BICOL UNIVERSITY – POLANGUI CAMPUS

Nursing and Health Sciences Department

Bachelor of Science in Nursing

Course Code / Title:

NCM 107: CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT)
RLE (SKILLS LABORATORY)

Term: 1st Semester, SY 2020-2021

Course Placement: Second Year

Course Description:
This course deals with concepts, principles, theories and techniques in the provision of basic
care in terms of health promotion, disease prevention, restoration and maintenance and rehabilitation
at the individual and family level. It includes the study of the Philippine Health Care System, national
health situation and the global context of public health. The learners are expected to provide safe,
appropriate and holistic nursing care to individual and family as clients in community setting utilizing
the nursing process.

RLE FOCUS:
- Gyne & OB, Postpartum Assessment

LECTURE

I. HISTORY TAKING
A. Age
B. Gravida / Parity
C. History and types of delivery
D. Familial history of medical illness
E. Surgery history
F. Medical history
G. Medications / Maintenance drug
H. Drug Abuse / Alchol intake / Smoking
I. Educational level
J. Socio-economic status
K. Support system

II. PHYSICAL ASSESSMENT (BUBBLEHED ASSESSMENT)

A. BREASTS
- Assess supply, latch, milk transfer, and pain due to engorgement
- Assess for signs of infection / mastitis: fever, erythema of breasts
- Assess for breast engorgement with low grade fever, is common and normal
- Assess for cracked nipples, pressure sores, cracks, or fissures. Evaluate whether nipples
are everted, flat, or inverted.
 Rationale: Promotes involution as breastfeeding causes the release of oxytocin which helps
uterus to contract.

Nursing care:
a. Breast engorgement usually occurs 2-3 days post partum; and pain can be relieved by heat
packs. Teach mom to: apply warm packs or K-pad 15-20 minutes pre-nursing and try a
warm shower before nursing.
b. All mothers should wear a supportive bra 24 hours a day for the first few days
postpartum.

B. UTERUS AND FUNDAL HEIGHT

- Immediately after delivery, uterine contractions begin triggering involution (the process
whereby the uterus and other reproductive organs return to their state prior to pregnancy)
- Uterine contractions can be measured by fundal height. Assess and evaluate the height
and consistency of the fundus (the part of the uterus that can be palpated abdominally)
and measures by fingerbreadths
- Immediately after delivery, the upper portion of the uterus (fundus) is midline and
palpable halfway between the symphysis pubis and the umbilicus. Aproximately one hour
post delivery, the fundus should be firm and at the level of the umbilicus
- The fundal height may be palpated off of midline, either right or left side because of a
distended bladder. If possible, the woman should be encouraged to empty her bladder
prior to assessment of the fundus. A full bladder can prevent uterine involution and may
cause bleeding

Procedures:
1. To properly palpate the uterus, assist in positioning flat on her back (supine).
2. Place one hand at the base of the uterus above the symphysis pubis (the interpubic joint of
the pelvis) in a cupping manner (to support the lower uterine ligaments).
3. Then, press in and downward with the other hand at the umbilicus until she makes contact
with a hard, globular mass.
4. If the uterus is not firm, light massaging usually results in tightening. Massaging of the
uterus should not be so vigorous as to cause the mother pain. A mother who has had a
cesarean delivery should be medicated, if possible, prior to assessment of the fundus, and
the nurse should use the minimal amount of pressure necessary to locate her fundus.
5. The height of the fundus after the first hour following delivery is at the umbilicus or
above it. Every day the fundal height decreases by approximately the width of one finger
(one cm) until it reaches 4 fingerbreadths.

Nursing Care:
Assess the condition of the uterus frequently and may need to massage the uterus
gently to encourage its clamping down on itself, especially when oxytocin has not been given.

Pharmacological management:
A woman sometimes receives the medication oxytocin (Pitocin) after the delivery of
the placenta. Oxytocin causes the uterus to contract and can decrease the amount of
postpartum bleeding.

