Script for Assessment of a Postpartum Woman

using the mnemonic Bubble Pleb.

Good day, everyone! I am Reniel Agito, a student Nurse from Our Lady of Fatima
University- Cabanatuan City Campus. 

For today’s video, I will be performing an assessment of a postpartum woman Using the
mnemonic Bubble Pleb. Bubble Pleb stands for Breast and Chest, Uterus, Bladder,
Bowels, Lochia, Episiotomy/Lacerations, Pain, Lower and Upper Extremities, Emotional
Status, and Bonding and Attachment.  

As usual, it is important to perform hand hygiene by doing hand washing before the
actual process. Provide Privacy by closing all the windows and curtains, and identify
clients by using the two identifiers such as name and the date of birth. 

After that, we will be wearing gloves. 

Good day, ma’am. I am Reniel Agito, your student nurse for today. May I know your
name and date of birth please?

Great. Hello Mrs. Cruz, today I’ll be performing a postpartum head-to-toe assessment on
you. Would that be fine for you? 

Breast and Chest Assessment:

1. The first thing is to assess method of infant feeding. For first time breast feeders,
reassure them that although they do not see abundant amount of milk in the first 2-
3 days, they are making colostrum which is rich in nutrients and immunoglobulins,
to boost the infant’s immunity. 
2. Determine the amount and frequency of feedings and record it in the infant’s flow
chart. (May I know if how frequent you feed your infant and its quantity?) 
3. Encourage the mother to breastfeed after 2-3 hours for 10-20 minutes or for as
long as the infants wants. This will help establish and maintain milk production. 
4. If the mother is bottle feeding the infant, encourage her to not stimulate her breast
because this may cause her body think that she needs to make milk for her baby. 
5. Record and update the feedings in the infant’s flow chart, type the formula,
amount of formula taken, and at what time. Encourage the mother to breastfeed
every 3-4 hours. The mother is also encouraged to wear a well-supporting bra
ASSESSMENT OF BREAST 
We’re going to ask the mother on how do her breast feel. She can say variety of
complaints and changes, like heaviness, being full of milk, or she can say that hers is
normal and haven’t experienced any changes yet. 

With that information, we can now actually assess it. 

1. First, inspect it for symmetry, fullness/engorgement, and or erythema. Assess for

flat, retracted nipples and signs of trauma from breastfeeding such as redness,
blisters, and fissures. Also, check if there’s bruising or suck mark because if so,
then the baby doesn’t have a good latch. 
2. Palpate for engorgement, tenderness, and plugged ducts. Also, you might check
the temperature weather it is cool or hot. 
3. Take note that having asymmetrical shape and size of the breast is normal, might it
have different nipples either concave or not, or having a stretch mark. Also, breast
maybe initially soft during 1-2 days after delivery. Colostrum production also
happens during this time. During 2-4 days, the breast may feel fuller with milk and
warmer to touch because of vasocongestion. Small nodules because of a plugged
duct may be present as well. 
4. If a nodule persists despite of milk transfer, further evaluation is needed to rule out
fibrocystic changes or malignant disease. Cracked and bleeding is a sign of bad
latch. 
5. Encourage mother to use a well-supporting bra and properly fitted bra for lactation
suppression in mothers who choose not to breastfeed. If the mother is
breastfeeding, instruct on use a cotton nursing garment with flaps that open for
breastfeeding. 

ASSESSMENT OF CHEST

1. Auscultate. Listen to heart and lungs

2. Expected result is normal cardiac rate and rhythm and clear lungs. 
3. Abnormal finding is adventitious lung sounds that needs further evaluation to
prevent complications such as pulmonary embolism 
4. For c-section patients, instruct the patient to cough, turn and deep breath and use
an incentive spirometer to prevent fluid accumulation in the alveoli. After 12 hours
of surgery, and within a fee hours after vaginal delivery, the patient should be
encouraged to gradually ambulate to mobilize the fluids in the lungs. The nurse
should assist the patient getting out of bed for the first time and make sure she is
hemodynamically stable.

Uterus And Abdomen

Make sure the position of the mother is flat 

Expose the abdomen

One hand to support the bottom of the uterus and one to actually feel the fundus

If the mother just delivered today, feel the uterus at the midline section and it should be
the belly button. 

The fundus should be firmed, firmed with massge, or boggy. The firmness is depending
of the size of the mother. If the mother is skinny and tiny, her fundus is gonna be like
rock hard. The normal finding should he Firm like a tennis ball, hard but bounce-back. 

1. Inspect the abdomen for distention. If patient had a cesarean section or a

postpartum tubal ligation, assess the incision for redness, ecchymosis (pasa),
edema, drainage, approximation of skin edges (mnemonic: REEDA).
2. Auscultate for the bowel sounds in all four quadrants 
3. Palpation: Determine the descent of the uterus in relation to the umbilicus using
finger breadths as your measuring tool. For example, U-1 or U/1 means that the
uterus is 1 finger breadth below the umbilicus. Assess the firmness of the uterus
and its position in relation to the midline of the abdomen.
4. Percuss: If tympany (drum-like sound) is heard, this may be an indication that the
abdomen is filled with gas and causing patient discomfort.
5. Expected findings: The skin of the abdomen will appear loose and floppy. The
cesarean section or tubal ligation incision should look clean, dry, and intact.
Within 12 hours after surgery, bowel sounds may be hypoactive and will return to
normal active sounds within 12 to 24 hours. Abdomen is soft to palpation and
nontender. The uterus should be firm and not boggy, located midline of the
abdomen, and appropriately descended. Immediately after delivery, the fundus
should be approximately at the level of the umbilicus. Every 24 hours, the fundus
should descend approximately 1 to 2 cm. After 2 weeks, the uterus should lie
within the true pelvis and should not be palpable.
6. • Abnormal findings. A distended abdomen with hypoactive bowel sounds, and
no report of passing flatus 72 hours surgery, may be an indication of a paralytic
ileus and needs to be evaluated. A displaced uterus from the midline, commonly to
the right, is likely due to a distended bladder. Assist the patient to the bathroom to
empty her bladder and reassess the uterus after voiding. Uterine tenderness, foul-
smelling drainage, and an erythematous, tender, dehiscing incision may be signs of
an infection.

