Maternal and Child Health Nursing

1. Module 7 : NursingCare of a Postpartal Family
Thismodule aims discussthe physiological andpsychological changesthatoccurin the postpartal
woman.
Topic1: Psychological and Physiologicchangesof the postpartal period
Topic2: Nursingcare of a womanand familyduringthe first24 hours afterbirth
Topic3: Nursingcare of a womanand familyinpreparationfordischarge andafterdischarge
Learning Targets 1. Explainthe physiologic andpsychological changesthatoccur
duringthe postpartumperiod.
2. Describe effectivematernal self-care measurestobe
implementedduringthe puerperium.
3. Discussthe 3 phasesof puerperium.
4. Describe nursingassessmentsandnursingcare duringthe
postpartumperiod.
5. Discussthe role of the nurse inhealtheducation, andidentify
importantareasof teaching.
6. Describe postpartumhome care intermsof criteriafor
discharge,commonproblems,andavailable healthcare
services.
References: Pilliteri,Adele(2010),Maternal and ChildHealthNursing:Care of the
ChildbearingandChildrearingFamily,6thedition.LippincotWilliamsand
Wilkins
Mckinney/James/Murray/Nelson/Ashwill (2013),Maternal-ChildNursing,
4th
edition. Saunders,animprintof ElsevierInc.
Ward/Hisley/(2009),Maternal-ChildNursingCare:OptimizingOutcomesfor
Mother,Children,&Families, F.A.DavisCompany
Silvestri,LindaAnne (2011),SaundersComprehensive Review forthe
NCLEX-RN!Examination,Saunders,animprintof ElsevierInc.

2. Topic 1: Psychological and Physiologicchangesof the postpartal period
Learning Targets: 1. Explainthe physiologic andpsychological changesthatoccurduringthe
postpartumperiod.
2. Describe effectivematernal self-care measurestobe implemented
duringthe puerperium.
3. Discussthe 3 phasesof puerperium.
References: Pilliteri,Adele(2010),Maternal and ChildHealthNursing:Care of the
ChildbearingandChildrearingFamily,6thedition.LippincotWilliamsandWilkins
Mckinney/James/Murray/Nelson/Ashwill (2013),Maternal-ChildNursing,4th
edition. Saunders,animprintof ElsevierInc.
Ward/Hisley/(2009),Maternal-ChildNursingCare:OptimizingOutcomesfor
Mother,Children,&Families, F.A.DavisCompany
Silvestri,LindaAnne (2011),SaundersComprehensive Review forthe NCLEX-RN!
Examination,Saunders,animprintof ElsevierInc.
Concept/Digest
 The postpartal period,orpuerperium(from the Latin puer, for “child,” andparere, for “tobring
forth”),referstothe 6-weekperiodafterchildbirth.Itisatime of maternal changesthatare both
retrogressive (involution of the uterus and vagina) and progressive (production of milk for
lactation, restoration of the normal menstrual cycle, and beginning of a parenting role).
 Protecting a woman’s health as these changes occur is important for preserving her future
childbearingfunctionandfor ensuringthatshe is physicallywell enoughtoincorporate hernew
child into her family. The period is popularly termed the fourth trimester of pregnancy.
PHASES OF THE PUERPERIUM
 In herclassicworkon maternal behavior, Reva Rubin, anurse,dividedthe puerperiumintothree
separate phases (Rubin, 1977).
1. Taking-in phase
2. Taking-hold phase
3. Letting go phase
 She viewedthe firstof these as a taking-inphase,The subsequentphases, calledthe taking-hold
phase and the letting-go phase, are times of renewed action and forward movement.
 At the time these phasesof the puerperiumwere identified,womenwere hospitalizedfor5 to 7
days after childbirth and moved in a paced manner from one step to the next. Today, with
hospitalizationasshortasa fewhours,womenappeartomove throughthesephasesmuchmore
quickly and may even be experiencing two different phases at once.
1. Taking-In Phase
 The taking-in phase, the first phase experienced, is a time of reflection.

