POSTNATAL MANAGEMENT

OBJECTIVES

• Assess the condition of postnatal mothers;

• Describe the specific nursing procedures and common
problems in postnatal mothers;
• Specify the nursing care needs of postnatal mothers and
indicate how to provide
• Appropriate care and support to the postnatal mothers; and
• Identify deviations from normal and take appropriate action.
• The major goal of postnatal care is to restore the health
of the mother and the newborn.
• It is a time of transition where physiological changes
occur, the woman adapts to mothering role and the
family system is altered by the addition of the newborn.
• Nursing care during the immediate postpartum period is
highly significant for the later period. This needs a
skilled nursing care for mother and the newborn.
 POSTPARTUM ASSESSMENT
• Postpartum period is a period from the birth of the
newborn to six weeks. An arbitrary time frame divides
the period into –

 Immediate postpartum (first 24 hours)

 Early postpartum (first week)
 Late postpartum (up to 90 days).
 Immediate Postpartum Assessment
• Assess vital signs every 15 minutes for one hour and as per the
protocol of the institution.
• Palpate fundus for uterine tone and position.
• Assess lochia every 15 minutes for one hour, then every 4 hours or
more frequently if indicated, for 12 to 24 hours.
• Massage the uterus gently if uterus does not remain firmly
contracted.
• Support the lower uterine segment during massage. It prevents
inversion of uterus or prolapse.
• Encourage breast feeding within half an hour after delivery.
 Immediate postpartum assessment
• https://youtu.be/vAQvwAWqx4o
 Late Postpartum Assessment
a) Emotional Status
Assess for interaction of mother with new born, fatigue level and social
support; e.g. support by her family members and friends.
b) Physical Assessment
· Assessment of Breast:
— Redness
— Pain
— Engorgement
— Technique of breast feeding to newborn
https://youtu.be/DzVhumIrqd0?t=30
 Late Postpartum Assessment
· Assessment of uterus and Lochia
· Assessment of bladder:
— Dullness before/after voiding
— Measure the first void
• Tone of abdominal muscles and assess for bowel sounds.
• Assess perineum, labia, and anus for edema, redness,
pain, bruising and hematoma. Assess episiotomy incision
for approximation.
 Late Postpartum Assessment- contd.
• Assess legs and feet for edema, varicosities.
• Assess Homan’s sign.
• https://youtu.be/DzVhumIrqd0?t=852

• If thrombophlebitis, take the width of calf and measure of both extremities.

• Assess activity tolerance.
• Assess for her comfort level.
• Assess for breath sound.
• Assess the needs of both-mother and baby.
• Do not forget to remember “Assessment BUBBLERS – Breast, Uterus, Bladder,
Bowel, Lochia, Episiotomy/Incision, Emotional Response and Homan’s Sign”.
 Care of the mother during postnatal period
a) Assessment
• Observe for sign of normal involution of uterus.
• Observe signs of healing of episiotomy.
• Observe for lactation and breast feeding.
• Observe the mother providing care to her newborn.
• Teach the mother aspects of self-care and newborn care.
• Report and record for increased pulse rate, decreased B.P. and elevated
temperature.
• Gently massage the fundus if boggy and express clots if any, from the
fundus.
b) Care of Episiotomy

i) Soon after delivery, apply ice or cold therapy to the episiotomy or

if any laceration.

• After that, apply moist or dry heat to promote comfort. Provide

sitz bath twice a day.

• Administer analgesics as per the physician’s instructions.

• Advice mother to squeeze both the buttocks together and tighten

the perineal region before sitting.

ii) Perineal hygiene:

• Help the mother in cleaning of her perineum after each voiding and evacuation.

• Clean the perineal area from the front to back to avoid infection. Clean with

warm water or clean water or with antiseptic solution.

• Apply perineal pad from front to back.

• Instruct mother to wear perineal pads loosely and to lie in Sim’s position

(sideline position).
• Clean the episiotomy suture with antiseptic solution.

