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Acta Obstetricia et
Gynecologica Scandinavica
ISSN 0001-6349

ORIGINAL ARTICLE

Urinary retention in the post-partum period

The relationship between obstetric factors and the post-partum post-void
residual bladder volume
SHING-KAIYIP, GEOFFREY
BRIEGER,LIN-YEEHIN AND TONYCHUNG
From the Department of Obstetrics and Gynecology, Chinese University of Hong Kong, Hong Kong

Acfu Obstet Gyneco/ Sand 1997; 76: 667-672. 0 Acta Obstet Gynecol Scand I997

Objective. The three objectives of this study are: to investigate the incidence of post-partum
urinary retention after vaginal delivery, to investigate the relationship between various obstet-
ric parameters and the post-partum post-void residual bladder volume and to study the natu-
ral progression of the post-void residual bladder volume in patients with covert post-partum
urinary retention.
Methodv. Women who had a vaginal delivery (n=691) in a teaching hospital during a 2-
month period were studied. They were classified into three groups: normal patients, those
with overt urinary retention, and covert urinary retention. Their day 1 post-partum post-void
residual bladder volume were recorded and analyzed with respect to the obstetric parameters.
Patients with covert retention were followed up daily with ultrasound to monitor their post-
void residual volume.
Results. The incidences of overt and covert retention in our unit were 4.9‘5, and 9.7%, respec-
tively. The overall incidence of post-partum urinary retention after vaginal delivery was
14.6%. The duration of the first and second stages of labor were significantly associated with
the post-partum post-void residual bladder volume. In all patients with covert retention, their
post-void residual volume returned to normal within 4 days.
Conclusion. Post-partum urinary retention is a common phenomenon that may be related to
the process of parturition. Covert retention is a self-limiting phenomenon and specific treat-
ment is unnecessary.

