This document provides an overview of the BUBBLE assessment for postpartum maternal care. BUBBLE is an acronym that stands for Breast, Uterus, Bladder, Bowels, Lochia, Homan's sign, and Episiotomy/perineum. For each component, the document describes how to assess for issues like breast engorgement, uterine atony, urinary retention, constipation, abnormal lochia, and perineal trauma. It emphasizes the importance of thorough assessment and interventions to promote maternal recovery and identify any postpartum complications.

2. ⚫BUBBLE- is a acronym used todenote the components
of the postpartum maternal nursing assessment.

3. The BUBBLE-
⚫B: Breast
⚫U: Uterus
⚫B: Bladder
⚫B: Bowels
⚫L: Lochia
⚫H: Homan’s
⚫E: Episiotomyand perineum

4. B: BREAST
⚫BREAST ASSESSMENT:
⚫Assessment includeevaluating the breast in the
postpartum period

5. ⚫The first step is to determine if the new mamma is
breastfeeding or bottle-feeding: This will guide the
assessmentalong with patienteducation

6. BREAST EVALUATION :
⚫Size
⚫Shape
⚫Firmness
⚫Redness
⚫Symmetry

7. BOTTLE-FEEDING: LACTATION
SUPPRESSION:
⚫Teach the motherabout breastengorgement. This
usuallyoccursabout 72 hours after birth
⚫The breastswill bevery tenderwith a feeling of
heaviness
⚫A firm, snug-fitting bra is ideal for thewomanwhose
not breastfeeding. Also this will help, engorgement
maystill occur

8. ⚫Iceand cabbage leavescan provide relief. There is an
enzyme in thecabbage leaves that helps
⚫Do notexpress milk as itwill encourageadditional
production
⚫Anywarmthoverthe breastsand stimulationof the
nipples will create a faucet-likeeffect

9. BREASTFEEDING:
⚫
⚫Focus on the nipple and areola. The nipple should be
erect, butsomeare flat or inverted. Hopefully, thiswas
identified during the pregnancy in order for shield to
be placed upon them.

10. ⚫Assess the nipples forsigns of bruising, crackling,
chapping. A deep crack or blister may indicate
incorrect placementoranother issue.
⚫Avoid placing wantcold packson the breasts

11. MASTITIS INFECTION:
⚫Nursing Considerations Mastitis is an infectionof the
breastsurrounding theducts that’scharacterized by
fullness, pain, warmth, and hardness of the breast. It’s
crucial todifferentiae infection from engorgement.

12. ⚫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 antibioticsand the patient is usually
encouraged tocontinue breastfeeding. The causeof
infection is associated with stagnant milk in theducts.
In mostcases, the milk is not infected; only theducts.

13. BREAST AND BOTTLE FEEDING

14. ⚫Thedecision to breastor bottle feed is highly personal.
While the benefits of breast milk nutritionally and
physiologically outweigh those of formula, it may not
always be possibleor in the best interestof the mom
and baby to breastfeed. The nurse’s role is to educate
the mom and support the family in whateverchoice is
made, not pass judgment.

15. BENEFITS OF BOTTLE FEEDING:
⚫Breastfeeding does notalways “come naturally” toall
moms- it may bedifficult forsome
⚫May beconsidered more sociallyacceptable towhip
out a bottle in the middle of a restaurant versus a
breast.
⚫May beeasier for momswhowork outsideof the
home.

16. DISADVANTAGES OF BOTTLE
FEEDING:
⚫Nopassive immunity
⚫Harder for baby todigest
⚫Expensive, especially if a specialized formula is needed
⚫Moreallergies
⚫Overfeeding iseasier
⚫Stool is moreodorous

17. BENEFITS OF BREAST FEEDING :
⚫Passive immunity
⚫Less incidentsof ear infections (formulapools into the
Eustachian tube)
⚫Easydigestibility
⚫Bonding between mom and baby
⚫Nocostand alwaysavailableand at the right
temperature

18. ⚫Forthe foodies: Some mother mayenjoy being able
toeatan extra 500 calories/day.
⚫Benefits to mother: Release of oxytocin (the “let-
down”) causes the uterus tocontract, which promotes
quickerreturn to pre-pregnancy weight. Italso
decreases risksof ovarian and breastcancer.

19. BREASTFEEDING TEACHING

20. ⚫Positioning: Holds- chest to chest or tummy to
tummy in someway, grab underthe breasts and push
down and out (taking the milk ducts and pushing it
forward, makea C-Hold around theareola (pull back,
down, and forward while bringing forward).

