Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429
Issue Date 10 February 2021
Review Date 10 February 2023
Level:
Service Ostetrics
Type:
Protocol
Name:
Obstetric Bladder Care and Management
(Antenatal, Intrapartum and Postpartum)
Purpose
The intrapartum and postpartum period pose significant risks for urine retention, and bladder
distension. For some women this may lead to long-term health issues related to bladder
dysfunction and incontinence, indicating that assessment of risk and preventative
management is merited (RCOG 2002).
Contributing factors include: the hormonal induced reduction in smooth muscle tone and
anatomical changes specific to pregnancy (Saultz 1991); pressure exerted by the presenting
part in the second stage of labour, temporary loss of sensation due to denervation of the
pelvic floor (Mostwin 2005) and the extra pressure exerted on the bladder due to postpartum
fluid shift and increased extracellular fluid. Health professionals also need to be vigilant in
their assessment of other risk factors such as the length of labour, mode of birth, perineal
trauma and the influence of analgesia/anaesthesia.
Delayed diagnosis and intervention may lead to irreversible damage of the detrusor muscle,
and long-standing health issues including urinary tract infection, voiding difficulties and
persistent painful urinary retention (Rizvi et al 2005, Baldini et al 2009).
Regular bladder assessments are required when a woman is in labour, especially when she
has had a regional block, an assisted vaginal birth, or there has been excessive
perineal/periurethral trauma. Guidelines are included to optimise care of the bladder and
the monitoring that assists in avoiding urinary retention.
Scope
All WHS midwives and nurses
All WHS obstetricians, registrars, senior house officers
All obstetric anaesthetists and anaesthetic registrars
All access holders
Obstetric Bladder Care and management
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ID 1.101429
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Document facilitator: CMM Obstetrics
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Document number: 1.101429
Issue Date 10 February 2021
Review Date 10 February 2023
Management
Antenatal
All women should be assessed during the antenatal period (for risk factors see below), and
their usual bladder function discussed. Refer as required.
Intrapartum
Bladder management for women with an epidural
Those with a long period of epidural administration are particularly at risk of retention. Whilst
women may be able to void if encouraged, bladder emptying may be insufficient and urinary
retention may be overlooked with a resultant poor outcome. Early insertion of an indwelling
urinary catheter (IDC) may reduce the risk of retention related complications.
For further guidance please see policy
Antenatal, Intrapartum and Postpartum Management
of Epidural Analgesia CapDocs ID 1.103846
Management without epidural
Bladder assessments are required at least four hourly. This includes an assessment of
the woman’s risk factors, her hydration state, and whether the bladder is palpable
either abdominally or vaginally
Accurate documentation of all voids in labour should include volume and time.
If the woman has not passed urine for four hours, catheterisation should be
considered
An in/out or intermittent catheter may be used if birth is imminent within 2 hours. If
not an IDC should be placed and remain until after birth
The woman’s bladder must be emptied prior to an assisted vaginal birth and during a
prolonged second stage. A full bladder can displace the uterus and pressure may
result in damage to the bladder neck.
All fluid input and output must be recorded on a Fluid balance chart for women with
epidurals and indwelling catheters.
For all women who have an IDC in situ; deflate the balloon to prevent trauma to
bladder neck during second stage, re-inflate balloon postpartum (RCOG 2011). If the
catheter is expelled during delivery a new catheter should be inserted using aseptic
technique.
An IDC is recommended following an assisted vaginal delivery or for ANY obstetric
intervention at birth, where spinal or epidural anaesthesia has been topped up for
birth. Obstetric intervention includes manual removal of the placenta, and complex
pelvic floor repairs. The IDC should remain in place for a minimum of 12 hours to
prevent asymptomatic bladder overfilling (RCOG 2011)
All women having caesarean section should have an IDC inserted; this should remain
insitu for 8 hours - 24 hours postpartum
Please follow “
Guidelines for first void and removal of IDC” which offers specific
guidance according to mode of birth and analgesia/anaesthesia
Obstetric Bladder Care and management
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ID 1.101429
Regard printed versions of this document as out of date – The
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Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429
Issue Date 10 February 2021
Review Date 10 February 2023
Risk factors for retention
While all women in the immediate postpartum period have the potential to experience
urinary problems, several factors increase the risk including:
Women with underlying neurological conditions
A previous history of bladder retention
Primiparity
> 3 births
Prolonged or difficult labour
Prolonged second stage
Instrumental and operative birth (Zaki et al 2004, RCOG 2002)
Large baby (> 4kg) (RCOG 2007)
Opioid use, including spinal opiods- opioids inhibit spontaneous bladder contractions
and decrease the urge to void, leading to increased bladder capacity and residual
volume (Liang et al 2007)
Oxytocin infusion, due to the anti-diuretic effects of the medication. Be especially
vigilant if a second oxytocin infusion was commenced during induction/augmentation
or postpartum
Excessive intravenous fluids leading to distension and detrusor inhibition (Baldini et al
2009) e.g. during PPH resuscitation
Perineal / vaginal trauma / haematoma
Oedematous perineum
Regional anaesthesia
Postnatal
Ongoing assessment of bladder function is required for all women during the postnatal
period. Offer adequate analgesia based on individual needs and ensure privacy. Consideration
must be given to the labour and birth history, any symptoms of urinary retention (listed
below) and whether (or not) the bladder is palpable.
