Postpartum Care Plan
Complete the Following Information within __72_ hrs from your clinical day on Postpartum
Maternal Information:
Student Name:
Mia Herman
Clinical Date:
January 22, 2023
Allergies;
NKDA
Pt Initials:____
E.K.
Gestational Age:
36.0
Term: 0
Preterm: 1
Abortions/losses: 1
Living children: 1
Room Number:
220
Reason for admission to labor and delivery: (Spontaneous Rupture of membranes,
contracting, induction of labor, etc…)
Scheduled primary C/S d/t bicornuate uterus and fetal breech presentation
Date of delivery:
January 20, 2023
Time of delivery:
0844
Spontaneous Rupture of Membranes: No
Or Artificial Rupture of Membranes: Yes
Hours from time ruptured to delivery: 1 minute
Amniotic fluid clear, meconium, or bloody: Clear
Method of delivery:
 SVD  VAVD  FAVD  VBAC
SVD=Spontaneous Vaginal Delivery
VAVD=Vacuum assisted Vaginal Delivery
FAVD=Forceps assisted Vaginal Delivery
VBAC=Vaginal Birth after Cesarean
OR
 Primary C/S  Repeat C/S
Gravida: 2
Para: 1
QBL: ______ or
EBL: 500 mL
*Quantitative
blood loss vs an
estimated
blood loss.
QBL was not
calculated for
this patient
Pain Management in Labor:
 No meds
 Local
 Pudendal
 Epidural
 Spinal
 General Anesthesia
CS Incision information:
Pfannenstiel or Vertical incision? Pfannestiel
Vaginal delivery:
Perineum intact_____________
Perineal Laceration__________
Episiotomy______________
Indicate if the patient has a 1st degree, 2nd degree, 3rd degree, 4th degree
Significant Medical History (Include surgical Procedures/Dates):
Breast Implants 2016
WTE 2008
Significant Obstetrical History:
Bicornuate uterus; previous loss @ 10wks, twin gestation
Significant Intrapartum History: (what happened during this labor and delivery that is significant)
Patient received antenatal steroid (Celestone) x3 doses
Postpartum Complications:
None
Voiding: Catheter  Measuring  Not Measuring
Last BM:
Patient had not
had a BM since
delivery
Flatus:  Yes  No
Diet:
Normal
IV Site:
Location: _____
Saline Lock or continuous
fluids?_______
If continuous, IV Fluid type and rate
______@____/hr
Or
 No IV site ________
Activity/Ambulation (level of assistance needed)
No assistance needed; patient ambulating independently and frequently
Other Information: (Accuchecks, SCD’s, breast pumping, baby in NICU, Etc.)
Pumping, SCD’s in place while in bed
Lab & Diagnostic Tests
Routine obstetrical lab tests:
Blood Type: A
Rh: Positive
*If mom is a
negative blood
type, does the baby
have a positive
blood type? ____
Rubella:
 Immune
 Nonimmune
VDRL/RPR:
 Reactive
 NonReactive
Hep B :
 Negative
 Positive
 Unknown
HIV:
 Negative
 Positive
 Unknown
Other
infectious
disease/illness:
N/A
Group B Strep:
 Negative
 Positive
 Unknown
IF GBS positive, was
mother treated?
_________
What Antibiotic:
________________
Number of doses:
______________
If yes,
Did patient receive
Rhogam?
Complete Blood Count (CBC)
Serum Component
WBC
Reference Range
PRE-PREGNANCY
4.5-11.0×10 3 /mm 3
Level at Admission
(Date)
Level
1/20/23
12.9
1st Postpartum Day
(Date)
Level
1/21/23
11.6
RBC
3.9 – 5.2 x 106/µL3
1/20/23
4.35
1/21/23
3.92
HGB
W 12.0-16.0 g/dl
M 13.0-18.0 g/dl
1/20/23
11.6
1/21/23
10.4
HCT
W 36.0% – 46.0% of
red blood cells
M 37.0% – 49.0% of
red blood cells
140-400 K/mm3
1/20/23
36.3
1/21/23
32.3
1/20/23
206
1/21/23
182
PLT
If abnormal, list etiology
While both values are abnormal per the pre-pregnancy reference values,
they are appropriate for a women in her third trimester and one day
postpartum (Perinatology.com, 2021)
While both values are abnormal per the pre-pregnancy reference values,
they are appropriate for a women in her third trimester and one day
postpartum (Perinatology.com, 2021)
While the postpartum level is abnormal per the pre-pregnancy reference
values, it is appropriate for a women one day postpartum
(Perinatology.com, 2021)
Please note the reference range are the pre-pregnancy values.
