Prevention of bladder overdistention demands observation ater delivery to ensure that the bladder does not overill and that it empties adequately with each voiding. he enlarged bladder can be palpated suprapubically, or it is evident abdominally indirectly as it elevates the fundus above the umbilicus. he use of an automated bladder scanner sonography system has been studied to detect high bladder volumes and thus postpartum urinary retention (Buchanan, 2014; Van Os, 2006).
If a woman has not voided within 4 hours ater delivery, it is likely that she cannot. If she has trouble voiding initially, she also is likely to have further trouble. n examination for perineal and genital-tract hematomas is completed. With an overdistended bladder, an indwelling catheter should be left in place until the factors causing retention have abated. Even without a demonstrable cause, it usually is best to leave the catheter in place for at least 24 hours. his prevents recurrence and allows recovery of normal bladder tone and sensation.
When the catheter is removed, a voiding trial is completed to demonstrate an ability to void appropriately. If a woman cannot void after 4 hours, she should be catheterized and the urine volume measured. If more than 200 mL, the bladder is not functioning appropriately, and the catheter is left for another 24 hours. Although rare, if retention persists after a second voiding trial, an indwelling catheter and leg bag can be elected, and the patient returns in 1 week for an outpatient voiding trial. Intermittent sel-catheterization is another option (Mulder, 2017).
During a voiding trial, if less than 200 mL of urine is obtained, the catheter can be removed and the bladder subsequently monitored clinically as described earlier. Harris and coworkers (1977) reported that 40 percent of such women develop bacteriuria, and thus a single dose or short course of antimicrobial therapy against uropathogens is reasonable after the catheter is removed.
• Pain, Mood, and Cognition
Discomfort and its causes following cesarean delivery are con sidered in Chapter 30 (p. 585). During the irst few days after vaginal delivery, the mother may be uncomfortable because of afterpains, episiotomy and lacerations, breast engorgement, and at times, postdural puncture headache. Mild analgesics contain ing codeine, aspirin, or acetaminophen, preferably in combina tions, are given as frequently as every 4 hours during the irst few days.
It is important to screen the postpartum woman for depression (American College of Obstetricians and Gynecologists, 2016b). It is fairly common for a mother to exhibit some degree of depressed mood a few days after delivery. Termed pospartum blues, this likely is the consequence of several factors. hese include emotional letdown that follows the excitement and fears experienced during pregnancy and delivery, discomforts of the early puerperium, fatigue from sleep deprivation, anxiety over the ability to provide appropriate newborn care, and body image concerns. In most women, efective treatment includes anticipation, recognition, and reassurance. This disorder is usually mild and self-limited to 2 to 3 days, although it sometimes lasts for up to 10 days. Should these moods persist or worsen, an evaluation for symptoms of major depression is done (Chap. 61, p. 1176). Suicidal or infanticidal ideation is dealt with emergently. Because major postpartum depression recurs in at least a fourth of women in subsequent pregnancies, some recommend pharmacological prophylaxis beginning in late pregnancy or immediately postpartum.
Last, postpartum hormonal changes in some women may afect brain function. Bannbers and colleagues (2013) compared a measure of executive function in postpartum women and controls and observed a functional decline in postpartum subjects.