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CH. 16 Postpartum Notes & Highlights
Postpartum assessment typically is performed as follows:
• During the first hour: every 15 minutes
• During the second hour: every 30 minutes
• During the first 24 hours: every 4 hours
• After 24 hours: every 8 hours
Postpartum assessment of the mother typically includes vital signs, pain level, and a systematic head-to-toe
review of body systems. The acronym BUBBLE-EE— breasts, uterus, bladder, bowels, lochia, episiotomy/
perineum, extremities, and emotional status
Some women experience a slight fever, up to 38°C (100.4°F),
during the first 24 hours. This elevation may be the result of
dehydration because of fluid loss during labor.
A temperature above 38°C (100.4°F) at any time or an abnormal
temperature after the first 24 hours may indicate infection and must be
reported
Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss,
infection, or underlying cardiac problems. Further investigation is warranted to rule out complications.
Inspect the breasts for size, contour, asymmetry, engorgement, or erythema. Check the nipples for cracks, redness,
fissures, or bleeding, and note
, 2
whether they are erect, flat, or inverted. Flat or inverted nipples can make breast- feeding challenging for both
mother and infant. Cracked, blistered, fissured, bruised, or bleeding nipples in the breast-feeding woman are
generally indications that the baby is improperly positioned on the breast.
For women who are not breast-feeding, use a gentle, light touch to avoid breast stimulation, which would
exacerbate engorgement.
Duct that may progress to mastitis if not treated promptly. Any discharge from the nipple should be described
and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).
Assess the fundus (top portion of the uterus) to determine the degree of uterine involution. If possible, have the
woman empty her bladder before assessing the fundus.
The fundus should be midline and should feel firm. A boggy or relaxed uterus is a sign of uterine atony. This can be
the result of bladder distention, which displaces the uterus upward and to the right, or retained placental
fragments. Either situation predisposes the woman to hemorrhage.
One to 2 hours after birth, the fundus typically is between the umbilicus and the symphysis pubis. Approximately
6 to 12 hours after birth, the fundus usually is at the level of the umbilicus
Normally, the fundus progresses downward at a rate of one fingerbreadth (or 1 cm) per day after childbirth
On the first postpartum day, the top of the fundus is located 1 cm below the umbilicus and is recorded as U-1.
Similarly, on the second postpar- tum day, the fundus would be 2 cm below the umbilicus and should be recorded
as U- 2, and so on. If the fundus is not firm, gently massage the uterus using a circular motion until it becomes
firm.
Considerable diuresis—as much as 3,000 mL—may follow for several days after childbirth, decreasing by
the third day
Palpation of a rounded mass suggests bladder distention. Also percuss the area: a full bladder is dull to percussion. If
the bladder is full, lochia drainage will be more than normal because the uterus cannot contract to suppress the
bleeding.
Assess lochia in terms of amount, color, odor, and change with activity and time. Foul-smelling lochia suggests an
infection, and large clots suggest poor uterine involution, necessitating additional intervention.
, 3
To determine the amount of lochia, observe the amount of lochia saturation
on the perineal pad and re- late it to time Typically, the amount of lochia is described as follows:
Scant: a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-mL loss
Light or small: an approximately 4-inch stain or a 10- to 25-mL loss
Moderate: a 4- to 6-inch stain with an estimated loss of 25 to 50 mL Large or heavy: a pad is
saturated within 1 hour after changing it
Report any abnormal findings, such as heavy, bright- red lochia with large tissue fragments or a foul odor. If
excessive bleeding occurs, the first step would be to massage the boggy fundus
until it is firm to reduce the flow of blood. Document
all findings.
Urge the woman to notify her health care provider if
lochia rubra returns after the serosa and alba transitions
have taken place.
To assess the episiotomy and perineal area, position the
woman on her side with her top leg flexed upward at the
knee and drawn up toward her waist.
The normal episiotomy site should not have redness,
discharge, or edema. The
majority of healing takes place within the first 2 weeks, but it may take 4 to 6 months for the episiotomy to heal
completely
Lacerations are classified based on their severity and tis- sue involvement:
First-degree laceration—involves only skin and superficial structures above muscle
Second-degree laceration—extends through perineal muscles
Third-degree laceration—extends through the anal sphincter muscle Fourth-degree
laceration—continues through anterior rectal wall
Assess the episiotomy and any lacerations at least every 8 hours Large areas of swollen, bluish
skin with complaints of severe
pain in the perineal area indicate pelvic or vulvar hematomas. Redness, swelling, increasing
discomfort, or purulent drainage
may indicate infection. Both findings need to be reported
CH. 16 Postpartum Notes & Highlights
Postpartum assessment typically is performed as follows:
• During the first hour: every 15 minutes
• During the second hour: every 30 minutes
• During the first 24 hours: every 4 hours
• After 24 hours: every 8 hours
Postpartum assessment of the mother typically includes vital signs, pain level, and a systematic head-to-toe
review of body systems. The acronym BUBBLE-EE— breasts, uterus, bladder, bowels, lochia, episiotomy/
perineum, extremities, and emotional status
Some women experience a slight fever, up to 38°C (100.4°F),
during the first 24 hours. This elevation may be the result of
dehydration because of fluid loss during labor.
