Bicol University

COLLEGE OF NURSING
Legazpi City

===============================================================================

NAME: _ DATE: _
YEAR AND BLOCK: _ RLE GROUP:

POSTPARTUM ASSESSMENT CHECKLIST

Examination of a postpartum mother and early identification of complication is one of the

important responsibilities of a nurse in the postnatal area. Adequate postpartum examination is
necessaryfor planning the care of postnatal mother.

PURPOSE:

1) To assess the health status of the mother and institute therapy to rectify the defect if any.
2) To detect and treat at the earliest any gynecological condition arising out of obstetric legacy.
3) To impart family planning guidance.

RATING QUANTITATIVE DESCRIPTION

5 EXCELLENT
4 COMPETENT
3 SATISFACTORY
2 NEEDS IMPROVEMENT
1 POOR
Efficiently perform tasks without supervision
Perform tasks with minimal supervision
Perform tasks with moderate supervision
Perform tasks with constant supervision
Perform tasks with maximum supervision

Instructions: Check the appropriate box next to each indicator

PROCEDURES 5 4 3 2 1 Remarks
ASSESSMENT
1. Assess the client’s OB/ Gynecological History
2. Assess the client’s ability to participate in the procedure
3. Assess the need for assistance
PLANNING
4. Perform hand hygiene and observe infection control procedures
 5. Prepare materials and supplies needed:
 Stethoscope, BP app, Thermometer, Watch with second hand
 Pair of gloves
 Extra maternity pads
 Gauze pad
 Linen (for draping)
 Bedpan (if needed)
6. Provide for client’s privacy
IMPLEMENTATION
7. Introduce self and verify clients’ identity
8. Explain the procedure to the client
9. Ask the mother to empty her bladder before the procedure
10. Check for the client’s general appearance
 Level of Consciousness
 Comfort and activity
 Hygiene and skin appearance
11. Check for the client’s vital signs (BP, TPR)
12. Wear clean gloves
PERFORM BUBBLE- HE ASSESSMENT
13. Breast Assessment
 Ask how the mother feels about her breasts
 Expose both breasts and perform inspection of the following:
 Size, color of the skin, engorgement of breasts
 Bruising, suck marks, cracks, bleeding in areola
 Eversion, inversion or flatness of nipples
 Presence of stretchmarks or orange-peel appearance or
lesions
 Check temperature
 Palpate for any masses/lumps/hardness
 Express milk and wipe with gauze piece
14. Uterine fundus Assessment
 Position the client in supine
 Expose the mother’s abdomen
 Support the bottom of the uterus with one hand while the
other hand palpates the fundus
 Note the location, position and consistency of the uterine
fundus
15. Bladder Assessment
 Palpate the urinary bladder for distention
 Ask the client when was the last time she urinated
16. Bowel Assessment
 Auscultate for bowel sounds in the four quadrants of the
abdomen
 Ask the mother when was the last time she was able to drink or
eat
17. Lochia Assessment
  Position the client in a dorsal recumbent position
 Expose the clients’ perineum
 Inspect the perineal pad and note the amount and character of
lochia
 Assess for presence of blood clots
 Ask the client when was the last time she change her pads.
18. Episiotomy/ Laceration Assessment
 Inspect the perineum for REEDA
 Redness
 Ecchymosis (bruising)
 Edema (Swelling)
 Discharge/ Drainage
 Approximation
19. Homan’s signs Assessment (Assess both legs, one at a time)
 Expose the client’s legs
 Support the client’s knee underneath with one hand and
sharply dorsiflex the foot of same leg with the other hand
 Ask the client if pain is felt on the calf upon dorsiflexion of the
foot, (if yes, it indicates (+) Homan’s sign)
 Look for presence of redness, swelling, and heat on the legs
(signs of DVT)
 Check for grade of pedal pulse, absence or weak pulse can be
signs of DVT
20. Emotional Status
 Throughout the assessment, notice and evaluate the mother’s
emotional status
 Explain to the mother and to her family that she may cry easily
for a while and that her emotions may shift from high to low.
The changes are normal and are probably caused by hormonal
changes occurring in her body and by her realization of new
responsibilities that accompany each child’s birth
21. Explain the assessment findings to client and provide self-care
information as needed
22. Return the client to position of comfort and drape client appropriately
23. Properly dispose used supplies, clean reusable equipment and store in
proper place
24. Perform hand hygiene
EVALUATION
25. Evaluate the client using the following criteria
 Client is comfortable, conscious, coherent and cooperative
 VS within normal range
 Capable to do breastfeeding, no Breast discomfort noted
 Uterus well contracted, fundus is in expected location
 Normal lochia discharge
 No signs of infection and hematoma of the perineum
 Negative Homan’s sign
  Good interactions with infant and significant others
DOCUMENTATION
26. Date and time assessment was done
27. Findings of assessment and intervention done
Total Grade:

References: http://www.perinatalservicesbc.ca/Documents/Resources/Checklists/PSBC_Postpartum_Checklist.pdf
https://www.webmd.com/baby/postpartum-care-checklist
Prepared by: MN. Bobier, RM, RN, MAN

Performed by:

____________________________
Name of the Student/ Signature

Evaluated by:

_______________________
Clinical Instructor