Postpartum Breast Assessment Form
Complete this structured assessment to document postpartum breast findings and symptoms.
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Breast Appearance (select all that apply)
*
Normal
Redness
Swelling
Engorgement
Warmth
Other
Nipple Condition
*
Intact
Cracked
Sore
Bleeding
Blistered
Other
Pain or Discomfort Level (0 = none, 10 = worst possible)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Milk Expression
*
Adequate
Low
Not expressing
Other
Feeding Difficulties Observed (select all that apply)
*
Latch difficulty
Infant not satisfied
Frequent feedings
Infant refusal
No difficulties
Other
Signs of Infection (select all that apply)
*
Fever
Chills
Localized pain
No signs
Other
Breast Assessment Table
*
Rows
Left Breast
Right Breast
Redness
1
2
Swelling
3
4
Pain
5
6
Lump
7
8
Discharge
9
10
Interventions Provided
Positioning advice
Warm compress
Cold compress
Referral
Other
Additional Notes
Submit Assessment
Should be Empty: