For Use in: Maternity department By: Clinical staff caring for women during pregnancy, labour and postnatally For: Obstetric patients Division responsible for document: Division 3- Women and Children s Bladder care, labour, postnatal, pregnancy, Key words: urinary retention, post void residual,trial without Catheter, Clean Intermittent Self-Catheterisation Name of document author: Catherine Appleby Job title of document author: Locum Consultant Name of document author s Line Manager: S Mukhopadhyay, Job title of author s Line Manager: Consultant Obstetrician and Gynaecologist Supported by: N Kuruba, I Giarenis, Gynaecology Consultants, Vicki Harvey, Urogynaecology Specialist Nurse Maternity Guidelines committee Assessed and approved by the: If approved by committee or Governance Lead Chair s Action; tick here Date of approval: 28/03/2018 Ratified by or reported as approved to (if applicable): To be reviewed before: This document remains current after this date but will be under review To be reviewed by: Clinical Standards Group and Effectiveness Sub-Board 28/03/2021 Dr C Appleby or Senior Registrar for Obstetrics Reference and / or Trust Docs ID No: 12617 Version No: 3 Minor changes regarding the flow charts easier to Description of changes: follow and removing references to PAWS as it s closed. Compliance links: (is there any NICE related to guidance) If Yes - does the strategy/policy deviate from the recommendations of NICE? If so why? NICE CG190 Intrapartum Care: Care of healthy women and their babies during childbirth 2014 NICE CG 37 Postpartum Care 2006 There is no deviation from the guidelines except that we suggest techniques to encourage voiding by 4 hours if there are difficulties with voiding. Otherwise 6 hours assessment of voiding is recommended This guideline has been approved by the Maternity Guidelines Committee as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 1 of 16
Rationale for the Recommendations All women are at risk of post partum urinary retention. Post partum urinary retention is associated with prolonged voiding dysfunction, urinary infection and long-term bladder dysfunction. It is associated with prolonged hospital stays. Objectives 1. To standardise practice for management of bladder cares intrapartum and postnatally. 2. To diagnosed poor bladder emptying intrapartum and postnatally in a timely manner to avoid large volume urinary retention and prolonged voiding dysfunction. 3. To promote the timely review of postpartum women after delivery or removal of catheters and appropriate assessment of post void residual volumes. 4. To encourage the use of simple measures to promote voiding postnatally and assist women in achieving voiding. 5. To ensure women with post partum voiding dysfunction have continuity of care during their admission and post discharge. Components of the guideline: 1. Bladder cares in labour 2. Bladder care at delivery 3. Post partum bladder cares 4. Recognition of postpartum voiding dysfunction 5. Management of postpartum voiding dysfunction 6. Trial without catheters in the postnatal period 7. Care of women with prolonged voiding dysfunction Abbreviations PUR postpartum urinary retention PVR post void residual CISC clean intermittent self catheterisation SRC self retaining catheter TWOC trial without catheter PAWS Pregnancy and Wellbeing Assessment Service IVF intravenous fluids Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 2 of 16
Background The reported incidence of postpartum urinary retention (PUR) ranges from 0.05 14.1%. 1,2,3 The rate of prolonged voiding dysfunction in one series was 0.07%. 1 There are no conclusions regarding the long-term implications of PUR. 4 Studies report rates of 30-75% of long term frequency and urgency following an episode of PUR. 1 If there is large volume retention (>700mLs) a woman is more likely to need ongoing catheterisation. 1,3 In pregnancy the bladder has reduced tone, secondary to hormonal changes, allowing for increased storage capacity for increased urine production. 1,5 The length of the intraabdominal urethra also lengthens to reduce stress urinary incontinence during pregnancy. These changes usually resolve postpartum without any long-term effect. However in the immediate postpartum period the bladder s tone remains reduced and therefore prone to over distension, compounded by a physiological postpartum diuresis. During labour and delivery pressure of the presenting part causes compression of soft tissues of pelvis and pelvic nerves. Oedema of tissues surrounding the lower urinary tract and trauma are a cause of potential urethral obstruction. Perineal pain is also associated with urinary retention. For these reasons ALL women are at risk of postpartum retention and voiding dysfunction. Additional risk factors include 1,3,6 Primiparity Instrumental delivery Caesarean section Long labour Epidural Extensive perineal and vaginal injury Large birth weight Previous voiding dysfunction Constipation Research into postpartum urinary retention is limit and there is no consensus regarding definitions or management. It is recommended all obstetric units have a postpartum bladder care guideline. Reference 6 Accepted Definitions 4 Overt urinary retention inability to void spontaneously within 6 hours of vaginal delivery or removal of catheter requiring catheterisation Covert urinary retention PVR 150mLs after spontaneous void, verified by USS or catheterisation Covert urinary retention appears to resolve spontaneously, however the long term evidence of harm/harmlessness lacking. 4 Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 3 of 16
