Guide for Maternal Postpartum Physical Assessment, Anticipatory Guidance and Health Teaching

Assessment Items	Norms	Abnormalities	Anticipatory Guidance and Health Teaching	Further Action Required
General Health	- woman maintains preventive health screenings and regular primary care and GYN appointments	- Any abnormalities assessed from health screenings or medical appointments are followed up with appropriate care provider	- assure the postpartum woman has an appointment for a 4-6 week postpartum check-up and is able to get there	Assess vital signs, call medical care provider immediately if abnormalities exist
Vital Signs
1.  Temperature	- temperature may increase to 100.4 (38 C) 1st 24 hrs - temperature may rise 100 F to 102 F when milk comes in	>100.4 (38C) indicates infection	- teach to take temp and to call medical care provider if >100.4 (38C)
2.  Heart rate	- bradycardia 50-70/min may last 6 – 10 days due to increase bleeding volume of pregnancy	-Tachycardia >100/min;  may indicate compromised blood volume, hypovolemia, anemia, infection, fear	- teach that postpartum hemorrhage can occur 24 hr to 6 weeks postpartum and to call medical care provider if bleeding heavily i.e. one pad per hour or more - teach signs of anxiety
3.  Respirations	- respirations essentially unchanged	- dyspnea, coughing, chest pain indicative of pulmonary embolus
4.  Blood pressure	-blood pressure essentially same	- Pregnancy Induced Hypertension (PIH) in postpartum period. BP > 140/90 - headache, blurred vision, epigastric pain, edema	- teach signs & symptoms of elevated BP and to call medical care provider if experiencing any of these s & s - low BP may be due to orthostatic hypotension or hemorrhage - If low BP also consider if the woman had excessive oxytocin
Lungs	- Should be clear to auscultation	- Wheezing, Crackles, Rhonchi, Diminished lung sounds - Women treated for PIH or PTL are at increased risk for pulmonary embolism		- Contact medical provider from the home if lungs sounds are abnormal or absent - Evaluate for other signs of pulmonary embolism
Breast/ Nipples	- colostrum present 1st 3 days (thick , yellow fluid) - milk comes in about 3-4 days - low grade fever 4-16 hours common - breasts feel smooth, may be soft , filling or engorged - tenderness 7-10 days - Mothers who bottlefeed will experience some breast tenderness as milk comes in, by 6 weeks return to prepregnant size	- pathological engorgement - excessive soreness, cracked, bleeding nipples - blocked ducts, lumps under skin which are sore to touch - palpable masses. - mastitis: · red, sore area · streaking · fever, chills, flu-like symptoms - breast abscess	- Suggest the following: · Expose breast to air after feeding. · Spread colostrum on breasts. · avoid soap on breast · wear supportive cotton bras,  avoid underwires - assist with varying positions i.e. clutch, cradle, hold, side lying, normal saline soaks to nipples - call OB provider with symptoms of mastitis - to eliminate milk: binding breasts, ice packs; refer to L.C.	- Assess breast/nipples, call medical care provider immediately if signs & symptoms of mastitis observed - Assess and refer to community resources if having difficulty breastfeeding
Uterus	- after 24 hr., fundus  1 cm. below umbilicus, decreases 1-2 cm./day - by 10-14 days, not palpable - uterus is firm, not boggy (multiparity, multiple gestation and bladder distention can influence size or position)	- uterine atony, boggy fundus - higher fundus and deviated from midline indicative of bladder distention -tender, prolonged involution may be due to hemorrhage, infection	-teach fundal massage to assure firmness and to check for involution	- Assess uterus, call medical care provider immediately if abnormalities observed - If fundus is deviated or higher than expected ask the woman to urinate and the reevaluate
Perineum	- swelling decreasing, redness, bruising improving - lacerations or episiotomy edges well approximated. -Classification of Perineal Lacerations: 1st degree-skin and superficial 2nd-perineal muscles 3rd-anal sphincter 4th-anterior rectal wall and sphincter	- increasing pain, swelling - increase in pulse and respirations may indicate vaginal hematoma. - ecchymosis, gaping stitches - purulent discharge, foul odor	- recommend comfort measures such as: ice packs 1st 24 hr; sitz baths starting after 12 hr postpartum; & side lying position - encourage good hygiene: good hand washing ; using perineal squeeze bottle after each void ; and wiping front to back -avoid tampons until PP visit -tub baths are ok -stitches will dissolve in about one week	- Assess perineum, refer to medical care provider if abnormality observed
