Peripartum Bladder Management

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Peripartum Bladder Management 1 WACS Clinproc3.9May-11

SDMS ID: 2010/0303-0013.9-06WACS

Title: Peripartum Bladder ManagementReplaces: New PolicyDescription: Peripartum bladder management

Target Audience: Midwifery, Medical Staff & Physiotherapist, QVMUKey Words: Urinary incontinence, retention, catheterisation

Policy Supported:P2010/0304-001 Care of the Postnatal Women Following anUncomplicated Pregnancy and Birth

P2010/0302-001 Care of the Women Following a CaesareanSection

Purpose:

To ensure identification of mothers at risk of developing urinary problems Prevention of potential urinary complications Ensure appropriate treatment and follow up when problems identified.

Risk Factors

Primigravidae Prolonged labour, especially prolonged second stage Epidural for labour/birth, irrespective of mode of birth Need for catheter in labour Assisted vaginal delivery Caesarean section Perineal injury: haematoma, bruising, tear with inadequate analgesia. Overdistension of the bladder during/immediately following birth Larger than normal term baby

Prevention of Acute Bladder Distension in Labour

Encourage women to void every 2 to 3 hours. If unable to void on 2 occasions, threshold for catheterisation should be low.

If bladder palpable and woman can not void catheterisation is indicated.

Prevention of Acute Bladder Distension Postpartum

Check that the woman has voided within six hours of birth or catheter removal. Encourage 3 to 4 hourly voiding for the first 24 hours. Urine volumes of greater than 150ml should be voided at least 3 times in 24 hours. Consider urinary retention if a woman complains of increasing lower abdominal pain.

Postpartum Assessment of Bladder FunctionAsk the woman

if she can feel her bladder filling and whether she has an urge to void. is she is experiencing any discomfort or difficulty when voiding the frequency with which urine is passed
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the volume passed with each voidIf concerns are identified then commence bladder diary and inform medical officer andwomens health physiotherapist.

Management of Inability to VoidIf woman has not voided within 6 hours of birth: Ensure adequate analgesia given Commence bladder diary (see attachment 1)

Encourage to void in toilet and measure volume If the volume voided is less than 150ml or the residual volume greater than 150ml

(assessed with bladder scanner)o proceed to catheterisationo catheter should be left insitu if greater than 600ml urine obtained.o if the woman is unable to void after the in/out catheterisation, an IDC should be

inserted and left in for 48 hours. Assessment of adequate voiding

o measured voided volumes of greater than 150ml on three occasions in 24 hourso measured residuals of less than 150ml (using ultrasound)

Referral to Womens Health Physiotherapist Consider MSU and antibiotics as appropriate Consider referral to urologist.

Indications for an indwelling catheter

Lack of sensation from epidural block following birth the catheter should remainuntil full sensation has returned

Long or difficult labour the catheter should be left in for 24 hours Extensive perineal/vulval trauma in which case the catheter should be left in for 24

hours, or until swelling subsides History of difficulty in voiding, abnormal voiding pattern or an inability to void for 6

hours in which case the catheter should be left insitu for 24 hours.

Removal of an indwelling catheter

Remove catheter in the morning Commence bladder diary and provide specipan After removal measure voids until normal voiding pattern established and two

measured voids of 300ml or greater are obtained. Check residual urine (using bladder scanner) if the woman becomes distressed, is

unable to void or has no sensation to void.

Management of Stress Incontinence

Referral to Womens Health Physiotherapist Educate the woman about the function and importance of the pelvic floor muscles in

relation to bladder control and how to perform pelvic floor exercises.

Womens Health Physiotherapist

Should be informed of all women who have experience urinary retention or who havecomplained of incontinence of urine to facilitate assessment and ongoing outpatientfollow-up.


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Attachments

Attachment 1 Bladder Diary

Attachment 2 Background Information

Attachment 3 References

Performance Indicators: Evaluation of compliance with guideline to be achieved throughmedical record audit annually by clinical Quality improvementMidwife WACS

Review Date: Annually verified for currency or as changes occur, andreviewed every 3 years via Policy and Procedure workinggroup coordinated by the Clinical and Quality improvementmidwife. November 2009

Stakeholders: Midwives and medical staff WACS

Developed by: Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director(Nursing & Midwifery) Womens & Childrens Services

Dr A Dennis Sue McBeathCo-Director (Medical) Co-Director (Nursing & Midwifery)Womens & Childrens Services Womens & Childrens Services

Date: _________________________


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APPENDIX 1BLADDER DIARY

Womens Health PhysiotherapyLaunceston General Hospital

Ph: 6348 7216

NAME: UR No:Date started:

BLADDER DIARYIf you are unable to feel when your bladder is full and you are not getting an urge to emptyyour bladder, then it is important to make sure that you make yourself go to the toilet toempty your bladder every 3-4 hours.