There is no evidence to suggest screening asymptomatic women is necessary. 4,6 However confirmation of normal voiding within six hours of delivery or removal of catheter for ALL women is advocated by RCOG and NICE. 6,7,8 Trial without catheter refers to any removal of catheter and monitoring of voiding. Procedures 1) Bladder care during labour (See Labour flow chart) 2) For delivery Bladder care begins in labour. Bladder care must be explained to women in labour Women must be encouraged to pass urine at least every 4 hours during labour Accurate urine output should be recorded on the partogram A fluid balance chart must be kept where epidurals of IVF are in progress If a woman is unable to pass urine after 4 hours a clinical assessment must be made. A palpable bladder or discomfort related to inability to void an in-out catheter suggests urinary retention. An in-out catheter should be passed and urine volume documented. Urine volume must be documented on the partogram. If 500mLs an SRC should be inserted and a fluid balance chart commenced Prior to delivery the SRC balloon, if in situ must be deflated Prior to instrumental delivery the bladder must be emptied, and volume measured If a SRC was in situ for labour it must be reinserted following delivery If a regional anaesthetic was utilised for delivery an SRC must be inserted post delivery with a plan for timing of removal documented in the notes If there has been urinary retention 700mLs in labour catheterisation for 1 week is indicated with a TWOC in GOPD If there has been urinary retention 1500mLs in labour catheterisation for 2 weeks is indicated with a TWOC in GOPD To arrange a TWOC in Gynaecology Outpatients: Complete Referral for Trial without Catheter (TWOC) Postnatal form Form on TrustDocs (search referral ) and at end of this guideline Email completed form to: urogynae@nnuh.nhs.uk Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 4 of 16
After delivery on Labour ward The delivering midwife or delivering doctor to triage whether or not a formal postnatal post void residual measurement is required. Who needs assessment of a PVR? 1. Women who are symptomatic of or suspected of having postpartum voiding dysfunction 2. Women who have had an SRC placed for retention during labour (any volume) 3. Women at high risk of postpartum voiding dysfunction. That is women who have 3 risks factors of: a. Long labour >12 hours b. Emergency Caesarean section c. Instrumental delivery (except for lift out Kiwi) d. Epidual or spinal analgesia or anasthesia e. Extensive perineal trauma or 3 rd /4 th degree tear Information for women The patient information leaflet Bladder Care after Pregnancy should be given to all women who require a catheter for bladder care. The leaflet can be found on TrustDocs. 3) Bladder care postpartum (Postpartum flow chart) - Process 1) Removal of catheter Catheters to be removed by 0800hrs. 2) Ask women to measure each void for 6 hours Ask women to inform their midwife if they are unable to void or are uncomfortable by 4 hours 3) Commence a Fluid Balance Chart These are an essential component of monitoring voiding function. If a fluid balance chart was used intrapartum it should continue postpartum Normal oral intake should be encouraged, excessive fluid intake may rapidly distend an atonic bladder. After removal of a catheter women must be encouraged to document the timing and volume of all oral intake and voids. The voided volume must be evaluated in relation to oral intake a large volume intake with small output suggests voiding dysfunction is possible. Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 5 of 16
4) If a woman reports being unable to void at 4 hours simple measures can be employed First void should be encouraged at either 4 hours from their last void in labour or after removal of catheter. This will allow the use of simple measures to be employed and a reassessment of voiding within 6 hours from their last void in labour or after removal of catheter. Simple measures may aid voiding 1 these include mobilising to the toilet vs. bed pan or commode, privacy, voiding in the shower, analgesia and water. If a woman is in distress with symptoms of urinary retention a PVR should be performed at this stage. 5) Review all women at 6 hours after their last void in labour or after removal of SRC The fluid balance chart is reviewed for volume and timing of voids. Women must be asked if the void was normal for them, with normal sensation and perceived complete emptying. A void of 200mLs with normal sensation suggests normal voiding. 4) Recognising postpartum voiding dysfunction (Postpartum flow chart) Being able to void does not mean that bladder emptying is complete. However most women who have voiding dysfunction will be symptomatic. Women who have had a regional anaesthetic may be asymptomatic. Symptoms of urinary retention or incomplete bladder emptying 6 Urinary frequency Slow stream Pain Incomplete emptying Incontinence Inability to void Measurement of PVR The need for a formal post void residual will have been documented at the time of delivery. Women who are symptomatic of voiding dysfunction with need a PVR regardless of risk factors at delivery. Catheterisation is the most accurate way off assessing the PVR and needs to be done as soon as possible after a void. A 12 or 14F female SRC with 10mL balloon should be used, to avoid recatheterisation of women with a large residual. This must be done within 6 hours of removal of SRC, sooner if symptomatic. This may be midwifery led as per the following flow chart. Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 6 of 16
