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POSTNATAL ASSESSMENT

INTRODUCTION:-

Examination of a postnatal mother and early identification of complication is one of the


important responsibility of a nurse in the postnatal area. Adequate postnatal examination is
necessary for planning the care of postnatal mother.

DEFINITION/MEANING:-

Postnatal care includes systematic examination of mother and the baby and the appropriate
advice given to the mother during postpartum period. Postnatal assessment is an important
component of postnatal care.

PURPOSE:-

1) To assess the health status of the mother and institute therapy to rectify the defect if
any.
2) To detect and treat at the earliest any gynaecological condition arising out of obstetric
legacy.
3) To impart family planning guidance.

AIMS:

1. Demonstrate understanding of the normal and expected postpartum changes.


2. Conduct thorough assessments to identify signs and symptoms of problems before they
become serious complications.
3. Initiate appropriate interventions when problems do occur.
4. Prevent problems by teaching the woman appropriate ways to care for herself and her
newborn.

EQUIPMENTS:

SL. ARTICLES PURPOSES

NO.

1. A trolley consists of, To check temperature, pulse and

TPR tray Respiration.

2. BP apparatus and stethoscope To check blood pressure.

3. A sterile bin with,


To check milk secretion.
2 gauze piece To observe tongue.
1 spatula To observe vagina and lochia.
1 right hand autoclaved gloves/paper
gloves
4. Inch tape To check fundal height

5. Torch To observe eyes, ears, nose, mouth and


genitalia.

6. Weighing machine To check weight of the mother.

7. Kidney dish To collect waste.

​ASSESSMENT

● Before beginning postpartum assessment, the nurse should review the woman’s records
to determine physical or psychosocial problems that may have been identified during
labour or delivery. This review will enable the nurse to pay special attention to those areas
most at risk.
● Physiologic stability is assessed by monitoring vital signs, assessing the contraction of the
uterus, determining the amount and type of lochia and assessing the tissues of the
perineum.
● Postpartum assessment is performed according to institutional policy. In most facilities
this includes assessments every hour until 4 hours after delivery and then at 4-8 hours
intervals until discharge.

PERLIMINARY ASSESSMENT:-

Check the articles available in the mother’s unit.

PREPARATION OF PATIENT​:-

i. Explain the procedure to the mother.


ii. Instruct the mother to empty the bladder and to wash the perineum with warm water.
iii. Place the mother in supine position with hands at the sides and legs straight.
iv. Drape the mother.
v. Bring the mother towards the examiner.
vi. Ask the mother to be relaxed.

PREPARATION OF ARTICLES:-

a) A large enamel tray containing:-


b) Large sheet to drape the client.
c) Draw sheet to drape the client.
d) Stethoscope to auscultate chest and bowel sounds.
e) Torch to visualize eyes, ears and mouth.
f) Bowl with gauze piece to clean the breast.
g) Paper bag to discard the solid waste.
h) Inch tape to measure fundal height.
i) Pen and paper to record the findings.

PREPARATION OF ENVIRONMENT:-

i. Select a clam and quite environment.


ii. Provide privacy.

PROCEDURE:-

● Explain the procedure to the woman completely and clearly.


● Ask mother to empty the bladder.
● Provide privacy and assemble articles at bedside.
● Check anthropometric measurements.
● General appearance – Looks dull/good/fair.
● Check vital signs including temperature, pulse, respiration and blood pressure.
● Head to foot examination.
● Postpartum assessments: BUBBLE HE should be checked carefully to know the
deviation from normal and prevent complications.
✓ B – Breast
✓ U – Uterus
✓ B – Bowels
✓ B – Bladder
✓ L – Lochia
✓ E – Episiotomy
✓ H – Homan’s Sign
✓ E – Emotional status

PHYSICAL EXAMINATION:-

Vital Signs:-

Blood pressure, pulse, respiration and temperature must be monitor accurately.

General Appearance:-

● Body build should be seen for appearance i.e. how it is looks.


● Activity should be monitoring that whether it is dull or active.
● Nourishment should be seen in postnatal mother that whether she is well nourished,
under nourished and poor nourished.

Skin:-

● Assess the patient skin colour.


● Assess the patient skin for turgor i.e. any rashes, lesion

Head:​-
● Scalp should be assessed for dandruff and cleanliness and any pediculi.
● Hair texture for roughness and dryness.

