01
BUBBLE-HE Assessment
The systematic postpartum assessment — performed every shift and with every assessment.
- B — Breasts
- Soft, filling, or engorged? Nipple condition (cracked, bleeding, inverted)? Colostrum/milk present? Latch quality if breastfeeding.
- U — Uterus
- Fundal height (should descend ~1 finger-breadth/day), firmness (firm = good, boggy = massage immediately), midline position (deviated = full bladder).
- B — Bladder
- Voiding within 6–8 hours after delivery? Bladder distension? Full bladder displaces uterus and increases PPH risk. May need straight cath.
- B — Bowels
- Bowel sounds present? Passing flatus? First BM expected within 2–3 days. Stool softeners if needed (especially with episiotomy/hemorrhoids).
- L — Lochia
- Color (rubra → serosa → alba), amount (scant/light/moderate/heavy), odor (foul = infection), clots (>golf ball = report).
- E — Episiotomy/Laceration
- REEDA assessment: Redness, Edema, Ecchymosis, Drainage, Approximation. Ice first 24 hrs, then sitz bath.
- H — Homans/DVT
- Assess for calf pain, redness, warmth, swelling (DVT signs). Early ambulation. C-section patients at higher risk.
- E — Emotional
- Bonding with baby? Eye contact? Holding baby? Mood — tearful, withdrawn, anxious? Screen for depression (Edinburgh Postnatal Depression Scale).
Exam Tip
If a question asks about a postpartum patient with a uterus that is deviated to the right and boggy → the FIRST action is to have her void (full bladder is displacing the uterus). If the fundus is boggy and midline → massage the fundus firmly until it becomes firm. A boggy uterus = PPH risk.
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02
Uterine Involution
The uterus returns to pre-pregnant size over 6 weeks.
- Immediately after delivery: Fundus at the umbilicus (U/U) or slightly below, firm and midline
- Descends ~1 cm (1 finger-breadth) per day
- By day 10: Fundus is no longer palpable above the symphysis pubis
- By 6 weeks: Uterus returns to pre-pregnant size
- Afterpains: Uterine cramping during involution — more intense in multiparas and during breastfeeding (oxytocin release stimulates contractions). Treat with ibuprofen.
Subinvolution — When the Uterus Doesn't Shrink
- Uterus remains larger than expected for the postpartum day
- Causes: retained placental fragments (#1 cause), infection (endometritis), overdistended uterus
- Signs: persistent lochia rubra, boggy uterus, foul-smelling discharge, pelvic pain, fever
- Treatment: oxytocin, methylergonovine (Methergine), antibiotics if infected, possible D&C
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Lochia Stages
The color tells you where the patient is in recovery — and when something is wrong.
- Rubradays 1–3
- Dark red. Blood, decidual tissue, mucus. Heaviest flow. Small clots normal.
- Serosadays 4–10
- Pinkish-brown. Old blood, serum, WBCs, cervical mucus. Flow decreasing.
- Albaday 10 – 6 weeks
- Yellowish-white. WBCs, decidual cells, mucus. Scant amount.
Abnormal Lochia — Report Immediately
- Return to rubra after progressing to serosa → retained fragments, overactivity
- Foul-smelling lochia → infection (endometritis)
- Large clots (>golf ball size) → report to provider
- Saturating a pad in <1 hour → hemorrhage
- Absence of lochia → may indicate clot blocking cervical os
Lochia Memory Trick
Think of a traffic light in REVERSE: Rubra = Red (days 1–3), Serosa = Salmon/pink (days 4–10), Alba = Almost gone / white (day 10+). If it goes backwards (from pink back to red) → something is wrong.
04
Breastfeeding
Know the hormones, the teaching, and when to report problems.
Key Hormones
- Prolactin = milk PRODUCTION ("pro-lactin = pro-duction")
- Oxytocin = milk EJECTION (let-down reflex). Also causes uterine contractions (afterpains during breastfeeding).
Breastfeeding Teaching
- Colostrum first 2–5 days — thick, yellow, rich in antibodies (IgA). Small volume is normal.
- Transitional milk days 5–14, then mature milk by ~2 weeks
- Feed every 2–3 hours (8–12 times/day). Frequent feeding prevents engorgement and establishes supply.
- Proper latch: wide open mouth, lips flanged out, areola in mouth (not just nipple), audible swallowing
- Alternate breasts each feeding. Start with the breast last used.
