Bonding appropriately with baby

Placenta delivered
Fundus firm
Lochia small–moderate
Without clots
Perineum intact/repaired
Hemodynamically stable
EBL <500 cc

B

append

ix

Clinical Paths

Active Phase

Expulsion/Pushing

Recovery 1st Hour Post Partum

Patient coping with labor

support

Patient utilizing appropriate

labor options

Patient verbalizes satisfaction

with plan

Management interventions

Cervix dilated 5 cms-complete
Contraction regularly with

progressive cervical change.

Maternal/fetal well being

maintained.

Hydration maintained.
If indicated: FSE and/or IUPC

placed

IV Pitocin started
Epidural placed/WE

encouraged

Medicate with Prn pain meds

Prenatal record available after

32 weeks

Prenatal labs WNL
Pre-registered to hospital
Pediatrician identified
Support after hospitalization

identified

Discharge plan discussed with

patient/family.

Communicates understanding

of hospital and community
resources

Patient demonstrates effective

pushing technique.

Patient coping effectively with

pushing.

Support person coping

effectively with labor

Vaginal birth

Labor and Delivery Clinical Path—Labor: Expected Outcomes

PATIENT

EDUCATION

PATIENT STATUS

CONTINUUM OF CARE

3132-28_ApdxBrev.qxd 12/15/05 3:47 PM Page 772

Appendix B

773

Assess: Uterus—fundus

Vital signs
Lochia
Bladder
Perineum
Placenta

Baby status
Breast feeding

Cord blood or Rhogam workup

if appropriate

Cord blood if O

+ Mom

Ice pack to perineum
Warm blankets

Pitocin IV

Assist with ambulate to bathroom
Infant care
Assist with positioning for breast

feeding

Infant ID bands present

Interventions

Assess: Continuous EFM or

auscultation

Q 15 of 30 minutes as

indicated.

Vital signs hourly/Temp Q4 hours

if intact membranes/Q 2 hrs
if membranes ruptured

Uterine by monitor or palpation
Bladder for distention
Hydration status
Cervical dilation, effacement,

station

Reinforce comfort measures
Encourage use of labor options
Inform patient/support person

of plan of care

Hgb or Hct (if not done

recently)

T & S (if ordered)
VE as indicated
IV therapy
AROM by M.D. or CNM: assess

for color, amount and odor,
as appropriate

FSE/IUPC placement if indicated

Comfort measures/Birthing

ball/ambulate/telemetry/
shower

IV therapy
Amnio Infusion for Variable

decelerations

If appropriate, Pain Mgmt.

reviewed.

Antibiotics as indicated for

+ GBS

Pitocin if indicated
PRN pain medication

(Encourage WE if
requesting this).

Labor option usage

Position changes

Assess: Q 15 minutes

monitoring of fetal well
being (Low-Risk) and
Q 5 minutes (High-Risk)

Vital signs hourly Temp. Q 2–4

hrs. depending on
membrane status

Bladder for distention
Hydration status
Pushing effectiveness
Descent of presenting part
Caput

Teaching of upright pushing

positions

Discourage prolonged

maternal breath holding

Encourage to assume position

of choice

Inform patient of progress

AROM: assess for color, amount

and odor, as appropriate

Perineal massage
Warm soaks to perineal area
Allow to rest until feels urge

to push

Frequent position changes
Cool cloth/Ice chips

Pitocin if indicated

Provide wedge if supine
Promote effective position for

pushing: ie: squatting, side
lying, upright

Breathing technique

patient/support person most
comfortable with

ASSESSMENT/

TREATMENT

PATIENT

EDUCATION

TESTS/

PROCEDURES

THERAPIES

MEDS

ACTIVITY/

SAFETY

(continued)

3132-28_ApdxBrev.qxd 12/15/05 3:47 PM Page 773

1–2 days

Incision well

approximated,
without drainage
or redness

Passing flatus
Lochia sm/mod

amt

Fundus firm u/1–2
Verbalizes comfort

using pain
medication as
described

774

Appendix B

Return to previous diet

Interventions

Clear liquids
Ice chips

OTHER

Clear liquids
Ice chips

NUTRITION

UNIQUE PATIENT

NEEDS

Integrated Plan of Care for Cesarean Delivery

Expected Patient Outcomes

Phase 1
Preadmission

Phase 2 Surgery/

(Cesarean

Immediate Postop/

Phase 3 Post Op

Delivery)

Day of Surgery

Day 1

N/A Date Started:

VS WNL for patient
Hgb or Hct/values

within normal
SLH antepartum
range

Up to 23 hours

VS WNL for

patient Systems
assessment:
Skin warm, dry,

Clear

➞

Alert & oriented

➞

Neg. Homan’s

sign

➞

Breast soft/nipples

intact

➞

Lungs clear

➞

Bowel sounds

present

➞

Fundus firm u/u or u

1–2 (

−/+)

Lochia sm—mod
Dsg dry and intact
No signs infiltration

IV site

Verbalizes comfort

using pain rating
scale 0–10

1 day

VS. WNL for patient
Afebrile
Voiding without

foley

➞

Passing flatus
Incision without

redness or
drainage

Lochia small amount
Fundus firm u/1–2
Verbalizes comfort

using pain scale
0–10 on oral pain
meds

Usual time in

Phase

Assessment /

Potential
Complications

Labor and Delivery Clinical Path—Labor: Expected Outcomes

(continued)