Lochia	- 1-4 days: lochia rubra (bright red blood, odor of fresh blood; some small clots; slight increase in flow during ambulation, breast feeding or upon arising after sleep - 3-10 days: lochia serosa (pink/brown in color) - 10 days to 3 weeks: lochia alba (yellow in color)	- excessive flow, soaking more than 1 pad per hour - foul smelling lochia - large clots (> golf ball size) - temperature > 100.4 (38C) - reappearance of red blood after onset of lochia serosa or after lochia alba is danger sign - postpartum hemorrhage can appear 6-14 days after delivery due to infection, subinvolution, retained placenta	- ask woman to describe flow and number of times pad changed in day - teach woman to massage uterus to assure firmness - teach woman the signs & symptoms of postpartum hemorrhage and to call her medical care provider immediately if she experiences any of these symptoms - discuss with woman that choice of feeding method does not affect lochia duration - encourage increased rest if lochia returns to rubra from serosa or alba and contact medical care provider if it does not stop - discuss range of time for return of menses	- Assess lochia, call medical care provider immediately if signs and symptoms of hemorrhage  or infection are observed - Women with heavy, persistent postpartum bleeding should be evaluated for complications such as retained placenta, uterine atony, laceration, hematoma, or coagulation disorders (e.g., disseminated intravascular coagulopathy, von Willebrand’s disease)
Elimination-Urinary	-diuresis after delivery due to fluid retention during pregnancy -bladder may be less sensitive  to fullness, incomplete emptying can occur -transient stress incontinence	- voiding small amounts or inability to void - Bladder distention should not be present after recent emptying. When it does occur, a pouch over the bladder area is observed, resistance is felt upon palpation, while at the same time, the woman usually feels a need to urinate - prolonged stress incontinence - costovertebral angle tenderness (CVA) - Signs of urinary tract infection (UTI): · dysuria · frequent voiding · burning pain · increased temperature · hematuria	- encourage woman to drink 1 ½ -2 quarts (6-8 glasses) fluids/day - void every 2 hours - explain increased urination normal - encourage Kegel exercises - wear pad if leaking urine from stress incontinence - teach signs & symptoms of UTI & instruct to call medical care provider if s/s develop	- Assess urinary elimination, refer to medical care provider if abnormalities observed
Elimination-Bowel	- 1st Bowel movement often 2-3 days after delivery due to medications, hormones, dehydration, perineal pain and decreased activity	- inability to pass feces - constipation due to fear of pain, hemorrhoids, perineal trauma	- suggest using witch hazel pads (e.g., Tucks) & sitz baths if experiencing hemorrhoids - teach woman to avoid constipation by: · drink 6-8 glasses fluid/day · eat foods high in fiber – prunes, bran · walking - if constipated, in addition to above suggest use of mild laxatives or stool softeners such as MiraLax
Circulation - extremities	-negative Homan's Sign -no calf, thigh tenderness, redness or swelling	- positive Homan's sign - pain, redness or swelling in calf or thigh - low grade fever often followed by high grade fever with chills - pain in popliteal & lateral tibial areas	- encourage early ambulation - avoid crossing legs when sitting - wear support hose if varicose veins problem during pregnancy - refer to MD if abnormal	- Assess the Homan's sign. Report a positive Homan's sign and do not retest. - Assess the legs for edema, redness, tenderness, and areas of increased temperature. - Assess for pedal edema. Assess degree of edema (+1, +2, +3, +4) and parts of the lower extremities involved. - Assess dorsal tendon reflexes--knee jerk. Use 0 - 4+ scale:  0 =no reflex elicited. +1=slightly depressed. +2=normal response. +3=slightly hyperreflexic. +4=hyperreflexic.
Cesarean birth	- incision approximated, no erythema, no tenderness, no purulent drainage. - no fever - incisional pain decreasing - need for analgesics lessening - activities of daily living gradually increasing with adequate rest periods	- redness, pain, exudate, swelling along incision - fever - continues to take narcotic analgesics beyond 4-5 days	- suggest regular rest periods and household help. - encourage use of Tylenol and NSAIDS for pain management. - avoid stairs and lifting anything heavier than the baby for first week	- Assess cesarean birth, refer to medical care provider if abnormalities observed - Inspect the incision for redness, edema, ecchymosis, drainage, and approximation of edges (REEDA scale.) & call medical care provider for any anomalies
Weight	-the rate of postpartum weight loss is influenced by many factors. Some women approach their pre-pregnancy weight several weeks after birth; most approach this weight about 6 months later	- extreme weight loss - little or no weight loss	- it took 9 months gain the weight, it will take time to lose the weight - breastfeeding moms should eat a well balanced diet and generally require approximately 300 – 500 extra calories per day - instruct woman to increase activity slowly but encourage her to use physical activity to lose weight - review diet and activity level - 1 pound a week is a suggested goal, more than 1 lb will result in loss of muscle and fat and may decrease milk supply	If extreme weight loss regimen is observed, refer to medical care provider or registered dietitian.
Anticipatory Guidance
Menses	-if bottlefeeding, menses may return in 4-6 weeks -if breastfeeding, menses may not return until breastfeeding frequency decreases or discontinues
Discomforts	-fatigue from discomforts, sleep deprivation -headaches from fluid shifts first week -pain from episiotomy, incision or breasts	-severe headaches -scotomata (spots before eyes) -blurred vision, photophobia may be prodromal signs of eclampsic seizure -spinal headache not relieved by lying down	-discuss the use of acetaminophen and NSAIDS for analgesia -discuss maximum daily dosage of pain meds -increase fluids -monitor s/s pre-eclampsia -discuss edema-expected duration	Assess discomforts (i.e. from c-section, pre-eclampsia, perineum) refer to medical care provider if abnormalities observed
