A. Assessment during the third and fourth stages on the following:
1. Maternal physiologic adjustment, including vital signs, bladder uterine firmness uterine fundus, perineum, and amount and color of lochia.
2. Maternal emotional adjustment.
3. Newborn physiological adjustment, including respiratory effort and maintenance of body temperature.
4. Signs of parents-newborn attachment.
5. Mother’s and newborn’s breast-feeding attempts, if the mother is breast-feeding.
B. Nursing diagnosis
1. Risk for Injury (Mother)
2. Ineffective Thermoregulation (newborn)
3. Risk for infection
4. Pain
5. Ineffective Breast-feeding
6. Altered Family Coping
C. Planning and Outcome Identification
1. Physiologic adaptation will be achieved by the new mothers
2. Physiologic adaptation will be achieved by the newborns.
3. Potential complications will be detected.
4. Comfort measures will be provided as needed.
5. An opportunity to breast-feed will be provided.
6. A parent-newborn relationship and family integration will be established.
7. Accurate documentation of intrapartum care will be maintained.
D. IMPLEMENTATION
1.Promote maternal physiologic adaptation
a. Initiate fundal massage gently, with adequate support to the lower uterine segment.
b. Evaluate vaginal bleeding and vital signs.
2. Promote newborn physiologic adaptation.
a. Suctions secretions from the newborn’s nose and mouth as necessary to maintain respirations.
b. Maintain the newborn’s temperature by placing him in skin-to-skin contact with mother covering him with warm blankets, or using a radiant warmer.