Editing Maternal and Newborn Nursing (section)

=== Systematic assessment: BUBBLE-HE ===

'''B'''reasts, '''U'''terus, '''B'''ladder, '''B'''owel, '''L'''ochia, '''E'''pisiotomy or perineum, '''H'''oman sign and lower extremities or VTE risk, '''E'''motional status. Many facilities add pain and Rh or rubella status.

* '''Uterus''': the fundus should be '''firm, midline, and at or near the umbilicus''' within a few hours of birth, then descend about 1 fingerbreadth (1 cm) per day, becoming nonpalpable by roughly 10 to 14 days. '''A boggy fundus is massaged first.''' A fundus that is '''high and deviated to the right''' almost always means a '''full bladder''', which prevents contraction and causes bleeding; have the patient void, then reassess. Afterpains are stronger in multiparas, with breastfeeding, and with an overdistended uterus.
* '''Lochia''': '''rubra''' (dark red, days 1 to 3), '''serosa''' (pinkish-brown, days 4 to 10), '''alba''' (creamy white or yellow, day 11 through about 4 to 6 weeks). Small clots can be normal early. '''Abnormal: saturating a perimeter pad in 1 hour or less, a foul odor, large clots, bright red bleeding that returns after progressing to serosa, or lochia that is heavier when the fundus is firm''' (suggesting a laceration rather than atony). Always check underneath the patient; blood pools under the buttocks.
* '''Breasts''': assess for engorgement, nipple integrity, and mastitis (usually unilateral, localized redness, warmth, tenderness, fever, and flu-like symptoms). '''Mastitis is treated with antibiotics and continued emptying of the breast; the patient keeps breastfeeding or pumping.'''
* '''Bladder''': postpartum diuresis is normal and large. Watch for urinary retention with overflow (frequent small voids) especially after an epidural. Aim for voiding within about 6 to 8 hours of birth.
* '''Bowel''': constipation is very common. Fluids, fiber, ambulation, and a stool softener; a third- or fourth-degree laceration is a contraindication to suppositories and enemas.
* '''Perineum''': assess with the '''REEDA''' framework - '''R'''edness, '''E'''dema, '''E'''cchymosis, '''D'''ischarge, '''A'''pproximation. Ice for the first 24 hours, then sitz baths, peri-bottle rinsing front to back, topical anesthetics, and a donut cushion as needed. A '''hematoma''' presents as severe unrelieved perineal or rectal pain with a bulging bluish discolored area, and it can hide significant blood loss.
* '''Extremities''': assess for unilateral calf swelling, warmth, redness, and pain. Homan sign is unreliable and is no longer recommended as a diagnostic maneuver, but it appears in older material. Early ambulation and prophylaxis reduce VTE risk, which is elevated for weeks after birth.