Postpartum Exam
Christina C. Reed and Susan Drummond
History
A.Chart review:
1.Antepartum course, including prenatal laboratory data: Pap smear, cervical cultures, maternal blood type and Rh, rubella and syphilis screen, and complete blood count (CBC).
2.Intrapartum course: Length of labor, type of delivery, and any maternal complications.
3.Neonatal course: Gestational age, weight, length, cord gases, admission to normal or intensive care nursery, length of stay in the intensive care nursery, and any neonatal complications.
4.Immediate postpartum course: Postpartum recovery, any postpartum complications, laboratory data, and length of hospital stay.
B.Interval history:
1.Number of weeks postpartum.
2.General maternal health and well-being, including diet or appetite, bowel and bladder function, level of activity, sleep patterns, and pain or discomfort.
3.Interval problems: Calls to healthcare provider, visits to emergency room, fever, or illness.
4.Adjustment and role adaptation to the baby: Motherhood, fatherhood, sibling rivalry, psychosocial assessment of depression, family support, housing, or financial issues.
5.Resumption of sexual activity: Need to wait 40 days postdelivery, comfort measures used, and contraception use to prevent unplanned pregnancies.
6.Family planning: Previous method of contraception used, success of method, plans to resume contraception, and options for contraception.
7.Status of infant: Breastfeeding or bottle feeding, consolability, sleep patterns, voiding, and stool patterns.
8.Establishment of healthcare follow-up: Pediatrician appointment, immunizations; referral to Women, Infant, and Children (WIC), public health, and so on, if applicable, or follow up with nurse practitioner or nurse–midwife.
C.Review of relevant systems:
1.Breasts: Cracked or sore nipples, clogged ducts, engorgement, mastitis; breast care practiced.
2.Bladder function: Stress incontinence, dysuria, urinary frequency, and flank pain.
3.Bowel function: Constipation; discomfort, especially if the patient has a history of third- or fourth-degree laceration; relief measures used and results.
4.Perineum: Problems or discomfort at episiotomy site, problems with wound healing, and signs of infection.
5.Lochia: Duration, type, odor, presence of clots; or resumption of menses: Date, duration, and amount.
6.Abdomen: If cesarean delivery, healing of wound, signs of infection; exercises initiated.
7.Legs: Varicosities, heat, swelling, and calf tenderness.
Physical Examination
A.Blood pressure (BP), pulse, respirations, and temperature (if indicated).
B.Weight.
C.Auscultate: Auscultate the heart and lungs.
D.Breast exam: Examine nipple integrity, masses, inflammation, and engorgement.
E.Palpate: Palpate the abdomen for tenderness, masses, involution of uterus; examine cesarean section and bilateral tubal ligation (if performed) incision for wound integrity and signs of infection.
F.Examine legs for varicosities and signs of thrombophlebitis.
G.Examine perineum, healing of episiotomy or lacerations, and abnormalities of Bartholin’s gland.
H.Speculum exam: Note lesions or lacerations of cervix and vagina, discharge, signs of infection; obtain Pap smear, if indicated.
I.Bimanual exam: Check for abnormalities of cervix, uterus, adnexa; status of involution; presence of cystocele or rectocele; and vaginal muscle tone.
J.Rectovaginal exam: Check for integrity of episiotomy or laceration if indicated.
Laboratory Data
A.Pap smear, if indicated.
B.CBC recommended if anemia or hemorrhage is documented or suspected.
C.75 g 2-hour glucose tolerance test recommended if gestational diabetes is documented or suspected.
D.Other tests as indicated if there were maternal or fetal complications.
Patient Teaching
This visit may be the last contact the woman has with the healthcare delivery system for some time. The practitioner should evaluate any problems and provide appropriate consultations, referrals, interventions, counseling, and teaching:
A.Explain the necessity of a yearly gynecologic exam.
B.Encourage regular aerobic, abdominal, and Kegel exercises.
C.Counsel the patient on choice of contraception including failure rates with typical use:
1.Abstinence.
2.Tubal ligation/vasectomy.
3.Contraceptive implants.
4.Intrauterine devices.
5.Depo-Provera injection.
6.Oral contraceptives (OCs).
7.Barrier methods: Condoms, cervical caps, diaphragm.
8.Spermicides.
9.Natural family planning, calendar method.
D.Explain the benefits of a healthy diet, especially if the patient is breastfeeding.
E.Discuss breastfeeding, if applicable; answer any questions, and address concerns.
F.Instruct the patient to communicate any breast changes to her provider, and explain the importance of yearly provider-performed breast exams during her well woman visit.
G.Explain the benefits of an inter-pregnancy interval of 1 to 2 years.
Follow-Up
A.Administer rubella vaccination if the patient has nonimmune status and administration of vaccine was missed in the hospital stay and she has not had unprotected intercourse since delivery.
B.If a woman’s physical exam and laboratory and Pap tests are normal, she does not require a physical for 1 year.
C.Establish a plan for the woman to obtain Pap smear results (follow-up phone call or letter with results). See the Postpartum Examination sheet (Exhibit 16.1) to use for documentation in the patient’s chart.
D.Schedule primary care provider appointments to address any chronic health conditions.