21. ⚫Geta nice big dropof colostrumon the nipple
⚫Tickle the lipwith nipple, shoveas much breastas
possible into the mouthonce it’sopen
⚫5 to 15 minutesa first topreventsoreness
⚫Startwith the breasts thatwas left from
⚫Try to feed every 2 hours

22. FORMULA TEACHING :
⚫Ready-to-feed: mostexpensive butconvenient
⚫Concentrate: do noteveradd morewateror
concentrate it Powder: followdirections per label
⚫Throw the bottlecontentsoutafter the feeding- do not
save for next feeding
⚫Startoff small byonly preparing 2 ouncesata time
⚫No need towarm formulaup.

23. 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. Massageof not firm- secure loweruterine
segment. The concern is for hemorrhage; the primary
causesarea distended bladderand retrained placental
fragments

24. ⚫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 onecentimeteror fingerwidth. The
position drops one centimeter every 24 hours for 10
days postpartum

25. ⚫3. MIDLINE OR DEVIATED TO THE LEFT OR
RIGHT: if deviated, it’s usuallya sign of a full bladder.
⚫ Uterine afterpains of a breastfeeding mom get worse
with each pregnancy
. The uterus is a muscleand the
more it is stretched, the more force is needed in order
tocontract.

26. ⚫NURSING CONSIDERATION: A boggy fundus may
bea sign of uterineatony, which places the patientat
risk fordeveloping a postpartum hemorrhage and
othercomplications.
⚫Also, fundal location that lies out of range with
anticipated locationaccording topostpartum status
may beanother indication.

27. ⚫The nurse should perform a uterine massage, which
promotes blood movementoutof the uterus, and also
encourage the patient tovoid, as a full ordistended
bladdercan impede uterine involutionand
contractions.
⚫The nurse is often in the positionas the first member
health care team to learn of these warning signs and
therefore must take swift action if an issue is
suspected.

28. B: BLADDER

29. ⚫BLADDER ASSESSMENT:
⚫Ask motherwhen she lastvoided
⚫Establish aVoiding Schedule to prevent bladder
distensionand urinary stasis
⚫Encourage mom tourinateevery time before she feed
baby (as they may fall asleep)

30. ⚫POSSIBLE OBSTACLES TO VOIDING:
⚫Mother may become soengrossed with baby thatshe
forgets tovoid
⚫Internal inflammation from labor trauma may impair
ability tovoid

31. ⚫Mother may hesitate tovoid from fearof pain,
especially if she has an episiotomyorvaginal tearing
⚫C-section patients mayalso have issuewith voiding
following removal of the folly.

32. ⚫ 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 faucetand occasionally mixed with an antisepticoranalgesic
solution if dered by the providerorpermitted by hospital policy
.
The contents are sprayed on the area following each void/bowel
movementto use ratherthan toilet paper
⚫ Teach motherto use Tuck’s Pads, which contain witch hazel
⚫ Dermaplast is a topical spray, may beapplied to helpcontrol pain
⚫ A straitcath may need to be used if mom doesn’tvoid within an
acceptable time (usually 12 hours postpartum)

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

34. B: BOWELS

35. ⚫BOWELS ASSESSMENT:
⚫Bowels in shock- just moved intosomestrange
positions.
⚫Takea stool softener- don’twant ripping or the
episiotomyor trauma to the C-section incision.

36. L: LOCHIA
⚫LOCHIAASSESSMENT:
⚫Assess thecolor, odor, and amount
⚫The lochiacolorshould forward in the progression of
lightness, nevergo backwards

37. ⚫ LOCHIA COLOR
⚫ LOCHIA RUBRA: Bright red, may havesmall clots,
usually lasts 3 days
⚫ LOCHIA SEROSA: Pink, serous, othertissues
⚫ LOCHIAALBA: Tissue, whitish

38. ⚫LOCHIA ODOR
⚫Lochia should have “noodor” 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 todescribe itas “foul”
.
⚫It’s important for the nurse to assess the odor to
eliminatesubjectivepatientdescriptionof the scent
⚫A truly foul odor or a change in odor may be a sign of
infection

39. ⚫LOCHIAAMOUNT:
⚫Scant = 2.5 centimeters saturation
⚫Light = < 10 centimeters saturation
⚫ Moderate = > 10 centimeters saturation.
⚫Heavy = pad is completelysaturated within 2 hours
⚫Postpartum hemorrhage is clinicallydefined as a pad
saturated within 15-30 minutes

40. ⚫ 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 foradditional evaluation.
⚫Scant saturation in the immediate postpartum period
can be just as concerning as excessive lochia
production. Clots: up tocherry sized areokay, peach or
plum sized is not. Clots are the most common in the
morning following the first void due to the saggy
textureof thevagina, which releases the lochia build-
up from the night.