Nutrition	-daily intake of nutrients. · Bread, cereals, rice, & pasta, group (6-11 servings/daily) · Fruits and vegetables group(2-5 servings/daily) · Milk, yogurt, and cheese group (2-3* servings/daily) · Meats, fish, poultry, dry beans, eggs & nuts group(2-3 servings/daily) · Multivitamin iron of needed · Water *Breastfeeding women, and women under age 24 need 3 servings from the Milk group and 300 - 500 cal/day increase	- dieting in early postpartum period to lose weight - excessive intake of processed foods, low in nutritional value - excessive intake of fried foods, sweets, high caloric snack foods e.g., cookies, chips - little or no weight loss - excessive weight loss - under/over weight per BMI	-Eating disorders – make referral if needed -Low income, single, and obese women between 20 and 40, are at higher risk of PP weight retention. Assess need for referral to WIC. Assess Mother’s willingness to accept WIC referral.	- Assess nutritional status, refer to medical care provider or nutritionist/dietitian if abnormalities observed - Use the USDA food guide pyramid website for nutrition education.  Found at http://www.mypyramid.gov/
Affect/Mood	-postpartum blues. · cries easily · feels tired · insomnia-trouble falling asleep or sleeping through the night · trouble concentrating · feels  irritable or angry sometimes for no reason · eating too little or too much -any of the above may occur and last 3-7 days realistic expectation of body, activity level  and maternal feelings for baby Psychological Stages- -1-2 days: Taking In: physical exhaustion, dependence, excitement and anxiety -2-3 days: Taking Hold: initiates action, seeks help, begins caring for baby, anxious about mothering -2-6 weeks: Letting Go: role defined, sees baby as individual, focuses on larger issues, family Supportive Network of husband/partner/family members/friends	- postpartum depression · feelings described last longer than 2 weeks or depression begins about 3rd week or later · feelings much stronger · feelings also include -worthlessness     -loss of control     -anxiety     -hostility     -depressed mood     -loss of interest            -insomnia     -sadness     -hopelessness     -isolation        -strong negative            feelings about baby Risk factors for Post Partum Depression (PPD) include: · prenatal anxiety · ambivalence toward pregnancy · history of depression, bipolar disorder · personal dissatisfaction · lack of support · life stress · unstable relationship · low income level · avoidance coping · sexual or physical abuse Postpartum Panic Disorder: 2-3 weeks postpartum: extreme anxiety, increase pulse, tightening in chest Postpartum Psychosis (PPP): delusional, hallucinating with potential to kill baby (1-2% of PPD.) PPD can occur days to months postpartum	-allow time for woman to review her birth experience -allow woman to talk about birth experience “expectations” vs. “reality” (i.e. labor and reaction to baby) -encourage openness with partner, family, friends -teach support persons of signs and symptoms of postpartum blues -encourage rest periods; suggest planning specific times for getting away to meet own needs before feeling exhausted; identify a trusted and willing person to allow such breaks -encourage woman to be realistic regarding expectations of self -explain maternal feelings may develop gradually, it takes time to get to know baby -encourage woman to ask for help -discuss community and mental health resources if appropriate -refer to MD if signs of PP depression -instruct on Shaken Baby	- Assess affect and call medical provider and/or mental health crisis line immediately signs and symptoms of potentially harming herself or baby are observed - Know the appropriate emergency services in your community and provide that information to post partum woman
Sleep/Rest Activity Level	-6-8 hrs. sleep/night often interrupted due to feedings -rest periods during day while baby napping -gradually increases activity levels after first few days -only slight increase in lochia with activity -demonstrates knowledge of safe postpartum exercises	-< 6 hr. sleep/night -unable to rest during day -bleeding increases with activity or reverts to bright red color	-encourage limitation of visitors - rest for first 2 weeks at home -give specific information on what activities are too strenuous and happens if doing too much -help woman set priorities to allow time to rest -discuss strategies for help with infant care to allow for rest times -encourage sleep when baby sleeps	Assess sleep/activity level, refer to medical care provider or community resources if abnormalities observed
Resources/ Support	-family and/or friends able to assist with meals, child care, errands, housework -able to identify resource phone #'s (e.g., medical care provider, home visitor, Lactation resources)	-no evidence of help/ support from others -lives in isolated area -no access to phone or transportation -stressful/negative home environment	-discuss setting priorities -encourage woman to accept offers of help - “helpers” should do household tasks, and meals not baby care -identify contact person if help needed -discuss community resources/supports if appropriate	Assess resources/support, refer to community support services if abnormality observed

