[OB Exam 1 2/4] MAIN CONTENT

Chapter 4: Prenatal Care

QEBP

• Prenatal care dramatically reduces infant and maternal morbidity and mortality rates by early detection and treatment of potential problems. A majority of birth defects occur between 2 and 8 weeks of gestation.

QS

• Client History Assessment for Prenatal Care includes Any hazardous environmental exposures; current work conditions.

QPCC

• Birth Plan: A nurse ascertains what a client’s goals are for the birthing process. The nurse should discuss birthing methods, such as Lamaze, and pain control options (epidural, natural childbirth). 

• Preconception and prenatal education emphasizes healthy behaviors that promote the health of the pregnant client and their fetus.

• The nurse anticipates reviewing prenatal education topics with a client based on their current knowledge and previous pregnancy and birth experiences. The client’s readiness to learn is enhanced when the nurse provides teaching during the appropriate trimester based on learning needs. Using a variety of educational methods (pamphlets, videos) and having the client verbalize and demonstrate learned topics will ensure that learning has taken place

QTC

• Assist the provider with the gynecological examination. This examination is performed to determine the status of a client’s reproductive organs and birth canal. Pelvic measurements determine whether the pelvis will allow for the passage of the fetus at delivery. 

Client History (Initial Assessment)

• Reproductive & Obstetrical History – Contraceptive use, STIs, gynecological conditions, previous pregnancies.

• Medical History – Chronic illnesses, surgeries, immune status (rubella, hepatitis B).

• Nutritional History – Identifies deficiencies or dietary risks affecting fetal growth.

• Family History – Genetic conditions or hereditary risks.

• Recent or Current Infections – Any illnesses that may impact pregnancy.

• Current Medications & Substance Use – Includes alcohol, tobacco, and illicit drugs.

• Psychosocial History – Emotional well-being, support system, history of depression, domestic violence.

• Environmental & Occupational Exposures – Workplace risks, chemical exposures.

• Exercise & Lifestyle – Impact on pregnancy health.

• Abuse History or Risk Factors – Screen for physical, sexual, or emotional abuse.

Birth Plan Discussion

• Patient’s goals for labor & delivery (e.g., natural birth, epidural).

• Childbirth education & pain management options (Lamaze, breathing techniques).

Lamaze

A childbirth technique that helps pregnant women prepare for labor and delivery. It is also known as the psychoprophylactic method.

Prenatal Assessments

First Visit (Initial Prenatal Visit, within 12 weeks)

• Determine EDD (estimated due date) using Naegele’s Rule.

• Obtain vital signs, baseline weight, pelvic exam.

• Order lab work: Hemoglobin, hematocrit, blood type & Rh, rubella titer, urinalysis, STI screening, HIV, Hepatitis B, Pap smear, toxoplasmosis, RPR/VDRL (syphilis).

Ongoing Prenatal Visits (Follow Schedule)

• 16-28 weeks: Every 4 weeks.

• 28-36 weeks: Every 2 weeks.

• 36 weeks to birth: Every week.

Ongoing Prenatal Visits (Follow Schedule)

16-28 weeks: Every 4 weeks.

28-36 weeks: Every 2 weeks.

36 weeks to birth: Every week.

Ongoing Care & Assessments

Monitor Weight, BP, Urine for Protein/Glucose (Gestational HTN & Diabetes screening).

Assess for Edema & Fetal Development

• FHR (fetal heart rate) heard by Doppler at 12 weeks.

• Fundal Height Measurement – Between 18-30 weeks, fundal height in cm = gestational age.

• Fetal Movement felt by 16-20 weeks.

Patient Education

• Common discomforts: Nausea, back pain, heartburn.

• Danger signs: Severe headache, vision changes, decreased fetal movement.

Nursing Interventions

Perform Leopold Maneuvers

• To assess fetal presentation & position.

Assist with Pelvic Exam

• Ensures pelvis is adequate for delivery.

Administer Rhogam (RhO(D) Immune Globulin)

• Given at 28 weeks if Rh-negative to prevent Rh incompatibility.

When must Rh- mothers receive Rhogam to prevent complications?

28 weeks

Fundal Height Measurement

Measurement correlates with gestation weeks (+-2)

• ONLY ACCURARE 18/20 - 31/32 weeks

Blood Tests

Blood Type & Rh Factor: Screens for Rh incompatibility

• Rh-negative mothers need Rhogam at 28 weeks.

CBC (Complete Blood Count): Detects infection and anemia.

Hgb Electrophoresis: Identifies sickle cell anemia & thalassemia.

Rubella Titer – Checks immunity to rubella

• Live vaccine cannot be given during pregnancy

Hepatitis B Screen – Identifies carriers of hepatitis B.

Infection Screening

Group B Streptococcus (GBS) – Vaginal/rectal culture at 36-37 weeks

• Antibiotics needed in labor if positive.

Pap Smear (Pap test) – Screens for cervical cancer, HPV, herpes simplex type 2.

Vaginal/Cervical Culture – Screens for STIs (gonorrhea, chlamydia, bacterial vaginosis, beta-hemolytic strep).

PPD (Tuberculosis Test) – Chest x-ray required after 20 weeks if positive.

VDRL/RPR – Syphilis screening (mandated by law).

HIV Screening – Offered at first visit (can be refused but recommended).

TORCH Screening (Toxoplasmosis, Rubella, CMV, Herpes) – Done if indicated (history of exposure).

Urinalysis & Glucose Screening

Urinalysis with Microscopy – Detects protein (preeclampsia), glucose (diabetes), ketones, infection.

hCG (Human Chorionic Gonadotropin) – Confirms pregnancy.

1-Hour Glucose Tolerance Test (24-28 weeks; no fasting) – If >140 mg/dL, follow-up needed.

3-Hour Glucose Tolerance Test (Fasting) – Confirms gestational diabetes if 1-hour test is abnormal.

Hemoglobin A1C – Used for pre-existing diabetes diagnosis (Normal: <5.9%).

Genetic & Fetal Abnormality Screening

Maternal Serum Alpha-Fetoprotein (MSAFP) (15-22 weeks)

• Low levels → Possible Down syndrome.

• High levels → Possible Neural tube defects (Spina bifida, anencephaly).

• Quad Screen (AFP + hCG + Estriol + Inhibin A) may be used for better accuracy.

What is the relation tp protein in urine to hypertension/preeclampsia

Hypertension damages kidney function, leading to protein leakage into urine.
Proteinuria + high BP = possible preeclampsia → requires close monitoring.
Severe preeclampsia needs urgent intervention to prevent complications (eclampsia, HELLP syndrome, stroke).

Initial Prenatal Visit (First Trimester: Up to 12 Weeks)

Blood Type & Rh Factor – Determines Rh incompatibility (Rh-negative moms need Rhogam at 28 weeks).

CBC (Complete Blood Count) – Screens for infection and anemia.

Hgb Electrophoresis – Detects sickle cell anemia & thalassemia.

Rubella Titer – Checks immunity to rubella (live vaccine not given in pregnancy).

Hepatitis B Screen – Identifies carriers of hepatitis B.

HIV Screening – Recommended but can be refused.

VDRL/RPR – Syphilis screening (mandated by law).

Pap Smear (if needed) – Screens for cervical cancer, HPV, herpes simplex type 2.

Urinalysis with Microscopy – Detects protein (preeclampsia), glucose (diabetes), ketones, infection.

hCG (Human Chorionic Gonadotropin) – Confirms pregnancy.

