ASSESSMENT NORMAL FINDINGS SIGNS OF POTENTIAL COMPLICATIONS

Blood pressure Consistent with BP baseline during pregnancy; can have orthostatic Hypertension: anxiety, preeclampsia, essential
(BP) hypotension for 48 hours hypertensionHypotension: hemorrhage

Temperature 36.2°-38° C (97.2° to 100.4° F) >38° C (100.4° F) after 24 hours: infection

Pulse 50-90 beats/min Tachycardia: pain, fever, dehydration, hemorrhage

Respirations 16-24 breaths/min Bradypnea: effects of narcotic medicationsTachypnea:

anxiety; may be sign of respiratory disease

Breath sounds Clear to auscultation Crackles: possible fluid overload

Breasts Days 1-2: soft Firmness, heat, pain: engorgement

Days 2-3: fillingDays 3-5: full, soften with breastfeeding (milk is “in”) Redness of breast tissue, heat, pain, fever, body aches:
mastitis

Nipples Skin intact; no soreness reported Redness, bruising, cracks, fissures, abrasions, blisters:
usually associated with latching problems

Uterus (fundus) Firm, midline; first 24 hours at level of umbilicus; involutes ≈1 cm/day Soft, boggy, higher than expected level: uterine atony

Lateral deviation: distended bladder

Lochia Days 1-3: rubra (dark red)Days 4-10: serosa (brownish red or pink)After 10 Large amount of lochia: uterine atony, vaginal or cervical
days: alba (yellowish white)Amount: scant to moderateFew
clotsFleshy odor
ASSESSMENT NORMAL FINDINGS SIGNS OF POTENTIAL COMPLICATIONS

lacerationFoul odor: infection

Perineum Minimal edema Pronounced edema, bruising, hematoma

Laceration or episiotomy: edges approximated Redness, warmth, drainage: infection

Pain minimal to moderate: controlled by analgesics, nonpharmacologic Excessive discomfort first 1-2 days: hematoma; after day 3:
techniques, or both infection

Rectal area No hemorrhoids; if hemorrhoids are present, soft and pink Discolored hemorrhoidal tissue, severe pain: thrombosed
hemorrhoid

Bladder Able to void spontaneously; no distention; able to empty completely; no Overdistended bladder possibly causing uterine atony,
dysuria excessive lochia

Diuresis begins ≈12 hours after birth; can void 3000 mL/day Dysuria, frequency, urgency: infection

Abdomen and Abdomen soft, active bowel sounds in all quadrantsBowel movement by day No bowel movement by day 3 or 4: constipation; diarrhea
bowels 2 or 3 after birth

Cesarean: incision dressing clean and dry; suture line intact Abdominal incision—redness, edema, warmth, drainage:
infection

Legs Deep tendon reflexes (DTRs) 1+ to 2+ DTRs ≥3+: preeclampsia

Peripheral edema possibly presentHomans’ sign* negative Redness, tenderness, pain, positive Homans’ sign*: venous
thromboembolism (VTE)
ASSESSMENT NORMAL FINDINGS SIGNS OF POTENTIAL COMPLICATIONS

Energy level Able to care for self and infant; able to sleep Lethargy, extreme fatigue, difficulty sleeping: postpartum
depression

Emotional status Excited, happy, interested or involved in infant care Sad, tearful, disinterested in infant care: postpartum blues
or depression