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
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
24 March 2016
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
24 March 2016
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
24 March 2016
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)
24 March 2016
5
Consequences of Postpartum Urinary
Retention

In short term, may lead to atonic bladder
and infection if not identified and relieved
Page (2005)
24 March 2016
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)
24 March 2016
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.
24 March 2016
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.
24 March 2016
Yip et al. (2004) Acta Obstet Gynecol Scand 83: 881-891
9
Literature Review

Dearth of studies

Limited urodynamic studies in women
following postpartum urinary retention

Bladder remains a largely neglected organ
24 March 2016
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)
24 March 2016
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)
24 March 2016
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
24 March 2016
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)
24 March 2016
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 evidencebased guidelines.
Zaki M., Pandit M., Jackson S. (2004) British Journal Obst & Gynae 111 (8):
874-6.
24 March 2016
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
24 March 2016
Musselwhite et al., 2007 Am J Obstet Gynaecol)
16
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)
24 March 2016
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
24 March 2016
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.
24 March 2016
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.
24 March 2016
20
Action Research Cycle
Coughlan, D. & Brannick, T. (2001) Doing Action Research in Your Own Organisation.
Sage pg 17
Diagnosing
Planning Action
Evaluation
Taking Action
24 March 2016
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
24 March 2016
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
Number
(blank)
BW Range (g)
24 March 2016
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
24 March 2016
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)
24 March 2016
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
24 March 2016
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)

24 March 2016
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)
24 March 2016
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)
24 March 2016
29
10
24 March 2016
15
20
25
30
Postpartum Urinary Retention
Integration of audit into clinical practice
 National Maternity Hospital Postpartum
Urinary Retention Guideline

24 March 2016
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.
24 March 2016
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
24 March 2016
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.
24 March 2016
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.
24 March 2016
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.
24 March 2016
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.
24 March 2016
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.
24 March 2016
38
Thank you
24 March 2016
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