postpartum bladder care

8/13/2019 Postpartum Bladder Care

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Title of Guideline (must include the word Guideline (notprotocol, policy, procedure etc) GUIDELINE FOR POSTPARTUM

BLADDER CARE

Contact Name and Job Title (author)Dr Mausumi DasConsultant Obstetrician and GynaecologistExt No: 54665

Directorate & Speciality Obstetrics & Gynaecology

Implementation date March 2013

Version Version 2

Supersedes Version 1

Date of submissionMarch 2013

Date on which guideline must be reviewed (this should be one tothree years)

March 2016

Explicit definition of patient group to which it applies (e.g.inclusion and exclusion criteria, diagnosis) All postnatal patients

Abstract This guideline describes the early diagnosis andmanagement of postnatal voiding dysfunction

Key WordsPostpartum voiding dysfunction

Statement of the evidence base of the guideline has theguideline been peer reviewed by colleagues?

Evidence base: (1-5)

1a meta analysis of randomised controlled trials

1b at least one randomised controlled trial

2a at least one well-designed controlled study withoutrandomisation

2b at least one other type of well-designed quasi-experimental study

3 well designed non-experimental descriptive studies(ie comparative / correlation and case studies)

4 expert committee reports or opinions and / or clinicalexperiences of respected authorities

5 recommended best practise based on the clinicalexperience of the guideline developer

2a

Consultation ProcessObstetricians, midwives & urogynaecologists

Target audienceObstetricians & midwives


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This guideline has been registered with the t rust. However, clinical guidelines are guidelines only. Theinterpretation and application of clinical guidelines will remain the responsibility of the individual clinic ian.If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the reviewdate.


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Postpartum Bladder Care Guideline

Introduction

Postpartum voiding dysfunction is defined as failure to pass urinespontaneously within 6 hours of vaginal delivery or catheterremoval after delivery. It occurs in 0.7-4% of deliveries (Glavindand Bjork 2003, Ching-Chung et al 2002).

The postpartum bladder has a tendency to be underactive andtherefore vulnerable to retention of urine following trauma to thebladder, pelvic floor muscles and nerves during delivery. If

postpartum voiding dysfunction is unrecognised, it can lead to longterm sequelae such as bladder underactivity, prolonged voidingdysfunction, recurrent urinary tract infection and incontinence(Dorflinger and Monga, 2001).

The importance of prompt diagnosis and appropriate managementof this condition cannot be overemphasised as early intervention isthe key to ensuring rapid return to normal bladder function (Teo etal 2007)

Current Practice

The Royal College of Obstetricians and Gynaecologists studygroup recommends that no women should be allowed to go longerthan 6 hours without voiding or catheterisation postpartum(McLean and Cardozo, 2002).

Aim

The aim to prevent long term sequelae of postpartum retention byindentifying all women unable to pass urine 6 hours post deliveryand women who are symptomatic of voiding dysfunction.


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Risk Factors for Puerperal Voiding Dysfunction

Many risk factors have been identified for the development ofpostpartum voiding dysfunction, including the following (Ching-

Chung et al 2002, Khullar and Cardozo 1993):

PrimiparityInstrumental deliveryEpidural analgesiaProlonged labourPerineal trauma

Postpartum warning signs

Inability to pass urine 6 hours following delivery

Voided volume of less than 250 mls

Women who are symptomatic of voiding dysfunction such asslow urinary stream, urinary frequency, incomplete emptyingand incontinence.

It is important to recognise that acute retention can be painless inpostpartum period especially following epidural analgesia.Overt urinary retention is the inability to void postpartum.Covert retention occurs when a woman has elevated postvoidresidual urine volume>150mls with no symptoms of urinaryretention.Abnormal voiding parameters has been defined as a mean flowrate of 150 mls andresidual urine volume is >100mls (Ramsay and Torbet 1993).

Postpartum Bladder Care

Hospital birth

All women should void within 6 hours of delivery or 6 hours ofcatheter removal. The time of first void following delivery mustbe recorded in the postnatal early warning score (EWS) chartby the midwife responsible for the womans care. The volumevoided should also be measured and documented in hospital

records.


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It is important to be aware that epidural anaesthesia can affectbladder sensation and therefore it may be appropriate to leave anindwelling catheter in place for a longer period of time followingdelivery. If a catheter is in situ following an instrumental delivery,

manual removal of placenta or repair of third degree tear, thecatheter should not be removed until the woman is mobile andcareful attention should be paid to voiding within the following 6hours.

For all deliveries and procedures in theatre, where an epidural hasbeen topped up or had a spinal anaesthesia, it is expected that thewoman will be immobile for a few hours and should have anindwelling catheter inserted.

