First 1–2 hours after birth.

Immediate Nursing Care

• Assess height, location, and tone of the fundus
• Quantify amount of vaginal bleeding and presence of clots
• 1 gm = 1 mL blood loss
• Assess condition of the perineum
• Cleanse and apply ice pack
• Provide clean linen under patient
• Provide warm blanket: Patients often tremble/shiver immediately after the birth
• Assess vital signs
• Assess level of consciousness/comfort
• Encourage bonding of mother and infant using kangaroo care
• Assist with proper latch-on to initiate breastfeeding
• Maintain IV fluids
• Administer uterotonic medication
• Promote uterine contractions
• Decrease amount of vaginal blood loss

Nursing Assessment of the Postpartum Patient

• Assess every 15 minutes for two hours
• Assess every 4 hours for the first 8 hours
• Assess every 8 hours until discharge
• Uterine tone
• Bleeding
• Perineum
• Bladder status
• Vital signs
• Blood pressure
• Pulse
• Respiration
• Temperature every 4 hours
• Fluid balance
• Circulation to extremities
• Comfort/level of consciousness
• Newborn interaction