BUBBLE HE Assessment: Postpartum Nursing Guide

LS
By Lindsay Smith, AGPCNP
Updated July 8, 2026

Reviewed for clinical accuracy · Methodology: NIH, NCBI, AANP guidelines

Between 70% and 80% of women experience “baby blues” after delivery. Many of the women that experience baby blues also experience more severe postpartum depression. One in seven women experiences depression in the year following childbirth. The BUBBLE HE assessment helps nurses identify these issues in patients.

What is the BUBBLE HE assessment?

BUBBLE HE is a mnemonic that nurses use to identify postpartum issues – including depression – in mothers after childbirth. Mothers can use this tool to recognize symptoms and speak to their doctor about them.

What BUBBLE HE stands for

  • **Breast: **Some women experience cracked nipples after delivery, which can get infected. It is critical for new mothers to continually examine their breasts and express breast milk even if the child is not feeding.
  • **Uterus: **Nurses regularly check the new mother’s cervix for firmness after birth. A softened cervix may be infected.
  • Bladder: Mothers are encouraged to drink a lot of water and frequently urinate after childbirth. Clear yellow urine and an undistended bladder are good signs and indicate that the mother is healthy.
  • Bowel: Bowel movements must be regular and painless.
  • Lochia: The mother’s body produces vaginal discharge containing blood, mucous, and uterine tissue after childbirth. It must follow a natural pattern. For up to five days after birth, the lochia is typically dark red. It can have blood clots, but they shouldn’t be larger than a plum. Between days four and ten after childbirth, the lochia should become more watery. The lochia turns light-pink or brownish. From day ten to day 28, the color usually changes to whitish-yellow. Signs of clotting and unpleasant smell are indicators of infection.
  • Episiotomy: Mothers that had an episiotomy may experience swelling for a few days after childbirth. If the swelling is excessive, or there’s bruising or discharge from the incision, the mother should see a doctor immediately.
  • Homans’ sign: Stinging in the calf is the Homan’s sign. It is an indicator of thrombosis (blood clotting in veins or arteries). If the mother is experiencing discomfort behind her knees, she should seek medical attention.
  • Emotional status: Women are most vulnerable to postpartum depression for six weeks after delivery. It can be concerning if the mother isn’t bonding with the newborn or displays erratic behavior. Nurses check the mother’s emotional status, and the mother should also monitor her emotional status and seek help if needed. It takes courage to look after yourself, and you should never hold back from asking for it. 

When a woman gives birth, she goes through both physical and mental changes. Therefore, nurses need to understand how she is coping. Many of the symptoms indicated in BUBBLE HE are physical, but the physical pain often takes an emotional toll on the parents. 

Using BUBBLE HE provides an excellent plan to look after the mother after childbirth. 

How to perform the BUBBLE HE assessment

Work through the mnemonic in order, head to toe, at each postpartum check. Document findings against the expected timeline for each system so any deviation is easy to flag.

  1. Breast: Inspect for engorgement, cracked or bleeding nipples, and redness. Palpate for firm, warm areas that could signal mastitis.
  2. Uterus: Palpate the fundus using a C-shaped hand over the abdomen. Within 12 hours of delivery the fundus sits about 1 cm above the umbilicus; it then descends roughly 1–2 cm every 24 hours as the uterus involutes. A boggy (soft) fundus needs immediate massage and reassessment, since it raises the risk of postpartum hemorrhage.
  3. Bladder: Confirm the mother voids within 6–8 hours of a vaginal delivery. Watch for distention, incomplete emptying, or reduced urine output, which can point to postpartum urinary retention.
  4. Bowel: Ask about flatus and bowel movements, and confirm they are returning to a normal, pain-free pattern.
  5. Lochia: Note color, amount, odor, and clots at each check, and track it against the expected rubra-to-serosa-to-alba progression described above. Saturating a pad in under an hour is a red flag for hemorrhage.
  6. Episiotomy/perineum: Assess the incision or perineal area for redness, edema, ecchymosis, discharge, and approximation of the wound edges.
  7. Homans’ sign: Ask about calf pain or tenderness, particularly with dorsiflexion of the foot. Combine this with a visual check for unilateral leg swelling or warmth, since either can suggest a deep vein thrombosis.
  8. Emotional status: Screen for mood, bonding with the newborn, sleep, and support at home. Escalate any indication of self-harm or harm to the infant immediately.

