WOMEN’S AND INFANT HEALTH

POLICY AND PROCEDURE

SUBJECT/TITLE: NUMBER PAGE

ADMISSION/CARE OF POSTPARTUM WOMEN FOLLOWING 3-A-3 1 of 4

VAGINAL BIRTH
ADDITIONAL REFERENCE NAMES DATE ESTABLISHED DATE ESTABLISHED

AUTHORIZATION: DATE ESTABLISHED DATE REVISED

POPA: Postpartum Nurse Managers and Instructors (March 8, 2005) REGIONALLY REGIONALLY

L&D Nurse Managers and Instructors (May 21, 2004) April 1, 1999 May 27, 2005
Women’s and Infant Health Managers (May 10, 2005)

PURPOSE

1. To provide evidence based guidelines for safe care including standards for frequency of bio-
psycho-social assessments, nursing interventions and documentation.

2. To promote family centered care.

APPLICABILITY

This policy applies to Calgary Health Region nursing staff caring for postpartum women and their families.

POLICY

1. Transfer of Care
1.1 Nursing staff, from the receiving unit, are to receive a patient report given by a nursing
staff member from the sending unit.

1.2 Nurse-to-nurse report is to include all relevant information related to antepartum and
intrapartum events, as well as a review of outstanding intrapartum and postpartum
orders.

1.3 All relevant documentation is to be completed prior to transfer of care (including the
discontinuation or completion of all physician/midwifery orders that are no longer relevant
to care, according to patient care information system {PCIS} protocols).

2. Postpartum Nursing Care

2.1 Postpartum nursing care encompasses family-centered care, and is to include assessment,
intervention, evaluation and appropriate revisions to plans for care.

2.2 Documentation on health records is to accurately reflect all aspects of this care.

2.2 Maternal assessments are to be made and documented on the patient health record
accordingly:
ƒ At admission, and
ƒ At least once during the following six (6) hours, then
ƒ Q12h and PRN, as determined by nursing judgment, until discharge.
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WOMEN’S AND INFANT HEALTH
POLICY AND PROCEDURE
SUBJECT/TITLE: DATE DATE REVISED: NUMBER: PAGE:
ESTABLISHED:

ADMISSION/CARE OF POSTPARTUM WOMEN April 1, 1999 May 27, 3-A-3 2 of 4

FOLLOWING VAGINAL BIRTH 2005

3. Infant Nutrition
3.1 Nursing staff are to support the mother’s choice of infant feeding (breast milk or formula).

3.2 Parents are to be provided with relevant, unbiased information about infant nutrition in
order to make informed decisions.

POINTS OF EMPHASIS

1. Mother-Infant Separation
1.1 Every effort must be made to limit separation of mother and infant.
1.2 Encourage skin-to-skin contact.

2. Breastfeeding
Breastfeeding is the recommended method of feeding for newborn infants; new parents require
information (through the use of appropriate current resources, including From Here Through
Maternity), support and encouragement in order to learn and understand:
• Benefits of breastfeeding
• Recognition of feeding cues
• Identification of proper latching and how to correct an improper latch
• Assessment of effective milk transfer by infant:
- Sucking
- Swallowing
- Output (urine and stool)
- Behaviour
• Breast care

3. Formula Feeding
3.1 Parents choosing to formula feed their infants require information and support in order
to learn the principles of effective, safe formula feeding; provide teaching and
encourage the use of appropriate current resources, including From Here Through
Maternity.

3.2 Women choosing to formula feed their infants require information on breast care.

PROCEDURE

1. Prepare patient room for admission.

2. Greet transferred family, assist mother into bed as necessary and orientate family to room/call
bells.

3. Verify and document mother and infant ID bands; refer to policy 4-I-1 Identification of the
Newborn.

4. Ensure mother understands importance of calling for assistance when getting out of bed for
the first time.
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POLICY AND PROCEDURE
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ADMISSION/CARE OF POSTPARTUM WOMEN April 1, 1999 May 27, 3-A-3 3 of 4