Bladder
Ask the mother if when is the last time she got up to go to the bathroom because it’s
common for postpartum women not to feel the urge to avoid even if their bladder is
completely full. 

If she says she haven’t gone to void, encourage her that every two to three hours, try to
go to the bathroom to void to prevent excessive bleeding, and pain. 

Expected findings: after a vaginal delivery, the mother usually void within first 6 hours
postpartum. An indwelling catheter is inserted before a cesarean section and it usually
remains after surgery at 12 hours when the patient can ambulate.

Abnormal findings: if patient is unable to void on her own, she may need to be
catheterized to empty bladder of urine. If the mother is experiencing pain while urinating,
accompanied with urgency and frequency because this maybe sign of urinary tract
infection and must be reported to the doctor. 

Patient Education: encourage the mother to pat dry from front to back after voiding.
Teach the patient to perform Kegel Exercise to strengthen her perineal muscle. 

Bowels: 
Listen to the four quadrant, including the left, lower left, right and lower right. 

There’s no reason why a postpartum woman who had a vaginal delivery would not have a
bowel sounds because spinals do not impact the bowels and neither do epidurals. If the
mother had undergone c section, she might have hypoactive or absent bowel sound for a
short period of time. 

Ask the mother if when was the last time she had anything to eat or drink 

Expected findings: anesthesia administered during labor and delivery may decrease
gastrointestinal motility. A patient should tolerate a regular diet after a vaginal delivery.
Depending on institutional policy,  a patient who underwent a c section is advanced to a
liquid, then to a regular diet at 12-24 hours after surgery. Bowel movement usually occur
within 2-3 days postpartum. 

Abnormal findings: if a patient can’t tolerate a regular diet and experiencing nausea and
vomiting, her diet may need to be changed back to a clear fluid diet or she may need to be
placed on an NPO status. 

Patient education: encourage the mother to ambulate as soon as tolerated to help with
gastrointestinal motility. 
Lochia
Exposing the perineum and check the mother’s pad. 

Ask the mother if when was the last time she changed the pad because if she says she just
changed 20minutes ago and there’s a lot of accumulation of blood already, that could be
an abnormal finding like hemorrhage. 

Teach the patient to change pad every 2-3 hours even if there’s not a lot of blood on it.
Postpartum women are at high risk of infection so changing of pad is very important. 

Lochia Rubra (0-3 days)- red, rust-colored discharge

Lochia serosa ((days 3-14) pink, brownish colored 
Lochia alba (2 weeks and beyond)- whitish, yellowish discharge

Abnormal findings: Foul smelling odor may be a sign of infection. Increased bleeding
needs to be assessed. 

Episiotomy and Laceration

Inspection: assess the patient’s perineum and if she had episiotomy and laceration, note
the presence of redness, ecchymosis (bruises) edema (swelling), drainage, and
approximation of skin edges 

Expected findings: include slight edema. Skin edges should be well approximated.
Hemorrhoids may be present. 

Abnormal Findings: include redness, ecchymosis, skin that is not approximated,

hematoma, and tenderness. 

Patient education: discuss to the client that discomfort and pain at the side of episiotomy
and laceration maybe present in the first week postpartum. Offer ice packs for the first 24
hours to prevent further edema, then heat using warm in a sitz bath. The patient may be
hesitant to defecate due to pain so stool softeners may be offered as ordered. 

Pain
Know if there’s a presence of pain and assess the site (location). Examine it properly
Explain nonpharmacologic interventions to elevate the lain, such as massage, imagery,
breathing, distraction, hot/cold therapy. 

After, discuss pharmacologic options prescribed by doctor

Narcotics may cause constipation. A stool softener may be prescribed and encourage
patient to drink plenty of fluids and ambulate. 

If patient’s pain needs to be reevaluated 30 minutes after therapy is implemented. Alert

the doctor if no change in pain.

Leg
Inspection and Palpation: Assess extremities for signs and symptoms of
thrombophlebitis such as erythema, warmth, and tenderness in the affected area and
unilateral swelling of an extremity. Assess for pedal pulses. 

Expected findings: free of signs and symptoms of thrombophlebitis, and IV sited free
from symptoms of infiltration or phlebitis. 

Abnormal Findings: If calf pain is elicited, this is a positive sign of homan’s sign. 

Emotional Status: 

Observe the mother on how she reacts according to situation. She may feel variety of
emotions during childbirth. The mother may experience excitement and joy together with
anxiety, fear, and stress. 

Refer to doctor if the mother is stressed or in a depressed state for evaluation and
management. 

Bonding and Attachment

• Bonding is the process of a unidirectional affection and regard from parent to neonate.
It is the instant affection a mother feels. It is important that during the first 30 to 60
minutes after birth, the “sensitive period”, the mother is given the time and privacy to
initiate this bond with her infant. Perhaps delay procedures such as Vitamin K
administration if it is possible.
• Attachment is the interaction between parent and neonate that is mutually satisfying.
This is enhanced by positive feedback from the infant. The mother strokes the baby’s
cheeks and in response the neonate moves his mouth a certain way and the mother
perceives it as a smile. The mother feels good and continues to stroke and touch the
neonate to reciprocate the perceived happiness. Attachment is the beginning of a lifelong
bond between mother and her child.