INTRAPARTUM AND POSTPARTUM BLADDER CARE

INTRAPARTUM AND POSTPARTUM BLADDER CARE This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. INTRODUCTION This guideline has been developed to optimise bladder health in labour and post delivery for ALL women, whilst reducing the risk of infection. Intermittent catheterisation is preferable to indwelling catheters as it has been demonstrated to be associated with lower rates of urinary tract infection whilst encouraging normal bladder function. The addition of Instillagel and an aseptic technique has been shown to further reduce the risk of Urinary Tract Infection (UTI) There is wide variation in intrapartum and postpartum bladder care and lack of evidence based guidelines. The following recommendations are derived from best practice and RCOG Operative Vaginal Delivery Guideline.26 Jan 2011 High risk women who remain on delivery suite will have an individual care plan e.g. women with pre-eclampsia or massive postpartum haemorrhage. THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS: All Midwives, Health Care Assistants and obstetricians. Urogynaecology Nurses, Continence Advisors Lead Clinician(s) Helen Greenham Urogynaecology Nurse Specialist Paul Moran Consultant Urogynaecologist Alex Blackwell Consultant Obstetrician and Gynaecologist Rabia Imtiaz Consultant Obstetrician Approved for 6 month extension on: 6 th July 2015 Extension approved by TMC on: 22 nd July 2015 This guideline should not be used after end of: 6 th July 2017 WAHT-OBS-094 Page 1 of 11 Version 4.3

Key amendments to this guideline Date Amendment By: 22.01.10 Encourage 4 hourly voiding. Judi Barratt Wear apron when performing catheterisation. 19.08.11 Amendments to guidance on voiding in labour and postdelivery, and urine retention, agreed by Obstetric Clinical Governance-Risk Management Committee Rabia Imtiaz Judi Barratt 16.11.12 Date and time of insertion of catheter should be recorded on the partogram or case notes as appropriate. The volume drained should be recorded on the partogram or fluid balance chart. If less than 200mls voided within 6 hours of previous bladder emptying efforts to assist voiding should be advised. In the presence of incomplete urine emptying send CSU and if nitrates present on dip stick commence antibiotics. If total volume drained by in-out catheter is more than 1000mls immediately insert indwelling catheter for 5 days. Removal of Promocon checklist. 04/02/2015 Document extended for 3 month period whilst being transferred into treatment pathway format 06/07/2015 Document extended for 6 months whilst being transferred into pathway format 29/03/2016 Document extended for 12 months as per TMC paper approved on 22 nd July 2015 Alex Blackwell S Agwu Mr Agwu TMC WAHT-OBS-094 Page 2 of 11 Version 4.3

INTRAPARTUM AND POSTPARTUM BLADDER CARE INTRODUCTION All pregnant women are at risk of developing bladder and bowel continence difficulties. There is a wide variety of contributory factors and it is virtually impossible to predict who will develop retention. Therefore all women should be treated as potentially being at risk of urinary retention and incomplete bladder emptying. Retention has been reported in up to 14.1% of women after vaginal delivery, and up to 24.1% after caesarean section. All women should receive the Trust information leaflet Expecting a Baby in their booking pack Women should be encouraged to empty their bladder 4 hourly during labour. Each void should be measured and tested where possible and the results documented on the partogram. The importance of accurate fluid balance in labour for all women should be explained to them. Within the first 24-48 hours following delivery women should pass copious amounts of urine. This diuresis rapidly reduces the plasma volume and is caused by the withdrawal of oestrogen. Along with a fall in progesterone levels which helps to reduce fluid retention and reduce the haemodilution of pregnancy. Urine output is further increased as a result of the autolysis of the uterine muscle fibres. Micturition following delivery may be difficult for some women and the bladder can become over distended. If it is not dealt with promptly, over-distension of the bladder can lead to long term bladder dysfunction. Urinary retention with bladder distension should be avoided. Bladder sensation may be temporarily affected by child birth/regional anaesthetics, so lack of sensation does not indicate that the bladder is not full. Multiple small voids may also suggest a degree of urinary retention. Midwives should establish whether any woman is experiencing pain or difficulty in passing urine postnatally. Over distension can cause permanent damage to the bladder muscle and function. Operative delivery, prolonged labour, traumatic delivery, dense epidural/spinal anaesthesia may predispose to postpartum urinary retention, even minor perineal tears or an episiotomy can put patients at increased risk. GUIDELINE All catheterisations should be performed using aseptic technique (see below) and Instillagel must be used. Instillagel takes 5 minutes to have an effect and this will last for 30 minutes. Instillagel can be repeated after 30 minutes if recatheterisation is needed. ( more than 40ml of Instillagel should be used in 3 hours). Date and time of insertion should be recorded in the partogram or case notes as appropriate. Aseptic technique for catheterisation Clean hands with a bactericidal alcohol handrub. Put on sterile gloves and apron Place sterile towels across the patient's thighs. Using low-linting swabs, and an antiseptic solution clean the outer labia, separate the labia minora so that the urethral meatus is seen. One hand should be used to maintain labial separation until catheterization is completed. Clean around the urethral orifice using single downward strokes. Insert the nozzle of the instillagel into the urethra. Squeeze the gel into the urethra, remove the nozzle and discard the tube. Place the catheter in the receiver, between the patient's legs. WAHT-OBS-094 Page 3 of 11 Version 4.3

