OIA2021120902 Response Attachment 2.pdf

Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429  Issue Date  10 February 2021  Review Date 10 February 2023

Level:
Service Ostetrics


Type:
Protocol

Name:
Obstetric Bladder Care and Management
        (Antenatal, Intrapartum and Postpartum)

Purpose
The intrapartum and postpartum period pose significant risks for urine retention, and bladder
distension.  For  some  women  this  may  lead  to  long-term  health  issues  related  to  bladder
dysfunction  and  incontinence,  indicating  that  assessment  of  risk  and  preventative
management is merited (RCOG 2002).

Contributing  factors  include:  the  hormonal  induced  reduction  in  smooth  muscle  tone  and
anatomical changes specific to pregnancy (Saultz 1991); pressure exerted by the presenting
part  in the  second  stage  of  labour, temporary  loss  of  sensation due  to  denervation  of  the
pelvic floor (Mostwin 2005) and the extra pressure exerted on the bladder due to postpartum
fluid shift and increased extracellular fluid. Health professionals  also need to be vigilant in
their assessment of other risk factors such as the length of labour, mode of birth, perineal
trauma and the influence of analgesia/anaesthesia.

Delayed diagnosis and intervention may lead to irreversible damage of the detrusor muscle,
and  long-standing  health  issues  including  urinary  tract  infection,  voiding  difficulties  and
persistent painful urinary retention (Rizvi et al 2005, Baldini et al 2009).

Regular bladder assessments are required when a woman is in labour, especially when she
has  had  a  regional  block,  an  assisted  vaginal  birth,  or  there  has  been  excessive
perineal/periurethral trauma.  Guidelines are included to optimise care of the bladder and
the monitoring that assists in avoiding urinary retention.

Scope
  All WHS midwives and nurses
  All WHS obstetricians, registrars, senior house officers
  All obstetric anaesthetists and anaesthetic registrars
  All access holders

Obstetric Bladder Care and management
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ID 1.101429
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Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429  Issue Date  10 February 2021  Review Date 10 February 2023
Management
Antenatal
All women should be assessed during the antenatal period (for risk factors see below), and
their usual bladder function discussed.  Refer as required.

Intrapartum
Bladder management for women with an epidural
Those with a long period of epidural administration are particularly at risk of retention. Whilst
women may be able to void if encouraged, bladder emptying may be insufficient and urinary
retention may be overlooked with a resultant poor outcome. Early insertion of an indwelling
urinary catheter (IDC) may reduce the risk of retention related complications.

For further guidance please see policy Antenatal, Intrapartum and Postpartum Management
of Epidural Analgesia CapDocs ID 1.103846

Management without epidural
  Bladder assessments are required at least four hourly. This includes an assessment of
the  woman’s  risk  factors,  her  hydration  state,  and  whether  the  bladder  is  palpable
either abdominally or vaginally
  Accurate documentation of all voids in labour should include volume and time.
  If  the  woman  has  not  passed  urine  for  four  hours,  catheterisation  should  be
considered
  An in/out or intermittent catheter may be used if birth is imminent within 2 hours. If
not an IDC should be placed and remain until after birth

  The woman’s bladder must be emptied prior to an assisted vaginal birth and during a
prolonged  second  stage.    A  full  bladder  can  displace  the  uterus  and  pressure  may
result in damage to the bladder neck.
  All fluid input and output must be recorded on a Fluid balance chart for women with
epidurals and indwelling catheters.
  For  all  women  who  have  an  IDC  in  situ;  deflate  the  balloon  to  prevent  trauma  to
bladder neck during second stage, re-inflate balloon postpartum (RCOG 2011). If the
catheter is expelled during delivery a new catheter should be inserted using aseptic
technique.
  An IDC is recommended following an assisted vaginal delivery or for ANY obstetric
intervention  at  birth,  where  spinal  or epidural anaesthesia  has  been  topped  up  for
birth. Obstetric intervention includes manual removal of the placenta, and complex
pelvic floor  repairs.  The IDC  should  remain  in place  for    a  minimum  of 12  hours  to
prevent asymptomatic bladder overfilling (RCOG 2011)
  All women having caesarean section should have an IDC inserted; this should remain
insitu for 8 hours - 24 hours postpartum
  Please  follow  “Guidelines  for  first  void  and  removal  of  IDC”  which  offers  specific
guidance according to mode of birth and analgesia/anaesthesia
Obstetric Bladder Care and management
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Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429  Issue Date  10 February 2021  Review Date 10 February 2023
Risk factors for retention
While  all  women  in  the  immediate  postpartum  period  have  the  potential  to  experience
urinary problems, several factors increase the risk including:
  Women with underlying neurological conditions
  A previous history of bladder retention
  Primiparity
  > 3 births
  Prolonged or difficult labour
  Prolonged second stage
  Instrumental and operative birth (Zaki et al 2004, RCOG 2002)
  Large baby (> 4kg) (RCOG 2007)
  Opioid use, including spinal opiods- opioids inhibit spontaneous bladder contractions
and  decrease  the  urge  to  void,  leading  to  increased  bladder  capacity  and  residual
volume (Liang et al 2007)
  Oxytocin  infusion,  due  to  the  anti-diuretic  effects  of  the  medication.  Be  especially
vigilant if a second oxytocin infusion was commenced during induction/augmentation
or postpartum
  Excessive intravenous fluids leading to distension and detrusor inhibition (Baldini et al
2009) e.g. during PPH resuscitation
  Perineal / vaginal trauma / haematoma
  Oedematous perineum
  Regional anaesthesia

