Devising an Algorithm for early recognition & management of

Urinary Retention in the Rotunda Hospital

Mary O’Reilly Midwifery Practice Co-ordinator

26th April 2016

Urinary Retention • Defined as the inability to completely or partially empty the bladder.

Overt

• Symptomatic inability to void spontaneously within six hours of birth or removal of IDC.

– Straining to void/decreased sensation to void

Covert

• Non symptomatic increased post void residual volumes >150mls after birth or removal of IDC.

– May be passing small volumes

• Common in the pregnancy/ post natal period

– Incidence varies from 0.05 to 37%

– Short term complications – Recurrent UTI’s

– Long term complications – Permanent voiding dysfunction (Lim 2010)

Risk factors for urinary retention • Primiparity

• Epidural

• Episiotomy

• Assisted birth

• Prolonged 1st and 2nd stage of labour

• Baby birth weight >4kg

• Perineal trauma and pain

• Over distension of bladder >700mls during delivery

• Communication barriers (Yip et al 2005)

Clinical Audit

Urinary Retention

• Key findings: Inconsistency in diagnosis and management

• Conflict between midwives and doctors regarding treatment

PLAN: Standardized evidence based approach for management

Review of the literature and develop an algorithm to guide decision making

Education package for clinical department staff

GOAL: Decrease Urinary Retention and long term damage for the women

Re-audit: 6 month period following education to assess improvement in uniformity of management

Why an Algorithm • Method for solving a problem or

achieving a specific goal. It has one or more finite steps

• A systematic process consisting of an ordered sequence of steps, each step depending on the outcome of the previous one

• Use has been identified as an effective method to impart knowledge and guide decision making (Rathbun & Sahd 2009)

Development

– Multidisciplinary team involved

– The algorithm defined UR and post void residual, voiding efficiency, when and how to assess the patient, when to catheterize and success

– Review of previous cases of UR, feedback from midwifery and medical staff, literature search

– User friendly and easy access of algorithm for all staff

Implementation – Midwifery staff engaged with in- service education,

• Physiology of the urinary tract

• Normal voiding function

• Complications and techniques to monitor and diagnose malfunction of voiding process

– Communication with the medics - awareness of algorithm

• Lead champions identified at ward level

• Involvement of multidisciplinary team

• Education of patient

Algorithm For Urinary Retention

Step 1 • Passing small amounts of urine, Covert urinary retention suspected

• If first void is <200mls, monitor second void.

Step 2

• If second void <200mls, check residual with Foley’s catheter within 10 minutes of voiding.

• If residual volumes <150mls reassure the woman and continue conservative measures including a record of intake/output on fluid balance chart.

Step 3

• When passed 2 voids >200mls with residual < 150 on 2 occasions no further action is required, the patient can be reassured and discharged home with follow –up advice

• Patient education

Evaluation

Use of the algorithm was evaluated by:

1. Time of first void following birth of baby

2. Measurement of the 1st two voids

3. Measurement of residual urine

4. Use of continuous/ intermittent catheterisation

5. Measurement of voiding efficiency

6. Urinary retention greater than 500mls

Results Compared to the pre-

implementation group

– Intervention took place at an earlier stage

– Frequency of measuring post void residual increased

– Voiding efficiency increased

– Fewer patients required long term follow-up

– Goal of standardizing practice was realised

Challenges

• Limited availability of staff to attend education

• Documentation

• Requires ongoing analysis for sustainable change in practice and outcomes

Conclusions

• Since the introduction of the algorithm significant improvement in the management of urinary retention

• Decision aid for better safer care

• Facilitates translation of evidence into midwifery practice at the bedside

• Enhanced clinical decision making

• Use as a teaching tool

References • Lim JL. Post-partum voiding dysfunction and urinary retention. Aust N Z J

Obstet Gynaecol. 2010;50:502–5.

• Rathbun, M C & Ruth-Sahd, LA (2009) Algorithmic tools for interpreting vital signs. Journal of Nursing Education 48(7) 395-400

• Yip, S., Sahota, D., Pang, M., & Chang, A. (2005). Screening test model using duration of labour for the detection of postpartum urinary retention. Neurology and Urodynamics, 24, 248-253

• Yip, S., Sahota, D., Pang, M., & Chang, A. (2004). Postpartum urinary retention. Acta Obstetricia et Gynacologica Scandinavica, 83, 887-891