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Postnatal Assessment Procedure

The document defines the postnatal period as the 6 weeks following childbirth where the body returns to its pre-pregnancy state. It is divided into immediate (24 hours), early (up to 7 days), and late (up to 6 weeks) phases. The postnatal assessment involves collecting the mother's medical history, preparing necessary equipment, and performing a full examination including vital signs, head-to-toe assessment of breasts, uterus, perineum, lochia, and emotional state. The assessment follows the BUBBLEHE acronym - Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy, Homans signs, Emotional response

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Apex College of Nursing
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2K views4 pages

Postnatal Assessment Procedure

The document defines the postnatal period as the 6 weeks following childbirth where the body returns to its pre-pregnancy state. It is divided into immediate (24 hours), early (up to 7 days), and late (up to 6 weeks) phases. The postnatal assessment involves collecting the mother's medical history, preparing necessary equipment, and performing a full examination including vital signs, head-to-toe assessment of breasts, uterus, perineum, lochia, and emotional state. The assessment follows the BUBBLEHE acronym - Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy, Homans signs, Emotional response

Uploaded by

Apex College of Nursing
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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POSTNATAL ASSESSMENT

Definition:
Puerperium is the period following childbirth during which the body tissues,
especially the pelvic organs revert back approximately to the prepregnant state
both anatomically and physiologically.
-D.C.Dutta
This is a 6 weeks period, which is divided into three phases:
 Immediate: 24 hours after
delivery.
 Early: up to 7days
 Late: up to 6 weeks.
Assessment and Examination during Postnatal Period
Before the procedure
 History /preparation of the mother
Collect the history in the following manner.
Steps Rationale
Greet the mother It opens the channel for
communication.
Collect information related to family With this information, the activity
profile, for example: level required from mother will be
 Support person known and accordingly instructions
 Other children can be given.
 Type of housing
 Education
 Occupation
 Socioeconomic
status Pregnancy history A quick review of pregnancy history
 Para is useful for further planning
 Gravida
 EDD
 Any problems
 Hypertension or spotting
Delivery history This information will help to plan
 Duration of labour postnatal procedures such as
 Position of fetus episiotomy care
 Type of delivery
 Date and time of delivery
 Problems during labour
Neonatal data This information helps to plan care
 Sex for the newborn
 Birth weight
 Any difficulty at birth
 Breastfeeding
 Any congenital anomalies
Postpartum This information is helpful in
 General health assessment of the mother‘s present
 Activity level since delivery condition and planning of her care
 Description of lochia and health education imparted to her
 Any complain of pain in and the family.
abdomen/breast/perineum.

Preparation of the articles:


Articles required are as follows:
Articles Purposes
 Measuring tape to measure the height of the mother
and fundal height
 Weighing machine to check the weight of the mother
 Vital signs articles to assess the vital signs and note any
deviation from normal
 Cotton swab to clean the breast if any secretion is
present
 Sterile perineal pad to apply in the perineum
 Newspaper to collect the soiled perineal pad

Actual steps of the procedure


Wash hands and do a full examination of the mother systematically as described
in the following text;
a. General appearance
 Gestures of pain and her facial expression
 Face: Oedema
 Whether she has combed her hair; neatly dressed?(to know about her
feeling of well-being )
b. Vital signs
 Pulse: Check the pulse, which varies from70 -80 per min. Pulse rate> 100
per min should be investigated for fever and shock
 Respiration: Observe the respiration whether it is normal or abnormal (i.e.
labored, shallow or fast breathing)
 Temperature: It should not be more than 99oF within the first 24 hrs. on
the third day, there may be slight rise in the temperature due to breast
engorgement
 Blood pressure: Blood pressure remains unchanged. If there has been any
history of hypertension in pregnancy. Blood pressure should be checked
at every visit
c. Head –to-toe examination
Eyes
- Examine eye for detecting anemia (conjunctiva)
Breast
- Expose the breast to observe for any engorgement, hardness or redness
- Observe for any abnormality of the nipple (i.e. cracked, retracted, or
depressed nipple)
- First and second day: breast tissue feels soft and palpation
- Third day: engorgement occurs, breast feel firm and warm to the touch.
Uterus
- Ensure that the mother has emptied the bladder before examination
- Ask the women to lie on flat surface
- Give a gentle fundal massage to stimulate uterine contraction and expel
out the clots
- Note the height of the fundal by placing the ulnar border of the left hand
over the fundus and other on the symphysis pubis with a measuring tape.
Note the findings in cm.
- Note the consistency of the uterus.
Findings
- Immediately after the delivery, the height of the Fundus will be below the
fundus.
- For first 24hrs, it will remain constant
- Thereafter, uterus involutes 1-1.2 cm in 24hrs.
Perineum
- Ask the women to turn on her side, inspect the perineum, as it is more
visible in lateral position. Look for
- Hematoma
- Intact episiotomy stitches
- Any discharged /bleeding from the wound
- Swelling
- Pain

Check lochia for


- Amount
- Consistency
- Pattern (rubra to serosa to alba)
- Odour

Assessment for weight loss


- Record weight of the mother. There is weight loss of at least 2kg apart
from the loss after delivery.
Observation for sings of thrombophlebitis
- Check for Homan‘s signs
- In supine position, ask the women to dorsiflex the legs;
noted pain in the calf muscle.
Assessment for bowel and bladder activities
- Ask the women
- Whether she has passed urine
- About the amount and frequency of micturition
- About pain and burning sensation during micturition
- About incontinence
- Ask when she passed
her first motion Assessing
psychological changes
 Her facial expression
 Involvement with her baby like breastfeeding, cuddling,
talking to the baby and taking care of the baby.
 Her appearance (Grooming)

Acronym for postnatal assessment:


BUBBLEHE
B: Breast
U: Uterus
B: Bladder
B: Bowel
L: Lochia
E: Episiotomy
H: Homans signs
E: Emotional response

After care of the mother and the Articles


1. Make the mother comfortable
2. Collect the soiled perineal pad and dispose it in the dustbin
covering with newspaper.
3. Give perineal care if necessary
4. Put new sterile vulva pad
5. Inform her about the findings for the examination
6. Clean equipment and return to their usual places
7. Wash hands

Recoding and reporting


1. Record on mothers chart and nurses notebook with date and time
2. Report any complication or abnormal findings to the ward
sister and doctor.

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