Postpartum Assessment
BUBBLLEE= B-Breast /U-Uterus/
B-Bladder/ B-Bowels /L-Lochia/ L-Lower
Extremities /E-Episiotomy /E-Emotions
Breast-location/symmetry/similarities/differences/skin/injury/masses/
soft/nontender/discomfort
Nipple-(Everted/Inverted/Flat)/cracked/dry/blisters/bleeding/bruises/breast cream
Skin to skin/breastfeeding 2 to 2 and ½ hours/breast pumping/ engorgement/
blocked ducts/mastitis/warm compress/massage/warm shower/supportive bra
Uterus- location/firm/soft/boggy/midline/right or left midline/check for deviation (full
bladder)decrease 1cm per day- above umbilicus/at umbilicus/below umbilicus
Bladder- ask about first void ( 6 hours after delivery) urge to void (Anesthesia-last
organ to feel sensation)
amount/frequency/color/complete emptying/passing blood clot/size/how often
Bowels-passing gas/ listen to bowel sounds (4 quadrants-ULQ/URQ/LLQ/LRQ)/
passing bowels/ regular bowel pattern/ color/consistency/ pain
active/increased fluids and fiber intake/stool softeners/Milk of Magnesia
(MOM)/Dulcolax
Lochia- bleeding heavy/moderate/mild
Lochia Rubra-1-3 days/ Lochia Serosa 3-10 days/ Lochia Alba 10-14 days
Color- bright red (acute bleeding) brown (old bleeding)/ odor
How often change the perineal pads- soaking through one pad/hour/ blood
clots-small size and the size of an egg or bigger
Hx of bleeding disorders/ factor deficiencies/anemia/blood type/Iron or blood
transfusions during the pregnancy/ pre and post H&H/WBC/platelets/ on blood
thinners during pregnancy(Aspirin/Heparin injection/Lovenox injection
Lower Extremities- pitting edema +1 / reflexes/ red or swollen leg that is painful or
warm to touch (DVT- unilateral leg/ order Doppler Studies -pos or neg)/ varicosities,
Homan’s sign
support legs with a pillow/ lift the end of the bed/no crossing the legs/balance the
activities
Episiotomy and Perineum - NSVD- 1-2-3-4 degree perineal laceration/ midline epis
(vertical)/right/left medium lateral epis(at an angle)/ redness/inflammation/ how big
is the tissue/edema/discharge
Ice pack, Dermoplast spray/ Dibucaine cream/ witch hazel pads/ sitz bath
Pain-pain score 1-10/ facial expressions
Cesarean Section- low transverse uterine/ incision- red/swollen/ discharge/not
healing/pain/fever
Repeat- schedule/ maternal request/macrosomia/breech/arrest of Dilatation/ arrest
of descent/ emergency
Emotions- Postpartum Depression (Hx/hormonal imbalance/mental illness/ suicidal
ideation) Screening test before d/c (how you felt past 7 days) Postpartum Depression
Support Group/national and community resources
WBC =4,500 and 11,000 per microliter of blood/(Hgb= female 11.6 to 15 g/dL/HCT
female=35.3% to 44.9% /PLT= 150, 000-450, 000 per cubic mL
O +=universal donor AB+=Universal recipient
Rh factor is an inherited protein found on the surface of red blood cells.
Blood Type with Rh factor is negative ( O-/A-/B-)- mom (Type and Screening at L&D
on admission) need to draw blood work on the baby (Type and Coombs).
If the baby’s blood type is o+/A+/ B+ then mom needs RhoGAM IM injection(back
side of the upper arm).
The direct Coomb test is done on a newborn baby with Rh-positive blood whose
mother has Rh negative blood. The direct Coomb test finds antibodies attached to
the mother's red blood cells.