TORCH Screening (Toxoplasmosis, Rubella, CMV, Herpes) – Done if indicated (e.g., history of exposure).

15-22 Weeks (Second Trimester)

Maternal Serum Alpha-Fetoprotein (MSAFP) OR Quad Screen

• Low AFP → Possible Down syndrome.

• High AFP → Possible Neural tube defects (Spina bifida, anencephaly).

• Quad Screen (AFP + hCG + Estriol + Inhibin A) may be used for better accuracy.

24-28 Weeks

1-Hour Glucose Tolerance Test – No fasting required.

• >140 mg/dL requires a follow-up 3-hour glucose test.

3-Hour Glucose Tolerance Test (If 1-hour test is abnormal) – Confirms gestational diabetes.

Hemoglobin A1C (if indicated) – Screens for pre-existing diabetes (Normal: <5.9%).

Indirect Coombs Test (if Rh-negative) – Checks if antibodies have developed; if negative, Rhogam is given at 28 weeks.

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28 weeks

Rhogam Injection (If Rh-negative & Indirect Coombs Test was negative) – Prevents Rh sensitization.

36-37 Weeks

Group B Streptococcus (GBS) Culture – Vaginal/rectal swab to detect GBS.

• If positive → IV antibiotics during labor to prevent neonatal infection.

40+ Weeks (Post-Dates Monitoring)

Non-Stress Test (NST) – Monitors fetal heart rate and movement.

Biophysical Profile (BPP) – Assesses fetal well-being (NST + ultrasound measurements).

Client Education

Health Promotion

• Avoid unnecessary medications, supplements, alcohol, tobacco, and illicit substances.

• Engage in 30 minutes of moderate exercise daily (walking/swimming) if no contraindications exist.

• Avoid hot tubs and saunas due to the risk of overheating and neural tube defects.

• Consume at least 8-10 glasses (2.3 L) of water daily.

Recommended Vaccinations

• Influenza vaccine is recommended during pregnancy.

• Tdap (Whooping cough) should be given between 27-35 weeks; family members should also receive it.

• COVID-19 vaccine should be given according to CDC guidelines.

Risk Reduction

• Encourage smoking cessation.

• Treat existing infections to prevent complications.

• Provide genetic testing and counseling if indicated.

• Educate on the risks of exposure to hazardous materials.

Preparation for Pregnancy and Birth

Nursing Education Topics

• Explain physical and emotional changes during pregnancy and interventions for relief.

• Identify warning signs and complications that should be reported.

• Discuss available birthing options and pain management choices.

Maternal Psychological Adaptation

• Emotional lability, including mood swings, irritability, and tearfulness, is common due to hormonal changes.

• Ambivalence about pregnancy is a normal response, often occurring early in pregnancy and resolving before the third trimester. This includes conflicting emotions such as joy, anxiety, and uncertainty.

Teaching Strategies

• Use multiple education methods, including pamphlets, videos, and verbal discussions.

• Assess the client’s readiness for learning based on their trimester and previous experiences.

• Encourage the client to verbalize and demonstrate understanding to ensure knowledge retention.

First Trimester (Weeks 1-12) Key Topics

1. Physical and emotional changes

2. Common pregnancy discomforts and relief strategies

3. Healthy lifestyle habits (exercise, nutrition, stress management, safe sexual practices)

4. Avoidance of harmful substances (alcohol, tobacco, drugs, unsafe medications)

5. Warning signs of complications (preterm labor symptoms)

6. Early fetal growth and development

7. Importance of prenatal exercise

8. Routine laboratory testing

Second Trimester (Weeks 13-27) Key Topics

1. Benefits of breastfeeding

2. Managing pregnancy discomforts

3. Healthy lifestyle habits (posture, body mechanics, clothing, seat belt safety, travel)

4. Recognizing fetal movement

5. Possible complications (preterm labor, gestational diabetes, hypertension, prelabor rupture of membranes)

6. Childbirth preparation & education classes

7. Exploring birthing methods

8. Birth plan development (verbal or written preferences for labor & delivery)

Third Trimester (Weeks 28-40+) Key Topics

Childbirth preparation

• Childbirth classes & birth planning

• Coping strategies (breathing, relaxation, counterpressure, effleurage, water therapy, TENS, acupuncture)

• Use of heat/cold, massage, aromatherapy

• Pain management discussion (natural childbirth vs. epidural)

• Role of a doula for labor support

• Signs of preterm labor & active labor

• Labor process & postpartum care

Fetal Movement & Kick Counts

• Count fetal kicks daily to monitor well-being

• Less than 3 movements per hour or no movement for 12 hours requires evaluation

Diagnostic Testing for Fetal Well-Being

• Non-Stress Test (NST)

• Biophysical Profile (BPP)

• Ultrasound

• Contraction Stress Test

How many kicks per hour requires evaluation?

Less than 3 or none in 12 hours

Diagnostic Testing for Fetal Well-Being

• Non-Stress Test (NST)

• Biophysical Profile (BPP)

• Ultrasound

• Contraction Stress Test

Prenatal Education by Trimester

First Trimester (Weeks 1-12)

Key Topics:

• Physical and emotional changes

• Common pregnancy discomforts and relief strategies

• Healthy lifestyle habits (exercise, nutrition, stress management, safe sexual practices)

• Avoidance of harmful substances (alcohol, tobacco, drugs, unsafe medications)

• Warning signs of complications (preterm labor symptoms)

• Early fetal growth and development

• Importance of prenatal exercise

• Routine laboratory testing

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Second Trimester (Weeks 13-27)

Key Topics:

• Benefits of breastfeeding

• Managing pregnancy discomforts

• Healthy lifestyle habits (posture, body mechanics, clothing, seat belt safety, travel)

• Recognizing fetal movement

• Possible complications (preterm labor, gestational diabetes, hypertension, prelabor rupture of membranes)

• Childbirth preparation & education classes

• Exploring birthing methods

• Birth plan development (verbal or written preferences for labor & delivery)

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Third Trimester (Weeks 28-40+)

Key Topics:

• Childbirth preparation

  • Childbirth classes & birth planning

  • Coping strategies (breathing, relaxation, counterpressure, effleurage, water therapy, TENS, acupuncture)

  • Use of heat/cold, massage, aromatherapy

  • Pain management discussion (natural childbirth vs. epidural)

  • Role of a doula for labor support

  • Signs of preterm labor & active labor

  • Labor process & postpartum care

• Fetal Movement & Kick Counts

  • Count fetal kicks daily to monitor well-being

  • Less than 3 movements per hour or no movement for 12 hours requires evaluation

• Diagnostic Testing for Fetal Well-Being

  • Non-Stress Test (NST)

  • Biophysical Profile (BPP)

  • Ultrasound

  • Contraction Stress Test

Common Discomforts of Pregnancy and Nursing Interventions (First Trimester)

Nausea and Vomiting

• Eat dry crackers or toast before getting out of bed.

• Avoid an empty stomach, spicy, greasy, or gas-forming foods.

• Encourage frequent fluid intake between meals.

Breast Tenderness

• Wear a well-supportive bra for comfort.

Urinary Frequency

• Empty the bladder frequently.

• Reduce fluid intake before bedtime.

• Perform Kegel exercises to strengthen pelvic muscles.

Fatigue

• Encourage frequent rest periods.

Common Discomforts of Pregnancy and Nursing Interventions (Second and Third Trimester)

Urinary Tract Infections (UTIs)

• Wipe front to back after urinating.

