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, such as those on a Medical-Surgical floor. 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

 H: Homan’s

 E: Episiotomy and perineum

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 bottle-feeding: This will
guide the assessment along with patient education

Breast Evaluation
 Size

 Shape

 Firmness

 Redness

 Symmetry

Bottle-Feeding Mom: Lactation Suppression

 Teach the mom about breast engorgement. This usually occurs about 72 hours after birth

 The breasts will be very tender with a feeling of heaviness

 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

 Do not express milk as it will encourage additional production

 Any warmth over the breasts and stimulation of the nipples will create a faucet-like effect

Breastfeeding Mom

 Focus on the nipple and areola. The nipple should be erect, but some are flat or inverted.
Hopefully, this was identified during the pregnancy in order for shield to be placed upon them

 Assess the nipples for signs of bruising, crackling, chapping. A deep crack or blister may
indicate incorrect placement or another issue

 Avoid placing want cold packs on the breasts

Mastitis Infection: Nursing Considerations

 Mastitis is an infection of the breast surrounding the ducts that’s characterized by fullness,
pain, warmth, and hardness of the breast. It’s crucial to differentiae infection from engorgement.
 Mastitis may involve fever, while localized symptoms are limited to specified area that usually
appears red and feels warm and possibly hardened

 Mastitis needs to be treated with antibiotics and the patient is usually encouraged to continue
breastfeeding. The cause of infection is associated with stagnant milk in the ducts. In most cases,
the milk is not infected; only the ducts

 The best way to feed is to start on the uninfected breast first. The mother should then switch
to the affected breast within a few minutes so this breast can be fully emptied and drained. The
infant is the best drainer- no breast pump can ever compare. The only time a breastfeeding mom
is asked to stop is when boils and/or cysts are present

Breast and Bottle Feeding

The decision to breast or bottle feed is highly personal. While the benefits of breast milk nutritionally
and physiologically outweigh those of formula, it may not always be possible or in the best interest of
the mom and baby to breastfeed. The nurse’s role is to educate the mom and support the family in
whatever choice is made, not pass judgment.

Benefits of Bottle Feeding

 Not solely a “Mom-only” responsibility

 Breastfeeding does not always “come naturally” to all moms- it may be difficult for some

 May be considered more socially acceptable to whip out a bottle in the middle of a restaurant
versus a breast

 May be easier for moms who work outside of the home

 Bonding ↔ dad and baby or other relatives who feed

Disadvantages of Bottle Feeding

 No passive immunity

 Harder for baby to digest

 Expensive, especially if a specialized formula is needed

 More allergies

 Overfeeding is easier

 Stool is more odorous

Benefits of Breast Feeding

 Passive immunity

 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

Breastfeeding Teaching

 Positioning: holds- chest to chest or tummy to tummy in some 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

Formula Teaching

 Ready-to-feed: most expensive but convenient

 Concentrate: do not ever add more water or concentrate it

 Powder: follow directions per label

 Throw the bottle contents out after the feeding- do not save for next feeding

 Start off small by only preparing 2 ounces at a time

 No need to warm formula up

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

Uterine afterpains of a breastfeeding mom get worse with each pregnancy. The uterus is a muscle
and the more it is stretched, the more force is needed in order to contract.

Nursing Consideration. 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.

Read more about uterine atony and postpartum hemorrhage treatment under the Perinatal
Complications Page

B: Bladder
Bladder Assessment

 Ask mom when she last voided

 Establish a Voiding Schedule to prevent bladder distension and urinary stasis

 Encourage mom to urinate every time before she feed baby (as they may fall asleep)

Possible Obstacles to Voiding

 Mom may become so engrossed with baby that she forgets to void

 Internal inflammation from labor trauma may impair ability to void

 Mom may hesitate to void from fear of pain, especially if she has an episiotomy or vaginal
tearing

 C-section patients may also have issue with voiding following removal of the folly

