FINALS: NCM 101 A

established
(primary
engorgement) with this
congestion subsiding in 1
or 2 days.

POST-PARTUM
Care of the mother during the
Post-partum period
Postpartum: after delivery when
the womans body has returned
as closely as possible to its prepregnant state. Last app. @ 6
weeks.
Postpartum:
Begins
at
the
delivery of the placenta to the
beginning of the first menstrual
cycle (6-8 weeks).
General Assessment:

Enter the room quietly.

Wash hands.
Provide for client privacy.
Inform
patient
before
turning on lights.
Note
level
of
consciousness
(LOC),
activities, position, color,
general demeanor.
Take note of the total
environment:
Safety/Patient
considerations
Equipments/medications/
medical devices

Assessment of the Physiologic

changes of the mother during
Puerperium

Uterine Changes:

B- reast
U-terus
B-ladder
B-owel
L-ochia
E-pisiotomy
R-esponse
(Emotional
Response)
S-ign (Homans Sign)

Breast Changes:

Colostrum
(immunoglobulins)
present
at
time
of
delivery,
breast
milk
produced by the 3rd and
4th day colostrums.
Breast becomes larger
and firmer as lactation is

Lochia (Post-partum discharges)

Constituents:
blood,
mucus,
particles
of
deciduas, cellular debris,
leukocytes, RBCs.
Rubra turns to Serosa.
Fleshy odor, decreases
daily amount.
Increases ambulation
Lochia disappearance =
healed
internal
reproductive tract
It takes 6 weeks for the
vagina
to
regain
its
normal condition.

Massaging the fundus:

Every 15 mins. During he

first hour. Every 30 mins.
During the next hour, until
patient is transferred from
DR to Patients room
Document fundal height
Evaluate
from
the
umbilicus using finger
breadths
Fundus should remain in
the midlines

Uterine Involution:

Changes in B.U.B.B.L.E.R.S. :

Location in relation to
umbilicus
Degree of firmness
It is @ midline or deviated
to one side
Bladder full
A boggy uterus may
indicate uterine atomy
retained
placental
fragments
Uterus refers to being
inadequately

water,
fluids,
fiber,
frequent ambulation, stool
softeners, teach effects of
pain medication.

Uterine involution: return

of the uterus to its prepregnancy
size
and
condition.
Fundus halfway umbilicus
and symphysis pubis

Bladder and bowel Changes:

When was the patients

last BM?
Is she passing flatus?
Asses for Bowel sounds
Voiding
pattern
(w/o
difficulty/pain, urine may
be blood tinged from
lochia)
Nursing
interventions:
Assist to the bathroom.
Use
measures
to
encourage
voiding
(provide privacy). Use of
peri-bottles with warm

Lochia: After birth (3+ days),

blood, mucous is redm fragments
of deciduas
Serosa: 4-10 days after delivery,
blood, pink to brown, debris,
mucous, leukocytes
Alba: Final discharge, 11-21 days
(2-3 weeks), some blood (white),
mostly yellow mucous
Signs of Abnormal Lochia
1.
2.
3.
-

Scant: 1 inch strain

Light/small: 4 inches/hr.
Heavy/large: Saturated/hr.
Excessive: pad saturated
in 15 mins.
500 ml = 1 1b/454
grams
500
ml
indicates
hemorrhage

Note: Assess postpartum lochia in

1 hour

Episiotomy pain relief:

1.
-

Instruct mother to:

Tighten her buttocks and
perineum before sitting
to prevent pulling on the
episiotomy/perineal area
and release tightening
after being seated.

Rest several times a day

with feet elevated to
perform kegel exercises

Episiotomy/ Perineal assessment:

Patient in lateral sims (side

lying position)
REEDA (Redness, edema,
ecchymosis
discharge,
approximation of suture
lines edges of episiotomy)
to guide assessment.
REEDA:
3
(very
poor
healing)
1st
postpartum
day,
REEDA score may range
from 0-3, 2nd week: 0-1

Note: If no episiotomy done,

perineal assessment must still be
done.
-

Assess for hemorrhoids

Perineal discomforts

Emotional and Behavioral status

of the mother:

After
delivery,
woman
may
progress through Rubins stages
of taking hold and letting go.

