Attachment 4.Bladder Care Postpartum and Management of Urinary Retention.pdf

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1.  Purpose of guideline
The purpose of this guideline is to assist health professionals in bladder care during the
postpartum period, with the aim of preventing urinary retention and its long-term consequences
within Auckland District Health Board (Auckland DHB).
2.  Guideline management principles and goals
Hormone induced reduction in smooth muscle tone decreases bladder tone (hypotonia) during
pregnancy and for a period following birth. These changes may persist for days or longer in some
women with the risk of over distension of the postpartum bladder (Saultz, 1991, see supporting
evidence).

Vigilant surveillance of bladder function and early intervention where problems exist should
prevent permanent bladder damage and long-term voiding problems (Rizvi, 2005, see supporting
evidence).

While all women in the immediate postpartum period have the potential to experience urinary
problems, several factors increase the risk:

  Prolonged/difficult labour
  Delay in the second stage
  Assisted birth
  Caesarean birth
  Epidural analgesia, particularly with local anaesthetic
  Perineal/vulval trauma
  Over distension of the bladder during/immediately following birth
  Large infant > 4 kg
  English as a second language
  Pain
  Constipation

  Aims of care
  To assess bladder function
  To detect any deviation/s from normal
  To carry out timely preventative measures to avoid complications of urinary dysfunction
following birth.

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3. Management
There are two types of urinary retention that can affect a woman in the postpartum period.

Type
Management
Overt retention
Symptomatic inability to void spontaneously within six hours of
birth or removal of indwelling catheter (IDC).
Covert retention
Non symptomatic increased post void residual volumes after birth
or removal of IDC.

See algorithms on the following two pages outlining procedures for management of these two
types of urinary retention.

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  Overt retention
POSTPARTUM OVERT URINARY RETENTION
PROCEDURE
DEFINITION: SYMPTOMATIC INABILITY TO VOID WITHIN 6 HOURS OF DELIVERY OR REMOVAL OF IDC
Symptoms:
Pain
S
E
Urgency
R
Hesitancy
U
S
Straining to void
A
E
Slow or intermittent stream
M
Sense of incomplete emptying
E
IV
S
IDENTIFICATION  OF
:
A
V
ONE OR MORE OF THE ABOVE SYMPTOM and No VOID> 4 HOURS POST DELIVERY  or R/O IDC
1
E
-IN
G
N
A
O
T
BOX 1
S
N
&
INSTIGATE NON-INVASIVE MEASURES
N
Analgesia, running water, ambulation, double voiding, provision of privacy, warm shower, ural
IO
T
ENSURE ADEQUATE FLUID INTAKE
A
IC
IF
T
N
START FLUID BALANCE CHART
E
ID
WAIT FOR FURTHER 2 HOURS
(OR SOONER IF UNCOMFORTABLE)
UNTIL 6 HOURS POST DELIVERY OR R/O IDC
NO
VOID
VOID
C
ID
VOLUME of void
VOLUME of
>200 mL
void
I/O
+
<200 mL
S
E
M
:
U
CONTINUE NON INVASIVE MEASURES
2
L
(BOX1)
E
O
G
V
A
F
SEND CSU FOR
T
DRAIN BLADDER WITH IDC AND RECORD VOLUME
S
O
ANALYSIS
T
N
E
M
VOLUME
VOLUME from
VOLUME
S
S
from IDC
IDC: BETWEEN
From IDC:
E
<150 mL
S
150-700 mL
>700 mL
S
A
IDC 24 Hours
IDC 48 Hours
After prescribed time period
REMOVE IDC
TRIAL OF VOID
NO VOID >4 HOURS POST R/O IDC
REPEAT BOX 1
WAIT FURTHER 2  HOURS (UNTIL 6
HOURS POST R/O IDC)
ID
:
O
3
V
E
F
Spontaneous
No spontaneous
G
O
Void >200 mL
A
Void or void <200 mL
T
L
S
IA
R
T
Residual
Residual
Insert IDC and measure volume
Volume via IDC:
Volume via IDC:
>150 mL
<150 mL
Residual Volume
Residual
Via IDC: Between
Volume
150-700 mL
Move to Covert Urinary
Via IDC: >700 mL
No further Action
Retention pathway
Commence 2 hourly timed
NB. After 2 failed TROC’s
voiding
IDC 24 hours
IDC 48 hours
refer for medical review
Repeat Trial of Void

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Covert retention
POSTPARTUM COVERT URINARY RETENTION
PROCEDURE
DEFINITION: INCREASED POST-VOID RESIDUAL VOLUME AFTER DELIVERY OR REMOVAL OF IDC
IDENTIFIED BY:
NO URGE to void
Ability to void

No symptoms of retention
n
:
1
tio
E
a
G
A
tific
n
At 4 HOURS POST DELIVERY
T
S
e
OR 4 HOURS POST R/O IDC-
Id
ASK WOMAN
“Have you voided?”
YES
NO
“DID YOU HAVE THE URGE TO VOID?” (also ask about amount and flow)
g
YES
NO
:
in
2
id
E
o
G
V
A
d
T
e
NO FURTHER ACTION
S
COMMENCE ON 2 HOURLY TIMED VOIDING
im
T
ENSURE ADEQUATE FLUID INTAKE (2.5-3L/DAY)
SEND MSU
FOR
START FLUID BALANCE CHART
ANALYSIS
MEASURE FIRST VOID
VOLUME of void
VOLUME of void between
VOLUME of void
<200 mL
200 ml- 700 mL
>700 mL
NO FURTHER
NEXT VOID (after 2 hours)
CONTINUE TIMED VOIDING 24 HOURS
“did you have the urge to
ACTION
void?”
AFTER 24 HOURS
“Do you have the urge to void?”
g
NO
YES
:
in
3
id
E
o
G
A
f v
T
l o
S
ria
NO FURTHER ACTION
YES
NO
T
MEASURE RESIDUAL VOLUME
Insert IDC
RESIDUAL VOLUME
RESIDUAL VOLUME
<150 mL
>150 mL
Leave IDC for 24 hours
Continue timed voiding
AFTER 24 HOURS
Until bladder sensation returns
REMOVE IDC REPEAT
Organise follow up 1/52
PROCESS

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4.  Admission assessment
The initial bladder assessment should include:
  A review of the labour and birth history to detect any risk factors
  History of urological problems
  Bladder palpation
  Check to see if the woman has voided after vaginal birth
  IDC in situ –check that it is draining.

An initial assessment should provide information on:
  The presence of any urinary problems
  Risk factors that may contribute to urinary problems.
5.  First six hours post-delivery or removal of IDC assessment
Continue to assess bladder functioning two hourly. If unable to void or quantity or flow is
abnormal at four hours, refer to the postpartum overt urinary retention flowchart (adapted from
the Women’s Hospitals Australasia [WHA] Guidelines, 2009).

Notes:
  During the night: If there is no history of urological problems, use opportunities when the
woman is awake to check bladder. A woman with a history may require two hourly checking
  Onset and progression of urinary retention may be gradual and asymptomatic
  It can take eight hours for the bladder to regain sensation following epidural analgesia.

Assessment:
  Establish by questioning void or no void
  If yes to void, ask the woman if she is experiencing any discomfort or difficulty when voiding
  Check the frequency with which urine is passed
  Ask volume and quality of flow with each void
  Examine the woman’s abdomen for displacement of the uterus and swelling of the lower
abdomen
  Palpate the woman’s bladder
  Establish by questioning void or no void.

The woman may complain of overt symptoms (symptomatic inability to void spontaneously within
six hours of birth or removal of IDC):
  An inability to void
  Increasing lower abdominal pain
  Urgency
  Straining to void
  Involuntary loss of urine
  Voiding frequent small amounts (retention with overflow).

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Note: A distended bladder displaces the uterus upward and to the right side. There may also be a
painful cystic swelling palpable in the suprapubic region.

If no void at four hours either post birth or removal of IDC use supportive measures, such as
ambulation, privacy, shower, hands under cold running water, warm flannel over bladder or if
necessary appropriate analgesia for pain relief to enhance the likelihood of micturition. Ensure
adequate fluid intake and commence fluid balance chart.

Monitor a further two hours: (i.e. until six hours post-delivery or sooner if discomfort)

  If void and volume > 200 mL continue with supportive measures and encourage two to three
hourly voiding
  If no void or volume < 200 mL drain bladder with IDC.

When inserting a catheter:
Step
Action
1.
Use a Foley’s catheter.
2.
Use a strict aseptic technique.
3.
Send catheter specimen of urine (CSU) to laboratory.
4.
Document on the fluid balance chart.

Note: Using a Foley catheter, instead of an in-out catheter prevents the risk of introducing
bacteria into the urinary tract from a second catheterization should an indwelling catheter be
required.

A woman may have covert urinary retention (non-symptomatic increased post void residual
volumes after birth or removal of IDC):
  Ability to void
  But no urge to void
  No obvious symptoms of retention.

