1. Nursing Care of the Family During the Postpatum Period

2. Key Points
Postpartum care is family centered and modeled on the concept of health.
Cultural beliefs and practices affect the maternal and family response to the postpartum period.
The nursing care plan includes assessments to detect deviations from normal, comfort measures to relieve discomfort or pain, and safety measures to prevent injury or infection.

3. Key Points (cont)
Common nursing interventions in the postpartum period focus on preventing excessive bleeding, bladder distention, and infection; providing nonpharmacologic and pharmacologic relief of discomfort associated with the episiotomy, lacerations, or breastfeeding; and instituting measures to promote or suppress lactation.
Teaching and counseling measures are designed to promote the woman’s feelings of competence in self-management and infant care.

4. Key Points (cont)
Meeting the psychosocial needs of new mothers involves taking into consideration the composition and functioning of the entire family.
Early discharge classes, telephone follow-up, home visits, warm lines, and support groups are effective means of facilitating physiologic and psychologic adjustments in the postpartum period.

5. Learning Objectives
Describe components of a systematic postpartum assessment.
Recognize signs of potential complications in the postpartum woman.
Formulate a nursing care plan for a woman in the postpartum period.
Explain the influence of cultural beliefs and practices on postpartum care.

6. Learning Objectives (cont)
Identify psychosocial needs of the woman in the early postpartum period.
Prepare a plan for postpartum teaching for self-management.
Describe the nurse’s role in these postpartum follow-up strategies: home visits, telephone follow-up, warm lines and help lines, support groups, and referrals to community resources.

7. Nursing Care of the Postpartum Woman
Goal of nursing care in the immediate postpartum period is: to assist women and their partners during their initial transition to parenting

8. Nursing Care of the Postpartum Woman
Fourth Stage of Labor
The first two hours after birth
Maternal organs start to undergo readjustments to the nonpregnant state
Nurse’s role during the fourth stage of labor is:
Identify and manage promptly any deviations from the normal processes that may occur
Promote and support parent-infant attachment

9. Nursing Care of the Postpartum Woman
Fourth stage of Labor
Assessment
During the first hour in the recovery room, physical assessments of the mother are frequent
All factors but temperature are assessed every 15 minutes for the first hour and then every thirty minutes in the second hour
Temperature is assessed at the beginning and end of the recovery period
Postpartum women experience intense tremors or shivering
Provide warm blankets

10. Nursing Care of the Postpartum Woman
Physiologic Assessments
Temperature
First 24 hours every 4 hours
Every 8 hours after that till discharge
Pulse, Respirations, and Blood Pressure
Every 15 minutes-first hour of delivery
Every 30 minutes for the next 2 hours after delivery
Then every 4 hours for the first 24 hours
Then every 8 hours till discharge

11. 1.Retake the temperature in 15 minutes 2.Notify the physician
A postpartum nurse is taking the vital signs on a woman who delivered a healthy newborn 4 hours ago. The nurse notes that the mother’s temperature is 100.2º F. Which of the following actions would be most appropriate?
1.Retake the temperature in 15 minutes 
2.Notify the physician
 3.Document the finding 
4.Increase hydration by encouraging oral fluids 

12. Nursing Care of the Postpartum Woman
Physiologic Assessments
Fundus, Lochia, and Bladder
Assess every 15 minutes for the first hour
Assess ever 4 hours for the next two hours after delivery
Then assess every 8 hours until discharge
Perineum
Assess once the first hour after delivery
Then assess every four hours for the first 24 hours
Then after 24 hours of delivery assess every 8 hours until discharge

13. 2.Lie flat on her back with the knees and legs flat and straight
 A nurse is preparing to perform a fundal assessment on a postpartum client. The nurse first asks the client to:
1.Turn on her side 
2.Lie flat on her back with the knees and legs flat and straight 
3.Urinate and empty her bladder 
4.Massage the fundus gently