The accuracy of bladder scanners in the postnatal period 9 does not appear to be as reliable due to the enlarged postpartum uterus and bladder oedema. Bedside 2-D USS can be used, but requires trained operators, and are more accurate vs. the bladder scanner formula bladder volume (mls) = height(cm) x width(cm) x length(cm) x 0.6. 5) Management of postpartum voiding dysfunction Assessment of voided Action Management volume and PVR PVR <150mL Remove SRC Nil further PVR/retention 150mL <700mLs PVR/retention 700mL PVR/retention 1500mL Leave SRC Inform registrar* Leave SRC Inform Urogynaecology SR*/Specialist Urogynaecology nurse Leave SRC Inform Urogynaecology SR*/Specialist Urogynaecology nurse Antibiotics SRC for 48 hours TWOC on Blakeney or Cley Obsetrics Ensure woman has Postpartum Bladder Care Information leaflet Antibiotics SRC at least 1 week TWOC GOPD outpatients Ensure woman has Postpartum Bladder Care Information leaflet Antibiotics SRC at least 2 weeks TWOC GOPD outpatients Ensure woman has Postpartum Bladder Care Information leaflet Complete Referral for Trial without Catheter (TWOC) Postnatal form Monitoring Form for urinary on TrustDocs tract infection (search referral ) and at end of this guideline Email completed form to: urogynae@nnuh.nhs.uk Urinary tract infection contributes to voiding dysfunction and should be sought in all women requiring catheterisation due to retention. 1 Catheter specimen urine must by dipsticked and sent for MC&S. If an SRC is inserted antibiotics should be prescribed for the length of catheterisation trimethoprim, nitrofurantion, cefradine. Medical Input* To arrange a TWOC in Gynaecology Outpatients: All women with postpartum voiding dysfunction must have a doctor s review can be the team doctors and plan for TWOC in 48 hours made if appropriate. Consider obstetric complication as cause or retention perineal/vaginal/pelvic exam +/- USS for pelvic haematoma. Chase MSU/CSU results Women requiring catheterisation for large volume retention and need prolonged Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 7 of 16
catheterisation they must be discussed and reviewed by a named urogynaecology senior registrar or consultant if senior registrar not available. Information for women The patient information leaflet Postpartum bladder care should be given to all women who require a catheter for bladder care. 6) Further Trial Without Catheter on Blakeney or Cley Obstetrics For women who have recognised postpartum voiding dysfunction and residual 150mL <700mL. Follow Flow Chart 3: 48 hour trial without catheter on Blakeney or Cley Obstetrics. Remove catheter by 0800hrs or on arrival in Cley Obstetrics. Within 6 hours ALL women must have a post void residual by SRC (see following table) If residual 150mLs SRC for one week and arranged TWOC in Gynaecology Outpatients Inform urogynaecology team urogynae@nnuh.nhs.uk. Antibiotics to continue while catheter in situ. Assessment of voided Action Management volume and PVR PVR <150mL Remove SRC Nil further VR/retention 150mL Leave SRC Inform Urogynaecology SR*/Specialist Urogynaecology nurse Antibiotics SRC for 1 week TWOC in GOPD To arrange a TWOC in Gynaecology Outpatients: Complete Referral for Trial without Catheter (TWOC) Postnatal form Form on TrustDocs (search referral ) and at end of this guideline Email completed form to: urogynae@nnuh.nhs.uk 7) Trial Without Catheter in Gynaecology Outpatients (Trial Without Catheter in GOPD flow chart) All women having a TWOC in GOPD will need evaluation of normal voiding with an assessment of PVR, as outlined above and as per the TWOC in GOPD flow chart. An input/output chart must be maintained and voided volumes interpreted with consideration of volume of oral intake. Volume voided Action Ongoing management Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 8 of 16