Key words; post-partum; ultrasound; urinary retention

Submitted 23 August. 1996

Accepted 28 December, 1996

Urinary retention in the post-partum period is a
common event and the reported incidence ranges
from 1.7 to 17.9%(1). The pathophysiology of post-
partum urinary retention is poorly understood. The
obstetric parameters commonly associated with
urinary retention are nulliparity, instrumental deliv-
ery and epidural analgesia (2). However, Kerr-Wil-
son et al. have reported that the current manage-
ment of labor does not predispose women to post-
partum bladder hypotonia and urinary retention ( 3 )
but there are few population-based studies that have
investigated post-partum urinary retention and
post-void residual bladder volume.
The usual management of post-partum urinary
retention is to insert an in-dwelling catheter and
leave it in situ for a few days. Some obstetric units
adopt a very vigorous management protocol for
the detection of post-partum urinary retention in-
cluding early catheterization of the bladder to re-
lieve the retention ( I , 3). Some even advocate the
use of early suprapubic catheterization to hasten
bladder recovery (4). Such management may not
always be necessary and are not without risk to
the patients. In-dwelling catheters have been as-
sociated with patient discomfort, urinary tract in-
fections, urethral mucosal irritation and sub-
sequent urethral stricture formation. Suprapubic
catheters may cause serious complications such as
bowel perforation, intra-peritoneal leakage of
urine or rarely necrotizing fasciitis (5).
0 Actu Obstet Gynecol Scund 76 (1997)
668 S.-K. Yip et al.
The purpose of the present study is to investi-
gate the association between various obstetric par-
ameters and post-partum urinary retention as
measured by the post-partum post-void residual
bladder volume. A minimal intervention manage-
ment for patients with asymptomatic urinary re-
tention was also tested in this study.
Material and methods
A prospective descriptive study was conducted be-
tween March 12 to May 12, 1996 and a total of
707 women delivered vaginally in the authors’ in-
stitution were eligible for the study. Informed ver-
bal consent had been obtained from all patients
recruited into the study. The exclusion criteria
wcrc:
1. All deliveries by cesarean section.
2. All patients with in-dwelling catheterization
during labor, or patients with in-dwelling cath-
eterization inserted after delivery for reasons
other than acute urinary retention, e.g. severe
pre-eclampsia.
3 . Multiple pregnancies.
The patients were divided into three categories:
Group I (overt urinury retention): Patients with in-
dwelling catheterization after delivery because of
acute post-partum urinary retention. This group
of patients had trouble voiding and presented with
strain to void, urgency, frequency, and strangury.
All patients in this group had indwelling catheter
inserted within 9 hours of delivery.
Group 2 (covert uriniiry retention): Patients who
had no urinary symptoms but with a post-void re-
sidual bladder volume of more than or equal to
150 ml on post-partum day 1.
Group 3 (normal patients): Patients who had no
urinary symptoms and their post-void residual
bladder volume was less than I50 ml on post-part-
um day I .
As there is no general agreement on volume
definition of pathological urinary retention, an ar-
bitrary volume of 150 ml was chosen as the normal
upper limit of post-void residual bladder volume
and it is a commonly used criterion in clinical
practice.
Ultrasound examination was used to identify
patients with covert urinary retention. A trans-ab-
dominal ultrasound scan was performed in the
morning of the first day of delivery to measure the
post-void residual bladder volume. All day 1 post-
partum patients who had not had an in-dwelling
catheter were scanned. The ultrasound examin-
ations were performed by one of the authors
(SKY) at least 9 hours after delivery to avoid over-
0 Actri Obstrt Gynecol Scanrl 76 (1997)
lapping with the overt retention group. An Aloka
SSD2000 real-time ultrasound machine with a 3.5-
MHz curvi-linear abdominal probe was used for
the examinations. All patients were asked to empty
their bladder 15 minutes before the scan. The
amount of the post-void residual bladder volume
in the bladder was estimated by measuring the 3
orthogonal diameters (dl, d2, d3) and calculated
using the formula for approximation of the ellip-
soid ( 6 ) :
x x d l Xd2Xd3
volume =
6
where d 1=widest diameter in the transverse scan
d2=anterior-posterior diameter in the
longitudinal scan
d3=cephalo-caudal diameter in the longi-
tudinal scan
If the post-void residual bladder volume was
greater than or equal to 150 ml on post-partum
day 1, further daily ultrasound examinations
would be performed until the post-void residual
bladder volume was less than 150 ml. There was
no other intervention.
The following obstetric parameters for each pa-
tient were examined: age, parity, duration of first,
second and third stage of labor, mode of delivery
(normal vaginal delivery or instrumental delivery),
birth weight, presence of unanticipated birth canal
trauma like vaginal or perineal lacerations, epi-
dural analgesia, and episiotomy. The first stage of
labor is defined as the onset of cervical dilatation
associated with uterine contractions to full cervical
dilatation. The second stage of labor is defined as
the period from full cervical dilatation to the full
expulsion of the fetus.
Statistical analyses were performed using com-
puter software package Statistical Package for the
Social Sciences (SPSSTM)for Windows version 6.0.
x2 test, Student’s t test and multiple linear re-
gression were used to analyze the data.
Results
During the 2-month study period, 707 women were
delivered vaginally in the authors’ institution and
691 of these agreed to participate in the study. Six-
teen patients were excluded because they had in-
dwelling catheter inserted during labor or in the
post-natal ward for reasons unrelated to urinary
retention such as severe pre-eclampsia or post-par-
tum hemorrhage.
In the 691 patients, there were 34 with overt re-
tention (Group l), 67 with covert retention (Group
2), and 590 normal patients (Group 3). On post-
partum day 1 the incidence of overt retention was

4.9%, and the incidence of covert retention was
9.7%. The overall incidence of patients with post-
void residual bladder volume of 2-150 ml was
14.6%. The post-void residual bladder volume
(meants.d.) of the 3 groups were 834.05359.0 ml
(Group l), 359.71223.2 ml (Group 2), and
39.9k30.2 ml (Group 3). There were no statisti-
cally significant differences in mean age, duration
of third stage of labor and birth weight of the three
groups. There was also no statistically significant
difference in the number of genital tract trauma in
the three groups (Table I).
Urinary retention in the post-partum period 669
The mean duration of first stage of labor was
statistically longer in both retention groups
(Groups 1 and 2) than that of Group 3. There was
no difference in the duration of labor between
Groups 1 and Group 2.
The mean duration of second stage of labor was
statistically longer in both retention groups
(Groups 1 and 2) than that in Group 3 but not
statistically different between Groups 1 and 2.
Instrumental delivery was associated with statis-
tically more overt or covert urinary retention (x2=
23.01, p<O.OOOOl). The same holds for multiparity

Table I. Obstetric characteristics of the three groups of patients

Group 1 Group 2 Group 3

Study population (n=34) (n=67) (n=590)
n=691 mean 2s.d. mean+-s.d. meants.d. Significancea

Incidence (Yo) 4.9 9.7 85.4

Post-partum day 1 post-void residual bladder
volume (ml) 834.02359.0 359.72223.2 39.9230.2

