Assessment of postnatal women

1. Assessment of
postnatal women
Neethu s s
First year MSc nursing

2. definition
PUERPERIUM
Puerperium is the period following
childbirth during which the body tissues,
especially the pelvic organs revert back
approximately to the prepregnant state
both anatomically and physiologically.

3. Involution is the process whereby the genital organs revert back
approximately to the state as they were before pregnancy. The women
is termed as puerpera.
DURATION: Puerperium begins as soon as the
placenta is expelled and lasts for approximately 6
weeks when the uterus becomes regressed almost to
the nonpregnant size.

4. The period is arbitrarily divided into
1.immediate - within 24 hour
2.early – up to 7 days
3.remote – up to 6 weeks

5. NURSING ASSESSMENT
PHYSIOLOGICAL POSTPARTUM
ASSESSMENT FOCUSES ON:
 The involution processes of the reproductive
organs
 Biophysical changes of other body systems
 The initiation or suppression of lactation

6. Psychosocial assessment focuses on:
 The mother's emotional state and response to the birth
experience
 Interactions with the newborn
 Newborn feeding
 Adjustment to the caretaking role and to new family
relationships
 Progress in learning self-care
 incorporation of the newborn into the family

7. Schedule of postpartum physiologic assessments
AREAASSESSED FREQUENCY
Temperature 1st hour after delivery: once
2nd – 8th hour: twice
9th – 24th hour : every 4 h
24th hour to discharge: every 8 h
Pulse, respiration and blood pressure 1st hour after delivery: every 15 min
2nd – 3rd hour: every 30 min
4th – 24 th hour: every 4 h
24th hour to discharge: every 8 h
Fundus, lochia, bladder 1st hour after delivery: every 15 min
2nd – 3rd hour: every 30 min
4th – 24 th hour: every 4 h
24th hour to discharge: every 8 h
Perineum 1st hour after delivery: once
2nd – 24 th hour: every 4 h
24th hour to discharge: every 8 h
Breasts, legs 1st – 8th hour: once at end of 8th h
9th – 24th hour : every 4 h
24th hour to discharge: every 8 h
Bowel elimination 9th hour to discharge: daily stool

8. Early postpartum period
 a chart review; interval history, including
physical, psychological, and emotional changes
since the birth
 physical examination, including observation of
family interactions
 management plans that focus on treatments for
symptoms and conditions of the puerperium,
follow-up visit plans, and health education.

9. CLINICALASSESSMENT OF
PARENT'S INTERACTION WITH NEWBORN
 Uses gentle touch with newborn
 Positions infant for face-to-face interaction
 Directs gaze toward newborn when interacting
 Makes visual contact
 Displays range of facial expressions
 Verbalizes to newborn
 Makes positive, affirming, loving comments to the newborn; avoids making
disparaging comments
 Modulates interaction in response to newborn's cues
 Elicits verbalizations and behaviors from the newborn and responds contingently
 Responds to newborn's distress

10. Physical examination
The examination during the early postpartum period is focused on the
physiologic changes that occur after birth. It is important to ensure
privacy is maintained according to the woman's wishes.
A comfortable location for the exam should be used, and pillows for
support may be helpful. Because the woman may have an expected level
of discomfort during the exam, a gentle touch should be used and
permission requested before examining any part of her body.
Physical assessments during the early puerperium include the heart,
lungs, breasts, abdomen, perineum and anus, and lower extremities. The
midwife may provide teaching about the physiologic changes of the
puerperium during the examination.

12. Heart And Lungs
The examination of the heart and lungs
during the early puerperium is performed
in the same manner as when the woman
is not pregnant or postpartum

13. Breasts
ASSESS
 Size , shape, fullness
 Consistency –Soft
- Filling (increasing firmness or slightly enlarged)
- Engorged (enlarged, hard, reddened, shiny)
 Colour
 Symmetry
 Tenderness
 Express colostrum
 Primary and secondary areola
 Soft swelling in axilla indicate accessory mammary tissue

14. ABDOMEN
Examination of abdomen begins with uterus
Assess INVOLUTION OF UTERUS by noting fundal height.
Take measurement at a fixed time every day.
 Following delivery, the fundus lies about 13.5 cm (51/2") above the symphysis pubis.
 During the first 24 hours, the level remains constant
 Thereafter, there is a steady decrease in height by 1.25 cm (0.5”) in 24 hours
 By the end of 2nd week the uterus becomes a pelvic organ.
 The rate of involution thereafter slows down until by 6 weeks, the uterus becomes
almost normal in size. While palpating the consistency of fundus should be a round,
smooth shape. A soft or boggy fundus indicates atony or subinvoluion. The bladder
should be empty for accurate fundal assessment; a full bladder displaces the uterus and
rises the height of the fundus.

16. Bladder
The woman is encouraged to void as soon as following delivery to avoid bladder distention.
Even with full bladder, the newly postpartum women may not experience an urge to void.
This decreased perception of bladder fullness is due to increased bladder capacity
resulting from reduced intra-abdominal pressure, edema of the trigone area at the base Of
the bladder resulting from trauma, and impaired transmission of afferent neural impulses
due to regional anesthesia.
The bladder may fill rapidly after delivery if the woman received intravenous fluids during
labor and because of increased physiologic urinary output in the early postpartum period.
The nurse assesses the condition of the bladder by abdominal palpation, percussion, and
observation. The contour of the abdomen, height and consistency of the fundus, and
characteristics of the suprapubic area are assessed.

17. lochia
The character and amount of lochia indirectly indicate the progress of
endometrial healing. In normal healing processes.
The amount of lochia gradually diminishes with typical color changes
that reflect decreasing blood components in the lochial flow.
The quantity of lochia varies with individuals and is generally more
profuse in multiparas. The amount of lochia may increase on early
ambulation because of vaginal pooling and increased uterine
contractions.

18. TYPES OF LOCHIA
Lochia rubra – first 1 to 3 days – red in
colour
Lochia serosa – 4 to 10 days – serous and
pink
Lochia alba – 10 days to 3 weeks –
yellowish white in colour

19. Lochia is dark red (lochia rubra) in the first 1-3
days after delivery and is usually moderate in
amount.
 Scant: less than 2.5 cm on menstrual pad in 1
hour
 Light: less than 10 cm on menstrual pad in 1 hour
 Moderate: less than 15 cm on menstrual pad in 1
hour
 Heavy: saturated menstrual pad in 1 hour
 Excessive: menstrual pad saturated in 15 minutes

20. Lochia smells similar to normal menstrual flow and
should not have a foul or disagreeable odor. Heavy,
persistent, and malodorous lochia rubra, especially if
accompanied by fever, indicates a potential infection or
retained placental fragments.
If lochia serosa or alba continues beyond the normal
time ranges and is accompanied by brownish
malodorous discharge, fever, and abdominal pain, the
woman may have endometritis.

22. Lacerations may be:
 First degree: through skin and structures that are
superficial to muscles
 Second degree: extends through perineal
muscles
 Third degree: continues through anal sphincter
muscle
 Fourth degree: extends through the anterior
rectal mucosa, exposing the rectal lumen

23. Lower extrimitiesAssess for
 Size
 Shape
 Colour
 Edema
 Symmetry
 Varicosities
 Temperature and swelling
 Thrombophlebitis-unilateral swelling, redness, heat and calf muscle tenderness
 Homan’s sign-presence of calf pain with active dorsiflexion
 Femoral vein thrombosis-pain and tenderness in the distal thigh and popliteal region
 Lower extrimities pulses

24. Laboratory tests
 To assess for anemia, a complete blood count, hematocrit, or
hemoglobin is done 24—48 hours after delivery. Blood values change
postpartum due to many physiologic adaptations as the woman returns
to a nonpregnant state. With an average blood loss of 400—500 mL, a
drop of 1 g in hemoglobin level or 3% in hematocrit value is within the
expected range. Larger decreases in these values result from heavy
bleeding at delivery, hemorrhage, or antenatal anemia.
 During the first 10 days postpartum, the white blood count may increase
to 20,000/mm3 before returning to normal values (Bond, 1993).
Because the cellular components of this leukocytosis are similar to
those during an infection, this increase may conceal an infectious
process unless the white blood count is higher than physiologic levels.

