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Category Referral First 4 Hours

For the Postpartum Period

48 Hours Past Birth Lactation consultation as needed CB: Respiratory therapist as needed 824 Hours Past Birth Home nursing, WIC referral if indicated Expected Outcomes Referrals made Continue postpartum assessment per protocol Breasts: nipples should remain free of cracks, fissures, bruising Feeding technique with newborn: should be good or improving Vital signs assessment q8h; all WNL; report temperature 38 C (100.4 F) Continue assessment of comfort level Expected Outcomes Vital signs medically acceptable, voids qs, postpartum assessment WNL; comfort level 3 on a 110 scale, involution of uterus in process, demonstrates and verbalizes appropriate newborn feeding techniques

VB: Report from labor nurse if applicable CB: Report from OR recovery nurse


VB: Postpartum assessments q30 min 2, q1h 2, then q4h. Includes Fundus firm, midline, at or below umbilicus Lochia rubra 1 pad/hr; no free flow or passage of clots with massage Bladder: voids large amounts of urine spontaneously; bladder not palpable following voiding Perineum: sutures intact; no bulging or marked swelling; no c/o severe pain. Minimal bruising may be present. If hemorrhoids present, no tenseness or marked engorgement; 2 cm diameter Breasts: soft, colostrum present Vital Signs: BP WNL: no hypotension; not 30 mm Hg systolic or 15 mm Hg diastolic over baseline Temperature: 38 C (100.4 F) Pulse: bradycardia normal, consistent with baseline Respirations: 1220/min; quiet, easy Comfort level: 3 on scale of 110 CB: Postpartal cesarean assessment q 15min 4, q30min 4, q1h per protocol; all assessment parameters for VB included, as well as Surgical dressing over incision clean and dry or with minimal drainage Foley catheter in place, urine color and amount noted IV: no swelling, pain, or redness at insertion site; infusing at prescribed rate Bowel sounds: present, decreased, or minimal LOC: alert and oriented, easily aroused if dozing LOS: sensation WNL for anesthesia or analgesia type administered Pulse ox: WNL Input and output: WNL

VB: Continue postpartum assessment q4h 2, then q8h Breast: evaluate nipple status; should be no evidence of cracks or bruising Observe feeding technique with newborn Vital signs assessment q8h; all WNL; report temperature 38 C (100.4 F) Assess Homans sign q8h Continue assessment of comfort level CB: Continue cesarean assessments per protocol, including all assessments covered in VB; as well as Determine if woman passing flatus Determine if bowel sounds present

Information is included for both vaginal birth (VB) and cesarean birth (CB). However, since many of the nursing care interventions are the same for either, specific interventions or suggestions related to vaginal birth are designated VB, and those specific to cesarean are designated CB. ADL, activities of daily living; BP, blood pressure; CB, cesarean birth; CNM, certified nurse-midwife; DC, discontinue; LDR, labor, delivery, and recovery; OOB, out of bed; OR, operating room; prn, as needed; VB, vaginal birth; WNL, within normal limits.

Category Teaching/ psychosocial First 4 Hours

For the Postpartum Periodcontinued

48 Hours Past Birth Discuss psychologic changes of postpartum period; facilitate transition through tasks of taking on maternal role Discuss perineal care/hygiene; encourage use of supportive brassiere for breast- or bottle-feeding Stress need for frequent rest periods Continue newborn teaching: soothing/comforting techniques, swaddling; return demonstrations indicate womans understanding Provide opportunities for questions and review, reinforce previous teaching Breastfeeding: nipple care: air-drying, lanolin; proper latch-on technique; tea bags Bottle-feeding: supportive bra, ice bags, breast binder Assess mother-infant attachment Stress need for movement and ambulation Discuss incision healing Explain benefit of a regular schedule of medications for pain to optimize comfort 824 Hours Past Birth Reinforce previous teaching, complete teaching evaluation Discuss involution; anticipated physical changes in first 2 weeks postpartum; postpartal exercises; need to limit visitors Discuss postpartal nutrition; balanced diet Breastfeeding: Increase calories by 500 kcal over nonpregnant state (200 kcal over pregnant intake) Explain milk production, letdown reflex, use of supplements, breast pumping, and milk storage Bottle-feeding: Return to nonpregnant caloric intake Explain formula preparation and storage Discuss birth control options, sexuality Discuss sibling rivalry and plan for supporting siblings at home Discuss pets; suggestions for improving acceptance of infant by pets Expected Outcomes Mother verbalizes teaching comprehension Positive bonding and emotional behaviors observed

Explain postpartum assessments Teach self-massage of fundus and expected findings; rationale for fundal massage Instruct to call for assistance first time OOB and prn Demonstrate perineal care, surgigator, sitz bath prn Explain comfort measures Begin newborn teaching; bulb suctioning, positioning, feeding, diaper change, cord care Orient to room if transferred from LDR room Provide information on early postpartal period Assess mother-infant attachment CB: Teach turn-cough and deep breathing exercise Explain importance of moving around in bed and moving legs up and down Demonstrate splinting of abdomen for increased comfort with movement Discuss plan of care related to cesarean recovery; activity and ambulation recommendations, advancement of diet, incision care, schedule for IV and Foley catheter removal Provide information about PCA, pain medications, and alternate measures for pain management

Nursing care management and reports

VB: Ice pack to perineum to decrease swelling and increase comfort Straight catheter prn 1 if distended or voiding small amounts If continues unable to void or only voids small amounts, insert Foley catheter and notify CNM or physician CB: Implement input and output regimen Maintain IV as ordered Medicate for pain Begin providing ice chips when bowel sounds are present

Sitz baths prn If woman Rh negative and infant Rh positive, Rh immune globulin workup; obtain consent; complete teaching Determine rubella status Obtain consent for rubella vaccine if indicated; explain purpose, procedure, implications of vaccine CB: Advance diet as ordered and tolerated Assist with perineal care and ADLs Obtain hematocrit and hemaglobin Discontinue Foley catheter when woman can ambulate to BR Discontinue of heplock IV when woman can tolerate oral fluids, or as ordered Maintain incision care as ordered

Continue sitz baths prn May shower if ambulating without difficulty DC buffalo cap (heparin lock) if present Administer rubella vaccine as indicated Expected Outcomes Using sitz bath; voids qs; lab work WNL; performs ADL without sequelae


VB: Assistance when OOB first time, then prn Ambulate ad lib Rests comfortably between assessments CB: Assistance with movement in bed, to include leg exercises and sitting upright

Encourage rest periods Ambulate ad lib; may leave birthing unit after notifying staff of plan to ambulate off unit CB: Advance movement to include hanging legs over edge of bed and brief standing

Up ad lib CB: Assist woman to ambulate as soon as possible Expected Outcomes Ambulates ad lib


Category Comfort First 4 Hours

For the Postpartum Periodcontinued

48 Hours Past Birth Continue with pain management techniques Offer alternative pain management options: distraction with music, television, visitors; massage; warmed blankets or towels to affected area; using breathing techniques when infant latches on to breast and/or during cramping until medications action is felt 824 Hours Past Birth Continue with pain management techniques Expected Outcomes Comfort level 3 on 110 scale Verbalizes alternative pain management options

Institute comfort measures: Perineal discomfort: peri-care; sitz baths, topical analgesics Hemorrhoids: sitz baths, topical analgesics, digital replacement of external hemorrhoids; side-lying or prone position Afterpains: prone with small pillow under abdomen; warm shower or sitz baths; ambulation Administer pain medication _____ CB: Implement PCA or pain medication schedule as ordered


VB: Regular diet Fluid 2,000 mL/day CB: Begin sips and chips when bowel sound present or per protocol

Continue diet and fluids CB: Advance diet to clear liquids as tolerated or per protocol

Continue diet and fluids CB: Advance diet as tolerated Expected Outcomes Regular diet/fluids tolerated Same Expected Outcomes Voiding qs; passing flatus or bowel movement Continue medications RhoGAM and rubella vaccine administered if indicated Expected Outcomes Vaccines administered; pain controlled Review discharge instruction sheet/checklist Describe postpartum warning signs and when to call CNM or physician Provide prescriptions; gift packs given appropriate for bottle- or breastfeeding Arrangements for baby pictures as desired Postpartum and newborn visits scheduled Expected Outcomes Discharged home; mother verbalizes postpartum warning s/s, follow-up appointment times and dates


Voiding large amounts straw-colored urine CB: A minimum of 30 cc qh clear urine output in Foley catheter

Voiding large quantities May have bowel movement CB: A minimum of 30 cc qh clear urine output in Foley catheter Continue meds Lanolin to nipples prn; tea bags to nipples if tender; heparin flush to buffalo cap/heplock (if present) q8h or as ordered May take own prenatal vitamins Discuss typical newborn schedule; plan for periods of rest Birth certificate paperwork completed Evaluate plans for transporting newborn; car seat available CB: Evaluate for physical help at home


Pain medications as ordered Methergine 0.2 mg q4h po if ordered Stool softener _______ Tucks pad prn, perineal analgesic spray

Discharge planning/home care

Evaluate knowledge of normal postpartum and newborn care Evaluate support systems

Family involvement

Identify available support persons Assess family perceptions of birth experience Parenting: demonstrates culturally expected early parenting behaviors

Involve support persons in care, teaching; answer questions Evidence of parental bonding behaviors present

Continue to involve support persons in teaching, involve siblings as appropriate. Plans made for providing support to mother following discharge Expected Outcomes Evidence of parental bonding behavior; support persons verbalize understanding of womans need for rest, good nutrition, fluids, and emotional support