POSTPARTUM ASSESSMENT:

BUBBLE-HE
BUBBLE-HE
BUBBLE-HE is an acronym used to denote the components
of the postpartum maternal nursing assessment. This
method enhances the standard physical assessment
process typically performed on hospitalized patients by the
RN. For stable patients, vital signs are taken every 15
minutes during the first hour following delivery and then
gradually less frequently. While performing the BUBBLE-HE,
the RN often uses the assessment time to provide for
patient education.
The BUBBLE-HE Acronym
B: Breast
U: Uterus
B: Bladder
B: Bowels
L: Lochia
E: Episiotomy
H: Homan’s sign
E: Emotional status
 B- BREAST Breast Assessment
Assessment include evaluating the breast in the postpartum period
The first step is to determine if the new mamma is breastfeeding or
Breast Evaluation bottle-feeding: This will guide the assessment along with patient
education
Size
Shape Bottle-Feeding Mom: Lactation Suppression
Firmness Teach the mom about breast engorgement. This usually occurs about 72
hours after birth
Redness
The breasts will be very tender with a feeling of heaviness
Symmetry A firm, snug-fitting bra is ideal for the woman whose not breastfeeding.
Also this will help, engorgement may still occur
Ice and cabbage leaves can provide relief. There is an enzyme in the
cabbage leaves that helps
Colostrum, a clear, yellowish fluid, precedes Do not express milk as it will encourage additional production
milk production. It is higher in protein and Any warmth over the breasts and stimulation of the nipples will create a
lower in carbohydrates than breast milk. It faucet-like effect
contains immunoglobulins G and A that
provides protection for the newborn during
the early weeks of life.
 Mastitis
•Mastitis is an inflammation or infection of the breast. The infection may be due
to bacterial entry through cracks in nipples.
•Symptoms: Fever, malaise, unilateral breast pain, and tenderness in the infected
area
•Treatment: Antibiotic therapy, analgesia, rest, hydration, continue breastfeeding

Breastfeeding Teaching Benefits of Breast Feeding

Positioning: holds- chest to chest or tummy to tummy in some Passive immunity

way, grab under the breasts and push down and out (taking
the milk ducts and pushing it forward, make a C-Hold around
the areola (pull back, down, and forward while bringing forward)
get a nice big drop of colostrum on the nipple
tickle the lip with nipple, shove as much breast as possible into
the mouth once it’s open 5 to 15 minutes a first to prevent
soreness
Start with the breasts that was left from
Try to feed every 2 hours
Less incidents of ear infections (formula pools into the Eustachian
tube)
Easy digestibility
Bonding between mom and baby
No cost and always available and at the right temperature
For the foodies: Some moms may enjoy being able to eat an extra
500 calories/day
Benefits to Mom: Release of oxytocin (the “let-down”) causes the
uterus to contract, which promotes quicker return to pre-
pregnancy weight. It also decreases risks of ovarian and breast
cancer

U: UTERUS
Uterine Assessment
1. Fundus: firm or boggy- make a “C-shape” with
your hand and push up on the lower fundus; if it’s
not stabilized, the uterus can prolapse, or fall into
the vagina. Massage of not firm- secure lower
uterine segment. The concern is for hemorrhage;
the primary causes are a distended bladder (uterus
can’t contract or uterine atony, or failure to contract
fully) and retrained placental fragments (usually a
later cause)
2. Fundal Height: where is it in relation to the
umbilicus? “U/U” or “At the U” (1/U = 1 cm above the
umbilicus) - drops one centimeter or finger width.
The position drops one centimeter every 24 hours
for 10 days postpartum
3. Midline or Deviated to the Left or Right: if
deviated, it’s usually a sign of a full bladder
Boggy Uterus
•A boggy uterus is a sign that the uterus is not in a contracted state.
•Risk of excessive blood loss and/or hemorrhage is increased.
•The immediate action is to massage the fundus with the palm of your hand in a circular motion
until firm and reevaluate within 30 minutes
•If the uterus does not respond to massage, follow the standing order for oxytocin and notify the
physician or midwife.
Nursing Considerations.
A boggy fundus may be a sign of uterine atony, which places the patient at risk for
developing a postpartum hemorrhage and other complications. Also, fundal location that lies
out of range with anticipated location according to postpartum status may be another
indication. The nurse should perform a uterine massage, which promotes blood movement
out of the uterus, and also encourage the patient to void, as a full or distended bladder can
impede uterine involution and contractions. The nurse is often in the position as the first
member health care team to learn of these warning signs and therefore must take swift
action if an issue is suspected
MEDICATION:
Oxytocin (Syntocinon)
•Indication: Postpartum control of bleeding
•Action: Stimulates uterine smooth muscle to produce uterine contraction
•Adverse reactions with IV use: Coma, seizures, hypotension, water intoxication
•Route and doses:10 units in a liter of IV solution or 10 units IM
 B: BOWELS
Bowels Assessment
Bowels in shock- just moved into
some strange positions.
Take a stool softener- don’t want
ripping or the episiotomy or trauma to
the C-section incision
There is a decrease in gastrointestinal muscle tone and motility post birth with a
return to normal bowel function by the end of the second postpartum week.
■ Constipation
Women are at risk for constipation due to:
Decreased GI motility
Decreased physical activity
Dehydration and fluid loss from labor
Perineal pain and trauma

MEDICATION: ■ Hemorrhoids
Docusate (Colace) It is common for women to develop hemorrhoids during pregnancy and/or the
•Indication: Prevention of constipation birthing process.
•Action: Promotes incorporation of water into Hemorrhoids will slowly resolve, but can be painful.
the stool
•Common side effects: Mild abdominal
cramps
•Route and dose: PO; 100 mg twice a day
 Expected assessment findings:
The woman spontaneously voids within 6 to 8 hours post-birth.
Each voiding is a minimum of 150 mL.
The woman does not experience frequency, urgency, and burning
on urination.

