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Purpose of guideline
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Ten to fifteen percent of women have some degree of voiding dysfunction and for some time following delivery.
Five percent of women have significant and longer lasting dysfunction, which if not recognized in the early peripartum period (birth suite, postnatal ward) may lead to bladder overdistension and overflow incontinence resulting in long-term, significant bladder damage and voiding dysfunction.
This clinical practice guideline provides advice aimed at the prevention and treatment of peripartum bladder dysfunction.
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Risk factors
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Women at highest risk include:
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- primigravidae
- prolonged labour, especially prolonged stage 2
- epidural for labour/birth, irrespective of mode of delivery
- need for catheter in labour
- assisted vaginal birth
- caesarean birth
- perineal injury including haematoma, bruising or tear with inadequate analgesia
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Women without these risk factors may be susceptible to voiding dysfunction; a high index of suspicion must be maintained.
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Prevention
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Prevention of acute bladder distension
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In labour
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| Encourage the woman to void every 2 hours.
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| | If patient is unable to void on 2 occasions, threshold for catheterisation should be low.
If the bladder is palpable and the patient cannot void – catheterize immediately.
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| | A soft catheter is preferable. Be sure to not tape the catheter stretched to the thigh as this will decrease the mobility of the urethra, and decrease the mobility of the balloon in the bladder neck.
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The balloon should be inflated with just 5mL of sterile water. If the woman does not have an epidural and catheterization is merely for the purpose of emptying the bladder prior to a procedure, then an in-out catheter should be considered.
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Postpartum
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Urine volumes of > 100mL should be voided at least 3 times in 24 hours
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Diagnosis
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A common error is failure to diagnose the bladder distension and incomplete bladder emptying.
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Symptoms of voiding dysfunction/retention
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Symptoms of voiding dysfunction may include:
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- no sensation to void
- inability to void within 6 hours of birth or within 6 hours of catheter removal after caesarean birth
- urinary frequency, urgency
- lower abdominal pain
- palpable bladder
- overflow incontinence
- voided volumes of <100mL.
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If a woman experiences the above symptoms, notify the physiotherapist (ext 3160) and continence nurse (ext 3144) and follow the flowchart commencing with STEP 1.
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Overt bladder retention
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This is the inability to pass urine within six hours of birth thus requiring catheterization, in which volumes greater than normal bladder capacity (normal 400-600mL in females) are drained from the bladder. The woman will often complain of pain and the desire to void, may have overflow incontinence mistaken as stress incontinence or may be asymptomatic particularly if an epidural was used during labour.
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Covert bladder retention
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The woman is able to void however fails to empty at least 50% of her normal bladder capacity, or a post void residual volume of greater than 150mL. These women will often have frequency and pass volumes of < 100mL.
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Treatment
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STEP 1: Trial of void:
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- Commence fluid balance chart
- Measure all voids and residual volumes using in/out catheter, residuals must be measured immediately after void. Do not use bladder scanner
- Encourage patient to void every 2-3 hours
- Ensure adequate fluid intake and analgesia
- Encourage double voiding
- Perform urinalysis to exclude infection and inform medical staff of any abnormalities
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If residuals volumes <150ml on 2 occasions:
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- Trial of void successful.
- Refer patient to physio for appointment in one week.
- Patient to continue timed voiding and double voiding at home.
- Provide fact sheet: ‘Difficulty emptying your bladder after childbirth’.
- Provide bladder diary.
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If residual volumes >150mL on 2 occasions:
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- IDC inserted for 24hrs. If perineum bruised or swollen catheter to remain for 48hrs.
- Send CSU
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STEP 2
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After 24-48hrs IDC removed and STEP 1 is repeated.
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Results
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A: If residual volume <150ml on 2 occasions:
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- Trial of void successful.
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If patient reports that normal sensation to void still not returned:
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- Refer patient to physio for appointment in one week.
- Patient to continue timed voiding and double voiding at home.
- Provide fact sheet: ‘Difficulty emptying your bladder after childbirth’.
- Provide bladder diary.
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B: If residual volumes >150ml on 2 occasions:
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- IDC inserted & patient discharged home for 5-7 days.
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STEP 3
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After 5-7 days patient readmitted and STEP 1 is repeated.
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Results
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C: Residual volume <150ml on 2occasions:
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- Trial of void successful
- Review in urogynaecology outpatient clinic in 6 months
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If patient reports that normal sensation to void still not returned:
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- Refer patient to physio for appointment in one week.
- Patient to continue timed voiding and double voiding at home.
- Provide fact sheet: ‘Difficulty emptying your bladder after childbirth’.
- Provide bladder diary.
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D: Residual volumes >150ml on 2 occasions:
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- Woman to be taught intermittent self-catheterisation (ISC). Refer to ISC fact sheet. ISC to cease when residual volumes are <100ml on 2 occasions.
- Refer to Continence nurse advisor for follow up in urogynaecology outpatient clinic in 2 weeks (ext 3144)
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There is no evidence that pharmacological interventions have any place in management of peripartum bladder dysfunction.
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Refer to Algorithm 1: Postpartum voiding dysfunction flow chart (see Appendix 1).
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Physiotherapist
| Continence nurse advisor
(urogynaecology outpatient clinic)
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|  | Phone: (03) 8345 3160
| Phone: (03) 8345 3144
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Appendices
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Algorithm 1: Postpartum voiding dysfunction flow chart.
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 Click on thumbnail to view full size image of flowchart (pdf 46kb)
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References
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References: PeripartumBladderManagement (on this website)
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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