Postpartum Period 

Is the period beginning immediately after the birth of a child and extending for about six
weeks.

The World Health Organization (WHO) describes the postnatal period as the most
critical and yet the most neglected phase in the lives of mothers and babies; most
deaths occur during the postnatal period

It is the time after birth, a time in which the mother's body, including hormone levels
and uterus size, returns to a non-pregnant state.

Postpartum Nursing Physical Assessment

• Physical Assessment is necessary to identify individual needs or potential problems

• Explain the purposes of the examination.

• obtain her consent.

• Record your findings and report results to the mother.

• Avoid exposure to body fluids.

• Teach patient as you assess – use every opportunity since there is limited time.

Assessment of the mother First 24 hours after birth

• All postpartum women should have regular assessment of vaginal bleeding, uterine
contraction, fundal height, temperature and heart rate (pulse) routinely during the first
24 hours starting from the first hour after birth.

• Blood pressure should be measured shortly after birth. If normal, the second blood
pressure measurement should be taken within six hours.

• Urine output should be documented within six hours.

Beyond 24 hours after birth

• At each subsequent postnatal contact, enquiries should continue to be made about
general well-being and assessments made regarding the following: micturition and
urinary incontinence, bowel function, healing of any perineal wound, headache,
fatigue,back pain, perineal pain and perineal hygiene,breast pain, uterine tenderness
and lochia.
• Breastfeeding progress should be assessed at each postnatal contact.
• At each postnatal contact, women should be asked about their:
– emotional wellbeing,

– what family and social support they have –

and their usual coping strategies for dealing with day-to-day matters.

• All women and their families/partners should be encouraged to tell their health care
professionals about any changes – in mood, – emotional state – and behavior, that are
outside of the woman’s normal pattern.

• Women should be observed for any risks, signs and symptoms of domestic abuse.

• Women should be told whom to contact for advice and management.

• All women should be asked about resumption of sexual intercourse and possible
dyspareunia as part of an assessment of overall well-being two to six weeks after birth.

Maternal history: restored function Ask the mother if since she delivered, she is :

• now ambulatory / not yet ambulatory

• has passed her bowels / has not yet passed her bowels

• has no flatus / is experiencing some flatus

• has voided her bladder (when) / has not yet voided her bladder Abnormal Findings

Bowel: Constipation, diarrhea, epigastric pain, hemorrhoids

Bladder: urinary retention, urgency, dysuria, incontinence.

• Postpartum Maternal Physical Assessment Summary- BUBBLE HE

B-U-B-B-L-E H-E

B: Breasts

U: Uterine fundus

B: Bladder function

B: Bowel function

L: Lochia

E: Episiotomy (Perineum)

H: Homan's sign (legs) E: Emotions

Assessment of Breasts

• inspect for redness & engorgement.

• Palpate breasts to determine if they are soft or filling, warm, engorged or tender.

• Teach to promote milk production & let down, and methods to prevent and treat
engorgement.

• Ensure proper bra fit

• Nipples should be soft, pliable & intact.

Abnormal Findings (Breasts)

• Redness, heat, pain, cracked, and fissured nipples, inverted nipples, palpable mass,
painful, bleeding, bruised, blistered, cracked nipples.

Abdomen

On inspection of the abdomen, Check for presence of visible scars, abdomen can:

• be distended : below / above the umbilicus.

• move / does not move with respiration,

Palpation of the abdomen:

• Ensure privacy and environment where the mother can lie on her back with her
head supported.
• Ensure bladder is empty & lay patient supine with legs flexed.
• The midwives hands should be clean and warm and help the woman expose the
abdomen.
• The midwife places the lower edge of her/his hand at the umbilical area and
gently palpates inwards towards the spine until the uterus fundus is located.

Assessment of the uterine fundus.

• It should be firm, if not, massage prior palpation .

• Assess its location and the degree of uterine contraction, any tenderness or pain
should be noted

• Normal findings: normal size and shape, mobile, regular, firm, in the midline, below
the umbilicus & non tender.

• Abnormal findings: immobile, irregular, soft, tender, deviated away from the midline
or above the umbilicus after 24hrs
• Fundal height is measured in cm.

• Note: * fundus is 2 cm below the level of the umbilicus immediately after birth; fundus
descends approximately 1 cm per day; by the 10th day the fundus should no longer be
palpated

• *If fundus is deviated or elevated above level of umbilicus always rule out DISTENDED
BLADDER

• Once the midwife has completed the assessment, she helps to dress and sit up.

Postpartum vaginal loss

• Lochia: is the vaginal discharge following birth.

▪ Assess the color,odor,and amount.

• Lochia rubra: dark red (red) discharge; occurs the first 3 days.