• Avoid bubble baths and tight-fitting clothing.

• Wear cotton underwear.

• Drink plenty of water (at least 8 glasses/day).

• Urinate before and after intercourse.

• Urinate as soon as the urge occurs to prevent bacterial growth.

• Notify the provider if urine is foul-smelling, contains blood, or appears cloudy.

Fatigue

• Encourage frequent rest periods.

Heartburn

• Eat small, frequent meals and avoid an empty stomach.

• Avoid spicy or greasy foods.

• Sit upright for at least 30 minutes after eating.

• Check with the provider before taking antacids.

Constipation

• Drink plenty of fluids.

• Eat a high-fiber diet.

• Exercise regularly.

Hemorrhoids

• Use warm sitz baths.

• Apply witch hazel pads and topical ointments.

Backaches

• Exercise regularly and perform pelvic tilts.

• Use proper body mechanics (lift with the legs instead of the back).

• Use side-lying positions.

Shortness of Breath & Dyspnea

• Maintain good posture and sleep with extra pillows.

• Contact the provider if symptoms worsen.

Leg Cramps

• Extend the affected leg, keeping the knee straight.

• Dorsiflex the foot (toes toward the head).

• Apply heat or massage to the muscle while the leg is extended.

• Notify the provider if cramping persists.

Varicose Veins & Lower-Extremity Edema

• Rest with legs and hips elevated.

• Avoid constricting clothing.

• Wear support hose.

• Avoid prolonged sitting or standing.

• Do not cross legs at the knees.

• Exercise moderately to stimulate venous return.

Gingivitis, Nasal Stuffiness, & Epistaxis (Nosebleeds)

• Brush teeth gently and maintain good oral hygiene.

• Use a humidifier.

• Use saline nose drops or spray if needed.

Braxton Hicks Contractions

• Change positions and walk to see if contractions decrease.

• If contractions become regular and increase in intensity, notify the provider.

Supine Hypotension

• Avoid lying on the back, as the gravid uterus compresses the vena cava.

• Encourage side-lying or semi-sitting positions.

Danger Signs During Pregnancy (First Trimester)

Infection Signs: Burning on urination, diarrhea, fever, or chills

Severe Vomiting: Could indicate hyperemesis gravidarum

Abdominal Cramping and/or Vaginal Bleeding: Could indicate miscarriage or ectopic pregnancy

Danger Signs During Pregnancy (Second and Third Trimester)

Signs of Preterm Labor & Fetal Distress:

• Gush of fluid from the vagina: Possible rupture of membranes before 37 weeks

• Vaginal bleeding: Possible placental problems (placenta previa or placental abruption)

• Abdominal pain: Could indicate preterm labor, placental abruption, or ectopic pregnancy

• Decreased fetal movement: Possible fetal distress

Signs of Gestational Hypertension & Preeclampsia:

• Severe headaches

• Blurred vision

• Edema of face and hands

• Epigastric pain

Signs of Infection & Other Medical Conditions:

• Persistent vomiting (hyperemesis gravidarum)

• Elevated temperature

• Painful urination (dysuria) (possible urinary tract infection)

Signs of Blood Sugar Imbalance:

• Hyperglycemia: Flushed dry skin, fruity breath, rapid breathing, increased thirst, frequent urination, headache

• Hypoglycemia: Clammy pale skin, weakness, tremors, irritability, dizziness

Chapter 17: Postpartum Physiological Adaptations

It is important to provide comfort measures for the client during the fourth stage of labor.

• This recovery period starts with delivery of the placenta and includes at least the first 2 hr after birth.

• Also during this stage, parent-newborn bonding should begin to occur.

The main goal during the immediate postpartum period is to prevent postpartum hemorrhage.

• Other goals include assisting in a client’s recovery, identifying deviations in the expected recovery process, providing comfort measures and pharmacological pain relief, providing client education about newborn and self-care, and providing baby-friendly activities to promote infant/family bonding.

QEBP

• Determine whether the fundus is firm or boggy. If the fundus is boggy (not firm), lightly massage the fundus in a circular motion.

• Enemas and suppositories are contraindicated for clients who have third- or fourth-degree perineal lacerations. Q

Postpartum Key Physiological Changes & Risks

Uterine & Cervical Involution

• The uterus contracts and shrinks back to its pre-pregnancy size.

• The cervix gradually returns to a closed position.

Lochia Flow (Vaginal Discharge)

• A mix of blood, mucus, and uterine tissue expelled after birth.

Vaginal & Ovarian Function Changes

• Decrease in vaginal distention.

• Return of ovulation and menstruation depends on lactation status.

Cardiovascular, Urinary, Breast & GI Changes

• Adaptations in fluid balance, blood volume, and hormone levels.

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1. Hemorrhage (due to uterine atony or retained placenta).

2. Shock (caused by excessive bleeding).

3. Infection (such as endometritis, UTIs, or mastitis).

Postpartum period (Puerperium)

Involves both physiological and psychological adjustments.

Time: Between birth and the return of the reproductive system to its nonpregnant state

• Traditionally lasts 6 weeks

Postpartum Hormonal Adjustments

After placental delivery, estrogen, progesterone, and placental enzyme insulinase drop, leading to:

• Lower blood glucose levels (reversal of pregnancy-induced diabetes effects).

• Breast engorgement and increased sweating (diaphoresis) & urination (diuresis) to eliminate excess fluid.

• Reduced vaginal lubrication → may cause intercourse discomfort.

• Higher muscle tone due to decreased progesterone.

• hCG disappears quickly but can be detected for up to 4 weeks postpartum.

Oxytocin's Role Postpartum

Released from the pituitary gland to strengthen uterine contractions.

Breastfeeding stimulates oxytocin, which aids in uterine contraction.

Synthetic oxytocin may be given to enhance uterine tone.

Causes afterpains (painful uterine cramps), especially during breastfeeding.

Human chorionic gonadotropin (hcG)

Hormone produced by the placenta that forms around the embryo during pregnancy

Ovulation & Menstruation Resumption

Lactating Clients:

• Elevated prolactin levels suppress ovulation.

• Ovulation return depends on breastfeeding frequency, feeding length, & supplementation use.

• First postpartum ovulation: ~6 months.

Nonlactating Clients:

• Prolactin levels drop to pre-pregnant levels by ~3 weeks postpartum.

• First postpartum ovulation: 7-9 weeks postpartum.

• Menstruation Resumption: 12 weeks postpartum.

Postpartum Frequency of Assessments

First 2 hours

• Blood pressure & pulse → Every 15 minutes (Q15×8)

• Temperature → Every 4 hours

After 8 hours:

• Temperature → Every 8 hours

Postpartum Assessment: BUBBLE-E

B: Breasts

• Check for engorgement, redness, lumps, pain, or cracked nipples.

• Assess latch and breastfeeding effectiveness (if applicable).

U: Uterus

• Measure fundal height (should decrease daily).

• Check uterine firmness → Should be firm, midline, and at or below umbilicus.

• A boggy uterus may indicate postpartum hemorrhage.

B: Bowel & GI Function

• Assess for constipation, hemorrhoids, and bowel sounds.

• Encourage hydration and fiber intake to prevent straining.

B: Bladder

• Monitor for urinary retention or burning sensation (UTI risk).

• Encourage frequent voiding to prevent uterine displacement.

