Postnatal assessment

postnatal assessment.

1. Postnatal Assessment Prepared by: Anju Bista MSc Nursing 1 st year(2021)

2. Objectives: At the end of this session participant will be able to know about postnatal assessment.

3. Content. Introduction of postnatal assessment. Aims and objectives of postnatal assessment. Advantages of postnatal assessment Procedure of postnatal examination.

4. Postnatal period : Is the period beginning immediately after the birth of a child and extending for about six weeks. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most deaths occur during the postnatal period.

5. Contd … Mother should be provided three PNC visit.(WHO Recommendation) 1 st PNC visit with in 24 hrs , 2 nd PNC visit on 3 rd days. 3 rd PNC visit on the 7 to 14 day. 4 th visit on 6 th weeks after delivery.

6. Postnatal Assessment: Postnatal assessment includes systematic examination of mother and the baby and appropriate advice given to the mother during postnatal period .

7. Demographic health survey 2016. The percentage of women who received a postnatal care (PNC) assessment within two days following delivery rose from 45% in 2011 to 57% in 2016. 81% of women who delivered in a health facility and 13% of women who delivered elsewhere received PNC within two days of delivery. However, there were significant socioeconomic disparities in PNC utilization: 81% of women in the highest wealth quintile had an early PNC visit compared to only 37% among women in the lowest wealth quintile .(DHS,2016)

8. Aims and objectives : To assess the health status of the mother. Medical disorder like diabetes, hypertension, and thyroid disorders should be reassessed. To provide necessary health teaching to mother and family. To detect and treat at the earliest any gynecological condition arising out of obstetric legacy.

9. Contd … To note the progress of the baby including the immunization schedule for the infant. To impart family planning guidance. To achieve healthy outcomes for both the mother and the baby.

10. Advantages: It is an opportunity to detect and treat at the earliest, any gynecological-medical disability, either pre-existing or appearing after childbirth. The process of the baby can be judged and effective therapy can be instituted for alignments if detected. Motivation and acceptance of family planning methods can best be imparted during this period.

11. Procedure for postnatal assessment : Examination of the mother. Advice given to the mother. Examination of the baby and advices.

12. Examination of mother : Equipment required: TPR tray. Screen. Bed pan. Tape measure. Equipment for urine test of protein and sugar. Weight machine. Sterile gloves. Kidney tray. Cotton balls.

13. Physical Assessment of mother Physical Assessment is necessary to identify individual needs or potential problems. Explain to patient purposes of the examination. obtain her consent. Record your findings and report results to the mother. Avoid exposure to body fluids. T each patient as you assess – use every opportunity since there is limited time.

14. Assessment of the mother First 24 hours after birth All postpartum women should have regular assessment of vaginal bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) routinely during the first 24 hours starting from the first hour after birth. Blood pressure should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within six hours. Urine void should be documented within six hours .

15. Beyond 24 hours after birth At each subsequent postnatal contact, enquiries should continue to be made about general well-being and assessments made regarding the following: micturition and urinary incontinence, bowel function, healing of any perineal wound, headache, fatigue, back pain, perineal pain and perineal hygiene, breast pain, uterine tenderness and lochia. Breastfeeding progress should be assessed at each postnatal contact.

16. Contd … At each postnatal contact, women should be asked about their: emotional wellbeing, what family and social support they have their usual coping strategies for dealing with day-to-day matters.

17. Contd … All women and their families/partners should be encouraged to tell their health care professionals about any changes in mood, emotional state behaviour that are outside of the woman’s normal pattern.

18. Contd … At 10–14 days after birth, all women should be asked about resolution of mild, transitory postpartum depression (“maternal blues”). If symptoms have not resolved, the woman’s psychological well-being should continue to be assessed for postnatal depression, and if symptoms persist, evaluated. Women should be observed for any risks, signs and symptoms of domestic abuse.

19. Contd … Women should be told whom to contact for advice and management. All women should be asked about resumption of sexual intercourse and possible dyspareunia as part of an assessment of overall well-being two to six weeks after birth. If there are any issues of concern at any postnatal contact, the woman should be managed and/or referred.

