Intra Partum and Postpartum Bladder Care Guideline

Bladder care during labour and immediate post partum period/ Sept 2012/review Sept 2015 of 9

CLINICAL GUIDELINE FOR INTRAPARTUM AND POST PARTUM BLADDER

CARE

1. Aim/Purpose of this Guideline 1.1. To provide guidance to midwives and obstetricians on the management of bladder care during labour and in the immediate post partum period. 1.2. To give guidance for the correct documentation of bladder care

2. The Guidance 2.1. Background

Voiding dysfunction includes: • urinary retention (failure to pass urine spontaneously or within 6 hrs of

catheter removal), • multiple small void: may indicate overflow incontinence • slow stream, dribble, • incomplete emptying, • hesitancy, • Frequency of micturition, • Dysuria • Feeling of a full bladder • Absence of sensation¹

Intrapartum bladder management is aimed at identifying risk factors for bladder dysfunction and adopting preventive measures to minimize the incidence and impact of post partum voiding dysfunction (PPVD). A woman’s bladder, post partum has a tendency to be under active and in the phase of post partum diuresis, is vulnerable to retention. Bladder sensation may be affected following birth and women my not have the sensation of a full or over distended bladder. Severe or prolonged bladder over distention can cause permanent damage to the detrusor muscle leading to bladder under activity, recurrent urinary tract infections, incontinence and significant voiding problems in the woman’s life3.The incidence reported varies from 0.7% to 4% of deliveries2, 7

2.2. Risk factors Any woman can develop PPVD regardless of mode of delivery and analgesia used. However the following women are at increased risk4, 5, 6, and 7

• Epidural or Spinal anaesthesia • Primigravida • Prolonged labour • Assisted vaginal deliveries • Caesarean section • Significant perineal or periurethral trauma • Significant immobility • Past history of voiding problems


2.3. Intrapartum and immediate post partum bladder care Adequate bladder care during labour and the immediate post partum period can reduce the incidence of bladder over distension and enable prompt recognition of a woman with voiding dysfunction.

• Bladder emptying including self void should be documented throughout labour1, on the partogram.

• The volume voided should be recorded. In the community setting, if measuring is not practical an estimation of the amount voided must be documented.

• If the woman cannot self void then the bladder should be emptied every 4 hours with intermittent catherisation.

• If an in and out catheter is required a second time during labour, and delivery is not imminent an indwelling catheter should be recommended.

• For women with epidural analgesia and an indwelling catheter insitu, the indwelling catheter should be left in for at least 6 hrs after the last epidural top up or until the woman is mobile which ever is the sooner. The time of removal of the catheter should be documented and the time of the first void should be documented in the post natal section of the hand held notes

• Operative delivery/procedure under a normal epidural top up an indwelling catheter should be sited for at least 6-8 hours. If an additional stronger top up is administered then this should be extended to at least 12 hours post delivery. The time of removal of the catheter should be documented and the time of the first void should be documented in the post natal section of the hand held notes

• Operative delivery with a local anaesthetic - The timing and volume of the first void should be documented on the immediate care after birth page. This should be no later than 6 hours post delivery. If the woman cannot void follow the flow chart in point 4.

• Spontaneous vaginal delivery: Women should have the timing of the first void documented on the immediate care after birth page, along with the subjective volume. This should be no later than 6 hours post delivery and prior to an early discharge home. For home births women should be asked to contact the on call midwife if she hasn’t passed urine within the 6 hour period.

• Women who have undergone repair of a third or forth degree tear under a spinal or epidural anaesthesia, should have an indwelling catheter for at least 12 hours. If there is other significant genital trauma, consideration should be given to an indwelling catheter for 24 hours following delivery5. The time of removal of the catheter should be documented and the time of the first void should be documented in the post natal section of the hand held notes

• If the woman has not voided prior to leaving delivery suite this should be communicated to the postnatal ward staff and the timing and subjective volume of first void should be documented on the immediate care after birth page 8.

• Caesarean section- all women who undergo either elective or emergency caesarean section should have an indwelling catheter inserted for at least 12 hours. The time of removal of the catheter should be documented and the time of the first void should be documented in the post natal section of the hand held notes


• Any woman who has had an indwelling catheter inserted during the

first stage of labour should have the balloon deflated for the active second stage.