G=Gravidity/ T=term (37+ weeks)/P=Preterm(20 and 36.6 weeks)/A=Abortion(<20
weeks)/L=living children
Common Medications use in PP and Procedures
Pain medication: Toradol(Liquid form of Motrin-IVP- push slowly burning
sensation/mix with normal saline)
/Motrin/Tylenol/(Narcotics-Percocet/Roxicodone/Morphine)
Dermoplast/Dubacain/Witch-hazel pads numb the area
NSVD-Tylenol 650 mg PO Q 6 hrs/Motrin 600mg * try to stay away from narcotics
unless pain is not relieved by Tylenol or Motrin. Roxycodone 5mg qx6 and Percocet
325/5 mg q 6 hours.
C/S - standard orders of 3 medications -administer 4 times / first one starts at L&D
and rest are at PP unit unless the patient stays in the L&D for further observation.
Toradol 30 mg /ml IVP q 6 hrs and Tylenol 975 mg PO (325mgx3) q 6 hrs and Heparin
5000 units /ml Subq Injection q 8 hrs
After the standard orders done continue PO medications: Torodol 30 mg qx6 or
Motrin 600 mg and Tylenol 625 mg. * try to stay away from narcotics unless pain is
not relieved by Tylenol or Motrin. Roxycodone 5mg qx6 and Percocet 325/5 mg q 6
hours.
Gas pain/BM :Colace -stool softener/MOM/Dulcolax(suppository)
Antibiotics:IVPB- Triple - (Ampicillin/Clindamycin/Gentamicin)
PO-Keflex/Flagyl
Blood Thinners: Heparin 5000 units/ Lovenox 40/ 80 mg Subq injection
Bleeding: Methergine tablets/blood transfusion/Iron transfusion/Venofer (Iron
transfusion)
Blood Pressure- Lobatalol/ Procardia
Type II Diabetes/GDM - Accu checks fasting and postprandial- Diet
Control/Humulin- Regular insulin human injection /(Metformin during the
pregnancy)
Thyroid-Synthroid
Newborn Assessment
Neurological- cry/suck/Hypertonia/tremors (low blood glucose level/ muscle
disorder) Hypotonia
Accu check on infants required-GDM/IDDM/SGA/LGA/GHTN on Labetalol
Respiratory- RR= 40-60 /RR <60= Bradycardia/RR>60= Tachypnea regular/irregular/
extra sounds/unlabored/symmetrical/no abnormal breathing/grunting/nasal flaring /
retractions/apnic/stridor/venting
Head- fontanelle open soft/flat/bulging/sunken (Anterior fontanelle -close 9 to 18
months/ posterior fontanelle-close 1-2 months) / symmetrical
open/molding/caput/Hydrocephalus/Cephalohematoma
EENT-facial symmetry/lip and palate intact/Rt Nare/Lt Nare/Rt Eye/Lt Eye/Rt Ear/Lt
Ear/Cleft lip Rt/Cleft Lip Lt/Cleft Lip Bilateral/facial symmetry/Cleft Palate
Cardio/Neuro Vascular-Heart rate regular (120-160 beats per min)
Murmur/Bradycardia(<60)/Tachycardia (>60) Pulse Ox%
Fetal Cord Vessel Description-3 vessels are normal (2 veins-oxygenation and 1
artery-deoxygenation)/2 vessels/1 vessels
GI-Abdomen soft/non-distended/bowel sounds presents/3 cord vessels/distension
GU/Rectal-Patent anus/normal genitalia/testes descended/Hypospadias/Imperforate
anus (opening is missing)/testes/Ambiguous (external genitals not defined to be
clearly either male or female-sex organs may function
Chest-symmetrical/asymmetrical/barral
Musculoskeletal-Skin integrity intact/normal temperature (98 F and above preferred
97.8 F is acceptable/ skin to skin/radiant warmer/swaddling/moisture/ color
pink/red-good blood circulation- blue/purple/gray -poor circulation/ROM of all
joints/no muscle weakness or deformity
soft/smooth/dry/peeling/laceration/thin transparent/rash/petechiae/dimple- sacral
open or closed/hydrated/dehydrated/birthmark/polydactyly/
cyanotic/pale/ruddy/jaundice/meconium stained/mongolian spot
Reflexes- (present or not present) Palmar-grasp/ Moro-stretching arms with a
startle/Stepping/babinski-stroke the lateral aspect of the sole from the heal to the
ball of the foot, curving medially across the ball-note movement of the toes,
normally plantar flexion/Rooting-turning head/sucking/lips/tongue moving.