25. ASSESSMENT OF POSTPARTUM RISK
FACTORS
Assess for risk factors of postpartum complications:
 Multipara
 Multiple pregnancy
 Hydramnios
 A large newborn
 Prolonged labour
 Lacerations of cervix, vagina or perineum
 High risk pregnancies
a

26. Psychosocial assessment- family dynamics
Assessment of emotional, behavioural, and social factors in the
postpartum periods allows the nurse to identify the mother’s and
family’s needs for support, teaching, and anticipatory guidance; their
response to the childbearing experience and postpartum care; and
factors affecting the assumption of new parenting responsibilities.
The nurse also assesses the mother’s knowledge and abilities related
to self- care, new born care, and health maintenance and feelings
about herself and her body image.

27. Psychologic changes
1.Role change is an important psychological change for the mother
 The mother must relinquish other roles and take on the role of
mother
 New mothers typically progress through a series of developmental
stages. The rate of progression through these stages is unique to
each mother.
 Dependent and taking-in phase of mother
 Increase in dependent behaviour ; wants care for herself
 Asks many questions and talk a great deal about delivery
experience
 Might be the only phase observed by nurse during hospitalization
because of the trend toward a shortened inpatient stay for obstetric
patients without complications

28.  Dependent-independent or “taking-hold” phase of mother
 Begins to focus on needs of infant
 Relinquishes pregnant role
 Takes on maternal role
 Is interested in learning to care for infant
 Experiences a period of high fatigue and increased demands by
infant
 Might experience baby blues at 3 to 4 days postpartum during
this phase
 Is typically in this phase 4 to 5 weeks

29. Interdependent, or letting- go phase of mother
 Lets go of perception of infant as extension of herself,
and views infant as separate
 Refocuses on relationship with partner
 Might return to work and relinquish part of child care to
other caretakers

30. 2.Attachment
 Attachment is an emotional tie between two people that endures
over time and involves close proximity and contact with each
other
 Attachment is described by health care professionals as the
interactive behaviours between infants and their caregivers in
their large surroundings
 The mother infant bond is the basis on which all subsequent
attachments are formed and plays a major role in the infants
developing sense of self
 Maternal attachment to the infant begins in utero due to fetal
movements and maternal fantasies about the infant

31. 3.Baby blues
 Baby blues or postpartum blues are described as a mild, transient
mood disturbance that frequently begins on the third postpartum
day and can last up to 10 days. Symptoms lasting longer than 10
days should be evaluated by health care providers
 Approximately 50% to 75% of women experience baby blues
during postpartum
 The onset of postpartum blues coincides with the normal
physiologic drop in estrogen and progesterone, and this, along with
fatigue, may be a possible cause of this emotional change.

32. Also assess
1.reaction to child birth process
- review of birth experience
- self evaluation
2.Adaptation to parenting and care taking
-adaptive and mal adaptive behaviour of
both parents
3.cultural variations

47. •Kristin P. Tully PhD
•, Alison M. Stuebe MD, MSc
• and Sarah B. Verbiest DrPH, MSW, MPH
American Journal of Obstetrics and Gynecology, 2017-07-01, Volume 217, Issue 1,
Pages 37-41, Copyright © 2017 Elsevier Inc.
An online national survey of 1072 postpartum women found that women struggled with a
variety of new health problems in the first 2 months after birth related to adjusting to the
demands of motherhood. These problems are extraordinarily common, affecting up to half of
the 4 million US women who give birth each year, but treatment is uneven, and health care is
often fragmented.