Taking in (1-2 days PP)

May
begin
with
a
refreshing
sleep
after
delivery
Passive,
dependent
behavior
Taking hold (3-10 days PP)
More independently (2-7
days PP), Openness to
teaching on care of self
and neonates
Starts to care for infant
Functioning well
Letting go (11 days-6 weeks
PP)
Influenced
by
cultural
beliefs
Reestablishment of couple
relationship
Woman meets success in
caring for neonate, her
concern extends to other
family members, and to
their activities.

Postpartum
blues
(3RD
Postpartum day): Irritability,
poor appetite, insomnia,
tearfulness or crying. It is
temporary
in
the
postpartum
period,
depression: more serious
condition
Thomass Sign: to detect
thrombophlebitis (formation
of clot in an inflamed vein
on L/R legs). + means
painful, - means not

Cervial Involution:
Cervix becomes thicker and
firmer, end of 1st week, dilated
about 1 cm. Cervical involutions
complete @ 3-4 months.

Nursing Diagnoses
-

Vaginal Changes: smooth and

swollern, poor tone alter delivery,
rugae by 3-4 weeks postpartum.

Edocrine system Changes:

-

Estrogen and progesterone

decrease rapidly
Ovulation,
return
menstruation whether or
not patient breastfeeds
For
lactating:
45%
of
woman
resumes
menstruation by 12 weeks.
80% have one or more
anovulatory cycles before
the 1st ovulation
For non-lactating: 40% of
women
resume
menstruation by 6 weeks
after delivery. 99% of them
after 24 weeks.

Post-partum Caesarean:

Acute pain related to peineal

discomfort
from
birth
trauma, hemorrhoids and
physiologic changes from
birth.
Ineffective
health
maintenance r/t lack of
knowledge

Nursing interventions:
-

Abdominal Changes: remains soft

and flabby from after delivery.
Striae remain but may take slivery
while appearance diastasis recti
(separation of abdominal recti
muscles) occur in woman with
poor muscle tone.

Incision
site:
redness,
swelling, discharge intact?
Flatus?
Abdomen soft, distended? BS
heard in each quadrants
Lochia is less than normal
spontaneous vaginal delivery
(NSVD) because uterus is
wiped with sponge
Pain?
Gluid intake and output
Ascultate BS
Palpate and manage pain
measures in lochia indicates
excessive bleeding

Monitor for hypertensions

and bleeding
Take vital signs (TPRBP)
Increase RR, increase blood
loss/ pulmonary edema (fluid
in
lungs),
pulmonary
embolus
Increase in PR (>100bpm)
isa caused by bloodloss,
fever, pain
Assess
patient
for
lightheadedness, dizziness
Vaginal discharge (assess)
Assess for excessive blood
discharges using peripad
Promoting
urinary
elimination: normal should
void 6-8 hours after delivery.
Note: If cant void, palpate
the bladder/lukewarm water
flush. If still cant void, action
is needed. Keep bladder
empty every after meal (so
that uterus will descend)
Promote
function:

proper

bladder

Inform
patient
that
lacerations,
episiotomy,
hemorrhoids can delay 1st
bowel
elimination

(encourage 8 water/
frequent ambulation)

day,

Hard stool = let patient to

drink stool softeners.

Advantages of breastfeeding?