Postnatal
Ongoing  assessment  of  bladder  function  is  required  for  all  women  during  the  postnatal
period. Offer adequate analgesia based on individual needs and ensure privacy. Consideration
must  be  given  to  the  labour  and  birth  history,  any  symptoms  of  urinary  retention  (listed
below) and whether (or not) the bladder is palpable.

There are two types of urinary retention that can affect women in the postpartum period

Overt retention: symptomatic inability to void spontaneously within 6 hours of birth or IDC
removal.  Assessment  should  be  ongoing  and  earlier  intervention  may  be  necessary.
Symptoms may include:
  Urgency
  Small frequent voids
  Inability to void
  Straining to void
  A slow or intermittent stream
  Woman has a sense of being unable to empty her bladder fully
Obstetric Bladder Care and management
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ID 1.101429
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Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429  Issue Date  10 February 2021  Review Date 10 February 2023
  Increasing lower abdominal pain
  Leakage of urine
  Palpable bladder

Covert  retention:  non  symptomatic  increased  post  void  residual  volumes  after  birth  or
removal of IDC.
  Ability to void, but no urge
  No obvious symptoms of retention

Guidelines for first void and removal of IDC
All women should pass urine within 6 hours of giving birth and ideally prior to leaving  the
Birthing Suite.
Document on the fluid balance chart voids (volume and timing) postpartum and/or removal
of IDC for the first 12 hours. Measurements can be stopped when there has been:
  A spontaneous void > 400mls, but less than 600mls
or
  Two successive spontaneous voids of > 200mls
and
  the woman is asymptomatic of urinary retention symptoms.

If a single spontaneous void > 600mls is passed there is a greater risk of bladder damage due
to distension. Assessment should take into consideration:
  Urge to void
  Ability to control the passage of urine
  Any leakage of urine prior to voiding

Care will include
  Palpation of the woman’s bladder post initial void to assess for incomplete emptying
  Prompt the woman to pass urine within the next 2 hours and record volume on the
fluid balance chart
  Repeated large voids carry the risk of long-term morbidity and medical advice should
be sought.

Obstetric Bladder Care and management
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ID 1.101429
Regard printed versions of this document as out of date – The
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Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429  Issue Date  10 February 2021  Review Date 10 February 2023

Guidelines for first void and removal of IDC
Removal of IDC if
Type of Delivery
Analgesia/anaesthesia
First void
present
Spontaneous
None/ entonox/ opioid
Individual decision
4-6 hours postpartum
Vaginal Birth
dependant on risk
or from removal of IDC
factors/once able to
mobilise independently to
toilet
Spontaneous
Epidural/PCEA
Once able to straight leg
4-6hrs postpartum or
Vaginal Birth
raise and mobilise
from removal of IDC
independently to toilet
Instrumental Birth
Local Anaesthesia i.e. pudendal  Minimum 8 hours from
4-6 hours postpartum
block, local perineal infiltration  birth
or from removal of IDC
Individual directive by
registrar/consultant may
apply, see maternal notes.
If no instructions IDC to be
removed prior to 06.00am
following morning
Instrumental
Spinal or epidural top up for
Minimum 8 hours
Up to 6 hours from
Birth
birth
and up to 24 hours where
removal of IDC
there is extensive perineal

trauma from birth
Individual directive by
registrar/consultant may
apply, see maternal notes.
If no instructions IDC to be
removed prior to 06.00am
following morning
Caesarean Section
Spinal or epidural top up
Minimum 8 hours from
Up to 6 hours from
birth
removal of IDC
Individual directive by
Registrar/Consultant may
apply, see maternal notes
If no instructions IDC to be
removed prior to 06.00am
following morning

Obstetric Bladder Care and management
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ID 1.101429
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Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429  Issue Date  10 February 2021  Review Date 10 February 2023
Management of Retention
If a postnatal woman has not passed urine within 6 hours of giving birth or she has not passed
>200mls as a single void then consideration should be given to the woman’s hydration status,
her risk factors for retention and her bladder should be drained using a Foleys catheter.

NB:  Bladder  scanners  are  not  a  reliable  measurement  of  residual  volumes  in  the  early
postpartum period and are not recommended for use.

1.  If residual urine < 200mls then continue to observe the woman
2.  If 200 – 600ml residual urine; the IDC should remain insitu for 24 hours.
3.  If > 600mls the IDC should remain in for 48 hours.  Medical review should be sought
to assess the need for prophylactic antibiotics and follow up.