Introduce the tip of the catheter into the urethral orifice in an upward and backward direction. Advance the catheter until 5 6 cm has been inserted. Either remove the catheter gently when urinary flow ceases, or: Advance the catheter 6 8 cm. Inflate the balloon according to the manufacturer's directions, having ensured that the catheter is draining adequately. Measure and record the volume which is drained at the time of in out catheter, or within the next 10 minutes if an indwelling catheter is inserted. Record on the partogram or fluid balance chart as appropriate. Intrapartum Bladder Care See Intrapartum Bladder Care flowcharts for care with or without epidural (appendices 1 & 2). During first stage for all women in established labour either with or without an epidural: Encourage bladder emptying every 4 hours. Each void should be measured and, where possible, tested including ketones. If ketones present, review fluid intake or refer to medical staff. Measure, test and record all obtained specimens on partogram. If volume <100mls review fluid intake and check for palpable bladder. If no bladder palpable increase fluid intake. If bladder palpable consider in/out catheterisation and document the volume. Revisit pathway every 4 hours. NB: If more than 500mls in any void, empty bladder more frequently. Maintain intake and output record in birth notes page 11. NB: Indwelling catheters should not be used unless medically indicated e.g. hourly urometer for women with pre-eclampsia. Second stage bladder care Ensure bladder is empty at beginning of active second stage. Prior to any operative delivery always remove indwelling catheter or empty bladder with in out catheter. All women who have had an instrumental delivery in theatre as a trial with a heavy spinal/epidural block should be recommended to have an indwelling catheter to remain for at least 12 hours to avoid asymptomatic bladder overfilling. Postpartum bladder care Encourage women to void after delivery. Timing and volume of first void should be recorded on page 18 of the birth notes under immediate postnatal observations and page 4 in the Postnatal tes for Mother. A void should have occurred within 6 hours of last bladder emptying (spontaneous/ catheterisation) and the volume measured. This should be documented in the purple notes. A post-void residual should be measured if retention is suspected.(see below) Women who have had spinal anaesthesia or epidural anaesthesia may be at increased risk of retention and should be offered an indwelling catheter, to be kept in place for at least 12 hours following delivery to prevent asymptomatic bladder overfilling (allow reasonable amount of flexibility to suit the woman). WAHT-OBS-094 Page 4 of 11 Version 4.3

