Royal College of
Obstetricians and
Gynaecologists
Setting standards to improve women’s health
Risk Management and Medico-Legal Issues In Women’s Health
Joint RCOG/ENTER Meeting
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National Maternity Hospital Dublin
Postpartum Urinary Retention
R.C.O.G. Risk Management & Medico Legal
Issues in Woman’s Health
30th April 2008
M. Jacob MSc BSc RGN RCN RM FFNMRCSI
Midwife Prescriber
30 November 2011 2
Definition of Postpartum Urinary Retention
No uniform definition exists
Has been classified into ‘overt’ or ‘covert’
categories
Rane and Frazer, (1999) 0bs &Gynae 1 (4): 311-313
30 November 2011 3
Overt Retention
Is the inability to pass urine within six hours
after delivery requiring catheterisation with
removal of a volume equal to or greater than
normal bladder capacity
Rane and Frazer (1999) 0bs &Gynae 1 (4): 311-313
30 November 2011 4
Covert Retention
More difficult to define
Clinically can be described as failure of the bladder
to empty properly where a catheter yields at least
50% of normal bladder capacity or a post void
residual bladder volume of 150 ml
Yip et al., (1998) Effect of duration of labour on postpartum post void residual
bladder volume (Gynaecol Obstet Invest 45, 3: 177-180)
30 November 2011 5
Consequences of Postpartum Urinary
Retention
In short term, may lead to atonic bladder
and infection if not identified and relieved
Page (2005)
30 November 2011 6
Consequences of Postpartum Urinary
Retention
Single episode of bladder over-distension
(Not diagnosed and treated early may cause
persistent postpartum urinary retention and
irreversible damage to the detrusor muscle
with recurrent urinary tract infections and
permanent voiding difficulties
Hinman, 1976; Versi, 1987; Mills, 1998)
30 November 2011 7
Pathophysiology
Poorly understood
Nervousness, modesty & similar factors causing
inhibition by the CNS.
Unnatural posture
Lack of elasticity of bladder
Injury, swelling of vulva, urethra and bladder trigone.
Reflex spasm of external urethral sphincter from
tears & incisions in perineum.
An unspecified temporary derangement of the
neuromuscular mechanism of bladder & urethra
Francis, W.J. J. Obstet Gynaecol Br. Emp (1960) 67: 353-366.
30 November 2011 8
Pathophysiology
Hormones and contractile responses of bladder –
hormone-responsive organ & functions may be
subjected to fluctuations of hormones during
pregnancy & postpartum period.
Injured bladder innervation – urinary retention
occurs when neurological lesions occur below the
spinal reflex arc, at or below the level of the outlet of
sacral nerves – hypotonic or acontractile bladder.
Pudendal nerve, with afferent nerve branches (S2-4)
supplying the bladder is damaged during pelvic
surgery & vaginal delivery – 1st pregnancy
significant pelvic floor tissue stretching & pudendal
nerve damage.
30 November 2011 9
Yip et al. (2004) Acta Obstet Gynecol Scand 83: 881-891
Literature Review
Dearth of studies
Limited urodynamic studies in women
following postpartum urinary retention
Bladder remains a largely neglected organ
30 November 2011 10
Literature Review
Voiding dysfunction after delivery 10-15% (Bennets,
1941)
Positive correlation between epidural
anaesthesia and postpartum urinary retention
irrespective of the mode of delivery (Weil et al., 1983;
Tapp et al., 1987; Yip et al., 1997)
30 November 2011 11
Literature Review
Urinary retention occurred in about 0.05% of pts.
could last as long as 30 – 40 days (Watson, 1991)
2 pts had prolonged urinary retention 10-15
days. 1 pt had persistent urgency, frequency and
strenuous voiding 9 months postpartum
(Watson,1991).
43% women abnormal postpartum voiding (Ramsay
& Tarbet, 1993)
30 November 2011 12
Literature Review
Voiding difficulties during labour and in
immediate postpartum period could be
associated with epidurals.
Early resort to ultrasound scan & supra pubic
catheter to estimate the residual volume
Kulkarni R, Bradford WP, Forster SJ, James ED (1994) Aust N Z J Ostet Gynaecol
34 (1): 107-8
30 November 2011 13
Literature Review
4 patients with prolonged postpartum urinary
retention who had U.D.S. 1 month after the
symptoms of retention ceased, 1 pt had S.U.I.
and 1 pt had urgency & urge incontinence (Groutz et
al. 2001)
Increased use of epidural analgesia and
instrumental deliveries (Ching Chung et al. 2002; Carey, 2002)
30 November 2011 14
National Survey for Intrapartum &
Postpartum Bladder Care U.K.
189 maternity units in England and Wales hospitals
Findings: Majority of units were non-compliant with
limited RCOG recommendations.
All units should be timing & measuring the voided
volume and ideally checking first post-void residual
volume.
Further research needed to develop evidence-
based guidelines.
Zaki M., Pandit M., Jackson S. (2004) British Journal Obst & Gynae 111 (8):
874-6.
30 November 2011 15
Use of epidural anesthesia and risk of acute
postpartum urinary retention
Sample – 2,000 women delivered at 3 primary
hospitals.
Findings: APUR may lead to serious short term and
long term problems – changes in detrusor
contractility and increased incidence of lower or
upper U.T.I.s.
Increased risk for APUR - prolonged 2nd stage
labour, instrumental delivery, perineal damage or
use of narcotics during delivery.
Risk of developing APUR after epidural analgesia
during labour may increase by up to 3-fold
30 November 2011 16
Musselwhite et al., 2007 Am J Obstet Gynaecol)
Acute Postpartum Urinary Retention in Calgary
Health Region’s Policy & Procedures
Need for at least 1 catheterisation within first 24
hours postpartum
Patient did not void within 6 hours postpartum.