• Observe for any edema, redness, varicosites etc. if so, apply ice or cold to
decrease edema and reduction in pain due to anaesthetic effect.
• Apply dry or moist heat to the episiotomy for comfort and healing.
c) Breast Care and Breast Feeding
• Assess the breast for softness or hardness, condition of breast
nipples (e.g. flat, inverted, big/small, cracked etc.).
• Assess mother’s knowledge on breast feeding.
• Help the mother to breast feed within ½ an hour of delivery
ASAP. Put the newborn in monkey position on the mothers’
chest.
• Tell the mother to breast feed whenever newborn cries (demand
feed). Instruct her to feed 6 to 10 times a day from both the
breasts at each feed.
• Help the mother to position the new born properly while breast
feeding for adequacy. Tell the mother to adopt to timely feeding
(2/3 hourly)—Advice her for wearing well fitting brassieres.
• Instruct regarding care of newborn during and after breast feeding.
• Instruct the mother to identify for rooting reflexes (i.e. tell mother
to bring her breast nipples near the cheeks of the newborn and
newborn automatically turns to fix the mouth to the breast
nipples).
• Instruct her to hold the feeding breast with her fingers in a scissors
grasp hold.
• Relax and feed the baby from each breast at least for 5-10 minutes.
• Advice her to burp the baby after feeding from the first breast.
After feeding, repeat for the next breast (To burp the baby, hold
the baby in upright position).
• Advice her to put the baby in right sideline positions after feeding.

• Advice her to express the extra milk from the breast after each
feed.
• Clean the mouth of the newborn.

• Advice her to put well fitting brassiers.

• Under privacy, ask her to expose the breast and nipple to air for a
few minutes every day.
• Observation for any abnormalities:

• — Cracked nipple
• — Sore nipple

• — Condition of breast (hardness or softness)

• — Redness, pain, varicosites, warmth and fever

d) Meeting the Nutritional Need of Lactating Mother (Postnatal
Women)-
• Assess the nutritional status of the mother.
• Help her to take well balanced diet rich in proteins, vitamins and
minerals and their importance.
• Help her to add foods of fiber content (e.g. Ladies finger,
drumstick, green leafy vegetables etc.).
• Help to take more fluids for adequate bowel movement. Assess for
adequacy of breast milk production.
• Advice her to add foodstuff for improving breast secretion.
• Provide the list of iron rich diets (e.g. dates, ragi, jaggery etc.).
 Menu: Sample
• 6.00 a.m.- milk 1 glass (200 ml).
• 8.00 a.m. - idli/dosa/soft food with sambar/chutney or any other soft diet as per the
choice of the mother.( 3-6 nos).
• 10.00 a.m. -Juice (any) 1 glass (200 ml).
• 1.00 p.m.- Rice/Chapati with curry/Sambar, vegetables, curd etc. — Full meals
• 3.00 p.m.- 1 glass of milk with snacks or tea (200 ml).
• 6.00 p.m. -1 glass of juice (200 ml).
• 8.00 p.m. -Tiffin as per the choice of the mother (meal)
• 10.00 p.m.- Dinner
• At bed time 1 glass of milk 200 ml.
• Midnight — one glass of milk 200 ml/ biscuits
• Encourage intake of 3,000 ml of water and other liquids in 24 hours.
e) Maintenance of Normal Elimination
• Encourage mothers for spontaneous voiding of urine at the
urge (within 6-10 hours) after birth.
• Motivate her to have adequate fluids and water.

• If required, provide her a clean bedpan.

