National survey for intrapartum and postpartum bladder care: assessing the need for guidelines
Ms M. M. Zaki, Women Centre, John Radcliffe Hospital, Level 4, Headington, Oxford OX3 9DU, UK.
Variation in the practice of intrapartum and postpartum bladder care reported by 189 maternity units in England and Wales hospitals was evaluated by analysing the data obtained from a postal questionnaire completed by labour ward managers or heads of midwifery. The survey revealed that there was no consensus of opinion about the diagnostic criteria for postpartum urinary retention and therefore the optimum management for voiding dysfunction remains controversial. In spite of the increasing awareness of the risk management issues involved, the majority of the units were found to be non-compliant with the limited RCOG recommendations currently available. Although further research is needed to develop evidence-based guidelines, all units should be timing and measuring the voided volume and ideally checking the first post-void residual volume to ensure that retention does not go unrecognised.
Urinary retention is a common complication in women during the immediate postpartum period.1 If voiding dysfunction is not recognised, bladder overdistension can lead to denervation, detrusor atony and prolonged voiding dysfunction. Retention following delivery is being noted with increasing frequency. This could be attributed to the greater awareness of the condition or the increased use of epidural analgesia and instrumental deliveries.2,3
A six month audit carried out at the John Radcliffe Hospital in Oxford (6000 deliveries per year) has revealed that 1 in 60 women failed to resume normal voiding during the immediate postpartum period. Although all these women had high initial postvoid residual volumes (mean = 600, range 450–1100), the majority, when managed appropriately, had normal bladder function at discharge. However, failure to recognise retention promptly resulted in five cases requiring self-catheterisation for two to five weeks.
We therefore felt that postpartum retention has become an increasingly important risk management issue and this prompted us to investigate how the condition was being diagnosed and treated in other hospitals. The aim of the study was to establish the criteria and methods currently employed to diagnose urinary retention. Furthermore, we sought to audit the compliance of the maternity units in England and Wales to the RCOG recommendation, which states that that no post-operative or post-delivery patient should be left more than six hours without voiding or catheterisation.4
In January 2003, the heads of midwifery and the labour ward managers of 189 maternity units in England and Wales were asked to complete a postal questionnaire about their hospital policy and practice for intrapartum and postpartum bladder care. The questionnaire was designed to identify the frequency of use of indwelling catheters and in/out catheters when spinal/epidural analgesia was used for elective and emergency caesarean section, vaginal delivery (instrumental and spontaneous), manual removal of placenta and repair of third degree perineal tears. We inquired about the time interval for catheter removal, the criteria to be fulfilled before removal and guidelines for measuring the first void volume after delivery or removal of catheter. Compliance with the RCOG recommendation was audited by inquiring about the length of time allowed before the women were considered in retention and whether ultrasound scanning was used to confirm the diagnosis before catheterisation. We asked whether the first post-void residual volume was measured after the removal of an indwelling catheter or after an episode of voiding dysfunction. Units were asked to provide the local incidence figures for postpartum retention, if known, and the follow up protocol for women with postpartum urinary retention.
We received 156 (83%) returned questionnaires. The number of annual deliveries among the units ranged from 850 to 6400 (median = 3100).
Which patients had indwelling catheters routinely inserted at delivery?
One hundred and thirty-seven units (88%) used indwelling catheters when a caesarean section was performed under regional block. During labour with regional analgesia, indwelling catheters were used in 15% (24/156) units. Indwelling catheters were used after instrumental delivery, repair of third degree tear and manual removal of placenta in 18% (28/156), 24% (37/156) and 19% (30/156) units, respectively.
When were other patients catheterised?
Twenty-three percent of units complied with the RCOG recommendation of catheterisation within six hours while 16% and 26% units allowed 8 and 12 hours, respectively, before non-voiders (after removal of indwelling catheter or post-delivery) were catheterised (Table 1). One-third of units had no specific guideline on timing before catheterisation.
Table 1. Variation in the period prior to and during catheterisation. Values are expressed as n (%).
|4 hours||3 (2)||6 hours||5 (3)|
|6 hours||36 (23)||8 hours||6 (5)|
|8 hours||24 (15)||12 hours||27 (17)|
|12 hours||41 (26)||18 hours||1 (0.6)|
|18 hours||1 (0.6)||20 hours||1 (0.6)|
|24 hours||3 (2)||24 hours||101 (64)|
|No specific time in 48 (31) units|| ||Non-specific answer in 14 (9) units|| |
When were catheters removed?