C. BLADDER
- Urine void should be documented within six hours. In the first 48 hours after delivery it is
normal to have an increase in the formation and secretion of urine (postpartum diuresis).
- Prevent and monitor for signs of bladder distension
- Recommend kegel exercises
- Observe for urinary tract infection
 Rationale: Promote involution (the process of returning back to its normal state wherein the
uterus transformed from pregnant to non-pregnant state and restoration of ovarian
function in order to prepare the body for a new pregnancy). Starts from the expulsion
of placenta and extends up to 5 to 6 weeks after delivery. The mother should empty
the bladder every 2 hours.
If no urine output, palpate for bladder distension. Bladder distension can displaced
uterus which my not contract effectively thus, causing bleeding. An over-distended
bladder can even cause injury to the urinary system.

Procedures:
1. Encourage patient to void within her first hour postpartum. Bladder should be palpated
above symphysis pubis every after voiding to assess urinary retention. Record first 2
voidings (normal amount 150 cc per voiding).
2. If the woman had a cesarean section and has a Foley catheter in place in her bladder, then
the output is checked every hour during the initial postpartum period. The Foley catheter
is likely to be removed approximately eight hours after surgery. Monitor intake and
output. The health care provider needs to assess for voiding after removal of the Foley
catheter.
3. If patient has not voided in 6-8 hours post-delivery or with severe bladder distension;
notify doctor for any voiding difficulties and bladder distension; straight urinary
catheterization per Doctor’s order.
4. Be alert for signs and sx of UTI:
--infrequent voiding
--painful urination (dysuria)
--burning
--frequency
--urinary retention
--foul-smelling urine
5. Assess for postpartum voiding difficulties related:
--fatigue
--perineal swelling
--long, difficult Labor and Delivery eg.use of Forceps, Vacuum Extractor

D. BOWEL
- Assess for peri-anal lacerations
- Assess for presence of perineal and anal pain
- Assess for complication of pregnancy and labor (ex. Haemorrhoids)
- Assess for presence of BS q shift; palpate abdomen for distension
- If constipated, administer daily stool softeners per doctor’s order. Avoid use of enemas
and or suppositories for mothers with a 3rd or 4th degree laceration. If needed, use with
caution.
- Often sent home with stool softeners & encouraged to eat high fiber diet & exercise.

Rationale: Promote returning back of intestine to its normal position. Expect resolution of
normal bowel movement by 3 months.

E. LOCHIA (Vaginal bleeding vs. Vaginal discharge)

- Assess peripad daily (1 X each shift) for color, amount, type, and for any foul odor.
Instruct pt to notify nurse if she passes clots. Note size and number.
- The color and amount of vaginal discharge (lochia) should be noted.
- Assess lochia. Normal lochia is brown and light after 2 weeks and finished by 6-8 weeks
after delivery
 Types of lochia:
a. The vaginal discharge is red for one to three days following delivery and is called
lochia rubra.
b. Between days two and 10, the discharge changes to a pink or brownish color and
is called lochia serosa.
c. The last phase occurs when the vaginal discharge turns white is called lochia
alba, whih may occur from 10-14 days postpartum.
- Peri-Care:
-- Instruct pt to fill peri-bottle with warm water and rinse stitches area after each
voiding or BM
--Wipe from front to back, patting gently
--Change peripads after each voiding
--Spray episiotomy area with anesthetic spray after wiping
--Apply 1 - 2 Tucks (witch hazel) pads to peripad with each pad change
--Encourage use of sitz bath 24 hrs postpartum per Doctor’s order for 20 minutes bid
or tid especially if pt had a 3rd or 4th degree laceration per Doctor’s order
- Call Doctor for any excessive bleeding

Rationale: An excessive amount could be a sign of a complication such as clot formation or a

retained portion of the placenta, bleeding from displaced and relaxed uterus.
The spotting can continue for another six weeks. It is common in mothers who breastfeed
their babies. A constant trickling of blood or the soaking through of a perineal pad in an hour
or less is not normal and should be further evaluated.

F. EPISIOTOMY / EPISIORRHAPY
- Observe for the presence of lacerations, episiotomy and episiorrhaphy
- Assess using REEDA every shift
--R=redness
--E-edema
--E=ecchymosis
--D=discharge
--A=approximation
- Observe for the presence of hematoma caused by rupture of small blood vessels during
delivery.
- Application of hot and cold compress.
- Proper perineal care and hygiene.