Prevent infection: if T=38C

above
1. Evaluate episiotomy using
REEDA
2. Evaluate pain
3. Evaluate urination
4. Administer medications as
ordered
Reducing fatique
1. Encourage
woman
to
sleep whenever baby is
sleeping
2. Nap @ least 30 mins. A
day or lie down for atleast
30 mins.
Minimizing pain
1. Instruct woman to apply
ice pack on her first 24
hours
2. After 24 hrs, apply heat
(to hastern the healing
process)
3. Sitz bath (for perineal
discomfort)

Cost effective
Milk contains nutrients that
the
baby
needs,
has
antibodies
Prevents breast cancer
Prevents lactose intolerance
Baby can easily digest the
milk
To
promote
mother-child
bonding
Burns calories
Helps contract the uterus,
thus helps prevent bleeding
Helps prevent anemia
Lessens the odor of babys
feces/ discharge

How can we say that the baby is

in good attachment with mother;s
breast?
1.
2.
3.
4.

5.
6.
7.

Babys chin should touch

the mother;s breast
Inner lips
should be
opened
Babys mouth should be
opened
Cheeks are found or
flattered
against
the
mothers chest
More areola is above the
babys mouth
Breast looks rounded
Lower lip turns outward

Engorgement of the breast

-

health

Proper use of napkin, proper

cleaning of the vagina for
about 500-750 calories daily
Perform
exercise:
twist,
bicycle

Promote breastfeeding

APGAR Score
-

Assesses
the
infants
cardiopulmonary adaptions to
extrauterine life
Provides a quick evaluation
Heart rate, respiratory rate,
muscle tone, reflex irritability
and color
Score of 0-2 for each item,
then totaled
APGAR score 8 or higher, no
intervention
APGAR Score 4-8 gentle
rubbing, 02
APGAR score 0-4 resuscitation

Prophylactic Care
-

Vitamin
K:
To
prevent
hemmorhagic
disorders.
Vitamin K (clotting process) it
synthesize
in
intestine
requires food for this process.
Newborns stomach is sterile,
has no food (aquaMEPHYTON)
Hepatitis B vaccination
Eye Prophylaxis (Erythromycin
ointment)
to
prevent
opalthamia
neonatorumgonorrhea/Chlamydia

VITAL SIGNS
T: 36.5-37C (97.7-98.6F)

Allow cold shower water to

flow to the breast
Apply cabbage to breast from
ref for 20 minutes
Cold (to relieve present pain)
Breast pump
Engorge
breast
without
breastfeeding
Avoid not to handle breast
Avoid warm water to flow to
her breast since it promotes
milk production
Moderately strong analgesic
(w/o BF)

Promote
postpartum
maintenance

impulses to respiratory center

in the medulla

Common variations
NEWBORN
Immediate needs:
-

Airway
Breathing
Circulation
Warmth

HR: 120-160 bpm

Common variations:
-

The neonatal transition: 1st few

hours
after
birth
newborn
stabilizes
respiratory
and
circulatory functions.
-

When the chord is clamped,

placenta
gas
exchange
ceases
These
changes
stimulate
carotid
and
aortic
chemoreceptors which send

Crying may elevate T

Stabilizes in 8-10 hours after
delivery

HR range to 100 bpm when

sleeping to 180 when crying
Color pink with acrocyanosis
HR irregular when crying

<5 Yr Old mortality decreased

40% (1988-1998)
Past 10 years, declined by
20%
Slow decline since neonatal
mortality hasn t improved

At perineal buging:

Check temperature of the

delivery room
Free of air drafts Free of air
drafts
25 - 28 C
Notify appropriate staff
Arrange needed supplies in
linear fashion
Check
resuscitation
equipment Wash hands with
clean water and soap
Double glove just before
delivery

Time Band: Within 1st 30 secs:

-

Immediate Thorough Drying

Call out the time of birth
Dry the newborn thoroughly
for at least 30
Wipe the eyes, face, head,
front and back, arms and legs
Remove the wet cloth

Time Band: Within 1st 30 secs:

