Postpartum care presents a special challenge, as it concerns two i.e. mother and her baby people with very distinct needs. However it is believed that contribution to good quality care ensure to balance the challenge. The major maternal and neonatal health challenges include nutrition and breastfeeding, birth spacing, immunization and HIV/AIDS, therefore Post partum care is pre-eminently about the provision of a supportive environment in which a woman, her baby and the wider family can begin their new life together. Therefore this guideline aims to identify the essential core (routine) care that every woman and her baby should receive in the first 6-8 weeks after birth, based on the best evidence available.
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This guideline has been written within a conceptual framework which places the woman and her baby at the centre of care, appreciating that all post partum care should be delivered in partnership with the woman and should be individualized to meet the needs of each mother-infant dyad. Thus this clinical guideline of post partum is to offer information to support midwives to increase the knowledge and skills that enable them to handle mothers and their neonates and management of postpartum complication, and referral.
Objectives:
Perform postpartum examination on mother and baby and provide care to ensure safe post partum.
Provide first line EmONC or referral for the complication occurring during postpartum period
Facilitate the process of lactation and infant bounding.
Support of the mother and her family in the transition to a new family constellation, and response to their needs prevention, early diagnosis and treatment of complications of mother and infant, including the prevention of vertical transmission of diseases from mother to infant
Counsel the couple for:
resumption of sexual activity and birth spacing regular contraception service, emergency contraceptive methods,
dispelling myths and birth spacing in special situation.
maternal nutrition, and supplementation if necessary
baby care support of breastfeeding
Immunization of the infant and mother.
Referral of mother and infant for specialist care when necessary
CLINICAL PLACEMENT
Out Patient Department
Postnatal wards
Well baby room
Community Primary Health Care centers
POST PARTUM VISIT SCHEDULE
AFTER 3rd STAGE OF LABOUR TILL 2 HOURS
AFTER 2 HOURS TILL 24 Hours
First visit (within the first week, preferably within 2-3 days)
Second visit (4-6 weeks)
More frequent visits or different schedules may be required according to client need and or hospital policy. Encourage the woman to bring her partner or family member to at least 1 visit.
KEY ELEMENTS OF POSTPARTUM CARE:
6-12 hours
3- 6 days
6 weeks
blood loss
pain
BP
advice/
warning signs
breast care
temperature/infection
lochia
mood
recovery
anaemia
contraception
IMMEDIATE POST PARTUM CARE (After 3rd stage of labor till 2 hrs)
Initial Postpartum Recovery Assessment: special
attention to: Monitoring and assessment of maternal well being, prevention and detection of complications (e.g. bleeding, hypertension, and infections)
Determine;
Assess amount and the character of BLEEDING ,
Measure and document vital sign (BLOOD PRESSURE, pulse rate and temperature
Other warning sign like fever, uterine involution, pain etc
Status of the perineum, (tears laceration)
Status of the fundus; position and firmness
Document urine void within 6 hours.
Ensure emptiness of urinary bladder
Monitor for signs of bladder distension.
After delivery IV fluids infusing type and amount
Response of the woman and her partner to the newborn
Give woman time with baby and family to facilitate bonding and celebrate the occasion.
Status of the breasts once immediately after delivery and then again just before transfer to postpartum
Allow women to rest
Pain assessment; if the woman is experiencing any pain;
Determine the characteristics, quality, timing, and relief after comfort measures,
Investigate the source (e.g., after pains, episiotomy, painful urination, pain in the calves).
If the woman had a cesarean delivery;
check the incision dressing for intactness and determine incision bleeding
if any complain for pain type, and success of analgesics and comfort measures to control the pain;
toleration of ambulation
status of the bladder;
Provide hygiene care.
Help woman to re – dress
Establishments of breastfeeding/
ROUTINE PROGRESSIVE POST PARTUM CARE (After 2hrs till 24 hrs)
Take medical and pregnancy histories and perform physical examination that are important to alert for postpartum risk such as postpartum Hemorrhage, infection, and lead to normal healing
First Visit
HISTORY (should include significant pregnancy, labor and birth newborn history
Review of Ante Partum chart and labs, problems which may need follow up
Review of Intra Partum course and labs
Check records:
any complications during delivery
Receiving any treatments
Review of status since birth to postpartum period
Review if patient is Tdap immunization status
Obtains information about cultural factors influencing client’s health and
compliance
Assesses clients and significant other’s feelings and level of understanding of
sexuality, post partum.
Observe the gravid woman for verbal and non-verbal clues to exclude post partum
bluesdepression
HIV status
CONTINOUS POST PARTUM ASSESSMENT (ONCE PER SHIFT)
Take the vital signs including of
Respiratory characteristic s and
Rule out labour breathing shortness of breath and chest pain.
Regular Heart rate
Height, And Weight
Performs review of systems appropriate to POSTPARTUM
Body parts
Assessment and Probable findings
Breasts
Inspect the:
Colostrum excretion
breasts for signs of engorgement,
nipples aversion/ redness, or
cracks, then
Palpate the breasts gently to determine
if they are soft, filling, or engorged with milk
Note if there is pain/ oedema/ swelling
Abdomen
Inspect the abdomen and note:
striae, scars,
shape and size of the abdomen
Any organs enlargement and any masses.
Palpate the abdomen to assess
uterus involution (by height of fundas)
determine consistency, tone, position,
size/height in relation to the umbilicus
Genitalia
Inspect
Vulva and perineum for: tear, swelling, pus.
Observe external genitalia for
color of skin, varicosities, and
laceration, episiotomy stitches healing.
vaginal opening for cystocele or rectocele.
