Introduction

The postpartum period covers a critical transitional time for a woman, her new-born and her family, both on a physiological as well as an emotional and social level. The postpartum period receives very little attention and care compared to pregnancy and labour in spite of the fact that majority of maternal deaths and disabilities occur during this period. The attention usually shifts to the new-born baby and the mother gets little care both at home and at the facility. NOTE: Both the mother and the baby should be examined, for it to be a complete postnatal exam.

Definition

• Puerperium: Refers to the period of six weeks after delivery when it is assumed the woman’s condition returns to the non-pregnant state.
• Postpartum: Refers to a period for the mother from the end of third stage of labour up to six weeks or more.
• Postnatal: It’s reserved for any references to the baby after delivery, not the mother. NOTE: The first 24 hours after delivery are very important, then the first 6 days and six weeks.

THE FIRST 24 HOURS AFTER BIRTH {VERY IMPORTANT}

Care of the Mother:

• Monitoring vital signs every 30 mins after delivery for the first one to two hours, then six hourly for 24 hours.
• Monitoring vaginal bleeding hourly in the first six hours, care of the perineum and personal hygiene {hand hygiene, breast hygiene, changing pads and bathe daily}.
• Advice on bladder emptying.
• Advise on enough rest and adequate time to sleep.
• Mother should be with a caretaker.
• Bonding with the baby.

Baby:

• Appropriate feeding.
• Cord care.
• Parental care.
• Easy accessibility of the mother.
• Adequate warmth.
• A safe environment.
• Nurturing, cuddling and stimulation.
• Protection from diseases, harmful practices, abuse and violence.
• Acceptance of sex, appearance and size.

SUBSEQUENT POSTNATAL CARE

Supportive care to mother and her family should continue being given and response to her needs and fears.

• Prevention, early detection, diagnosis and management of complications, including vertical transmission.
• Early referral if necessary.
• Education on sex resumption.
• Education on baby care.
• Promotion of breastfeeding.
• Education on maternal nutrition.
• Counsel on FP and provision, where necessary.
• Immunisation of infant.

POSTNATAL CLINICAL EXAMINATION

EQUIPMENT NEEDED

ASSESSMENT/EXAMINATION

Before beginning postpartum assessment:

• The midwife should ask the mother questions concerning herself and the baby, just to ascertain both her and the baby’s well-being. This can help give a go ahead during the examination.
• The midwife should review the woman’s records to determine physical or psychosocial problems that may have been identified during labour or delivery. This review will enable the midwife to pay special attention to those areas most at risk.
• Physiologic stability is assessed by monitoring vital signs {both mother and baby} assessing the contraction of the uterus, determining the amount and type of lochia and assessing the tissues of the perineum.

PROCEDURE:

• Introduce yourself to the mother and explain the procedure to the woman completely and clearly.
• Ask mother to empty the bladder.
• Provide privacy and assemble articles at bedside.
• Check anthropometric measurements.
• General appearance – Looks dull/good/fair.
• Check vital signs including temperature, pulse, respiration and blood pressure.
• Make a complete head to toe examination however more emphasis should be put on BUBBLE HE.
• Postpartum assessments: BUBBLE HE should be checked carefully to know the deviation from normal and prevent complications.
• B – Breast
• U – Uterus
• B – Bowels
• B – Bladder
• L – Lochia
• E – Episiotomy
• H – Homan’s Sign
• E – Emotional status

HEAD TO TOE EXAMINATION:

• HEAD: Scalp – Dandruff/lies. Hair distribution, texture. Colour of hair. Any surgical scars.
• FACE: Fore head is normal/any abnormality.
• EYES: Eyebrows and eyelashes. Check for jaundice and anaemia. Reaction to light. Discharges/haemorrhage/any other. Visual acuity.
• EARS: Low set ears/any other abnormalities. Discharges/wax.
• NOSE: Deviated nasal septum/any other abnormalities. Discharges/epistaxis.
• MOUTH: Colour of the lips and tongue. Dental carries/any other abnormalities {dental formula}. Thyroid/lymph node enlargement.
• CHEST:
  • INSPECTION: Symmetrical/non symmetrical in chest movements.
  • Breast: Symmetry of breast. Primary and secondary areola development. Montgomery’s tubercles. Nipples erected/cracked or any other abnormalities. Discharges. Surgical scars.
• ABDOMEN: Inspection: Umbilicus, linea nigra, striae gravidarum, surgical scars. Palpation: Fundal height, tenderness, distension. Percussion: Resonance/dullness. Auscultation: Bowel sounds.
• BACK: Inspect for scars, deformities. Palpate for tenderness.
• EXTREMITIES: Inspect for edema, varicosities. Palpate for pulses, temperature.
• GENITALIA: Inspect for vulval oedema, hematoma and lacerations.