2 voids >200mLs Normal sensation 2 voids >200mLs Normal sensation If unable to pass urine or small frequent voids PVR <150 ml PVR 150mL and <200mL At four hours: Remain asymptomatic with PVR <200mLs At four hours: PVR 200mLs OR 150mL and <200mL and symptomatic Insert SRC PVR 150mL Insert SRC PVR <150mL No further action Measured voids two hourly with assessment of PVR at 4 hours Discharge with advice re timed voids 2-3 hourly Open access gynaecology 48 hours See following row for further management Inform Urogynaecology SR Rule out infection, dehydration review fluid balance Encourage timed voids Check 4 hour residual Open access gynaecology 48 hours Women requiring catheterisation for voiding dysfunction will be discussed and reviewed by a named urogynaecology senior registrar or consultant in their absence. This doctor will maintain continuity of care for the women regarding ongoing bladder cares, supported by the urogynaecology consultants and specialist urogynaecology nurse. Intermittent self catheterisation may be preferred vs. self retaining catheter with lower risk of infection. 10 In the immediate postpartum period perineal pain may preclude this. This should be considered in liaison with urogynaecology team after a failed 1 week TWOC, or if not possible a flip-flow valve with timed bladder emptying. 8) Care of women with prolonged voiding dysfunction If the first 1 week TWOC is failed further bladder management will be coordinated by the urogynaecology team in gynaecology outpatients, with a named urogynaecology consultant. Intermittent self catheterisation should be offered in this situation. If it is not possible a flip-flow valve with timed bladder emptying is preferred. Clinical Audit Standards derived from Guideline Retrospective study of patients notes. Compliance with intrapartum guidance Compliance with postnatal guidance - specifically Documentation of normal bladder sensation Completion of input/output charts Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 9 of 16
Percentage of women having PVR measured when indicated Percentage of women failing removal of catheter after retention of <500mLs or 500-700mLs in labour Number of women with: Retention >700mLs in labour/postnatal Postnatal readmission with urinary retention After TWOC Blakeney/PAWS GOPD Summary of Development and Consultation process undertaken before Registration and Dissemination The Guideline was drafted by the authors above and is intended for all clinical staff caring for obstetric patients during and following trial without catheter. Distribution list / Dissemination Method A copy to be supplied to areas within the Trust where gynaecological patients who are undergoing trial without catheter are being cared for. To be placed on the hospital intranet. References / Source Documents 1. Ching-Chung L et al. Postpartum urinary retention: an assessment of contributing factors and long-term clinical impact. Aust NZ J Obstet Gynaecol 2002; 42(4):367-370 2. Glavind K, Bjork J. Incidence and treatment of urinary retention post partum. Int Urogynaeco J Pelvic Floor Dysfunction 2003; 14:119-21 3. Teo R, Punter J, Abrams K et al. Clinically overt postpartum urinary retention after vaginal delivery: a retrospective case-control study. Int Urogynecol J 2007; 18:521 524 4. Mulder FEM, et al. Postpartum urinary retention: a systematic review of adverse effects and management. Int Urogynecol J 2014; 25:1605-1612 5. Cutner A, Cardozo LD. The lower urinary tract in pregnancy and the puerperium. Int Urogynecol J 1992; 3:317-323 6. Kearney R, Cutner A. Review Postpartum voiding dysfunction. TOG 2008; 10:71-74 7. NICE guidelines CG190 Intrapartum care: care of healthy women and their babies during childbirth. 2014 8. NICE guidelines [CG37] Postpartum Care. 2006 9. Lee JWS, Doumouchtsis SK, Fynes MM. Is Doppler planimetry a valid technique for the evaluation of postpartum urinary bladder volume? Int Urogynecol J 2008; 19:1019-1025 10. Hakvoort R, Thijs S, Bouwmeester F et al. Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for incomplete voiding after vaginal prolapse surgery: a multicentre randomised trial. BJOG 2011;118:1055 1060. Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 10 of 16
FLOW CHART 1: INTRAPARTUM BLADDER CARE Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 11 of 16
FLOW CHART 2: POSTPARTUM BLADDER CARE Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 12 of 16
FLOW CHART 3: 48 HOUR TRIAL WITHOUT CATHETER ON BLAKENEY AND CLEY OBSTETRICS This flow chart applies to women who have had recognised postpartum voiding dysfunction with post void residuals of 150mL <700mL in the postpartum period. Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 13 of 16
FLOW CHART 3: TRIAL WITHOUT CATHETER IN GOPD Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 14 of 16
Appendix 1 Date dd/mm/yyyy Patient Name.. Please keep your midwife up to date with your fluid intake Examples of fluid amounts: 85 mls Time Patient fluid intake Time Patient fluid intake 08:00 20:00 09:00 21:00 10:00 22:00 11:00 23:00 12:00 00:00 13:00 01:00 14:00 02:00 15:00 03:00 16:00 04:00 17:00 05:00 18:00 06:00 19:00 07:00 200 mls Total Total Grand Total of fluids 200 mls 750 mls Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 15 of 16
Appendix 2 Urogynaecology and Pelvic Reconstructive Surgery Referral for Trial without Catheter (TWOC) Postnatal Please complete all boxes below and email to urogynae@nnuh.nhs.uk Patient Name Hospital Number Date of Birth (dd/mm/yyyy) Patient Contact Telephone Number(s) Consultant Date of Delivery (dd/mm/yyyy) Mode of Delivery Post Void Residual Volume Date of Catheter Insertion (dd/mm/yyyy) Bladder Injury? Cystogram? Epidural? Other Relevant Delivery Information Patient Specific Information (if appropriate) Name of Person Requesting TWOC Designation Available via Trust Docs Version: 3 Trust Docs ID: 12617 Page 16 of 16