If you do get an urge to empty your bladder then go. Record each time you pass urine DAY and NIGHT Write down the AMOUNT of urine passed each time (using the Specipan collection

unit provided white plastic) Tick if you felt an URGE TO GO or NO URGE FELT Write down what you were doing at the time of being wet eg: standing up, on the way

to the toilet, coughing and sneezing.

Urine OUT Fluid IN

Time AmountPassed

Urgeto go

Nourgefelt

Reason for being wet Timehaddrink

Type ofdrink

Amount(1cup =250ml)

Eg:7am

300ml 7.30am Tea 250ml


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APPENDIX 2BACKGROUND INFORMATION

Postpartum Urinary Retention (PUR)There is currently no standardized definition of PUR. Suggested definitions include: absence of spontaneous micturition within six hours of vaginal birth. in the case of caesarean section it is defined as no spontaneous micturition within 6

hour after removal of an indwelling catheter. as sudden painful or painless inability to void over a 24 hour period.

PUR may result due to: Hormones and contractile responses of the bladder Injured bladder innervation

Overt Bladder RetentionInability to pass urine within 6 hours of delivery, requiring catheterisation to drain a volumeabove normal bladder capacity (normal 400 600ml in females). Women will often

complain of pain and the desire to void, may have overflow incontinence mistaken asstress incontinence or maybe asymptomatic, particularly if an epidural was employed inlabour.

Covert Bladder RetentionFailure of the bladder to empty at least 50% of normal capacity or a post void residualvolume of 150ml. This woman will often have frequency and pass volumes of less than150 ml.

Assessing the BladderClinically preferred methods to estimated post void residual bladder volumes are palpation,

catheterisation and ultrasound. Bladder palpation using a single hand abdominally may detect a bladder with 300ml

or more. Catheterisation is associated with pain, haematuria, UTI Ultrasound (bladder scan) - ultrasound estimation of post void residual bladder

volume (PVRBV) in the postpartum period is accurate and not invasive.

Women wi th residual ur ine volumes of less than 700ml immediately postpartum areless likely to need repeat catheterisation.

Urinary retention in the postpartum period is common with reported incidenceranging from 1.5 to 17.9%


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APPENDIX 3REFERENCES

Ching-Chung L, Shuenne-Dhy C, Ling-Hong T, Ching-Chung H, Chao-Lun C & Po-J en C2002 Postpartum urinary retention: assessment of contributing factors and long-termclinical impactAustralian and New Zealand Journal Obstetrics & Gynaecology; 42: 4; 365.

Glavind K & Bjork J 2003 Incidence and treatment of urinary retention postpartumInternational Urogynecological Journal; 14: 119-121

Gyampoh B, Crouch N, OBrien, OSullivan C & Cutner A 2004 Intrapartum ultrasoundestimation of total bladder volume. BJOG; 111:103-108

King Edward Memorial Hospital Clinical Guidelines 2006 Management of third and fourthdegree perineal trauma. Online:http://www.kemh.health.wa.gov.au/development/manuals/guidelines.htm

National Institute for Health and Clinical Excellence 2006 Routine postnatal care of womenand their babies. Online:http://www.nice.org.uk/guidance/CG37/guidance/pdf/English

Royal Womens Hospital Clinical Practice Guidelines 2005 Management of third and fourthdegree tears. Online:http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3143

Yip S, Sahota D, Pang M & Chang A 2004 Postpartum urinary retentionActa Obstetricia etGynaecologica Scandinavica; 83: 881-891.

Yip S, Sahota D & Chang A 2003 Determining the reliability of ultrasound measurementsand the validity of the formulae for ultrasound estimation of postvoid residual bladder

volume in postpartum women. Neurology and Urodynamics; 22:255-260.

Zaki M, Pandit M & J ackson S 2004 National survey for intrapartum and postpartumbladder care: assessing the need for guidelines. BJOG: 111: 874-876
http://www.kemh.health.wa.gov.au/development/manuals/guidelines.htmhttp://www.kemh.health.wa.gov.au/development/manuals/guidelines.htmhttp://www.nice.org.uk/guidance/CG37/guidance/pdf/Englishhttp://www.nice.org.uk/guidance/CG37/guidance/pdf/Englishhttp://www.nice.org.uk/guidance/CG37/guidance/pdf/Englishhttp://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3143http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3143http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3143http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3143http://www.nice.org.uk/guidance/CG37/guidance/pdf/Englishhttp://www.kemh.health.wa.gov.au/development/manuals/guidelines.htm

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Peripartum Bladder Management