Procedures:
1. Position in lateral Sims position with upper knee bent.
2. Gently lift the buttocks to view perineum. Flashlight may be helpful.

Types of Episiotomy:
--Midline
--R or L mediolateral
--3rd degree extension-- laceration extends to the rectum
--4th degree extension-- laceration extends through the rectum

G. HOMAN’S SIGN
- Assess daily for redness, nodular or warm areas, discolorations, leg varicosities or signs
of DVT; and notify Doctor.
- Assess Homan’s Sign q shift
- Assess peripheral pulses and for presence of and amount of edema
 Rationale: Women are more prone to thrombophlebitis post-partum related to
hypercoagulability of the blood caused by:
--pregnancy( hormonal changes)
--anemia
--pelvic infection
--traumatic delivery
--obesity

H. EMOTIONAL STATUS
- Expect mild mood changes that may last 1-6 weeks.

3 Normal Phases
1. “Taking In” - immediately after delivery till up to 2 days postpartum
--need rest and sleep
--self-focus
--relives events of Labor and Delivery
2. “Taking Hold” - preoccupied with the present
--usually encompasses days 2 - 5 postpartum
--interested in self-care
--optimal time for teaching
--focus on caring for baby
3. “Letting Go” -reestablishes relationships with others with outward focus

**Postpartum Blues / \postpartum depression - a normal temporary state related to hormonal

changes,role redefinition, fatigue, or pain. Patient may “cry for no reason”.

I. DIASTASIS RECTI
- a separation of the rectus abdominis muscles, may occur with pregnancy, especially in
women with poor abdominal muscle tone.

Procedures:
1. Following the uterine assessment, examine the abdomen for Diastasis Recti by asking the
mother to lift her head and place her chin on her chest.
2. While mother maintains that position, the nurse should begin to palpate at the level of the
umbilicus for a separation in the muscle.
3. Strive to measure both a length and a width and record on assessment, if indicated, as
Diastasis: 2 cm X 8 cm.
4. Teach mother importance of exercise to regain muscle tone, in order to have strong
abdominal support for future pregnancies. Reassure mom that diastasis recti does respond
well to exercise.

https://www.pelvicexercises.com.au/diastasis-recti/?
fbclid=IwAR2uSG5pSiuE_JOPNubAG7DjjLFCByNu3GsfoIAY1bpVhVvzWgckQwL9ZJ4

Additional Important Assessment:

1. Temperature
Rationale: high temperature – for early detection of infection, dehydration, hypovolemia,
routine check for covid
low temperature – indicates septic shock (severe infection), severe dehydration,
hypovolemia
for presence of infection, suspect retained placental fragments.
 2. heart rate (pulse)
- routinely during the first 24 hours starting from the first hour after birth.
Rationale: tachycardia – indicates early symptoms of bleeding / dehydration (compensatory),
impending hypovolemia, and fever. Emotional and psychological
origin. Emotional and psychological origin. Assess for history of
hypertension, medication intake, psychological status.
bradycardia – indicates late symptoms of bleeding / dehydration / hypovolemia

3. Blood pressure
- should be measured shortly after birth. If normal, the second blood pressure measurement
should be taken within six hours.
Rationale: high blood pressure – indicates early symptoms of bleeding / dehydration
(compensatory), impending hypovolemia. Emotional and
psychological origin. Assess for history of hypertension,
medication intake, psychological status. Assess for the
history of pregnancy-induced hypertension.
low blood pressure – indicates late symptoms of bleeding / dehydration /
hypovolemia.

Evaluate pulse, respiratory rate, and blood pressure every 15 minutes during the first hour postpartum,
every 30 minutes for two hours, and then every eight hours. Evaluate the woman's temperature at the
end of the first hour postpartum and then every four hours for the first two to 12 hours postpartum.

4. Pain and Discomforts

- Assess for the degree of pain and discomfort from incisions, lacerations, and uterine
cramping (afterbirth pains). As well as muscle and body pains.
- Observe for the presence of calf pain, suggesting thrombophlebitis or DVT.
- Spinal headache for those who underwent CS due to epidural anesthesia.

5. Birth Control
- Discuss by six weeks.

References:
1. World Health Organization (2018) WHO recommendation on routine postpartum maternal
assessment. https://extranet.who.int/rhl/topics/preconception-pregnancy-childbirth-and-
postpartum-care/care-during-childbirth/who-recommendation-routine-postpartum-maternal-
assessment#:~:text=All%20postpartum%20women%20should%20have,be%20measured
%20shortly%20after%20birth.
2. Perry Potter (2014), Clinical Nursing Skills and Techniques, 8th Edition, Elsevier.
3. Geraldine Rebeiro (2012), Fundamentals of Nursing Clinical Workbook, Elsevier.
4. Adele Pilliteri (2010), Maternal & Child health Nursing, 6th Edition, Lippincott Williams.
5. Marilyn Doenges (2010), Nursing Care Plans, 8th Edition, F. A. Davis Company.
 BICOL UNIVERSITY – POLANGUI CAMPUS
Nursing and Health Sciences Department
Bachelor of Science in Nursing

EVALUATION CHECKLIST

Name: _______________________________________________________ Date: ______________

Year / Section: _______________

Course Code / Title:

NCM 107: CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT)
RLE (SKILLS LABORATORY)