The duration of catheterisation varied markedly among units from 6 to 24 hours (Table 1). Forty-seven percent (73/156) of the units specified no criteria to be met before removal of the indwelling catheter, whereas other units employed criteria such as absence of haematuria, mobility of the patient and satisfactory urinary volume.
How was the resumption of normal voiding checked?
After a normal delivery, the voided volume was measured in 26% (40/156) of the units whereas 61% (95/156) of them recorded that the patient has passed urine without measuring voided volume. There were no existing protocols regarding resumption of voiding after vaginal delivery in 13% (21/156) units.
If patients were catheterised, 47% (73/156) of the units measured the volume of the first void after removal of the indwelling catheter, and in one-third of these, the time interval from the removal of catheter to voiding was recorded. Most units (95%) did not measure post-void residual volume routinely although this was measured for patients who needed recatheterisation in 34% (53/156) units. Ultrasound was used to estimate the volume of urine prior to recatheterisation in 7% (11/156) units.
How are patients followed up?
There was a follow up policy for patients with postpartum voiding dysfunction mainly in the form of referral to the physiotherapists or continence advisors and specialist urogynaecologist in 85% maternity units. Only one maternity unit was able to quote the local incidence of urinary retention.
The high prevalence of epidural analgesia and instrumental delivery in modern obstetrics results in an increased risk of postpartum urinary retention and up to 43% of women have abnormal postpartum voiding.1 It is reported that high residual volumes occurred in 1.5% of women in the immediate postpartum period, but none of these women had urinary symptoms at follow up four years later.5 Severe unrecognised retention can lead to bladder overdistention, detrusor atony and long term voiding dysfunction requiring a catheter to drain the bladder (indwelling catheter or intermittent self-catheterisation). Rarely, this damage can be permanent.
A wide variety of contributing factors have been reported, including longer labour,2,3 epidural analgesia, instrumental delivery and extensive vaginal/perineal lacerations. Therefore, it is virtually impossible to predict who would develop retention and all women should be regarded at risk and managed accordingly.
Less than a quarter of the units in England and Wales complied with the recommendation of the RCOG stating that no post-operative or post-delivery patient should be left more than six hours without voiding or catheterisation. Clear guidelines to implement strict input/output charts, measure voided volumes and check residual volume before catheterisation are lacking.
Post-micturition assessment of residual urine is the best screening method for the diagnosis of abnormal voiding1; however, only 5% (8/156) units check residual urine after the first void. Residual volume can be checked by catheterisation or ultrasound estimation. Whereas catheterisation may increase the incidence of urinary tract infection and cause discomfort, studies show that the mean accuracy rate of ultrasonography for the estimation of bladder volume is approximately 10%.6 The non-invasive nature of the investigation and the short learning curve for the technique render bladder ultrasound scanning an attractive method for the estimation of the post-void residual volume. However, some clinicians are cautious about employing this technology because of concern about technical difficulties that may arise due to the size of the postpartum uterus resulting in inaccurate measurements. This may explain its limited utilisation in our study.
In this survey, we asked labour ward managers and heads of midwifery to complete the questionnaires and acknowledge that this may create bias in the results. Being in management roles, they may not be aware of any local difficulties implementing practice, such as staffing levels and excessive workload. Also, they may only have indirect contact with the clinical situation we were surveying. Postal questionnaires of reported practice are always open to reporting bias, but this would mean that the actual situation is probably less satisfactory than our data suggest. A survey of all registered midwives may have better assessed current practice, but designing such a study would have been unwieldy. Not withstanding these biases, our study has shown variation in protocols used for bladder drainage and the time interval for catheter removal.
Intrapartum bladder care and the prevention and management of postpartum urinary retention are of great clinical importance. There is a lack of evidence-based guidelines, and as a result, there is a wide variation in care across maternity units in the UK. Staff caring for women after delivery need to be aware of risk factors and symptoms for retention. As a minimum, units should set out protocols to ensure compliance with the limited RCOG recommendations currently available. The management of postpartum retention should be researched, allowing the development of evidence-based guidelines, which could then be adopted by all units. In the meantime, all postpartum women should be considered at risk of developing retention, all units should be timing and measuring the voided volume and ideally checking the residual volume to ensure that retention does not go unrecognised.