List ALL other ABNORMAL Lab Tests not listed above: N/A
Postpartum BUBBLEE Physical Assessment Findings
Vital Signs:
B:
Time: 1225
Temp: 98.2
Pulse: 66 Resp: 19
B/P: 116/77
SpO2: 99 Pain: 2/10
Breasts:
Soft: ___ or Firm: ___
Nipple Trauma (Redness___ Bruising ___ Blisters ___ Fissures___): None noted
Other Info (ie: Lanolin, gels, pumping, lactation consult done): Breast implants, pumping, Lanolin provided
U:
Uterus/Fundus:
Midline___ or Deviated___
Firm___ or Boggy_____
Location of fundus: Midline or deviated to right or left: Midline, bicornuate
At UE, U-1, U-2,U+1,or U+2(at the umbilicus, or 1,2,3 fingerbreadths below the umbilicus, or 1 or 2 fingerbreadths above the umbilicus): UE
B:
Bladder:
Distended ___ Non-Distended __
Voids(ml): Not being measured, last void at 1200
Catheter: No
Quantity Sufficient: Yes
Other Info:_ N/A
B:
Bowels:
Bowel Sounds: Hypo/Hyper/normal: NORMAL x 4 Quadrants
Passing Flatus: Yes
Hemorrhoids: No
Other Info:__________
L:
Lochia:
Scant, small, moderate or heavy? Scant
Color is rubra, serosa, or alba? Light brown
Other Info: ____________________________
E:
Episiotomy or Perineal/vaginal Laceration? N/A
1st, 2nd, 3rd, 4th : N/A
Comfort measures: ice, tucks, Dermaplast spray, peri bottle with warm water: N/A
C/S: Describe the incision site OTA (open to air): Clear, occlusive dressing in place
Use REEDA to describe the wound (R=redness, E=ecchymosis, E=erythema, D=drainage, A=approximation): No redness, ecchymosis,
erythema, drainage noted; wound was well approximated
If the dressing is still on, is it CDI (clean, dry, intact)? Yes
Extremities:
Varicosities: No Redness: No Heat: No Edema: No Tenderness: No DTRs: No
E:
Emotions:
Maternal Role Adaptation:
Taking-In-Phase___
Taking-Hold Phase ___
or Letting-Go Phase___
Depression:
Any concerns that patient is exhibiting signs of postpartum depression? No
Has she been given the Edinburgh Postpartum Depression Screening (EPPDS) test yet? No, patient was not being discharged.
The EPDS is a set of 10 screening questions that can indicate whether a patient has symptoms that are common in women with depression and anxiety
during pregnancy and in the year following the birth of a child. The EPDS is given before the patient goes home. A score over a ‘10’ needs to be
reported to the healthcare provider. A social worker/case management is notified. The patient needs to re-screen at home. She needs a mood check
with her doctor in 1-2 weeks.)
Are there any other relevant findings you noticed: No, the patient and support person (husband) appeared confident and capable in their care of the newborn.
The patient was having successful latching with the baby and seemed well prepared for her postpartum journey. They had no concerns or questions.
Prioritize 3 Nursing Diagnoses with 3 Interventions – (cite resources used)
Nursing Diagnosis #1
Nursing Interventions (at least 3)
Problem or potential problem
related to
something physical, psychological, social
spiritual
Acute Pain (Wayne, 2022)
1. Administer analgesics as prescribed
Related to surgical trauma, continued uterine
contractions
2. Encourage adequate rest periods
3. Teach/demonstrate proper relaxation and pain management techniques
As evidenced by reports of pain (7/10 on pain
scale) and requests for pain medication
Nursing Diagnosis #2
Problem or potential problem
related to
something physical, psychological, social
spiritual
Nursing Interventions (at least 3)
Ineffective Breastfeeding (Wagner, 2023)
1. Coordinate consultation with lactation consultant
Related to infant prematurity
2. Provide 1:1 time with emotional support
As evidenced by poor sucking reflex of infant
3. Educate patient on recognizing feeding cues and feeding in a timely manner
Nursing Diagnosis #3
Nursing Interventions (at least 3)
Problem or potential problem
related to
something physical, psychological, social
spiritual
Knowledge Deficit (Wagner, 2023)
1. Work to create a quiet and positive learning environment prior to teaching
Related to unfamiliarity with situation
2. Include patient in the coordination of the care of them and their baby
As evidenced by patient being a first-time mom
3. Provide additional resources (i.e., community resources, support groups, websites) for continued
learning
Discharge Teaching: (What important information would you tell your patient before you send her home? Be specific. For example, if you tell your patient to
call if she has a fever, this is not adequate. You need to provide your patient with a specific number.). Address all sections with important discharge
information.
Bleeding precautions: Call your provider immediately for the repeated passing of large clots (larger than a quarter) and/or any bleeding that soaks a pad
within an hour. Your bleeding should lessen as times goes on, but can continue for up to 6 weeks postpartum.
Infection precautions: Call your provider immediately if you have a fever of 100.4°F or higher, any redness/swelling/discharge from your incision site, or if
you experience severe abdominal pain
Preeclampsia precautions: Notify your provider if you experience frequent and severe headaches, any changes in vision (blurry vision, dark spots, light
sensitivity), or pain in the upper right abdominal area.
Pain control: Prior to discharge your provider will send prescriptions for Tylenol (acetaminophen) and Advil (ibuprofen) to your pharmacy. They may or may
not include an opoid (Percocet/Norco) medication for breakthrough incisional pain.
Incision care or perineal care: Shower as needed, PAT (do not rub) incision dry; apply abdominal pressure via pillow/abdominal binder to incision when
coughing or laughing; allow up to 6 weeks for your c-section incision to heal; do not lift anything heavier than your baby until cleared by your provider
Emotional health/postpartum depression information: It is normal to experience a wide range of emotions in the coming weeks, including feelings of
depression/anxiety/sadness, due to hormonal changes, lack of sleep, and taking care of a baby. This is often referred to as “baby blues” and is common in
many postpartum mothers. Postpartum depression is a much more serious and less common. Please call your doctor if you experience lasting depression,
hopelessness, or a lack of self-worth. Contact your doctor immediately if you have thoughts of harming yourself or your baby.
Here is information for a postpartum support hotline: Postpartum Support International - www.postpartum.net, 1-800-944-4PPD
When does she need to see her OB for follow up? You should have a 2 week follow up with your provider to check the healing of your incision.
References:
Normal Reference Ranges and Laboratory Values in Pregnancy. Perinatology.com. (2021). Retrieved January 25, 2023, from
https://www.perinatology.com/Reference/Reference%20Ranges/Reference%20for%20Serum.htm
Wagner, M. (2023, January 9). Knowledge deficit nursing diagnosis & care plan. NurseTogether. Retrieved January 25, 2023, from
https://www.nursetogether.com/knowledge-deficit-nursing-diagnosis-care-plan/
Wagner, M. (2023, January 9). Postpartum nursing diagnosis & care plan. NurseTogether. Retrieved January 25, 2023, from
https://www.nursetogether.com/postpartum-nursing-diagnosis-care-plan/
Wayne, G. (2022, September 9). 10 cesarean birth (C-section) nursing care plans. Nurseslabs. Retrieved January 25, 2023, from
https://nurseslabs.com/cesarean-birth-nursing-care-plans/2/
Medications in the Postpartum Period (Complete for all medications took during your shift)
Generic Name: Acetaminophen
Brand Name: Tylenol
Classification: Analgesics
Dosage/Frequency: 1000mg PO q6h
Action: analgesic MOA unknown; antipyretic via direct action on hypothalamic heat-regulating center
Why is patient taking the medication? To manage postpartum pain
IV push medication (rate of administration and dilution): N/A
IV infusion (infusion rate and compatibilities): N/A
How does the medication work, the therapeutic effects? Put in terms your patient would understand.
Tylenol is thought to work by raising the body’s overall pain threshold, therefore lowering the level of pain experienced by the
patient
Contraindications: Hypersensitivity, hepatic damage/impairment, renal damage/impairment, hypovolemia
Nursing Care/Monitoring: AST/ALT monitoring with long-term therapy or overdose; never give more than 4000mg in a 24-hour
period
Common Side Effects: Rash, nausea, headache
Life Threatening Side Effects: Anaphylaxis, hepatotoxicity, anemia, thrombocytopenia, neuropathy
Medications in the Postpartum Period
Generic Name: Ibuprofen
Brand Name: Advil/Motrin
Classification: NSAID’s
Dosage/Frequency: 600mg PO q6h
Action: Reduces prostaglandin and thromboxane synthesis
Why is patient taking the medication? Postpartum pain management
IV push medication (rate of administration and dilution): N/A
IV infusion (infusion rate and compatibilities) : N/A
How does the medication work, the therapeutic effects? Put in terms your patient would understand.