1.Assist the woman to the bathroom and encourage her to void within

B: BLADDER 6 hours postbirth.

Early voiding decreases the risk of cystitis.
Bladder Assessment
Ask mom when she last voided
Establish a Voiding Schedule to
2.Instruct the woman to increase fluid intake to a minimum of 8
prevent bladder distension and urinary glasses per day.
stasis
Encourage mom to urinate every time 3.Document findings and interventions.
before she feed baby (as they may fall
asleep)
Sample charting: The patient spontaneously voided 250 mL. The
patient states no burning on urination.
 L: LOCHIA
LOCHIA ASSESSMENT LOCHIA COLOR
Assess the color, odor, Lochia Rubra: bright red, may have
small clots, usually lasts 1-3 days
and amount
Lochia Serosa: pink, serous, other
The lochia color should tissues, usually lasts 4-10 days
forward in the
progression of lightness, Lochia Alba: tissue, whitish, usually
lasts 10-14 days *Can last up to 6
never go backwards
weeks
LOCHIA AMOUNT
Scant = 2.5 centimeters saturation
Light = < 10 centimeters saturation
Moderate = > 10 centimeters
saturation
Heavy = pad is completely
saturated within 2 hours
Postpartum hemorrhage is clinically
defined as a pad saturated within
15-30 minutes
 Excessive Bleeding
•Heavy lochia is a sign of excessive bleeding and/or
postpartum hemorrhage.
•Assess the tone of uterus.
•If the uterus is boggy, massage.
•If the uterusis boggy and displaced to the side, instruct
the patient to void and reevaluate.
•If firm, change the pad and reevaluate in 15 minutes.
•In case of continued excessivebleeding, notify the
physician or midwife.
 E: EPISIOTOMY
REEDA Assessment R: Redness - E: edema
E: ecchymosis - D: discharge - A: approximation
Perineal Area Assessment
Pull the labia from front to back
Check the episiotomy or areas of vaginal tearing
Look for hematoma formation- a collection of blood in
between tissue
Look for hemorrhoids (developed during pregnancy or
during labor from the pushing process)
Nursing Intervention: Always help mom get up and ambulate
the first two times after birth to assess for mobility, reduce the
risk of falling, and prevent trauma to the perineum and C-
section incision
Hemorrhoids
Vasculature that forms a pouch
Color can match the skin of the rectal area and may look more like a
blood blister when irritated
Severe hemorrhoids appear as grape clusters
Dermaplast spray
Patient may not be aware, may only know that business down there is
not as usual
Nursing Interventions. Sitz Bath: a rotating fluid that moves the water.
May fit over the commode or one can be performed with no special
equipment using the bathtub other than a bathing ring. Turn tub on and
allow drain to open and use a ring for circulating water. It’s very shallow
and only bathes the perineal area.
 Assess for Signs of DVT by the Homan’s Sign
A positive Homan’s sign is indicative of DVT, although it’s not the most reliable
indicator
H: HOMAN’S SIGN All of the characteristic changes to maternal clotting factors are higher than any
other point as the body prepares for labor
Combine this with being in bed, especially if mom underwent a C-section, and it’s
easy to see why the postpartum woman is at such a huge risk for DVT

Performing the Homan’s Test

Homans's sign is often Most commonly performed with the mom in a supine position while lying in bed
used in the diagnosis of The calf is flexed at a 90° angle
The nurse manipulates the foot in a dorsiflexion movement
deep venous thrombosis If pain is felt in the calf, the Homan’s Sign is said to be positive
of the leg. A positive
Homans's sign (calf pain
at dorsiflexion of the
foot) is thought to be
Signs of DVT
associated with the A sudden and unexplainable pain, usually in the back of the leg or calf
presence of thrombosis. Tachycardia and shortness of breath or dyspnea
Edema, redness, and warmth localized over the area of the DVT
 E: EMOTIONAL
STATUS
Maternal phases, as defined by Rubin
(1963,1967), is a three-phase process that
occurs during the first few weeks of the
postpartum period. A delay in transitioning
through the phases may indicate that the
woman is experiencing difficulty in
becoming a mother.
Emotional Status and Bonding Patterns
Fluctuations in estrogen levels are blamed for the emotional roller-coaster
that many moms experience after birth
High levels of stress, increased responsibility, and sleep deprivation
Bonding refers to the interactions between the mamma and baby
Caregiving of self and baby is an indicator of emotional status
Common Postpartum Assessment Findings
The Taking in Phase. The taking–in phase, a period of dependent behaviors,
occurs during the first 24– 48hours after birth and includes the following
■
maternal behaviors: The woman is focused on her personal comfort and
■
physical changes The woman relives and speaks of the birth experience
■The woman adjusts to psychological changes.
Taking Hold Phase. The taking-hold phase, the movement between
dependent and independent behaviors, follow the taking-in phase and can
■
last up to weeks and includes the following maternal behaviors: The focus
■
moves from self to the infant. The woman begins to be independent.
Letting go Phase. In the letting-go phase,the movement from independence
to the new role of mother is fluid and interchangeable with the taking-hold
phase.