- Signs baby is getting enough: 6+ wet diapers/day by day 4, 3+ stools/day, weight gain after initial loss, satisfied after feeding
- Normal weight loss: 5–7% in first 3–5 days. Should regain birth weight by day 10–14. >10% loss = concerning.
Breast Problems
- Engorgement: Warm compresses before feeding (promotes let-down), cold compresses after. Frequent feeding is the best prevention.
- Sore/cracked nipples: Correct the latch (most common cause). Air-dry nipples. Apply breast milk or lanolin. Do NOT use soap on nipples.
- Mastitis: Infection — fever, flu-like symptoms, red/warm wedge-shaped area on breast. Treatment: antibiotics, CONTINUE breastfeeding (emptying the breast helps resolve it). Do NOT stop nursing.
Mastitis = Keep Breastfeeding
If a question says "the breastfeeding mother has mastitis — what should the nurse teach?" → CONTINUE breastfeeding. Stopping breastfeeding makes mastitis worse (milk stasis). The infection is in the breast tissue, not the milk — the baby will not get sick. This is one of the most commonly tested breastfeeding questions.
05
Postpartum Hemorrhage (PPH)
The #1 cause is uterine atony (boggy uterus) — and the #1 intervention is fundal massage.
Definition
- Vaginal birth: blood loss >500 mL
- C-section: blood loss >1,000 mL
- Early PPH: within 24 hours (most common)
- Late PPH: 24 hours to 6 weeks postpartum
Causes — "4 T's"
- Tone — uterine atony (boggy uterus) — #1 cause (accounts for ~80% of PPH)
- Tissue — retained placental fragments
- Trauma — lacerations, episiotomy, uterine rupture
- Thrombin — coagulation disorders (DIC)
Nursing Actions
1
Fundal massage — firmly massage the boggy uterus until firm. This is the FIRST action.
2
Have patient void — full bladder prevents uterine contraction
3
Oxytocin IV — first-line medication for PPH
4
If oxytocin fails → Methergine IM (NO in HTN), Hemabate IM (NO in asthma), Misoprostol (rectal)
5
Monitor VS, I&O, H&H. Type and crossmatch. IV fluids — two large-bore IVs for volume replacement.
Boggy Uterus = Massage FIRST
If the fundus is boggy → massage it FIRST, THEN call the provider. Do NOT wait for orders. Fundal massage is a standing nursing intervention for uterine atony. While massaging, check if the bladder is full (have her void or straight cath). Document the response.
06
Postpartum Mood Disorders
Three levels of severity — know the differences and when to escalate.
- Baby Blues2–3 days PP, resolves by 2 weeks
- Mood swings, tearfulness, irritability, anxiety, difficulty sleeping. Affects up to 80%. Supportive care. Reassurance. Rest. Self-limiting — no medication needed.
- Postpartum Depressionwithin 4 weeks PP, persists >2 weeks
- Persistent sadness, loss of interest, difficulty bonding, changes in appetite/sleep, feelings of worthlessness, guilt. May have thoughts of harming self. Therapy (CBT), SSRIs (sertraline safe in breastfeeding), support groups.
- Postpartum Psychosis48–72 hours PP, psychiatric emergency
- Hallucinations, delusions, paranoia, confusion, disorganized thinking. Risk of harming self or baby. Hospitalization. Antipsychotics. NEVER leave mother alone with baby.
Rubin's Phases of Maternal Adaptation
- Taking-In (1–2 days): Passive, dependent. Focused on self. Reliving birth experience. Needs rest and nurturing. Let her talk about the birth.
- Taking-Hold (2–7 days): Becoming independent. Eager to learn newborn care. Anxious about competence. Best time for teaching — she's motivated and receptive.
- Letting-Go (after 7 days): Adjusting to new role. Establishing new family routines. May grieve the loss of previous lifestyle.
Postpartum Psychosis = NEVER Leave Mom Alone with Baby
If a mother is expressing delusional thoughts, hearing voices, or exhibiting bizarre behavior → this is postpartum psychosis. It is a psychiatric emergency. Do NOT leave her alone with the infant. Notify the provider immediately. Safety of the mother and baby is the #1 priority.
? A patient on day 5 postpartum is tearful and says she feels overwhelmed — what category is this and what is the nurse's priority?
This is consistent with baby blues (days 2–14 postpartum, mild, self-limiting). Priority: reassurance, rest, and support. No medication is needed. However, screen for escalation to postpartum depression if symptoms persist beyond 2 weeks or worsen.
07
Postpartum Immunizations
What gets given after delivery — and when.
- RhoGAM: Given within 72 hours to Rh-negative mothers who delivered an Rh-positive baby. IM injection.
