Accepted Practice

Postpartum assessment
During postpartum, the time between delivery and the return of the reproductive system to its
pre-pregnancy state, youll assess your patients vital signs, breasts, fundus, bladder, lochia,
perineum, legs, and any incisions.
Measure vital signs with the frequency your facilitys policies specify or according to the
providers prescription. Include temperature, heart rate, respiration, blood pressure, and pain
level. Temperature may rise due to the dehydration that can accompany labor and sometimes as a
result of epidural anesthesia. After the first 24 hours, however, elevations in temperature warrant
further investigation as they suggest infection. Pulse rates may be somewhat elevated but should
return to their pre-pregnant status gradually. A sustained rapid pulse can indicate hemorrhage.
Respiratory rates may be low after epidural anesthesia and after a cesarean birth but should
gradually return to the expected range. Orthostatic hypotension is common after delivery.
Hypotension can indicate hemorrhage, and hypertension may persist in women who have had
pre-eclampsia.
Assess your patients pain, including location, type, quality, and severity. Administer pain
medication to keep the patients pain at a manageable level. For perineal pain, apply cold during
the first 24 hours, including cool sitz baths. This helps reduce swelling and irritation. After the
first 24 hours, warmth is helpful for promoting circulation and healing. To help reduce pain from
sitting down, suggest that your patient compress or tighten her buttocks just before sitting. This
reduces pressure on healing perineal tissues.
Encourage your patient to urinate prior to assessing her fundus. Assist her to a supine position.
First, inspect and gently palpate her breasts for redness, pain, and engorgement. Inspect the
nipples for redness, cracks, and bleeding. If she is breastfeeding and her breasts are engorged,
suggest warm compresses or a warm shower before breastfeeding to stimulate milk flow. Or, if
her newborn isnt emptying both breasts, suggest she pump her breasts to relieve discomfort. If
she is not breastfeeding, suggest ice packs to help suppress milk production and reduce
discomfort.
Next, check your patients fundus. Assess uterine height, location, and consistency. Determine
the fundal height by placing one hand at the base of the uterus and the other at the umbilicus.
Measure how many fingerbreadths, which are roughly equivalent to centimeters, you can place
between the fundus and the umbilicus above or below it. If none, then the fundus is at the
umbilical level. At 12 hours after delivery, the fundus is typically 1 cm above the umbilicus, but
this does vary. The uterus descends into the pelvis approximately 1 to 2 cm per day. About a
week after delivery, the fundus should be halfway between the umbilicus and the symphysis
pubis. Also, assess whether the fundus is boggy or firm. If the fundus is boggy, gently massage
the uterus with a rotating motion while supporting the lower uterine segment until it feels firm.

Without stabilization of the lower segment, the uterus could invert, and severe hemorrhaging
could result.
Assess and palpate the bladder at this time as well. Determine whether the fundus is at midline in
the pelvis or displaced laterally due to a full bladder. If the bladder is full, encourage the patient
to urinate and monitor her fluid intake and output. For some patients, insertion of a straight
urinary catheter may become necessary.
Examine the patients perineal pad for bleeding, noting the character, quantity, presence of clots,
and odor. Lochia rubra is typical 1 to 3 days following delivery, and small clots are common.
Determine the amount of saturation as scant, light, moderate, heavy, or excessive. Be sure to
check under the patients buttocks to be sure blood is not pooling beneath her. Lochia typically
increases with breastfeeding and ambulation. If bleeding is excessive, the patient will soak an
entire perineal pad within 15 minutes or so. For that finding as well as for numerous large clots
or a foul odor, notify the provider immediately.
If the patient has had a cesarean delivery, examine the incision for redness, edema, ecchymosis,
drainage, and approximation of its edges. If the patient has had an episiotomy, have her lie on her
side and assess the episiotomy incision for approximation, edema, and ecchymosis. Also check
her rectum for hemorrhoids and assess bowel function by auscultating bowel sounds.
Assess for thrombophlebitis by checking the patients calves for pain, tenderness, or redness.
Notify the provider immediately if you find any of these. Check for edema of the hands, the face,
and the lower extremities.
Finally, assess your patients comfort level and emotional status.
Accepted Practice
Pregnancy
Pregnancy is a time of profound physiological and emotional change. It is beyond the scope of
this skills module to present a comprehensive review of pregnancy. However, to meet your
patients learning needs during its various trimesters, it is essential have to basic understanding
of what she might experience during each of these phases.
The first trimester