References

Arenson, J. & Drake, P. (2007). Maternal and newborn health. Boston, MA: Jones & Bartlett .

Blenning, C., & Paladine, H. (2005, December 15). An Approach to the Postpartum Office Visit. American Family Physician, 72(12), 2491-2496. Retrieved September 28, 2008, from Academic Search Premier database.

Guide to postpartum and newborn physical assessment, anticipatory guidance and health teaching. (2005). Division of Community Public Health Maternal Child Health Program Department of Health.

Jarvis, C. (2003). Physical examination & health assessment. St. Louis, Missouri: Elsevier.

Olds, S., London, M., Ladewig, P. & Davidson, M. (2004). Maternal-Newborn Nursing and Women’s Health Care. (7th ed.). Pearson-Prentice Hall. Chapter 34.

Webb, D., Bloch, J., Coyne, J., Chung, E., Bennett, I., & Culhane, J. (2008, September). Postpartum Physical Symptoms in New Mothers: Their Relationship to Functional Limitations and Emotional Well-being. Birth: Issues in Perinatal Care, 35(3), 179-187. Retrieved September 28, 2008, doi:10.1111/j.1523-536X.2008.00238.x

World Health Organization. Postpartum care of the mother and newborn: A practical guide. Website: http://www.who.int/reproductive-health/publications/msm_98_3/msm_98_3_11.html