RLE FOCUS:
- Gyne & OB, Postpartum Assessment

Competencies KNOWLEDGE = 48 / SKILLS = 32 /

(Procedures)
Able to Able to Able to Identify Very Satisfactory Unable to perform
Enumerate explain nursing Satisfactory 1 pts. properly
1 pt. rationale considerations 2 pts. 0 pt.
1 pt. 1 pt.
1. Identify patient.
2. Proper handwashing. Complete equipments and PPE as
needed (eg. Gloves)
3. Enter the room with courtesy. Provide privacy.
4. Check patient’s identification.
5. History taking
a. Age
b. Gravida / Parity
c. History and types of delivery
d. Familial history of medical illness
e. Surgery history
f. Medical history
g. Medications / Maintenance drug
h. Drug Abuse / Alchol intake / Smoking
i. Educational level
j. Socio-economic status
k. Support system
6. Breasts
a. Assess supply, latch, milk transfer, and pain due to engorgement
b. Assess for signs of infection / mastitis: fever, erythema of breasts
c. Assess for cracked nipples, pressure sores, or fissures. Evaluate
whether nipples are everted, flat, or inverted.
7. Uterine / Fundal height
a. To properly palpate the uterus, assist in positioning flat on her
back (supine).
b. Place one hand at the base of the uterus above the symphysis
pubis (the interpubic joint of the pelvis) in a cupping manner (to
support the lower uterine ligaments).
c. Then, press in and downward with the other hand at the umbilicus
until she makes contact with a hard, globular mass.
d. If the uterus is not firm, light massaging usually results in
tightening. Massaging of the uterus should not be so vigorous as
to cause the mother pain. A mother who has had a cesarean
delivery should be medicated, if possible, prior to assessment of
 the fundus, and the nurse should use the minimal amount of
pressure necessary to locate her fundus.
e. The height of the fundus after the first hour following delivery is
at the umbilicus or above it. Every day the fundal height
decreases by approximately the width of one finger (one cm) until
it reaches 4 fingerbreadths.
8. Bladder
a. Encourage patient to void within her first hour postpartum.
Bladder should be palpated above symphysis pubis every after
voiding to assess urinary retention. Record first 2 voidings
(normal amount 150 cc per voiding).
b. If the woman had a cesarean section and has a Foley catheter in
place in her bladder, then the output is checked every hour during
the initial postpartum period. The Foley catheter is likely to be
removed approximately eight hours after surgery. Monitor intake
and output. The health care provider needs to assess for voiding
after removal of the Foley catheter.
c. If patient has not voided in 6-8 hours post-delivery or with severe
bladder distension; notify doctor for any voiding difficulties and
bladder distension; straight urinary catheterization per Doctor’s
order.
d. Be alert for signs and sx of UTI:
--infrequent voiding
--painful urination (dysuria)
--burning
--frequency
--urinary retention
--foul-smelling urine
5. Assess for postpartum voiding difficulties related:
--fatigue
--perineal swelling
--long, difficult Labor and Delivery eg.use of
Forceps, Vacuum Extractor
9. Bowel
a. Assess for peri-anal lacerations
b. Assess for presence of perineal and anal pain
c. Assess for complication of pregnancy and labor (ex.
Haemorrhoids)
d. Assess for presence of bowel sounds q shift; palpate
abdomen for distension
e. If constipated, administer daily stool softeners per doctor’s
order. Avoid use of enemas and or suppositories for mothers
with a 3rd or 4th degree laceration. If needed, use with
caution.
f. Often sent home with stool softeners & encouraged to eat
high fiber diet & exercise
10. Lochia
a. Assess peripad daily (1 X each shift) for color, amount,
type, and for any foul odor.
b. Instruct pt to notify nurse if she passes clots. Note size and
number.
c. The color and amount of vaginal discharge (lochia) should
be noted.
d. Assess lochia. Normal lochia is brown and light after 2
weeks and finished by 6-8 weeks after delivery
Types of lochia:
The vaginal discharge is red for one to three days following delivery
and is called lochia rubra.
Between days two and 10, the discharge changes to a pink or brownish
color and is called lochia serosa.
The last phase occurs when the vaginal discharge turns white is called
lochia alba, whih may occur from 10-14 days postpartum.
e. Provide peri-anal care.
f. Call Doctor for any excessive bleeding
11. Episiotomy / Episiorrhaphy
a. Position in lateral Sims position with upper knee bent or
assessment can be done during peri-anal care.
b. Gently lift the buttocks to view perineum. Flashlight may be
helpful.
c. Observe for the presence of lacerations, episiotomy and
episiorrhaphy Types of Episiotomy:
--Midline
--R or L mediolateral
--3rd degree extension-- laceration extends to the rectum
--4th degree extension-- laceration extends through the rectum
d. Assess using REEDA every shift
--R=redness
--E-edema
--E=ecchymosis
--D=discharge
--A=approximation
e. Observe for the presence of hematoma caused by rupture of small
blood vessels during delivery.
f. Application of hot and cold compress as indicated with doctor’s
order.
12. Homan’s Sign
a. Assess for homan’s signs q shift.
b. Assess daily for redness, nodular or warm areas, discolorations,
leg varicosities or signs of DVT.
c. Assess peripheral pulses and for presence of and amount of
edema
d. Notify doctor immediately.
13. Emotional Status
a. Assess emotional status.
b. Identify level of emotional phases and coping mechanism.
1. “Taking In” - immediately after delivery till up to 2 days
postpartum
--need rest and sleep
--self-focus
--relives events of Labor and Delivery
2. “Taking Hold” - preoccupied with the present
--usually encompasses days 2 - 5 postpartum
--interested in self-care
--optimal time for teaching
--focus on caring for baby
3. “Letting Go” - reestablishes relationships with others
with outward focus
e. Provide emotional support and diversional activities.
f. Encourage support system.
14. Diastasis Recti
a. Following the uterine assessment, examine the abdomen for
Diastasis Recti by asking the mother to lift her head and place her
chin on her chest.
b. While mother maintains that position, the nurse should begin to
palpate at the level of the umbilicus for a separation in the
muscle.
c. Strive to measure both a length and a width and record on
assessment using finger / centimetre.
d. Teach mother importance of exercise to regain muscle tone, in
order to have strong abdominal support for future pregnancies.
Reassure mom that diastasis recti does respond well to exercise.
15. Additional important assessment
a. Temperature
b. Heart / pulse rate
c. Blood pressure
d. Pain and discomforts
e. Birth control
16. Proper documentation
Total
17. ATTITUDE 20 pts (positive) 10 pts (fair) 0 pt (negative)
Comments: Total: 100% Score:

Recommendations: Evaluator:

Prepared by:
Mrs. DANELA COSEJO DURAN, RN