4.5 Postpartum Care (BUBBLE-HE)

NCLEX-RN Registered Nurse

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1 Introduction

About the NCLEX-RN Exam Next Generation NCLEX (NGN) Clinical Judgment Measurement Model (NCJMM) How to Use This Course

2 Chapter 2: Management of Care

2.1 Legal Rights and Responsibilities 2.2 Advance Directives and Self-Determination 2.3 Informed Consent Protocols 2.4 Client Advocacy and Rights (HIPAA) 2.5 Assignment, Delegation, and Supervision 2.6 Five Rights of Delegation 2.7 Scope of Practice (RN vs LPN vs UAP) 2.8 Ethical Practice Principles

3 Chapter 3: Safety and Infection Prevention and Control

3.1 Standard Precautions and Hand Hygiene 3.2 Transmission-Based Precautions (Contact, Droplet, Airborne) 3.3 PPE Donning and Doffing Sequences 3.4 Fall Prevention and Restraints 3.5 Fire Safety (RACE/PASS) 3.6 Disaster Triage and Emergency Response

4 Chapter 4: Health Promotion and Maintenance

4.1 Growth and Development (Erikson/Piaget) 4.2 Developmental Stages: Infancy through Older Adult 4.3 Maternal and Newborn Care (Antepartum) 4.4 Intrapartum Care and Fetal Monitoring 4.5 Postpartum Care (BUBBLE-HE) 4.6 Health Screening Guidelines 4.7 Immunization Schedules

5 Chapter 5: Psychosocial Integrity

5.1 Therapeutic Communication Techniques 5.2 Non-Therapeutic Communication (What to Avoid) 5.3 Anxiety Disorders and Mental Health Concepts 5.4 Schizophrenia: Hallucinations and Delusions 5.5 Depression and Suicide Assessment 5.6 Substance Misuse and Withdrawal 5.7 Grief and End-of-Life Care

6 Chapter 6: Basic Care and Comfort

6.1 Mobility and Hazards of Immobility 6.2 Assistive Devices (Crutches, Canes, Walkers) 6.3 Nutrition and Diet Therapy 6.4 Enteral Nutrition (Tube Feeding) 6.5 Bowel Elimination and Ostomy Care 6.6 Urinary Elimination and Catheter Care

7 Chapter 7: Pharmacological and Parenteral Therapies

7.1 Medication Administration Rights 7.2 Medication Calculations 7.3 High-Alert Medications: Insulins 7.4 High-Alert Medications: Anticoagulants 7.5 High-Alert Medications: Opioids 7.6 High-Alert Medications: Digoxin and Electrolytes 7.7 IV Therapy and Complications 7.8 Blood Product Administration 7.9 Total Parenteral Nutrition (TPN)

8 Chapter 8: Reduction of Risk Potential

8.1 Laboratory Values: Hematology (CBC) 8.2 Laboratory Values: Metabolic Panel (BMP) 8.3 Laboratory Values: Coagulation Studies 8.4 Vital Signs and Trend Recognition 8.5 Perioperative Care (Pre-Op and Post-Op) 8.6 Nasogastric Tubes and Therapeutic Procedures

9 Chapter 9: Physiological Adaptation

9.1 Fluid Imbalances (Hypovolemia and Hypervolemia) 9.2 Arterial Blood Gases (ABGs) and Acid-Base Balance 9.3 Medical Emergencies: Stroke (CVA) 9.4 Medical Emergencies: Myocardial Infarction (MONA) 9.5 Diabetic Emergencies (Hypoglycemia and DKA) 9.6 Respiratory Conditions (COPD, Pneumonia) 9.7 Cardiac Conditions (Heart Failure) 9.8 Neurological Conditions (Seizures)

4.5 Postpartum Care (BUBBLE-HE)

Key Takeaways Explain This Topic AI

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 definitions differ by body: ACOG uses cumulative blood loss ≥1,000 mL or blood loss with signs of hypovolemia within 24 hours of birth, and WHO (2025) uses ≥300 mL with an abnormal vital sign or ≥500 mL; 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: October 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

Definitions differ by organization, and the older route-based thresholds (more than 500 mL after vaginal birth or more than 1,000 mL after cesarean) are still widely taught:

ACOG (Practice Bulletin 183, 2017): cumulative blood loss ≥ 1,000 mL, or blood loss accompanied by signs or symptoms of hypovolemia, within 24 hours after birth, whatever the route

WHO (consolidated guideline, 2025): measured blood loss ≥ 300 mL with any abnormal sign (pulse > 100, shock index > 1, systolic BP < 100 mmHg or diastolic BP < 60 mmHg), or ≥ 500 mL, within 24 hours after birth

Most Common Cause: Uterine Atony

The Four T's of PPH :

Cause Description
Tone Uterine atony (most common cause)
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