All women undergoing an operative delivery should have a fluid balance chart, for at least 24 hours, to detect postpartum urinary retention. Mother alerts should be completed on page 3 of postnatal notes which highlight a risk of urgency or incontinence, and a management plan documented on page 5. MANAGEMENT OF SUSPECTED POSTPARTUM URINE RETENTION If a woman has not passed urine or has passed only minimal amounts eg less than 200ml per void, within 6 hours of previous bladder emptying (spontaneous/ catheterisation), efforts to assist voiding should be advised - such as taking a warm bath or shower, optimise oral fluid intake and provide or optimise analgesia. If good urine volumes have not been passed by 6 hours after the birth and measures to encourage voiding are not immediately successful, the bladder volume or residual should be assessed by bladder scan and catheterisation should be performed if bladder scan indicates > 400ml in bladder (see below). Commence fluid balance chart at time of operative vaginal delivery or removal of indwelling catheter, or at 6 hours post delivery if not voiding normally. Record voided volumes and post void residual volumes on the fluid balance chart. Incomplete bladder emptying / retention: If residual urine volume on scan is >400 ml empty bladder by in-out catheter in first instance and record volume of urine drained and time of catheterisation on fluid balance chart. Dip urine sample and send CSU if indicated to rule out infection. If infection suspected ie nitrites present on dipstick, commence antibiotics. If total volume of urine drained via in out catheter is less than 400mls, encourage to drink normally and void again within 4-6 hours. Continue fluid balance chart and revisit pathway again at 6 hours with a further bladder scan and in-out catheter if bladder scan shows volume >400mls. If total volume drained via in out catheter is 400-800mls, encourage to drink normally and void again within 4-6 hours. Continue fluid balance chart and revisit pathway again at 6 hours with a further bladder scan and in-out catheter if bladder scan shows volume >400mls. If the second residual is over 400 mls insert an indwelling Foley catheter for 24 48 hrs. If total volume of urine drained via in out catheter is over 800 mls, immediately insert indwelling Foley catheter for 24 48hrs. If total volume of urine drained via in out catheter is greater than 1000ml immediately insert indwelling foley catheter for 5 days. Patients with a loss of sensation when passing urine must have an urgent neurological assessment. This should be done by the physiotherapist via and urgent referral (insert details of on call physio bleep etc). If a patient has an indwelling catheter for post partum voiding difficulty please inform the urogynae nurses by telephone extension 33803. The woman can go home and return for review on postnatal ward. (Supply and explain Care of Catheter leaflet.) Senior medical staff must be informed if a patient has an indwelling Foley catheter for post partum urinary retention or any loss of sensory neurological function. Trial WithOut Catheter (TWOC): WAHT-OBS-094 Page 5 of 11 Version 4.3

After removal of an indwelling catheter check 3 voids and post voids residuals. If void >400mls and residuals <100ml reassure the women and send home for review at 6 weeks in gynaecology clinic. If a patient requires re-catheterisation/has high post void residual volumes and confirmed urinary retention liaise with Community Continence Advisor or Urogynaecology Team. These women should be offered a physiotherapy referral to prevent urinary incontinence. If patient is diagnosed with postpartum urinary retention a Datix critical incident form should be completed to enable the midwife/doctor conducting the delivery and the consultant in-charge of the patient care to be informed. MONITORING TOOL How will monitoring be carried out? Who will monitor compliance with the guideline? Clinical Audit Obstetric Governance Committee STANDARDS % CLINICAL EXCEPTIONS Bladder emptying encouraged every 4 hours in labour 100% Voided volumes measured and recorded in labour 100% Bladder emptied before all instrumental deliveries 100% Recording in all post natal notes timing of catheter removal Recording in postnatal notes volume and time of first void Fluid Balance Chart completed for all assisted deliveries for first 24 hours post natal Documented involvement of Urogynaecology Team for all patients with postpartum voiding difficulty needing indwelling catheter Refer to consultant obstetrician when urinary retention is suspected REFERENCES 100% 100% 100% 100% 100% RCOG Guideline. 26, Operative Vaginal Deliveries; January 2011. NICE guideline CG37 Routine postnatal care of women and their babies, July 2006 NICE guideline CG55 Intrapartum care 2007 WAHT-OBS-094 Page 6 of 11 Version 4.3

APPENDIX 1 INTRAPARTUM BLADDER FLOW CHART WITH EPIDURAL IN SITU Encourage all women in labour to empty their bladder 4 hourly void for 4 hours Offer Bed pan Spontaneous void, measure test and record in partogram spontaneous void or volume <50mls Volume >100mls <= 100mls review fluid intake Check for palpable bladder In and out catheter using instillagel, measure test and record Observe for further 4 hours Important: Keep bladder capacity within 500mls.If > 500mls in one void empty bladder more frequently to prevent over distension. Measure test and record in partogram. Encourage women to void within one hour of delivery WAHT-OBS-094 Page 7 of 11 Version 4.3

APPENDIX 2 INTRAPARTUM BLADDER FLOW CHART WITHOUT EPIDURALS IN SITU Encourage all women in labour to empty their bladder 4 hourly void for 4 hours Offer Bed pan / UTT Spontaneous void, measure test and record in partogram spontaneous void or volume <50mls Volume >100mls <= 100mls review fluid intake Check for palpable bladder Palpable bladder Observe for further 4 hours palpable bladder consider fluid intake In and out catheter using instillagel, measure test and record Important: Keep bladder capacity within 500mls.If > 500mls in one void empty bladder more frequently to prevent over distension. Measure test and record in partogram. Encourage women to void within one hour of delivery WAHT-OBS-094 Page 8 of 11 Version 4.3

CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Judi Barratt Clinical Midwife Specialist Helen Greenham Urogynaecology Nurse Specialist Miss R Imtiaz Consultant Obstetrician Mr P A Moran Mr A Thomson Elaine Sutcliffe Continence Nurse Specialist Ann Skinner Continence Nurse Specialist Circulated to the following individuals for comments Name Designation Mrs A Blackwell Ms R Duckett Mrs S Ghosh Mr J Labib Miss J Meggy Mr M D Pickrell Mr B A Ruparelia Mrs J Shahid Mr J Uhiara Mr J F Watts Clinical Director C Poyzer Senior Midwife/Supervisor of Midwives J Byrne Senior Midwife/Supervisor of Midwives M Stewart Senior Midwife/Supervisor of Midwives D Daly Ward Manager, Postnatal Ward, WRH R Fletcher Clinical Pharmacist Members of Guideline Group (For consultation with their peers) J A Barratt Clinical Midwife Specialist (Chair) T Cooper Consultant Midwife M Chong Matron/Senior Midwife Delivery Suite, WRH L Coleman Community Midwife Team Leader, Worcester Team Y Cowling/H Walker Community Midwife, West Team C Crompton Team Leaders, Ward 15, Alexandra Hospital E Davis Midwife, Transitional Care Unit, WRH J S Farmer Midwife, Antenatal Clinic, WRH G Field/K Perkes Community Midwife Team Leader, Bromsgrove Team M Gough Midwife, Lavender Postnatal, WRH L Heywood Community Midwife, Evesham Team D Hughes Midwife, Lavender Postnatal, WRH B Kavanagh Community Midwife Team Leader, Redditch Team J Martin Midwife, Central Delivery Suite, Alexandra Hospital T Meredy Midwife, Antenatal Clinic, Alexandra Hospital S Tabberer Community Midwife Team Leader, Kidderminster M Boeck Community Midwife, Droitwich Team V Tristram Midwife, Kidderminster Hospital R Williams Midwife, Delivery Suite/PN Ward, WRH L Hatch Continence Nurse Specialist Circulated to the chair of the following committees/groups for comments/approval Name Committee/Group Alison Smith Medicines Safety Committee WAHT-OBS-094 Page 9 of 11 Version 4.3

Supporting Document 1 Checklist for review and approval of key documents This checklist is designed to be completed whilst a key document is being developed / reviewed. A completed checklist will need to be returned with the document before it can be published on the intranet. For documents that are being reviewed and reissued without change, this checklist will still need to be completed, to ensure that the document is in the correct format, has any new documentation included. 1 Type of document Guideline 2 Title of document 3 Is this a new document? If no, what is the reference number WAHT-OBS-094 4 For existing documents, have you included and completed the key amendments box? 5 Owning department Obstetrics 6 Clinical lead/s Miss Rachel Duckett 7 Pharmacist name (required if medication is involved) 8 Has all mandatory content been included (see relevant document template) 9 If this is a new document have properly completed Equality Impact and Financial Assessments been included? 10 Please describe the consultation that has been carried out for this document 11 Please state how you want the title of this document to appear on the intranet, for search purposes and which specialty this document relates to. Rosie Fletcher N/A Circulated to members of the Obstetric Governance Committees Once the document has been developed and is ready for approval, send to the Clinical Governance Department, along with this partially completed checklist, for them to check format, mandatory content etc. Once checked, the document and checklist will be submitted to relevant committee for approval. WAHT-OBS-094 Page 10 of 11 Version 4.3

Implementation Briefly describe the steps that will be taken to ensure that this key document is implemented Action Person responsible Timescale Information included in Effective Handover Miss Rachel Duckett October-vember 2012 Plan for dissemination Disseminated to Date Medical and midwifery staff via Effective Handover October-vember 2012 1 Step 1 To be completed by Clinical Governance Department Is the document in the correct format? Has all mandatory content been included? Date form returned 2 Name of the approving body (person or committee/s) / / Obstetric Governance Committee Step 2 To be completed by Committee Chair/ Accountable Director 3 Approved by (Name of Chair/ Accountable Director): Miss Rabia Imtiaz 4 Approval date 16 vember 2012 Please return an electronic version of the approved document and completed checklist to the Clinical Governance Department, and ensure that a copy of the committee minutes is also provided (or approval email from accountable director in the case of minor amendments). Office use only Reference Number Date form received Date document published Version. WAHT-OBS-094 Page 11 of 11 Version 4.3