- Rubella vaccine (MMR): If the mother is non-immune (rubella titer negative). Given before discharge. Live vaccine → advise avoiding pregnancy for 4 weeks. Safe to breastfeed after receiving.
- Tdap: If not received during pregnancy (recommended at 27–36 weeks). Protects newborn from pertussis (whooping cough) via "cocoon strategy" — vaccinate everyone around the baby.
- Flu vaccine: If not received during pregnancy and it's flu season.
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Discharge Teaching
Key teaching points before the patient goes home.
- Lochia monitoring: Expected progression (rubra → serosa → alba). Report: foul smell, return to rubra, saturation in <1 hour, large clots.
- Activity: No heavy lifting (>10 lbs) for 4–6 weeks. Gradually increase activity. No stairs initially if C-section.
- Sexual activity: Avoid intercourse until cleared by provider (typically 4–6 weeks or when lochia stops). Discuss contraception.
- Perineal care: Peri bottle (warm water, front to back). Sitz bath 3–4 times/day for comfort. Change pads frequently.
- Danger signs to report: Fever >100.4°F, foul-smelling lochia, heavy bleeding or clots, severe headache, vision changes, chest pain/SOB (PE), calf pain/swelling (DVT), difficulty urinating, signs of depression
- Newborn care: Feeding schedule, diapering, cord care (keep clean and dry), circumcision care, safe sleep (back to sleep, firm surface, no loose bedding)
- Follow-up: OB visit at 6 weeks. Pediatric visit within 3–5 days.
- Car seat: Rear-facing in the back seat until age 2 or until reaching the height/weight limit of the seat.
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Frequently Asked Questions
Common student questions on this topic.
What is the BUBBLE-HE postpartum assessment?
Mnemonic for postpartum check: Breasts (engorgement, nipples, lactation), Uterus (fundal height, firmness, position), Bladder (output, distention), Bowels (movement, sounds, gas), Lochia (amount, color, odor), Episiotomy/perineum (REEDA: redness, edema, ecchymosis, discharge, approximation), Homans sign/Hemorrhoids/DVT signs, Emotional status. Complete this check every shift, more often in the first 24 hours.
What are the stages of lochia and what is abnormal?
Lochia rubra: dark red, days 1–3. Lochia serosa: pinkish-brown, days 4–10. Lochia alba: white/yellow, days 11–28. Total flow lasts up to 6 weeks. Abnormal: foul odor (infection), large clots (> quarter size), saturating a pad in an hour (hemorrhage), bright red return after it had become serosa or alba, or persistent rubra past day 4. Always report abnormal lochia immediately.
Where should the fundus be after delivery?
Immediately after delivery: at the umbilicus, midline, firm. Then descends roughly 1 fingerbreadth per day — by day 10 it should no longer be palpable. Firm and midline = good. Boggy (soft) fundus = uterine atony, the #1 cause of postpartum hemorrhage. Massage immediately. Displaced to one side = full bladder — have the patient void.
What is postpartum hemorrhage and how is it managed?
Postpartum hemorrhage = blood loss > 500 mL vaginal delivery, > 1,000 mL C-section, or any significant drop in H&H. Causes: 4 T's — Tone (uterine atony, #1), Trauma (lacerations), Tissue (retained placenta), Thrombin (coagulopathy). First action for boggy uterus: fundal massage. Then oxytocin (Pitocin), other uterotonics (methylergonovine, carboprost, misoprostol), IV fluids/blood, possible surgery.
What is postpartum depression and how is it different from baby blues?
Baby blues = mild, transient mood swings, tearfulness, anxiety in the first 2 weeks — affects ~80% of new mothers, resolves on its own. Postpartum depression = lasts > 2 weeks, more severe — persistent sadness, hopelessness, inability to bond, sleep/appetite disturbance, thoughts of harm to self or baby. Requires treatment (therapy, sometimes SSRIs). Postpartum psychosis is rare but emergent — hallucinations, delusions, risk of harm to baby — immediate hospitalization.
What are the signs of a postpartum DVT?
Pregnancy and postpartum are hypercoagulable states — DVT risk is elevated. Watch for: unilateral leg pain, swelling, warmth, redness, or a positive Homans sign (calf pain on dorsiflexion of the foot — though Homans is no longer considered reliable on its own). If suspected: stop ambulation, elevate the leg, notify the provider. Diagnosis by Doppler. Treatment: anticoagulation. Pulmonary embolism is the worst-case complication.
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Postpartum Care Cheatsheet
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