Nursing Care of the Family During the Postpartum

Period
Chapter 19

Nursing Care of the Family During the Postpartum

Period
Kathryn R. Alden

Learning Objectives

On completion of this chapter, the reader will be able to:

• Describe components of a systematic postpartum assessment.

• Recognize signs of potential complications in the postpartum woman.

• Identify common selection criteria for safe early postpartum discharge.

• Formulate a nursing care plan for a woman in the postpartum period.

• Explain the influence of cultural beliefs and practices on postpartum care.

• Identify psychosocial needs of the woman in the early postpartum period.

• Prepare a plan for postpartum teaching for self-management.

• Describe the nurse’s role in these postpartum follow-up strategies: home visits, telephone follow-up, warm
lines and help lines, support groups, and referrals to community resources.

At no other time is family-centered maternity care more important than in the postpartum period. Nursing care
is provided in the context of the family unit and focuses on assessment and support of the woman’s physiologic
and emotional adaptation after birth. During the early postpartum period components of nursing care include
assisting the mother with rest and recovery from the process of labor and birth, assessing physiologic and
psychologic adaptation after birth, preventing complications, educating regarding self-management and infant
care, and supporting the mother and her partner during the initial transition to parenthood. In addition, the nurse
considers the needs of other family members and includes strategies in the nursing care plan to help the family
adjust to the new baby.

The approach to the care of women after birth is wellness oriented. In the United States most women remain
hospitalized no more than 1 or 2 days after vaginal birth and some for as few as 6 hours. Because so much
important information needs to be shared with these women in a very short time, their care must be thoughtfully
planned and provided. This chapter discusses nursing care of the woman and her family in the postpartum
period extending into the fourth trimester—the first 3 months after birth.

Transfer from the Recovery Area

After the initial recovery period has been completed, the woman may be transferred to a postpartum room in the
same or another nursing unit. In facilities with labor, delivery, recovery, postpartum (LDRP) rooms, the woman
stays in the same room; the nurse who provides care during the recovery period usually continues caring for the
woman. In many settings women who have received general or regional anesthesia must be cleared for transfer
from the recovery area by a member of the anesthesia care team. In other settings a nurse makes the
determination.

In preparing the transfer report, the recovery nurse uses information from the records of admission, labor and
birth, and recovery (Fig. 19-1). Information communicated to the postpartum nurse includes identity of the
health care provider; gravidity and parity; age; anesthetic used; any medications given; duration of labor and
time of rupture of membranes; whether labor was induced or augmented; type of birth and repair; blood type
and Rh status; group B streptococcus status; status of rubella immunity; human immunodeficiency virus (HIV),
hepatitis B, and syphilis serology test results; other infections identified during pregnancy (e.g., chlamydia,
gonorrhea) and whether these were treated; intravenous infusion of any fluids; physiologic status since birth;
description of fundus, lochia, bladder, and perineum; sex and weight of infant; time of birth; name of pediatric
care provider; chosen method of feeding; any abnormalities noted; and assessment of initial parent-infant
interaction.

FIG 19-1
Part of a vaginal birth recovery screen in an electronic record. (Courtesy Kitty Cashion, Memphis, TN.)

Most of this information is also communicated to the nurse on the mother/baby unit or the nursing staff in the
newborn nursery if the infant is transferred to that unit. In addition, specific information should be provided
regarding the infant’s Apgar scores (see Chapter 23), weight, voiding, and stooling and whether fed since birth.
Nursing interventions that have been completed (e.g., eye prophylaxis and vitamin K injection) and
identification procedures (e.g., footprints, armbands) must be recorded.
Planning for Discharge

From their initial contact with the postpartum woman, nurses prepare the new mother for the time when she will
return home. Planning for discharge begins with the first interaction between the nurse, the woman, and her
family and continues until they leave the hospital or birthing facility (Fig. 19-2).

FIG 19-2
Part of a postpartum discharge teaching screen in an electronic medical record. (Courtesy Kitty Cashion,
Memphis, TN.)

The length of stay after giving birth depends on many factors, including the physical condition of the mother
and the newborn, mental and emotional status of the mother, social support at home, patient education needs for
self-management and infant care, and financial constraints.

Women who give birth in birthing centers may be discharged within a few hours, after the woman’s and infant’s
conditions are stable. Mothers and newborns who are at low risk for complications may be discharged from the
hospital within 24 to 36 hours after vaginal birth. This short time frame is often called early postpartum
discharge, shortened hospital stay, or 1-day maternity stay. Early discharge was popular in the late 1980s and
early 1990s, but concerns related to the health and well-being of mothers and newborns led to legislation
promoting longer hospital stays. The passage of the Newborns’ and Mothers’ Health Protection Act of 1996
provided minimum federal standards for health plan coverage for mothers and their newborns (AAP Committee
on Fetus and Newborn, 2010). Under this Act all health plans are required to allow the new mother and
newborn to remain in the hospital for a minimum of 48 hours after an uncomplicated vaginal birth and for 96
hours after a cesarean birth, unless the attending provider in consultation with the mother decides on early
discharge.

Criteria for Discharge

The AAP (2010) recommends that the hospital stay for a mother with a healthy term newborn should be of
sufficient length to identify early problems and determine that the mother and family are prepared and able to
care for the neonate at home. The health of the mother and her newborn should be stable; the mother should be
able and confident to provide care for her infant; there should be adequate support systems in place and access
to follow-up care (AAP Committee on Fetus and Newborn, 2010).

It is essential that nurses consider the individual needs of the woman and her newborn and provide care that is
coordinated to meet these needs to provide timely physiologic interventions and treatment to prevent morbidity
and hospital readmission. Hospital-based maternity nurses continue to play invaluable roles as caregivers,
teachers, and advocates for mothers, newborns, and families in developing and implementing effective home-
care strategies. Postpartum order sets and maternal-newborn teaching checklists can be used to accomplish
patient care tasks and educational outcomes. With coordination, clinical care and education can be planned and
provided throughout pregnancy, during the hospital stay, and in the home after discharge to promote and
support the family’s continued well-being (see Evidence-Based Practice box).

Evidence-Based Practice

Perineal Trauma and Postpartum Sexual Function

Pat Mahaffee Gingrich

Ask the Question

Which perinatal interventions for perineal trauma minimize pain and prevent sexual dysfunction?

Search for the Evidence

Search Strategies

English research-based publications on perineal trauma, birth, postpartum, sexual were included.

Databases Used

Cochrane Collaborative Database, National Guideline Clearinghouse (AHRQ), CINAHL, PubMed, and
UpToDate

Critically Analyze the Evidence

• Sexual dysfunction can affect more than half of all women at 2 to 3 months after birth. One major cause is
dyspareunia (painful intercourse) after perineal trauma, especially third- and fourth-degree lacerations requiring
repair. Other causes can include decreased libido and lower estrogen resulting from breastfeeding, postpartum
depression, and fatigue.

• Both episiotomy and second-degree lacerations with repair are associated with lower libido, orgasm, sexual
satisfaction, and greater dyspareunia than in women with intact perineums (Rathfisch, Dikencik, Beji, et al.,
2010). Routine episiotomy and fundal pressure during birth are not recommended.

• Warm compresses and perineal massage during first- and second-stage birth significantly decrease third- and
fourth-degree tears (Aasheim, Nilsen, Lukasse, et al., 2011).

• Evidence is still mixed for whether to suture or not suture first- and second-degree lacerations. Although small
studies find little difference between groups for pain and wound complications, despite slower wound healing
the unsutured group still experiences greater satisfaction than the sutured group (Elharmeel, Chaudhary, Tan,
et al., 2011).
Apply the Evidence: Nursing Implications

Women can be embarrassed to discuss sexual function with their partners and/or with their health care team.
Nurses are ideally placed to initiate and keep the dialog going throughout childbearing. Leeman and Rogers
(2012) recommend the following clinical approach for assessing and preventing postpartum sexual dysfunction:

• Discussion of anatomy, physiology, and sexual function should begin in early pregnancy and continue
throughout the postpartum period, including a brief valid and reliable sexual function survey.

