CRITICAL PATHWAY | for the Pospartal Period
Category First 4 Hours 4-8 Hours Past Birth 8-24 Hours Past Birth
Referral Report from labor nurse if not continuing in an LDR room Lactation consultation as needed Home nursing, WIC referral if indi- Expected Outcomes: Referrals made
Assessments Postpartum assessments q 30min X 2, qlh X 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 systolic or 15 mm 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
 Continue postpartum assessment q4th X 2, then q8h Breasts: evaluate nipple status; should be no evidence of cracks or bruising Observe feeding technique with newborn Vital signs: assessment q8 hrs; all WNL; report temperature >38°C (I00.4°F) Assess Homan's sign q8h Continue assessment of comfort level Continue postpartum assessment q8h 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) Expected Outcomes: Vital signs medically acceptable, voids qs, postpartum assessment WNL; comfort level <3 on 1-10 scale, involution of uterus in process, demonstrates and verbalizes appropriate newborn feeding techniques with baseline Respirations: 12-20/min; quiet, easy Comfort level: <3 on scale of 1-10
Teaching/ psychosocial 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 peri-care, surgigator, sitz bath pm 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 Discuss psychological changes of postpartum period; facilitate transition through tasks of taking on maternal role Discuss peri-care/hygiene; encourage use of supportive brassiere for breast- or bottlefeeding 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: airdrying, lanolin; proper latchon technique; tea bags Bottle-feeding: supportive bra, ice bags, breast binder Assess mother/infant attach- Reinforce previous teaching, complete teaching 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 non-pregnant state (200 kcal over pregnant intake)
  • Explain milk production, let-down reflex, use of supplements, breast pumping, and milk storage
Bottle-feeding:
  • Return to nonpregnant caloric in-
  • 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
Nursing care management and reports Ice pack to perineum to decrease swelling and increase comfort Straight catheter pm X 1 if distended or voiding small amounts If continues unable to void or voiding small amounts, insert Foley catheter and notify CNM/physician Sitz baths prn If woman Rh- and infant Rh+, RhoGAM work up; obtain consent; complete teaching Determine rubella status Obtain consent for rubella vaccine if indicated; explain purpose, procedure, implications of vaccine Obtain hematocrit Continue sitz baths prn May shower if ambulating without difficulty DC saline lock if present Administer rubella vaccine as indicated Expected Outcomes: Using sitz bath; voids qs; lab work WNL; performs ADL without sequelae
Activity Assistance when OOB first time, then Ambulate ad lib Rests comfortably between assessments Encourage rest periods Ambulate ad lib; may leave birthing unit after notifying staff of plan to ambulate off Up ad lib Expected Outcomes: Ambulates ad lib
Comfort Institute comfort measures:
  • Perineal discomfort: peri-care; sitz D baths, topical analgesics
  • Hemorrhoids: sitz baths, topical analgesics, digital replacement of external B hemorrhoids; side-lying or prone position
  • Afterpains: prone with small pillow
B under abdomen; warm shower or sitz baths; ambulation
  • Administer pain medication
 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 Regular diet Fluid > 2000 ml/day Continue diet and fluids Continue diet and fluids Expected Outcomes: Regular diet/fluids tolerated
Elimination Voiding large amounts straw-colored Voiding large quantities May have bowel movement Same Expected Outcomes: Voiding qs; passing flatus or bowel movement
Medications Pain medications as ordered Methergine 0.2 mg q4th PO if ordered Stool softener Tucks pad pm, perineal analgesic spray Continue meds Lanolin to nipples PRN; tea bags to nipples if tender; saline flush to Luer local adaptor (if present) q8h or as ordered May take own prenatal vitamins Continue medications RhoGAM and rubella vaccine administered as indicated Expected Outcomes: Vaccines administered; pain controlled
Discharge planning/ home care Evaluate knowledge of normal postpartum and newborn care Evaluate support systems Discuss typical newborn schedule; plan for periods of rest Birth certificate paperwork completed Evaluate plans for transporting newborn; car seat available Review discharge instruction sheet/checklist Describe postpartum warning signs and when to call CNM/physician Provide prescriptions. Gift packs given appropriate for bottle- or breastfeeding Arrangements for baby pictures as de- Postpartum and newborn visits scheduled Expected Outcomes: Discharged home; mother verbalizes postpartum warning s/s, follow-up appointment times/dates
Family involvement Identify available support persons Assess family perceptions of birth expe- Parenting: demonstrates culturally expected early parenting behaviours 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