Key Takeaways
- BUBBLE-HE guides postpartum assessment: Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy/incision, Homan's sign, Emotional status
- The uterine fundus should be firm, midline, and at or below the umbilicus; a boggy uterus indicates atony requiring fundal massage
- Lochia progresses from rubra (red, days 1-3) to serosa (pink/brown, days 4-10) to alba (white/yellow, days 10-14+); return to rubra after progression is abnormal
- Postpartum hemorrhage is defined as blood loss >500 mL vaginal or >1,000 mL cesarean; uterine atony is the most common cause
- Postpartum blues (days 3-14) are normal; symptoms lasting >2 weeks or severe symptoms indicate postpartum depression requiring intervention
Last updated: January 2026
Postpartum Care Overview
The postpartum period (puerperium) begins with delivery of the placenta and extends through 6 weeks. During this time, maternal physiology returns to the pre-pregnant state, breastfeeding is established, and the family adjusts to the newborn.
BUBBLE-HE Assessment Framework
BUBBLE-HE provides a systematic approach to postpartum assessment:
| Letter | Assessment | Key Points |
|---|---|---|
| B | Breasts | Engorgement, nipple condition, milk supply |
| U | Uterus | Fundal height, firmness, position |
| B | Bladder | Voiding, distension, output |
| B | Bowel | Bowel sounds, first stool, hemorrhoids |
| L | Lochia | Color, amount, odor, clots |
| E | Episiotomy/Incision | Healing, redness, edema, discharge |
| H | Homan's sign | DVT assessment |
| E | Emotional status | Bonding, mood, support system |
Breasts
Assessment
- Soft, filling, or engorged?
- Nipple condition (intact, cracked, inverted?)
- Colostrum or milk production
- Signs of mastitis (redness, warmth, fever)?
Normal Progression
| Timeframe | Finding |
|---|---|
| Days 1-2 | Colostrum (yellow, thick, antibody-rich) |
| Days 3-4 | Transitional milk; engorgement may occur |
| Day 10+ | Mature milk established |
Engorgement Management
- Frequent breastfeeding (8-12 times/24 hours)
- Warm compresses before feeding
- Cold compresses after feeding
- Hand expression to soften areola
- Supportive bra
Uterus
Normal Involution
The uterus should be:
- Firm (like a grapefruit)
- Midline (not deviated to the side)
- At or below umbilicus (descends ~1 cm/day)
Fundal Height Progression
| Day Postpartum | Fundal Position |
|---|---|
| Immediately after birth | At umbilicus |
| Day 1 | 1 cm above umbilicus |
| Day 3 | 3 cm below umbilicus |
| Day 10 | At symphysis pubis (not palpable) |
Boggy Uterus (Atony)
A boggy (soft, relaxed) uterus indicates atony and risk for hemorrhage.
Immediate Intervention:
- Massage the fundus until firm
- Express clots (if present)
- Encourage breastfeeding (releases oxytocin)
- Monitor vital signs
- Notify provider if massage ineffective
- Administer uterotonic medications as ordered (Pitocin, Methergine)
Bladder
Assessment
- Time of last void
- Voiding difficulty
- Urine output (should be >150 mL per void initially)
- Bladder distension (may displace uterus)
Common Issues
| Problem | Intervention |
|---|---|
| Urinary retention | Run water, warm sitz bath, catheterize if needed |
| Bladder distension | Assess fundus (may be displaced), catheterize |
| Frequency/urgency | Normal initially; assess for UTI if persists |
Key Point: A full bladder can displace the uterus to the side, preventing proper contraction and increasing hemorrhage risk.
Bowel
Assessment
- Bowel sounds present?
- Passing flatus?
- First bowel movement (usually by day 2-3)?
- Hemorrhoids present?
Constipation Prevention
- High-fiber diet
- Adequate fluids
- Ambulation
- Stool softeners as ordered
- Do not strain (especially with episiotomy)
Hemorrhoid Management
- Sitz baths
- Witch hazel pads (Tucks)
- Topical anesthetics
- Ice packs initially
Lochia
Lochia is the vaginal discharge following birth, consisting of blood, mucus, and tissue.