Vaginal discharge (lochia); special attention to color, amount and odor
Bladder and bowel;
Assess voiding amounts (more than 100 mL per each voiding) frequency
If amounts smaller than 100 mL check for urinary retention, i.e. suprapubic distention
Auscultate for bowel sounds in each quaderant.
Ask the woman if she has had a bowel movement after delivery.
Peripheral vascular
Inspect the extremities for edema equality of pulses, and capillary refill.
Check for Homans’ sign when the feet are dorsiflexed or woman is walking.
Hemoglobin and hematocrit (h&h).
Compare the H&H before delivery.
Note the blood type and Rh. If the woman is Rh-negative, arrange for RhoGAM
MEDICATION
For pain relief advise:
Topical cold therapy
Paracetamol
NSAIDs if not contraindicated
In areas of high prevalence of iron deficiency anaemia, 400 mg ferrous sulphate (2 tablets) per day or once a week, with 250 μg folate for 4 months is recommended for pregnant and lactating women. In areas of low prevalence 1 tablet of ferrous sulphate daily may be sufficient.
IMMUNIZATION
Offer Anti-D immunoglobulin within 72 hours to every non-sensitized Rh-D-negative woman following the delivery of an RhD-positive baby.
Complete TT vaccination for woman according to given schedule if required
Offered an MMR (measles, mumps, rubella) vaccination following birth and before discharge from the maternity unit if they are in hospital if on antenatal screening women found to be sero-negative for rubella following the safety protocol
Health Education for mother
All women should be given information about the physiological process of recovery after birth, and that some health problems are common, with advice to report any health concerns to healthcare professional, in particular:
Signs and symptoms of PPH: sudden and profuse blood loss or persistent increased blood loss; faintness; dizziness; palpitations/tachycardia.
Signs and symptoms of infection: fever; shaking; abdominal pain and/or offensive vaginal loss.
Signs and symptoms of thromboembolism: unilateral calf pain; redness or swelling of calves; shortness of breath or chest pain.
Signs and symptoms of pre-eclampsia: headaches accompanied by one or more of the symptoms of visual disturbances, nausea, vomiting, feeling faint.
Women who have had an epidural or spinal anesthesia should be advised to report any severe headache, particularly when sitting or standing
Diet during post partum
Caring breast while breast feeding
Fundal Massage
Perineum and Vaginal Care
Pain Management: explain the non- medicinal ways of easing pain, such as applying warmth to the abdomen to help soothe after pains.
Activities contribute to or prevent constipation.
If non immune for rubella educate for rubella immunization
SECOND VISIT (4-6 weeks)
HISTORY
Follow the guideline of ROUTINE POST PARTUM CARE (After 2hrs till 6hrs)
CONTINOUS POST PARTUM ASSESSMENT follow the guideline of (After 2hrs till
6hrs)
MEDICATION
Follow the guideline of ROUTINE POST PARTUM CARE (After 2hrs till 6hrs)
VACCINATION
Follow the guideline of ROUTINE POST PARTUM CARE (After 2hrs till 6hrs)
HEALTH EDUCATION
Follow the guideline of ROUTINE POST PARTUM CARE (After 2hrs till 6 hrs)
Postpartum Discharge
Plan and complete all necessary assessment and care as per hospital policy by consider
maternal and infant health and financial status.
HISTORY
Review of the woman’s physical, emotional and social well-being at taking in account the routine examinations
Counsel mother & family on baby care.
ASSESSMENT OR EXAMINATION
Follow the guideline of ROUTINE POST PARTUM CARE (After 2hrs till 6hrs)
HEALTH EDUCATION
Explain all take home medication with their effects and side effects.
Allow them to resolve their queries.
Educate mother about
danger signs,
personal hygiene,
perineal care,
postpartum exercises,
follow-up visit
baby care,
baby & mother immunization,
breast feeding,
Postpartum COMPLICATION MANAGEMENT
essentc
Hypertension during postnatal period
Continue to assess patients for signs and symptoms or worsening of preeclampsia in the postpartum period.
For postpartum patients on magnesium sulfate:
In general the magnesium sulfate is continued for 24 hours postpartum
Strict I&O in the initial 24 hours postpartum
Evaluation between 4 and 8 hours postpartum for vital signs especially BP, I&O, signs of magnesium toxicity, evaluation
for further information Refer:
World Health Organization, International Confederation of Midwifery (ICM) (2008). Midwifery education modules – second edition Managing Eclampsia Available: http://whqlibdoc.who.int/publications/2008
Baby Blues/ Post Partum Depression
Definition: A transient period of depression that occurs during the first week or two after birth
Causes: hormonal changes, fatigue
Sign and symptoms: mood swings, anger, weepiness, anorexia, insomnia
Intervention
Usually will resolve naturally
Should receive social support
Needs plenty of rest
Anemia
(Refer PHRplus/Albania (2005) Toolkits for Strengthening Primary Health Care Clinical Practice Guideline for Family Doctors; Quick References Partners for Health Reforms, & USAID) Available: http://www.who.int/management/ToolkitsforStrengtheningPHCAlbaniaPHC.pdf
Postpartum Hemorrhage
Refer: World Health Organization, International Confederation of Midwifery (ICM) (2008). Midwifery education modules – second edition Managing postpartum hemorrhage Available: http://whqlibdoc.who.int/publications/2008
Puerperal Sepsis
Refer: World Health Organization, International Confederation of Midwifery (ICM) (2008). Midwifery education
modules – second edition Managing Puerperal Sepsis Available: http://whqlibdoc.who.int/publications/2008
Diabetes in postpartum period
Refer: World Health Organization Reproductive Health AND Research (2005). A pocket guide for essential practice Sexually Transmitted and Other Reproductive Tract Infections integrating STI/RTI, HIV Care for Reproductive Health
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