Voiding frequently in small amounts.
Urge to void but unable to do so
Musselwhite et al., 2007 Am J Obstet Gynaecol)
30 November 2011 17
Background
Large numbers of clinical incident report
forms relating to urinary retention
Add to the body of knowledge already
existing on the subject of urinary retention
30 November 2011 18
Definition of Clinical Audit
A quality improvement process that seeks
to improve patient care and outcomes
through systematic review of care against
explicit criteria and the implementation of
change
National Institute for Clinical Excellence (2002) Principles for Best Practice in Clinical
Audit.
30 November 2011 19
Results of NMH audit of patients with postpartum
urinary retention (volumes >1,000ml)
Action research cycle methodology
Retrospective medical records review of women
March 2006 – April 2007
Data recorded
Parity, birth weight, type of delivery, epidural,
bladder scan, Foley catheter, residuals,
supra pubic catheter, time post delivery,
intermittent self catheterisation.
30 November 2011 20
Action Research Cycle
Coughlan, D. & Brannick, T. (2001) Doing Action Research in Your Own Organisation.
Sage pg 17
Diagnosing
Evaluation Planning Action
Taking Action
30 November 2011 21
NMH audit of patients with postpartum
urinary retention
Total sample 91 – 3 pts without epidural
11 patients had second Foley Catheter
3 patients had Supra Pubic Catheter
1 patient required intermittent self
catheterisation
30 November 2011 22
Birth Weight Range
Drop Page Fields Here
Total
Count of BW Range (g)
45
40
35
30
25 Drop Series Fields Here
Total
20
15
10
5
0
2500 - 2999 3000 - 3499 3500 - 3999 4000 - 4449 4500 - 4999 Unknow n (blank)
Number
BW Range (g)
30 November 2011 23
Parity
Drop Page Fields Here
Total
Count of Parity
60
50
40
Drop Series Fields Here
30
Total
20
10
0
1+0 1+1 1+2 1+3 2+0 2+1 2+2 2+3 3+0 3+1 3+2 (blank)
Parity
30 November 2011 24
Primips
Number in cohort 62/91: 68.1%
Number of primips 2006 3579/7986: 44.8%
Chi squared test for proportions 18.8
(p<0.0001)
30 November 2011 25
Multips
4407 multips delivered in 2006
Relative risk in multiparous women =0.84
multips were 16% less likely to get urinary
retention than primiparous women -
statistically significant (p<0.05)
In primiparous women retention rate 1.52
Primips were 52% more likely to get urinary
retention
30 November 2011 26
Instrumental
Number in cohort 31/91: 34%
Number of instrumentals in 2006:
2051/7986: 25%
Chi squared test for proportions: 2.88 (p
value between 0.1 and 0.05)
30 November 2011 27
Epidural
Number in cohort: 62/91: 68.1%
Number of epidurals in 2006: 3567/7986:
44.6%
Chi squared test for proportions: 19.08;
(p<0.001)
30 November 2011 28
Kaplan Meier Plot of Time to First
Measuring Residual
91 observations
15 women - no time recorded
76 remaining
Non-parametric data so median and range
described
Median: 6 hours (1.5 – 24 hours)
30 November 2011 29
15
10 20
25
30 November 2011 30
Postpartum Urinary Retention
Integration of audit into clinical practice
National Maternity Hospital Postpartum
Urinary Retention Guideline
30 November 2011 31
Prevention and Detection of Urinary
Retention
History
voiding difficulties, urinary problems or neurological
disorders
Examine perineum (midwife) to exclude perineal
haematoma, oedema or infection.
Efforts should be made to assist the woman to empty her
bladder e.g. running the taps, bath or shower.
Reflexology
All women who have had an instrumental delivery or
epidural anaesthesia should have their urinary output
measured until adequate bladder function is established.
30 November 2011 32
Postnatal Urine Production
Is increased by marked diuresis that occurs in
first 2-3 days postpartum
Very large volumes of urine produced
This may compound the problem
30 November 2011 33
Management of urinary retention
If within 6 hours a woman has not passed urine,
or <200ml or symptoms or signs of retention a
bladder scan is performed.
If volume 200ml insert Foley catheter and CSU.
Record initial catheterisation volume and
intake/output.
30 November 2011 34
Management of Urinary
Retention
On removal of Foley measure urine output for
next 6 hours with bladder scan
if further retention exists, insert second Foley
catheter
Second Foley to remain for 48 hours.
Senior registrar or consultant input throughout.
30 November 2011 35
Recommendations
Management of postpartum retention should be
researched.
Evidence-based guidelines.
All postpartum women should be considered at
risk of developing retention.
Voided volumes should be timed and measured
and the residual volume ideally being checked to
ensure that retention does not go unrecognised.
30 November 2011 36
Recommendations
Improved documentation for intrapartum care
with regard to catheterisation in labour and in
the post partum period with regard to
implementation of conservative measures
attempted, and recording of residual volumes.
All patients with retention should have
MSU/CSU sent.
All patients with retention should have a bladder
scan to measure residual volumes prior to
catheterisation.
30 November 2011 37
Recommendations
All patients with retention should be reviewed by
a senior medical person or A.M.P. when the post
partum period is complicated by urinary
retention.
There is a need for continued training in
management for post partum urinary retention
as per guideline to ensure compliance with
guidelines.
30 November 2011 38
Thank you
30 November 2011 39
Royal College of
Obstetricians and
Gynaecologists
Setting standards to improve women’s health
Risk Management and Medico-Legal Issues In Women’s Health
Joint RCOG/ENTER Meeting
Please turn off all mobile phones and pagers