2.4. Postpartum bladder care

If the woman has not successfully voided within 6 hours of birth or catheter removal, efforts to assist voiding should be undertaken, such as taking a warm bath or shower. If measures to encourage voiding are not immediately successful the flow chart below should be followed. If a woman is at home and has not successfully passed urine within 6 hours, immediate arrangements should be made to admit her to the post natal ward.

2.5. Following the emptying of the bladder by catheterisation in the post partum period1: -

• Check for vulval oedema and if present, maintain an indwelling catheter for 24hrs or until oedema has resolved.

• Check urine dipstick and send MSU or CSU to check for infection • Ensure the woman is drinking at least 1500 ml of fluid in 24 hours.

Insert in/out catheter and measure and document volume drained or measure residual volume with a bladder scanner

If < 500mls drained/measured

Encourage voiding within next 2 hours, measure

volume voided and post void residual with either an in out catheter or bladder scanner

Insert indwelling catheter for 24 hours Inform Obstetrician

Remove catheter and encourage voiding within 4 hours. If

residual volume <150 mls for discharge with

no follow up

If post void residual

<150ml then no further

management unless

symptomatic

If unable to void or post void

residual >150ml

If post void residual >150 mls catheter to

stay in for 7 days. For persistent

voiding problems, to teach intermittent

self catheterisation (ISC) and refer to

Nurse Consultant for continence

If >500ml drained


2.6. References 1. Rohna Kearney, Alfred Cutner; Postpartum voiding dysfunction; The

Obstetrician & Gynaecologist, 2008; 10:2:71-74 2. Ching-Chung L. Shuenn-Dhy C. Ling-Hong T. Ching-Chang H. Chao-Lun C.

Po-Jen C. Postpartum urinary retention: assessment of contributing factors and long-term clinical impact; Australian & New Zealand Journal of Obstetrics & Gynaecology. 2002; 42(4):365-8,

3. Dorflinger A, Monga A.Voiding dysfunction.Curr Opin Obstet Gyneco 2001; 13:507-12

4. Jeffery TJ. Thyer B. Tsokos N. Taylor JD. (1990) chronic urinary retention postpartum. Australian & New Zealand Journal of Obstetrics & Gynaecology; 1990 Nov. 30(4):364-6.

5. Watson WJ. (1991) Prolonged postpartum urinary retention. Military Medicine; 1991. 156(9):502-3.

6. Carley ME. Carley JM. Vasdev G. Lesnick TG. Webb MJ. Ramin KD. Lee RA. Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery. American Journal of Obstetrics & Gynecology; 2002; Aug 187(2):430-3.

7. Glavind K. Bjork J. (2003) Incidence and treatment of urinary retention postpartum. International Urogynecology Journal; 2003; Jun 14(2):119-21.

8. Zaki MM, et al. National survey for intrapartum and postpartum bladder care: assessing the need for guidelines. BJOG; 2004Monitoring compliance and effectiveness

3. Monitoring compliance and effectiveness Element to be monitored

• The audit will take into account record keeping by obstetric, anaesthetic and paediatric doctors, midwives, nurse, students and maternity support workers.

• The results will be inputted onto an excel spreadsheet • The audit will be registered with the Trust’s audit department

Lead • Maternity risk management midwife

Tool No intrapartum catheter in situ: • Was the timing of the first void documented on the

immediate care after birth page. • Was the timing of the first void within 6 hours, prior to

discharge home or prior to the midwife leaving the woman’s home.

• If there was no void within 6 hours was the flow chart on page 3 followed.

Catheter insitu:

• Was the time the catheter was removed documented in the post natal notes.

• Was the timing of the first void following catheter removal documented in the post natal notes.