Other maternal nursing mnemonics

BUBBLE HE is only one of the many mnemonics that nurses in the labor and delivery unit need to remember. Other mnemonics that these professionals use include VEAL CHOP, HELLP, and LARA CROFT. I also have an EKG interpretation cheat sheet you might find useful.

Frequently asked questions

What is the difference between BUBBLE HE and BUBBLE LE? Both cover the same core postpartum systems, but the last two letters diverge. BUBBLE HE ends in Homans’ sign (a calf-pain check for deep vein thrombosis) and Episiotomy. BUBBLE LE ends in Lower extremities (a broader DVT check covering swelling and warmth, not just calf pain) and Emotional status. Some programs teach BUBBLE HE, others teach BUBBLE LE – check which version your instructor or unit uses before an exam or clinical.

Is Homans’ sign still considered reliable? No. Homans’ sign has low sensitivity and specificity for deep vein thrombosis and can be falsely reassuring. Many facilities now assess lower extremities more broadly for unilateral swelling, warmth, and tenderness rather than relying on calf pain alone, which is part of why some programs have shifted toward the BUBBLE LE version of the mnemonic.

How often is the BUBBLE HE assessment performed? Frequency depends on time since delivery and facility protocol. It is typically done every 15 minutes for the first hour after birth, then every 4–8 hours during the rest of the postpartum stay, and at each home health or outpatient postpartum visit after discharge.

What is a boggy fundus and why does it matter? A boggy fundus is a uterus that feels soft rather than firm on palpation. It means the uterus is not contracting effectively, which increases the risk of postpartum hemorrhage. Nurses respond with fundal massage and reassessment, and escalate if the fundus does not firm up.

References

  1. American College of Obstetricians and Gynecologists. Optimizing Postpartum Care. ACOG Committee Opinion No. 736. Obstet Gynecol. 2018;131(5):e140–e150. doi:10.1097/AOG.0000000000002633
  2. American College of Obstetricians and Gynecologists. Breastfeeding Challenges. ACOG Committee Opinion No. 820. Obstet Gynecol. 2021;137(2):e42–e53. doi:10.1097/AOG.0000000000004253
  3. American College of Obstetricians and Gynecologists. Postpartum Hemorrhage. ACOG Practice Bulletin No. 183. Obstet Gynecol. 2017;130(4):e168–e186. doi:10.1097/AOG.0000000000002351
  4. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–786. doi:10.1192/bjp.150.6.782
  5. Wisner KL, Sit DKY, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013;70(5):490–498. doi:10.1001/jamapsychiatry.2013.87
  6. Mitchell KB, Johnson HM, Rodríguez JM, et al.; Academy of Breastfeeding Medicine. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeed Med. 2022;17(5):360–376. doi:10.1089/bfm.2022.29207.kbm
  7. Paola AD, Martín JN Jr, Bhatt S. Risk factors and management of postpartum urinary retention: a scoping review. Int J Urol Nurs. 2022;16(1):3–14. doi:10.1111/ijun.12309
  8. Thuillier C, Roy S, Deffieux X, Raiffort C, Huchon C, Fauconnier A. Implementing a clinical practice guideline to manage postpartum urinary retention. J Obstet Gynaecol Can. 2014;36(12):1062–1066. doi:10.1016/S1701-2163(15)30433-7
  9. Rabe H, Bhatt-Mehta V, Bhutani VK, et al. Preventing postpartum venous thromboembolism in 2022: a narrative review. Obstet Gynecol Surv. 2022;77(9):547–557. doi:10.1097/OGX.0000000000001062
  10. Batista TSD, de Sousa MNA, de Oliveira CF, et al. Episiotomy healing assessment: REEDA scale reliability. Rev Lat Am Enfermagem. 2015;23(1):162–168. doi:10.1590/0104-1169.3633.2538
  11. Evenson KR, Mottola MF, Owe KM, Rousham EK, Brown WJ. Summary of international guidelines for physical activity after pregnancy. Obstet Gynecol Surv. 2014;69(7):407–414. doi:10.1097/OGX.0000000000000077
  12. Herdman TH, Kamitsuru S, Lopes CT, eds. NANDA International Nursing Diagnoses: Definitions and Classification 2021–2023. 12th ed. Thieme; 2021.