• Antenatal perineal massage should be taught to minimize perineal damage.

• Perineal management at birth should include limited use of instrumental delivery, especially forceps, and
avoiding episiotomy, along with careful assessment and repair of anal sphincter lacerations with synthetic,
absorbable sutures.

• Before hospital discharge initiate discussions with the woman and her partner regarding pain, dyspareunia,
resumption of intercourse, and contraception. Women should know the hypoestogenic and sensitivity changes
that they can experience as a result of breastfeeding and the need for additional vaginal lubrication.

• At postpartum visits assess urine, bowel, and sexual function; inspect perineum; and assess and discuss mood
and intimacy challenges such as fatigue and timing issues. Suggest alternate positions to help increase comfort
during intercourse. Evaluate satisfaction with contraceptive method.

Quality and Safety Competencies: Evidence-Based Practice*

Knowledge

Describe Evidence-Based Practice to Include the Components of Research Evidence, Clinical Expertise, and
Patient/Family Values.

Sexuality is affected by childbirth. Nurses can sensitively initiate discussion of sexual intimacy.

Skills

Base Individualized Care Plan on Patient Values, Clinical Expertise, and Evidence.

The nurse models a view of human sexuality as a healthy and normal part of one’s quality of life.

Attitudes

Value the Concept of Evidence-Based Practice as Integral to Determining Best Clinical Practice.

The nurse can educate the patient and partner and dispel myths about sexuality.

References
Aasheim, V, Nilsen, AB, Lukasse, M, et al. Perineal techniques during the second stage of labour for reducing
perineal trauma. In: Cochrane Database Syst Rev. Chichester, UK: John Wiley & Sons; 2011.

Elharmeel, SM, Chaudhary, Y, Tan, S, et al. Surgical repair of spontaneous perineal tears that occur during
childbirth versus no intervention. In: Cochrane Database Syst Rev. Chichester, UK: John Wiley & Sons; 2011.
Leeman, LM, Rogers, RG. Sex after childbirth. Obstet Gynecol. 2012; 119(3):647–655.

Rathfisch, G, Dikencik, BK, Beji, NK, et al. Effects of perineal trauma on postpartum sexual function. J Adv
Nurs. 2010; 66(12):2640–2649.

*
Adapted from QSEN at www.qsen.org/.

Care Management—Physical Needs

The nursing plan of care includes both the postpartum woman and her infant. It is also family centered,
considering the needs and concerns of the family and focusing on family unity (Waller-Wise, 2012). Although
in some hospitals the nursery nurse retains primary responsibility for the infant, most perinatal settings use the
couplet or mother/baby model of care (AWHONN, 2010). Nurses in these settings have been educated in both
mother and infant care and function as primary nurses for both mother and infant, even if the infant is kept in
the nursery. This approach is a variation of rooming-in, in which the mother and infant room together and
mother and nurse share the care of the infant. The organization of the mother’s care must take the newborn’s
feeding and care needs into consideration.

Ongoing Physical Assessment

Ongoing assessments are performed throughout hospitalization. In addition to vital signs, physical assessment
of the postpartum woman focuses on evaluation of the breasts, uterine fundus, lochia, perineum, bladder and
bowel function, vital signs, and legs (Table 19-1).