20. Maternal history: restored function Ask the mother if since she delivered, she is : now ambulatory / not yet ambulatory has passed her bowels / has not yet passed her bowels. has no flatus / is experiencing some flatus has voided her bladder (when) / has not yet voided her bladder. Breast problems. Vaginal bleeding or discharge .

21. Abnormal history Findings Constipation , diarrhea, epigastric pain, hemorrhoids urinary retention, urgency, dysuria, incontinence. Bowel Bladder

22. Procedure for getting ready : Prepare the necessary equipment and brings on bedside or right side of examiner. Screen the patient to maintain privacy. Explain the mother with polite language about procedure. Ask mother to empty the bladder and bring specimen of urine for sugar and protein test.

23. Contd … Wash the hands with soap and water thoroughly . Take weight, TPR,BP and test urine for sugar and protein. Inspect the mother’s general appearance eg . Facial expression, tiredness, happy, sad, stress as well as any sign of pale e.g. anemic, yellowish color(jaundice).cyanosis.

24. Contd … Assess the physical status of the mother in systematic way from head to toe. During this process, if any abnormalities is found .we should tell her and suggest for improving them. During examination process, interaction makes her to confidence or encourage to tell her problem.

25. Systematic examination form head to toe examination.

26. Physical examination: When you have finished taking women history, perform a physical examination .be sure to record all those findings .

27. 3. Assessment of Breasts:

28. Inspect. • Inspect for size, redness, cracks, lesions & engorgement. Palpate breasts to determine if they are soft or filling, warm, engorged or tender. Teach to promote milk production & let down, and methods to prevent and treat engorgement.

29. Contd … Ensure proper bra fit Nipples should be soft, pliable, intact & inverted . If mother is NOT breast feeding - DO NOT palpate breasts or assess nipples

30. Normal Findings Of Breast One breast is slightly larger than other. • If breastfeeding, breasts look lumpy or irregular than usual. • Veins larger and darker, more visible beneath the skin. • Regular with no dimpling, no visible lumps, skin is smooth with no puckering, no redness, no lesion sores or rashes. • Tenderness and lumpiness in both breasts during the menstrual cycle. Areolas larger and darker

31. Abnormal Findings (Breasts): Redness, heat, pain, cracked, and fissured nipples, inverted nipples, palpable mass, painful, bleeding, bruised, blistered, cracked nipples. Changes in color of breast or nipple, wrinkling, dimpling, thickening, puckering. A nipple sink into breast.

32. 4. Abdomen: On inspection of the abdomen: Check for presence of visible scars. abdomen can be distended : below / above the umbilicus. move / does not move with respiration ,

33. P alpation of the abdomen: Ensure privacy and environment where the mother can lie on her back with her head supported. Ensure bladder is empty & lay patient supine with legs flexed. The midwives hands should be clean and warm and help the woman expose the abdomen. The midwife places the lower edge of her/his hand at the umbilical area and gently palpates inwards towards the spine until the uterus fundus is located

34. 5.Assessment of the uterine fundus:   The mother should keep in dorsal recumbent or supine position. Palpate abdomen from symphysis pubis and feel the uterus. Press the abdomen just above the uterine fundus by ulnar side of the hand.

35. Contd … Measure the length from symphysis pubis to the fundus of uterus and record the fundal height in centimeters. It should be firm, if not, massage prior palpation & assess for any blood discharged during massage. Assess its location and the degree of uterine contraction, any tenderness or pain should be noted

36. Contd … Normal findings : normal size( 12.5 cm ) Should decrease by 1.25 cm daily. and shape, mobile, regular, firm, in the midline, below the umbilicus & non tender.

37. Abnormal findings : Immobile , irregular, soft, tender, deviated away from the midline or above the umbilicus after 24hrs . Fundal height is measured in cm above or below the umbilicus. Note : fundus is 2 cm below the level of the umbilicus immediately after birth; fundus descends approximately 1 cm per day; by the 10th day the fundus should no longer be palpated .

38. Contd … If fundus is deviated or elevated above level of umbilicus always rule out DISTENDED BLADDER. Once the midwife has completed the assessment, she helps to dress and sit up.