BUBBLE HE DETAILS:

• B – Breast: Assess for size, symmetry, engorgement, colostrum/milk, nipples (cracked, sore, inverted).
• U – Uterus: After delivery the fundus is at the umbilicus. Every day it descends 1–2 cm. By the 10th postpartum day it is located in the pelvic cavity. The uterus should be firmly contracted. Afterpains are more acute for multiparas, and breastfeeding may cause temporary discomfort. The midwife should palpate the fundus gently. No vigorous massage should be implemented. If relaxation is detected, then gentle massage to increase contraction of the uterine muscle fibres.
• B – Bowels: Most women do not have the urge to defecate for a few days following delivery, although some may do so. Loss of abdominal tone contributes to problems with constipation following child birth. Fear of pain or tissue damage during the first defecation after delivery is also common. The midwife should identify specific concerns so that any potential problems can be addressed.
• B – Bladder: The urinary bladder should be assessed for the presence of distention. When the bladder becomes distended, inspection and palpation will reveal a bulge directly above the symphysis pubis. A distended bladder is dangerous following delivery because it will interfere with normal contraction of the uterus. The woman should void within 4-6 hours following delivery. This time is monitored closely. The volume of the initial voiding is typically measured and documented. Subsequent voiding should be measured if incomplete emptying of the bladder is suspected. Any signs or symptoms of infection, such as pain or burning with urination should be documented and reported.
• L – Lochia: The amount and characteristics of the lochia are assessed each time the fundus is checked. Immediately after delivery this drainage is red and contains blood, small clots and tissue fragments. It progresses through 3 stages; rubra {red} day 1-4, serosa {pink} day 5-9 and alba {yellowish-white} day 10-15. Lochia should stop after about 2 weeks but sometimes it persists longer. The amount of lochia described as scant, light, moderate or heavy. This is determined by assessing how rapidly perineal pads are saturated. The midwife must be careful to look underneath the woman’s buttocks and back to make sure that the drainage is not missing the pad and pooling in the bed linens. For the first 1-2 hours following delivery the flow is expected to be moderate, with one or two pads being saturated in an hour. A heavier rate of flow than this is considered excessive. The midwife should maintain careful records of the number of pads saturated in an hour in order to determine overall blood loss. When more detailed assessment is needed, the pads can be weighed to determine blood loss more precisely. One gram of weight is approximately equivalent to 1 ml of blood. Less than expected flow should also be viewed with caution to determine that the uterus is contracting and clots are not forming within the uterus or vaginal canal. The amount of lochia diminishes gradually over time. Lochia changes colour and consistency as healing of the endometrium takes place.
• E – Episiotomy: The woman should be positioned in lithotomy position and good room light or flash light is needed to visualize the stitches/suture line adequately. REEDA should be observed:
  • R – Redness
  • E – Edema
  • E – Ecchymosis
  • D – Discharges
  • A – Approximation of suture line
• RECTUM: Inspect for haemorrhoids.
• EXTREMITIES: Any congenital abnormalities syndactyly/polydactyl. Capillary refill.
• HOMAN’S Sign: Problems related to venous stasis generally begin during the last few months of pregnancy when the enlarged uterus restricts the return of blood to the heart. These problems are further aggravated by pressure on the femoral veins during bearing down and use of stirrups during delivery. Impaired venous return increases the risk of thrombus formation. The midwife inspects both the legs for any signs of superficial or deep vein thrombosis (DVT) formation, such as pain in the calf muscle, warmth, redness or swelling. Both the legs are checked for the presence of Homan’s sign, which is an indicator of venous thrombosis. With the woman lying in the supine position, the midwife supports the knee of one leg while dorsiflexing the foot. Homan’s sign is considered positive when the woman reports pain, not just a stretching sensation in the calf.
• E – Emotional Status:
  • Relationship with the newborn and family dynamics: The early postpartum period is the ideal time for bonding between mother and newborn. The immediate family should have the opportunity to spend time with each other and the newborn while their emotions and level of excitement are high. The midwife should provide privacy and encourage the family to interact with a minimum amount of interruption. And the rooming-in or bonding should be developed between mother and the baby.
  • Self care ability: The midwife must assess the woman’s ability to care for herself and her newborn.

DOCUMENTATION OF PROCEDURE AND INFORMING THE DEVIATIONS FROM NORMAL TO THE PHYSICIANS

• Education to the mother regarding personal hygiene, postnatal diet, postnatal exercise, breast feeding techniques, immunization schedule and care of the new-born.

THE BABY

NOTE: Make sure you ask the mother about the baby’s state. It will give you a go ahead. Check for:

• General appearance; skin colour, cord, activity
• Take vitals (respiration rate, pulse, bowel sound and temperature)
• Take anthropometric measurements (Length, weight, head circumference, chest circumference)
• Examine head to toe (Don’t forget the Fontanelles)
• Examine the reflexes (Suckling, rooting’s, startling, grasping, and babinski)
• Close by giving a general health education talk