Bladder Care Postpartum

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Document Classification

Document Title Bladder Care Postpartum and Management ofUrinary Retention

Document Type Guideline

Key words bladder, urinary retention,

Author(s) role only Midwifery Educator , WH Physiotherapist andUrogynaecologist

Owner (seetable) role only Clinical Director of Obstetrics, Womens Health

Function(s) (seetable) Clinical Service Delivery

Scope (seetable) Single Service: Womens health: Obstetrics

Target Audience All clinicians involved in care of the Postpartum women

Date first published April 2008

Date this version published May 2010Date next scheduled review May 2012

Unique Identifier NMP200/SSM/073

CONTENTS

1. Introduction2. Management

a. Assessment on admission to the wardb. Subsequent assessment during first 6 hoursc. Urinary retentiond. Management following removal of catheter

3. Supporting Evidence4. Associated Documents5. Disclaimer
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1. Introduction: Post partum Urinary Retention: a risk management issue

The purpose of this guideline is to assist health professionals in bladder care duringthe post partum period, with the aim of preventing urinary retention and its long-termconsequences.

Hormone induced reduction in smooth muscle tone decreases bladder tone(hypotonia) during pregnancy and for a period following birth. These changes maypersist for days or longer in some women with the risk of over distension of the post-partum bladder(Saultz, 1991).

Vigilant surveillance of bladder function and early intervention where problems exist willprevent permanent bladder damage and long-term voiding problems (Rizvi, 2005).

While all women in the immediate postpartum period have the potential to experienceurinary problems, several factors increase the risk:

Prolonged/difficult labour

Delay in the second stage

Assisted birth

Caesarian birth

Epidural analgesia, particularly with local anesthetic

Perineal /vulval trauma

Over distension of the bladder during/immediately following birthLarge infant >4 kg

English as a second language

Pain

Constipation

Aims of Care

To assess bladder function

To detect any deviation/s from normal

To carry out timely preventative measures to avoid complications of urinarydysfunction following birth

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2. Management

There are two types of urinary retention that can affect women in the post-partumperiod:

Overt Retention: Symptomatic inability to void spontaneously within six hours ofbirth or removal of IDC

Covert Retention: Non symptomatic increased post void residual volumes afterbirth or removal of IDC
http://www.ncbi.nlm.nih.gov/pubmed/1746303http://www.ncbi.nlm.nih.gov/pubmed/1746303http://www.ncbi.nlm.nih.gov/pubmed/1746303http://www.ncbi.nlm.nih.gov/pubmed/16099462http://www.ncbi.nlm.nih.gov/pubmed/16099462http://www.ncbi.nlm.nih.gov/pubmed/16099462http://www.ncbi.nlm.nih.gov/pubmed/16099462http://www.ncbi.nlm.nih.gov/pubmed/1746303


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Back to Contents

a. Assessment on admission to the ward

The initial bladder assessment should include:

i. A review of the labour and birth history to detect any risk factorsii. History of urological problemsiii. Bladder palpationiv. Check to see if the woman has voided after vaginal birthv. IDC in situcheck that it is draining

An initial assessment will provide information on:

i. The presence of any urinary problemsii. Risk factors that may contribute to urinary problems

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b. Subsequent Assessment during first 6 hours post delivery or removal ofIDC

Continue to assess bladder functioning 2 hourly. If unable to void or quantity or flowis abnormal at 4 hours, refer to the post partumOvert urinary retention flowchart

(adapted from the WHA Guidelines, 2009).

Notes:

During the night: If there is no history of urological problems, use opportunitieswhen the woman is awake to check bladder. Women with a history may require2 hourly checking.

Onset and progression of urinary retention may be gradual and asymptomatic

It can take 8hrs for the bladder to regain sensation following epidural analgesia

Assessment:

Establish by questioning void or no void

If yes to void, ask the woman if she is experiencing any discomfort ordifficulty when voiding

Check the frequency with which urine is passed

Ask volume and quality of flow with each void

Examine the womens abdomen for displacement of the uterus and swellingof the lower abdomen

Palpate the womens bladder

Establish by questioning void or no void
http://ahsl6.adhb.govt.nz/main/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Overt.pdfhttp://ahsl6.adhb.govt.nz/main/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Overt.pdfhttp://ahsl6.adhb.govt.nz/main/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Overt.pdfhttp://ahsl6.adhb.govt.nz/main/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Overt.pdf


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The woman may complain ofovert symptoms (symptomatic inability to voidspontaneously within six hours of birth or removal of IDC):

An inability to voidIncreasing lower abdominal pain

Urgency

Straining to void

Involuntary loss of urine

Voiding frequent small amounts (retention with overflow)

Note: A distended bladder displaces the uterus upward and to the right side.There may also be a painful cystic swelling palpable in the suprapubic region.

