Nursing Care of the Family During the Postpartum Period

Nursing Care of the Family During the Postpartum Period

Kathryn R. Alden

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.

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).

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

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.

*Adapted from QSEN at

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


Blood pressure (BP) Consistent with BP baseline during pregnancy; can have orthostatic hypotension for 48 hours Hypertension: anxiety, preeclampsia, essential hypertension
Hypotension: hemorrhage
Temperature 36.2°-38° C (97.2° to 100.4° F) >38° C (100.4° F) after 24 hours: infection
Pulse 50-90 beats/min Tachycardia: pain, fever, dehydration, hemorrhage
Respirations 16-24 breaths/min Bradypnea: effects of narcotic medications
Tachypnea: anxiety; may be sign of respiratory disease
Breath sounds Clear to auscultation Crackles: possible fluid overload
Breasts Days 1-2: soft Firmness, heat, pain: engorgement
Days 2-3: filling
Days 3-5: full, soften with breastfeeding (milk is “in”)
Redness of breast tissue, heat, pain, fever, body aches: mastitis
Nipples Skin intact; no soreness reported Redness, bruising, cracks, fissures, abrasions, blisters: usually associated with latching problems
Uterus (fundus) Firm, midline; first 24 hours at level of umbilicus; involutes ≈1 cm/day Soft, boggy, higher than expected level: uterine atony
Lateral deviation: distended bladder
Lochia Days 1-3: rubra (dark red)
Days 4-10: serosa (brownish red or pink)
After 10 days: alba (yellowish white)
Amount: scant to moderate
Few clots
Fleshy odor
Large amount of lochia: uterine atony, vaginal or cervical laceration
Foul odor: infection
Perineum Minimal edema Pronounced edema, bruising, hematoma
Laceration or episiotomy: edges approximated Redness, warmth, drainage: infection
Pain minimal to moderate: controlled by analgesics, nonpharmacologic techniques, or both Excessive discomfort first 1-2 days: hematoma; after day 3: infection
Rectal area No hemorrhoids; if hemorrhoids are present, soft and pink Discolored hemorrhoidal tissue, severe pain: thrombosed hemorrhoid
Bladder Able to void spontaneously; no distention; able to empty completely; no dysuria Overdistended bladder possibly causing uterine atony, excessive lochia
Diuresis begins ≈12 hours after birth; can void 3000 mL/day Dysuria, frequency, urgency: infection
Abdomen and bowels Abdomen soft, active bowel sounds in all quadrants
Bowel movement by day 2 or 3 after birth
No bowel movement by day 3 or 4: constipation; diarrhea
Cesarean: incision dressing clean and dry; suture line intact Abdominal incision—redness, edema, warmth, drainage: infection
Legs Deep tendon reflexes (DTRs) 1+ to 2+ DTRs ≥3+: preeclampsia
Peripheral edema possibly present
Homans’ sign* negative
Redness, tenderness, pain, positive Homans’ sign*: venous thromboembolism (VTE)
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


*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.

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.

image Nursing Care Plan

Postpartum Care—Vaginal Birth

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

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.

Sitz Bath

Built-In Type

Stay updated, free articles. Join our Telegram channel

Sep 16, 2016 | Posted by in NURSING | Comments Off on Nursing Care of the Family During the Postpartum Period

Full access? Get Clinical Tree

Get Clinical Tree app for offline access