Obstetrical Nursing – Post-partum Assessment

Post-Partum Assessment

Is done early AM right after report. The 1st day after the first couple hours is when it expresses the
difficulty after given birth. You do this assessment after doing a regular assessment of lungs, bowels, skin
and pulses. Vital signs are check q 15 min. for the 1 st hr plus fundus (uterus).

You will focus on:

B – Breast
U – Uterus
B – Bladder
B – Bowel Sounds
L – Lochia
E – Episiotomy
H – Hemorrhoids & Homan?s Sign
E – Education & Edema

1. Breast:
You will look at colostrums (precursor to mature milk- come on the 3rd day and it is bluish)
Feel the breast tissue for any lumps, redness, hot areas, the nipples (cracks-soreness from baby not latching
properly).
1st find out if pt is breast feeding or bottle feeding?
Educate pt from the minute you meet them.
*If pt is breastfeeding- use a well fitted bra A.S.A.P. No soap or creams on nipple ? squeeze nipple and
spread the milk around the nipple and let it air dry. Frozen pads & cabbage leafs and Tylenol helps with
engorgement of breast. Breastfeeding is encouraged right after giving birth.
*If pt is bottle-feeding- use a tight bra (smaller size) to prevent breast from stimulation (also no warm water
around the breast while taking a shower).

2. Uterus:
The top of the uterus is called the fundus, right after giving birth its felt half way between the symphysis
pubis and the umbilicus. After 12 hrs you could feel it back in the umbilicus again. Then it starts to involutes
(contracts) one finger per day. EX; 2nd day post partum you could expect to feel 2 fingers below the
umbilicus)
Body produces oxytocin but additionally oxytocin is added to the IV bag after the placenta has been
expelled to prevent hemorrhage.
Check uterus after the bathroom is used and you will record how many finger bellow (-) the uterus or if it is
above (+) it is recorded.
*LOCATION: it is significant to know where it is (right, left) If uterus is to the side R it might mean the pt is
full bladder and it could stop the contractions from happening.
*FIRMNESS: with massage.

3. Bladder:
Could experience urinary retention or periurethral cut.
8-12 hr after (C-sect Foley stays after).
*Void within the 1st hr post delivery vaginal.
*Void within the 12 hr post delivery C-sect (Foley) the 1st 2 voids should be measured after removing Foley.

4. Bowel Sound:
Paralytic Ileus : Hypoactive X4Q (C-sect)

5. Lochia:
Anything left inside the uterus (blood-placenta fragments)
*State the type of menstrual period.
*State how much (it should not be heavier that your heaviest day of your menstrual period) There should not
be a full pad in less than 15 min.
*State any odors (is should not smell)

Three phases:
1.Rubra: Red Bright ( The first 3 day post delivery)
2.Serosa: Pinkish Color ( Day 4th ? 7th post delivery)
3.Alba: White Color ( Day 8 ? 2wks)
Educate pt about changing pad frequently to prevent infections.
6. Episiotomy:
The perineum is a muscle, which could be cut or tearing at delivery, then it is sawed up in layers.
You must asses all wounds including abdominal areas.
To assess wounds:
*R- Redness
*E- Ecchymosis
*E- Edema
*D- Discharge ( color & odor)
*A- Approximation ( edges should be nicely closed together)

Pt has regained her modesty after delivery, therefore to asses wound turn pt in a Sims position, use gloves
and lift buttocks, then observed pad and sutures.
While in this position you may asses Lochia, Peritoneum area and Anus for hemorrhoids.

7. Skin. Inspect appearance of the skin (paleness, reddened area, ecchymosis), color, lesion, hair
distribution, temperature. Palpate the skin for any lumps, nodules, tumor etc.

8. Homan’s Sign:
Elevate leg at knee lightly and dorsiflex foot for 3 sec. Pt should be flat on back.
Assess for DVT, by assessing and touching legs for redness, any swollen or hot areas. Do not massage.

9. Education & Edema:

Teach pt constantly. Check for any Edema at the ankle -Press down to rule out pitting edema.

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