Ifno void at 4 hours either post birth or removal of IDC use supportive measures,such as ambulation, privacy, shower, hands under cold running water, warmflannel over bladder or if necessary appropriate analgesia for pain relief toenhance the likelihood of micturition. Ensure adequate fluid intake and commencefluid balance chart.

Monitora further 2 hours: (i.e. until 6 hours post delivery or sooner if

discomfort)

if void and volume > 200mls continue with supportive measures andencourage 2 -3 hourly voiding

If no void or volume < 200mls drain bladder with IDC

When inserting a catheter:

i. Use a Foleys catheterii. Use a strict aseptic techniqueiii. Send CSU to labiv. Document on fluid balance chart

Note: Using a Foley catheter, instead of an in-out catheter prevents the risk ofintroducing bacteria into the urinary tract from a second catheterization should an

indwelling catheter be required.

A woman may have Covert urinary retention (Non symptomatic increased postvoid residual volumes after birth or removal of IDC):

Ability to void

But no urge to void

No obvious symptoms of retention

Refer to post-partumcovert urinary retention flowchart(adapted from the WHAGuidelines, 2009).

Back to Contents
http://ahsl6.adhb.govt.nz/main/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Covert.pdfhttp://ahsl6.adhb.govt.nz/main/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Covert.pdfhttp://ahsl6.adhb.govt.nz/main/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Covert.pdfhttp://ahsl6.adhb.govt.nz/main/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Covert.pdf


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c. Urinary retention

Alert Obstetric team

Diagnosed by symptoms and volume drained following insertion of IDC

Residual urinary volume of 150-700 mls will require IDC for 24 hours

Residual urinary volume > 700 mls will require IDC 48 hours

Women who have a residual volume of more than 700mls are more likely to requirerepeat catheterization (Ching-Chung, 2002). After a failed trial of removal ofcatheter consider discussion with urgogynae team for further management andrefer to the Ward physiotherapist.

Catheterization rests the over distended bladder allowing it to gain its elastic recoil.

It is advisable to remove urinary catheters early in the day to allow time for carefuland regular post catheterization bladder assessment.

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d. Management following removal of catheter (Trial of void)

Encourage 2-3 hourly voiding and document voids until normal voiding

patterns are established and two measured voids of 200mls or greater areobtained.

Reassess the bladder as documented and follow the appropriate flowchartfor post partumOverturinary retention or post partumCoverturinaryretention (adapted from the WHA Guidelines, 2009).

Document all findings on the fluid balance chart and in the clinical notes.

Persistent urinary retention will require long term resting of the bladder andmanagement by the Obstetric team in conjunction with Urogynaecology.

Note: Bladder scanners are not a reliable measurement of residual volumes in the

postpartum woman and are not recommended for use. The automatic calculation isrendered inaccurate because of the volume of the involuting uterus and itstendency to distort the bladder outline (Pallis & Wilson 2003).

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http://www.ncbi.nlm.nih.gov/pubmed/12403282http://www.ncbi.nlm.nih.gov/pubmed/12403282http://www.ncbi.nlm.nih.gov/pubmed/12403282http://localhost/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Overt.pdfhttp://localhost/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Overt.pdfhttp://localhost/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Overt.pdfhttp://localhost/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Covert.pdfhttp://localhost/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Covert.pdfhttp://localhost/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Covert.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/14712950http://www.ncbi.nlm.nih.gov/pubmed/14712950http://www.ncbi.nlm.nih.gov/pubmed/14712950http://www.ncbi.nlm.nih.gov/pubmed/14712950http://localhost/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Covert.pdfhttp://localhost/Groups/Everyone/POLICY/LocalProtocols/WomensHealth/Maternity/non-document%20controlled%20attachments/Post-PartumUrinaryRetention-Overt.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/12403282


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3. Supporting Evidence

a. Clickherefor: Zaki, M.M., Panid, M. & Jackson, S. (2204). National survey for

intrapartum bladder care: assessing the need for guidelines. BJOG: anInternational Journal of Obstetrics and Gynaecology, 111, 874-876.

b. Clickherefor: Yip, S., Sahota, D., Pang, M., & Chang, A. (2005). Screeningtest model using duration of labour for the detection of postpartum urinaryretention. Neurology and Urodynamics, 24, 248-253

c. Clickherefor: Yip, S., Sahota, D., Pang, M., & Chang, A. (2004). Postpartumurinary retention.Acta Obstetricia et Gynacologica Scandinavica, 83, 887-891.

d. Clickherefor: Van Os, A.F.M., & Van der Linden, P.J.Q. (2006).Reliability of anautomatic ultrasound system in the postpartum period in measuring urinaryretention. Acta Obstetricia et Gynecologica Scandinavica, 85, 604-607.

e. Clickherefor: World Health Organization. Postpartum care of the mother and

newborn: a practical guide. Maternal and newborn health.f. http://www.who.int/reproductive-health/publictions/msm_98_3_3.html Retrieved

