BUBBLE HE · Postpartum Maternal Assessment Acronym

The second “B” in BUBBLE HE stands for bowels. Assessing bowel function is an essential aspect of postpartum care. Postpartum women may experience a temporary decrease in gastrointestinal (GI) tone and motility, which typically returns to normal by the end of the second postpartum week. Several factors contribute to the risk of constipation during this period, including decreased GI motility, reduced physical activity, dehydration and fluid loss from labor, perineal pain, and trauma. To prevent constipation and ensure proper bowel function, stool softeners may be advised. This precaution minimizes the increase of intraabdominal pressure, which can cause pain or disrupt the healing of an episiotomy (i.e., surgical incision made in the perineum, the area between the vagina and the anus, during childbirth to enlarge the vaginal opening and facilitate delivery) or C-section incision. Additionally, increased fiber intake and hydration are crucial for maintaining bowel regularity. Constipation and pregnancy can increase the risk of hemorrhoids, or swollen veins in the lower rectum. Although they typically resolve slowly, hemorrhoids can be quite painful. Management strategies include using topical treatments, sitz baths (i.e., warm, shallow bath), and laxatives to ensure bowel movements are effortless and do not cause discomfort. 

The “L” in BUBBLE HE stands for lochia, which refers to the vaginal discharge consisting of blood, mucus, and uterine tissue identified after childbirth, typically lasting a total of 6 weeks. Lochia progresses through three stages, differing in color and composition. The initial stage, lochia rubra, is characterized by bright red discharge that may contain small blood clots and typically lasts 1 to 3 days postpartum. This is followed by lochia serosa, marked by pink-brown, serous (i.e., watery) discharge, lasting 4 to 10 days postpartum. The final stage, lochia alba, features a yellow-white discharge containing white blood cells and the lining of the uterus, usually persisting 10 to 14 days. 

When assessing lochia, it is essential to evaluate its color, odor, and amount. The lochia should transition forward in stage, moving from rubra to serosa to alba, and should not regress to a previous stage in terms of color and composition. Any strong odor could be indicative of an intrauterine infection and further investigations may be necessary. Postpartum hemorrhage is clinically defined as a pad being filled with lochia within 15-30 minutes due to heavy bleeding and requires immediate medical attention.  

The first "E" stands for episiotomy, which refers to vaginal tearing of the perineum during childbirth or the surgical incision that may be made to facilitate delivery. The REEDA assessment is used to evaluate the episiotomy site or perineal tear. The acronym represents redness, edema (i.e., swelling), ecchymosis (i.e., bruising), discharge, and approximation of the wound edges. 

To perform a thorough perineal area assessment, the healthcare provider may gently pull the labia from front to back to inspect the episiotomy or tear sites. They may check for the collection of blood between tissues and assess for hemorrhoids, which can develop during pregnancy or as a result of the pushing process during labor. Monitoring and managing the episiotomy site and perineal area are crucial for preventing complications such as infection and for ensuring proper healing.  

The “H” stands for Homan sign in the postpartum assessment. It is a clinical assessment tool used to detect signs of deep vein thrombosis (DVT), a serious condition where a blood clot forms in the deep veins of the leg. The Homan test is performed with the individual’s knee in a flexed position. The examiner then forcefully and abruptly dorsiflexes the individual’s ankle. If pain is felt in the calf, Homan sign is considered positive, indicating the possibility of DVT. Other signs of DVT include sudden, unexplained pain in the back of the leg or calf, tachycardia, shortness of breath, localized edema, redness, and warmth over the affected area. 

To minimize the risk of DVT, early mobilization is encouraged. The postpartum patient should dangle her legs at the side of the bed within six hours of birth and stand up within eight hours. Progressive mobilization, starting with assistance and advancing to independent walking when ready, is essential. Potential complications of DVT include pulmonary embolism (PE), a life-threatening condition where a clot travels to the lungs, necessitating immediate medical intervention. 

The second "E" stands for the emotional status of the postpartum individual. Emotional fluctuations in the postpartum period are often attributed to the dramatic changes in estrogen levels. Additional factors contributing to this state include high stress levels, increased responsibility, and sleep deprivation. Observing how a mother takes care of herself, and her baby is an essential indicator of her emotional status. Common postpartum assessment findings are categorized into three phases. 

The Taking-In Phase occurs during the first 24 to 48 hours after birth. During this time, the postpartum patient is primarily focused on personal comfort and physical changes. They may often re-live and talk about their birth experience and start to adjust to the psychological changes that accompany motherhood. The Taking-Hold Phase follows as a transition from dependent to independent behaviors and can last for several weeks. During this phase, the parent’s focus shifts to the infant. They begin to exhibit more independence and decision-making, demonstrating a growing confidence in their new role. The Letting-Go Phase involves the movement from independence to fully embracing the new role of a parent. It often overlaps with the taking-hold phase. This period is characterized by the postpartum patient integrating the new identity and responsibilities. A delay or difficulty in transitioning through these phases may indicate that the postpartum patient is experiencing challenges in adjusting to parenthood. 

Recognizing and supporting these emotional and bonding stages are critical in the postpartum period to ensure the postpartum patient’s mental health and the development of a strong parent-infant bond. Healthcare providers, such as postpartum nurses, should be attentive to signs of postpartum depression , also known as “baby blues”, or anxiety and provide appropriate interventions and support to promote the well-being of both the postpartum patient and the baby.