1. Nursing management during the postpartal period
    1. Assessment-minimum of twice daily.
      1. Vital signs.
      2. Emotional status, response to baby.
      3. Breasts
        1. Observe: size, symmetry, placement and condition of nipples, leakage of colostrum. Normal: although one breast is usually larger than the other, breasts are essentially symmetrical in shape; nipples: in breast midline, erectile, intact (no signs of fissure); bilateral leakage of colostrum is common.
        2. Note: reddened areas, elevations, supernumerary nipples, inverted nipples, cracks.
        3. Observe for signs of (normal) engorgement (tenderness, distention, prominent veins). Transient; normally occurs shortly before lactation is established- due to venous and lymphatic stasis.
        4. Palpate for: local heat, edema, tenderness, swelling (signs of localized infection).
      4. Fundus, lochia, perineum.
      5. Voiding and bowel function.
      6. Legs.
      7. Signs of complications.
    2. Analysis/nursing diagnosis:
    3. Nursing care plan/implementation:
      1. Goal: comfort measures.
        1. Perineal care-to promote healing, prevent infection.
        2. Sitz baths-to promote healing.
        3. Apply topical anesthetics, witch hazel to episiotomy area, hemorrhoids.
        4. Administer mild analgesia, as ordered.
        5. Instruct in tensing buttocks on position change-to reduce stress on suture line, discomfort.
        6. Breast care: bottle-feeding mother
          1. Wash daily with clear water and mild soap.
          2. Support with well-fitting brassiere.
          3. For engorgement:
            1. Prevent with tight binder.
            2. Treat with ice pack and mild analgesic.
            3. Avoid nipple stimulation.
      2. Goal: encourage normal bowel function. (Normal to take 1-3 days for function to resume.)
        1. Administer stool softeners, as ordered.
        2. Encourage ambulation.
        3. Increase dietary fiber (salads, fresh fruit, vegetables, bran cereals).
        4. Provide adequate fluid intake.
      3. Goal: health teaching and discharge planning
        1. Reinforce appropriate perineal self-care,
        2. Reinforce hand washing
        3. Infant care
          1. Bathing, cord care, circumcision care, diapering.
          2. Feeding, burping, scheduling.
          3. Assessment-temperature, skin color, newborn rash, jaundice.
          4. Normal stool cycle and voiding pattern.
          5. Common sleep/activity patterns.
          6. Signs to report immediately:
            1. Fever, vomiting, diarrhea.
            2. Signs of inflammation or infection at cord stump.
            3. Bleeding from circumcision site.
            4. Lethargy, irritability.
        4. Self-care
          1. Adequate rest, nutrition, hydration.
          2. Breast self-examination; wear bra to
          3. support breasts and promote comfort.
          4. Normal process of involution; lochia
          5. patterns.
        5. Resumption of intercourse approximately 4 weeks postpartum (wait until lochia stops).
          1. Explain that time interval varies as to first postpartal ovulation.
          2. Family planning options may resume if desired:
            1. If not breastfeeding, oral contraceptives (estrogen and progesterone); low-dose progesterone given to breastfeeding mothers.
            2. Long-acting progestins (subcutaneous implants or injectable). Safe to use during lactation.
            3. Use of IUD or diaphragm decided at postpartal check-up.
            4. Emphasize need to recheck size and fit of diaphragm.
            5. Other options: condom plus spermicides.
        6. Exercises-to restore muscle tone, relieve tension.
          1. Mild exercise during first few weeks.
            1. Deep abdominal breathing.
            2. Supine head-raising.
            3. Stretching from head to toe.
            4. Pelvic tilt.
            5. Kegel-to regain perineal muscle tone.
          2. Strenuous exercises (sit-ups, leg lifts)-deferred until later in postpartum.
        7. Maternal signs to report immediately:
          1. Prolonged lochia rubra.
          2. Cramping.
          3. Signs of infection.
          4. Excessive fatigue, depression.
          5. Dysuria.
      4. Goal: anticipatory guidance-discharge planning: mothers are discharged earlier in their postpartum recovery today-(6-48 hours after birth if asymptomatic).
        1. Discuss, assist in organizing time schedule Nap, when possible, when infant asleep-to minimize fatigue.
        2. Common maternal emotional/behavior changes, feelings:
          1. Jealous of infant; guilt feelings.
          2. "Baby blues”-due to hormonal fluctuations, fatigue, change of lifestyle.
          3. Feelings of inadequacy.
        3. Discuss support groups, aid in identifying supportive people.
    4. Evaluation/outcome criteria:
      1. Woman experiences normal, uncomplicated postpartal period. All assessment findings within normal limits.
        1. Perineal care, pad change, hand-washing.
        2. Breast care, breast self-examination.
      2. Woman returns demonstrations of appropriate self-care measures/techniques:
      3. Woman verbalizes understanding of:
        1. Need for adequate rest and diversion.
        2. Appropriate time for resumption of intercourse and exercise.
        3. Appropriate nutritional intake to meet needs (own and, if breastfeeding, infant’s).
        4. Signs to be reported immediately.
        5. Returns demonstration of appropriate infant care measures.
        6. Evidences beginning comfort and increasing confidence in parenting role.
    5. Postpartal assessment-6 or less weeks after birth:
      1. Weight, vital signs, urine for protein, complete blood count (CBC).
      2. Breast examination lactating or not.
      3. Pelvic examination-involution and position of uterus; perineal healing; tone of pelvic floor.
      4. Desire for selection of method of contraception.