TABLE 19-1

POSTPARTUM ASSESSMENT AND SIGNS OF POTENTIAL COMPLICATIONS

SIGNS OF POTENTIAL
ASSESSMENT NORMAL FINDINGS
COMPLICATIONS
Hypertension: anxiety, preeclampsia,
Blood pressure Consistent with BP baseline during pregnancy;
essential hypertensionHypotension:
(BP) can have orthostatic hypotension for 48 hours
hemorrhage
Temperature 36.2°-38° C (97.2° to 100.4° F) >38° C (100.4° F) after 24 hours: infection
Tachycardia: pain, fever, dehydration,
Pulse 50-90 beats/min
hemorrhage
Bradypnea: effects of narcotic
Respirations 16-24 breaths/min medicationsTachypnea: anxiety; may be
sign of respiratory disease
Breath sounds Clear to auscultation Crackles: possible fluid overload
Days 1-2: soft Firmness, heat, pain: engorgement
Breasts Days 2-3: fillingDays 3-5: full, soften with Redness of breast tissue, heat, pain, fever,
breastfeeding (milk is “in”) body aches: mastitis
Redness, bruising, cracks, fissures,
Nipples Skin intact; no soreness reported abrasions, blisters: usually associated with
latching problems
Uterus (fundus) Firm, midline; first 24 hours at level of umbilicus; Soft, boggy, higher than expected level:
involutes ≈1 cm/day uterine atony
 SIGNS OF POTENTIAL
ASSESSMENT NORMAL FINDINGS
COMPLICATIONS
Lateral deviation: distended bladder
Days 1-3: rubra (dark red)Days 4-10: serosa
Large amount of lochia: uterine atony,
(brownish red or pink)After 10 days: alba
Lochia vaginal or cervical lacerationFoul odor:
(yellowish white)Amount: scant to moderateFew
infection
clotsFleshy odor
Minimal edema Pronounced edema, bruising, hematoma
Laceration or episiotomy: edges approximated Redness, warmth, drainage: infection
Perineum
Pain minimal to moderate: controlled by Excessive discomfort first 1-2 days:
analgesics, nonpharmacologic techniques, or both hematoma; after day 3: infection
No hemorrhoids; if hemorrhoids are present, soft Discolored hemorrhoidal tissue, severe
Rectal area
and pink pain: thrombosed hemorrhoid
Able to void spontaneously; no distention; able to Overdistended bladder possibly causing
empty completely; no dysuria uterine atony, excessive lochia
Bladder
Diuresis begins ≈12 hours after birth; can void
Dysuria, frequency, urgency: infection
3000 mL/day
Abdomen soft, active bowel sounds in all
No bowel movement by day 3 or 4:
quadrantsBowel movement by day 2 or 3 after
Abdomen and constipation; diarrhea
birth
bowels
Cesarean: incision dressing clean and dry; suture Abdominal incision—redness, edema,
line intact warmth, drainage: infection
Deep tendon reflexes (DTRs) 1+ to 2+ DTRs ≥3+: preeclampsia
Redness, tenderness, pain, positive
Legs Peripheral edema possibly presentHomans’ sign*
Homans’ sign*: venous thromboembolism
negative
(VTE)
Lethargy, extreme fatigue, difficulty
Energy level Able to care for self and infant; able to sleep
sleeping: postpartum depression
Excited, happy, interested or involved in infant Sad, tearful, disinterested in infant care:
Emotional status
care postpartum blues or depression
*
Homans’ sign may or may not be included in routine postpartum assessments; there is concern about its limited
sensitivity and specificity in diagnosing venous thromboembolism.

Routine Laboratory Tests

Several laboratory tests may be performed in the immediate postpartum period. Hemoglobin and hematocrit
values are often evaluated on the first postpartum day to assess blood loss during birth, especially after cesarean
birth. In some hospitals a clean-catch or catheterized urine specimen may be obtained and sent for routine
urinalysis or culture and sensitivity, especially if an indwelling urinary catheter was inserted during the
intrapartum period. In addition, if the woman’s rubella and Rh status are unknown, tests to determine her status
and need for possible treatment should be performed at this time.