L: Lochia (Postpartum Bleeding)

• Assess COCA:

  • Color: Rubra (red, 1-3 days), Serosa (pink, 4-10 days), Alba (white, 10-6 weeks).

  • Odor: Should be mild, foul odor = infection.

  • Consistency: Clots should be small; large clots may indicate hemorrhage.

  • Amount: Moderate to light flow; excessive soaking may signal PPH.

E: Episiotomy / Perineum

• Check for redness, swelling, bruising (ecchymosis), and proper healing.

• Encourage sitz baths and pain management if needed.

Vital Signs & Pain

• Monitor temperature, heart rate, respiratory rate, and blood pressure.

• Assess pain level and provide appropriate interventions.

Education & Teaching Needs

• Educate on breastfeeding, self-care, and signs of complications.

• Encourage hydration, ambulation, and emotional support.

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H - Homan’s Sign (DVT assessment) (OUTDATED)

• Assess for pain, redness, or swelling in the calves

• Dorsiflex the foot → If calf pain occurs, it may indicate DVT (Deep Vein Thrombosis)

E - Emotional Status

• Monitor for postpartum blues, anxiety, or signs of depression

• Encourage open communication about mood, bonding with baby, and support system

Postpartum Laboratory Tests

1. Complete Blood Count (CBC)

   • Monitors:

     • Hemoglobin (Hgb) & Hematocrit (Hct) → Detects anemia due to blood loss.

     • White Blood Cell (WBC) Count → Elevated levels may indicate infection.

     • Platelet Count → Monitors clotting ability (important after birth).

2. Urinalysis

   • Checks for protein, glucose, and infection indicators (WBCs, nitrites, bacteria).

   • Detects postpartum complications like UTIs or kidney issues.

   (Future Pregnancy Health)

3. Rubella Immunity Test (If status is unknown)

   • Why? If the mother is not immune, she may need a rubella vaccine postpartum to protect future pregnancies.

4. Rh Factor (Blood Type Compatibility)

   • If the mother is Rh-negative, testing ensures the newborn’s blood type is compatible.

   • If the newborn is Rh-positive, RhoGAM is given within 72 hours to prevent complications in future pregnancies.

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Detects postpartum hemorrhage effects (low Hgb & Hct).

Prevents infections & complications (WBC count & urinalysis).

Ensures future pregnancy health (Rubella & Rh testing).

Ovulation vs Menstruation (Table)

The release of a mature egg (ovum) from the ovary into the fallopian tube.

Allows for fertilization and potential pregnancy.

Occurs mid-cycle (around day 14 in a 28-day cycle).

Increase in basal body temperature, stretchy cervical mucus (egg-white consistency), mild pelvic pain (mittelschmerz).

Highest fertility period (best time for conception).

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The shedding of the uterine lining (endometrium) when pregnancy does not occur.

Clears out the unfertilized egg and old uterine lining to prepare for the next cycle.

Occurs at the start of the cycle (typically days 1–5).

Bleeding, cramps, bloating, mood changes.

Lowest fertility period (pregnancy is unlikely).

BUBBLE-E vs BUBBLE-HEE Acronym

(Adds two extra assessments!)

Everything in BUBBLE-E, plus:

H - Homan’s Sign (DVT assessment) (OUTDATED)

• Assess for pain, redness, or swelling in the calves

• Dorsiflex the foot → If calf pain occurs, it may indicate DVT (Deep Vein Thrombosis)

E - Emotional Status

• Monitor for postpartum blues, anxiety, or signs of depression

• Encourage open communication about mood, bonding with baby, and support system

Uterus (of BUBBLE-HEE): Fundal Assessment & Nursing Care

Assessment Guidelines

• Frequency: Every 8 hours after the initial recovery period.

• Steps:

  1. Explain the procedure to the patient.

  2. Position the patient supine with knees slightly flexed.

  3. Use gloves and a lower perineal pad to observe lochia during assessment.

Palpation Technique

• Use both hands: One above the symphysis pubis for support, the other to palpate the fundus.

• NEVER palpate without support to prevent uterine inversion.

• Fundal Documentation:

  • Above umbilicus: +1, U+1, 1/U

  • Below umbilicus: -1, U-1, 1/U

Uterus (of BUBBLE-HEE): Fundal Height Progression

Brief Ascent

Immediately after birth:

• Firm, midline, and about 2 cm below the umbilicus.

1 hour post-birth: Rises to umbilical level.

12 hours post-birth: Can be palpated 1 cm above umbilicus.

Gradual Descent

Each 24 hours

• Descends 1-2 cm per day.

By day 6: Fundus is halfway between symphysis pubis & umbilicus.

By 2 weeks: No longer palpable in the abdomen.

Uterine Involution (Image)

(Uterine Shrinking)

• After birth, the uterus contracts to return to its pre-pregnancy size (involution).

• Reduces from 1,000g (immediately postpartum) to 60-80g at 6 weeks postpartum.

• Fundal height decreases by 1 cm per day until it is no longer palpable (~2 weeks postpartum).

Uterus (of BUBBLE-HEE): Postpartum Uterine Care

Medications to Promote Uterine Contractions

• Oxytocin (Pitocin) - First-line drug

• Methylergonovine (Methergine) - Avoid in hypertension

• Carboprost (Hemabate) - Avoid in asthma

• Misoprostol (Cytotec) - Prostaglandin used to prevent hemorrhage

Additional Nursing Interventions

• Encourage early breastfeeding (stimulates natural oxytocin).

• Encourage bladder emptying

  • Prevents uterine displacement.

• Monitor for side effects:

  • Oxytocin & Misoprostol → Hypotension

  • Methergine & Carboprost → Hypertension

Lochia (BUBBLE-HEE): Assessing Lochia Amount

Amount of blood saturating a perineal pad:

• Scant: Less than 2.5 cm / 1 inch (small spot of blood)

• Light: 2.5 to 10 cm / 1-4 inch (small stain)

• Moderate: More than 10 cm (covers a portion of the pad)

• Heavy: One pad saturated within 2 hours

• Excessive Blood Loss (Warning Sign!):

  • One pad saturated in ≤15 min

  • Pooling of blood under the buttocks

Lochia (BUBBLE-HEE): Assessing Lochia for Normal Appearance

Monitor lochia frequently to check for bleeding changes:

• First hour: Every 15 minutes (x8)

• Next 4 hours: Every 1 hour

• Next 24 hours: Every 4 hours

• After 24 hours: Every 4-8 hours, per facility protocol

Lochia flow pattern:

• Typically trickles but may flow more steadily during uterine contractions.

• Pooling under the client (especially when lying down) may indicate heavy bleeding.

• Massaging the uterus or walking may cause a gush of lochia (normal)

  • Should return to a trickle.

Weighing pads helps estimate blood loss accurately.

Clients who had a C-section will have less lochia

• The uterus is cleaned out during surgery.

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• Monitor for hemorrhage signs (excessive saturation or pooling).

• Educate clients on expected vs. abnormal lochia patterns.

• Encourage early movement to prevent clot formation

Lochia (BUBBLE-HEE): Abnormal Findings & Nursing Care

Report these findings immediately!

• Bright red blood spurting from the vagina

  • Possible cervical or vaginal tear

• Large clots & excessive bleeding (saturating a pad in ≤15 min)

  • Possible postpartum hemorrhage

• Foul-smelling lochia

  • Infection (endometritis)

• Persistent heavy lochia rubra beyond Day 3

  • Possible retained placental fragments

• Lochia serosa or alba lasting too long (beyond expected duration)

  • Endometritis (inflamed inner lining especially if with fever, pain, or tenderness)

Nursing Interventions

• Notify the provider immediately

• Assess vital signs (watch for tachycardia & hypotension

• Monitor fundal height & firmness

  • To rule out uterine atony

• Encourage frequent bladder emptying

  • Prevent proper uterine contractions)

• Administer prescribed medications (e.g., oxytocin, methylergonovine)

• Prepare for possible surgical intervention (D&C for retained placenta)

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Client Education

• Change pads frequently

• Perform hand hygiene after perineal care

• Avoid tampons (higher risk of infection)

Dilation and curettage (D&C)

Surgical procedure that involves dilating (opening) the cervix and removing tissue from the inside of the uterus (endometrium)

Postpartum Changes: Cervix, Vagina, and Perineum

Cervical

• Immediately after birth: Soft, edematous (swollen), bruised, and may have small lacerations

• By 2-3 days postpartum:

  • Shortens, regains its firm shape, and gradually closes

  • Lacerations can reduce cervical mucus production

  • The external os shape changes from round to a slit-like opening

Vaginal

• Stretched during birth, then gradually returns to prepregnancy size

• Reappearance of rugae

• folds in the vaginal wall) and thicker vaginal mucosa

• Permanent muscle tone loss

  • Does not fully return to pre-pregnancy state

• Breastfeeding mothers may experience increased vaginal dryness & atrophy

  • Low estrogen levels

Perineal

• Redness (erythema) & swelling (edema) common

  • Especially near episiotomy or laceration sites

• Pelvic floor muscles may be weak and overstretched

• Hemorrhoids & hematomas may develop

  • Pressure and pushing during labor

Cervix Anatomy (Image)

Postpartum Assessment & Care: Cervix, Vagina, and Perineum

Assessment

• Monitor perineal healing for:

  • Redness (erythema), swelling (edema), and hematoma formation

  • Episiotomy/laceration site for approximation, drainage, bleeding, and healing

  • Bright red trickle of blood from episiotomy is normal in the early postpartum period

• Healing Timeline:

  • Initial healing: 2 to 3 weeks

  • Complete healing: 4 to 6 months

Perineal Tenderness, Laceration, & Episiotomy Care

• Ice/cold packs for first 24 hours

  • Reduce swelling and pain (do not apply directly to skin)

• Heat therapy (hot packs, sitz baths, moist heat) for circulation & healing

• Sitz baths (warm or cool) for 20 minutes, twice a day

• Pain relief:

  • Nonopioid (Acetaminophen) & NSAIDs (Ibuprofen)

  • Opioids (Codeine, Hydrocodone) for severe pain

• Topical anesthetics (Benzocaine spray) & witch hazel pads for pain & hemorrhoid relief

Infection Prevention:

• Educate on proper perineal hygiene

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Client Education

• Wash hands before & after voiding

• Use warm water or antiseptic squeeze bottle after each voiding

• Blot dry from front to back (urethra to anus)

• Avoid rubbing—instead, pat dry gently

• Change perineal pad frequently, removing from front to back

Breasts (of BUBBLE-HEE)

Physical Change

• Colostrum: Clear yellow fluid produced 2–3 days after birth

• Milk Production: Begins 72 to 96 hours postpartum

• Engorgement: Breasts become tight, tender, warm, and full due to increased blood flow and lymphatic circulation

  • Non-breastfeeding clients: Use breast binders, support bras, ice packs, or cabbage leaves to relieve discomfort

  • Breastfeeding clients: Frequent feedings and proper breast care help manage engorgement

Assessment

• Redness (erythema), tenderness, cracked nipples, or mastitis (breast infection with flu-like symptoms)

• Proper newborn latch to prevent nipple soreness

• Ineffective feeding patterns (related to dehydration, discomfort, or poor positioning)

Patient-Centered Care

• Encourage breastfeeding within 1–2 hours after birth

  • Early & frequent feeding stimulates oxytocin release, which helps with uterine contractions and prevents hemorrhage

• Assist with comfortable breastfeeding positions:

  • Football hold (under the arm)

  • Cradle hold

  • Modified cradle hold

  • Side-lying position

• Teach proper latching techniques (baby should take in part of the areola, not just the nipple) to prevent soreness

• Clients who do not plan to breastfeed should avoid stimulation and expression of milk

Postpartum Cardiovascular and Vital Sign Changes

Blood loss during childbirth

• Vaginal birth: 300–500 mL (~10% of blood volume)

• Cesarean birth: 500–1,000 mL (~15–30% of blood volume)

• Diaphoresis (sweating) and diuresis (urination): Eliminates excess fluid accumulated during pregnancy

• Weight loss of ~19 lb (8.6 kg) occurs within the first 5 days postpartum

Hypovolemic shock is uncommon postpartum because:

• The placenta is eliminated, reducing demand for blood flow

• The uterus shrinks, redirecting blood back into maternal circulation

Blood Composition

• Hematocrit (Hct) decreases for 3–4 days postpartum, then increases to normal by 8 weeks

• Elevated white blood cell (WBC) count:

  • Common range: 20,000–25,000/mm³ (may reach 30,000/mm³)

  • This is called postpartum leukocytosis, a normal response to prevent infection and aid healing

• Coagulation factors and fibrinogen levels remain elevated postpartum

  • Increases risk for blood clots (DVT, thrombophlebitis)

VS

• Blood pressure (BP) remains stable, but a significant increase may indicate preeclampsia

• Postural hypotension: Can occur when standing due to fluid shifts—advise sitting at the bedside before standing

• Heart rate (HR) can drop to 40 bpm (postpartum bradycardia) within the first 2 days, returning to normal by 6–8 weeks

• Elevated temperature up to 38°C (100.4°F) within 24 hours after labor is normal due to dehydration

  • Persistent fever after 24 hours may indicate infection

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Assessment

• Monitor cardiovascular and blood changes

• Compare postpartum vitals to pregnancy baseline

• Check pulses, skin turgor, and assess legs/feet for edema

• Inspect lower legs for redness, warmth, swelling (signs of venous thrombosis)

Care

• Encourage hydration to prevent dehydration and hypotension

• Promote early ambulation to prevent blood stasis and clots

• Apply compression stockings/SCDs to high-risk clients for DVT prevention

• Administer medications (anticoagulants, pain relief) as needed

Laceration Tears (Image)

Enemas and suppositories are contraindicated for clients who have third- or fourth-degree perineal lacerations.

Bowels (of BUBBLE-HEE)

Physical Changes

• Increased appetite immediately after birth

• Constipation

  • Decreased peristalsis and muscle tone

• Hemorrhoids (common)

  • From pushing during labor

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Assessment

• Hunger levels (clients will likely have a strong appetite)

• Bowel sounds and function

  • Delayed bowel movement (2–3 days postpartum) is normal

    • Muscle tone changes, dehydration, or pain medications

• Defecation discomfort

  • Perineal tenderness, episiotomy, lacerations, or hemorrhoids

• Rectal area assessment for hemorrhoids or varicosities

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Care

• Encourage early ambulation, fluid intake, and high-fiber foods to improve bowel function

• Administer stool softeners (docusate sodium)

  • Prevents constipation

• Avoid enemas/suppositories in clients with third- or fourth-degree perineal lacerations

• Manage gas pain (common after cesarean birth)

  • Encourage movement (rocking, walking) to relieve flatus

  • Avoid gas-producing foods

  • Anti-flatulent medications may be needed

Urinary (of BUBBLE-HEE)

Changes

• Urinary retention may occur

  • Loss of bladder elasticity, decreased bladder sensation from trauma or anesthesia, and the effects of labor.

