Assessing the Postpartum Patient

  1. Perform hand hygiene.
  2. Verify the patient's identity using two patient identifiers in accordance with institutional policy.
  3. Assess vital signs every 15 minutes for 1 hour, then every half hour to 1 hour during the second hour following the birth. Continue to assess vital signs per institutional policy.
  4. Perform hand hygiene and apply clean gloves.
  5. Assess fundus every 15 minutes for first hour and then every half hour to 1 hour for second hour.
  6. Position patient in supine or low semi-Fowler position with knees flexed.
  7. While stabilizing uterus at the symphysis with one hand, cup the other hand over the fundus (top of the uterus) and press firmly.
  8. Observe perineum for amount of lochia and for any expelled clots.
  9. Assess lochia with each fundal assessment.
  10. Measure the fundus position in relation to the umbilicus.
  11. Observe lochia on perineal pads and under patient.
  12. Estimate amount of bleeding and assess perineal pads.
  13. Assess color and odor of bleeding.
  14. Assess source of bleeding (i.e., lochia, episiotomy, and lacerations).
  15. Assess perineum for signs of trauma (hematomas, tears and/or lacerations) during the lochia assessment.
  16. Assess for bladder distension, ability to void, or patency of Foley catheter, as indicated.
  17. Instruct/assist patient to lateral position and flex upper leg on hip.
  18. Separate buttocks gently.
  19. Assess episiotomy and/or laceration repairs for intactness, hematoma, edema, bruising, redness, and drainage.
  20. Assess general perineum for intactness, hematoma, edema, bruising, and redness.
  21. Assess rectal area for hemorrhoids.
  22. Remove gloves and discard in proper trash receptacle. Perform hand hygiene.
  23. Assess patient's level of pain.
  24. Provide warm blankets if the patient feels cold.
  25. Assess breasts.
  26. Palpate each breast gently. Observe contour, firmness, skin temperature, and presence of any nodules.
  27. Inspect breasts for venous engorgement.
  28. Inspect nipples for discharge and intactness (e.g., blisters, cracks, bleeding).
  29. Assess for breast/nipple tenderness.
  30. Assess patient's nutritional and bowel status. If the patient has had a normal vaginal delivery, it is appropriate to allow the patient a regular diet. If the patient had a cesarean delivery, she is usually restricted to a clear liquid diet initially.
  31. Assess Homans' sign.
  32. If the patient had either regional or general anesthesia, assess patient's postanesthesia recovery (PAR) score with each assessment during the recovery period.
  33. Assess intravenous (IV) therapy and the patient's fluid balance.
  34. Assess need for Rho(D) immune globulin and for rubella vaccine.
  35. Assess abdominal dressing, if applicable.
  36. Assess knowledge of self-care and infant care.
  37. Assess feeding method of infant (bottle or breast).
  38. Perform hand hygiene.
  39. Document the procedure in the patient's record.