APGAR score(2 points)= Muscle Tone/HR/Response to stimulation or Reflex/skin
color/respiration
ROM-Rupture Of Membrane >18 hours/ test for GBS-Group B Strep- a bacteria (36
through 37 weeks of pregnancy) negative/positive (if positive and no antibiotic
treatments- need labs but treated with antibiotics x2 before the delivery- no lab work
needed) maternal fever 100.4 F and above before the delivery/chorioamnionitis/color
of amniotic fluid and odor( Lab work- CBC/Blood culture)
Newborn Screenings: Metabolic screening-test for genetic and metabolic
disorders-PKU- Phenylketonuria at 24 hrs of age
Hearing Screening-hearing loss/bilateral
Pulse Oximetry Screening for Heart Disease-measure oxygen saturation in blood
after 24 hours of life- completer blood circulation
Jaundice- bilirubin level/yellow skin/sclera of eye/cephalohematoma/ O positive
mom may produce antibodies that destroy some of the newborn’s red blood cellsneed to check bilirubin levels at 12 hours of life and all babies at 24 hours of life.
Mom’s with negative blood types (A-/B-/O-) check baby’s blood type and
coombs/TCB- Transcutaneous Bilirubin / TSB Transcutaneous Serum Bilirubin
(measure Total and Direct bilirubin). Reticulocyte-Anemia due to red blood cells
being destroyed earlier than normal (hemolytic anemia).
The # of wet and stool diapers count. Breast feed baby every 2 to 2.5 hrs with
supplement with formula/ Phototherapy (single/double/triple)
Acrocyanosis- bluish discoloration of the extremities due to decreased amount of
oxygen delivered to the peripheral part.
Circumcision (male infant)- consent/ Emla cream/7-10 days to heal/check for
bleeding/apply gentle pressure/apply A&D ointment or Vaseline/ sign of infection:
redness, fever,swelling,discharge, or order
Umbilical Cord- 14 days to fall off/ sponge bath/no alcohol pad unless
oozing/infection/ tub bath after fall off
Diaper- change before each feeding. 1 urine and 1 stool diaper for the first 24 hours.
Then 2 to 6 urine and 1-2 stool diapers within 24 hours. No stool for 2 days (48 hours
ok). meconium/ transitioning stool-dark green/brown/yellow/loose/seedy stool
Breast- Mother-baby unit- baby friendly-babies rooming in with parents. Skin to skin
Kangaroo care/ follow feeding cues/ latching/removing from the breast/lactation
consultation
Nipple-(Everted/Inverted/Flat)/cracked/dry/blisters/bleeding/bruises/breast cream
Skin to skin/breastfeeding 2 to 2 and ½ hours/breast pumping/ engorgement/
blocked ducts/mastitis/warm compress/massage/warm shower/supportive bra
Formula-indicated for supplement with breastfeeding. bottle feed every 3 hours
unless indicated otherwise
Newborn Stomach Size: Day 1 -Size of a grape (5-7ml/ 1-1.5 teaspoons)
Day 2-Size of Cherry tomato (22-27ml / 1.5-2 tablespoons)
Day 3 -Size of an apricot (45-60ml/ 1.5-2 ounces)
NICU- breast pump/ breast pumping every 2 to 3 hours.
Freshly expressed/pumped breast milk can leave outside 4 hours/ refrigerator -4
days/ Freezer-3 months/ deep freezer 6-12 months.