FOLLOWING VAGINAL BIRTH 2005

5. Receive report from sending unit.

6. Conduct assessments according to policy item 2.2 and include:

• Comfort: pain management, rest
• Vital signs: temperature, pulse, respirations and blood pressure
• Hydration: IV infusion (solution, flow rate, volume to be absorbed, additives,
condition of insertion site); swelling; dry lips
• Breasts/nipples: physical features; relevant history e.g. surgery
• Fundus/involution: height, tone and position.
• Bladder: palpable; voids; urinary drainage (color and amount) if catheter in situ; refer
to policy 4-B-2 Bladder Care/Fluid Balance: Antepartum and Postpartum.
• Blood loss: estimated volume
• Lochia: color, odor, amount, clots (examine to determine if tissue present)
• Perineum/vulva: episiotomy, tears, sutures, hemorrhoids
• Bowel function: bowel movement/constipation
• Nourishment
• Mobility: ambulation
• Epidural site: if relevant
• Lower extremities: changes in colour, temperature, swelling, pain
• Infant feeding: effectiveness, mother’s/parent’s preferences
• Parents’ emotional status: participation in self-care activities; responses
to/interactions with infant
• Parents’ educational needs

7. Identify mothers requiring further evaluation/intervention on a case-by-case basis, using nursing

judgment and expertise, often in collaboration with nursing colleagues; consult and/or notify the
charge nurse (or designate) and physician, depending on assessment findings; refer to policy 3-C-
4 Complications in a Postpartum Woman’s Condition Requiring Medical Evaluation: Contacting
a Physician or Registered Midwife.
8. Review and implement postpartum orders.

9. Address family learning needs based on the maternal bio-psycho-social assessment findings,
past experience with infant care, educational level and available family and community
support.

10. If necessary, initiate Social Work or other referrals, preferably with maternal consent; refer to
policy 4-S-1 Social Work Referral.

11. Instruct mother about peri-care and self-care activities.

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POLICY AND PROCEDURE
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ESTABLISHED:

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FOLLOWING VAGINAL BIRTH 2005

12. Document all assessments and interventions/responses and plans for subsequent care using
appropriate health record forms and/or the PCIS, e.g., multidisciplinary progress record, flow
sheets, graphic sheets and discharge teaching record; refer to Calgary Health Region policy
1611: Clinical Responsibility for Documentation of Health Information.

REFERENCES
1. American Academy of (2005) Position Paper on Breastfeeding and the Use of Human Milk.
2. AWHONN (1996). Compendium of Postpartum Care.
3. AWHONN (2002). AWHONN Standards For Perinatal Nursing Practice.
4. Green, CJ, & Wilkinson, JM. (2003). Maternal Newborn Nursing Care Plans, Mosby.
5. Lowdermilk, DL. Perry, SE. (2003). Maternity Nursing 6th Edition. Mosby.
6. Pillitteri. A. (2002). Maternal & child health nursing 4th Edition. Lippincott.
7. Simpson, K. R., & Creehan, P. A. (Eds.). (1996). AWHONN Perinatal Nursing. Philadelphia PA: Lippincott.

CROSS REFERENCES

Subject Number Manual

• Adoptions 4-A-2 Women’s & Infant Health
• Bladder Care/Fluid Balance: AP & PP 3-B-3 Women’s & Infant Health
• Breastfeeding-Supplementation 3-B-1 Women’s & Infant Health
• Breastfeeding Support 3-B-2 Women’s & Infant Health
• Breastmilk: Safe Handling, Prevention and Follow-up of Incidents 3-C-5 Women’s & Infant Health
• Clinical Responsibility for Documentation of Health Information 1611 CHR Policy Manual
• Complications in a Postpartum Woman’s Condition Requiring Medical 3-C-4 Women’s & Infant Health
Evaluation
• Discharge: Postpartum Mother and Newborn 4-D-2 Women’s & Infant Health
• Forms: 00285R Relizon; on units
- Post Spinal/Epidural (Singe Dose Narcotic) 00259R Relizon; on units
- Patient Controlled Analgesia PHYSICIAN’S ORDER SHEET 00094R Relizon; on units
- Pain Flow Sheet
• From Here Through Maternity On units
• Identification of the Newborn 4-I-1 Women’s & Infant Health
• Newborn Admission & Physician Notification of Birth 4-A-1 Women’s & Infant Health
• Social Work Referrals 4-S-2 Women’s & Infant Health IP
• Standard Practice Guidelines & C Manual
• Venous Thromboembolism (VTE): Prevention and Treatment 3-V-3 Women’s & Infant Health