(3) Nerve blocks may alter the sensation of a full bladder to the patient and
prevent her from urinating.
If at all possible, ambulate the patient to the bathroom.
(5) Urine output less than 300cc on initial void after delivery may suggest
Document the fundal height and bladder status before the patient
(b) Reevaluate and document the fundal height and bladder status
after the patient urinates to accurately document an empty bladder.
j. Evaluate the perineal area for signs of developing edema and/or hematoma.
(1) Predisposing conditions includes prolonged second stage, delivery of a
large infant, rapid delivery, forceps delivery, and fourth degree lacerations.
Nursing considerations for perineal edema.
(a) Apply an ice pack to the perineum as soon as possible to decrease
the amount of developing edema.
(b) Stress the importance of peri-care and use of "sitz-baths" on the
Assess for urinary distention which is due to edema of the urethra.
Assessment for perineal hematoma.
Look for discoloration of the perineum.
(b) Listen for the patient's complaints or expression of severe perineal
Observe for edema of the area.
(d) Observe/listen for patient's feeling the need to defecate if forming
hematoma is creating rectal pressure.
(e) Observe for patient's sensitivity of the area by touch (by sterile
k. Observe for signs of hemorrhage.