3.  During this 2- to 3-day period, a woman is largely passive.
 She prefers having a nurse minister to her (such as bringing her a bath towel or a clean
nightgown) and make decisions for her, rather than do these things herself. This
dependence results partly from her physical discomfort because of afterpains or
hemorrhoids;partlyfromheruncertaintyincaring for hernewborn;andpartly fromthe
extreme exhaustion that follows childbirth.
2. Taking-Hold Phase
 After a time of passive dependence, a woman begins to initiate action.
 She prefers to get her own washcloth and to make her own decisions.
 Womenwho give birthwithoutany anesthesiamayreach thissecondphase in a matter
of hours after birth.
 Duringthe taking-inperiod,awomanmay have expressedlittle interestincaringfor her
child.
 Now,she beginstotake a strong interest.Asa rule,therefore,itisalwaysbest to give a
woman brief demonstrations of baby care and then allow her to care for her child
herself—with watchful guidance.
3. Letting-Go Phase
 In the third phase, called letting-go, a woman finally redefines her new role.
 She givesup the fantasizedimage of herchildand acceptsthe real one;she givesupher
old role of being childlessor the mother of only one or two (or however many children
she had before this birth).
 Thisprocessrequiressome grief workandreadjustmentof relationships,similartowhat
occurred during pregnancy.
MATERNAL CONCERNS AND FEELINGS IN THE POSTPARTAL PERIOD
 Traditionally,it is assumed that the bulk of a woman’s concerns in the postpartal period center
on the care of her new infant.
 Based on this, classes in the postpartal period have traditionally focused on teaching how to
breastfeed and bathe infants.
 Althoughthese actsare concernsformanymothers,theyare notnecessarilyeverynewmother’s
chief concern.
 A woman has come through a tremendous psychological experience during pregnancy and the
birth of a child.
 She is in the middle of a complete role change. It can be expected, therefore,that some of her
attentionand interestduringthistime will be directedinwardasshe tries to view herself inthis
new role.
Abandonment
 Many mothers,if giventhe opportunity,admittofeelingabandonedandlessimportantafter
giving birth than they did during pregnancy or labor.
 Onlyhoursbefore,theywere the centerof attention,witheveryoneaskingabouttheirhealth
and well-being.
 Now,suddenly,the babyseemstobe everyone’schief interest.Relativesaskaboutthe baby;
the gifts are all for the baby.
Disappointment
 Another common feeling parents may experience is disappointment in the baby.
 All during pregnancy, they pictured a chubby-cheeked, curly-haired, smiling girl or boy.
 They have instead a skinny baby, without any hair, who seems to cry constantly.

4.  It can be difficult for parents to feel positive immediately about a child who does not meet
their expectations in this way.
 It can cause parentsto remembertheiradolescence,whentheyfeltganglyandunattractive,
or to experience feelings of inadequacy all over again.
Postpartal Blues
 During the postpartal period, as many as 50% of women experience some feelings of
overwhelming sadness (Buultjens & Liamputtong, 2007).
 They may burst into tears easily or feel let down or irritable.
 Thistemporaryfeelingafterbirthhaslongbeenknownasthe “babyblues.”Thisphenomenon
may be causedbyhormonal changes,particularlythe decreaseinestrogenandprogesterone
that occurs with delivery of the placenta.
 For some women, it may be a response to dependence and low self-esteem caused by
exhaustion, being away from home, physical discomfort, and the tension engendered by
assuming a new role, especially if a woman is not receiving support from her partner.
 The syndrome is evidenced by tearfulness, feelings of inadequacy, mood lability, anorexia,
and sleep disturbance.
Effects of Retrogressive Changes
The overall effects of postpartal retrogressive changes are exhaustion and weight loss.
Exhaustion
 As soon as birth is completed, a woman experiences total exhaustion. For the last
several monthsof pregnancy,she probablyhasexperiencedsome difficultysleeping.
 Near the end of pregnancy, she probably was unable to find a comfortable position
to sleep because of the fetus’ activity or the presence of back or leg pain.
 All during labor, she worked hard with little or no sleep.
 Now she has “sleep hunger,” which may make it difficult for her to cope with new
experiencesandstressful situationsuntilshe hasenjoyedasustainedperiodof sleep.
Weight Loss
 The rapid diuresisanddiaphoresisduringthe secondto fifthdaysafter birth usually
result in a weight loss of 5 lb (2 to 4 kg), in addition to the approximately12 lb (5.8
kg) lost at birth.
 Lochia flowcausesanadditional 2- to 3-lb(1-kg) loss,for a total weightlossof about
19 lb.
 Additional weight loss is most dependent on the amount of pregnancy weight gain
and on whether a woman takes active measures to lose weight.
 It is also influenced by nutrition, exercise, and breastfeeding.
Vital Sign Changes
 Vital signchangesinthe postpartumperiodreflectthe internal adjustmentsthatoccuras
a woman’s body returns to its prepregnant state.
Temperature
 A womanmay showa slightincrease intemperature duringthe first24 hours afterbirth
because of dehydration that occurred during labor.
 If she receives adequate fluid during the first 24 hours, this temperature elevation will
return to normal.
 Most women are thirsty immediately after birth and are eager to take in fluid.

5.  Thismakesdrinkingalarge quantityof fluidnotaproblemunlessthe womanisnauseated
from a birth anesthetic.
Pulse
 A woman’spulse rate duringthe postpartal periodisusuallyslightlyslowerthannormal.
 During pregnancy, the dis- tended uterus obstructed the amount of venous blood
returning to the heart; after birth, to accommodate the in- creased blood volume
returning to the heart, stroke volume increases.
 This increased stroke volume reduces the pulse rate to between 60 and 70 beats per
minute.
Blood Pressure
 Bloodpressure shouldalsobe monitoredcarefullyduringthe postpartal period,because
a decrease in this can indicate bleeding.
 In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate
the development of postpartal pregnancy-induced hypertension, an unusual serious
complication of the puerperium
Progressive Changes
 Two physiologic changes that occur during the puerperium involve progressive changes, or the
building of new tissue. Because building new tissue requires good nutrition, caution women
againststrict dietingthat wouldlimitcell-buildingabilityduringthe first6 weeksafterchildbirth
(Rolfes, Pinna, & Whitney, 2009).
Lactation
 The formationof breast milk(lactation) beginsinapostpartal womanwhetherornotshe
plans to breastfeed (Pavone, Purinton, & Petersen, 2007).
 Early in pregnancy, the in- creased estrogen level produced by the placenta stimulates
the growth of milk glands; breasts increase in size because of the larger glands,
accumulated fluid, and some extra adipose tissue.
Return of Menstrual Flow
 Withthe deliveryof the placenta,the productionof placentalestrogenandprogesterone
ends.
 The resulting decrease in hormone concentrations causesa rise in productionof FSH by
the pituitary,whichleads,withonlyaslightdelay,tothe returnof ovulation.Thisinitiates
the return of normal menstrual cycles.
 A woman who is not breastfeeding can expect her menstrual flow to return in 6 to 10
weeks after birth.
 If she is breastfeeding, a menstrual flow may not return for 3 or 4 months (lactational
amenorrhea) or, in some women, for the entire lactation period.
PHYSIOLOGICAL MATERNAL CHANGES
A. INVOLUTION
1. Description
a. Involutionisthe rapiddecrease inthe size of the uterusasitreturnsto the nonpregnantstate.
b. Clients who breast-feed may experience a more rapid involution because of the release of
oxytocin during breastfeeding.
c. Uterine involution entails three processes:
1. Contraction of muscle fibers
2. Catabolism (die process of converting cells into simpler compounds), and

6. 3. Regeneration of uterine epithelium.
d. When the process of involution doesnot occur properly, subinvolution occurs. Subinvolution
can cause postpartum hemorrhage
2. Assessment
a. The weight of the uterus decreases from approximately 2 lb to 2 oz in 6 weeks.
b. The endometrium regenerates.
c. The fundus steadily descends into the pelvis.
d. Fundal height decreases about 1 finger- breadth (1 cm) per day (Fig. 28-1).
e. By 10 days postpartum, the uterus cannot be palpated abdominally.
f. A flaccid fundus indicates uterine atony and should be massaged until firm; a tender fundus
indicates an infection (Fig. 28-2).
g. Afterpains decrease in frequency after the first few days.
B. LOCHIA
1. Description:Discharge fromthe uterusthatconsistsof bloodfromthe vesselsof the placentalsite and
debris from the decidua
2. Changes in Color.
a. Lochia rubra
 Reddish or red-brown color, it is called
 Forthe first3daysafterchildbirth,lochiaconsistsalmostentirelyof blood,withsmallparticles
of decidua and mucus.
B. Lochia serosa
 The amount of blood decreases by about the 4th day
 the color of lochia changes from red to pink or brown-tinged
 Lochia serosaiscomposedof serousexudate,erythrocytes,leukocytes, and cervical mucus.
C. Lochia alba
 By about the 11th day, the erythrocyte component decreases.
 The discharge becomes white, cream, or light yellow in color
 Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and
bacteria.It ispresentinmostwomenuntil the 3rdweekafterchildbirthbutmaypersistuntil
the 6thweek (Whitmer, 2011).
 Table20-1 summarizes the characteristics of normal and abnormal lochia.

7. 3. Amount.
 Because estimatingthe amountof lochiaonaperipad(perineal pad) isdifficult,nursesfrequently
record lochia in terms that are difficult to quantify, such as "scant," "moderate," and "heavy."
 One methodforestimatingthe amount of lochiainIhourusesthe followinglabels(Whitmer,201
1):
o Scant: Less than a 2.5-cm (I-inch) stain on the perineal pad
o Light.:2.5- to 10-cm (I- to 4-inch) stain
o Moderate: 10- to 15-cm (4- to 6-inch) stain
o Heavy: Saturated perineal pad
o Excessive: Saturated peripad in 15 minutes
 Determiningthe timethe peripadhasbeeninplaceisimportantinassessinglochia.Whatappears
to be a lightflowmayactuallybe amoderate flowif the peripadhasbeeninuse lessthananhour
( Figure 20-2).
4. Assessment (Box 28-1)
a. Rubra is bright red discharge that occurs from delivery day to day 3.
b. Serosa is brownish pink discharge that occurs from days 4 to 10.
c. Alba is white discharge that occurs from days 11 to 14.
d. The discharge should smell like normal menstrual flow.
e. Discharge decreases daily in amount.
f. Discharge may increase with ambulation.
To determinemostaccurately theamountof lochialflow,weigh theperinealpad beforeand afteruseand
identify the amount of time between pad changes.
C. CERVIX
 Immediately after childbirth the cervix formless, flabby, and open wide.
 Small tears or lacerations may be present, and me cervix is often edematous.
 Healingoccursrapidly,andbythe endof the 1st weekthe cervix feelsfirm,andthe externalosis
dilated l cm (Whitmer, 2011).
 The internal os closes as before pregnancy, but the shape of the external os is permanently
changed.
 It remains slightly open and appears slit-like rather than round, as in the nulliparous woman.
 Cervical involution occurs, and the muscle begins to regenerate after 1 week.
D. VAGINA
 Vaginal distentiondecreases,althoughmuscle toneisneverrestoredcompletelytothe pregravid
state.
 Soon afterchildbirththe vaginal wallsappearedematous,andmultiple small lacerationsmaybe
present.
 Very few vaginal rugae (folds) are present.

8.  The hymenispermanentlytornandhealswithsmall,irregulartagsof tissue visible atthe vaginal
introitus.
 Althoughthe rugae are regainedby3to4weeks,ittakes6to10 weeksforthe vaginatocomplete
involution and to gain approximately the same size and contour it had before pregnancy.
 The vagina does not entirely regain the nulliparous size, however (Blackburn, 2013).
 Because ovarian function, and therefore estrogen production, is not well established during
lactation, breastfeeding mothers are likely to experience vaginal dryness and may experience
dyspareunia (discomfort during intercourse).
E. PERINEUM
 Because of pressure from the fetal head, the muscles of the pelvic floor stretch and thin greatly
during the second stage of labor.
 After childbirth the perineum may be edematous and bruised.
 Some womenhave asurgical incision(episiotomy)of the perinealareatoenlarge the openingfor
birth.
 Initial healingof the episiotomysite occursin2 to 3 weeks,butcomplete healingmaytake 4 to
6 months (Blackburn, 2013).
 Lacerations of the perineum also may occur during delivery.
 Lacerations and episiotomies are classified according to tissue involved.
 With adequate lighting in place, the nurse gently lifts the buttock cheeks to visualize the
perineum.
 Use of the acronym REEDA guidesthe nurse toassessfor Redness,Edema,Ecchymosis,Drainage
or discharge, and Approximation of the episiotomy if present (Table 15-1).
 The episiotomy and/or laceration repairs should appear intact with the tissue edges closely
approximated.
Lacerations of the birth canal
Perineum
 PerineaI lacerations are classifiedin degrees to describe the amount of tissue involved. Some
physiciansornurse-midwivesalsouse degrees to describe the extent of midline episiotomies.
a. First-degree: Involves the superficial vaginal mucosa or perinea! skin.
b. Second-degree. Involves the vaginal mucosa, perinea! skin, and deeper
tissues which may include fascia and muscles of the perineum.
c. Third- degree: Same as second degree lacerations but involves the anal
sphincter.
d. Fourth-degree. Extends through the anal sphincter into the rectal mucosa

9. Periurethral Area
 A laceration in the area of the urethra may cause women difficulty urinating after birth. An
indwelling catheter may be necessary for a day or two.
Vaginal Wall
 A laceration involving the mucosa of the vaginal wall.
Cervix
 Tears in the cervix may be a source of significant bleeding after birth.
F. OVARIAN FUNCTION AND MENSTRUATION
1. Ovarian function depends on the rapidity with which pituitary function is restored.
2. Menstrual flow resumes within 1 to 2 months in non–breastfeeding mothers.
3. Menstrual flow usually resumes within 3 to 6 months in breast-feeding mothers.
4. Breast-feeding mothers may experience amenorrhea during the entire period of lactation.
4. Approxin1ately 40% to 45% of non-nursing mothers resume menstruationat 6 to 8 weeks after
childbirth, 75% by 12 weeks, and all within 6 months.
5. Menseswhile lactatingmayresume as early as 8 weeks or as late as 18 months(Whitmer, 2011
).
6. Frequent breastfeeding with no supplements is more likely to delay menses, but menses and
ovulation are increasingly likely after the infant is 6 months old.
Women may ovulate without menstruating, so breast-feeding should not be considered a form of birth
control.
G. BREASTS
1. Breasts continue to secrete colostrum for the first 48 to 72 hours after delivery.
2. A decrease in estrogen and progesterone levels after delivery stimulatesincreased prolactin levels,
which promote breast milk production.
3. Breasts become distended with milk on the third day.
4. Engorgement occurs on approximately day 4 in non–breast-feeding mothers.
5. Breast-feeding relieves engorgement.
Breast Care for Non–Breast-Feeding Mothers
 Avoid nipple stimulation.
 Apply a breast binder, wear a snug-fitting bra, apply ice packs, or take a mild analgesic.
 Engorgement usually resolves within 24 to 36 hours after it begins.
H. URINARY TRACT
1. The clientmay have urinary retentionasa resultof lossof elasticityandtone and lossof sensationin
the bladder from trauma, medications, anesthesia, and lack of privacy.
2. Diuresis usually begins within the first 12 hours after delivery.
I. GASTROINTESTINAL TRACT
1. Clients are usually hungry after delivery.
2. Constipationcanoccur,withbowel movement(soft,formedstool) bythe secondorthirdpost- partum
day.
3. Hemorrhoids are common.

10. J. VITAL SIGNS (TABLE 28-1)
1. Temperature may be elevated during the first 24 hours because of dehydration.
2. Bradycardia is common during the first week (range of 50 to 70 beats/min).
3. Blood pressure remains unchanged.
A CONCISE POSTPARTUM ASSESSMENT GUIDE TO FACILITATE NURSING CARE
THE BUBBLE-HE MNEMONIC
 Use of a systematic assessment process helps the nurse ensure that the special needs of
postpartum patients are met.
 As with all nursing care, a complete head-to-toe assessment must be completed for the
postpartum patient who has unique needs not found in any other nursing environment.
 To assistwiththe postpartumassessment,the mnemonicBUBBLE-HEiscommonlyusedtoguide
nursing practice. BUBBLE-HE reminds the nurse to assess the breasts, uterus, bladder, bowel,
lochia, and episiotomy.
 Assessmentof maternal pain,Homans’sign,the patient’semotional statusandinitiationof infant
bondingare otherimportantcomponentstobe includedinthe postpartumevaluation(Table 15-
2).
 Medications commonly prescribed during the puerperium are presented in Table 15-3.
POSTPARTUM DISCOMFORTS
A. Afterbirth pains
1. Afterbirth pains occur as a result of contractions of the uterus.
2. Afterbirth painsare more common in multiparas,breastfeeding mothers,clients treated with
oxytocin (Pitocin), and clients who had an overdistended uterus during pregnancy, such as with
carrying twins.
B. Perineal discomfort
1. Apply ice packs to the perineum during the first 24 hours to reduce swelling.
2. After the first 24 hours, apply warmth by sitz baths.
C. Episiotomy
1. Instruct the client to administer perineal care after each voiding.
2. Encourage the use of an analgesic spray as prescribed.
3. Administer analgesics as prescribed if comfort measures are unsuccessful.
D. Perineal lacerations
1. Care as for an episiotomy;administerperineal care anduse analgesicsprayand analgesicsfor
comfort.
2. Rectal suppositories and enemas may be contraindicated (to avoid injury to sutures).
E. Breast discomfort from engorgement
1. Encourage the client to wear a support bra at all times, even while she is sleeping.
2. Encourage the use of ice packs between feedings if the client is breast-feeding.
3. Encourage the use of warm soaks or a warm shower before feeding for the breast-feeding
mother.

11. 4. Administer analgesics as prescribed if comfort measures are unsuccessful.
F. Constipation
1. Encourage adequate intake of fluids (2000 mL/day).
2. Encourage diet high in fiber.
3. Encourage ambulation.
4. Administer stool softener, laxative, enema, or suppository if needed and prescribed.
G. Postpartum depression (Box 28-3).
1. Acknowledge the client’s feelings and demonstrate a caring attitude.
2. Determine availabilityof familysupportandothersupportsystemsand resources as needed.
3. Encourage and assist the client to verbalize her feelings.
4. Monitor newborn for appropriate growth and development expectations.
5. Assist the significant other and other appropriate family members to discuss feelings and
identify ways to assist the client.
Topic 2 : Nursing care of a woman and family during the first 24 hours after birth
Learning Targets: 1. Explainthe physiologic andpsychological changesthatoccurduringthe
postpartumperiod.
2. Describe effectivematernal self-care measurestobe implemented
duringthe puerperium.
3. Discussthe 3 phasesof puerperium.
References: Pilliteri,Adele(2010),Maternal and ChildHealthNursing:Care of the
ChildbearingandChildrearingFamily,6thedition.LippincotWilliamsandWilkins