There are two types of urinary retention that can affect women in the postpartum period
Overt retention: symptomatic inability to void spontaneously within 6 hours of birth or IDC
removal. Assessment should be ongoing and earlier intervention may be necessary.
Symptoms may include:
Urgency
Small frequent voids
Inability to void
Straining to void
A slow or intermittent stream
Woman has a sense of being unable to empty her bladder fully
Obstetric Bladder Care and management
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Review Date 10 February 2023
Increasing lower abdominal pain
Leakage of urine
Palpable bladder
Covert retention: non symptomatic increased post void residual volumes after birth or
removal of IDC.
Ability to void, but no urge
No obvious symptoms of retention
Guidelines for first void and removal of IDC
All women should pass urine within 6 hours of giving birth and ideally prior to leaving the
Birthing Suite.
Document on the fluid balance chart voids (volume and timing) postpartum and/or removal
of IDC for the first 12 hours. Measurements can be stopped when there has been:
A spontaneous void > 400mls, but less than 600mls
or
Two successive spontaneous voids of > 200mls
and
the woman is asymptomatic of urinary retention symptoms.
If a single spontaneous void > 600mls is passed there is a greater risk of bladder damage due
to distension. Assessment should take into consideration:
Urge to void
Ability to control the passage of urine
Any leakage of urine prior to voiding
Care will include
Palpation of the woman’s bladder post initial void to assess for incomplete emptying
Prompt the woman to pass urine within the next 2 hours and record volume on the
fluid balance chart
Repeated large voids carry the risk of long-term morbidity and medical advice should
be sought.
Obstetric Bladder Care and management
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Document number: 1.101429
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Review Date 10 February 2023
Guidelines for first void and removal of IDC
Removal of IDC if
Type of Delivery
Analgesia/anaesthesia
First void
present
Spontaneous
None/ entonox/ opioid
Individual decision
4-6 hours postpartum
Vaginal Birth
dependant on risk
or from removal of IDC
factors/once able to
mobilise independently to
toilet
Spontaneous
Epidural/PCEA
Once able to straight leg
4-6hrs postpartum or
Vaginal Birth
raise and mobilise
from removal of IDC
independently to toilet
Instrumental Birth
Local Anaesthesia i.e. pudendal
Minimum 8 hours from
4-6 hours postpartum
block, local perineal infiltration birth
or from removal of IDC
Individual directive by
registrar/consultant may
apply, see maternal notes.
If no instructions IDC to be
removed prior to 06.00am
following morning
Instrumental
Spinal or epidural top up for
Minimum 8 hours
Up to 6 hours from
Birth
birth
and up to 24 hours where
removal of IDC
there is extensive perineal
trauma from birth
Individual directive by
registrar/consultant may
apply, see maternal notes.
If no instructions IDC to be
removed prior to 06.00am
following morning
Caesarean Section
Spinal or epidural top up
Minimum 8 hours from
Up to 6 hours from
birth
removal of IDC
Individual directive by
Registrar/Consultant may
apply, see maternal notes
If no instructions IDC to be
removed prior to 06.00am
following morning
Obstetric Bladder Care and management
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ID 1.101429
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Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429
Issue Date 10 February 2021
Review Date 10 February 2023
Management of Retention
If a postnatal woman
has not passed urine within 6 hours of giving birth or she has not passed
>200mls as a single void then consideration should be given to the woman’s hydration status,
her risk factors for retention and her bladder should be drained using a Foleys catheter.
NB: Bladder scanners are not a reliable measurement of residual volumes in the early
postpartum period and are not recommended for use.
1. If residual urine < 200mls then continue to observe the woman
2. If 200 – 600ml residual urine; the IDC should remain insitu for 24 hours.
3. If > 600mls the IDC should remain in for 48 hours. Medical review should be sought
to assess the need for prophylactic antibiotics and follow up.
A urinary catheter specimen should be sent to the lab.
4. The fluid balance chart must be completed if the woman is catheterised.
5. Regular observation of the IDC for drainage is required. The collection bag should be
securely attached to the bed with a blue clip holder and not allowed to overfill as
increased weight may cause traction of the catheter and pain.
