Health & Physical Assessment
Focused Postpartum Health History
Infection prevention
Introduction
Collaboration with
the patient/Informed
Consent
Patient profile
Primary Concern
PQRSTIUA
Past health history
Functional
Assessment
Items
Hand hygiene before touching patient
State name
State role
Permission is obtained before engaging assessments
Explanation of assessment process
State’s patients right to refuse assessment
Full Name
Date of birth
Pronouns
Contact person and number
Asks patient to elicit any concerns.
1. Provoking Factors
2. Palliating Factors
3. Quality (numbness, tingling, sharp, dull)
4. Radiation
5. Region
6. Severity (scale 0 to 10)
7. Timing (onset and how long)
8. Impact on ADLs
9. Patient understanding
10. Associated Symptoms
Obstetrical history: GTPAL status
History of current pregnancy:
Medications (prescription; OTC; herbal)
Allergies to Medication/Food/environment
Plan to breastfeed or formula feed
Exercise & Mobility
Nutrition (generally healthy)
Smoking (current or past, number of cigarettes, number of years)
ETOH use and amount
Substance use
Sexual health/STI screening/Contraception
Describe relationship with family members/support system
Do you feel safe with your partner (screening for intimate partner violence)
Financial
Home environment
Coping strategies
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Focused Postpartum Health Assessment
Breasts
Bowels
Bladder
Uterus
Lochia
Legs
Episiotomy
Emotional
State
Proper palpation technique (ensuring to palpate into axilla)
Palpate to determine whether breasts are soft or firm
Palpate for presence or absence of any lumps, nodules or masses
Assess overall breast color, any signs of redness?
Assess if skin around nipples is intact or cracked
Assess if nipples are inverted, erect or flat
Ask patient if breasts are sore and palpate for tenderness
Patient should be supine
Ask about habitual elimination routine
Ask if any use of laxatives during pregnancy
Take note of the last bowel movement
If none, is the mom passing gas
Auscultate bowel sounds in all 4 quadrants
Ask mom if voided since labor and when
Make sure mom doesn’t have to void now (Should be asked before beginning assessment)
Any dysuria
Assess for increased frequency or urgency
Ask about color of urine
Ask about foul odor
Palpate bladder for possible distension
Patient must be supine
Palpate for fundus starting above the umbilicus
State location in relation to umbilicus (ex: 1/U) and whether it’s midline or deviated
States consistency: firm or boggy
Ensure protected with gloves
Assess and note color: rubra, serosa or alba
Assess and specify amount on pad
Ask when pad last changed or how often changing
Educate patient that clots should be no larger than egg/golf ball
Assess for foul odor
Inspect legs for redness
Palpate legs for any pitting edema
Palpate legs for any tenderness
Compare temperature of both legs
**includes laceration, C-section and epidural site
Assess presence or absence of any: swelling, redness, drainage/discharge, if sutures are intact
Assess if any pain/discomfort to laceration site
Inspects for hemorrhoids: What colour are they and how many are there?
Ask patient about general mood
Ask patient about fatigue
Educate patient about postpartum/baby blues and how they differ. What is
normal? After how long should the mom seek help? What are some of the symptoms she may
experience?
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