-

Immediate
and
Thorough
Drying
Do a quick check of breathing
while drying

Notes: During the 1st secs: Do

not ventilate unless the baby is.
Do not ventilate unless the baby
is floppy/limp and not breathing
Do not suction unless the
mouth/nose are blocked with
secretions or other material
Time Band 0 - 3 mins:
Immediate, Thorough Drying
Notes:
Do not wipe off vernix. Do not
bathe the newborn. Do not bathe
the newborn.
Do not do footprinting.
No
slapping.
No hanging upside down. No
squeezing of chest
Time Band:
After 30 secs of
drying: Early Skin-to-Skin Contact
If newborn is breathing or crying:
Position the newborn prone on the
mother s abdomen or chest
abdomen or chest. Cover the
newborn s back with a dry
blanket. Cover the newborn s
head with a bonnet

Time Band:
After 30 secs of
drying: Early Skin-to-Skin Contact
If newborn is breathing or
crying:
Position the newborn prone on
the mother s abdomen or chest
abdomen or chest. Cover the
newborn s back with a dry
blanket.
Cover the newborn s
head with a bonnet.
Time Band:
After 30 secs of
drying: Early Skin-to-Skin Contact
If newborn is breathing or
crying:
Position the newborn prone on
the mother s abdomen or chest
abdomen or chest.
Cover the
newborn s back with a dry
blanket.
Cover the newborn s
head with a bonnet.
Time Band: 1 - 3 mins (Properly timed cord clamping)
Do not milk the cord towards the
baby. After the 1st clamp, you
may strip the cord. After the 1st
clamp, you may strip the cord
of blood before applying the 2nd
clamp. Cut the cord close to the
plastic clamp so that
there is no need for a 2nd trim.
Do not apply any substance onto
the cord.
Time Band: Within 90 mins Nonseparation of Newborn from
Mother for Early Breastfeeding:
Leave the newborn in skin-to-skin
contact. Observe for feeding cues,
including tonguing,
licking, rooting. Point these out to
the mother and encourage her to
nudge the newborn towards the
breast.
Time Band: Within 90 mins: Nonseparation of Newborn from
Mother for Early Breastfeeding:
Counsel on positioning. Newborn
s neck is neither flexed nor
twisted. Newborn is facing the
breast. Newborn s body is close to
mother s body. Newborn s whole
body is supported.

Time Band: Within 90 mins: Nonseparation of Newborn from

Mother for Early Breastfeeding:
Counsel on attachment and
suckling. Mouth wide open. Lower
lip turned outwards. Baby s chin
touching breast. Suckling is slow,
deep with some pauses
Time Band: Within 90 mins: Nonseparation of Newborn from
Mother for Early Breastfeeding:
Minimize handling by health
workers. Do not give sugar water,
formula or other.
Notes:
Prelacteals. Do not give bottles or
pacifiers
Do not throw away colostrums.
Time Band: Within 90 mins: Nonseparation of Newborn from
Mother for Early Breastfeeding:
Weighing, bathing, eye care,
examinations, injections (hepatitis
B, BCG) should be done after the
first full breastfeed is completed.
Postpone washing until at least 6
hours
Time Band: Within 90 mins: Nonseparation of Newborn from
Mother for Early Breastfeeding:
Weighing, bathing, eye care,
examinations, injections should
be done after the first full.
breastfeed
is
completed.
Postpone washing until at least 6
hours.
Newborn care
-

Immediate
and
thorough
drying
Skin to skin contact
Proper chord clamping
Nonseparation of newborn
with mother

Newborn Assessment
-

Weight:
7
pounds/3,400
grams
Height: 20 inches long
Males are heavier
Baby loses weith (loss during
first 4-5 days after birth, due
to loss of fluids)
Head C: 33-35 cm
Chest C: 30.5-33cm

Fontanels
-

6 soft spots on the skull

(bones are not yet fused)
Anterior fontanels: Diamond
shaped: 2-3 cm or 3-4 cm.
Posterior fontanels: triangular
shaped, 0.5-1 cm
Fontanels soft, firm and flat
Molding is shaping of fetal
head to adapt to the mothers
pelvis during labor
Swelling of the soft tissue of
the scalp caused by pressure
of the fetal head on the cervix
that is not fully dilated
2-3 days it disappears