• If there was no void within 6 hours of catheter removal was the flow chart on page 3 followed

Frequency 1% or 10 sets whichever is the greater, of all health records of women who have delivered will be audited over a 12 month period

Reporting arrangements

• A formal report of the results will be received annually at the maternity risk management and clinical audit forum, as per the audit plan

• During the process of the audit if compliance is below 75% or other deficiencies identified, this will be highlighted at the next maternity risk management and clinical audit forum and an action plan agreed

Acting on recommendations and Lead(s)

• Any deficiencies identified on the annual report will be discussed at the maternity risk management and clinical audit forum and an action plan developed

• Action leads will be identified and a time frame for the action to be completed by

• The action plan will be monitored by the maternity risk management and clinical audit forum until all actions complete

Change in practice and lessons to be shared

• Required changes to practice will be identified and actioned within a time frame agreed on the action plan

• A lead member of the forum will be identified to take each change forward where appropriate.

• The results of the audits will be distributed to all staff through the risk management newsletter/audit forum as per the action plan

4. Equality and Diversity 4.1This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement.

4.2Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2.


Appendix 1. Governance Information

Document Title Clinical guideline for intrapartum and post partum bladder care

Date Issued/Approved: 8th October 2012

Date Valid From: 8th October 2012

Date for Review: 1st October 2015

Directorate / Department responsible (author/owner):

Dr Rajasri Obs and gynae directorate

Contact details: 01872 252729

Brief summary of contents

To provide guidance to midwives and obstetricians on the management of bladder care during labour and in the immediate post partum period. To give guidance for the correct documentation of bladder care

Suggested Keywords: Bladder care during labour and post delivery

Target Audience RCHT PCT CFT

Executive Director responsible for Policy: Medical Director

Date revised:

This document replaces (exact title of previous version):

Guideline for Intrapartum and postpartum bladder care

Approval route (names of committees)/consultation:

Maternity guideline group Obs and gynae directorate meeting

Divisional Manager confirming approval processes

Name and Post Title of additional signatories

Signature of Executive Director giving approval {Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Midwifery and obstetrics


Links to key external standards CNST 5.7

Related Documents:

Training Need Identified? no Version Control Table

Date Version No Summary of Changes Changes Made by

(Name and Job Title)

March 2011 1.0 Initial document

Dr Rajasri Consultant obstetrician

September 2012 1.1 Changes to compliance monitoring only

Jan Clarkson Maternity risk manager

All or part of this document can be released under the Freedom of Information Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the

express permission of the author or their Line Manager.


Appendix 2.Initial Equality Impact Assessment Screening Form

*Please see Glossary 7. The Impact Please complete the following table using ticks. You should refer to the EA guidance notes for areas of possible impact and also the Glossary if needed.

• Where you think that the policy could have a positive impact on any of the equality group(s) like promoting equality and equal opportunities or improving relations within equality groups, tick the ‘Positive impact’ box.

Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: Clinical guideline for intrapartum and post partum bladder care Directorate and service area: Obs and gynae diractorate

Is this a new or existing Procedure? Exisiting

Name of individual completing assessment: Jan clarkson

Telephone: 01872 252270

1. Policy Aim*

To provide guidance to midwives and obstetricians on the management of bladder care during labour and in the immediate post partum period. To give guidance for the correct documentation of bladder care

2. Policy Objectives*

To ensure safe management of the bladder through labour and immediate post partum period

3. Policy – intended Outcomes*

Up to date, evidence based practice

4 How will you measure the outcome?

Via compliance monitoring tool

5. Who is intended to benefit from the Policy?

Pregnant and newly delivered woman

6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b. If yes, have these groups been consulted? c. Please list any groups who have been consulted about this procedure.


• Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.

• Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.

Equality Group

Positive Impact

Negative Impact

No Impact

Reasons for decision

Age

Yes All pregnant and newly delivered women

Disability


Religion or belief


Gender


Transgender


Pregnancy/ Maternity


Race


Sexual Orientation


Marriage / Civil Partnership


You will need to continue to a full Equality Impact Assessment if the following have

been highlighted: • A negative impact and • No consultation (this excludes any policies which have been identified as not

requiring consultation).

8. If there is no evidence that the policy promotes equality, equal opportunities

or improved relations - could it be adapted so that it does? How?

Full statement of commitment to policy of equal opportunities is included in the policy

Please sign and date this form.

Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,

c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ

A summary of the results will be published on the Trust’s web site.

Signed Jan Clarkson

Date 24th September 2012

Intra Partum and Postpartum Bladder Care Guideline

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Transcript of Intra Partum and Postpartum Bladder Care Guideline