Part of the ICU Emergencies Hub — browse every related guide in one place.
BUBBLE-HE is the systematic framework for postpartum assessment, ensuring no system is missed on each assessment. Perform every 15 minutes for the first hour, every 30 minutes for the next hour, then hourly.
| Letter | System | What to Assess |
|---|---|---|
| B | Breasts | Engorgement (none expected until day 3–4), nipple integrity (cracks, blisters, pain), colostrum presence, breastfeeding latch if applicable |
| U | Uterus | Fundal height (should be at or 1 cm below umbilicus immediately post-delivery, descending 1 cm/day), uterine firmness (firm = well-contracted; soft/boggy = atony → immediate uterine massage) |
| B | Bladder | Voiding — first void should occur within 4–6 hours; monitor for urinary retention (distended bladder displaces uterus and contributes to atony); bladder distension is a major contributor to postpartum hemorrhage |
| B | Bowel | Bowel sounds, last bowel movement, hemorrhoids (common post-delivery), constipation (common due to pain medications, perineal discomfort inhibiting pushing) |
| L | Lochia | Character, color, and amount (see table below); odor (foul odor suggests infection); presence of clots (>golf ball size is abnormal) |
| E | Episiotomy/Laceration | REEDA scale (Redness, Edema, Ecchymosis, Discharge, Approximation); perineal integrity, hemorrhoids |
| H | Homan's sign / Homans | DVT assessment (note: Homan's sign — calf pain on dorsiflexion — is neither sensitive nor specific; assess for calf warmth, redness, and tenderness; postpartum patients are at high DVT risk) |
| E | Emotion | Mood, affect, bonding with infant, Edinburgh Postnatal Depression Scale screening; "baby blues" (days 1–5, transient) vs postpartum depression (persists beyond 2 weeks, requires intervention) |
| Stage | Timing | Color | Character |
|---|---|---|---|
| Lochia rubra | Days 1–4 | Bright to dark red | Blood, decidua, and fetal debris; heaviest flow; 1 pad per hour maximum is normal |
| Lochia serosa | Days 4–10 | Pink to brownish | Serous fluid, old blood, leukocytes; lighter than rubra |
| Lochia alba | Days 10–6 weeks | Yellowish white | Leukocytes and decidual cells; minimal flow |
Postpartum hemorrhage is defined as blood loss greater than 500 mL after vaginal delivery or 1,000 mL after cesarean delivery (or any blood loss causing hemodynamic instability). It is the leading cause of maternal mortality worldwide and affects approximately 1–5% of deliveries.
The "4 T's" of PPH causes: Tone (uterine atony — the most common cause, 70–80% of PPH; uterus fails to contract after placenta delivers); Trauma (lacerations to cervix, vagina, perineum, or uterus); Tissue (retained placental tissue or membranes preventing uterine contraction); Thrombin (coagulopathy — less common but present in placental abruption, DIC, pre-existing coagulopathy).
Uterine atony nursing response: Perform fundal massage immediately — place one hand on the lower uterine segment above the pubic symphysis (to support the uterus and prevent inversion), and massage the fundus with the other hand using a firm circular motion. A well-contracted uterus feels like a firm ball; a boggy uterus feels soft and doughy. If the uterus does not firm up within 15 seconds of massage, call the provider immediately. Ensure the bladder is empty (bladder distension is the #1 correctable cause of uterine atony). Administer uterotonic medications per order (oxytocin is first-line).
Uterotonic medications:
| Drug | Route | Clinical Notes |
|---|---|---|
| Oxytocin (Pitocin) | IV infusion or IM | First-line; causes uterine contraction; IV rapid bolus causes hypotension — give as infusion not IV push |
| Methylergonovine (Methergine) | IM (never IV push — hypertensive crisis) | Contraindicated in hypertension or preeclampsia — causes vasoconstriction and severe BP elevation |
| Carboprost (Hemabate) | IM | Prostaglandin F2-alpha; contraindicated in asthma (causes bronchospasm) |
| Misoprostol | Rectal, sublingual, or vaginal | Can be used when IV access unavailable; causes fever as side effect |
Preeclampsia can develop or worsen in the postpartum period — up to 6 weeks after delivery. New-onset hypertension (BP ≥140/90 on two readings 4 hours apart) with proteinuria or severe features after delivery is postpartum preeclampsia. Signs of severe features: headache unresponsive to acetaminophen, visual changes, right upper quadrant pain, BP ≥160/110. Eclamptic seizures can occur postpartum even in women without antepartum preeclampsia diagnosis.
Monitor BP every 4 hours for the first 24 hours after delivery in all patients, and for 72 hours in patients with antepartum hypertension. Magnesium sulfate seizure prophylaxis is commonly continued for 24–48 hours postpartum in patients with preeclampsia with severe features. Monitor for magnesium toxicity (absent DTRs, respiratory depression) and maintain calcium gluconate at the bedside.
Baby blues (tearfulness, mood lability, anxiety, occurring days 1–5 post-delivery) affects 50–80% of new mothers and resolves spontaneously within 2 weeks. Postpartum depression (PPD) is distinct: persists beyond 2 weeks, significantly impairs functioning, and requires treatment. The Edinburgh Postnatal Depression Scale (EPDS) is the standard 10-question screening tool — score ≥10 warrants further evaluation; question 10 (self-harm ideation) triggers immediate assessment regardless of total score.
Related guides: Vital signs | DVT and PE | Fluid and electrolytes
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