12. Mckinney/James/Murray/Nelson/Ashwill (2013),Maternal-ChildNursing,4th
edition. Saunders,animprintof ElsevierInc.
Ward/Hisley/(2009),Maternal-ChildNursingCare:OptimizingOutcomesfor
Mother,Children,&Families, F.A.DavisCompany
Silvestri,LindaAnne (2011),SaundersComprehensive Review forthe NCLEX-RN!
Examination,Saunders,animprintof ElsevierInc.
Concept/Digest
NURSING CARE OF A WOMAN AND FAMILY DURING THE FIRST 24 HOURS AFTER BIRTH
 A womanremainsinabirthingroomforatleastthe firstencourageawomantoshower.She then
remainsin the room as a postpartal patientor is transferredto a separate postpartal room. The
most dangerous hour in childbearing—the first hour after birth—has passed.
 Hemorrhage is still a possibility for the first 2 or 3 days after birth, until the myometrial vessels
have sclerosed.
ASSESSMENT
Assessment of a postpartal woman includes history, physical examination, and analysis of laboratory
findings.
Health History
 The technical aspectsof a woman’spregnancy,labor,and birth can be learned fromher
pregnancy, labor, and birth charts.
Family Profile
 Information for a family profile includes age, support persons, other children,
type of housing and com- munity setting, occupation, education level, and
socioeconomic level or the informationnecessary to evaluate the impact a new
child will have on the woman and her family.
Pregnancy History
o Information for a pregnancy history includes para and gravida status (and the
reasonfor any discrepancy),expecteddate of birth,whetherthe pregnancywas
planned, and any problems or complications such as spotting or pregnancy-
induced hypertension that occurred.
Labor and Birth History
o It isimportantto gatherinformationonthe lengthof labor,positionof the fetus,
type of birth, any analgesia or anesthesia used, problems during labor such as
fetal distress, supine hypotension syndrome, and the presence of perineal
sutures.
Infant Data.
o The sex and weight of the infant, any difficulty at birth such as the need for
resuscitation,planstobreastfeedor formulafeed,andanycongenital anomalies
presentare the major facts to obtain.Thisinformationhelpsinplanningcare for
the infant and promoting bonding with the parents.
Postpartal Course.

13. o Ask about a woman’s general health; her activity level since the birth; a
description of lochia; the presence of perineal, abdominal, or breast pain;
difficulty with elimination; success with infant feeding; and response of her
support person to parenting.
Laboratory Data
 Womenroutinelyhave theirhemoglobinandhematocritlevelsmeasured12to 24 hours
after birth, to determine whether blood loss at birth has left them anemic.
 If the hemoglobin finding is lower than 10 g/100 mL, supplementary iron is usually
prescribed.
 Take note of the laboratory reports on a postpartal woman, and make certain that any
abnormal finding, such as low hemoglobin, is brought to the attention of the woman’s
physician or nurse-midwife.
Physical Assessment
 During early labor, a woman is given a fairly complete physical examination.During the
immediate postpartal period, therefore, repetition of a complete examination is not
necessary.
 Crucial assessments examining particular aspects of health, such as an estimation of
nutritionandfluidstate,energylevel,presence orabsence of pain,breasthealth,fundal
height and consistency, lochia amount and character, perineal integrity, and circulatory
adequacy, are required.
General Appearance.
 A woman’sgeneralappearanceinthepostpartal periodrevealsagreatdeal about
herenergylevel,herself-esteem,andwhethersheismovingintothe taking- hold
phase of recovery.
 Before beginning assessment, ask a woman to void so that she has an empty
bladder.
Hair
 Palpate the woman’s hair to determine its firmness and strength. Whenever a
diet is deficient in nutrients, hair becomes listless and “stringy.”
 A womanwhohad goodnutritional intake duringpregnancyhasfirm, crisp hair.
 Many women begin to lose a quantity of hair in the postpartal period. This is
because,duringpregnancy,metabolismwasincreasedandhairgrowthwasrapid,
so many hairs reachedmaturityat the same time.As the woman’sbody returns
to a normal metabolism level, this hair is lost.
Face
 Assess the woman’s face for evidence of edema such as puffy eyelids or a
prominent fold of tissue inferior to the lower eyelid.
 Normally, this is negligible. However, in a woman who had pregnancy-induced
hypertension and accumulated excessive fluid, it may be evident.
 It also will become evidentina womanwho isdevelopingpostpartal pregnancy-
induced hypertension, although this condition is rare. Facial edema is most
apparent early in the morning if a woman has been lying supine with her head
level during the night.
Eyes
 Inspect the color and texture of the inner conjunctiva.
 If a woman is dehydrated, the area appears dry.

14.  A woman who is anemic from poor pregnancy nutrition or excessive blood loss
at birth has pale conjunctiva.
 Checkthe hemoglobinlevel of anywomanwithpalerthanusual conjunctivaeto
determine whether anemia is present.
Breasts
 Breast tissue increases in size as breast milk forms, so a bra that was adequate
during pregnancy may no longer be adequate by the second or third postpartal
day.
 Use of a bra supports breast tissue that feels heavybecause of in- creased fluid
accumulation and aids comfort.
 Advise awomanto buya nursingbra forthe postpartal periodthatisone to two
sizes larger than her pregnancy size to allow for this increase.
 Properlyfitted,abra shouldfitfirmlyand snugly.The straps of a bra shouldnot
leave erythematic marks on a woman’s shoulders.
Uterus
 For uterine assessment, position the woman supine so that the height of the
uterus is not influenced by an elevated position.
 Observe herabdomenfor contour,to detect distention,andforthe appearance
of striae or a diastasis.
 Palpate the fundusof the uterusby placingone hand on the base of the uterus,
just above the symphysis pubis, and the other at the umbilicus.
 Pressin and downwardwiththe hand at the umbilicusuntil you“bump”against
a firm globular mass in the abdomen: the uterine fundus (Fig. 17.5). Assess
consistency (firm, soft, or boggy), location (midline), and height.
Lochia
 A woman can expect to have lochia for 2 to 6 weeks.
 Characteristics of normal lochia and the change in pattern from red to pink to
white.
Perineum
 While evaluating lochia, also inspect the perineum.
 Aska womantoturn on herside,intoa Sims’positionwithherbacktowardyou.
 If a midline episiotomy was performed, position the mother on either side.
 If a mediolateral incision is present, turning her so that the incision is on the
bottom buttock often causes less pain and offers better visibility.
 Gently lift the upper buttock and inspect the perineum.
 Observe forecchymosis,hematoma,erythema,edema,intactness,andpresence
of drainage or bleeding from any episiotomy stitches.
Exercises/Questions
1. Watch video on postpartum assessment:
https://www.youtube.com/watch?v=AfL9unQo2uE
2. Identify potential causes for increased blood pressure, pulse, and respirations during the
postpartum period?
3. Discussthe normal progressioninlochiafromthe firstpostpartumdayto 6 weeksafter delivery