• Encourage mother to consume a balanced diet.
• Observe for bladder distention. Mother will report of fullness
of bladder with urge to urinate, but inability to do so.
• Avoid rapid emptying if catheterization is done
f) Observation and Early Identification of Stress in Mother
• Observe for adequate sleep and rest and general behaviour towards
self, baby and others.
g) Essential Exercises Following Normal Delivery
IDENTIFICATION OF DEVIATIONS FROM NORMAL PUERPERIUM

a) Appearance of Signs and Symptoms of Breast Engorgement

 b) Postpartum Hemorrhage
 Assessment H/O any-  Mean arterial pressure (MAP)
• Previous PPH
 Assessment of intake-output
• Rapid or prolonged labor
• Uterine overdistension accurately
• Operative birth due to parity  Plan the care e.g. early recognition
• Placental abnormality
and early attention
• Previous uterine surgery
• Assess blood loss  Nursing intervention to be planned
• Weigh pads (1 gm = 1 ml) — IV Tray. Draw blood for hemoglobin
 Assess vital signs every 15 minutes and hematocrits cross match type,
coagulation time.
— Insert Foley’s catheter to empty the
bladder
— Administer IV fluid with prescribed
drops
— Administer oxygen
 c) Postpartum Infection

· Assessment of vital signs

· Increase fluid intake and encourage adequate nutrients
intake
· Encourage adequate output.
· Provide comfort by meeting mother’s personal hygiene,
cool compress, perineal care and positioning.
· Prompt observation to avoid septic shock
· Postpartum learning — needs assessment and education
· On assessing learning needs the teaching be planned and conducted
on any of the selected topics:
— Pelvic floor exercises: Kegels exercises.

— Abdominal breathing exercises.

— Sexuality: Coping mechanism to both parents should be explained.
— Contraception: Discuss and provide the best choice of selection of
contraception to the couples.
— Transition to parenthood: Fatigue is most commonly found among
post partum period. Need prompt guidance to the family members for
support will help.
— Additional stress on: Adoption to post partum period. Role
conflict, newborn needs, changes in parent relationship. Encourage to
develop a greater sense of well being through guidance and support.
— Postpartum blues and depression: Assess for any transient
emotional disturbances to “baby blues” which occurs 3 to 4 days post
partum and lasts for some time. Identify symptoms e.g. Fatigues,
psychic anxiety,
worry.
— Family transition to parenthood.
— Assess risk mothers and their social status in the family.
CARE OF NEWBORN
 Immediate Care of the Baby at Birth
• · As baby’s head is born, wipe excess mucus gently from her/his mother
• · Handle the newborn gently, note the time of birth and sex of the baby

Clearing the Airway

• · Clean the mouth and nose
• · Suck the oropharynx with mucus extraction or soft rubber catheter suction and
continue suction for nasopharynx
• · Cutting the cord
• · Clamp the umbilical cord 8-10 cms away from the umbillicus.
• · Cut the umbilical cord leaving 4-5 cms away from the umbilicus.

Identification
• · Tie identification band for the baby and mother with the same information of date and
time of delivery, sex, name of father and mother.
• Essentials of Newborn Assessment
• · During transition period
• · Check APGAR SCORE at 1 minute and 5 minutes.
• · Clear the airway if there is excessive secretion.
• · Wrap the baby in a thick towel.
• · Put the baby under the warmer if it is necessary.
• · Assess the general status (size , weight, length, head and chest
circumference), gestational status, normality of body system, vital
signs.
• · Measure body temperature every 30 minutes until stable and 4 hours
thereafter
 Physical Assessment of Newborn
• Physical assessment includes vital signs and head to toe examination.

Vital Signs
• · Respiratory rate (normal: 30-60 per minute)
• · Heart Rate: Apical rate (Normal : 120-160 per minute)
• · Temperature: Either axillary or anal
• · Weight: Weigh newborn at the same time each time before feeding.
• · Place newborn on flat surface and extend legs fully before measuring to check
the length of the baby.
• · Measure around the fullest part of the occiput to check head circumference.
• · Measure the chest circumference over the nipples and across the lower border
of the scapula
 Detailed Physical Assessment
Head and Face
• · Head size in proportion to body
• · Presence of moulding.
• · Symmetry features,

Fontannels
• · Anterior fontannels: Diamond shaped 3-4 cms long, 2-3 cms wide at 18
months.
• · Posterior fontannels: Triangle shaped, closed by 8-12 weeks.
• · Tense bulging fontannels indicate increase of intra-cranial pressure
• · Sunken fontannel indicates dehydration
Eyes
• · Colour

• · Transient strabismus and nystagmus common in newborn

• · Doll’s eye phenomenon.