Non Voiders

If bladder emptying has not occurred within 6 hours of delivery orcatheter removal, bladder must be emptied by catheterisation (inand out) and the volume of urine recorded in the notes the midwiferesponsible for postnatal care. If the volume of urine drained bycatheterisation is less than 500 mls, the next voided volume andthe post void residual (PVR) needs to be measured either bycatheterisation (in and out) again or by bladder scan. If the PVR is

less than 150 mls, no further action needs to be taken.

If the drained volume on the first instance is more than 500 mls orthe PVR is more than 150 mls after the second void, an indwellingcatheter should be inserted. The catheter should be then left in situfor 24 hours. The consultant obstetrician must be informed atthis point.

Low voiders

All women whose initial voided volume is less than 250mls orreports any symptoms of voiding dysfunction should have theirpost void residual volumes measured and then the same protocolas above should be followed.

In all of the above cases, the time of voiding must bedocumented in the postnatal EWS chart. The voided volumes

and the post void residuals must also be recorded.Measurement of intake and output volumes needs to be


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recorded in these cases and a fluid balance chartcommenced.

Home birth

Following homebirth, the woman should be instructed to make anote of the time of first void and contact the community midwifethis has not occurred within 6 hours or if there are any symptomsof voiding problems. .Hospital referral must be considered if -

The woman has failed to void within 6 hours

The voided volume is less than 250 mls communitymidwives must assess this volume to the best of their ability,

considering the limitation of being able to accuratelymeasure the voided volume in the home environment.

There are any symptoms of voiding difficulty.

Further management and treatment

Further management aims to identify any factors contributing todelayed bladder emptying and to ensure adequate bladderdrainage while waiting for normal function to return.Following the diagnosis of urinary retention, following actionsshould be taken

A sample of urine must to be analysed (by dipstick) and sentfor culture (either by the midwife or the obstetrician) aspresence of infection is an important contributory factor toprolonged voiding dysfunction.

If a urinary tract infection is suspected, prompt antibiotictherapy should be initiated (see antibiotics in obstetricsguideline, NUH).

The perineum should be examined (either by the midwife orthe obstetrician) and if swollen or painful, a catheter shouldbe sited until the swelling and pain have settled.

Adequate analgesia is important, as perineal pain is asignificant factor in development of retention.

Constipation should be avoided and treatment given ifrequired. All of the above should be documented in hospitalrecords.


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After removal of catheter, the voided volume and post void residualvolume should be recorded by the midwife. Any further retention orincreased post void residuals, warrant continued bladder emptying

by indwelling urethral catheter for one week. Alternatively,intermittent self catheterisation(ISC) can be considered which canbe taught by a trained midwife on the ward. If the perineum is stilltender, indwelling catheter up to 2 weeks can be justified. Voidingdysfunction beyond this point warrants careful assessment andexaminationby an urogynaecologistas an outpatient.

The investigations, treatment and management plan must bedocumented in the hospital post natal records.

All women experiencing voiding dysfunction must have follow upappointment to be reviewed in the Pelvis after Pregnancy clinic.It is the responsibility of the midwife who discharges the womanfrom the postnatal area to ensure that this appointment has beenarranged


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Suggested management of post partum voiding dysfunction(Algorithm)

PVR Post void residual

TWOC Trial without catheter

>500mls

Insert in and out catheter and measure thevolume drained

150 mls

No void within 6 hours

Reassess ifPVR>150mls,

Catheter to stayin for 1 week/ISC

If PVR


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Monitoring Plan

The guideline for postpartum bladder care will be monitored in

conjunction with the NUH Maternity Services Clinical andOperational Monitoring Plan.

References

Ching-Chung L, Shuenn-Dhy C, Ling-Hong T, Ching-Chang H,Chao-Lun C, Po-Jen C. Postpartum urinary retention:assessment of contributing factors and long-term clinical

impact. Aust N Z J Obstet Gynaecol 2002;42:365-8

Dorflinger A, Monga A. Voiding dysfunction. Curr Opin ObstetGynaecol 2001;13:507-12

Glavind K, Bjork J, Incidence and treatment of urinary retentionpostpartum, Int Urogynecol J Pelvic Floor Dysfunct2003;14:119-21

Khullar V, Cardozo LD,Bladder sensation after epidural

analgesia. Neurourol Urodyn 1993;89:424-5

MacLean AB, Cardozo L. Incontinence in Women, London;RCOG Press; 2002

Ramsay IN, Torbet TE. Incidence of abnormal voidingparameters in the immediate postpartum period. NeurourolUrdyn 1993;12:179-83

Reo R, Punter J, Abrams K, Mayne C, Tincello D. Clinicallyovert postpartum urinary retemtion after vaginal delivery: arestrospective case-control study. Int Urogynecol J Pelvic Floordysfunc 2007; 18: 521-524

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