• A distended bladder can lead to uterine displacement, increasing the risk of hemorrhage and infection.

• Postpartum diuresis (increased urine output) typically begins within 12 hours after birth

  • Helps eliminate excess fluids retained during pregnancy.

Assessment

• Check for pain or difficulty urinating due to perineal or urethral swelling.

• Assess the elimination pattern

  • Eecessive urination over 3,000 mL/day is normal for the first 2-3 days

• Look for signs of bladder distension, which may include:

  • Fundal height above the umbilicus or baseline level

  • Uterus displaced laterally

  • Visible or palpable bladder bulge

  • Excessive lochia (postpartum vaginal discharge)

  • Tenderness over the bladder area

• Frequent voiding of less than 150 mL per urination

  • Can indicate urinary retention with overflow.

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Care

• Encourage urination within 6-8 hours after birth

  • If unable to void, catheterization may be necessary.

• Promote frequent bladder emptying

  • Prevents uterine displacement and atony (lack of uterine tone).

• Measure the first few voidings to ensure proper bladder emptying.

• Encourage oral fluid intake to replace lost fluids and prevent dehydration.

Postpartum Musculoskeletal System

Changes

• Joints stabilize and return to their normal state.

• Feet may remain permanently increased in size.

• Muscle tone begins to restore as progesterone levels drop after placenta delivery.

• Abdominal muscles (rectus abdominis) and pelvic muscles (pubococcygeus) regain strength over time.

Assessment

• Monitor musculoskeletal changes as the body recovers.

• Assess for diastasis recti (separation of the abdominal muscles)

  • Usually resolves in 6 weeks.

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Care

• Fall prevention protocol

Client Education

• Start with gentle postpartum exercises, gradually increasing intensity.

• Delay abdominal exercises for 4 to 6 weeks after a cesarean birth (or follow provider recommendations).

• Use proper body mechanics to avoid strain.

• Ambulate early to improve circulation and muscle strength.

• Perform Kegel exercises to strengthen pelvic muscles.

Postpartum Immune System Considerations

Rubella (MMR Vaccine)

• Given postpartum to clients nonimmune to rubella or with a low titer.

• Protects future pregnancies from congenital rubella syndrome.

• Contraindication: Avoid pregnancy for 4 weeks (28 days) after vaccination.

Rh Factor (Rho(D) Immune Globulin)

• For Rh-negative mothers who give birth to an Rh-positive newborn.

• Administer IM within 72 hours postpartum to prevent maternal sensitization.

• Nursing Considerations:

  • Check if the client has already been sensitized before administration.

  • Monitor for allergic reactions for at least 20 minutes post-administration.

  • Test immunity after 3 months to confirm effectiveness.

Varicella (Chickenpox Vaccine)

• Given if the client has no immunity to varicella.

• Avoid pregnancy for 1 month after vaccination.

• A second dose is administered 4 to 8 weeks later.

Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccine

• Recommended for clients who have never received it.

• Also recommended for family members and caregivers who will be around the newborn.

• Administer before discharge or as soon as possible postpartum.

• Safe during breastfeeding.

Rubella (MMR Vaccine)

Given postpartum to clients nonimmune or with a low titer.

Protects future pregnancies from congenital syndrome.

Contraindication

• Avoid pregnancy for 4 weeks (28 days) after vaccination.

Rh Factor (Rho(D) Immune Globulin)

For Rh-negative mothers who give birth to an Rh-positive newborn.

Administer IM within 72 hours postpartum to prevent maternal sensitization.

Nursing Considerations:

• Check if the client has already been sensitized before administration.

• Monitor for allergic reactions for at least 20 minutes post-administration.

• Test immunity after 3 months to confirm effectiveness.

Varicella (Chickenpox Vaccine)

Given if the client has no immunity

A second dose is administered 4 to 8 weeks later.

Contraindication

• Avoid pregnancy for 1 month after vaccination.

Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccine

Recommended for clients who have never received it.

Also recommended for family members and caregivers who will be around the newborn.

Administer before discharge or as soon as possible postpartum.

Safe during breastfeeding.

Postpartum Comfort & Psychosocial Well-being

Assessment & Interventions

• Assess pain related to:

  • Episiotomy, lacerations, incisions

  • Afterpains (uterine contractions postpartum)

  • Sore nipples from breastfeeding

• Assess pain location, type, and intensity to tailor interventions.

• Administer prescribed pain medications.

• Teach nonpharmacological pain relief:

  • Distraction techniques (e.g., music, imagery)

  • Heating pads, cold packs

  • Position changes

Psychosocial Adjustments

Clients may experience a wide range of emotions due to hormonal changes, adjusting to newborn care, and fatigue.

Assessment & Interventions

• Encourage verbalization of feelings.

• Assess emotional status.

• Observe parent-newborn bonding.

• Monitor for postpartum blues or depression, which may include:

  • Decreased appetite

  • Difficulty sleeping

  • Decreased social interactions

  • Lack of communication

Patient-Centered Care

• Encourage skin-to-skin contact with the baby.

• Document bonding interactions.

• Encourage rooming-in (keeping the baby in the client’s room at all times).

• Provide emotional support and refer for counseling if needed.

Chapter 18: Baby-Friendly Care

Importance of Bonding

• Helps establish emotional connection between parent and baby.

• Delaying nursing procedures (e.g., weighing, bathing) during the first hour after birth allows for skin-to-skin contact and early breastfeeding.

• Immediate interaction enhances maternal role attainment and helps parents recognize any bonding difficulties.

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Factors Affecting Bonding

Maternal Factors

• Unwanted pregnancy or adolescent pregnancy

• History of depression or previous traumatic birth experiences

• Physical recovery challenges after labor

Neonatal Factors

• Prematurity (requires NICU care, delaying bonding)

• Congenital anomalies (may cause emotional distress)

• Difficult birth leading to medical interventions

Social & Cultural Factors

• Age and socioeconomic status

• Cultural beliefs about newborn care and bonding

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Nursing Interventions

• Encourage skin-to-skin contact.

• Promote breastfeeding within the first hour.

• Provide emotional support for clients facing challenges.

• Assess for signs of delayed bonding and provide early interventions.

Stages of Maternal Role Attainment

1. Dependent: Taking-In Phase

Duration: First 24 to 48 hours after birth
Characteristics:

• Focuses on personal needs such as recovery, rest, and nutrition.

• Relies on others for help, including family and nurses.

• Excited and talkative, eager to share birth experience.

• Processes birth experience to gain closure.

2. Dependent-Independent: Taking-Hold Phase

Duration: Begins on day two or three and lasts ten days to several weeks
Characteristics:

• Shifts focus from self to baby care, including feeding, diapering, and bonding.

• Wants to take control but still needs reassurance.

• Open to learning and seeks guidance.

• Can experience baby blues, including mood swings and anxiety.

3. Interdependent: Letting-Go Phase

Duration: Weeks to months postpartum
Characteristics:

• Adjusts to new identity as a mother.

• Balances family responsibilities and self-care.

• Resumes partner intimacy and individual goals.

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Nursing Interventions

• Provide education on baby care and self-care.

• Offer emotional support and assess for postpartum depression.

• Encourage bonding activities such as skin-to-skin contact and eye contact.