Nursing Interventions for Postpartum Bladder Care

 Peri-bottle- teach mom to always bring the bottle, which is used for perineal irrigation, to the
restroom to use rather than toilet paper; the bottle is filled with warm (NOT hot) water from the
faucet and occasionally mixed with an antiseptic or analgesic solution if ordered by the provider
or permitted by hospital policy. The contents are sprayed on the area following each void/bowel
movement to use rather than toilet paper
 Teach mom to use Tuck’s Pads, which contain witch hazel

 Dermaplast is a topical spray, may be applied to help control pain

 A strait cath may need to be used if mom doesn’t void within an acceptable time (usually 12
hours postpartum)

WARNING SIGNS: Perineal area is dark, moist, and bloody, especially when combined urinary
stasis

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

L: Lochia
Lochia Assessment

 Assess the color, odor, and amount

 The lochia color should forward in the progression of lightness, never go backwards

Lochia Color

 Lochia Rubra: bright red, may have small clots, usually lasts 3 days

 Lochia Serosa: pink, serous, other tissues

 Lochia Alba: tissue, whitish

Lochia Odor
 NCLEX: lochia should have “no odor” or “no foul odor”

 Real world: virtually all lochia has an unpleasant or at least a neutral odor associated with it
and moms may be quick to describe it as “foul”

 It’s important for the nurse to assess the odor to eliminate subjective patient description of
the scent

 A truly foul odor or a change in odor may be a sign of infection

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

 NCLEX world: The pad is saturated within 15 minutes to be considered a hemorrhage

situation. In the real world, a pad that becomes saturated within 30 minutes is a cause for
additional evaluation

 Scant saturation in the immediate postpartum period can be just as concerning as excessive
lochia production. Clots: up to cherry sized are okay, peach or plum sized is not. Clots are the
most common in the morning following the first void due to the saggy texture of the vagina, which
releases the lochia build-up from the night.

E: Episiotomy and Perineum

REEDA Assessment

 R: Redness

 E: edema
 E: ecchymosis

 D: discharge

 A: approximation. Read more about REEDA

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

Hematoma Care

 Start with cold to stop the bleeding, once it stops, begin warm

 Continue to monitor

 If it get worse, that active area of bleeding is non-healing and it will need to be opened and
the active area is discovered and cauterized

 May not appear so much of an out-pouching as much as a disfigurement

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 known that business down there is not as usual

Nursing Interventions. Seitz 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.

H: Homan’s Sign
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

 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

 Most commonly performed with the mom in a supine position while laying in bed

 The calf is flexed at a 90° angle

 The nurse manipulates the foot in a dorsiflexion movement

 If pain is felt in the calf, the Homan’s Sign is said to be positive

Signs of DVT

 A sudden and unexplainable pain, usually in the back of the leg or calf

 Tachycardia and shortness of breath or dyspnea (from decreased oxygenation status)

 Edema, redness, and warmth localized over the area of the DVT (from the vascular build-up
around the clot)

Preventing a DVT

 Dangle at the side of the bed within 6 hours

 Stand up within 8 hours

 Encourage ambulation at first and independent walking when ready

Potential Complications of a DVT

 Pulmonary embolism (PE) occurs when a clot breaks way from the leg area and travels to
the lungs

 A PE is medical emergency!

E: Emotional Status
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 exacerbate this

 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. May be considered as a self-focused, re-lived experience. This is

different from the maladaptive
 Taking Hold Phase. A little bit about the mamma, a little about the baby. The world appears
to be revolved around the baby and mamma as an unit

 Letting-In Phase. Mamma allows other people in

Comparing Blues, Depression, and Psychosis

 Postpartum Blues. Usually occurs within 2-3 weeks. Mamma may be sensitive, such as
crying during a commercial, mamma may view it as humorous in hindsight

 Postpartum Depression (PPD). When the blues moves to the point where momma can’t
care for herself or the baby

 Postpartum Psychosis. A severe form of depression that warrants immediate intervention.

When mamma harms herself or the neonate or considers doing so. Typically is predicated by
depressive episodes

Nursing Interventions

 The patient should fill out a form to assess emotional risks. The form will ask if the patient
has a history of PPD or depression not associated with pregnancy

 There’s always a social worker available in the event that the patient is acting strangely. The
nurse may need to fill out a document such as a Risk Assessment Form