48. Early intervention to protect the mother-infant relationship following postnatal depression:
study protocol for a randomised controlled trial
•Jeannette Milgrom &
•Charlene Holt
Trials volume 15, Article number: 385 (2014) Cite this article
•6111 Accesses
•19 Citations
•1 Altmetric
•Metricsdetails
At least 13% of mothers experience depression in the first postnatal year, with accompanying feelings
of despair and a range of debilitating symptoms. Serious sequelae include disturbances in the
mother-infant relationship and poor long-term cognitive and behavioural outcomes for the child.
Surprisingly, treatment of maternal symptoms of postnatal depression does not improve the mother-
infant relationship for a majority of women. Targeted interventions to improve the mother-infant
relationship following postnatal depression are scarce and, of those that exist, the majority are not
evaluated in randomised controlled trials. This study aims to evaluate a brief targeted mother-infant
intervention, to follow cognitive behavioural therapy treatment of postnatal depression, which has
the potential to improve developmental outcomes of children of depressed mother

49. To encourage use of skin-to-skin contact with all healthy term infants during the first
two hours of life and throughout their mothers’ postpartum hospitalization, an easy,
rapid newborn assessment tool, the “RAPP”, has been developed to enhance labor
and delivery and mother-baby nurses’ ability to swiftly and accurately assess newborn
physiologic condition. The “RAPP” assessment (respiratory activity, perfusion, and
position) tool is being proposed as a way to swiftly evaluate infants’ physiologic
condition and position. Position of the infant is a key factor in minimizing risk of
Sudden Unexpected Postnatal Collapse (SUPC). SUPC is an emerging complication
of skin-to-skin contact and breastfeeding in the first hours and days post-birth. The
“RAPP” assessment parameters and flow sheet are discussed, risk factors for SUPC
are enumerated, and a checklist to prevent SUPC is presented so skin-to-skin contact
can be safely provided.
Infant assessment and reduction of sudden unexpected postnatal collapse
risk during skin-to-skin contact
SM Ludington-Hoe, K Morgan - Newborn and Infant Nursing Reviews, 2014 -
Elsevier

50. Infant Sleep During the First Postnatal Day: An Opportunity for Assessment of Vulnerability
Kimberly A. Freudigman and Evelyn B. Thoman
Methods. The sleep of 36 healthy newborns was recorded continuously throughout
the first two postnatal days, starting immediately after birth, using an automated
Motility Monitoring System. The Motility Monitoring System consists of a pressure-
sensitive mattress pad connected to an amplifier and a small 24-hour analog
recorder. A single channel of analog signals produced by the newborn's respiration
and motility is continuously recorded onto a 60-minute cassette tape. The signals are
digitized and scored, in 30-second epochs, for Active Sleep, Quiet Sleep, Active-Quiet
Transition, Sleep-Wake Transition, and Wake. In addition to the percent of time spent
in each state, the Mean Bout Length of Active Sleep, Mean Bout Length of Quiet
Sleep, Mean Sleep Period, Longest Sleep Period, and Arousals in Quiet Sleep were
also measured
Results. On postnatal day 1, four measures were significantly related to 6-month Bayley mental scores:
Mean Sleep Period, Longest Sleep Period, Sleep-Wake Transition, and Arousals in Quiet Sleep; and two
measures were significantly related to Bayley motor scores: Mean Sleep Period and Sleep-Wake
Transition. On postnatal day 2, none of the measures were related to mental scores, while two measures
were related to the motor scores: Quiet Sleep and Mean Bout Length of Quiet Sleep.
Conclusions. The results suggest that the newborn's sleep characteristics during the first postnatal day
provide uniquely sensitive indices of later neurobehavioral function