Age 28.825.0 28.7?5.2 28.6?5.0 1 vs 2 NS

2 vs 3 NS
1 vs 3 NS
Parity average 0.5-tO.6 0.720.9 0.920.9 1 vs 2 NS
2 vs 3 NS
1 vs3 <0.05
First stage duration (minutes) 400.1 2232.9 380.1 2253.8 291.1 +184.8 1 vs 2 NS
2 vs 3 40005
1 vs 3 <0.001
Second stage duration (minutes) 42.7t39.5 30.2231 .O 21.6224.4 1 vs 2 NS
2 vs 3 <0.01
1 vs 3 <0.0001
Third stage duration (minutes) 10.6+4.9 11.I k 6 . 0 11.8212.1 1 vs 2 NS
2 vs 3 NS
1 vs3 NS
Birth weight (grams) 3278.5?349.9 3140.42 383.1 3225.42487.1 1 vs 2 NS
2 vs 3 NS
1 vs 3 NS

Group 1 Group 2 Group 3 x2 (2df) Significanceb

Instrumental delivery
No 20 54 517 23.01 <0.00001
Yes 14 13 73
Epidural analgesia
No 29 63 578 19.68 <0.0005
Yes 5 4 12
Episiotomy
No 2 13 150 7.57 <0.05
Yes 32 54 440
Genital tract trauma
No 27 52 446 0.37 NS
Yes 7 15 144
Parity
Nulliparous 19 34 220 8.57 <0.05
Muitiparous 15 33 370
~~~

Group 1 =overt retention Group 2=covert retention Group 3=normal patients Genital trauma=unantrcipated genital tract lacerations during labor a=Student's
ttest comparing the 3 groups b=x2test with 2 degrees of freedom NS=not statistically significant

0 Actu Obstet Gynecol Scund 76 (1997)

670 S.-K. Yip ef nl.
Table I0 Multiple regression analysis of patient characteristics and the post-
void residual bladder volume on post-partum day 1
Coefficient Standard error
Variable b t
First stage
duration 0 138 0047 2 942
Second stage
duration 1003 0347 2888
*-Backward stepwise multiple analysis
(x2=X.57, p<0.05), epidural analgesia (x2=19.68,
p<0.0005), and episiotomy (x2=7.57, p<0.05).
There was no difference in the incidence of birth
canal trauma betwcen the three groups (x2=0.37,
y>0.05).
Backward stepwise multiple regression analysis
controlling for epidural analgesia was performed
to test the obstetric parameters (age, parity, dur-
ation of first, second and third stage of labor, birth
weight, mode of delivery, episiotomy, genital tract
trauma, and parity) in order to determine which
obstetric parameters have the strongest association
with the post-void residual bladder volume on
post-partum day 1. The duration of first and sec-
ond stage of labor were significantly related with
the post-void residual bladder volume on post-par-
tum day 1 (Table 11). The other variables did not
show any significant relationship.
A progressive decrease in the number of patients
with post-void residual bladder volume 2 150 ml
was documented (Table 111). None of the patients
had a post-void residual bladder volume 2 1 50 ml
on post-partum day 4.
Discussion
Cesarean section patients were excluded from this
study because the aim of the present study was to
examine the relationship between labor and va-
ginal delivery and the lower genito-urinary tract
and subsequently the effect on the post-partum
post-void residual bladder volume.
In previous studies, bladder volume or function
Table 111 Number of patients with covert urinary retention detected by serial ultrasound examinations. Student's t test comparing the post-void residual bladder
volumes on consecutive days (post-partum days 1, 2 and 3) showed no statisticai significant difference
~
Number of patients with PVR
volume 2150 rnl (covert
retention)
Day 1 post-partum 67
Day 2 post-partum 12
Day 3 post-parturn 2 0.29
Day 4 post-partum 0 0
had been assessed from post-partum day 2 or day
3 onwards (2, 3). We chose to assess the post-void
residual bladder volume from post-partum day 1
Significance- because this most closely reflected the effect of lab-
or and enabled us to chart the course of bladder
<0.005
function from shortly after delivery.
Ultrasound assessment of post-void residual
<0.005 bladder volume had been shown to be accurate
(2). The trans-abdominal ultrasound technique
was employed because it is associated with mini-
mal patient discomfort and is as accurate in esti-
mating volumes of intra-abdominal structures as
the more invasive transvaginal route (7). The
formula for the volume of an ellipsoid was
chosen to estimate the post-void residual bladder
n x d l xd2Xd3
for its practi-
6
cality and accuracy. It requires only the measure-
ment of the three orthogonal diameters of the
bladder, namely the cephalo-caudal and the an-
terior-posterior diameters in the longitudinal
scan, and the widest diameter in the transverse
scan, all of which are easy to measure using the
trans-abdominal ultrasound, Griffiths et al. have
demonstrated the bladder volume thus estimated
has an accuracy of 0.84 and the repeatability of
the measurement was 2 10.2% (6).
In the initial analyses of our data, urinary reten-
tion was shown to be related to several obstetric
parameters, namely parity, duration of first and
second stage of labor, instrumental delivery, episi-
otomy, and epidural analgesia. Some of these in-
itial findings were compatible with previous similar
studies. Nulliparity was found to be associated
with more post-partum urinary retention (1, 2).
Nulliparous women also had a significantly in-
creased post-partum maximum cystometric ca-
pacity and urine volume at first desire to void in
urodynamic studies ( 3 ) . In Andolf et a1.k study,
forceps delivery and vacuum extraction were
shown to be associated with a higher rate of
asymptomatic urinary retention on day 3 post-par-
Percentage in study Post-void residual bladder Range of post-void residual
population n=691 volume (ml) rnean5s.d. bladder volume (ml)
9.70 359.72223.2 150.2-1067.9
1.74 260.2+101.5 152.8-448.2
179.9?13.0 170.7-189.1
- -

tum (2). Epidural analgesia’s effect on the urinary
bladder and urinary retention has been well docu-
mented (1, 2, 8, 9, 10). Our study patients who had
had episiotomy or long labor also had a higher
rate of urinary retention, which has not been re-
ported in other studies. In our study, long labor is
defined as either the first stage of labor and was
more than 12 hours or the second stage of labor,
which was more than 2 hours.
The major contributory obstetric parameters to
post-partum urinary retention were the duration of
the first and the second stages of labor. We believe
this is the first study that has used multiple re-
gression to determine which obstetric parameters
are significant variables in post-partum urinary re-
tention. The length of the first or second stages of
labor were directly related to the post-partum post-
void residual bladder volume. The regression analy-
sis was performed with epidural analgesia con-
trolled for several reasons. Epidural analgesia is al-
ready a well documented associated factor with
post-partum urinary retention (1,2,8,9,10) and the
intention of this study is to investigate other poss-
ible obstetric parameters associated with post-part-
um urinary retention. The number of patients in this
study who had epidural analgesia was small (n= 19),
and the majority of patients who had epidural anal-
gesia also had urinary retention (10/19=52.6%). In-
clusion of such strong urinary retention-associated
covariate into the regression model will invariably
mask the rest of the covariates.
One hypothesis for the association between post-
partum urinary retention and the duration of the
first and second stage of labor is that during pro-
tracted labor the presenting part of the fetus may
exert pressure on the pelvic floor and the pelvic
soft tissues, which include the pelvic nerve plexus-
es. This may subsequently lead to either urinary
outflow obstruction by tissue edema, or detrusor
dysfunction due to neuropraxia. These pressure-re-
lated injuries to the components of the voiding
mechanisms may lead to urinary retention.
It is logical to speculate that the longer the lab-
or, the longer the pelvic structures would be ex-
posed to unusual pressure. It has been shown that
to expel the fetus the uterus needs to generate sub-
stantial pressure during the first and second stages
of labor (1 1, 12). This pressure is transmitted onto
the pelvic floor structures in the process of birth
leading to injury and perhaps urinary retention.
The duration of labor may be considered as pro-
portional to the total amount of force that the pel-
vic structures have absorbed (12) and therefore it
is not surprising that it is related to urinary reten-
tion. Likewise, stretching of the perineal muscles
during labor has been shown to lead to neuroprax-
ia and long term urinary problems ( I 3).
Urinury retention in the post-purtum period 671
It is unclear whether the two groups of retention
(overt and covert) patients represent two genuinely
distinct groups with separate pathophysiology, or
they constitute a spectrum of the same disease.
Further investigations using urodynamics or elec-
trophysiological techniques like electromyography
is necessary to clarify this matter.
We have demonstrated that covert urinary reten-
tion is a self-limiting phenomenon. The number of
patients with significant urinary retention de-
creased rapidly and progressively and none had a
significant post-void residual bladder volume 4
days after delivery (Table 111). No specific treat-
ment was required in these women as long as they
remained asymptomatic. Some of these women
had post-partum post-void residual bladder vol-
umes as large as 1000 ml.
Detection of patients with covert urinary reten-
tion in the post-partum period did not lead to
short-term benefit. The long term effect of this
short term and self-limiting post-partum covert
urinary retention is unclear. Andolf et al. followed
up a group of such patients with post-partum uri-
nary retention 4 years after delivery and they
found one third had voiding difficulties (2). How-
ever, the follow-up was incomplete and the num-
bers were small. A proper randomized, controlled
trial with systematic long-term follow-up of
women who have post-partum urinary retention is
necessary to detirmine whether catheterization
prevents urinary continence problems. The relief
of the retention in the women with asymptomatic
retention may be counterproductive if it leads to
more intervention-related problems than it pre-
vents in the long term.
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Addrtss ji)r correspondcwt,:
Dr. Shing-Kai Yip, M.R.C.O.G.
Department of Obstetrics and Gymecology
Shatin, NT
Hong Kong