Postpartum Bubble E Assessment Notes (Comprehensive)

Hand Hygiene and Consent

Perform hand hygiene and apply appropriate PPE before entering the patient’s room.
Introduce yourself and ask for the patient’s full name and date of birth.
In a hospital setting, verify the accuracy of this information with the patient’s ID bracelet. If in a home or clinic setting, confirm that the patient’s information matches previous documentation or a Medicare card.
Explain to the patient what you will be doing.
Obtain consent: explain the procedure and ensure the patient understands they have the right to refuse at any point and can consent to continue.
Gather all relevant information before starting any physical assessment (full health history or focused postpartum history) and perform a PQRST IUA assessment as indicated.

Pre-assessment Preparations and Safety

Ensure patient comfort and privacy; provide time to use the bathroom before the exam.
Have the patient lie in bed with the head of the bed flat when examining the abdominal area; raise the bed height as needed for your own ergonomics and to protect your back.
Ensure appropriate lighting and a private space.

Bubble E Assessment Overview

Bubble E stands for: breast, uterus, bowels, bladder, lochia, legs, episiotomy, and emotional state.
Order of assessment: bowels should be auscultated before bladder or uterus to complete bowel sounds assessment.
Always obtain consent and explain each step before palpation or exposure.
Skin-to-skin contact and direct skin examination are required for all physical assessments.

Breast Examination

Apply gloves if contact with bodily fluids is anticipated.
Observe symmetry and skin color for changes or signs of infection; no redness present and skin color uniform.
Inspect nipples for inversion, erection, or flatness; breastfeeding plans may affect nipple presentation.
If breastfeeding, consider lactation consultant referral for inverted or flat nipples or breast concern.
Nipple condition: in the example, nipples are erect; skin around nipples intact and not cracked.
Before palpation, ask the patient if the breasts are sore.
Ask the patient to report tenderness during palpation.
Palpate both breasts starting near the center and moving outward in a circular pattern; include the axilla during palpation.
Assess for lumps, nodules, masses; determine whether breasts feel soft or firm.
In the immediate postpartum period, breasts are usually soft for the first 1–2 days and may firm before softening again; patient denied tenderness throughout palpation.
Privacy: cover the patient after palpation to maintain dignity.
Practical note: document any tenderness, lumps, nipple condition, and plan for lactation support if needed.

Bowel and Abdomen Assessment

Ensure the patient has been urinating regularly since delivery; ensure the patient is flat in bed during bowel assessment and subsequent bladder and uterus assessments.
Gather information about usual elimination patterns to assess baseline.
Ask about laxative use during pregnancy and whether continued postpartum.
Query last bowel movement; if delivery occurred the same day, expect a bowel movement within ~ $2-3$ days; if none, assess pass gas.
Inquire about perineal pain that may cause fear of voiding or defecation.
Auscultate bowel sounds with the diaphragm of the stethoscope in all four quadrants, starting at the right lower quadrant and moving clockwise.
Normal bowel sounds: $5-30\ \text{bowel sounds per minute}$ .

Bladder Assessment

Ask whether the patient has voided since delivery and when the last void occurred.
If the patient had an epidural, assess for urinary retention.
Expect voiding within $6 ext{-}8\ \text{hours}$ after delivery.
Inquire about dysuria, increased frequency, urgency, and foul odor, which can be signs of a urinary tract infection (UTI).
Note that UTIs take time to develop postpartum; symptoms may reflect lacerations or irritation rather than infection immediately after birth.
Ask about urine color; it should be a clear yellow.
Palpate the bladder for distention if indicated.
If the patient has just voided, the bladder should not be palpably distended.

Uterus Assessment

With the patient supine and flat, assess the uterus after delivery.
The uterus immediately begins shrinking post-delivery; height decreases by approximately $1 ext{-}2\ \text{cm per day}$ .
Technique: place one hand at the symphysis pubis and the other hand above the umbilicus; slide hands downward until you feel the fundus (top of the uterus).
Fundus position within 24 hours postpartum should be at the level of the umbilicus (notation: $U/U$ ). If the fundus is one centimeter above the umbilicus, this is noted as $1/U$ , and if it is two centimeters below the umbilicus, this is noted as $U/2$ .
The fundus should be midline and not deviated to the right or left (which could indicate a full bladder).
The fundus should feel firm; a boggy fundus indicates uterine atony and risk for hemorrhage; management includes fundal massage as a nursing intervention.

