
76 | ||||||||||||||||||||||||
77 | ||||||||||||||||||||||||
78 | ||||||||||||||||||||||||
79 | ||||||||||||||||||||||||
80 | ||||||||||||||||||||||||
81 | ||||||||||||||||||||||||
82 | ||||||||||||||||||||||||
83 | ||||||||||||||||||||||||
84 | ||||||||||||||||||||||||
85 | ||||||||||||||||||||||||
86 | ||||||||||||||||||||||||
87 | ||||||||||||||||||||||||
88 | ||||||||||||||||||||||||
89 | ||||||||||||||||||||||||
90 | ||||||||||||||||||||||||
91 | ||||||||||||||||||||||||
92 | ||||||||||||||||||||||||
93 | ||||||||||||||||||||||||
94 | ||||||||||||||||||||||||
95 | ||||||||||||||||||||||||
96 | ||||||||||||||||||||||||
97 | ||||||||||||||||||||||||
98 | ||||||||||||||||||||||||
99 | ||||||||||||||||||||||||
100 |