14. 2.Document the findings and reassess in 1 hour 3.Massage the fundus
A nurse is assessing the fundal height on a postpartum woman and notes that the fundus feels flaccid and soft. The nurse would immediately:
1.Contact the physician
 2.Document the findings and reassess in 1 hour 
3.Massage the fundus 
4.Ask the client to ambulate

15. 1.Increases during ambulation 2.Increases during sleep
A nurse is providing information about lochia flow to a woman who just delivered a newborn. The nurse tells the woman that the amount of lochia flow:
1.Increases during ambulation 
2.Increases during sleep 
3.Is scant immediately following delivery 
4.Increases in amount on the third postpartum day 

16. 2.Encourage increased oral intake of fluids
When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?
1.Document the findings
 2.Encourage increased oral intake of fluids 
3.Reassess the client in 2 hours 
4.Notify the physician

17. 2.Lie flat on her back with the knees and legs flat and straight
A nurse is preparing to perform a fundal assessment on a postpartum client. The nurse first asks the client to:
1.Turn on her side
 2.Lie flat on her back with the knees and legs flat and straight
 3.Urinate and empty her bladder 
4.Massage the fundus gently

18. Nursing care of the Postpartum Woman
Physiologic Assessments
Breasts, Legs
Assess every four hours in the first twenty-four hours
Then assess every 8 hours thereafter until discharge

19. Nursing Care of the Postpartum Woman
Laws Related to Discharge
Newborn’s and Mother’s Health Protection Act of 1996
Provided minimum federal standards for health plan coverage for mothers and their newborns
New mothers and newborns could remain in the hospital for a minimum of 48 hours after a normal vaginal delivery
New mothers and newborns could remain in the hospital for a minimum of 96 hours after a normal cesarean birth
Healthcare providers expressed concern that some medical problems do not show up for 24 hours after birth and that new mothers have not sufficiently learned how to care for their newborn health problems such as jaundice related to breastfeeding difficulties
There also was concern that the shortened hospital stays would increase maternal hospital readmissions for infection, hypertension, and hemorrhage I women who gave birth vaginally
Enactment of federal and various state maternity length-of-stay bills to ensure adequate care for both mother and newborn

20. Nursing Care of the Postpartum Woman
Routine Laboratory Test
Hemoglobin
Hematocrit
Rubella
Rh status

21. Nursing Care of the Postpartum Woman
Nursing Diagnoses
Alteration in comfort related to afterpains, episiotomy, laceration, hemorrhoids, breast engorgement, surgical incision
Sleep pattern disturbances
Health seeking behaviors regarding self-care, newborn care, health maintenance, prevention of infections, or complications
Altered parenting
Potential for infection/hemorrhage

22. Nursing care of the Postpartum W- Woman
Couplet Care
Also called mother and baby care or single-room maternity care
Nurse functions as the primary nurse for both the mother and baby, even if the baby is in the nursery
Rooming-in
Mother and baby room together
Mother and nurse share the care of the infant

23. Nursing Care of the Postpartum Woman
Plan of Care
Perineal Care
Pouring a stream of water over the vulva and perineum after voiding or defecation
Wiping from front to back after voiding or defecation
Change peri-pad with each voiding or defecation
Cold therapy for 24 to 48 hours
Ice packs
Cold packs
Heat therapy

24. Nursing Care of the Postpartum Woman
Plan of Care
Perineal Care
Sitz bath 2-3 times a day
Warm packs
Medications
Anesthetic sprays, epifoam, witch hazel pads (tucks)
Sitting with perineal sutures
Bring buttocks together and contract pelvic floor muscles

25. 2.“I will use warm water to rinse the perineum after elimination.”
A nurse has provided instructions to a postpartum woman regarding care of the episiotomy site to prevent an infection. Which statement by the woman indicates a need for further instructions?
1.“I will wipe my perineum from front to back after voiding and defecation.” 
2.“I will use warm water to rinse the perineum after elimination.” 
3.“I will change the perineal pad three times a day.”
 4.“I will perform warm sitz baths three times a day.”