15. 4. Joan Cooper,at 18 hourspostpartum, statesthat she has had to change her perineal padstwice
inthe last30 minutesbecause theywere satu- rated.She noticedtwolarge clotsonthe last pad.
What assessment should you first perform on her, and why?
Topic 3: Nursing care of a woman and family in preparation for discharge and after
discharge
Learning Targets: 1. Discuss the role of the nurse in health education, and identify
important areas of teaching.
2. Describe postpartum home care in terms of criteria for discharge,
common problems, and available health care services.
References: Pilliteri,Adele(2010),Maternal and ChildHealthNursing:Care of the
ChildbearingandChildrearingFamily, 6thedition.LippincotWilliamsandWilkins
Mckinney/James/Murray/Nelson/Ashwill (2013),Maternal-ChildNursing,4th
edition. Saunders,animprintof ElsevierInc.
Ward/Hisley/(2009),Maternal-ChildNursingCare:OptimizingOutcomesfor
Mother,Children,&Families, F.A.DavisCompany
Silvestri,Linda Anne (2011), Saunders Comprehensive Review for the NCLEX-RN!
Examination, Saunders, an imprint of Elsevier Inc.
Concept/Digest
 The greatestneedof apostpartal womanbeforedischargefromahealthcare agencyiseducation
to prepare herto care forherself andhernewbornat home . She must be aware of dangersigns
to look for and know whom to call if she notices any of them.
 Most women attend classes in newborn care during their pregnancies. They remember many
pointsfromthese classes,butwhentheyactuallyhave anewborntheycanbecome worriedthat
they do not remember enough. Many mothers say that child care did not seem real during
pregnancy.
Group classes

16.  Providinggroupclassesonbathinginfants,breastfeedingtechniques,minimizingjealousyinolder
children,andmaintaininghealthinthe newborncan be helpful tomothersand fathers,because
in these settings they can learn not only from the instructor but also from other parents.
 Brainstorming this way is helpful to women who envisionjealousyproblemswith older children
or who plan to return to a full-time job and also breastfeed (Abdulwadud & Snow, 2009).
 Urging fatherstoattendclassesishelpful, becausemanyfathersgive directchildcare forat least
part of every day
Individual Instruction
 Every family needs some individual instruction in how to care for their infant and how the
woman can care for herself after discharge.
 How to bathe and feed the baby, how to care for the infant’s cord and circumcision if the
infanthasthis,areviewof how muchinfantssleepduring24hours,andhow to fitanewborn
into the family’s pattern of living are topics
parents like to discuss.
Teachingdoesnot have to be formal.You can teachwithoutlecturingbymakinga comment
suchas,“Notice howlarge all newborns’headsseem”while youare showingthe parentshow
to bathe the baby,or “Babieslike tobe bundledfirmly”whileyouare helpingdressthe child,
or “Notice how uneven newborn respirations are.”
DISCHARGE PLANNING
 Before a postpartal family is discharged from the health care agency, a woman will be given
instructions by her physician or nurse-midwife concerning her care at home. These instructions
differamonghealthcare providersbuthave commonpoints that are summarized in Table 17.3.
 Before discharge, make sure a woman is aware that she must return for an examination 4 to 6
weeksafterbirth,and that she shouldmake an appointmenttotake her baby to a primary care
provider for an examination at 2 to 4 weeks of age.
 If a womandoesnothave anadequate rubellaantibodytiterandanticipatesfurtherpregnancies,
she may receive a rubella immunization before discharge.
Postpartal Discharge Instructions
Work
 All womenshouldavoidheavywork(liftingorstraining)foratleastthe first3weeksafter
birth.Womendifferintheirconceptof heavywork,soitisa goodideato explore whata
woman considers heavy work.
 If she plans to do too much, you can perhaps help her to modify her plans. It is usually
advised that a woman not return to an outside job for at least 3 weeks (or better, 6
weeks), not onlyfor her own health but also for enjoyment of the earlyweeks with her
newborn.
Rest
 A womanshouldplanatleastone restperiodeachdayandtrytogetagoodnight’ssleep.
 She can restduring the day whenhernewbornissleeping,unlessshe hasotherchildren
or an aged parent to care for.
 If she has othersdependentonher,explore the possibilityof havinganeighbor,another
family member, or a person from a community health agency relieve her.
Exercise
 A womanshouldlimitthe numberof stairsshe climbstoone flight/dayforthe firstweek
at home.