When you first encounter a patient in her early weeks of pregnancy, she has probably just found
out that she is pregnant. She may have any of a wide range of emotional responses and might not
be prepared to take in a lot of information about pregnancy and childbirth at this time. Besides
answering any questions she might have, your priority will be to point out any danger signs
indications she must report to her provider because they might warrant intervention.
Your patients first question is likely to be about when her baby will arrive. To calculate this, use
Ngeles rule. Take the first day of the womans last menstrual cycle, subtract 3 months, and then

add 7 days and adjust the year as needed to make it a future date. So, if the first day of her last
menstruation was November 20 of the current year, subtracting 3 months takes you to August,
and adding 7 days and one year makes her due date August 27 of the following year.
Many women develop morning sickness during early pregnancy; indeed, your patient might
tell you that she does feel nauseated from time to time. Make sure she knows to report severe
vomiting, as it could be hyperemesis gravidarum, a serious complication that involves weight
loss, fluid and electrolyte imbalances, and nutritional deficits.
Tell your patient to report abdominal cramping and any vaginal bleeding at all. In the first
trimester, these could indicate miscarriage or ectopic pregnancy.
Another major consideration during the first trimester is infection. Burning with urination could
mean a urinary tract infection. Diarrhea could mean a gastrointestinal infection. And fever and
chills could indicate a systemic infection. All require prompt reporting and intervention.
Also instruct your patient to avoid taking any prescription or over-the-counter medications or
supplements without first checking with her provider. Be sure she is aware of the dangers to her
fetus from her ingestion of alcohol or other dangerous substances.
The second trimester
During the second trimester, many women undergo an ultrasound examination and find out their
babys gender. It can be an exciting time, particularly as women feel their babys movement, or
quickening, for the first time. Your patient may also look to you for help with some of the
common discomforts of pregnancy that develop from her ever-expanding uterus.
The danger signs from the first trimester still apply; however, in this trimester, vaginal bleeding
can also indicate placental problems such as placenta previa and abruptio placentae. Abdominal
pain or cramping can mean preterm labor, and a sudden gush of clear fluid from the vagina
indicates a rupture of the amniotic membranes a serious complication this early in pregnancy.
Once a woman is accustomed to the pattern and frequency of fetal movement, she must report
any significant increase or decrease. Either could be a fetal response to inadequate oxygenation.
At this time, be sure to instruct your patient to report any indications that her blood pressure has
risen and she has developed pre-eclampsia. Classic manifestations include headache, vision
changes, epigastric or abdominal pain, and edema, especially of the face and hands.
Gestational diabetes is another complication of pregnancy that manifests with specific warning
signs. Instruct your patient to report the concurrent occurrence of flushed dry skin, fruity breath,
rapid breathing, increased thirst and urination, and headache. These are manifestations of
hyperglycemia. Clammy pale skin, weakness, tremors, irritability, and lightheadedness are
manifestations of hypoglycemia.

It is also important at this time to teach your patient about the benefits of breastfeeding and of
taking childbirth preparation classes.
The third trimester
During the third trimester, when women are preparing for the birth of their baby, they will want
to know how they can tell the difference between true and false labor.
During true labor, your patient will have regular contractions that gradually become stronger and
closer together. She will feel the pain of true labor in her lower back, and it will move forward
across her lower abdomen. Her cervix will dilate and efface, and as the cervix dilates, she will
pass what is called a bloody show vaginally and feel the baby moving down into the birth canal.
With false labor, contractions are usually irregular, although they can be regular for short
periods. Walking and other activities will stop false labor, as will comfort measures and
hydration. (These do not stop true labor.) And of course, with false labor, the cervix does not
dilate and it does not efface.
The previous danger signs still apply, although after 37 weeks, ruptured membranes are likely to
signal an imminent onset of term labor and not a danger sign of preterm labor.