A temperature above 38°C (100.4°F) at any time or an abnormal
temperature after the first 24 hours may indicate infection and must be
reported
Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss,
infection, or underlying cardiac problems. Further investigation is warranted to rule out complications.
Inspect the breasts for size, contour, asymmetry, engorgement, or erythema. Check the nipples for cracks, redness,
fissures, or bleeding, and note
, 2
whether they are erect, flat, or inverted. Flat or inverted nipples can make breast- feeding challenging for both
mother and infant. Cracked, blistered, fissured, bruised, or bleeding nipples in the breast-feeding woman are
generally indications that the baby is improperly positioned on the breast.
For women who are not breast-feeding, use a gentle, light touch to avoid breast stimulation, which would
exacerbate engorgement.
Duct that may progress to mastitis if not treated promptly. Any discharge from the nipple should be described
and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).
Assess the fundus (top portion of the uterus) to determine the degree of uterine involution. If possible, have the
woman empty her bladder before assessing the fundus.
The fundus should be midline and should feel firm. A boggy or relaxed uterus is a sign of uterine atony. This can be
the result of bladder distention, which displaces the uterus upward and to the right, or retained placental
fragments. Either situation predisposes the woman to hemorrhage.
One to 2 hours after birth, the fundus typically is between the umbilicus and the symphysis pubis. Approximately
6 to 12 hours after birth, the fundus usually is at the level of the umbilicus
Normally, the fundus progresses downward at a rate of one fingerbreadth (or 1 cm) per day after childbirth
On the first postpartum day, the top of the fundus is located 1 cm below the umbilicus and is recorded as U-1.
Similarly, on the second postpar- tum day, the fundus would be 2 cm below the umbilicus and should be recorded
as U- 2, and so on. If the fundus is not firm, gently massage the uterus using a circular motion until it becomes
firm.
Considerable diuresis—as much as 3,000 mL—may follow for several days after childbirth, decreasing by
the third day
Palpation of a rounded mass suggests bladder distention. Also percuss the area: a full bladder is dull to percussion. If
the bladder is full, lochia drainage will be more than normal because the uterus cannot contract to suppress the
bleeding.
Assess lochia in terms of amount, color, odor, and change with activity and time. Foul-smelling lochia suggests an
infection, and large clots suggest poor uterine involution, necessitating additional intervention.
, 3
To determine the amount of lochia, observe the amount of lochia saturation
on the perineal pad and re- late it to time Typically, the amount of lochia is described as follows:
Scant: a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-mL loss
Light or small: an approximately 4-inch stain or a 10- to 25-mL loss
Moderate: a 4- to 6-inch stain with an estimated loss of 25 to 50 mL Large or heavy: a pad is
saturated within 1 hour after changing it
Report any abnormal findings, such as heavy, bright- red lochia with large tissue fragments or a foul odor. If
excessive bleeding occurs, the first step would be to massage the boggy fundus
until it is firm to reduce the flow of blood. Document
all findings.
Urge the woman to notify her health care provider if
lochia rubra returns after the serosa and alba transitions
have taken place.
To assess the episiotomy and perineal area, position the
woman on her side with her top leg flexed upward at the
knee and drawn up toward her waist.
The normal episiotomy site should not have redness,
discharge, or edema. The
majority of healing takes place within the first 2 weeks, but it may take 4 to 6 months for the episiotomy to heal
completely
Lacerations are classified based on their severity and tis- sue involvement:
First-degree laceration—involves only skin and superficial structures above muscle
Second-degree laceration—extends through perineal muscles
Third-degree laceration—extends through the anal sphincter muscle Fourth-degree
laceration—continues through anterior rectal wall
Assess the episiotomy and any lacerations at least every 8 hours Large areas of swollen, bluish
skin with complaints of severe
pain in the perineal area indicate pelvic or vulvar hematomas. Redness, swelling, increasing
discomfort, or purulent drainage
may indicate infection. Both findings need to be reported