Nose and Mouth

• · Nasal patency

• · Mucous secretions, if excessive, indicates tracheoesophageal fistula

• · Precocious teeth

• · Epstein’s pearl over the hard palate.

Ears and Neck

• · Ear pliability and flexibility

• · Low set ears indicate chromosomal or organ abnormality

• · Hearing

• · Neck size
Chest
• · Contour and symmetry (normally round and symmetrical)
• · Breast engorgement may be evident 2-3 days after birth due to maternal hormone withdrawal
• · Respiration: (normally shallow, symmetrical, synchronous with abdominal movement).
• · Breath sounds (crackles may be present during transitional period representing fetal lung fluid
and areas of atelectasis.
• · Rhonchi indicate fluid, mucus or meconium in the larger bronchi.
• · Heart sound: (murmurs can be heard in case of improper closure of foramen ovale or ductus
arterioles.
Abdomen
• · Contour of abdomen (normally round)
• · Umbilical cord (normally check for two arteries and one vein)
• · Scaffold (deflated) sunken abdomen indicates diaphragmatic hernia.
• · Bowel sounds (normally audible when newborn is relaxed).
Genitalia
• Female
• · Labia minora may have vernix
• · Labia majora (normally covers minora and clitoris)

• · Vaginal discharge (may be present due to maternal hormones called pseudomenstruation)

• Male
• · Scrotum (normally rugae present and both testis descended into the scrotum)

• · Penis (urethral meatus normally located at tip of glans)

Back and Buttocks

• · Spine (normally flat and round)

• · Patent anal opening

Upper Extremities
• · Flexion and movement (normally well flexed with symmetrical movement)
• · Grasp reflex (normally present)
• · Muscle tone and strength
• · Brachial pulses (normally present)

Lower Extremities
• · Length and flexion (normally short, bowed and flexed)

• · Femoral and pedal pulses (normally present

 Nursing Care of Neonate
Establishment and Maintenance of Respiration
• · Assess the cry of the baby (failure to cry may be due to obstruction of the air passage with mucus).
• · Suck the oropharynx and nasopharynx with bulb syringe or a catheter connected to suction as soon as the
infant’s head is delivered.
• · Position the newborn on the back or the abdomen with the head lowered 15-30º to facilitate mucus drainage.
• · Keep the newborn warm.

Stabilization and Maintenance of Body Temperature

• · Assess the body temperature of newborn.

• · Dry the hair and skin with warm soft dry towels.
• · Drape the neonate in blankets or put the neonate in heated environment.
• · Do not give bath until body temperature is normal and stable.

• · Do not expose the newborn.

• · Dress the infant and cover with blankets.
• · Head can be covered with cap and feet with booties if heat loss is a problem.
Prevention of Infection and Injury
• · Keep the baby’s environment clean and tidy.
• · Hand-wash before handling the baby.
• · Use clean clothes, linen and equipments only.
• · Give injection Vitamin K, if prescribed.
• · Assess the condition of umbilical cord.
• · Teach parents to tie diaper below the cord.
• · Change napkins whenever soiled.
• · Do not apply powder in excess on skin.

Provision of Optimal Nutrition

• · Feed baby within 1/2 hour of delivery.
• · Explain mother regarding importance of breast-feeding and teach breast feeding technique.
• · Feed child on demand for 2-3 days thereafter and burp the newborn after breast feeding.
• · Advice parents and relatives to feed neonate exclusively with breast milk.
Establishment of Mother Child Bonding
• · Place the baby over the mother’s abdomen immediately after
delivery.
• · Promote rooming-in by advising mother to put the baby near her.
• · Assess maternal attaching behaviour by watching for gazing,
kissing and holding the infant.
• · Advice mother to talk to the infant.

• · Assess infant attachment behaviours like sucking, crying, body

and eye movements.