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Purpose of guideline
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10-15% of women have voiding dysfunction to some degree and for some time following delivery.
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5% have significant and longer lasting dysfunction, which if not recognised in the early peripartum period (birth suite, postnatal ward) may lead to bladder overdistension and overflow incontinence with long-term, significant bladder dysfunction.
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Women at highest risk include:
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- Prolonged labour, especially prolonged stage 2
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- Epidural for labour/delivery, irrespective of mode of delivery
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- Need for catheter in labour
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- Assisted vaginal delivery
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- Perineal injury: haematoma / bruising / tear with inadequate analgesia
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Many women with voiding dysfunction peri and postpartum have no discernible risk factors. A high index of suspicion must be maintained.
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Diagnosis: How does it present?
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A common error is failure to diagnose the bladder distension and incomplete bladder emptying.
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- Frequency, urgency, lower abdominal pain
- No sensation to void, or inability to void
- Palpable bladder
- Overflow incontinence
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An arbitrary residual volume of 150mL may imply a degree of dysfunction.
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Overt bladder retention
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Inability to pass urine within six hours of delivery, requiring catheterisation to drain a volume > normal bladder capacity (normal 400-600mL in females). This woman will often complain of pain and the desire to void, may have oveflow incontinence mistaken as stress incontinence. OR may be asymptomatic particularly if an epidural was employed in labour.
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Covert bladder retention
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Failure of the bladder to empty at least 50% of normal capacity, or a post void residual volume of greater than 150mL. These women will often have frequency and pass volumes of < 150mL.
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Preventing acute bladder distension
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In labour
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1. Encourage patient to void every 3 hours.
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- 2. If unable to void on 2 occasions, threshold for catheterisation should be low.
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| - If the bladder is palpable and patient cannot void - catheterise.
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3. A soft catheter is preferable. Be sure not to tape it on the stretch to the thigh as this will decrease the mobility of the urethra, and decrease the mobility of the balloon in the bladder neck; it needs to be loose enough to allow the balloon to float above the presenting part as it descends below the bladder neck during the late first and second stages of labour.
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Postpartum
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- Urine volumes of > 150mL should be voided at least 3 times in 24 hours
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Treatment
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Start if has not voided within 6 hours of delivery:
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| | - Encourage to void in the toilet.
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| Assessment of adequate voiding
| Measured voided volumes of >150mL on three occasions in 24 hours, or measured residuals of 150mL (using in / out catheter).
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| If the volume voided is < 150mL, or the residual volume is >150mL (check post void residual with an in/out catheter, the bladder scanner is not accurate in the postpartum woman) an IDC should be inserted and left for 24-48 hours. Please refer to CNC Urogynaecology or Unit manager Ward 43.
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| Send MSU, if MSU positive institute antibiotics as appropriate
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| If the initial 'trial of void' fails, insert an indwelling catheter for approximately one week, If the subsequent trioal of void fails, intermittent catheterisation is commenced, with follow up in Urogynaecology Clinic.
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| If a trial of void is required please liaise with the Nurse Unit Manager in Ward 43 (Gynaecology).
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There is no evidence that pharmacological interventions have any place in management.
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Postpartum chronic/covert retention is usually a self-limiting condition and most patients are better by day 7.
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Continence Advisor: Urogynaecology Pelvic Floor Service; Tel: (03) 9344 2781
| Nurse Unit Manager Gynaecology; Tel: (03) 9344 2364
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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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