26. Nursing Care of the Postpartum Woman
Plan of Care
Prevention of Excessive Bleeding
Uterine Atony
Failure of the uterine muscle to contract firmly
Most frequent cause of excessive bleeding after childbirth
Two most important interventions for preventing excessive bleeding are:
Maintaining good uterine tone
Preventing bladder distention

27. Nursing Care of the Postpartum Patient
Plan of Care
Maintenance of Uterine Tone
Fundal massage
Teaching patient to do fundal self- massage
IV oxytocin, such as pitocin
Oral or IM medications (drugs that stimulate contraction of the uterine smooth muscle) such as methergine, cytotec, and hemobate

30. Nursing Care of the Postpartum Woman
Plan of care
Prevention of Bladder Distention
Full bladder causes the uterus to be displaced above the umbilicus well to one side of the midline of the abdomen
Prevents uterus from contracting normally
Focus on helping the woman to empty her bladder spontaneously as soon as possible

31. 1.Diuresis 2.Stress incontinence 3.Urge incontinence 4.Retention
In the immediate postpartum period, the nurse monitors the new mother for which risk related to the urinary system?
1.Diuresis 
2.Stress incontinence
 3.Urge incontinence 
4.Retention 

32. Nursing Care of the Postpartum Woman
Prevention of Bladder Distention
Techniques to help the woman void
Assist woman to the bathroom
Have woman listen to running water
Pouring water from a squeeze bottle over her perineum
Assisting woman into the shower or sitz bath

33. Nursing Care of the Postpartum Woman
Afterbirth pains
Menstrual-like cramps felt by many women as the uterus contracts after childbirth
Warmth
Distraction
Deep breathing
Imagery
Therapeutic touch and relaxation
Interaction with the infant may decrease the discomfort associated with these uterine contractions

34. Nursing Care of the Postpartum Woman
Plan of Care
Ambulation
Early ambulation is successful in reducing the incidence of thromboembolism and in promoting the woman’s more rapid recovery of strength
Orthostatic hypotension
Women with varicosities are encouraged to wear support hose

35. Nursing Care of the Postpartum Woman
Plan of Care
Ambulation
Thrombus is suspected
Warmth, redness, or tenderness in the suspected leg
Notify MD immediately
Confine woman to bed with affected limb elevated on pillows

36. Nursing Care of the Postpartum Woman
Fatigue
Common in the postpartum period
Interventions must be planned to meet the woman’s individual need for sleep and rest
Support and encouragement in mother’s behaviors help reduce anxiety
Hospital and nursing routines also may be adjusted to meet individual needs

37. Nursing Care of the Postpartum Woman
Plan of Care
Bladder
After giving birth the woman should void spontaneously within 6 to 8 hours
Several of the first voidings should be measured to document adequate emptying of the bladder
A volume of 150 ml is expected for each voiding

38. Nursing Care of the Postpartum Woman
Plan of Care
Educating the woman about measures to avoid constipation
Adequate roughage
Plenty of fluids
Exercise
Decreased narcotic usage
Stool softeners and laxative use
fort

39. 4. Within 2 weeks postpartum
 A postpartum nurse is providing home care instructions to a woman following delivery of a healthy newborn. The nurse tells the mother that she should expect normal bowel elimination to return:
1. 1 day postpartum 
2. 3 days postpartum
 3. 7 days postpartum 
4. Within 2 weeks postpartum 

40. Nursing Care of the Postpartum Woman
Plan of Care
Breast Care
Breastfeeding
First 2 hours after birth
Infant is an alert state
Aids in the contraction of the uterus
Hygiene
Avoid soap, alcohol, and other drying agents
Cleans nipple with clear water
Apply lanolin for sore or cracked nipples