30 April 2007.g. Clickherefor: Carley M.E et al., 2002: Factors that are associated with

clinically overt postpartum urinary retention after vaginal delivery Americanjournal of Obstetrics and Gynaecology

h. Clickherefor: Rogers, R G & leeman, L.lL. 2007 Postpartum genitourinarychanges. Urological Clinics of North America, 34 13-21

i. Clickherefor: Ching-Chung, L Shuenn-Dhy, C, Ling-Hong,T 2002 Postpartumurinary retention: assessment of contributing factors and long term clinicalimpact. Australia and New Zealand Journal and Obstetrics and Gynaecology,42 (4) 367-370

j. Click here for: WHA Clinical Practice Guideline March 2009k. Clickherefor: R.M. Rizvi, Z.S. Khan and Z. Khan, Diagnosis and management

of postpartum urinary retention, Int J Obstet Gynecol 91 (2005) (1), pp. 7172.l. Clickherefor: Saultz J.W., William L., Toffler W.L. & Shackles J. Y. (1991) Post

partum urinary retention. Journal of the American Board of Family Practitioners4, 341-344

m. Clickherefor: Pallis L. M. & Wilson M. (2003) Ultrasound assessment ofbladder volume: Is it valid after delivery? Australian and New Zealand Journalof Obstetrics and Gynaecology 43, 453-456.

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4. Associated ADHB Documents

n/a

5. Disclaimer

No set of guidelines can cover all variations required for specific circumstances. It isthe responsibility of the health care practitioners using these guidelines to adapt themfor safe use within their institutions and for the individual needs of patients.

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http://www3.interscience.wiley.com/cgi-bin/fulltext/118813664/PDFSTARThttp://www3.interscience.wiley.com/cgi-bin/fulltext/118813664/PDFSTARThttp://www3.interscience.wiley.com/cgi-bin/fulltext/118813664/PDFSTARThttp://www.ncbi.nlm.nih.gov/pubmed/15791626http://www.ncbi.nlm.nih.gov/pubmed/15791626http://www.ncbi.nlm.nih.gov/pubmed/15791626http://www.ncbi.nlm.nih.gov/pubmed/15453880http://www.ncbi.nlm.nih.gov/pubmed/15453880http://www.ncbi.nlm.nih.gov/pubmed/15453880http://www.ncbi.nlm.nih.gov/pubmed/16752241http://www.ncbi.nlm.nih.gov/pubmed/16752241http://www.ncbi.nlm.nih.gov/pubmed/16752241http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/MSM_98_3_/en/index.htmlhttp://www.who.int/reproductivehealth/publications/maternal_perinatal_health/MSM_98_3_/en/index.htmlhttp://www.who.int/reproductivehealth/publications/maternal_perinatal_health/MSM_98_3_/en/index.htmlhttp://www.who.int/reproductive-health/publictions/msm_98_3_3.htmlhttp://www.who.int/reproductive-health/publictions/msm_98_3_3.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/12193938http://www.ncbi.nlm.nih.gov/pubmed/12193938http://www.ncbi.nlm.nih.gov/pubmed/12193938http://www.ncbi.nlm.nih.gov/pubmed/17145356http://www.ncbi.nlm.nih.gov/pubmed/17145356http://www.ncbi.nlm.nih.gov/pubmed/17145356http://www.ncbi.nlm.nih.gov/pubmed/12403282http://www.ncbi.nlm.nih.gov/pubmed/12403282http://www.ncbi.nlm.nih.gov/pubmed/12403282http://www.ncbi.nlm.nih.gov/pubmed/16099462http://www.ncbi.nlm.nih.gov/pubmed/16099462http://www.ncbi.nlm.nih.gov/pubmed/16099462http://www.ncbi.nlm.nih.gov/pubmed/1746303http://www.ncbi.nlm.nih.gov/pubmed/1746303http://www.ncbi.nlm.nih.gov/pubmed/1746303http://www.ncbi.nlm.nih.gov/pubmed/14712950http://www.ncbi.nlm.nih.gov/pubmed/14712950http://www.ncbi.nlm.nih.gov/pubmed/14712950http://www.ncbi.nlm.nih.gov/pubmed/14712950http://www.ncbi.nlm.nih.gov/pubmed/1746303http://www.ncbi.nlm.nih.gov/pubmed/16099462http://www.ncbi.nlm.nih.gov/pubmed/12403282http://www.ncbi.nlm.nih.gov/pubmed/17145356http://www.ncbi.nlm.nih.gov/pubmed/12193938http://www.who.int/reproductive-health/publictions/msm_98_3_3.htmlhttp://www.who.int/reproductivehealth/publications/maternal_perinatal_health/MSM_98_3_/en/index.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/16752241http://www.ncbi.nlm.nih.gov/pubmed/15453880http://www.ncbi.nlm.nih.gov/pubmed/15791626http://www3.interscience.wiley.com/cgi-bin/fulltext/118813664/PDFSTART

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