Nursing Care of the Family during the Fourth Trimester

Nursing Care of the Family during the Fourth Trimester

Kathryn Rhodes Alden

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A t 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, assessment of physiologic and psychologic adaptation after birth, prevention of complications, education regarding self-care and infant care, and support of 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 plan of care to assist the family in adjusting to the new baby.

The approach to the care of women after birth is wellness oriented. Most women in the United States 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. Care during the first 1 to 2 hours after birth, also known as the fourth stage of labor, is covered in Chapter 12. This chapter discusses nursing care of the postpartum woman and her family subsequent to the initial recovery period after birth, extending into the fourth trimester—the first 3 months after birth.

Transfer from the Recovery Area image

After the initial recovery period has been completed, and provided that her condition is stable, the woman may be transferred to a postpartum room in the same or another nursing unit. In facilities with labor, delivery, recovery, and postpartum (LDRP) rooms the nurse who provides care during the recovery period usually continues caring for the woman. 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 preparing the transfer report the recovery nurse uses information from the records of admission, labor and birth, and recovery. Information that must be communicated to the postpartum nurse includes the 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 streptococci status; status of rubella immunity; syphilis, hepatitis B, and human immunodeficiency virus (HIV) test results (if positive); intravenous infusion of any fluids; physiologic status since birth; description of the fundus, lochia, bladder, and perineum; sex and weight of the infant; time of birth; name of the pediatric care provider, chosen method of feeding; any abnormalities noted; and assessment of initial parent-infant interaction.

Most of this information is also documented for the nursing staff in the newborn nursery if the infant is transferred to that unit (in some settings the newborn never leaves the mother’s room). In addition, specific information should be provided regarding the newborn’s Apgar scores, weight, voiding, stooling, and any feedings since birth. Nursing interventions that have been completed (e.g., eye prophylaxis, vitamin K injection) are also recorded.

Planning for Discharge image

From their initial contact with the postpartum woman, nurses are preparing the new mother for the time when she will return home. The length of hospital 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-care 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 the 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, often called early postpartum discharge, shortened hospital stay, or 1-day maternity stay. The trend of shortened hospital stays is based largely on efforts to reduce health care costs coupled with consumer demands to have fewer medical interventions and more family-focused experiences. Although some advantages to early postpartum discharge can be found, disadvantages also exist (Box 14-1).

Laws Relating to Discharge

The trend toward early postpartum discharge in the early 1990s raised serious concerns among health care providers because some medical problems do not show up in the first 24 hours after birth. The greatest risk associated with early discharge is for the infant who may develop jaundice, feeding difficulties, infection, gastrointestinal obstruction, or unrecognized respiratory or cardiac problems. In addition, new mothers have not had sufficient time to learn how to care for their newborns, and breastfeeding may not be well established (AAP Committee on Fetus and Newborn, 2010).

The concern for the potential increase in adverse maternal-infant outcomes from early discharge practices led the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and other professional health care organizations to promote the enactment of federal and state maternity length-of-stay bills to ensure adequate care for both the mother and the newborn. The passage of the Newborns’ and Mothers’ Health Protection Act of 1996 provided minimal federal standards for health plan coverage for mothers and their newborns. 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 a normal vaginal birth and for 96 hours after a cesarean birth unless the attending provider, in consultation with the mother, decides on early discharge (AAP Committee on Fetus and Newborn, 2010).

Criteria for Discharge

The American Academy of Pediatrics (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 newborn at home. The health of the mother and newborn should be stable. There should be adequate support systems in place and access to follow-up care (AAP Committee on Fetus and Newborn, 2010).

Ideally, hospital stays are long enough to identify problems and to ensure that the woman is sufficiently recovered and is prepared to care for herself and the baby at home. Nurses must consider the medical needs of the woman and her baby and provide care that is coordinated to meet those needs so as to provide timely physiologic interventions and treatment to prevent morbidity and hospital readmission. With predetermined criteria for identifying low risk mothers and newborns (Box 14-2) the length of hospitalization can be based on the medical need for care in an acute care setting or in consideration of the ongoing care needed in the home environment. Early follow-up visits are key to reduce readmissions of newborns.

Hospital-based maternity nurses continue to play invaluable roles as caregivers, teachers, and patient and family advocates in developing and implementing effective home care strategies. Postpartum order sets and maternal-newborn teaching checklists (Box 14-3) 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 ensure the family’s continued well-being.

Care Management—Physiologic Needs image

The nursing care plan includes both the postpartum woman and her newborn, even if the nursery nurse retains primary responsibility for the infant. In many hospitals, couplet care (also called mother-baby care or single-room maternity care) is practiced. 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 into consideration. The day actually revolves around the baby’s feeding and care times.