A urinary catheter specimen should be sent to the lab.
4.  The fluid balance chart must be completed if the woman is catheterised.
5.  Regular observation of the IDC for drainage is required. The collection bag should be
securely  attached  to  the  bed  with  a  blue  clip  holder  and  not  allowed  to  overfill  as
increased weight may cause traction of the catheter and pain.
If a woman is discharged with an indwelling urinary catheter insitu she must have
  Adequate education around catheter management.
  Follow up with WHAS for removal at a date agreed with the medical team.

For trial removal of catheter following retention
  Manage as per Guidelines for first void and removal of IDC
  If voids < 150mls discuss with registrar and consider replacing the IDC
  If voids 150-250 mls, continue measuring voids, liaise with medical staff
  Ensure the abdomen is palpated to assess bladder emptying
  Assess symptoms for overt / covert urinary retention previously listed
Option Protocol for TROC
When  there  are  recognisable  risks  for  urinary  retention  when  removing  a  catheter,  a
systematic approach to TROC is to retrograde fill the bladder through the Foley catheter. This
may be considered in discussion with the obstetric registrar and guidelines may be found in
the protocol Catheter management and Trial Removal of Catheter (TROC) for post-operative
Gynaecology Patients CapitalDoc ID 1.101411

Subsequent Management
  Pelvic floor exercises should be discussed and supporting literature provided.  Women
should be aware that pelvic floor exercises will need to continue in the longer term
  A physiotherapy referral is required for women considered to be at high risk of urinary
retention and bladder damage e.g. neurological disease, 3rd degree or 4th degree tear,
retention  associated  catheterisations  >24  hours and for  all  women  with more  than
one failed trial of void
Obstetric Bladder Care and management
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ID 1.101429
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Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429  Issue Date  10 February 2021  Review Date 10 February 2023
  Before  discharge  ensure  that  follow  up  has  been  arranged,  as  discussed  with  the
obstetric team consultant
  A discharge summary must be completed by the House Surgeon or Registrar

References
Baldini, G, Bagry, H, Aprikian, A, Carli, F, (2009) Postoperative urinary retention: Anaesthetic
and
perioperative
considerations
Anesthesiology
110(5):1139-57.
doi:10.1097/ALN.0b013e31819f7aea
Liang,  C.C,  Chang,  S.D,  Chang,  Y.L,  Chen,  S.H,  Chueh,  H.Y,  Cheng,  P.J.  (2007)  Postpartum
urinary  retention  after  caesarean  delivery  International  Journal  of  Gynaecology  and
Obstetrics 99, 229-232  doi:10.1016/j.ijgo.2007.05.037
Mostwin et al (2005) Third international consultation on incontinence recommendations of
the
international
scientific
committee,
retrieved
from
http://www.icsoffice.org/documents/ici_3/v2.pdf/summary.pdf
Nice (2003) Infection control. Prevention of health care associated infection in primary and
community
care
retrieved
from
http://www.nice.org.uk/nicemedia/pdf/Infection_control_fullguideline.pdf
Nice  (2007)  Intrapartum  care:  management  of  and  delivery  of  care  to  women  in  labour
retrieved from http://www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf
RCOG  (2002)  Study  Group  Recommendations,  incontinence  in  women  retrieved  from
http://www.rcog.org.uk/print/news/rcog-study-group-publishes-incontinence-
recommendations
RCOG (2007) Management of third and fourth degree perineal tears following vaginal delivery
(green-top  guideline  29)  Royal  college  of  Obstetricians  and  Gynaecologists  retrieved  from
http://www.rcog.org.uk/womens-health/clinical-guidance/management-third-and-fourth-
degree-perineal-tears-green-top-29
RCOG (2011) operative vaginal delivery guideline (Green-top guideline 26) Royal College of
Obstetricians  and  Gynaecologists  retrieved  from  http://www.rcog.org.uk/womens-
health/clinical-guidance/operative-vaginal-delivery-green-top-26
Rizvi,  R.M,  Khan,  Z.S,  Khan  Z  (2005)  Diagnosis  and  Management  of  postpartum  urinary
retention.  International Journal  of  Gynecology  and  Obstetrics  91  (1),  71-72  retrieved from
http://www.ijgo.org./article/S0020-7292(05)00387-5/pdf
Saultz,  J.W,  Toffler,  W.L,  Shackles,  J.Y.  (1991)  Postpartum  urinary  retention.  Journal  of
American
Board
Family
Practice
4
(5):
341-4
retrieved
from
http://www.ncbi.nlm.nih.gov/pubmed/1746303
Zaki, 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  and
Gynaecology 111, 874-876 doi:10.1111/j.1472-0528.2004.00200.x
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Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429  Issue Date  10 February 2021  Review Date 10 February 2023
Rogers  R  G  &  Leeman  LL.  Postpartum  genitourinary  changes.  Urological  Clinics  of  North
America 2007; 34 13-21

Disclaimer: This document has been developed by Capital & Coast District Health Board
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