POSTPARTUM

NURSING CARE

Diana Barrios RN, MSN

Merritt College ADN Program
Nursing 3A: Perinatal Nursing

EXPECTED OUTCOMES DURING

THE POSTPARTAL PERIOD

The woman will:

Undergo a normal involution process with normal
lochia discharge

Remain comfortable and injury free

Demonstrate normal bladder and bowel function

Demonstrate knowledge of breast care

Demonstrate knowledge of infant safety, infant
care activities, and infant feeding

Integrate the newborn into the family

POSTPARTUM ASSESSMENTS

Initial general assessment

Body systems assessment

Assessment specific to postpartum
changes

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 GENERAL ASSESSMENT

Enter the room quietly, speak quietly. Wash

hands and provide for privacy. Inform patient
before turning on lights.

Note LOC, activity level, position, color,
general demeanor.

Take note of the total environment:

Safety/patient considerations

Note equipment and medical devices

BODY SYSTEMS ASSESSMENT

Vital signs
Musculoskeletal

Level of pain
Gastrointestinal

Neurological
Genitourinary

Pulmonary
Integumentary

Cardiovascular
Psychosocial

ALTA BATES’ MATERNAL FLOWSHEET

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 ASSESSMENT SPECIFIC TO
POSTPARTUM ADAPTATION

Vital signs (q 4-8 hrs)

Breasts/breastfeeding

Uterus

Lochia/perineum

Bladder & bowel function

Edema, Homan’s sign

Bonding & attachment process

Teaching/learning/referral needs assessment

VITAL SIGNS

SBP 90-140, DBP 50-90 (compare to
baseline values)

Pulse 60-100 bpm

RR 10-24 breaths/min

ASSESSMENT OF
BREASTS & BREASTFEEDING

Breasts soft & non-tender;

nipples everted

Begin by asking how
feedings are going.

Ask if patient feels lumps
in breasts, or has
redness, soreness, or
blisters on nipples.

Observe for signs that
might indicate incorrect
latch

LATCH score

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 THE POSTPARTUM DECISION

NURSING DIAGNOSES RELATED

TO BREASTS & BREASTFEEDING

Pain r/t improper positioning, engorged

breasts

Ineffective breastfeeding r/t maternal
discomfort, improper infant positioning

Knowledge deficit r/t normal physiologic
changes, breastfeeding

Infection r/t improper breastfeeding
techniques, improper breast care

ASSESSMENT OF THE
UTERUS

Uterus midline, FF @ U/U or below following the first
12-24 hrs after birth

Rising uterus, displaced to side  full bladder?

Boggy uterus  subinvolution?

Lochia: scant-moderate, rubra-serosa

Perineal lacerations/episiotomy – well-
approximated, no signs of infection

C/S dressing: CDI, REEDA

Patient should be educated about normal and
abnormal changes, what to report, and when to ask
for help.

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 PAD COUNT: LOCHIA

Scant: 1-inch stain on pad in 1 hour

Light/small: 4 inches in 1 hour

Moderate: 6 inches in 1 hour

Heavy/large: Pad saturated in 1 hour

Excessive: Pad saturated in 15 min

Can estimate blood loss by weighing

pads

500 mL = 1 lb. or 454 g

LOCHIA AMOUNTS

ASSESSMENT OF BOWEL &

BLADDER FUNCTION

Void without difficulty/pain, urine may be blood-
tinged from lochia

Possible diagnosis: Urinary retention or constipation
r/t post childbirth discomfort or tissue trauma

Expected outcome: Return to normal bowel and
bladder habits, void at least 240mL in 8 hrs, bowel
movement in 3 days without pain.

Nursing interventions: Assist to the bathroom. Use
measures to encourage voiding (privacy). Measure
1st 2 voids after SVD or Foley catheter removed.
Encourage use of peribottle with warm water, fluids,
fiber, frequent ambulation, stool softeners; teach
effects of pain medication.

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 ASSESSMENT OF EDEMA &
HOMAN’S SIGN

Assess legs for presence and degree of
edema; may have dependent edema in feet
and legs (facial and hand edema may
indicate preeclampsia)

Assess for Homan’s sign (thromboembolism);
should be negative

Obtain lab values: 8-hr post-delivery
hemogram, urinalysis/C&S, blood type/Rh
status

CHECKING HOMAN’S SIGN

SUMMARY OF POSTPARTUM
ASSESSMENT & CARE

Box 16-1, page 468: Postpartum
Assessment

Care Path: 24-Hour Vaginal Birth without
Complications, page 470-471

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