GUIDELINES FOR POSTPARTUM ASSESSMENT Reference: Olds, S. And others. (2004). Maternal-Newborn Nursing and Womens Health Care.

(7th ed.). N.Y. PearsonPrentice Hall. Chapter 34.

PRINCIPLES (1) Select a time that will provide the most accurate data. Perform at beginning of shift and as ordered or needed. (2) The patient should be relaxed. (3) Have patient empty her bladder. (4) Patient should be as pain free as possible. (5) Bed should be flat. (6) Bed should be raised to prevent back strain. (7) Provide privacy. (8) perform procedures as gently as possible. (9) Report and record data clearly. Perform appropriate routine med-surg assessments also, such as level of consciousness, breath sounds, respiratory efforts, apical pulse, peripheral pulses, etc. BREASTS Assess the fit and support provided by the bra. Instruct the patient on reasons for wearing supportive bra if patient does not have one. Examine and palpate the breasts, including the axilla and upper chest. Note the size and shape. Assess for abnormalities, reddened areas and engorgement. Palpate the breasts--check for softness; firmness associated with filling and engorgement. Assess for heat, edema, swelling of the lobules, and tenderness. Assess the nipples for fissures, cracks, redness, soreness and inversion if breast-feeding. ABDOMEN AND FUNDUS Ask patient to void prior to this assessment. Assess fundal height by palpating the fundus and noting its relationship to the umbilicus (i.e. above or below umbilicus.) Note whether the fundus is midline or displaced to either side of the abdomen. Assess for complaints of excessive tenderness when the uterus is palpated. If the uterus is not firm, gently massage the fundus while supporting the lower uterine segment, and assess results. Assess the amount of lochial flow with massage if massage is necessary. If a boggy uterus does not respond to light massage, massage more vigorously while observing lochial flow. If uterine atony occurs: (a) reevaluate for full bladder; (b) if breastfeeding, put newborn to breast; (c) reassess the uterus, if still boggy, notify physician or nurse-midwife. Assess for diastasis recti abdominis. Evaluate separation according to length and width. Ask patient to lift her head to contract the rectus muscles and more clearly define their edges if necessary. If a C-Section was done, additionally palpate the uterus gently on each side of the abdomen. Inspect the incision for redness, edema, ecchymosis, drainage, and approximation of edges (REEDA scale.) Some physicians do not want the fundus checked if the patient had a Bilateral Tubal Ligation. Check on this before assessing the fundus on these patients. ELIMINATION Inspect and palpate the bladder simultaneously while checking the height of the fundus. Bladder distention should not be present after recent emptying. When it does occur, a pouch over the bladder area is observed, resistance is felt upon palpation, while at the same time, the woman usually feels a need to urinate. Assess frequency and amount of voids for the first three voids. Each void should exceed 250 ml. Assess for fundal bogginess and displacement to the right or left. Ask the patient if she feels she is emptying her bladder completely when she voids. Ask the patient if she experiences any signs/symptoms of UTI with urination--urgency, frequency, dysuria. Assess bowel sound. Ask patient about passing of flatus. Assess if the patient has had a bowel movement since delivery and record. Teach methods for avoiding constipation and promoting bowel elimination. LOCHIA Assess lochia for character, amount, odor, and the presence of clots. LOCHIA RUBRA-1 to 3 days-- dark red, possibly a few small clots. LOCHIA SEROSA-3 to 7 days--pinkish-brown in color. LOCHIA ALBA-after 7 days--yellowish-whitish in color. Lochia serosa should occur sooner for breastfeeding women. Lochia should never exceed moderate amount. Ask the patient how long the perineal pad has been in place prior to assessing amount of lochia. Ask the patient if she has passed clots while ambulating or voiding. If unsure of amount, put on clean pad and assess in 1 hour. SCANT-less than a 1 inch stain on pad. LIGHT-less than 4 inch stain on pad in 1 hour. MODERATE-less than 6 inch stain on pad in 1 hour. HEAVY-saturated pad within 1 hour. Assess lochia for odor--should be nonoffensive and never foul. Women with C-Sections should have less lochial flow after the first 24 hours than women with vaginal deliveries.

PERINEUM While in lithotomy position, assess the labia for edema. Observe for vaginal or labial hematomas. Inspect the perineum with the woman lying in a Sim's position. Lift the buttocks to expose the perineum and anus. Assess the episiotomy using the REEDA scale. Palpate the sides of the suture line for occult hematomas and complaints of excessive pain. Inspect the rectal area for hemorrhoids. Assess the size and number of hemorrhoids, and the amount of pain. LOWER EXTREMITIES Assess the Homan's sign. Report a positive Homan's sign and do not retest. Assess the legs for edema, redness, tenderness, and areas of increased temperature. Assess for pedal edema. Assess degree of edema (+1, +2, +3, +4) and parts of the lower extremities involved. Assess dorsal tendon reflexes--knee jerk. Use 0 to 4+ scale. 0=no reflex elicited. +1=slightly depressed. +2=normal response. +3=slightly hyperreflexic. +4=hyperreflexic. REST AND SLEEP Evaluate the amount of rest the woman is getting. Ask about any difficulty sleeping. Assess causes of interferences with sleep and rest and implement corrective actions. PSYCHOLOGIC ADJUSTMENT Assess the woman's general attitude, feelings of competence, available support systems, and care-giving skills. Evaluate her fatigue level, sense of satisfaction with her L&D experience and newborn interactions and her ability to accomplish for developmental tasks. Listen to her description of her L&D experience. Problem clues might include continued fatigue, marked depression, excessive preoccupation with physical status and/or discomfort, evidence of low self-esteem, lack of support systems, marital problems, inability to care for or nurture the newborn, and current family crises. Assess for normal progression through the taking-in and taking-hold phases of the restorative process. ATTACHMENT Observe the parent-infant interaction. Assess for signs of positive attachment (cuddling, talking to the newborn, feeding, responding to the needs/cues of the baby, expressing positive feelings and descriptions of the newborn, eye contact, expressing concern for the newborn's well-being and safety, etc.) Assess for problems with attachment (lack of cuddling, slow or hesitant response to needs of the baby, repetitive negative statements about the baby, hesitancy or refusal to perform caretaking tasks, etc.) CULTURE Assess cultural/ethnic background. Ask questions about preferences about food and fluids. Ask questions about childrearing and caretaking tasks that she learned from her mother, grandmother, etc. Assess feelings about breastfeeding/bottlefeeding. Assess desires for privacy.