Thawed, previously frozen-1-2 hours / refrigerator up to 1 day/never refreeze human
milk after it has been thawed.
Left over from a feeding- use it within 2 hours after the baby is finished feeding
Labor & Delivery
Maternal age/ Advanced maternal age
GTPAL= Gravida/Term/Para/Abortion/Living children
Parental History-Prenatal visits/labs work on timely manner-blood
type/Hgb/Hct/WBC/Platelet count/GBS (36 to 37 weeks)/Rubella/HIV status/Hepatitis
B, STDs/Covid status/Prenatal sonograms/IVF
Obstetrical History-GDM/IDDM/GHTN/Hypothyroidism/medications during the
pregnancy/surgeries associated with reproductive organs/breast
augmentation/Med/Surge Hx/PE/DVT….
LMP=Last Menstrual Period
Allergies/ SOB/labored breathing/Respiratory infections
EDD=Expected Delivery Date
Feeding Preferences-NPO/Smoking Hx/Diet/weight gain/Childbirth Classes
Significant Prenatal Testing-Glucose tolerance test/GBS
Onset of labor-Labor usually starts two weeks before or after the estimated date of
delivery/common sign of labor are contractions and Rupture of amniotic sac (water
break)
Contraction: Frequency/duration/intensity (ideal frequency of contractions will be
about 2-3 min apart and lasting 60 to 90 seconds.
O/A:Dilation-Effacement (thinning the cervix)/station
Rupture of Membranes(A/S)/Time/fluid color
First Stage of Labor-(2 phases)-Latent phase of labor(waiting time) Active stage of
labor-cervix dilate to 5 to 6 cm and contractions begin to get longer, stronger, and
closer together.
FHR-Fetal Heart Rate-110-160 bpm/Location/Changes in FHR/Type- Decelerations are
temporary drops in the FHR / 3 types-early/late/variable
Category I is baseline rate variability
Category II is bradycardia with variability/tachycardia/minimal variability, no variability
with no recurrent decelerations
Category III is defined as FHR pattern with absent variability, recurrent variable, and
late decelerations,bradycardia, or sinusoidal pattern
V/S=Temp/BP/HR/RR/O2 saturation
Nursing interventions-obtaining maternal Hx/starting IV/draw blood/insert
foley/assisting anesthesiologist,delivering MD, OR tech/documentation…
Analgesia/Anesthesia/medications/comfort/measures
2nd Stage of Labor (Full Dilation): cervix opens 10cm/Time
Type of Delivery(NSVD/CS)/ Time of Delivery
Operative assistance-medical residents/OR tech
Episiotomy/Type of Incision
1-2-3-4 degree perineal laceration/ midline epis(vertical)/right or left medium lateral
epis(at an angle)
Analgesia/Anesthesia Type-epidural/spinal (regional anesthesia)
Local (particular area)/regional(portion that undergo the surgery)/general
Infant’s sex
APGAR score(2 points)= Muscle Tone/HR/Response to stimulation or Reflex/skin
color/respiration
3rd Stage of Labor Placenta Delivery Time
Maternal/Fetal Complications-Maternal
(hemorrhaging/preeclampsia/eclampsia/maternal fever… / Fetal(RDS/chorio/birth
traumas/congenital abnormalities…
Nurse’s Role
Nurse’s role during the 1st stage and 2nd stage of labor-1st stage assessment of mom
and fetus(V/S, heart tones), pain control,comfort and encouragement. 2nd stage-as
same as above but coach through pushing.
Nurse’s role during the 1st hour postpartum-Assess V/S, baby assessment, breast
feeding, skin to skin, golden hour, episiotomy/laceration/assess for cervical laceration
Nurse’s role during the preoperative for C/S-Antibiotics/NPO status/encouragement
Nurse’s role during the preoperative period for C/S-count instruments/assess
bleeding
Nurse’s role during the postoperative hour-Assess V/S, baby assessment, breast
feeding, skin to skin, golden hour,incision and bleeding