This medication works by reducing the amount of inflammation causing chemicals in the body
Contraindications: asthma, urticaria, pregnancy, aspirin-exacerbated respiratory disease (AERD)
Nursing Care/Monitoring: Creatinine level for severe renal impairment; CBC and CMP for long term treatment
Common Side Effects: dyspepsia, nausea, abdominal pain, constipation, headache, dizziness
Life Threatening Side Effects: GI bleeding/perforation/ulcer, myocardial infarction, stroke, hypertension, thomboembolism
Medications in the Postpartum Period
Generic Name: dextromethorphan
Brand Name: Robitussin
Classification: NMDA receptor antagonist
Dosage/Frequency: 30mg PO q6h
Action: suppresses the medullary cough center in the brain
Why is patient taking the medication? ERAS protocol; to assist other analgesics with pain management
IV push medication (rate of administration and dilution): N/A
IV infusion (infusion rate and compatibilities): N/A
How does the medication work, the therapeutic effects? Put in terms your patient would understand.
This medication works with other pain medications to make them more effective
Contraindications: MAOI use within 14 days
Nursing Care/Monitoring: no routine monitoring is required
Common Side Effects: drowsiness, nausea, abdominal pain, fatigue
Life Threatening Side Effects: serotonin syndrome, potential for abuse
Medications in the Postpartum Period
Generic Name: oxycodone HCl
Brand Name: Roxicodone
Classification: Opioid analgesic
Dosage/Frequency: 10mg PO q6h PRN
Action: binds to opioid receptors in the brain to produce analgesia and sedation effect
Why is patient taking the medication? Post c-section pain management
IV push medication (rate of administration and dilution): N/A
IV infusion (infusion rate and compatibilities): N/A
How does the medication work, the therapeutic effects? Put in terms your patient would understand.
This medication changes how your body responds to pain by binding with the pain receptors in your brain
Contraindications: MAOI use within 14 days, asthma, GI obstruction, paralytic ileus
Nursing Care/Monitoring: Creatinine at baseline, watch for signs/symptoms of respiratory depression, hypotension, hypoxia
Common Side Effects: nausea, constipation, vomiting, headache, pruritis, insomnia, dizziness, drowsiness
Life Threatening Side Effects: respiratory arrest, apnea, cardiac arrest, shock, hypotension, seizures, potential or addiction
Medications in the Postpartum Period
Generic Name: docusate sodium
Brand Name: Colace
Classification: stool softener
Dosage/Frequency: 100mg PO bid
Action: facilitates mixture of stool fat and water
Why is patient taking the medication? decrease effort required to pass a bowel movement
IV push medication (rate of administration and dilution): N/A
IV infusion (infusion rate and compatibilities): N/A
How does the medication work, the therapeutic effects? Put in terms your patient would understand.
Colace draws water into the stool to make it softer and easier to pass through the GI system
Contraindications: fecal impaction, mineral oil use, appendicitis, GI obstruction
Nursing Care/Monitoring: no routine monitoring is required
Common Side Effects: diarrhea, abdominal cramps, throat irritation, rash, electrolyte disorder
Life Threatening Side Effects: N/A
Medications in the Postpartum Period
Generic Name: gabapentin
Brand Name: Neurontin
Classification: anticonvulsant
Dosage/Frequency: 100mg PO tid
Action: blocks voltage-dependent calcium channels, modulating excitatory neurotransmitter release
Why is patient taking the medication? ERAS protocol; to reduce opioid analgesic use; increase effectiveness of other pain
management drugs
IV push medication (rate of administration and dilution): N/A
IV infusion (infusion rate and compatibilities): N/A
How does the medication work, the therapeutic effects? Put in terms your patient would understand.
Gabapentin acts specifically on the nerves to alter the way they send messages to your brain
Contraindications: hypersensitivity
Nursing Care/Monitoring: avoid alcohol use, do not abruptly stop taking this medication, creatinine at baseline, signs/symptoms of
depression, behavior changes
Common Side Effects: dizziness, ataxia, fatigue, fever, peripheral edema, nystagmus, nausea, vomiting, tremors
Life Threatening Side Effects: depression/suicidality, angioedema, Stevens-Johnson Syndrome, rhabdomyolysis