• Lochia serosa: pink, serosangineous discharge; lasts 3-10 days

• Lochia alba : creamy or yellowish discharge (white); occurs after the Tenth day and
may last a weeks or two.

Lochia odor:

❖ Lochia should have no odoror”or no foul odor”

❖ A foul odor or a change in odor may be a sign of infection.

Lochia amount:

❖ Scant: 2.5cm saturation

❖ Light: <10cm saturation
❖ Moderate: >10cm saturation
❖ Heavy: pad is completely saturated within 2 hours.
❖ PPH is clinically defined as a pad saturated within 15-30 minutes

Abnormal Findings (Lochia)

– Heavy, foul odour, bright red bleeding, clots, amount more than a period. Assessment
of vaginal blood loss
URINARY TRACT

1. Risk for urinary tract infection is increased, if client was catheterized during labor and
delivery.

2. May have bruising and swelling caused by trauma around the urinary meatus.

3. Increased bladder capacity, along with decreased sensitivity to pressure leads to

urinary retention.

4. Diuresis occurs during the first 2 days after delivery.

5.Bladder distention may displace the uterus, leading to a boggy uterus and increase
risk for atony.

Assessment of Episiotomy (Perineum)

• Inspect with patient in Sims position.

• Lift buttock to expose perineum & anus

• If present, assess episiotomy or laceration for REEDA.

R-redness

E-edema

E-ecchymosis

D-discharge

A-approximation.

• Assess knowledge, practice, & effectiveness of self perinealcare.

• Educate about suture absorption

• Advice on what might help perineal pain.

• Abnormal Findings (Perineum)

– Pronounced edema, wound edges not intact, signs of infection, marked discomfort.

Assessment of perinial pain

• Women feel brused around the vagina regardless the trauma in the first few days
after birth.
• In cases of actual pereneal injury, a woman will experience pain for several days until
healing takes place

• Long term psychological and physiological trauma is also evident

• The midwife observes perineal area to ascertain progress of healing from any trauma.

• Appropriate care immediately after birth or where suturing has taken place can help
reducing edema or bruising.

• Very important Qn: the midwife ask the mother whether she has any discomfort in the
perineal area regardless of any record of actual perneal trauma.

• Clear information and reassurance are helpful where women have a poor
understanding of what happened and are anxious or embarrassed about urinary, bowel
or sexual functioning in the future

• If there is no pain in the perineal area, the midwife should not examine.

• For majority of the women, the perineal wound gradually becomes less painful and
should cure 7 to 10 days after birth.

Maternal examination: legs

Do a Homan’s sign test (to detect early DVT)

• Assess for signs of DVTs, i.e. asymmetric: size, color, or temperature.

• Asses for signs of superficial thrombophlebitis (redness, warmth, tenderness, pain in

that limb, darkening of skin over or hardening of vein)

Assess for:

• sleep deprivation

• ability to rest

• energy level

• comfort level

• anxiety level

• Appetite

• bonding behaviours

• support system (family, husband, self supported)

Vital signs and general health

• Pulse rate, respiratory rate, body temperature, any outward odour, skin condition and
the woman’s overall color and complexion as you listen to what the mother is saying.

• If no history of hypertension, BP should return to normal within 24 hours.

Chest

• chest should be: clear, with good air entry bilaterally, and no added breath sounds

• Note the respiratory rate.

Post-Natal Care

• Encourage prescribed medications and supplementation; e.g. iron tablets, vitamin A

• Introduce exercises (e.g., Kegal/vaginal, abdominal).

• Remind or give postnatal clinic visit appointment.

• Encourage and provide family planning counseling.

• Answer both mother’s and family’s questions.

• Counsel Mother about Infant Immunization Schedule and ensure the mother can get
access to immunization center.

• Assess and advise on breastfeeding.

• Monitor and advise the mother on feeding, hygiene and life style.

• Assess and care for the mother about any infection or disease and manage as soon as
possible.

EVALUATING BREASTFEEDING

• How do you know that an infant is getting enough breast milk?

• Hear infant swallow and make “ka” or “ah” sounds.

• See smooth nutritive suckling, smooth series of sucking and swallowing with
occasional rest periods, not the short, choppy sucks that occur when the baby is falling
asleep.

• Breast gets softer during the feeding

• Breast-feeding 8-12 times per day; more milk is produced with frequent breast-
feeding.
• Infant has at least 2-6 wet diapers per day for 1st 2 days after birth; 6-8 diapers per
day by the 5th day.

• Infant has at least 3 bowel movements daily during the 1st month and often more.

• Infant is gaining weight and is satisfied after feedings.

Postnatal complications

• Hemorrhage

• Puerperal infections

• Mastitis

• Subinvolution

• cystitis and pyelitis

• Postpartum Depression