• Validate concerns and reassure the mother about her progress.

Dependent: Taking-In Phase (1 of 3 of Maternal Role Attainment)

Duration: Day 1-2
Characteristics:

• Focuses on personal needs such as recovery, rest, and nutrition.

• Relies on others for help, including family and nurses.

• Excited and talkative, eager to share birth experience.

• Processes birth experience to gain closure.

Dependent-Independent: Taking-Hold Phase (2 of 3 of Maternal Role Attainment)

Duration: Day 2/3 to 10 days OR several weeks
Characteristics:

• Shifts focus from self to baby care, including feeding, diapering, and bonding.

• Wants to take control but still needs reassurance.

• Open to learning and seeks guidance.

• Can experience baby blues, including mood swings and anxiety.

Interdependent: Letting-Go Phase (3 of 3 of Maternal Role Attainment)

Duration: Weeks to months postpartum
Characteristics:

• Adjusts to new identity as a mother.

• Balances family responsibilities and self-care.

• Resumes partner intimacy and individual goals.

A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Discuss the action the nurse should take. ​​​​​​​

The nurse should give the client time to express their feelings and recognize that the client is excited about the birth of their baby by giving them the opportunity to discuss the birth. This also helps to develop rapport with the client and allows for therapeutic communication. NCLEX Connection: Health Promotion and Maintenance/Ante-/Intra-/Postpartum and Newborn Care

Positive Indicators of Bonding

The client considers the newborn a family member.

Maintains face-to-face contact and eye contact.

Interprets the newborn’s behavior positively.

Identifies the newborn’s unique characteristics.

Names the newborn, showing attachment.

Maintains physical contact like holding, touching, or skin-to-skin contact.

Provides physical care such as feeding and diapering.

Responds to the newborn’s crying.

Talks, sings, and smiles at the newborn.

Impaired or Absent Bonding Behaviors

Apathy when the newborn cries.

Displays disgust when the newborn voids, stools, or spits up.

Expresses disappointment in the newborn.

Turns away and avoids looking at the newborn.

Does not seek physical closeness.

Does not talk about or acknowledge the newborn’s features.

Handles the newborn roughly.

Ignores the newborn.

Does not refer to the newborn as part of the family.

Views the newborn as difficult or uncooperative.

Signs of Maternal Emotional Challenges

Mood swings, feeling "down," inadequacy, or anxiety.

Frequent crying, flat affect, or withdrawal.

Feeling unable to care for the newborn.

Nursing Interventions for Bonding

Encourage skin-to-skin contact and face-to-face positioning right after birth.

Support rooming-in to provide a quiet environment for bonding.

Promote early breastfeeding initiation and recognition of newborn feeding cues.

Educate on newborn care to improve confidence in parenting.

Encourage parents to interact through cuddling, feeding, bathing, and observing the newborn.

Provide praise, support, and reassurance to guide the client into their parental role.

Encourage parents to express feelings, fears, and concerns about newborn care.

Co-Parent Adaptation

The bonding and role adjustment a non-birthing parent experiences in caring for a newborn.

• Engaging in skin-to-skin contact, holding the newborn, and making eye-to-eye contact.

• Observing the newborn for similarities to their own features.

• Talking, singing, and reading to the newborn

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Assessment

• Observe bonding behaviors such as holding, talking to, or feeding the newborn.

• Assess if the co-parent is actively involved or feeling excluded from newborn care.

• Look for signs of emotional distress such as frustration, sadness, or withdrawal.

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Nursing Interventions

1. Provide education on newborn care for both parents.

2. Encourage a hands-on approach by allowing active participation in caregiving.

3. Assist in the transition to the parental role by offering guidance and support.

4. Promote communication between parents regarding their expectations and feelings.

5. Acknowledge emotions and reassure the co-parent that adaptation takes time.

Transition Phases in Co-Parenting

1. Expectations and Intentions

• The co-parent wants to be emotionally and deeply connected with the newborn.

2. Confronting Reality

• The co-parent realizes parenting is more challenging than expected.

• Common feelings include sadness, frustration, and jealousy if they feel left out of newborn care.

• May feel distanced from the birthing parent, who is focused on newborn caregiving.

3. Creating the Role of the Involved Co-Parent

• The co-parent actively participates in newborn care and builds confidence.

4. Reaping Rewards

• Parental involvement leads to newborn smiles, emotional fulfillment, and a sense of purpose.

Sibling Adaptation

Positive Responses (Indicate Good Adaptation)

• Shows interest and concern for the newborn

• Demonstrates increased independence

Adverse Responses (Indicate Difficulty in Adaptation)

• Displays sibling rivalry and jealousy

• Regression in toileting or sleep habits

• Aggressive behavior toward the newborn

• Attention-seeking behaviors such as whining or clinginess

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Nursing Interventions

• Familiarization

  • Take the sibling on a tour of the obstetric unit to introduce them to the newborn’s environment.

• Parental Guidance & Involvement

  • Allow the sibling to be one of the first to see the newborn.

  • Encourage parents to give a gift "from the newborn" to the sibling.

  • Suggest dedicated one-on-one time with the sibling while the other parent cares for the newborn.

  • Allow older siblings to assist in newborn care with simple tasks.

  • Provide preschool-aged siblings with a doll to simulate baby care.

Chapter 19: Client Education and Discharge Teaching

Discharge teaching is an important aspect of postpartum care. It is important for a client to be able to perform self-care and recognize effects that suggest possible complications prior to discharge.

Discharge planning should be initiated at admission with time spent during the hospitalization on providing client education regarding postpartum self-care.

A nurse should use a variety of teaching strategies to promote learning. Return demonstrations are important to ensure that adequate learning has taken place.

QS

• REPORT: Change in vaginal discharge with increased amount, large clots, change to a previous lochia color, such as bright red bleeding, and a foul odo

Letdown (Oxytocin) reflex

A physiological response that occurs in lactating women when their baby or a pump stimulates the breast.

• Triggers the release of milk from the mammary glands into the milk ducts.

Oxytocin is produced more quickly than prolactin.

• It makes the milk that is already in the breast flow for the current feed, and helps the baby to get the milk easily.

Prolactin vs Oxytocin

Signals the body to produce milk

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Signals the body to release milk

A nurse is providing discharge instructions to a postpartum client following a vaginal birth with a 4^th degree laceration. The client reports leaking urine every time they sneeze or cough. What interventions should the nurse suggest? 

The nurse should recommend performing Kegel exercises because they consist of the voluntary contraction and relaxation of the pubococcygeus muscle to strengthen the pelvic muscles. This will assist the client in decreasing urinary stress incontinence that occurs with sneezing and coughing.

NCLEX Connection: Health Promotion and Maintenance, Ante-/Intra-/Postpartum and Newborn Care

Assessing a Client’s Knowledge of Postpartum Care

1. Evaluate Current Knowledge

   • Ask about self-care routines and any prior experience with postpartum recovery.

2. Assess Support System

   • Identify who will assist the client at home and involve them in education.

3. Determine Readiness to Learn

   • Ensure the client can verbalize or demonstrate postpartum care instructions.

Perineal Care

Cleanse the perineal area from front to back after each voiding or bowel movement.

Blot dry from front to back.

Replace perineal pads from front to back to prevent infection.

Breastfeeding Breast Care

Hand Hygiene

• Wash hands before breastfeeding to prevent infections.

Client Education

• Bra Fit: Wear a well-fitted, nonbinding bra for comfort and support.

