Nursing Care in the Postpartum Period

Postdelivery Assessment

• Greatest risk for postpartum complications is during the first 24 hours after delivery

• Identification of potential problems; immediate intervention; reassessment

• Assessment includes:– Condition of uterus– Amount of bleeding– Bladder & voiding– Vital Signs– Perineum

• Fundus = Palpated to assess firm & well contracted

• Bleeding = Assess drainage on pad

• Pulse & Bp = Assess cardiovascular function

• Perineum = Assess for signs of hematoma, lacerations, & edema

• Assessments are q 15 minutes for the first hour post delivery

• Temperature is taken at the end of first hour

• Transferred to Postpartum Unit when stable

Admission to Postpartum Unit

• Report between L&D Nurse & PP Nurse

• Preparations made for receiving the Mother such as:– Room Ready– IV Pole– Admission Assessment– Vital Signs Equipment

Assessment

• Assessment is immediately upon arrival to the PP Unit– Complete Assessment– BUBBLE HE & VS included

• Reassessment q Hour x 4 Hours– Uterus, Lochia, Bladder, Bp & Pulse– Abnormal Findings

Vital Signs

• Elevated Temperature– Normal finding for first 24 hours– Sign of Dehydration– Sign of Infection

• Bradycardia– Normal Finding

• Tachycardia– Infection– Hemorrhage– Pain– Anxiety

• Lowered Blood Pressure– Orthostatic Hypotension– Shock

• Elevated Blood Pressure– Pregnancy-induced Hypertension

Breasts

• Soft, firm, can be lumpy

• Secretion of Colostrum

• Engorgement

• Assessment of:– Breasts– Nipples

Uterus• Process of Involution• Height

– First Day = at Umbilicus– Decreases 1 FB per Day

• Consistency– Firm, Round, Smooth; Not “Boggy”

• Location– Midline

Bladder

• Often times will be catheterized in L&D post delivery

• Assess for Bladder Distention:– Uterine Atony– UTI

• Recatheterize in 6 hours if not voided (Dr.)

• Measure Urine Output

Bowel

• Assessment for Bowel Sounds

• Complaints of Gas Pains

• Usually has Stool 2-3 days post delivery

• May need medication for gas pains, laxatives, stool softeners, enemas

Lochia

• Amount– Estimate of Drainage– Number of Pads

• Color– Rubra– Serosa– Alba

Episiotomy

• Assessment for:– Hematomas– Ecchymosis– Edema– Erythema– Intact Suture Line– Signs of Infection

Homan’s Sign

• Assessment for Thrombophlebitis– Swelling– Reddness– Warmth– Pain

• Unilateral Findings

• C/S Mother at Higher Risk

Emotional Status

• Can have Mood Swings

• Observing Bonding Behavior & Ability to give Infant Care– Rubin’s Phases– En face– Engrossment

Patient Post Epidural

• Assessment of Lower Extremities for:– Sensation– Movement

• Remains on Bedrest

Post C/S

• Additional Assessment:– Incision– Fluid Intake– Bladder & Bowel– Ambulation/Orthostatic Hypotention– Thrombophlebitis

Documentation of Findings

• Assessment Checklist Form

• Graphic Sheet

• Narrative Notes– Admission– Daily

Nursing Diagnoses

• Throughout the chapter

• NCP

Interventions

• Prevention of Complications• Reduce Discomfort• ADL

– Nutrition– Rest & Sleep– Ambulation– Bathing– Kegel Exercises

Predischarge

• Rubella Vaccine– Titer– Hypersensitivity to eggs– Administration of Vaccine– Patient Teaching

• Rho Immune Globulin– Criteria– Administration of Rhogam

Discharge

• Instructions for Mother & Infant Care

• Next Appointment

• Referrals