41. Lactation Benefits of breast feeding Mother Infant Promotes bonding
Helps weight loss
Stimulates uterine contractions
Decreases risk of thromboembolism
Protects against breast cancer
Some contraceptive protection
Readily available
Infant

42. Breast feeding benefits Con’t
Infant
Milk contains natural components to facilitate immune system and anti-inflammatory agents
Nutrients are easily tolerated and digested
No artificial colorings, flavors, preservatives
Active & passive protection against viral and bacterial pathogens
Promotes better tooth and jaw development
Protects against food allergies
Not likely to over feed

43. Lactation Nutritional needs Calories Protein Fluid
Increase calorie intake by 500 cal/day -6 mo
cal/day while breast feeding
Protein
Needs additional 20 gm
Extra 2 c. of milk = 16g protein
Fluid
2-3 quarts per day
Water, milk, fruit juice
Encourage 1 glass of fluid with each nursing of infant
Vitamins and minerals
Balanced supplement for less than 1800 cal/da

44. 1.100 calories per day 2.300 calories per day 3.500 calories per day
A nurse is providing nutritional counseling to a new mother who is planning to breast-feed her newborn. The nurse instructs the mother that her calorie needs need to increase by:
1.100 calories per day 
2.300 calories per day 
3.500 calories per day
  calories per day

45. A home care nurse visits a client who delivered a healthy newborn infant 2 days ago. The mother is complaining of breast discomfort and the nurse notes that the mother is experiencing breast engorgement. The nurse provides instructions to the mother regarding relief of the engorgement. Which statement by the mother indicates a need for further instructions?
1.“I should feed my infant at least every 2½ hours for 15 to 20 minutes on each side.” 
2.“I should avoid breast-feeding during the time of breast engorgement.” 
3.“I should apply moist heat to both breasts for about 20 minutes before a feeding.” 
4.“I should gently massage the breasts during a feeding from the outer areas to the nipples.” 

46. Nursing Care of the Postpartum Woman
Lactation Suppression
Wearing a well-fitted support bra or binder
Avoid any breast stimulation
Severe breast engorgement
Ice packs to the breast
Cabbage leaves
Mild analgesics

47. Nursing Care of the Postpartum Woman
Rubella –women who have not had rubella
Titer of 1:8 or enzyme immunoassay level less than 0.8
Given sub Q
Women are cautioned to avoid pregnancy for 28 days

48. Nursing Care of the Postpartum Woman
Varicella Vaccine
Women with no immunity
Avoid pregnancy for 28 days
A second dose is given at the postpartum follow-up visit (4 to 8 weeks after the first
dose

49. Nursing Care of the Postpartum Womman
Varicella Vaccination Before discharge in women with no immunity
Second dose 4-6 weeks postpartum
Tetanus-Diphtheria-Acellular Pertussis Vaccine (Tdap)

50. Nursing Care of the Postpartum Woman
Prevention of RH Isoimmunization
Injection of Rh immune globulin (Rhogam) must be given within 72 hours after birth to prevent sensitization in the RH-negative woman who has had a fetomaternal transfusion of Rh-positive red blood cells
Administration of 300 mcg (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization

51. Nursing Care of the Postpartum Woman
Prevention of RH Isoimmunization
Large fetomaternal transfusions
Kleihauer-Betke- which detects the amount of fetal blood in maternal circulation
More than 30 ml of fetal blood is present in maternal circulation, the dosage of Rh immune globulin must be increased

52. Nursing Care of the Postpartum Woman
Cultural Variations
Mother” beliefs about postpartal care influenced by her culture and personal values
Many cultures emphasize certain postpartal routines or rituals for mother and baby
Some Hispanics, African, and Asian cultures may avoid cold after birth
Rest and seclusion
Hygiene

53. Nursing Care of the Postpartum Woman
Follow-Up After Discharge
Home Visits
Telephone follow-up
Warm lines
Support groups
Referral to community resources