41. E: EPISIOTOMY AND PERINEUM

42. REEDA Assessment
⚫R: Redness
⚫ E: Edema
⚫ E: Ecchymosis
⚫ D: discharge
⚫ A: approximation

43. PERINEAL AREA ASSESSMENT:
⚫Pull the labia from front to back
⚫Check the episiotomyorareas of vaginal tearing
⚫Look for hematoma formation- a collection of blood in
between tissue
⚫Look for hemorrhoids (developed during pregnancyor
during labor from the pushing process).

44. ⚫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

45. ⚫section incision
⚫HEMATOMA CARE :
⚫Startwith cold tostop the bleeding, once it stops,
begin warm
⚫Continue to monitor
⚫If itgetworse, thatactivearea of bleeding is non-
healing and itwill need to beopened and theactive
area is discovered and cauterized
⚫May notappearso much of an out-pouching as much
as a disfigurement.

46. ⚫HEMORRHOIDS:
⚫Vasculature that formsa pouch
⚫Colorcan match the skin of the rectal area and may
look more likea blood blisterwhen irritated
⚫Severe hemorrhoids appearas grape clusters
Dermaplastspray
⚫Patient may not be aware, mayonly known that
businessdown there is notas usual

47. ⚫ NURSING INTERVENTIONS:
⚫Seitz Bath: a rotating fluid that moves thewater. May
fit overthecommodeoronecan 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.

48. H: HOMAN’S SIGN
⚫Assess for Signsof DVT by the Homan’s Sign
⚫A positive Homan’ssign is indicativeof DVT, although
it’s not the mostreliable indicator.
⚫All of thecharacteristic 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
postpartumwoman is at such a huge risk for DVT.

49. PERFORMING THE HOMAN’S TEST:
⚫Mostcommonlyperformed with the mom in a supine
positionwhile laying in bed
⚫Thecalf is flexed ata 90° angle
⚫The nurse manipulates the foot in a dorsiflexion
movement
⚫If pain is felt in thecalf, the Homan’s Sign is said to be
positive.

50. SIGNS OF DVT:
⚫A sudden and unexplainable pain, usually in the back
of the leg orcalf
⚫Tachycardiaand shortnessof breath ordyspnea (from
decreased oxygenation status)
⚫Edema, redness, and warmth localized overthearea of
the DVT (from thevascular builduparound theclot)

51. PREVENTING A DVT:
⚫Dangleat the side of the bed within 6 hours
⚫Stand upwithin 8 hours
⚫Encourageambulationat first and independent
walking when ready

52. POTENTIAL COMPLICATIONS OF A
DVT:
⚫Pulmonaryembolism (PE) occurswhen a clot breaks
way from the leg areaand travels to the lungs.
⚫A PE is medical emergency.

53. E: EMOTIONAL STATUS
⚫Emotional Statusand Bonding Patterns
⚫Fluctuations in estrogen levels are blamed for the
emotional roller-coasterthat many momsexperience
after birth.
⚫High levelsof stress, increased responsibility, and
sleepdeprivation exacerbate this

54. ⚫Bonding refers to the interactions between the
mammaand baby
⚫Care giving of self and baby is an indicatorof
emotional status

55. 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 mother, a
little about the baby. The world appears to be revolved
around the babyand mammaas an unit.
⚫ Letting-In Phase; Motherallowsotherpeople in.

56. COMPARING BLUES,
DEPRESSION, AND PSYCHOSIS

57. ⚫POSTPARTUM BLUES: Usuallyoccurswithin 2-3
weeks. Mamma may be sensitive, such as crying
during a commercial, mamma mayview itas
humorous in hindsight.

58. ⚫POSTPARTUM DEPRESSION (PPD): When the
blues moves to the pointwhere mommacan’t care for
herself or the baby.

59. ⚫ POSTPARTUM PSYCHOSIS: A severe form of
depression thatwarrants immediate intervention.
When mamma harms herself or the neonate or
considers doing so. Typically is predicated by
depressiveepisodes.

60. NURSING INTERVENTIONS:
⚫The patientshould fill outa form toassess emotional
risks. The form will ask if the patient has a history of
PPD ordepression notassociated with pregnancy.
⚫There’salways a social workeravailable in theevent
that the patient is acting strangely. The nurse may
need to fill outadocumentsuch as a Risk Assessment
Form

61. THANK YOU