17.  Beginning the secondweek, if her lochial discharge is normal, she may start to increase
this activity.
 This limitationwill involve some planningonher part, especiallyif herwashingmachine
is inthe basementandshe must wash diaperseveryday,or if she mustgo up and down
stairs to check on her baby.
 It is probably better to arrange for a place for the baby to sleep downstairs as well as
upstairs, so the baby must be taken upstairs only at bedtime. She should continue with
muscle- strengthening exercises, such as abdominal crunches.
Hygiene
 A womanmay take eithertubbathsor showers.She shouldcontinuetoapplyanycream
orointmentasorderedforthe perineal areaandcleanseherperineumfromfronttoback.
 Anyperineal stitcheswillbe absorbedwithin10days.She shouldnotuse vaginaldouches
until she returns for her post-partal checkup.
Coitus
 Coitus is safe as soon as a woman’s lochia has turned to alba and, if present, the
episiotomyishealed(usuallyaboutthe firstweekafterbirth).Vaginalcellsmaynotbe as
thick as formerly because prepregnancy hormone balance has not yet completely
returned.
 Use of a contraceptive foam or lubricating jelly will aid comfort. Be certain she knows
safer sex precautions.
Contraception
 If desired,awomanshouldbeginacontraceptionmeasurewiththe initiationof coitus.If
she wishes an IUD, this may be fitted immediately after birth or at her first postpartal
checkup.
 Oral contraceptivesare begunabout2–3weeksafterbirth.A diaphragmmustbe refitted
at a 6-weekcheckup.Until she returnsforthischeckup,an over-the-counterspermicidal
jelly and condoms can provide protection.
Follow-up
 A woman should notify her physician or nurse-midwife if she notices an increase, not a
decrease, in lochial discharge, or if lochia serosa or lochia alba becomes lochia rubra.
 Delayed postpartal hemorrhage can occur in women who become extremely fatigued.
Getting adequate rest during her first weeks at home will do much to prevent the
possibility of this complication.
 Fourto 6 weeksafterbirth,awomanshouldreturntoherphysicianornurse-midwife for
an examination.
 This visit is important to ensure that involution is complete, immunization against the
virusassociatedwithcervicalcancer(HPV),andreproductivelife planning(if desired)can
be discussed
NURSING CARE OF A WOMAN AND FAMILY AFTER DISCHARGE
Postpartal Home Visits
 In today’s health care climate of cost containment, most women are discharged from a health
care facility 2 to 3 days after childbirth.
 Sucha practice hasthe advantage of allowingthe familyunittobe interruptedaslittle aspossible.
 A new mother may rest better at home than in a strange setting, and she may eat better if she
has cultural preferences for specific foods.

18.  The infant can be more quickly exposed to family routines rather than a superficial facility
schedule.However,earlydischargehasthe disadvantageof notallowinganew familytohave the
readysupport of healthcare personnel if theyhave questionsabouttheirnewbornoraboutthe
woman’s condition.
 Because womenneedtopreservetheirenergyduringthepostpartalperiod,trytoarrange ahome
visit at the woman’s convenience.
 Important assessments to make at a postpartal home visit include:
o Pregnancy History
o Postpartal Course
o Future Plans
o Family Assessment
o Physical Examination of the Mother
o Physical Examination of the Infant
o Follow-up Information
Postpartal Examination
 Every newborn should have a health maintenance visit 2 to 4 weeks after birth. Every woman
shouldhave a checkupby her physicianor nurse-midwife at4 to 6 weeksafterbirth(the endof
the postpartal period),to assure herself and her health care provider that she is in good health
and has no residual problems from childbearing.
 During this examination, the woman’s abdominal wall is inspected for tone. Her breasts are
inspectedtoseewhethertheyhavereturnedtotheirnonpregnantstateifshe isnotbreastfeeding
or to see that they are unfissured and free of complications if she is breastfeeding.
 Most important, a thorough internal examination is performed to be certain that involutionis
complete, the ligaments and the pelvic muscle supports have returned to good functional
alignment, and any lacerations sustained during birth have healed (Table 17.4).

19. Exercises/Questions
1. Outline postpartal teaching guidelines that include information about self-assessment of the
fundus, lochia, hygiene, incisional site, body temperature, and elimination?
2. Demonstrate appropriate exercises for the postpartal patient?
3. Identify at least six symptoms indicative of poor emotional adjustment that, if present for more
than 2 weeks, should be reported to the healthcare provider?