# Situation: A 22-year-old primipara gave birth vaginally to a healthy term newborn at a lying-in clinic, and her episiotomy was repaired. She plans to breastfeed exclusively, and the nurse follows her through the first days after birth. Ten hours after birth, the mother says she has to urinate very often. She has drunk about 1,800 mL of fluids since birth. She has no burning on voiding, and her temperature is 37.2 °C. Time after birth | Voided volume 6 hours | 110 mL 7 hours | 90 mL 8 hours | 120 mL 9 hours | 100 mL Her fundus is firm, 2 fingerbreadths above the umbilicus, and displaced to the right. What is the MOST likely explanation?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A 22-year-old primipara gave birth vaginally to a healthy term newborn at a lying-in clinic, and her episiotomy was repaired. She plans to breastfeed exclusively, and the nurse follows her through the first days after birth.

Ten hours after birth, the mother says she has to urinate very often. She has drunk about 1,800 mL of fluids since birth. She has no burning on voiding, and her temperature is 37.2 °C.

Time after birth | Voided volume
6 hours | 110 mL
7 hours | 90 mL
8 hours | 120 mL
9 hours | 100 mL

Her fundus is firm, 2 fingerbreadths above the umbilicus, and displaced to the right. What is the MOST likely explanation?

## 보기

1. Normal postpartum diuresis with frequent voiding
2. Lower urinary tract infection causing frequency
3. Uterine atony with blood clots collecting inside
4. Urinary retention with overflow voiding **✔ 정답**

**정답: 4**

## 해설

Frequent voids of only 90 to 120 mL, far below her fluid intake, together with a fundus that is high and displaced to one side, show a distended bladder that is not emptying; she is passing only the overflow. Birth trauma, edema, and anesthesia reduce bladder sensation in the first hours. Postpartum diuresis produces large voids, usually from about day 2, and leaves the fundus midline.

## 심화 해설

Clinical context In the immediate postpartum period, bladder function is altered by perineal trauma, edema, and the lingering effects of anesthesia or analgesia. A primipara may not perceive a full bladder, so the nurse must rely on objective signs rather than the mother’s reported urge to void.

Why this is urinary retention with overflow The mother has drunk 1,800 mL since birth, yet each void is only 90–120 mL. When intake far exceeds output and the voids remain small and frequent, the bladder is not truly emptying; urine is simply spilling over once intravesical pressure exceeds the outlet resistance. The displaced, high fundus is the key confirmatory finding. A distended bladder pushes the uterus upward and to the side, typically to the right, because the bladder occupies the midline pelvis.

Interpreting the fundal assessment The fundus is described as firm, 2 fingerbreadths above the umbilicus, and displaced to the right. A firm fundus rules out uterine atony as the primary problem, but a high, laterally deviated fundus in the first 24 hours almost always means a full bladder is lifting the uterus out of the midline. Once the bladder is emptied, the fundus should descend and return to the midline.

Why the other options do not fit

| Option | Why it is less likely |
| --- | --- |
| 1. Normal postpartum diuresis | Postpartum diuresis typically begins around day 2 and produces large-volume voids, not repeated small ones of 90–120 mL. It also leaves the fundus midline. |
| 2. Lower urinary tract infection | Frequency from cystitis is usually accompanied by dysuria, urgency, or suprapubic discomfort. This mother has no burning on voiding and is afebrile at 37.2 °C. |
| 3. Uterine atony with clots | Atony causes a boggy, poorly contracted uterus and heavy bleeding. This fundus is firm, and there is no reported excessive lochia. The high, deviated position points to an extrauterine mass—the full bladder—not intrauterine clot. |

Pathophysiology of postpartum bladder dysfunction Vaginal delivery stretches and compresses the bladder, urethra, and pelvic nerves. Perineal edema and episiotomy repair add local swelling and pain, while regional anesthesia temporarily reduces detrusor contractility and sensory input. The combination of reduced sensation and impaired detrusor tone allows the bladder to fill silently, sometimes to 1,000 mL or more, before overflow voiding begins. The mother interprets the resulting small, frequent losses as normal voiding, which is why objective measurement of each void and palpation of the fundus are essential.

Clinical implications for nursing care Watch out! A displaced, high fundus in the first 24 hours is a bladder sign until proven otherwise. Key point! Always assess the bladder before massaging a deviated fundus; massaging a uterus that is displaced by a full bladder can cause unnecessary pain and may not correct the position. The priority intervention is to assist the mother to empty her bladder, using measures such as privacy, warm water, or prescribed catheterization if spontaneous voiding remains inadequate. Persistent overdistention can damage the detrusor muscle and increase the risk of postpartum hemorrhage because the full bladder prevents effective uterine contraction.

## 임상 시나리오

Postpartum Bladder AssessmentDetecting urinary retention with overflow voiding
In the first 24 hours after birth, a high, laterally deviated fundus is the key sign of a distended bladder lifting the uterus. A firm fundus rules out atony, but displacement to the right with elevation above the umbilicus strongly suggests the bladder is full.

When intake far exceeds output and voids remain small (90–120 mL each) and frequent, the bladder is not truly emptying. Urine is spilling over once intravesical pressure exceeds outlet resistance—this is overflow voiding, not normal voiding.

Birth trauma, perineal edema, and anesthesia reduce bladder sensation, so a primipara may not perceive fullness. Rely on objective signs: palpate the fundus, track intake and output, and assess for bladder distension rather than depending only on the mother's reported urge to void.

CautionAfter emptying the bladder, reassess the fundus—it should descend and return to midline. If it remains high or deviated, consider retained clots or other uterine pathology. Never assume frequent small voids mean adequate bladder emptying.

## 핵심 개념

- **Overflow voiding** — Passage of small amounts of urine from a chronically or acutely distended bladder once intravesical pressure exceeds outlet resistance, without true emptying.
- **Postpartum diuresis** — Physiologic increase in urine output after delivery, typically beginning around day 2, characterized by large-volume voids.
- **Fundal displacement** — A full bladder pushes the uterus upward and laterally, usually to the right, causing a high, deviated fundus on palpation.
- **Uterine atony** — Loss of uterine muscle tone after delivery, presenting with a boggy, soft fundus and excessive bleeding.

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