Prolonged/difficult delivery
Vacuum extraction
Period of absorption: 3-4 days
Mechanical trauma
Both hemispheres, crosses
the suture lines (extent of
involvement)

Cephalohematoma
-

Collection of blood between

the periosteum and skull of
the newborn/ scalp of a
newborn.
Does not cross the suture
lines.
Caused by rupturing og the
periosteal bridging veins due
to friction and pressure during
labor.
Lasts 3-6 weeks
Caused by pressure during
labor
Period absorption: weeks
months
Treatment: Support
Individual bone (extent of
involvement)

Milia: tiny white bumps (papules)

Sensitive to touch
Comforted
by
closeness,
warmth, touching
Responds to changes in all T

Taste and smell

-

Pluckers lips after a strong

flavor
Breaths faster and kicks when
smelling strong odors
Epstein pearls: whitish yello
cysts that form on the gums
and root of the mouth
Thrush

Communication
-

Cries, coos, smiles

Responds to parents mood
and feelings
Develops attachment to care
givers

Reflexes

Rooting (Birth 3-4 months)

Sucking (Birth to 10 months)
Tonic Neck Reflex (Fencing)
Extends arm and leg on
the side that the face
points
6-8 weeks to 6 months
Flexes opposite the arm
and leg
Moro reflex
Plantar grasp reflex (upto 9
months)
Palmar reflex (birth-4 months)
Babinski reflex (+) normal,
birth to 12-18 months age
Sleeping reflex (birth to 4
months)

Skin

Normal: Reddish, smooth, puffy @

birth

Sound

Acrocyanosis:
results
from
sluggish peripheral circulations
Erythematoxicum: most common
newborn rash

Sight
Sees best @ 8 inch distance
Likes to look @ human face
Follows a moving target with
eyes
Responds to light
Likes to look at patients with
sharp outlines, dark and light
contrast

Common normal variations

Touch

Caput Succedaneum: Swelling of

the tissue caused by pressure

Sensitive to voices
Preferred high pitched voices
Turns head towards sound
Tries to focus on the source of
a sound

24-36 hours after, skin is flacky,

dry and pink in color. Edema
around eyes, feet and genitals.
Vernix caseosa, Lanugo (baby
hair), good skin turgor with recoil.

Mongolian Spots: Patch of purpleblack

or
blue-black
color
distributed over coccygeal and
sacral regions of infants of
African-American/Asian descent.
Hyperbilirubinemia: appears 72
hours after birth to 24 hours.
Bilirubin may reach 6-10 mg/dL
and resolves in 5-7 days

Pathogenic Jaundice: appears in

the 24 hours, leads to kenicterus
(deposits of bilirubin in the brain)
Bilirubin > 20 mg /dL is caused by
Rh incompatibility
Kernicterus:
brain
dfamage
caused by excessive jaundice.
The substance, Bilirubin is si high
that it can move out of the blood
into the brain tissue.

Clinical Manifestations
Lethargic: they are too sleepy,
they are difficulty to arouse
either they dont wake up from
sleep easily like normal baby, or
they dont wake up fully or they
cant be kept awake.
High-pitched cry
Decreased muscle-tone (becomes
hypotonic)

Stages of Newborn
1.

Quiet Alert: Awake and

content. Eyes wide open.
Eyes try tp focus on
object. Enjoys interesting
environment.
Maintains

2.
3.

starte if full, warm and

dry.
Active Alert: Movement
increases
Crying:
way
of
communicating his needs
Cry of pain: followed by
holding the breath

4.

5.

Hunger cries: usually start

with whimpering, then
become more intense
Drowsiness:
Movement
may occur. State of being
between
awake
and
asleep.
Quiet
sleep:
Sleep
soundly.
Noises
dont

6.

disturb him. Does not

move
much.
Breaths
deeply.
Active sleep: Eyes may
flutter.
Movement
is
common.
May
smile,
frown, suck and chew.