3132-28_ApdxBrev.qxd 12/15/05 3:47 PM Page 774

Appendix B

775

Date All Above Met

Verbalizes follow-

up appointment
date and time

Verbalizes proper

dosing of pain
medication

Date All Above Met

Ambulating in hall

Date All Above Met

Date All Above Met

Entire Phase

Outcomes Met;
Progress patient
to next phase

Assess pain control
0–10 scale
Incision
Volding
Fundus
lochia
Homan’s sign
IV site as needed
ID band on mother
Activity

Expected Patient Outcomes

Phase 1
Preadmission

Phase 2 Surgery/

(Cesarean

Immediate Postop/

Phase 3 Post Op

Delivery)

Day of Surgery

Day 1

Date All Above Met

Verbalizes

understanding
of condition and
need for surgery

Verbalizes

understanding
of all pre-op
teaching

Date All Above Met

Verbalizes

understanding
of NPO status

Date All Above Met

Date All Above Met

Entire Phase

Outcomes Met;
Progress patient
to next phase

Vital Signs

Fetal status

immediately
prior to surgery

Date All Above Met

verbalizes correct

use of PCA/
Fentanyl pump
and when to
request pain
medication

Turn, Cough &

deep breath
appropriately

Date All Above Met

Able to ambulate

with minimal
assistance

Tolerating clear/full

liquid diet

Bonding observed

with newborn—
Taking-in
phase

➞

Date All Above Met

Date All Above Met

Entire Phase

Outcomes Met;
Progress patient
to next phase

VS per PACU then

q 4 hr

Systems assessment:
*Skin, LOC, FROM,

Homan’s sign,

*Breasts, Lungs,

Fundus, Incision,

*Lochia, bladder,

bowel sounds,
IV & site

Date All Above Met

can state criteria

for when to call
doctor for
problems post
discharge

➞

↑ bleeding

↑ Temperature ➞

incision redness,

odor or
drainage

➞

Date All Above Met

Ambulating without

assistance

Tolerating soft to

regular diet

Date All Above Met

Date All Above Met

Entire Phase

Outcomes Met;
Progress patient
to next phase

VS q 6 hr
Assess pain control

0–10 scale

Incision
Foley-volding
Fundus/lochia
Homan’s sign
IV site
Breasts
ID band on mother
Activity

Patient / Family

Knowledge

ADL’s / Activity

Unique Patient

Needs

Assessments

Plan of Care

# 2 Surgery/
Immediate Postop/

#3 Post Op

#4 Post Op Day 2-

#1 Preadmission

Day of Surgery

Day 1

Discharge

(continued)

3132-28_ApdxBrev.qxd 12/15/05 3:47 PM Page 775

776

Appendix B

Social Work,

Lactation,
Dietitian as
needed

Verify follow-up

appointment
date and time

Activity restrictions
Follow-up for staple

removal as
needed

Offer Home follow-

up care

Discuss birth control

DC IV lock as

ordered

Plan of Care

# 2 Surgery/
Immediate Postop/

#3 Post Op

#4 Post Op Day 2-

#1 Preadmission

Day of Surgery

Day 1

Discharge

Anesthesia

— Need for surgery
— Review Cesarean

Delivery

— Review

procedure,
postop
expectations

— Demonstrate/

Discuss
equipment—
PCA, Fentanyl
pump

— Tour of OR area

& Nsy

PAT; Hgb or Hot (if

not done
recently—within
one month)

T & S (if ordered)

*I & O q shift
*Assess pain control

0–10 scale

*Assess Rhogam

status

*Assess Rubella titer

status

*ID band on

mother

Social Work as

needed,
Anesthesia,
Lactation,
Dietitian as
needed

Review post-op

expectations

Review equipment

us prn

Instruct pt on:

Hospital/Infant

security systems

Unity orientation
Newborn

orientation/care
/feeding (if
breastfeeding
problems see
decision trees)

IV fluids as ordered
Pain control: PCA,

Fentanyl pump,
IM to PO

Social Work,

Lactation,
Dietitian as
needed

Review dietary

needs post
surgery

Review Bleeding/

Lochia

Precautions post

cesarean
delivery

Review follow-up

care and doctor

Appointments
Review incision

care, peri care

Infant care
Infant feeding

IV lock

PO pain meds
Give Rhogam if

indicated

Give Rubella if

indicated

Consults

Patient / Family

Education
Discharge
Planning

Tests and

Procedures

Pharmacologic

Needs

Integrated Plan of Care for Cesarean Delivery

(continued)

3132-28_ApdxBrev.qxd 12/15/05 3:47 PM Page 776

Appendix B

777

Ambulate in halls

without
assistance

Plan of Care

# 2 Surgery/
Immediate Postop/

#3 Post Op

#4 Post Op Day 2-

#1 Preadmission

Day of Surgery

Day 1

Discharge

Patients usual

Change position

q 2 hr while in
bed, OOB stand
at bedside post-
op night/dangle
and transfer to
chair

Progress to pt.

endurance

Observe bonding

with infant

Observe family

support system
(if inadequate
consult SW)

NPO then clear

liquids to DAT

Foley empty q shift

TCDB q 2 hr while

awake

Progress

endurance/
begin

Ambulation in hall

OOB in AM
May shower

DAT to regular or

previous diet at
home

FOLEY DC’d

Dressing removed

by MD or RN with
MD request

Activity /

Rehabilitation

Nutrition /

Elimination

Miscellaneous

Interventions

Unique Patient

Needs

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