📋 CPE – Postpartum Assessment Script
"Hi, my name is (Your Name), I’m your nurse, and I’ll be doing your
postpartum assessment today. I’ll be checking on different parts of your body
to ensure everything is healing well and that both you and the baby are doing
okay. This process should take no longer than 20-30 minutes. I’ll be washing
my hands and putting on gloves." Closing curtain for privacy. For you and babies'
safety, can you confirm your name and DOB?
"How are you feeling emotionally? Any feelings of sadness or being overwhelmed?" Patient
appears to be content and happy with her baby.
1. Breast Assessment
"I'm going to check your breasts for any signs of engorgement, redness,
or irritation. Please let me know if you feel any pain.”
Palpate both breasts gently, checking for firmness, nodules, or skin
breakdown. Breasts are soft and intact
"I also see that you're wearing a supportive bra, which is great."
If you develop any pain and tenderness, please notify your PCP
immediately.
2. Abdominal Assessment
"Now I’ll assess your abdomen."
Abdomen is nondistended, I will now listen to bowel sounds. Bowel sounds
are present in all four quadrants (RLǪ, RUǪ, LUǪ, LLǪ).
"I’ll gently feel your belly to check the tone and position of your uterus."
Palpate fundus and bladder, Fundus is @ “U”, is firm, and midline and
no tenderness noted.
There is no redness, edema, ecchymosis, drainage and is well approximated at
the cesarean site
I see that you’ve left me a urine sample: Urine is Rubra, there’s no odor and
sedimentation is a moderate amount
Have you had any burning sensation while urinating, urinary frequency? If
you happen to, please be sure to notify your doctor.
"Have you had a bowel movement yet? What was the consistency and
amount?"
If you develop a fever or have any complications notify your doctor.
, 3. Perineal/Epidural Assessment
"I’m going to examine your perineal area, episiotomy site and check for
bleeding."
lochia: Rubra, amount is moderate, no odor and presence of clots are not
noted. Lochia will transition to serosa in 7-14 days, then eventually will
become alba
episiotomy site shows no redness, edema, ecchymosis, drainage and
is approximated.
If you notice a reverse in color or foul odor, please notify your provider.
Can you roll over on your side?
Check for hemorrhoids – No hemorrhoids noted.
Now I will assess the epidural site—there is no redness, edema,
ecchymosis, drainage, and the site is approximated.
CHANGE GLOVES
4. Extremities Assessment
"Next, I’ll check your legs for any signs of swelling or circulation issues."
Palpate dorsalis pedis and popliteal pulses – pulses are 2+ equally bilaterally.
"I’ll also assess for Clonus: Can you flex your foot upward for
me? Clonus is negative
5. Needs Assessment and Teaching
"Let’s talk about care for yourself and your baby."
o Nutrition: "You need to stay hydrated and increase your caloric
intake by at least 300 calories while breastfeeding."
o Birth control: "Do you have a preferred birth control method in
mind?"
o Are you familiar with Shaking Baby Syndrome? Babies will cry,
however if you become overwhelmed, put baby down and walk
away to keep from hurting your baby.
o Infant care: Is this your first baby? I will teach you how to use a
bulb syringe for suctioning (squeeze bulb, place inside of side of
cheek at the back and release, if more suction is needed in nose
repeat) this helps suction excess fluid in the mouth, also place
baby on their back to sleep, and keep the cord site clean and
dry, in 7-21 days the cord will fall off.
"Hi, my name is (Your Name), I’m your nurse, and I’ll be doing your
postpartum assessment today. I’ll be checking on different parts of your body
to ensure everything is healing well and that both you and the baby are doing
okay. This process should take no longer than 20-30 minutes. I’ll be washing
my hands and putting on gloves." Closing curtain for privacy. For you and babies'
safety, can you confirm your name and DOB?
"How are you feeling emotionally? Any feelings of sadness or being overwhelmed?" Patient
appears to be content and happy with her baby.
1. Breast Assessment
"I'm going to check your breasts for any signs of engorgement, redness,
or irritation. Please let me know if you feel any pain.”
Palpate both breasts gently, checking for firmness, nodules, or skin
breakdown. Breasts are soft and intact
"I also see that you're wearing a supportive bra, which is great."
If you develop any pain and tenderness, please notify your PCP
immediately.
2. Abdominal Assessment
"Now I’ll assess your abdomen."
Abdomen is nondistended, I will now listen to bowel sounds. Bowel sounds
are present in all four quadrants (RLǪ, RUǪ, LUǪ, LLǪ).
"I’ll gently feel your belly to check the tone and position of your uterus."
Palpate fundus and bladder, Fundus is @ “U”, is firm, and midline and
no tenderness noted.
There is no redness, edema, ecchymosis, drainage and is well approximated at
the cesarean site
I see that you’ve left me a urine sample: Urine is Rubra, there’s no odor and
sedimentation is a moderate amount
Have you had any burning sensation while urinating, urinary frequency? If
you happen to, please be sure to notify your doctor.
"Have you had a bowel movement yet? What was the consistency and
amount?"
If you develop a fever or have any complications notify your doctor.
, 3. Perineal/Epidural Assessment
"I’m going to examine your perineal area, episiotomy site and check for
bleeding."
lochia: Rubra, amount is moderate, no odor and presence of clots are not
noted. Lochia will transition to serosa in 7-14 days, then eventually will
become alba
episiotomy site shows no redness, edema, ecchymosis, drainage and
is approximated.
If you notice a reverse in color or foul odor, please notify your provider.
Can you roll over on your side?
Check for hemorrhoids – No hemorrhoids noted.
Now I will assess the epidural site—there is no redness, edema,
ecchymosis, drainage, and the site is approximated.
CHANGE GLOVES
4. Extremities Assessment
"Next, I’ll check your legs for any signs of swelling or circulation issues."
Palpate dorsalis pedis and popliteal pulses – pulses are 2+ equally bilaterally.
"I’ll also assess for Clonus: Can you flex your foot upward for
me? Clonus is negative
5. Needs Assessment and Teaching
"Let’s talk about care for yourself and your baby."
o Nutrition: "You need to stay hydrated and increase your caloric
intake by at least 300 calories while breastfeeding."
o Birth control: "Do you have a preferred birth control method in
mind?"
o Are you familiar with Shaking Baby Syndrome? Babies will cry,
however if you become overwhelmed, put baby down and walk
away to keep from hurting your baby.
o Infant care: Is this your first baby? I will teach you how to use a
bulb syringe for suctioning (squeeze bulb, place inside of side of
cheek at the back and release, if more suction is needed in nose
repeat) this helps suction excess fluid in the mouth, also place
baby on their back to sleep, and keep the cord site clean and
dry, in 7-21 days the cord will fall off.
