Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc)

GUIDELINE FOR POSTPARTUM BLADDER CARE

Contact Name and Job Title (author) Dr Mausumi Das Consultant Obstetrician and Gynaecologist Ext No: 54665

Directorate & Speciality Implementation date Version Supersedes Date of submission Date on which guideline must be reviewed (this should be one to three years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract

Obstetrics & Gynaecology March 2013 Version 2 Version 1

March 2013 March 2016

All postnatal patients This guideline describes the early diagnosis and management of postnatal voiding dysfunction

Key Words Postpartum voiding dysfunction Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-5) 1a meta analysis of randomised controlled trials 1b at least one randomised controlled trial 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasiexperimental study 3 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer Consultation Process Obstetricians, midwives & urogynaecologists Target audience Obstetricians & midwives 2a

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

Postpartum Bladder Care Guideline

Introduction Postpartum voiding dysfunction is defined as failure to pass urine spontaneously within 6 hours of vaginal delivery or catheter removal after delivery. It occurs in 0.7-4% of deliveries (Glavind and Bjork 2003, Ching-Chung et al 2002). The postpartum bladder has a tendency to be underactive and therefore vulnerable to retention of urine following trauma to the bladder, pelvic floor muscles and nerves during delivery. If postpartum voiding dysfunction is unrecognised, it can lead to long term sequelae such as bladder underactivity, prolonged voiding dysfunction, recurrent urinary tract infection and incontinence (Dorflinger and Monga, 2001). The importance of prompt diagnosis and appropriate management of this condition cannot be overemphasised as early intervention is the key to ensuring rapid return to normal bladder function (Teo et al 2007)

Current Practice The Royal College of Obstetricians and Gynaecologists study group recommends that no women should be allowed to go longer than 6 hours without voiding or catheterisation postpartum (McLean and Cardozo, 2002).

Aim The aim to prevent long term sequelae of postpartum retention by indentifying all women unable to pass urine 6 hours post delivery and women who are symptomatic of voiding dysfunction.

Risk Factors for Puerperal Voiding Dysfunction Many risk factors have been identified for the development of postpartum voiding dysfunction, including the following (ChingChung et al 2002, Khullar and Cardozo 1993): Primiparity Instrumental delivery Epidural analgesia Prolonged labour Perineal trauma

Postpartum warning signs Inability to pass urine 6 hours following delivery Voided volume of less than 250 mls Women who are symptomatic of voiding dysfunction such as slow urinary stream, urinary frequency, incomplete emptying and incontinence. It is important to recognise that acute retention can be painless in postpartum period especially following epidural analgesia. Overt urinary retention is the inability to void postpartum. Covert retention occurs when a woman has elevated postvoid residual urine volume>150mls with no symptoms of urinary retention. Abnormal voiding parameters has been defined as a mean flow rate of <10mls/sec when the voided volume is > 150 mls and residual urine volume is >100mls (Ramsay and Torbet 1993).

Postpartum Bladder Care Hospital birth All women should void within 6 hours of delivery or 6 hours of catheter removal. The time of first void following delivery must be recorded in the postnatal early warning score (EWS) chart by the midwife responsible for the womans care. The volume voided should also be measured and documented in hospital records.

It is important to be aware that epidural anaesthesia can affect bladder sensation and therefore it may be appropriate to leave an indwelling catheter in place for a longer period of time following delivery. If a catheter is in situ following an instrumental delivery, manual removal of placenta or repair of third degree tear, the catheter should not be removed until the woman is mobile and careful attention should be paid to voiding within the following 6 hours. For all deliveries and procedures in theatre, where an epidural has been topped up or had a spinal anaesthesia, it is expected that the woman will be immobile for a few hours and should have an indwelling catheter inserted. Non Voiders If bladder emptying has not occurred within 6 hours of delivery or catheter removal, bladder must be emptied by catheterisation (in and out) and the volume of urine recorded in the notes the midwife responsible for postnatal care. If the volume of urine drained by catheterisation is less than 500 mls, the next voided volume and the post void residual (PVR) needs to be measured either by catheterisation (in and out) again or by bladder scan. If the PVR is less than 150 mls, no further action needs to be taken.

If the drained volume on the first instance is more than 500 mls or the PVR is more than 150 mls after the second void, an indwelling catheter should be inserted. The catheter should be then left in situ for 24 hours. The consultant obstetrician must be informed at this point. Low voiders All women whose initial voided volume is less than 250mls or reports any symptoms of voiding dysfunction should have their post void residual volumes measured and then the same protocol as above should be followed. In all of the above cases, the time of voiding must be documented in the postnatal EWS chart. The voided volumes and the post void residuals must also be recorded. Measurement of intake and output volumes needs to be
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recorded in these cases and a fluid balance chart commenced. Home birth Following homebirth, the woman should be instructed to make a note of the time of first void and contact the community midwife this has not occurred within 6 hours or if there are any symptoms of voiding problems. . Hospital referral must be considered if The woman has failed to void within 6 hours The voided volume is less than 250 mls community midwives must assess this volume to the best of their ability, considering the limitation of being able to accurately measure the voided volume in the home environment. There are any symptoms of voiding difficulty.

Further management and treatment Further management aims to identify any factors contributing to delayed bladder emptying and to ensure adequate bladder drainage while waiting for normal function to return. Following the diagnosis of urinary retention, following actions should be taken A sample of urine must to be analysed (by dipstick) and sent for culture (either by the midwife or the obstetrician) as presence of infection is an important contributory factor to prolonged voiding dysfunction. If a urinary tract infection is suspected, prompt antibiotic therapy should be initiated (see antibiotics in obstetrics guideline, NUH). The perineum should be examined (either by the midwife or the obstetrician) and if swollen or painful, a catheter should be sited until the swelling and pain have settled. Adequate analgesia is important, as perineal pain is a significant factor in development of retention. Constipation should be avoided and treatment given if required. All of the above should be documented in hospital records.

After removal of catheter, the voided volume and post void residual volume should be recorded by the midwife. Any further retention or increased post void residuals, warrant continued bladder emptying by indwelling urethral catheter for one week. Alternatively, intermittent self catheterisation(ISC) can be considered which can be taught by a trained midwife on the ward. If the perineum is still tender, indwelling catheter up to 2 weeks can be justified. Voiding dysfunction beyond this point warrants careful assessment and examination by an urogynaecologist as an outpatient. The investigations, treatment and management plan must be documented in the hospital post natal records. All women experiencing voiding dysfunction must have follow up appointment to be reviewed in the Pelvis after Pregnancy clinic. It is the responsibility of the midwife who discharges the woman from the postnatal area to ensure that this appointment has been arranged

Suggested management of post partum voiding dysfunction (Algorithm)

No void within 6 hours

First voided volume less than 250 mls or symptoms of voiding dysfunction

Insert in and out catheter and measure the volume drained

<500mls

>500mls

Measure next voided volume and PVR

Insert indwelling catheter for 24 hours

Reassess if PVR>150mls, Catheter to stay in for 1 week/ISC

If PVR<150mls, no further management unless symptomatic

Unable to void or PVR>150 mls

Arrange TWOC on ward if has catheter for a week Arrange follow up in PAP clinic in case of ISC Reassess if persistent voiding problem, refer for urogynaecology opinion .

PVR Post void residual TWOC Trial without catheter

Monitoring Plan The guideline for postpartum bladder care will be monitored in conjunction with the NUH Maternity Services Clinical and Operational Monitoring Plan.

References 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. Aust N Z J Obstet Gynaecol 2002;42:365-8 Dorflinger A, Monga A. Voiding dysfunction. Curr Opin Obstet Gynaecol 2001;13:507-12 Glavind K, Bjork J, Incidence and treatment of urinary retention postpartum, Int Urogynecol J Pelvic Floor Dysfunct 2003;14:119-21 Khullar V, Cardozo LD,Bladder sensation after epidural analgesia. Neurourol Urodyn 1993;89:424-5 MacLean AB, Cardozo L. Incontinence in Women, London; RCOG Press; 2002 Ramsay IN, Torbet TE. Incidence of abnormal voiding parameters in the immediate postpartum period. Neurourol Urdyn 1993;12:179-83 Reo R, Punter J, Abrams K, Mayne C, Tincello D. Clinically overt postpartum urinary retemtion after vaginal delivery: a restrospective case-control study. Int Urogynecol J Pelvic Floor dysfunc 2007; 18: 521-524