🧠 Postpartum Assessment & Complications
BUBBLE-HE, what each letter is actually looking for, and the three postpartum mood disorders that are not the same thing.
⭐ BUBBLE-HE
| Letter | Assess | Normal |
|---|---|---|
| Breasts | Soft, filling, engorged; nipples intact | Milk in day 3–5 |
| Uterus | Firm, midline, descending | ~1 cm lower per day |
| Bladder | Emptying fully; not distended | Void within 6–8 h |
| Bowels | Sounds, first movement, flatus | BM in 2–3 days |
| Lochia | Amount, color, clots, odor | Rubra → serosa → alba |
| Episiotomy | REEDA | Mild edema, no discharge |
| Homans / legs | Calf pain, warmth, swelling | DVT risk is raised |
| Emotional | Mood, bonding, support | Some tearfulness normal |
REEDA = Redness, Edema, Ecchymosis, Discharge, Approximation.
🧠 The fundus tells you most
Immediately after birth it should be firm, midline, at or just below the umbilicus.
- Boggy → massage → empty bladder → reassess
- Deviated to the right and high → full bladder
- Not descending → think retained fragments or infection
Always support the lower uterine segment with one hand while massaging with the other, or you risk inverting the uterus.
🚨 Postpartum complications
| Complication | Recognize by | Key point |
|---|---|---|
| Hemorrhage | Boggy uterus, saturating a pad in <1 h | Massage first; pulse rises before BP falls |
| Endometritis | Fever after 24 h, foul lochia, uterine tenderness | Antibiotics; a fever in the first 24 h is often dehydration |
| UTI | Frequency, burning, suprapubic pain | Catheterisation in labor raises risk |
| Mastitis | Red wedge on one breast, flu-like, fever | Keep breastfeeding + antibiotics |
| DVT / PE | Unilateral calf pain and swelling; sudden dyspnea and chest pain | Pregnancy is a hypercoagulable state |
| Hematoma | Severe perineal pain with a firm uterus and little visible bleeding | Bulging bluish mass; report |
Homans sign is no longer recommended as a DVT test - it can dislodge a clot. Assess for unilateral pain, warmth, swelling and redness instead.
Severe perineal pain with a firm uterus is a hematoma, not normal soreness. That distinction is a favorite question.
💐 The three mood disorders
| Baby blues | Postpartum depression | Postpartum psychosis | |
|---|---|---|---|
| Onset | Days 3–5 | Weeks to months | Usually first 2 weeks |
| Duration | Up to 2 weeks | Months if untreated | Emergency |
| Picture | Tearful, mood swings, still functioning | Hopeless, guilty, cannot function, may not bond | Hallucinations, delusions, thoughts of harming self or baby |
| Treatment | Support, reassurance, rest | Therapy, medication, screening | Psychiatric emergency, hospitalization |
Postpartum psychosis is a psychiatric emergency. The infant must not be left alone with her, and she needs immediate psychiatric care.
Ask directly about thoughts of harming herself or the baby. Asking does not plant the idea, and it is the only way to find out.
Baby blues is normal and self-limiting. The distinguishing question is always duration and function: still coping and improving by two weeks = blues; worsening or unable to function = depression.
🎯 NCLEX traps
- Fever after 24 hours = infection. In the first 24 h, suspect dehydration
- Severe perineal pain + firm uterus = hematoma
- Do not use Homans sign
- Blues resolve by 2 weeks; beyond that, screen for depression
- Psychosis = emergency, never leave her alone with the baby