Normal Lochia Progression
| Type | Color | Timeframe | Characteristics |
|---|---|---|---|
| Rubra | Red | Days 1-3 | Like heavy menstrual flow; small clots OK |
| Serosa | Pink/brown | Days 4-10 | Decreasing amount |
| Alba | White/yellow | Days 10-14+ | Minimal, mucoid |
Abnormal Findings
| Finding | Concern |
|---|---|
| Foul odor | Infection (endometritis) |
| Return to rubra after progression | Subinvolution, infection, retained tissue |
| Large clots (golf ball size or larger) | Hemorrhage |
| Saturating pad in 15 minutes | Hemorrhage |
| Lochia persisting >6 weeks | Subinvolution |
Episiotomy/Incision (REEDA)
Assess perineal healing using REEDA:
| Letter | Assessment | Normal | Abnormal |
|---|---|---|---|
| R | Redness | Mild at edges | Significant spreading |
| E | Edema | Mild | Severe swelling |
| E | Ecchymosis (bruising) | Mild | Extensive |
| D | Discharge | None | Purulent drainage |
| A | Approximation | Edges together | Gaping, dehiscence |
Comfort Measures
- Ice packs (first 24 hours)
- Sitz baths (after 24 hours)
- Topical anesthetics (Dermoplast spray)
- Peribottle for cleansing
- Kegel exercises
Cesarean Incision
- Assess for signs of infection (redness, warmth, drainage)
- Check approximation
- Keep clean and dry
- Splint incision when coughing or moving
Homan's Sign (DVT Assessment)
Homan's Sign: Pain in calf with dorsiflexion of foot
Note: Homan's sign is unreliable for DVT diagnosis. More importantly, assess for:
- Calf redness
- Warmth
- Swelling (unilateral)
- Tenderness
DVT Prevention:
- Early ambulation
- Leg exercises if on bed rest
- Adequate hydration
- Sequential compression devices if indicated
Emotional Status
Normal Adjustment
| Phase | Timeframe | Characteristics |
|---|---|---|
| Taking In | Days 1-2 | Passive, focused on self, retells birth |
| Taking Hold | Days 2-3 | More independent, ready to learn |
| Letting Go | Days 3+ | Adjusting to new role and reality |
Postpartum Blues vs. Depression
| Feature | Postpartum Blues | Postpartum Depression |
|---|---|---|
| Onset | Days 3-14 | 2 weeks to 12 months |
| Duration | Resolves by 2 weeks | Persists without treatment |
| Symptoms | Tearfulness, mood swings, anxiety | Hopelessness, guilt, inability to care for baby |
| Severity | Mild, self-limiting | May include suicidal ideation |
| Intervention | Support, reassurance | Professional treatment required |
Warning Signs Requiring Referral
- Symptoms lasting >2 weeks
- Inability to sleep when baby sleeps
- Thoughts of harming self or baby
- Inability to care for self or baby
- Severe anxiety or panic
- Hallucinations or delusions (postpartum psychosis - emergency)
Postpartum Hemorrhage
Definition
- Vaginal birth: Blood loss >500 mL
- Cesarean birth: Blood loss >1,000 mL
Most Common Cause: Uterine Atony
The Four T's of PPH:
| Cause | Description |
|---|---|
| Tone | Uterine atony (most common - 70%) |
| Trauma | Lacerations, hematoma, uterine rupture |
| Tissue | Retained placental fragments |
| Thrombin | Coagulation disorders |
Interventions for Atony
- Fundal massage
- Empty bladder (full bladder prevents contraction)
- IV Pitocin (first-line medication)
- Methergine (contraindicated in hypertension)
- Hemabate (contraindicated in asthma)
- Surgical intervention if unresponsive
Test Your Knowledge
The nurse assesses a postpartum client and finds a soft, boggy uterus displaced to the right of midline. What is the priority nursing action?
A
B
C
D
Test Your Knowledge
On postpartum day 5, a client has pink-brown vaginal discharge. The nurse recognizes this as:
A
B
C
D
Test Your Knowledge
A postpartum client reports feeling tearful, anxious, and overwhelmed on day 4. She is sleeping when the baby sleeps and is bonding well. What is the appropriate nursing response?
A
B
C
D