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. The postnatal period is a critical phase in the lives of mothers and newborn babies. Most maternal and infant deaths occur during this time. ... The guidelines address timing, number and place of postnatal contacts, and content of postnatal care for all mothers and babies during the six weeks after birth

1. Dr.lalitha Manoharan College of nursing
CSI hospital chickkaballapur.
Postnatal Assessment
Identification profile
Name of the mother: _____________________________________________________________
Age of the mother:_________________________________________________________________
Name of the husband:________________________________________________________________
Age of the husband: ____________________________________________________________________
Educationof the mother:_____________________________________________________________
Educationof the husband: _______________________________________________________________
Occupationof the mother: _______________________________________________________________
Occupationof the husband: ______________________________________________________________
Familyincome status:__________________________________________________________________
Type of family:________________________________________________________________________
Socioeconomicstatus: __________________________________________________________________
Date andtime of the delivery: ____________________________________________________________
Name of the doctor,dais to conduct delivery: ________________________________________________
Name of the primaryhealthcenter: ________________________________________________________
Address: ____________________________________________________________________________
Age of marriage:_______________________________________________________________________
Use of contraceptives: __________________________________________________________________
RelationshipwithSpouse: consanguineous/Nonconsanguineous
Diagnosis:____________________________________________________________________________

2. Personal and family history:
_______________________________________________________________
Dietary:______________________________________________________________________________
Habits:_______________________________________________________________________________
Illness: Tb/ Hypertension/ Diabetes;______________________________________________________
Congenital deformities: Present/Absent
Hereditarydisease: Present/Absent
If present,mention: ___________________________________________________________________
Multipregnancies; ______________________________________________________________________
Menstrual history
Age of at menarche: ___________________________________________________________________
Duration of menstrual cycles:____________________________________________________________
Menstrual cycle regularity: ______________________________________________________________
Dysmenorrhea/leucorrhea/menorrhagia: __________________________________________________
Duration; ____________________________________________________________________________
Last menstrual period:Date ________________month _____________________________
Presentobstetrical history: ______________________________________________________________
Periodof gestational weeks:_____________________________________________________________
Date of conformation of pregnancy: ______________________________________________________
Last menstrual period;________________________________________________________________
Expecteddate of delivery:_______________________________________________________________
Gravida: _____________________________________________________________________________
Para: ______________________________________________________________________________
Blood group and Rh: ___________________________________________________________________

3. Investigation:
Sl
no Investigation Result
Minor disorders:
High –risk group: yes /no (any, specify)
Postnatal examination:
parameters 1st
week
2nd
week
3rd
week
4th
week
5th
week
6th
week
7th
week
8th
week
9th
week
Weight(kg)
Height(cm)
Temperature
Pulse
Respiration
Blood
pressure
Urine Test
Sugar:
Albumin:
Delivery Details:
Date of delivery:

4. Mode of delivery:
Parity:
Inspection:
General appearance:
Suture (normal/short):
Normal vaginal:
With episiotomy:
Without episiotomy:
Any tear: 1stdegree/2nd degree/3rd degree
Spontaneous/medical/cesarean/any other
Full term/preterm or premature:
Presentation
Shoulder / face
Palpation of delivery
Types of delivery:
1st child 2nd child 3rd child 4th child
N = normal delivery
Cs = cesarean delivery
Sex of the child:
1st child 2nd child 3rd child 4th child
M = male
F = female

5. Any complaints present: _________________________________________________________________________
Past obstetrical history:
Sl ;
no
Age of
the
child
Type of
delivery
Infantalive
or dead
Sex of
the child
Birth
weight
of the
infant
Any
congenital
deformities
term abortion Remarks

6. Physical examination:
Nourishment: well-nourished / undernourished
Body built: ____________________________________________________________________
Weight: ______________________________________________________________________
Height: _______________________________________________________________________
Vital signs:
Temperature: _________________________________________________________________
Pulse: ________________________________________________________________________
Respiration: ___________________________________________________________________
Bp: _________________________________________________________________________
General appearance
Skin turgor: _________________________________________________________________
Warmth / temperature: ________________________________________________________
Nails: color _________________________________________________________________
Capillary refill: _______________________________________________________________
Shape: _______________________________________________________________________
Face
Facial puffiness: ______________________________________________________________
Lips: ________________________________________________________________________
Eyes: ________________________________________________________________________
Conjunctiva: __________________________________________________________________
Mouth: ______________________________________________________________________
Tongue: ______________________________________________________________________

7. Neck
Throat and pharynx: ____________________________________________________________
Thyroid gland: _________________________________________________________________
Chest
Thorax: _______________________________________________________________________
Breath sound: _________________________________________________________________
Heart: _______________________________________________________________________
Axilla: _______________________________________________________________________
Breast
Inspection:
______________________________________________________________________________
______________________________________________________________________________
Palpation: _____________________________________________________________________
______________________________________________________________________________
Nipples: ______________________________________________________________________
_____________________________________________________________________________
Abdomen: presence of scar / wound / if cesarean, discharge / tenderness presence of stria.
Inspection: ____________________________________________________________________
Palpation: _____________________________________________________________________
Consistency: ___________________________________________________________________
Auscultation
Bowel sound: __________________________________________________________________
Perineum: intact / lateral / medial

8. Episiotomy: mediolateral / lateral / medial
Condition of the wound: redness / edematous / hematoma / discharge / approximation
Lochia: _______________________________________________________________________
Amount of bleeding: scanty / moderate / heavy
Color: red / yellow / white / rubra/ serosa / Alba
Odor: fishy odor / foul smelling
Clots: present / absent
Cervix: edematous / thin / fragile
So: open / closed any tear
Vaginal introitus: erythematous / edematous
Vaginal mucosa: smooth / distended / atrophic
Bladder function: ______________________________________________________________
Hemorrhoids / anal: ____________________________________________________________
Varicosities: present / absent
Ankle edema / varicose: _______________________________________________________
Vein: ________________________________________________________________________
Extremities: generalized muscular fatigue
Human’s sign: positive / negative
Mental status:
Consciousness: conscious / unconscious / delirious
Mood: anxious / worried / depressed
Present history of delivery:
Mode of the delivery: ___________________________________________________________
Term of the baby: ______________________________________________________________

9. Abortion: _____________________________________________________________________
Birth baby: alive / dead
Sex of the baby: ________________________________________________________________
Birth weight: __________________________________________________________________
Immunization:
At birth: ______________________________________________________________________
Mother: ______________________________________________________________________
Initiation of breastfeeding: _______________________________________________________
If no, specify: __________________________________________________________________
Any abnormality: _______________________________________________________________
Health assessment of newborn baby:
Apgar score: ___________________________________________________________________
Anthropometric measurements
Weight: ______________________________________________________________________
Height: _______________________________________________________________________
Head circumference: ____________________________________________________________
Chest circumference: ___________________________________________________________
Midarm circumference: __________________________________________________________
Anterior fontanel: ______________________________________________________________
Posterior fontanel: _____________________________________________________________
If any abnormality: ______________________________________________________________

10. Health education :
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________
Conclusion :
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________
Signature of the student: signature of the clinical coordinator:

11. Date: Date: