Normal pregnancy-induced glomerular hyperiltration persists during the puerperium but returns to prepregnancy baseline by 2 weeks (Hladunewich, 2004). Dilated ureters and renal pelves return to their prep regnant state by 2 to 8 weeks postpartum. Because of this dilated collecting system, coupled with residual urine and bacteriuria in a traumatized bladder, symptomatic urinary tract infection remains a concern in the puerperium.
Funnell and colleagues (1954) used cystoscopy immediately postpartum and described varying degrees of submucosal hemorrhage and edema. Bladder trauma is associated most
The Puerperium 655 closely with labor length and thus to some degree is a normal accompaniment of vaginal delivery. Postpartum, the bladder has an increased capacity and a relative insensitivity to intravesical pressure. hus, overdistention, incomplete emptying, and excessive residual urine are frequent (Buchanan, 2014; Mulder, 2014). Acute urinary retention is also more common with narcotic analgesia (Kandadai, 2014). heir management is discussed on page 660.
It is unusual for urinary incontinence to manifest during the puerperium. hat said, much attention has been given to the potential for subsequent development of urinary incontinence and other pelvic loor disorders in the years following delivery. A more detailed discussion is found in Chapter 30 (p. 568).
The broad and round ligaments require considerable time to recover from stretching and loosening during pregnancy. As a result of ruptured elastic ibers in the skin and prolonged distention by the pregnant uterus, the abdominal wall remains soft and laccid. If the abdomen is unusually labby or pendulous, an ordinary girdle is often satisfactory. n abdominal binder is another temporary measure. Several weeks are required for these structures to return to normal, and recovery is aided by exercise. hese may be started anytime following vaginal delivery. Ater cesarean delivery, a 6-week interval to allow fascia to heal and abdominal soreness to diminish is reasonable. Silvery abdominal striae commonly develop as striae graviarum (Chap. 4, p. 53). Except for these, the abdominal wall usually resumes its prep regnancy appearance. When muscles remain atonic, however, the abdominal wall also remains lax. Marked separation of the rectus abdominis muscles-diastasis recti-may result.
Marked leukocytosis and thrombocytosis may occur during and after labor. The white blood cell count sometimes reaches 30,000/�L, with the increase predominantly due to granulocytes. There is a relative lymphopenia and an absolute eosinopenia. Normally, during the irst few postpartum days, hemoglobin concentration and hematocrit luctuate moderately. We routinely check these on the irst postpartum day or earlier if indicated. If they fall much below the levels present just before labor, a considerable amount of blood has been lost.
By the end of pregnancy, laboratory values that assess coagulation are altered (Kenny, 2014). These changes are discussed in Chapter 4 (p. 59) and listed in the Appendix (p. 1256). Many persist variably in the puerperium. For example, a markedly increased plasma ibrinogen level is maintained at least through the irst week and hence so is an elevated sedimentation rate. Hypercoagulability appears to be greater and is relected by the likelihood of deep-vein thrombosis and pulmonary embolism in the 12 weeks following childbirth (Kamel, 2014). his is depicted in Figure 36-3 and is discussed further in Chapter 52 (p. 1004).