39. 6 . Assessment of vaginal blood loss Questions to ask: Is the blood loss more or less? Color and the amount of blood loss(Lighter/ dark). Any concerns about the blood loss? Ask if she has passed any clots and when it occurred. (Clots are associated with prolonged bleeding postpartum). Ask the mother to describe the size of vaginal loss in a sanitary pad, frequency of changing the pad because of saturation level, comparison of clots to familiar items.

40. 8. Urinary tract : May have bruising and swelling caused by trauma around the urinary meatus . Increased risk of urinary tract infection, if client was catheterized during labor and delivery . Check signs of UTI, including fever, urinary frequency and/ or urgency, difficult or painful urination. Infrequent or insufficient voiding (less than 200 ml) discomfort,or foul smelling urine suggest infection and decreased sensitivity to pressure leads to urinary retention. Bladder distention may displace the uterus, leading to a boggy uterus and increase risk for atony .

41. Bowel examination   Inspect the woman's abdomen for distention, auscultation for bowel sounds in all four quadrants prior to palpating the uterine fundus , and palpate for tenderness. Ask the patient about daily bowel movement or has passed gas since giving birth. She must no become constipated. Explain that she should wipe from front to back after voiding or defecating. Normal assessment findings are active bowel sounds, passing gas, and a non-distended abdomen.

42. 9. Assessment of Episiotomy (Perineum) Inspect with patient in Sims position. Lift buttock to expose perineum & anus If present, assess episiotomy or laceration for REEDA . Should have minimal tenderness with gentle palpation, No hardened areas or hematomas. Assess knowledge, practice, & effectiveness of self peri - care.

43. Contd … Educate about suture absorption . Advice on what might help perinial pain: - use of salts, or savlon in bath water to reduce pain and improve healing. Abnormal Findings (Perineum) . – Pronounced edema, wound edges not intact, signs of infection, marked discomfort.

44. 10. Assessment of perinial pain Women feel bruised around the vagina regardless the trauma in the first few days after birth. In cases of actual perenial injury, a woman will experience pain for several days until healing takes place. Long term psychological and physiological trauma is also evident.

45. Contd … The midwife observes perineal area to ascertain progress of healing from any trauma. Appropriate care immediately after birth or where suturing has taken place can help reducing edema or bruising.

46. Very important Question s Midwife should ask the mother whether she has any discomfort in the perinial area regardless of any record of actual perinial trauma. Clear information and reassurance are helpful where women have a poor understanding of what happened and are anxious or embarrassed about urinary, bowel or sexual functioning in the future. If there is no pain in the perinial area, the midwife should not examine. For majority of the women, the perinial wound gradually becomes less painful and should occur 7 to 10 days after birth.

47. Maternal examination lower extremities Assess for edema of leg,pain during sitting and sleeping, any sign of sign of deep vein thrombosis,varicose vein, thrombo -embolic sign etc. The risk of developing blood clots (thrombophlebitis) is increased for about 6 to 8 weeks after delivery .

48. Contd … Asses for signs of superficial thrombophebitis (redness, warmth, tenderness, pain in that limb, darkening of skin over or hardening of vein) Assess for signs of DVTs, i.e. asymmetric: size, color, or temperature. DVT is the most common cause of maternal death in the developed world.( devis & knuttinen,2017)

49. Homan’s sign to indicate DVT. Technique : In performing this test the patient will need to actively extend his knee. Once the knee is extended the examiner raises the patient’s straight leg to 10 degrees, then passively and abruptly dorsiflexes the foot and squeezes the calf with the other hand. Deep calf pain and tenderness may indicate presence of DVT. A positive Homan’s sign in the presence of other clinical signs may be a quick indicator of DVT.

50. Give advice and health teacing : General advice: If the patient is in sound health she is allowed to do her usual duites . Postpartum exercise ( kegal exercise) may be continued for another 4-6 weeks. Infant vaccination. To evaluate the progress of the baby periodically and to continue breastfeeding for 6 months. Family planning counseling and guidance.

51. References Margret Myles textbook for midwifery, 15th edition Datta,Dc.Text book of obstetrics.hiralal knoar.jyapee.9 th edition.2019. https:// www.medicalnewstoday.com/articles/153704#diagnosis http://www.clinicalexam.com/pda/o_obs_pos tnatal_history_exam.htm https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf