T he best postpartum care is family centered; incorporates

the family’s needs, desires, and values as much as possible;

and disrupts the family unit as little as possible. This approach
uses the family’s resources to support an early and smooth
adjustment to the newborn by all family members. Nursing
care during this time is aimed at meeting individual and fam-
ily needs. Goals are formulated after careful assessment, con-
sultation with the woman and her family, and consideration
of factors that could influence the outcome of care.
Chapter 21 provides a thorough discussion of postpar-
tum assessment. How can the nurse use the re-
maining steps of the nursing process effectively to plan
and provide care? This chapter provides that information,
in addition to describing the specific nursing responses
to the mother’s physical needs and the family’s psycho-
social needs. See the “Clinical Pathway for the Postpartum
Period.”

CLINICAL PATHWAY For the Postpartum Period

Category First 4 Hours 4–8 Hours Past Birth 8–24 Hours Past Birth

Referral VB: Report from labor nurse if applicable Lactation consultation as needed Home nursing, WIC referral if indicated
CB: Report from OR recovery nurse CB: Respiratory therapist as needed Expected Outcomes
Referrals made

Assessments VB: Postpartum assessments q30 min
2, VB: Continue postpartum assessment q4h
Continue postpartum assessment per protocol
q1h
2, then q4h. Includes 2, then q8h Breasts: nipples should remain free of cracks,
• Fundus firm, midline, at or below umbilicus Breast: evaluate nipple status; should be no fissures, bruising
• Lochia rubra 1 pad/hr; no free flow or evidence of cracks or bruising Feeding technique with newborn: should be
passage of clots with massage Observe feeding technique with newborn good or improving
• Bladder: voids large amounts of urine Vital signs assessment q8h; all WNL; report Vital signs assessment q8h; all WNL; report
spontaneously; bladder not palpable temperature  38 °C (100.4 °F) temperature  38 °C (100.4 °F)
following voiding Continue assessment of comfort level
Assess Homans’ sign q8h
• Perineum: sutures intact; no bulging or Expected Outcomes
Continue assessment of comfort level
marked swelling; no c/o severe pain. Vital signs medically acceptable, voids qs,
Minimal bruising may be present. If CB: Continue cesarean assessments per postpartum assessment WNL; comfort level
hemorrhoids present, no tenseness or marked protocol, including all assessments covered 3 on a 1–10 scale, involution of uterus in
engorgement; 2 cm diameter in VB; as well as process, demonstrates and verbalizes
• Breasts: soft, colostrum present • Determine if woman passing flatus appropriate newborn feeding techniques
Vital Signs: • Determine if bowel sounds present
• 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: 12–20/min; quiet, easy
Comfort level: 3 on scale of 1–10
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

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.

464 UNIT V • The Postpartal Childbearing Family and Newborn

CLINICAL PATHWAY For the Postpartum Period—continued
Category First 4 Hours
Teaching/ Explain postpartum assessments
psychosocial 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 VB: Ice pack to perineum to decrease swelling
management and increase comfort
and reports 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
Activity 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
4–8 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 woman’s
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
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
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
CHAPTER 22 • The Postpartum Family: Needs and Care
8–24 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
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
Up ad lib
CB: Assist woman to ambulate as soon as
possible
Expected Outcomes
Ambulates ad lib
(continued)
465
CLINICAL PATHWAY For the Postpartum Period—continued
Category First 4 Hours 4–8 Hours Past Birth 8–24 Hours Past Birth

Comfort 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
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 medication’s action
is felt
Continue with pain management techniques
Expected Outcomes
Comfort level 3 on 1–10 scale
Verbalizes alternative pain management
options

Nutrition VB: Regular diet Continue diet and fluids Continue diet and fluids
Fluid  2,000 mL/day CB: Advance diet to clear liquids as CB: Advance diet as tolerated
CB: Begin sips and chips when bowel sound tolerated or per protocol Expected Outcomes
present or per protocol Regular diet/fluids tolerated

Elimination Voiding large amounts straw-colored urine Voiding large quantities Same
CB: A minimum of 30 cc qh clear urine output May have bowel movement Expected Outcomes
in Foley catheter CB: A minimum of 30 cc qh clear urine Voiding qs; passing flatus or bowel
output in Foley catheter movement

Medications Pain medications as ordered Continue meds Continue medications

Methergine 0.2 mg q4h po if ordered Lanolin to nipples prn; tea bags to nipples if RhoGAM and rubella vaccine administered if
Stool softener _______ tender; heparin flush to buffalo cap/heplock indicated
Tucks pad prn, perineal analgesic spray (if present) q8h or as ordered Expected Outcomes
May take own prenatal vitamins Vaccines administered; pain controlled

Discharge Evaluate knowledge of normal postpartum and Discuss typical newborn schedule; plan for Review discharge instruction sheet/checklist
planning/home newborn care periods of rest Describe postpartum warning signs and
care Evaluate support systems Birth certificate paperwork completed when to call CNM or physician
Evaluate plans for transporting newborn; car Provide prescriptions; gift packs given
seat available appropriate for bottle- or breastfeeding
CB: Evaluate for physical help at home 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

Family Identify available support persons
involvement 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
woman’s need for rest, good nutrition, fluids,
and emotional support

Date

466 UNIT V • The Postpartal Childbearing Family and Newborn