Lochia Assessment

Apply gloves as lochia assessment involves bodily fluids.
Have the patient show the pad and ask when it was last changed and how frequently they are changing it.
Record the color of lochia: in this case, lochia is rubra (dark red), which is normal within the first 1–2 days postpartum.
Record the amount: scant, light, moderate, or heavy. In this case, the amount is moderate.
Definition notes:
- Rubra: dark red; serosa: brownish-red or pink; alba: yellowish-white.
- Serosa is common from ~4–10 days postpartum; alba typically appears after ~10 days postpartum.
Monitor progression toward lighter color; different pad brands absorb differently.
Turn the patient to the side to check for leakage or pooling under sheets.
Question about foul odor, which may indicate infection.
Encourage pad changes with every bathroom visit to reduce infection risk.
Note or ask about blood clots: clots are common, but clots larger than a golf ball are concerning. If unsure whether a clot is placenta or a clot, rub the clot or run it under water: if it dissolves, it is a clot; if it stays solid, it may be placental tissue.
For cesarean section patients, inspect the incision site for swelling, redness, drainage, or discharge; ensure edges of the incision are well approximated and sutures intact.

Perineal Area and Episiotomy/Incision Check

Inspect the perineal area for tears or episiotomy; have the patient turn to the side to visualize the whole area.
In the example, there is minimal swelling and redness, which is normal for a fresh laceration; no drainage.
Check that wound edges are well approximated and intact if sutures are present.
Ask about pain in the perineal area.
Palpate for discomfort in the perineal region.
Inspect the rectal area for hemorrhoids; record color and number.
In this case, hemorrhoids are dark red and five hemorrhoids are present.

Legs and Vascular Risk Assessment

Remove gloves and wash hands after touching the pad and perineal area.
Inspect the legs for redness; ask about tenderness during palpation.
Skin temperature should be warm and bilaterally equal; observe for edema.
No pitting edema is present; some edema can be normal and should improve over time.
Be alert for signs of deep vein thrombosis (DVT): tender, red, hot area with pitting edema.

Emotional State and Mental Health

Assess the patient’s general mood and fatigue after delivery.
Explain that it is common to feel tired but the patient should be able to care for herself and the infant.
Provide education throughout the assessment about abnormal findings and red flags (e.g., color and amount of lochia, signs of UTI).
Educate about postpartum blues: characterized by sadness or tearfulness within $3 ext{-}14\ \text{days}$ postpartum, typically resolving by the second or third week.
If symptoms worsen (e.g., inability to care for herself or infant, disinterest in the infant), or last longer than $3\ \text{weeks}$ , this could indicate postpartum depression; seek help immediately.

Post-assessment Nursing Care Priorities, Teaching, and Collaboration

Identify nursing care priorities based on findings from history and physical assessment.
Provide relevant teaching and nursing interventions to support the patient and infant.
Identify strengths and challenges from the information gathered and tailor care plan accordingly.
Include follow-up instructions that reflect a collaborative approach with the patient; ensure mutual understanding of next steps.
Thank the patient and invite questions to confirm understanding.
Ensure the patient is comfortable and has the call bell within reach in a hospital setting.
Bring the bed to the lowest position after completing the assessment.
In a hospital setting, you may raise bed rails if needed for safety.
Always perform hand hygiene after contact with the patient and their environment.

Practical and Ethical Considerations

Emphasize patient autonomy: consent can be withdrawn at any time; respect patient preferences (e.g., breastfeeding intent, privacy).
Maintain privacy and dignity during all assessments (exposure minimized, covered when possible).
Document findings clearly and accurately to guide ongoing care and potential referrals (lactation consultant, physical therapy for diastasis, mental health resources).
Provide consistent education about warning signs and when to seek care (e.g., heavy lochia, foul odor, fever, severe pain, signs of DVT, mental health concerns).
Coordinate care with obstetric, nursing, and lactation services to ensure a cohesive care plan.

Quick Reference: Key Numbers and Notations

Normal bowel sounds: $5\text{-}30\ \text{per minute}$
Fundal height change: $1\text{-}2\ \text{cm/day}$ lowering post-delivery
Fundus position notations:
- $U/U$ : fundus at the level of the umbilicus
- $1/U$ : fundus 1 cm above the umbilicus
- $U/2$ : fundus 2 cm below the umbilicus
Timeframes:
- First 24 hours postpartum: fundus at $U/U$
- Postpartum blues: $3\text{-}14\ \text{days}$ postpartum; typically resolves by $2\text{-}3\ \text{weeks}$
- Voiding expected within $6\text{-}8\ \text{hours}$ after delivery

Documentation and Communication

Record each assessment finding with objective descriptions (color, amount, location, consistency).
Note any interventions performed (e.g., fundal massage) and patient responses.
Provide clear written and verbal instructions for follow-up, including when to contact care providers and how to access lactation or mental health resources.
Confirm patient understanding by asking to summarize the plan and encouraging questions.

Safety and Hygiene Reminders

Always wash hands after patient contact and after removing gloves.
Ensure bed rails and bed position safety as appropriate for the setting.
Keep the patient covered and maintain modesty throughout the examination.
Sanitize any equipment used during the examination (stethoscope, gloves, etc.).