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Postpartum Assessment & Nursing Care

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During postpartum, the time between delivery and the return of the reproductive system to its pre-pregnancy state, you’ll assess your patient’s vital signs, breasts, fundus, bladder, lochia, perineum, legs, and any incisions.

Measure vital signs with the frequency your facility’s policies specify or according to the provider’s prescription. Include temperature, heart rate, respiration, blood pressure, and pain level. Temperature may rise due to the dehydration that can accompany labor and sometimes as a result of epidural anesthesia. After the first 24 hours, however, elevations in temperature warrant further investigation as they suggest infection. Pulse rates may be somewhat elevated but should return to their pre-pregnant status gradually. A sustained rapid pulse can indicate hemorrhage. Respiratory rates may be low after epidural anesthesia and after a cesarean birth but should gradually return to the expected range. Orthostatic hypotension is common after delivery. Hypotension can indicate hemorrhage, and hypertension may persist in women who have had pre-eclampsia.

Assess your patient’s pain, including location, type, quality, and severity. Administer pain medication to keep the patient’s pain at a manageable level. For perineal pain, apply cold during the first 24 hours, including cool sitz baths. This helps reduce swelling and irritation. After the first 24 hours, warmth is helpful for promoting circulation and healing. To help reduce pain from sitting down, suggest that your patient compress or tighten her buttocks just before sitting. This reduces pressure on healing perineal tissues.

Encourage your patient to urinate prior to assessing her fundus. Assist her to a supine position.

First, inspect and gently palpate her breasts for redness, pain, and engorgement. Inspect the nipples for redness, cracks, and bleeding. If she is breastfeeding and her breasts are engorged, suggest warm compresses or a warm shower before breastfeeding to stimulate milk flow. Or, if her newborn isn’t emptying both breasts, suggest she pump her breasts to relieve discomfort. If she is not breastfeeding, suggest ice packs to help suppress milk production and reduce discomfort.

Next, check your patient’s fundus. Assess uterine height, location, and consistency. Determine the fundal height by placing one hand at the base of the uterus and the other at the umbilicus. Measure how many fingerbreadths, which are roughly equivalent to centimeters, you can place between the fundus and the umbilicus above or below it. If none, then the fundus is at the umbilical level. At 12 hours after delivery, the fundus is typically 1 cm above the umbilicus, but this does vary. The uterus descends into the pelvis approximately 1 to 2 cm per day. About a week after delivery, the fundus should be halfway between the umbilicus and the symphysis pubis. Also, assess whether the fundus is boggy or firm. If the fundus is boggy, gently massage the uterus with a rotating motion while supporting the lower uterine segment until it feels firm. Without stabilization of the lower segment, the uterus could invert, and severe hemorrhaging could result.

Assess and palpate the bladder at this time as well. Determine whether the fundus is at midline in the pelvis or displaced laterally due to a full bladder. If the bladder is full, encourage the patient to urinate and monitor her fluid intake and output. For some patients, insertion of a straight urinary catheter may become necessary.

Examine the patient’s perineal pad for bleeding, noting the character, quantity, presence of clots, and odor. Lochia rubra is typical 1 to 3 days following delivery, and small clots are common. Determine the amount of saturation as scant, light, moderate, heavy, or excessive. Be sure to check under the patient’s buttocks to be sure blood is not pooling beneath her. Lochia typically increases with breastfeeding and ambulation. If bleeding is excessive, the patient will soak an entire perineal pad within 15 minutes or so. For that finding as well as for numerous large clots or a foul odor, notify the provider immediately.

If the patient has had a cesarean delivery, examine the incision for redness, edema, ecchymosis, drainage, and approximation of its edges. If the patient has had an episiotomy, have her lie on her side and assess the episiotomy incision for approximation, edema, and ecchymosis. Also check her rectum for hemorrhoids and assess bowel function by auscultating bowel sounds.

Assess for thrombophlebitis by checking the patient’s calves for pain, tenderness, or redness. Notify the provider immediately if you find any of these. Check for edema of the hands, the face, and the lower extremities.

Finally, assess your patient’s comfort level and emotional status.

References

Lowdermilk, D. L., Perry, S. E, Cashion, K., & Alden, K. R. (2012). Maternity & women’s health care (10th ed.). St. Louis, MO: Elsevier Mosby. pp. 478-479, 483, 491, 493.

Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2010). Maternal child nursing care (4th ed.). Maryland Heights, MO: Mosby Elsevier. p. 525.

Pillitteri, A. P. (2007). Maternal & child health nursing: Care of the childbearing & childrearing family.Philadelphia, PA: Lippincott Williams & Wilkins. pp. 634-636.

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