• Avoid underwire bras (risk of clogged ducts).

  • Leads to mastitis

• Feeding Schedule: 8 to 12 times a day

• Breast Engorgement Relief:

  • Before feeding: Apply warm compresses or take a warm shower to promote milk flow.

  • After feeding: Use cold compresses to reduce swelling.

• Cracked Nipples: Apply prescribed breast creams or wear breast shells to prevent irritation.

• Flat/Inverted Nipples: Use breast shells between feedings.

• Hydration: Drink plenty of fluids to maintain milk production.

Non Breastfeeding Breast Care

Lactation Suppression

• Wear a supportive bra continuously for 72 hours postpartum.

• Avoid breast stimulation and warm water over the breasts.

• Engorgement Relief

  • Apply cold compresses (15 minutes on, 45 minutes off).

  • Use fresh cold cabbage leaves inside the bra to reduce swelling.

  • Mild analgesics or anti-inflammatory medication can be taken if needed.

Postpartum Activity

Assess the client’s usual activity level to identify tasks that may be strenuous.

Encourage the client to accept help from others when needed.

Teach pelvic tilt exercises

• Strengthens back muscles and reduce lower back strain.

• These involve arching and straightening the back alternately.

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Client Education

• Pelvic Floor Strengthening: Perform Kegel exercises to regain pelvic muscle control, as these muscles assist in controlling urination.

• Progressive Exercise: Begin with simple movements and gradually increase to more strenuous activities.

• After Cesarean Birth:

  • Avoid strenuous, abdominal exercises, stair use for about 4 to 6 weeks

• Stair Climbing Restrictions:

  • After vaginal birth, limit stair climbing for the first few weeks.

  • A general guideline: no more than one flight of stairs per day and avoid lifting more than 10 lbs for the first 2 weeks postpartum.

• Rest and Recovery: Schedule at least one daily rest period and try to nap when the newborn naps to promote healing.

Postpartum Nutrition

Nonlactating clients

• 1,800 to 2,200 kcal/day.

Lactating clients

• Increase caloric intake by 450 to 500 calories/day

• Include calcium-rich foods.

Iron supplements may be prescribed for clients with low hemoglobin and hematocrit levels.

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Client Education

• Eat a nutritious, balanced diet high in protein for tissue repair.

• Continue taking prenatal vitamins for six weeks after birth.

Postpartum Sexual Activity

Safe to resume intercourse within 2 to 4 weeks after birth

• If bleeding has stopped and the perineum has healed.

Over-the-counter lubricants may be needed

• During the first 6 weeks to 6 months.

Sexual response may be slower and less intense

• For the first 3 months postpartum.

Postpartum Contraception

Discuss before resuming sexual activity.

Inform clients that pregnancy can occur even if menses has not returned while breastfeeding.

Client Education

• Breastfeeding clients should avoid oral contraceptives until milk production is well established (around 6 weeks).

• Nonlactating clients: Menses may not return for 4 to 10 weeks, but ovulation can occur as early as 1 month postpartum.

• Lactating clients: Menses may not resume for 6 months or until breastfeeding ends.

Postpartum Signs of Potential Complications

1. Fever and Chills

   • Temperature greater than 38° C (100.4° F) for over 24 hours.

2. Abnormal Vaginal Discharge

   • Increased amount, large clots, or change in color (e.g., bright red bleeding).

   • Foul-smelling lochia could indicate infection.

   • Normal Lochia Flow Patterns:

     • Rubra: Dark red discharge (Days 1 to 3).

     • Serosa: Brownish-red or pink discharge (Days 3 to 10).

     • Alba: Yellowish-white discharge (Days 10 to 8 weeks).

3. Wound or Incision Complications

   • Pain from episiotomy, laceration, or incision that does not improve with pain medication.

   • Foul-smelling drainage, redness, or swelling at the incision site.

4. Pelvic or Abdominal Pain

   • Pain or tenderness that does not improve with medication.

5. Breast Pain or Infection Signs

   • Localized areas of pain, swelling, or tenderness.

   • Cracked, red, or bruised nipples, blisters, or fissures.

6. Leg Pain or Swelling

   • Calf pain, tenderness, redness, or swelling.

   • One leg is more swollen, red, or warm compared to the other.

7. Urinary Tract Symptoms

   • Pain, burning, frequency, or urgency when urinating.

8. Mental Health Concerns

   • Persistent feelings of sadness, anxiety, or apathy toward the newborn.

   • Difficulty providing self-care or newborn care.

   • Thoughts of harming self or baby.

Postpartum Discharge Instructions

Follow-up visit should be scheduled within 3 weeks after vaginal or cesarean birth.

Follow-up care should be ongoing and individualized for each client.

The appointment date and time should be written on discharge paperwork and discussed before leaving.

Chapter 24: Nursing Care of Newborns

Newborn care consists of stabilization and/or resuscitation. This can include establishing a patent airway, maintaining adequate oxygenation, and thermoregulation for the maintenance of body temperature. A physical assessment (physical examination, measurements, and monitoring laboratory studies) is done every 8 hr or as needed.

Nursing interventions and family teaching (umbilical cord care, prophylactic measures, newborn screening, newborn feedings and bathing, and fostering baby-friendly activities) are integrated into a newborn’s plan of care.

QEBP

• Using the facility’s preferred pain assessment tool, conduct a pain assessment on the newborn with routine assessments and following painful procedures. Q

• Newborn hearing screening is required in most states. Newborns are screened so that hearing impairments can be detected and treated early. 

• Provide family education and promote family-newborn attachment. 

• The newborn should be warmed slowly over a period of 2 to 4 hr. Correct hypoxia by administering oxygen. Correct acidosis and hypoglycemia.

QPCC

• Decreased risk of penile cancer and cervical cancer in female partners (Circumcision)

QS

• Identification (using two identifiers) is applied to the newborn immediately after birth by the nurse. It is an important safety measure to prevent the newborn from being given to the wrong parents, switched, or abducted. 

• Newborns sleep approximately 16 to 19 hr/day with periods of wakefulness gradually increasing. Newborns are positioned supine, “safe sleep,” to decrease the incidence of sudden unexpected infant death (SUID).

Newborn Physical Assessment

Vital signs should be checked frequently per facility protocol.

Daily weight should be measured at the same time using the same scale.

Umbilical cord should be inspected for bleeding and secured to prevent hemorrhage.

Observe periods of reactivity within the first 6 to 8 hours after birth:

First period of reactivity (first 30 min)

• Newborn is alert, active, and makes sucking sounds.

• Heart rate rises to 160-180 bpm, then stabilizes at 100-120 bpm.

• Respiratory rate is elevated.

Period of relative inactivity (lasts 60 to 100 min)

• Newborn becomes quiet, rests, and sleeps.

• Heart rate and respirations slow down.

Second period of reactivity (2 to 8 hours after birth)

• Newborn reawakens, becomes active again.

• Gagging and choking on mucus may occur.

• Can last from 10 minutes to several hours.

Conduct a pain assessment using the facility’s preferred pain assessment tool.

First period of reactivity (first 30 min after birth) (1 of 3)

Newborn is alert, active, and makes sucking sounds.

Heart rate rises to 160-180 bpm, then stabilizes at 100-120 bpm.

Respiratory rate is elevated.

Period of relative inactivity (lasts 60 to 100 min after birth) (2 of 3)

Newborn becomes quiet, rests, and sleeps.

Heart rate and respirations slow down.