Definition
Postnatal assessment and examination of the mother refers to observing and noting her physical, physiological, and emotional well-being every day for at least the first three postnatal days and up to 10 days if visiting homes and on a lesser frequency up to 28 days.
Purposes
- To assess the normal physiological changes in the body following childbirth.
- To assess the normal psychological changes in the immediate postpartum period.
- To find any potential medical problems.
- To assess the involution of various organs.
- To assess the emotional status of mother.
- To teach the mother regarding care of herself and the baby.
Articles
- A pair of gloves.
- Mask.
- Weighing machine.
- Measuring tape.
- ТРR trау.
- Blood pressure apparatus and stethoscope.
- Articles for perineal cleaning and examination.
- Kidney tray and waste disposal bag.
- Sterile pad.
- Flashlight.
Procedure
| Nursing Action | Rationale | |
| 1. | Before procedure Explain the procedures to be performed to mother. | Promotes compliance. |
| 2. | Assemble articles at the bedside. | Promotes convenience for performing procedure. |
| 3. | Ask mother to empty her bladder. | Avoids discomfort during examination and for correct estimation of fundal height. |
| 4. | Assist mother to assume correct and comfortable position. | Promotes comfort to mother and convenience for examination. |
| 5. | Provide privacy. | Avoids embarrassment. |
| 6. | During procedure Wash and dry hands. | Prevent chance of infection. |
| a. Clinical assessment | ||
| 7. | Check blood pressure and if needed temperature, pulse, and respiration. | Obtains baseline physiological data. |
| 8. | Carry out a head to foot assessment (observation and examination) | |
| Head | Cleanliness, infection, pediculosis, etc. | |
| Eyes: Sclera and conjunctiva | Pallor, infection, jaundice. | |
| Ears | Hearing, discharge, and wax. | |
| Nose | Discharge and epistaxis. | |
| Mouth | Cracked lips, dental caries, bleeding gums, and coated tongue. | |
| Neck | Swelling, lymph nodes. | |
| Breasts | Nipples, areola, and engorgement. | |
| Upper extremities | Deformities, capillary and refill. | |
| Lower extremities | Edema, deformities, varicose veins, and Homans sign. | |
| Genital area Bowel and bladder | Bleeding, lochia, haemorrhoids, and hygiene. Constipation and incontinence. | |
| b. Physical assessment | ||
| 9. | Examine the different elements using the acronym “BUBBLE HE” Breasts Uterus Bladder Bowel Lochia Episiotomy Homans sign Emotions | |
| Breasts: Inspect breasts for color, shape, contour, and any discharge other than milk. Palpate each breast gently for fullness, redness, and tenderness. Nipples. | Detects any abnormal changes, if present. Presence of colostrum or milk is normal. To find if inverted, cracked, flat, bruised. | |
| Uterus: Palpate uterus to check for position, consistency, and tonicity. | Contracted uterus centrally situated is normal. | |
| Bladder: Inspect and palpate the bladder before checking the height of fundus. | Frequent, small voiding with or without pain and burning may indicate infection or retention. | |
| Bowel: Auscultate for bowel sounds and check if bowel movements are regular. | Daily bowel movements and avoid constipation. | |
| Lochia: Check vaginal discharge for odor, reaction, color, composition, and amount. | Non offensive lochia of average amount and normal color change is expected. | |
| Episiotomy: Inspect episiotomy thoroughly using flashlight if necessary· and assess using the acronym REEDA. R-Redness (hyperemia) E-Edema E-Ecchymosis D-Drainage A-Approximation of wound edges | To exclude presence of infection and delayed healing. | |
| Homan sign: Have the patient lie on her back, with legs extended flat on bed, ask her to dorsiflex her foot one at a time. Check for pain or tenderness in the calf muscles. Check lower extremities for presence of red, painful, or edematous area. | Presence of pain is a positive sign for thrombophlebitis. Detects signs of deep vein thrombosis (DVT). | |
| C. Emotional status | ||
| 10. | Asses for symptoms of “baby blues”or postpartum blues demonstrated by tearfulness, irritability, insomnia, and exhaustion. | Helps in detection of any psychological complication in the postnatal period. |
| 11. | At the completion of assessment steps, assist patient to assume comfortable position. | Promotes rest and relaxation. |
| 12. | After procedure Replace all articles in appropriate place. | Facilitates availability for further use. |
| 13. | Record the findings in patient’s chart and report as needed. | Promotes communication among staff members. |
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Annamma Jacob, Manual of Midwifery and Gynaecological Nursing, 4th Edition, 2023, Jaypee Publishers, ISBN: 978-9356961593
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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