Nursing Interventions

Based on the available data (e.g., medical record) and assessment findings, the nurse plans with the woman
which nursing measures are appropriate and which are to be given priority. The nursing plan of care includes
periodic assessments to detect deviations from normal physical changes, measures to relieve discomfort or pain,
safety measures to prevent injury or infection, and teaching and counseling measures designed to promote the
woman’s feelings of competence in self-management and newborn care. The spouse or partner, and other
family members who are present can be included in the teaching. The nurse evaluates continuously and is ready
to change the plan if indicated. Almost all hospitals use standardized care plans as a base. Nurses individualize
care of the postpartum woman and neonate according to their specific needs (see Nursing Care Plan). Signs of
potential problems that may be identified during the assessment process are listed in Table 19-1.

 Nursing Care Plan

Postpartum Care—Vaginal Birth

EXPECTED
NURSING DIAGNOSIS NURSING INTERVENTIONS RATIONALES
OUTCOME
Monitor lochia (color, amount,
To evaluate amount of
consistency) and count sanitary pads if
bleeding
lochia is heavy
Monitor and palpate fundus for Because uterine atony is
location and tone to determine status of most common cause of
uterus and dictate further interventions postpartum hemorrhage
Monitor intake and output, assess for Because a full bladder
bladder fullness, and encourage interferes with involution of
voiding uterus
Monitor vital signs (increased pulse
and respirations, decreased blood To detect signs of
pressure) and skin temperature and hemorrhage/shock
color
Monitor postpartum hematology To assess effects of blood
Fundus is firm,
studies loss
Risk for Deficient Fluid lochia is
To promote uterine
Volume related to moderate, and
contractions and increase
uterine there is no
If fundus is boggy, apply gentle uterine tone (Do not
atony/hemorrhage evidence of
massage and assess tone response. overstimulate because
hemorrhage.
doing so can cause fundal
relaxation.)
To promote uterine
Express uterine clots
contraction
Explain to woman process of
To involve her in self-
involution and teach her to assess and
management and increase
massage fundus and report any
sense of self-control
persistent bogginess
Administer uterotonic agents per health
To promote continuing
care provider order and evaluate
uterine contraction
effectiveness
Administer fluids, blood, blood
To replace lost fluid and
products, or plasma expanders as
lost blood volume
ordered
Acute Pain related to Woman exhibits Assess location, type, and quality of
To direct intervention
postpartum physiologic signs of pain
changes (hemorrhoids, decreased Explain to woman source and reasons To decrease anxiety and
episiotomy, breast discomfort. for pain, its expected duration, and increase sense of control
engorgement, treatments
 EXPECTED
NURSING DIAGNOSIS NURSING INTERVENTIONS RATIONALES
OUTCOME
Administer prescribed pain
To provide pain relief
medications
If pain is perineal (episiotomy, To reduce edema and
hemorrhoids), apply ice packs in first vulvar irritation and reduce
24 hours discomfort
Encourage sitz baths using cool water To reduce edema and
the first 24 hours discomfort
Use warm water for sitz baths after 24 To promote circulation and
hours reduce discomfort
Apply witch hazel compresses To reduce edema
Teach woman to use prescribed To depress response of
perineal creams, sprays, or ointments peripheral nerves
Teach woman to tighten buttocks To compress buttocks and
before sitting and to sit on flat, hard reduce pressure on
surfaces perineum (Avoid donuts
and soft pillows because
they separate buttocks and
decrease venous blood
flow, increasing pain.)
If nipples are sore or damaged, assess
sore/damaged nipples) To prevent further nipple
infant positioning and latch; assist
soreness and damage
mother to correct problems
If breasts are engorged, have woman
apply ice packs and/or cabbage leaves To reduce tissue swelling
(15-20 minutes on, 45 minutes off) and promote milk flow
between feedings
Suggest that woman takes a warm To stimulate milk flow and
shower before breastfeeding relieve stasis
If nipples are sore, have woman rub
expressed milk into them after feeding To promote healing
and leave nipples open to air
Apply hydrogel pads to sore nipples
To promote comfort
between feedings
Wear breast shell To prevent irritation
If pain is from breast and woman is not
To suppress milk
breastfeeding, encourage use of tight
production and reduce
supportive bra or breast binder and
tissue swelling from
application of ice packs or cold
engorgement
cabbage leaves
Disturbed Sleep Pattern Woman sleeps Establish woman’s routine sleep
To determine scope of
related to excitement, for uninterrupted patterns and compare with current
problem and direct
discomfort, and periods of time sleep pattern, exploring things that
interventions
environmental and feels rested interfere with sleep
interruptions after waking. Individualize nursing routines to fit To promote optimum
woman’s natural body rhythms (i.e., conditions for sleep
wake/sleep cycles); provide a sleep-
promoting environment (i.e., darkness,
quiet, adequate ventilation, appropriate
 EXPECTED
NURSING DIAGNOSIS NURSING INTERVENTIONS RATIONALES
OUTCOME
room temperature); prepare for sleep
using woman’s usual routines (i.e.,
back rub, soothing music, warm milk);
teach use of guided imagery and
relaxation techniques
Avoid things or routines that can
interfere with sleep (i.e., caffeine,
To enhance quality of sleep
foods that induce heartburn, fluids,
strenuous mental/physical activity)
Administer sedative or pain medication
To enhance quality of sleep
as prescribed
Advise woman/partner to limit visitors To avoid further taxation
and activities and fatigue
Teach woman to use infant nap time as To nap and replenish
a time for her also energy and decrease fatigue
To ascertain if any further
interventions are indicated
Assess position and character of
because of displacement of
uterine fundus and bladder
fundus or distention of
bladder
Measure intake and output To assess adequacy of fluid
intake and urine output; a
Woman will void full or distended bladder
Risk for Impaired
within 6 to 8 increases the risk for uterine
Urinary Elimination
hours after birth atony
related to perineal
and empty
trauma and effects of Encourage voiding by assisting woman
bladder
anesthesia to bathroom, running water over
completely. To encourage voiding
perineum, running water in sink, and
providing privacy
To replace any fluids lost
Encourage oral fluid intake during birth and prevent
dehydration
Catheterize as necessary with To ensure bladder emptying
indwelling or straight method and prevent uterine atony