Nursing Process

Physiologic Postpartum Concerns


Nursing Diagnoses

Examples of nursing diagnoses for meeting physical needs in the postpartum period include:

• Risk for deficient fluid volume (hemorrhage) related to:

• Risk for constipation related to:

• Acute pain related to:

• Disturbed sleep pattern related to:

• Ineffective breastfeeding related to:

Expected Outcomes of Care

Expected outcomes for the postpartum period are based on the nursing diagnoses identified for the individual patient. Examples of expected outcomes are:

A focused physical assessment, including vital signs, is performed on admission to the postpartum unit. If the woman’s vital signs are stable, they are usually assessed every 4 to 8 hours while she is hospitalized. Other components of the initial assessment include the mother’s emotional status, energy level, physical discomfort, hunger, and thirst. Intake and output assessments are performed if an intravenous infusion or urinary catheter is in place. For the woman who gave birth by cesarean the incisional dressing is also assessed.

Ongoing assessments are performed throughout hospitalization. In addition to vital signs, physical assessment of the postpartum woman focuses on evaluation of breasts, uterine fundus, lochia, perineum, bladder and bowel function, and legs (Table 14-1).

TABLE 14-1

Postpartum Assessment and Signs of Potential Complications

Blood pressure (BP) Consistent with BP baseline during pregnancy; may have orthostatic hypotension for 48 hours
Temperature 36.2°-38° C >38° C after 24 hours: infection
Pulse 50-90 beats/min Tachycardia: pain, fever, dehydration, hemorrhage
Respirations 16-24 breaths/min
Breath sounds Clear to auscultation Crackles: possible fluid overload

Nipples Skin intact; no soreness reported Redness, bruising, cracks, fissures, abrasions, blisters: usually associated with latch problems
Uterus (fundus) Firm, midline; first 24 hours at level of umbilicus; involutes ∼1 cm/day


Rectal area No hemorrhoids; if hemorrhoids are present, soft and pink Discolored hemorrhoidal tissue, severe pain: thrombosed hemorrhoid

Abdomen and bowels
No bowel movement by day 3-4: constipation; diarrhea
Cesarean: incision dressing clean and dry; suture line intact Abdominal incision—redness, edema, warmth, drainage: infection

Energy level Able to care for self and infant; able to sleep Lethargy, extreme fatigue, difficulty sleeping: postpartum depression
Emotional status Excited, happy, interested or involved in infant care Sad, tearful, disinterested in infant care: postpartum blues or depression


Several laboratory tests may be performed in the early postpartum period. Hemoglobin and hematocrit values are often evaluated on the first postpartum day to assess the effects of blood loss during birth, especially after cesarean birth. In some hospitals, a clean-catch or catheterized urine specimen is obtained and sent to the laboratory for routine urinalysis or culture and sensitivity, especially if an indwelling 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 the need for possible treatment should be performed at this time.

Plan of Care and Interventions

Once the nursing diagnoses are formulated the nurse plans with the woman what 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 infant care. The spouse or partner and other family members who are present may 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 or care paths as a basis for planning. Nurses individualize care of the postpartum woman and neonate according to their specific needs (see Nursing Care Plan box). Signs of potential problems that may be identified during the assessment process are listed in Table 14-1.

Nursing Care Plan

Postpartum Care: Vaginal Birth

Nursing Diagnosis Risk for deficient fluid volume related to uterine atony and hemorrhage

Expected outcome Fundus is firm and midline, lochia is moderate, and no evidence of hemorrhage is seen.

Nursing Interventions/Rationales

• Monitor lochia (color, amount, consistency), and count and weigh sanitary pads if lochia is heavy to evaluate amount of bleeding.

• Monitor and palpate fundus for location and tone to determine status of uterus and dictate further interventions because uterine atony is most common cause of postpartum hemorrhage.

• Monitor intake and output, assess for bladder fullness, and encourage voiding because a full bladder interferes with involution of the uterus.

• Monitor vital signs (increased pulse and respirations, decreased blood pressure) and skin temperature and color to detect signs of hemorrhage or shock.

• Monitor postpartum hematology studies to assess effects of blood loss.

• If fundus is boggy, apply gentle massage and assess tone response to promote uterine contractions and increase uterine tone. (Do not overstimulate because doing so can cause fundal relaxation.)

• Express uterine clots to promote uterine contraction.

• Explain to the woman the process of involution and teach her to assess and massage the fundus and to report any persistent bogginess to involve her in self-management and increase sense of self-control.

• Administer oxytocic agents per physician or nurse-midwife order and evaluate effectiveness to promote continuing uterine contraction.

• Administer fluids, blood, blood products, or plasma expanders as ordered to replace lost fluid and lost blood volume.

Nursing Diagnosis Acute pain related to postpartum physiologic changes (hemorrhoids, episiotomy, breast engorgement, cracked and sore nipples)

Expected outcome Woman exhibits signs of decreased discomfort.

Nursing Interventions/Rationales

• Assess location, type, and quality of pain to direct intervention.

• Explain to the woman the source and reasons for the pain, its expected duration, and treatments to decrease anxiety and increase sense of control.

• Administer prescribed pain medications to provide pain relief.

• If pain is perineal (laceration episiotomy, hemorrhoids), apply ice packs in the first 24 hours to reduce edema and vulvar irritation and reduce discomfort; encourage sitz baths using cool water for first 24 hours to reduce edema and warm water thereafter to promote circulation; apply witch hazel compresses to reduce edema; teach the woman to use prescribed perineal creams, sprays, or ointments to depress response of peripheral nerves; teach the woman to tighten buttocks before sitting and to sit on flat, hard surfaces to compress buttocks and reduce pressure on the perineum. (Avoid donuts and soft pillows because they separate the buttocks and decrease venous blood flow, increasing pain.)

• If nipples are sore, have the woman rub breast milk into nipples after feeding and air-dry nipples, apply purified lanolin or other breast creams as prescribed or hydrogel pads, and wear breast shields in her bra to minimize nipple irritation. Assist the woman to correct latch problem to prevent further nipple soreness.

• If breasts are engorged, have woman apply ice packs to breasts (15 minutes on, 45 minutes off), and apply cabbage leaves in same manner to relieve discomfort (use only two to three times). Use warm compresses or take a warm shower before breastfeeding to stimulate milk flow and relieve stasis. Hand express milk or pump milk to relieve discomfort if infant is unable to latch on and feed.

• If pain is from breast and woman is not breastfeeding, encourage the use of a well-fitted, supportive bra or breast binder and application of ice packs and cabbage leaves to suppress milk production and decrease discomfort.

Nursing Diagnosis Disturbed sleep pattern related to excitement, discomfort, and environmental interruptions

Expected outcome Woman sleeps for uninterrupted periods and states she feels rested after waking.

Nursing Interventions/Rationales

• Establish the woman’s routine sleep patterns and compare with current sleep patterns, exploring factors that interfere with sleep, to determine scope of problem and direct interventions.

• Individualize nursing routines to fit the woman’s natural body rhythms (i.e., wake-sleep cycles), provide a sleep-promoting environment (i.e., darkness, quiet, adequate ventilation, appropriate room temperature), prepare for sleep using the woman’s usual routines (i.e., back rub, soothing music, warm milk), and teach the use of guided imagery and relaxation techniques to promote optimum conditions for sleep.

• Avoid circumstances or routines that may interfere with sleep (e.g., caffeine, foods that induce heartburn, fluids, strenuous mental or physical activity) to promote healthy sleep patterns.

• Administer sedation or pain medication as prescribed to enhance quality of sleep.

• Advise the woman or partner to limit visitors and activities to prevent fatigue.

• Teach the woman to use infant nap time as a time for her also to nap and replenish energy and decrease fatigue.

Nursing Diagnosis Risk for impaired urinary elimination related to perineal trauma and effects of anesthesia

Expected outcome Woman will void within 6 to 8 hours after birth and will empty bladder completely.

Nurses assume many roles while implementing the nursing care plan. They provide direct physical care, teach mother-baby care, and provide anticipatory guidance and counseling. 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.

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 wrist. The nurse determines how the mother wishes to be addressed and then notes her preference in her record and in 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 services and supplies. If the woman’s usual daily routine before admission differs from the facility’s routine, then the nurse works with the woman to develop a mutually acceptable routine.

As part of orientation to the environment, nurses provide information about unit policies and procedures related to infant security. Infant abduction from hospitals in the United States is an ongoing concern. As a result, many units now have special limited-entry systems in place. Nurses teach mothers 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. Other units use closed-circuit television, computer monitoring systems, or fingerprint identification pads. As a rule the neonate is never carried in a staff member’s arms between the mother’s room and the nursery but is always wheeled in a bassinet. Patients and nurses must work together to ensure the safety of newborns in the hospital environment.

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 involves maintaining a clean environment. Bed linens should be changed as needed, and disposable pads and draw sheets are changed frequently. Women should wear slippers when walking about to prevent contaminating the linens when they return to bed. 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 1]) must follow hospital protocol when in contact with postpartum patients. In many hospitals, staff members 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.

Perineal lacerations and episiotomies increase the risk of infection as a result of interruption in skin integrity. Proper perineal care helps to 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 should wash her hands thoroughly before and after doing so (Box 14-4).

Oct 8, 2016 | Posted by in NURSING | Comments Off on Nursing Care of the Family during the Fourth Trimester

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