Face:- ​The mother face should be observed for wrinkles, puffiness and scars.

Eye:-​Palpebral conjunctiva for paler, sclera for jaundice and eyes for evidence of infection.

Nose- ​Deviated nasal septum, infection and blockage.

Mouth- ​Observe tongue for pallor, glossitis ( vitamin deficiencies), teeth and gums for caries,
stomatitis, tonsil for tonsillitis.

Ear- I​ nfection ,blockage, wax.

Neck- ​Observe neck veins, thyroid glands, lymph glands for any abnormalties.

BREAST EXAMINATION:-

● Expose only the needed area that is one breast at a time.


● Inspect for the engorged veins, redness.
● Inspect nipple for retracted, erect, cracked, crust formation.

PALPATION:​-

● Feel for warmth


● Palpate from the periphery to the centre with finger pads in a circulatory motion
● Palpate for any masses/ lumps, hardness
● While palpating for axillary tails, instruct the to raise the hands above the shoulder level
● Express the colostrums/ milk and wipe with gauze piece
● Repeat this for the other side.

ABDOMINAL EXAMINATON

Inspection

Cover the chest with draw sheet and expose only the abdomen. Similarly use the other sheet to
cover up the pelvic region. Inspect the abdomen for consistency, presence of any wound( ​LSCS,
PPS​) and if present assess the condition of the wound.

Palpation

Start from the xiphisternum down, feel for the uterine fundus. Place the ulnar border of the hand.
Feel for the upper border of the symphysis pubis, place inchtape inch part up and measure the
symphysis fundul height. Feel the consistency of the uterus-hard/well contracted and flabby.

Auscultation

Auscultate for bowel sound.

UTERUS:
Examine the fundus by placing one hand above the symphysis pubis to support the lower uterine
segment and using the side of the other hand to locate the fundus. And measure the fundal height
with inch tape. Here, the fundal height decreases 1.25cm daily to get beyond the symphysis pubis
and become a pelvic organ at 6weeks of puerperial period.

Immediately after delivey the fundus should be firm and in the midline at approximately the level
of the umbilicus.

Following delivery the uterine muscle must remain in a state of contraction to prevent
hemorrhage. If the uterus is not contracting adequately, the nurse can support the lower uterine
segment and use gentle massage to increase contraction of the uterine muscle fibres.

BOWELS:

Most women do not have the urge to defecate for a few days following delivery, although some
may do so. Loss of abdominal tone contributes to Problems with constipation following child
birth. Fear of pain or tissue damage during the first defecation after delivery is also common. The
nurse Should identify specific concerns so that any potential problems can be addressed.

BLADDER:

The urinary bladder should be assessed for the presence of distention. When the bladder
becomes distended , inspection and palpation will reveal a bulge directly above the symphysis
pubis. A distended bladder is dangerous following delivery because it will interfere with normal
contraction of the uterus. The woman should void within 4-6 hours following delivery. This time
is monitored closely. The volume of the initial voiding is typically measures and documented.
Subsequent voiding should be measured if incomplete emptying of the bladder is suspected. Any
signs or symptoms of infection, such as pain or burning with urination should be documented and
reported.

GENITALIA​: Inspect for vulval oedema, hematoma and lacerations.

1. LOCHIA ​– The amount and characteristics of the lochia are assessed each time the fundus
is checked. Immediately after delivery this drainage is red and contains blood, small clots
and tissue fragments.
2. In case of uterine atony increases blood loss. So, general condition should be checked by
monitoring vital signs.
3. The amount of lochia described as scant, light, moderate or heavy. This is determined by
assessing how rapidly perineal pads are saturated. The nurse must be careful to look
underneath the woman’s buttocks and back to make sure that the drainage is not missing
the pad and pooling in the bed linens.
4. For the first 1-2 hours following delivery the flow is expected to be moderate, with one or
two pads being saturated in an hour. A heavier rate of flow than this is considered
excessive.
5. The nurse should maintains careful records of the number of pads saturated in an hour
inorder to determine overall blood loss.
6. When more detailed assessment is needed, the pads can be weighed to determine blood
loss more precisely. One gram of weight is approximately equivalent to 1ml of blood.
7. Less than expected flow should also be viewed with caution to determine that the uterus is
contracting and clots are not forming within the uterus or vaginal canal.
8. The amount of lochia diminishes gradually over time. Lochia changes colour and
consistency as healing of the endometrium takesplace.