Nurses assume many roles while implementing the nursing plan of care. They provide direct physical care,
education about mother and baby care, counseling, and anticipatory guidance. Perhaps most important of all,
they nurture the woman by providing encouragement and support as she begins to assume the many tasks of
motherhood. Nurses who take the time to “mother the mother” do much to increase feelings of self-confidence
in new mothers. Nurses are careful to include the woman’s spouse or partner and other primary support persons
in education and counseling.

The first step in providing individualized care is to confirm the woman’s identity by checking her wristband. At
the same time the infant’s identification number is matched with the corresponding band on the mother’s wrist
and in some instances the father’s or partner’s wrist. The nurse determines how the mother wishes to be
addressed and notes her preference in her record and her nursing care plan.
The woman and her family are oriented to their surroundings. Familiarity with the unit, routines, resources, and
personnel reduces one potential source of anxiety—the unknown. The mother is reassured through knowing
whom and how she can call for assistance and what she can expect in the way of supplies and services. If the
woman’s usual daily routine before admission differs from the routine of the facility, the nurse works with the
woman to develop a mutually acceptable routine.

Nurses discuss infant security precautions with the mother and her family because infant abductions are an
ongoing concern. Between 1983 and 2012, 130 infants were abducted from health care facilities in the United
States; most (58%) of the babies were taken from the mother’s room (National Center for Missing and
Exploited Children, 2012). The Joint Commission (1999) calls for hospitals to have a management plan to
prevent infant abductions. Such a plan might include security devices such as access control to the unit, closed-
circuit television, computer monitoring systems, and electronic infant security systems in which tamper-proof
tags are placed on the neonate immediately after birth and removed at the time of hospital discharge. The
mother should be taught to check the identity of any person who comes to remove the baby from her room.
Hospital personnel usually wear picture identification badges. On some units all staff members wear matching
scrubs or special badges that are unique to the perinatal unit. As a rule the baby is never carried in a staff
member’s arms between the mother’s room and the nursery but rather is always wheeled in a bassinet, which
also contains baby care supplies. Patients and nurses must work together to ensure the safety of newborns in the
hospital environment (Vincent, 2009).