Refer to postpartum covert urinary retention flowchart (adapted from the WHA Guidelines, 2009).
6.  Urinary retention
  Alert obstetric team.
  Diagnosed by symptoms and volume drained following insertion of IDC.
○  Residual urinary volume of 150 - 700 mL will require IDC for 24 hours
○  Residual urinary volume > 700 mL will require IDC 48 hours
○  Residual volumes of > 1500mls require discussion with the Urogynaecology team.
  A woman who has a residual volume of more than 700 mL is more likely to require repeat
catheterization (Ching-Chung, 2002, see supporting evidence). After a failed trial of removal of
catheter discussion with Urogynaecology team is required for further management and refer
to the ward physiotherapist.
  Catheterization rests the over distended bladder allowing it to gain its elastic recoil.
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  It is advisable to remove urinary catheters early in the day to allow time for careful and regular
post catheterization bladder assessment.
7.  Removal of catheter (trial of void) management
Step
Action
1.
Encourage two to three hourly voiding and document voids until normal voiding patterns
are established and two measured voids of 200 mL or greater are obtained.
2.
Reassess the bladder as documented and follow the appropriate flowchart for postpartum
overt urinary retention or postpartum covert urinary retention (adapted from the WHA
Guidelines, 2009).
3.
Document all findings on the fluid balance chart and in the clinical record.
4.
Persistent urinary retention and large urinary residuals will require long term resting of the
bladder and management by the obstetric team in conjunction with Urogynaecology.

Note: Bladder scanners are not a reliable measurement of residual volumes in the postpartum
woman and are not recommended for use. The automatic calculation is rendered inaccurate
because of the volume of the involuting uterus and its tendency to distort the bladder outline
(Pallis & Wilson 2003, see supporting evidence).
8.  Supporting evidence
  Carley, M. E., Carley, J. M., Vasdev, G., Lesnick, T. G., Webb, M. J., Ramin, K. D., & Lee, R. A.
(2002). Factors that are associated with clinically overt postpartum urinary retention after
vaginal delivery. American journal of obstetrics and gynecology, 187(2), 430-433.
  Ching‐Chung, L., Shuenn‐Dhy, C., Ling‐Hong, T., Ching‐Chang, H., Chao‐Lun, C., & Po‐Jen, C.
(2002). Postpartum urinary retention: assessment of contributing factors and long‐term clinical
impact. Australian and New Zealand journal of obstetrics and gynaecology, 42(4), 367-370.
  Rizvi, R. M., Khan, Z. S., & Khan, Z. (2005). Diagnosis and management of postpartum urinary
retention. International journal of gynaecology and obstetrics, 91(1), 71-72.
  Rogers, R. G., & Leeman, L. L. (2007). Postpartum genitourinary changes. Urologic Clinics,
34(1), 13-21.
  Saultz, J. W., Toffler, W. L., & Shackles, J. Y. (1991). Postpartum urinary retention. The Journal
of the American Board of Family Practice, 4(5), 341-344.
  Pallis, L. M., & Wilson, M. (2003). Ultrasound assessment of bladder volume: is it valid after
delivery?. Australian and New Zealand Journal of Obstetrics and Gynaecology, 43(6), 453-456.
  Lauszus, F. (2006). Regarding “Reliability of an automatic ultrasound system in the postpartum
period in measuring urinary retention”. DOI: 10.1080/00016340600606992
  Women’s Hospitals Australasia. Clinical Practice Guideline. March 2009. Available:
https://women.wcha.asn.au/
  World Health Organisation. Sexual and reproductive health. Retrieved 30 April 2007. Available:
https://www.who.int/teams/sexual-and-reproductive-health-and-research
  World Health Organization. Postpartum care of the mother and newborn: a practical guide.
Maternal and newborn health. Available:
https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/en
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  Yip, S., Sahota, D., Pang, M., & Chang, A. (2004). Postpartum urinary retention. Acta Obstetricia
et Gynacologica Scandinavica, 83, 887-891
  Yip, S., Sahota, D., Pang, M., & Chang, A. (2005). Screening test model using duration of labour
for the detection of postpartum urinary retention. Neurology and Urodynamics, 24, 248-253
  Zaki, M. M., Pandit, M., & Jackson, S. (2004). National survey for intrapartum and postpartum
bladder care: assessing the need for guidelines. BJOG: An International Journal of Obstetrics &
Gynaecology, 111(8), 874-876.
9.  Associated documents
  Bladder Care Post Gynaecology & Urogynaecology Surgery
10.  Disclaimer
No guideline can cover all variations required for specific circumstances. It is the responsibility of
the health care practitioners using this Auckland DHB guideline to adapt it for safe use within their
own institution, recognise the need for specialist help, and call for it without delay, when an
individual patient falls outside of the boundaries of this guideline.
11.  Corrections and amendments
The next scheduled review of this document is as per the document classification table (page 1).
However, if the reader notices any errors or believes that the document should be reviewed
before the scheduled date, they should contact the owner or Document Control without delay.
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