Bladder care, intrapartum and postnatal (1160)

Good intrapartum bladder care and prevention of postpartum urinary retention are of great clinical importance. During labour and birth, 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.

During labour:

• Encourage the woman to void spontaneously at least every 3- 4 hours.
• If unable to or has difficulty voiding insert indwelling catheter or in/out catheter every 4 hours, or earlier if woman needs to void.
• Insert indwelling catheter if an epidural is sited with free flow drainage bag attached. Urometers should be used where clinically indicated.
• Prolonged use of IV oxytocin (Syntocinon®) is associated with fluid retention and reduced urinary output.
• Manage fluid input as per intrapartum guidance, according to the woman’s needs, and in conjunction with the medical team.
• Document the catheterisation, the reason, type, size and amount of water inserted into balloon in the appropriate Badger tab.
• The amount of urine passed should be measured and volume, time, whether void was spontaneous or catheterised and urinalysis documented on the partogram. An accurate record of urine and fluid balance chart should be recorded on Badger throughout the intrapartum period.
• If urine output is < 100mls over 4 hours, refer to medical staff for review.
• Ensure bladder is empty before start of pushing. Then remove the catheter, rather than just deflating the balloon. After delivery, if required, re-insert a clean catheter.

Fluid balance charts must be completed on Badgernet in the following instances:

• All intrapartum women
• All postnatal women until they have provided a credible first void
• All women with an indwelling catheter in situ post birth
• If intravenous fluids are in progress
• Any woman reporting concerns with voiding

Ensure fluid balance includes fluid intake (oral and IV) and all fluid output (Urine, vomit and blood loss). Aim for a neutral fluid balance.

Ensure to include fluid balance information and bladder care in each SBAR handover.

Aim

• To standardise the practice for management of bladder care in the postnatal period
• To diagnose and manage postnatal voiding problems

Background

It is vital to monitor bladder function in the postnatal period. This will ensure there are no issues preventing the woman from passing urine, which could risk the development urinary retention. If a woman has not passed urine within 6 hours of birth or removal of an indwelling catheter, investigations should be carried out to determine whether this is a voiding dysfunction or acute urinary retention.

Acute urinary retention is defined by the International Continence Society as a ‘Painful, palpable or percussable bladder when the women is unable to pass any urine’ (ICS 2018). This can follow labour or birth especially when the woman has any of the risk factors below:

• Instrumental birth
• Prolonged second stage
• Caesarean birth
• Epidural or Spinal anesthesia
• Obstetric Anal Sphincter Injury (OASIS)
• Episodes of urinary retention in labour

Common causes of postnatal urinary retention are:

• Bruising/swelling around bladder/urethra
• Pain
• Over-distention of bladder – delaying a trial of voiding (TOV) can affect voiding due to bladder atony
• Pre-existing voiding dysfunction
• Unable to relax
• Urinary tract infection (UTI)
• Pudendal nerve damage following child birth

Some of these factors (such as pain or UTI) are modifiable and should be explored and addressed if there are any concerns with bladder function in postnatal period.

Signs and Symptoms of Urinary retention:

• Frequency – every half hour to an hour.
• Urgency – needing to rush to the toilet.
• Feeling of incomplete emptying and needing to go back soon after to try and empty again.
• Constant sensation of needing to void.
• A lack of sensation in the bladder – not aware that the bladder is full.
• Unable to pass urine at all.
• New onset of urinary incontinence.
• Pain associated with not being able to pass urine.
• Passing small volumes – 100mls or less.

Removal of Catheter in the Postnatal Period

The planned date for catheter removal should be clearly documented in the postnatal care plan if clinical circumstances dictate this should be different to the routine.

Once women are able to mobilise, timing of removal of indwelling catheter from birth/ last regional anaesthetic top up:

Points to remember:

• Encourage all women to void within 6 hours of delivery or removal of indwelling catheter. First void must be measured for all women to ensure adequate volume is passed.
• Catheters should be removed during the normal working day, NOT OVERNIGHT. If catheter is due for removal after 20:00 hours, it should be left in situ until the next morning due to reduced fluid intake and the increased risk of failure to recognise/ escalate retention overnight. This rationale should be communicated with the women.
• Whilst awaiting void, women should be encouraged to drink normally. Women should drink to thirst, not drink as much as they can with 1½ -2 litre maximum over 24 hours.
• Fluid balance volume chart to be accurately completed. The amount of urine voided and bladder scan post void residual (PVR) volumes should be recorded. (See flowchart.)
• All women should be given a bedpan to record their voided volume and report to their midwife for recording.
• PVR volume should be measured immediately after the woman passes urine.
• If a woman is reporting bladder pain and unable to pass urine at any point, check PVR by real-time bladder scanner and follow protocol as below.
• Women should not be left longer than 6 hours without attempting to void.
• Any abnormalities in voiding urine please follow the flow chart attached.
• All women with urinary retention or increased post void residuals should have an MSSU sent.
• Any postnatal women with a catheter passing <30mls/hour or with a positive fluid balance >1500mls should have their catheter checked and be escalated to medical staff for review.

