CPE A&B Postpartum Assessment_ Comprehensive Guidelines for Care

Postpartum Assessment

Wash hands at sink when entering
IWIPES and gloves
oIntroduce yourself
oAsk pt name and DOB and check arm band
oWash hands/gloves
oExplain what you will be doing with pt and baby
oSAFETY
“I have already completed my general physical assessment, and everything is within normal
limits”
Ask mom how she is bonding with baby.
Ask if she is feeling any sadness or depression.
Ask if baby has a name yet.
Ask pt if she is ok with you performing a breast exam.
Palpate both breasts. Say breasts are soft and filling. There is no redness, cracking or bruising of
the nipples/areolas.
Ask, “Mom do you have a good supportive bra? I need to be wearing that bra 24/7”.
Ask mom of she is breast or bottle feeding. If breast, tell her to be sure to feed baby every 2-3
hours. If bottle, tell her to be sure to feed baby every 3-4 hours.
Ask mom the last time she pooped. Was it normal for her (amount, color, consistency)? Remind
her to make sure she is drinking plenty of fluids, ambulation is beneficial, and when she feels the
need to go do not hold it.
Ask mom the last time she voided. Was color, amount and odor normal? Was it painful?
Educate mom to be sure she is voiding every 2 hours.
Tell mom you are now going to lift her gown to assess her stomach area and vaginal bleeding
(explain we call that Lochia).
Auscultate abdomen in all 4 quadrants. Say all 4 quadrants are active.
Palpate the bladder. Say abdomen is soft and bladder is not distended.
Palpate the fundus with other hand supporting the bottom of the uterus. Say that is firm and
midline to umbilicus.
Check lochia. Say it is moderate rubra with no abnormal odor and no clots.
Educate mom that the lochia is bright red now and will change. Once it has changed, if it returns
to the bright red, she needs to call her doctor.
If mom had a c-section say that the incision is in tact and there is no redness, no ecchymosis, no
edema, no drainage and the incision is approximated
Tell mom you are going to have her roll over on her side to check her epidural site and
episiotomy (if vaginal delivery).
Epidural/Spinal block site- Say there is no redness, no ecchymosis, no edema, no drainage and it
is approximated.
Episiotomy- Say the episiotomy is intact, there is no redness, no ecchymosis, no edema, no
drainage and the episiotomy is approximated.
Say there is no presence of hemorrhoids.
Help mom back to laying on her back and put her gown back down.