If a woman is discharged with an indwelling urinary catheter insitu she must have
Adequate education around catheter management.
Follow up with WHAS for removal at a date agreed with the medical team.
For trial removal of catheter following retention
Manage as per
Guidelines for first void and removal of IDC
If voids < 150mls discuss with registrar and consider replacing the IDC
If voids 150-250 mls, continue measuring voids, liaise with medical staff
Ensure the abdomen is palpated to assess bladder emptying
Assess symptoms for overt / covert urinary retention previously listed
Option Protocol for TROC
When there are recognisable risks for urinary retention when removing a catheter, a
systematic approach to TROC is to retrograde fill the bladder through the Foley catheter. This
may be considered in discussion with the obstetric registrar and guidelines may be found in
the protocol
Catheter management and Trial Removal of Catheter (TROC) for post-operative
Gynaecology Patients CapitalDoc ID 1.101411
Subsequent Management
Pelvic floor exercises should be discussed and supporting literature provided. Women
should be aware that pelvic floor exercises will need to continue in the longer term
A physiotherapy referral is required for women considered to be at high risk of urinary
retention and bladder damage e.g. neurological disease, 3rd degree or 4th degree tear,
retention associated catheterisations >24 hours and for all women with more than
one failed trial of void
Obstetric Bladder Care and management
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Document number: 1.101429
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Review Date 10 February 2023
Before discharge ensure that follow up has been arranged, as discussed with the
obstetric team consultant
A discharge summary must be completed by the House Surgeon or Registrar
References
Baldini, G, Bagry, H, Aprikian, A, Carli, F, (2009) Postoperative urinary retention: Anaesthetic
and
perioperative
considerations
Anesthesiology
110(5):1139-57.
doi:10.1097/ALN.0b013e31819f7aea
Liang, C.C, Chang, S.D, Chang, Y.L, Chen, S.H, Chueh, H.Y, Cheng, P.J. (2007) Postpartum
urinary retention after caesarean delivery International Journal of Gynaecology and
Obstetrics 99, 229-232 doi:10.1016/j.ijgo.2007.05.037
Mostwin et al (2005) Third international consultation on incontinence recommendations of
the
international
scientific
committee,
retrieved
from
http://www.icsoffice.org/documents/ici_3/v2.pdf/summary.pdf
Nice (2003) Infection control. Prevention of health care associated infection in primary and
community
care
retrieved
from
http://www.nice.org.uk/nicemedia/pdf/Infection_control_fullguideline.pdf
Nice (2007) Intrapartum care: management of and delivery of care to women in labour
retrieved from http://www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf
RCOG (2002) Study Group Recommendations, incontinence in women retrieved from
http://www.rcog.org.uk/print/news/rcog-study-group-publishes-incontinence-
recommendations
RCOG (2007) Management of third and fourth degree perineal tears following vaginal delivery
(green-top guideline 29) Royal college of Obstetricians and Gynaecologists retrieved from
http://www.rcog.org.uk/womens-health/clinical-guidance/management-third-and-fourth-
degree-perineal-tears-green-top-29
RCOG (2011) operative vaginal delivery guideline (Green-top guideline 26) Royal College of
Obstetricians and Gynaecologists retrieved from
http://www.rcog.org.uk/womens-
health/clinical-guidance/operative-vaginal-delivery-green-top-26
Rizvi, R.M, Khan, Z.S, Khan Z (2005) Diagnosis and Management of postpartum urinary
retention. International Journal of Gynecology and Obstetrics 91 (1), 71-72 retrieved from
http://www.ijgo.org./article/S0020-7292(05)00387-5/pdf
Saultz, J.W, Toffler, W.L, Shackles, J.Y. (1991) Postpartum urinary retention. Journal of
American
Board
Family
Practice
4
(5):
341-4
retrieved
from
http://www.ncbi.nlm.nih.gov/pubmed/1746303
Zaki, M, Pandit, M, Jackson, S. (2004) National survey for intrapartum and postpartum bladder
care: assessing the need for guidelines, BJOG: an International Journal of Obstetrics and
Gynaecology 111, 874-876 doi:10.1111/j.1472-0528.2004.00200.x
Obstetric Bladder Care and management
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Document facilitator: CMM Obstetrics
Senior document owner: Clinical Leader Obstetrics
Document number: 1.101429
Issue Date 10 February 2021
Review Date 10 February 2023
Rogers R G & Leeman LL. Postpartum genitourinary changes. Urological Clinics of North
America 2007; 34 13-21
Disclaimer: This document has been developed by Capital & Coast District Health Board
(CCDHB) specifically for its own use. Use of this document and any reliance on the
information contained therein by any third party is at their own risk and CCDHB assumes no
responsibility whatsoever.
Obstetric Bladder Care and management
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