Trial of Voiding

• Ask the woman to void and measure the voided volume. If voided volume is more than 250ml follow green pathway.
• If the woman voids less than 250ml check post void residual (PVR) using a real time bladder scanner preferably or by in and out catheter
  • If PVR ≤ 150mls encourage regular fluid intake and repeat TOV after 4hours
  • If PVR >150mls and < 1000mls follow the red pathway.  Insert indwelling catheter for 24 hours and leave on free flow. You may also consider Clean Intermittent Self Catheterisation (CISC). Women following this method must be taught how to self catheterise as described below. The woman should repeat the TOV after 24 hours.
  • If PVR ≥ 1000mls follow the red pathway. Insert indwelling catheter for 1 week and leave on free flow. You may also consider Clean Intermittent Self Catheterisation (CISC). Women following this method must be taught how to self catheterise as described below. Follow up should be arranged as below for trial without catheter (TWOC)

• If catheter is inserted document timing of catheter insertion and amount of urine drained (usually 20 min after insertion)
• After 2^nd failed TOV, women should have a catheter reinserted and follow up arranged in 1 week at the hospital (postnatal ward for QEUH, gynecology Ward for PRMH and DCU for RAH) for repeat trial without catheter. You can also consider CISC. (See flowchart). In dwelling catheters should be left on free drainage to allow bladder to rest and maximise bladder function after removal.
• Women who are doing CISC should be referred to Urogynaecology/Urology (see flowchart)
• For further referral see below.

Guidelines for women sent home with an indwelling catheter

• Ensure woman understands catheter care. She should have an emergency contact number for the ward
• Ensure woman has a follow-up appointment for TWOC in 1 week (trial of void without catheter)
  • In QEUH they should return to the postnatal ward.
  • In PRMH they should return to the gynaecology ward
  • In RAH they should return to maternity daycare
• Prophylactic antibiotics are not routinely required unless women is symptomatic of UTI or have a positive MSSU.
• A Foley catheter size 12 with a free drainage leg bag should be used as preferred practice. Flip flo valve with leg bag can be considered as an alternative option. The valve should be released every 4 hours during the day and the leg bag should be left on free drainage overnight
• If TWOC unsuccessful after 1 week, please inform the responsible clinician

Guidance on using bladder scanner

• Once a woman is identified as needing to be scanned the procedure must be explained to her and consent obtained
• If checking for Post Void Residuals (PVRs), the woman must be scanned as soon as possible after voiding.
• Assist the woman into a comfortable supine position with their head supported on a pillow
• Expose only the suprapubic area to allow access to scan
• Turn bladder scanner on
  • Select gender

• Apply ultrasound gel to the round dome of the scan dome, ensuring no air bubbles
• Place scan head 3cm above Symphysis Pubis and point towards expected bladder location
• Patient icon on scan head should point towards woman’s head
• Press the scan head button to start scanning
  • Keep steady / do not rotate whilst scanning

• Obtain 3 readings to confirm reproducibility and accuracy
• Once satisfied reading is correct press done and print out result.
• Inform the woman that procedure is finished and the result
• Clean scan head with alco-wipes
• The following must be documented:
  • Time of scan
  • Volume urine the woman voided spontaneously
  • PVR
  • Action taken as a consequence of result

Teaching Clean Intermittent Self- Catheterisation

Clean Intermittent self-catheterisation (CISC) is the act of passing a small hollow tube (the catheter) into the bladder to drain urine and removing it immediately afterwards when drainage ceased.

Advantages of CISC:

• More bladder control and complete emptying
• Improved quality of life and independence
• Discreet and convenient. No need for other appliances such as drainage bags, pads etc.

Advise women to:

• Assemble all the equipment, prepare the room, usually bathroom.
• Try to pass urine before catheterising.
• Using a disposable wipe, wash vulval area from front to back.
• Stick the catheter sachet with the adhesive patch to a place within reach.
• Wash hands thoroughly using liquid soap and water. Dry with disposable kitchen towel or wipe. Make fists with your hands until you ready to use.
• Choose a comfortable position, either sitting on the toilet, a chair or squatting-examples are in the booklet.
• Remember to tilt hips.
• Separate the labia with the non-dominant hand and then stretch the vulval area upwards.
• Hold the catheter like a pen with your dominant hand (See Image below)
• Identify the Urethra and slowly insert the catheter until urine starts to flow.
• If the catheter is inserted into the vagina by mistake, remove it and start again with a new catheter.
• When the flow stops gently insert the catheter a little further into the bladder, allowing any urine to drain into the toilet.
• Place a finger over the end of the catheter and gently pull out.
• Dispose of catheter
• Women who catheterise 4-5 times a day – should drink 1.5 - 2litres per day
• Staff register women with catheter company for delivery of catheters to woman’s home

Contact details:

It is the responsibility of midwife providing bladder care to refer woman as below using appropriate referral (see table above).

Referral form for QEUH (pdf)