EPISIOTOMY:

The woman should be positioned in lithotomy position and good room light or flash light
is needed to visualize the stitches/suture line adequately.

REEDA should be observed,

R – Redness

E – Edema

E – Ecchymosis

D – Discharges

A – Approximation of suture line

RECTUM:​ Inspect for hemorroids.

EXTREMITIES:

● Any congenital abnormalities syndactyly/polydactyl


● Capillary refill

HOMAN’S Sign;

● Ask the mother to flex the leg at the knee level and relax. Support at the calf muscle with
other hand dorsiflex the foot. If the mother experiences pain at the calf region then
homan’s sign is positive.
● Problems related to venous stasis generally begin during the last few months of pregnancy
when the enlarged uterus restricts the return of blood to the heart. These problems are
further aggravated by pressure on the femoral veins during bearing down and use of
stirrups during delivery. Impaired venous return increases the risk of thrombus
formation.
● The nurse inspects both the legs for any signs of superficial or deep vein thrombosis (DVT)
formation, such as pain in the calf muscle, warmth, redness or swelling.
● Both the legs are checked for the presence of Homan’s sign, which is an indicator of
venous thrombosis. With the woman lying in the supine position, the nurse supports the
knee of one leg while dorsiflexing the foot. Homan’s sign is considered positive when the
woman reports pain, not just a stretching sensation in the calf.

EMOTIONAL STATUS​:
● Relationship with the newborn and family dynamics:
● The early postpartum period is the ideal time for bonding between mother and newborn.
The immediate family should have the opportunity to spend time with each other and the
newborn while their emotions and level of excitement are high.
● The nurse should provide privacy and encourage the family to interact with a minimum
amount of interruption. And the rooming-in or bonding should be developed between
mother and the baby.
● Self care ability:
● The nurse must assess the woman’s ability to care for herself and her newborn.
● Documentation of procedure and informing the deviations from normal to the physiciens.
● Education to the mother regarding personal hygiene, postnatal diet, postnatal
exercise,breast feeding techniques, immunization schedule and care of the newborn.
● Replace the article

Examination of the perineum

✓ Position client in lithotomy/ dorsal recumbent position.


✓ Drape the client.
✓ Put the light on.
✓ Wash hands.
✓ Wear gloves
✓ Examine the perineum for-
● Condition of episiotomy wound( REEDA)
● Colour and amount of lochia.
● Condition of perineum
● Number of pads changed/day

RECORDING:-

● Record the findings in nurse’s record with date and time.


● Vital signs record in the vital signs chart.

PERINEAL CARE:-

Perineal care is washing down of external genitilia and perinea under a aseptic precaution.

PURPOSES

1. To clean the perineum in preoperative preparation for a antiseptic action.


2. To deodourize the perineum.
3. To stimulate circulation and thus reliving the pain, inflammation and congestion.
4. To promote healing by preventing infection.
5. To enhance comfort.

INDICATIONS:-

1. Before per vaginal examination of any other per vaginal procedure.


2. Before and after delivery.
3. Post-natal mother.
4. Post abortion.
5. Gynecological contions-prolapsed uterus, any infection e.g. vaganitis.

PRECAUTIONS

1. Explanation to get cooperation.


2. Mother must empty her bladder before the procedure.
3. Maintain temperature and strength of the solution(temp-105​O​ F Dettol 1:60 and sevlon
1:100)
4. Keep nine basic principles of safety , economy, comfort and effectiveness in mind.

SUMMARY:-

In this teching practice, I have conducting teching practice on postnatal assessment Today we
discussed about the definition, purposes, preparation of patient, environment and articles in
postnatal assessment, procedure of assessment and perineal care.

CONCLUSION:-

Examination after the delivery is postnatal examination. It include systematic examination of


baby and also advices given during postpartum period.

With the objectives to assess the health status of mother and baby and to institude effective
therapy, to detect and treat any gyanecological condition or associated illness arising out of
obstetric condition.

POINTS TO BE REMEMBERED

INSTRUCTIONS

Breast

1. Gently palpate each breast


2. If you feel nodules in the breast, the ducts may not have been emptied at last.
3. Stroke downward towards the nipple, then gently release the milk by manual.
4. If nodules remain, notify the doctor.
5. Take this opportunity to explain the process of milk production, what to do about
engorgement, how to perform self breast examinations, and answer any questions she
may have about breastfeeding.
6. What is the contour?
7. Are the breast full, firm, tender, shiny?
8. Are the veins distended?
9. Is the skin warm?
10. Does the patient complain of sore nipples?
11. Are breasts so engorged that she requires pain medication?

Uterus
1. Palpate the uterus
2. Have the patient feel her uterus as you explain the process of involution
3. If uterus is not involution properly, check for infection, fibroids and lack of tone.
4. Uterus should the firm decrease approximately one finger breadth below
5. Unsatisfactory involution may result if there are retained secundines or the bladder not
completely empty

Bladder

1. Inspect and palpate the bladder simultaneously while checking the height of the fundus.
2. An order from the physician is necessary cauterization may be done. An order for culture
and sensitivity test since definitive treatment may be required.
3. Talk to mother about proper perineal care. Explain that she should wipe from front to
back after voiding and defecating.
4. Bladder distention should not be present after recent emptying.
5. When bladder distention does occur, a pouch over the bladder area is observed, felt upon
palpation; mother usually feels need to urinate.
6. It is imperative that the first three post-partum voiding be measured and should be at
least 150cc. Frequent small voiding with or without pain and burning may indicate
infection or retention.

Bowel Function

1. Question patient daily about bowel movements. She must not become constipated. If her
bowels have not functioned by the second postpartum day, the doctor may start her on a
mild laxative
2. Encourage patient to drink extra fluids.
3. Have patient select fruits and vegetables from her menu

Lochia

1. Assess the amount and type of lochia on pad in relations to the number of postpartum
days. First 3 days of postpartum, you should find a very red lochia similar to the menstrual
flow (lochia ruba).
2. During the next few days, it should become watery serous (lochia serosa). On the tenth
day, it
3. should become thin and colorless (lochia alba).
4. Inform the mother about what changes she should expect in the lochia and when it should
cease.
5. Tell the mother when her next menstrual period will probably begin and when she can
resume sexual relations.
6. Discuss family planning at this time.
7. Notify the doctor if the lochia looks abnormal in to color or contains clogs other than small
ones.
Episiotomy

1. Inspect episiotomy thoroughly using flashlight if necessary, for better visibility.


2. Check rectal area. If hemorrhoids are present, the doctor may want to start on sitz bath
and local analgesic medication. Reassure patient and answer questions she may have
regarding pain, cleanliness, and coitus.
3. Check episiotomy for proper wound healing, infection, inflammation and suture sloughing.
4. Is the surrounding skin warm to touch?
5. Does the patient complain of discomfort? Notify the doctor if any occurs.

Homan’s Sign

1. Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot
2. Pain or tenderness in the calf is a positive Homan’s sign and indication of
thrombophlebitis. Physician should be notified immediately.

Emotional Status

1. Throughout the physical assessment, notice and evaluate the mother’s emotional status.
2. Explain to the mother and to her family that she may cry easily for a while and that her
emotions may shift from high to low. The changes are normal and are probably caused by
the tremendous hormonal changes occurring in her body and by her realization of new
responsibilities that accompany each child’s birth.

AFTER CARE:-

Client/patient

● Explain the findings.


● Help her to dress up.
● Remove the drappings.
● Position comfortably.

Articles
● Wash and replace the articles.
● Wash hands.

Environment

● Put off the light.


● Keep the bed/table clean.
● Dispose the waste
3. s she say about family?Are there other nonverbal responses​?

REFERENCES:-
1) Manocha Snehlata, “PROCEDURE AND PRACTICE IN MIDWIFERY”, Published by- Kumar
Publishing House, edition- 3​rd​ Year2013, Page No. 135-160.
2) Prakash Ratna, “NURSING PROCEDURE”, Published by- CBS publisher and distributors,
Volume- 2​nd​ Year 2009, Page No. 58-70
3) Dutta Dc , “ Textbook of obstetrics” Edition- 6​th​ ,Published by- Calcutta :New Central Book
Agency ; 2004, page no.146-149
4) Gloria Hoffmann Wold; “Contemporary maternity nursing”, Mosby publications,
Philadelphia,1997,page no.258-264.

WEBSITES:-

www.wikipedia.com

http://igce.med.sc.ed

http://www.pubmed.com

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