Topic : Postpartum Care by Association of Professors of Gynecology and Obstetrics (APGO)
Postpartum Maternal Physical Assessment Summary- BUBBLE HE
Breasts:
- inspect: size, symmetry, shape of breast and nipples taking note of erection, flatness, redness, bruising, open wounds, presence of mastitis and colostrum
- palpate: fullness, soft or engorged, firmness and lumps
- pain assessment
Uterus (Fundus):
- palpate: firmness/bogginess, location of the fundus in relation to the abdomen, determine the location of the fundus in relation to the belly button to determine amount of fundal involution
- inspect incision site
- check policy: in some organizations, they may not assess fundal involution by palpation due to fear of dehiscence
Bladder:
- void amount (~30ml/hr)
- assess for distention, incontinence, urinary retention, urinary infection especially if the patient had a foley catheter
Bowel:
- last bowel movement/flatus
- assess for distention, abdominal pain
Lochia:
- amount, color, odour
- assess for postpartum hemorrhage
- Persistent red lochia suggested delay involution that is usually associated with infections or retained piece of placenta tissue.
- Offensive lochia, which may be accompanied by pyrexia and a tender uterus, suggests infections and should be treated with broad spectrum antibiotics.
- Retained placental tissue is associated with increased red blood cell loss and blood clots, and this may be suspected if the placenta and membranes were incomplete at delivery. Management includes uses of antibiotics and evacuation of retained products under regional or general anaesthesia.
Episiotomy
- level of laceration
- number of stitches, redness, edema, bruisin, discharge, approximation of wound edges
- assess perineal area
Homan’s Sign-for DVT
- assess for pain with dorsiflexion
- check policy: this is sometimes not done in organizations
Emotional State:
- assess for signs and symptoms of postpartum depression and infant-maternal bonding
At my postpartum placement, one of the nurses gave us a very helpful handout on what to look for specifically in cesarean and vaginal deliveries postpartum. Again, the Disclaimer is that these were tips she found useful in assessing her patients, do not use this information to guide your practice, checking college standards and organizational regulations is imperative to good practice.
Vaginal Birth Assessment
- VS: on admission; 2 hrs post 1st set of VS; 24hr postpartum or qshift; within 2hr of d/c
- Urine Output: d/c foley when patient is walking; delay foley removal if there is swelling in labia
- IV: d/c when patient is stable and no signs of postpartum hemorrhage
Cesarean Assessment
- VS: on admission; 1hr post 1st set of vitals; q4hrs for the next 48 hrs; qshift until d/c; within 2hrs of d/c
- Urine Output: d/c foley catheter 12 hrs post opt unless ordered; output for first 2 voids should match ~30ml/hr; if no void within 6-8 hrs post foley removal then do I/O catheter
- IV: assess for complications such as infiltration, fluid overload; d/c 24hrs or when stable VS
Neonatal Physical Assessment
- Check: GBS, Bloodtype, HepB, HIV and Rubella status of mother and baby
- VS: on admission; qshift (if GBS+ive then q4h)
- Head to Toe: on admission; qshift; the mother is a great resource wen you are doing vital assessments or when you are getting blood samples for the heel prick. Have the mother hold the baby skin-skin or breast feed the baby when you assess, they cry less and will make the assessment go faster.
- Blood Work: GBS+ive babies need cbc and blood culture 4hrs after birth; bilirubine and newborn screen with heel prick is done after 24hrs for Vaginal births and 48hrs for Cesarean sections
- Breastfeeding: skin-skin as much as possible; breask feed 12-3 hrs or when baby shows feeding cues.
Credit: Nurse Student Opinion
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