Elimination

Recovery Stage

Diuresis and diaphoresis are common immediately after delivery. If the woman received IV fluids, urinary output may be increased. Support the bladder above the symphysis pubis and palpate it to check for fullness. Encourage voiding because a full bladder may interfere with complete contraction of the uterus, potentially causing hemorrhage.

The initial voiding should occur within 4 to 6 hours after delivery. Tissue edema from the delivery may cause difficulty with voiding. In addition, some women may have reduced sensitivity and are unaware that the bladder is full. Some agencies have a policy to assess voiding three times in measurable amounts of 300 mL or more after delivery to determine urinary elimination. Try measures to stimulate voiding. If the patient is unsuccessful voiding a sufficient quantity, catheterization may be necessary. If repeated catheterization is needed, a Foley catheter may be inserted. An indwelling catheter is routinely inserted before cesarean delivery and may remain in place for 1 or 2 days after delivery.

Later Postpartum Stage

Women may not have a strong sense of urgency when the bladder is full. The perineum may also be sore, resulting in a reluctance to regularly void. The nurse must encourage the woman to void at regular intervals of 2 to 4 hours. Urinary retention should be considered if a woman is voiding small amounts (less than 100 mL) frequently. The assessment of voiding patterns should include inquiries about symptoms urgency and frequency or dysuria. Incomplete emptying of the bladder prevents the uterus from contracting normally and also predisposes the patient to urinary tract infections.

Review proper cleansing technique after delivery. Instruct the woman to gently cleanse and pat dry from the anterior to posterior of the perineum. This method of cleansing prevents microorganisms from the rectal area being transported to the cleaner urinary or vaginal areas. A “peri bottle” (a plastic squeeze bottle) may be used after each urination or bowel movement. Water should be warm (100° F [37.7° C]). Cleansing with toilet tissue is discouraged until the episiotomy or laceration is healed.

The shortened length of hospitalization after childbirth may result in the woman being discharged before she has a bowel movement. Health care providers differ on requirements that the new mother have a bowel movement before discharge Fear of discomfort from the episiotomy, lacerations, or hemorrhoids may result in the woman’s resisting the urge to defecate. Bowel peristalsis may continue to be slowed. Constipation may result when these factors are combined with a decrease in activity and loss of abdominal tone. Stool softeners may be prescribed. The nurse should promote good bowel habits by encouraging activity, fluid intake, and increased fiber in the diet. Occasionally, suppositories or fleet enemas are administered to promote bowel evacuation. Enemas and suppositories are contraindicated for women who have experienced third-degree or fourth-degree lacerations or extensions to their episiotomies. Sitz baths can also soothe the perineum and promote bowel elimination.

Patients with cesarean births, particularly those who received general anesthesia, are likely to develop problems with bowel function. The combination of general anesthesia and lost abdominal tone increases the risk of ileus, so pay close attention to bowel function and report any abnormal observations promptly. To promote bowel function, assist with and encourage the patient to ambulate periodically throughout the day.

Perineal pads, worn to absorb vaginal drainage, should be changed after each urination or defecation. Teach the woman the importance of correct application and changing of the pad. Pads should be applied and removed from anterior to posterior and secured so as not to move about. If they are not correctly worn, contaminated areas could touch cleaner areas of the perineum and increase the risk of infection. Stress correct and scrupulous handwashing before and after changing to prevent cross contamination.