 Safety Alert

Nurses play a critical role in educating parents about measures to prevent infant abduction. Parents should be
instructed how to identify legitimate hospital personnel, to never leave the newborn in the hospital room
without direct supervision, and to request a second staff member to verify the identity of any questionable
person who wants to take the baby from the mother’s room. Parents should be instructed to use caution when
posting photos of the new baby on the Internet and publishing public notices about the birth (Vincent, 2009).

Prevention of Infection

Nurses in the postpartum setting are acutely aware of the importance of preventing infection in their patients.
One important means of preventing infection is maintenance of a clean environment. Bed linens should be
changed as needed. Disposable pads should be changed frequently. Women should wear shoes when walking
about to avoid contaminating the linens when they return to bed. A sitz bath or heat lamp used by more than one
patient must be scrubbed after each woman’s use. Personnel must be conscientious about their hand hygiene to
prevent cross-infection. Standard Precautions must be practiced. Staff members with colds, coughs, or skin
infections (e.g., a cold sore on the lips [herpes simplex virus type I]) must follow hospital protocol when in
contact with postpartum patients. In many hospitals staff with open herpetic lesions, strep throat, conjunctivitis,
upper respiratory infections, or diarrhea are encouraged to avoid contact with mothers and infants by staying
home until the condition is no longer contagious. Visitors with signs of illness are not permitted to enter the
postpartum unit.

Perineal lacerations and episiotomies can increase the risk of infection as a result of interruption in skin
integrity. Proper perineal care helps prevent infection in the genitourinary area and aids the healing process.
Educating the woman to wipe from front to back (urethra to anus) after voiding or defecating is a simple first
step. In many hospitals a squeeze bottle filled with warm water or an antiseptic solution is used after each
voiding to cleanse the perineal area. The woman should change her perineal pad from front to back each time
she voids or defecates and wash her hands thoroughly before and after doing so (Box 19-1).

Box 19-1   Interventions for Episiotomy, Lacerations, and Hemorrhoids

Explain procedure and rationale before implementation.

Cleansing

• Wash hands before and after cleansing perineum and changing pads.

• Wash perineum with mild soap and warm water at least once daily.

• Cleanse from symphysis pubis to anal area.

• Apply peripad from front to back, protecting inner surface of pad from contamination.

• Wrap soiled pad and place in covered waste container.

• Change pad with each void or defecation or at least 4 times per day.

• Assess amount and character of lochia with each pad change.

Ice Pack

• Apply a covered ice pack to perineum from front to back:

• During first 24 hours to decrease edema formation and increase comfort.

• After first 24 hours following birth as needed to provide anesthetic effect.

Squeeze Bottle

• Demonstrate use and assist woman; explain rationale.

• Fill bottle with tap water warmed to approximately 38° C (100.4° F) (comfortably warm on wrist).

• Instruct woman to position nozzle between her legs so squirts of water reach perineum as she sits on toilet
seat. Explain that it will take whole bottle of water to cleanse perineum.

• Remind her to blot dry with toilet paper or clean wipes.

• Remind her to avoid contamination from anal area.

• Apply clean pad.

Sitz Bath

Built-In Type

• Prepare bath by thoroughly scrubbing with cleaning agent and rinsing.

• Pad with towel before filling.

• Fill one-third to one-half full with water of correct temperature 38° to 40.6° C (100.4° to 105.1° F). Some
women prefer cool sitz baths. Ice is added to water to lower temperature to level comfortable for woman.
• Encourage woman to use at least twice a day for 20 minutes.

• Place call bell within easy reach.

• Teach woman to enter bath by tightening gluteal muscles and keeping them tightened and then relaxing them
after she is in bath.

• Place dry towels within reach.

• Ensure privacy.

• Check woman in 15 minutes.