SDMS ID: 2010/0303-001 3.

9-06WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: P2010/0304-001 Care of the Postnatal Women Following an Uncomplicated Pregnancy and Birth P2010/0302-001 Care of the Women Following a Caesarean Section Purpose: To ensure identification of mothers at risk of developing urinary problems Prevention of potential urinary complications Ensure appropriate treatment and follow up when problems identified. Risk Factors Primigravidae Prolonged labour, especially prolonged second stage Epidural for labour/birth, irrespective of mode of birth Need for catheter in labour Assisted vaginal delivery Caesarean section Perineal injury: haematoma, bruising, tear with inadequate analgesia. Overdistension of the bladder during/immediately following birth Larger than normal term baby Prevention of Acute Bladder Distension in Labour Encourage women to void every 2 to 3 hours. If unable to void on 2 occasions, threshold for catheterisation should be low. If bladder palpable and woman can not void catheterisation is indicated. Prevention of Acute Bladder Distension Postpartum Check that the woman has voided within six hours of birth or catheter removal. Encourage 3 to 4 hourly voiding for the first 24 hours. Urine volumes of greater than 150ml should be voided at least 3 times in 24 hours. Consider urinary retention if a woman complains of increasing lower abdominal pain. Postpartum Assessment of Bladder Function Ask the woman if she can feel her bladder filling and whether she has an urge to void. is she is experiencing any discomfort or difficulty when voiding the frequency with which urine is passed
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Peripartum Bladder Management

New Policy Peripartum bladder management Midwifery, Medical Staff & Physiotherapist, QVMU Urinary incontinence, retention, catheterisation

 the volume passed with each void If concerns are identified then commence bladder diary and inform medical officer and womens health physiotherapist. Management of Inability to Void If woman has not voided within 6 hours of birth: Ensure adequate analgesia given Commence bladder diary (see attachment 1) Encourage to void in toilet and measure volume If the volume voided is less than 150ml or the residual volume greater than 150ml (assessed with bladder scanner) o proceed to catheterisation o catheter should be left insitu if greater than 600ml urine obtained. o if the woman is unable to void after the in/out catheterisation, an IDC should be inserted and left in for 48 hours. Assessment of adequate voiding o measured voided volumes of greater than 150ml on three occasions in 24 hours o measured residuals of less than 150ml (using ultrasound) Referral to Womens Health Physiotherapist Consider MSU and antibiotics as appropriate Consider referral to urologist. Indications for an indwelling catheter Lack of sensation from epidural block following birth the catheter should remain until full sensation has returned Long or difficult labour the catheter should be left in for 24 hours Extensive perineal/vulval trauma in which case the catheter should be left in for 24 hours, or until swelling subsides History of difficulty in voiding, abnormal voiding pattern or an inability to void for 6 hours in which case the catheter should be left insitu for 24 hours. Removal of an indwelling catheter Remove catheter in the morning Commence bladder diary and provide specipan After removal measure voids until normal voiding pattern established and two measured voids of 300ml or greater are obtained. Check residual urine (using bladder scanner) if the woman becomes distressed, is unable to void or has no sensation to void. Management of Stress Incontinence Referral to Womens Health Physiotherapist Educate the woman about the function and importance of the pelvic floor muscles in relation to bladder control and how to perform pelvic floor exercises. Womens Health Physiotherapist Should be informed of all women who have experience urinary retention or who have complained of incontinence of urine to facilitate assessment and ongoing outpatient follow-up.

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Attachments
Attachment 1 Attachment 2 Attachment 3 Bladder Diary Background Information References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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APPENDIX 1 BLADDER DIARY Womens Health Physiotherapy Launceston General Hospital Ph: 6348 7216

NAME: Date started:

UR No:

BLADDER DIARY
If you are unable to feel when your bladder is full and you are not getting an urge to empty your bladder, then it is important to make sure that you make yourself go to the toilet to empty your bladder every 3-4 hours. If you do get an urge to empty your bladder then go. Record each time you pass urine DAY and NIGHT Write down the AMOUNT of urine passed each time (using the Specipan collection unit provided white plastic) Tick if you felt an URGE TO GO or NO URGE FELT Write down what you were doing at the time of being wet eg: standing up, on the way to the toilet, coughing and sneezing. Urine OUT Time Amount Urge Passed to go Eg: 7am 300ml Fluid IN Time had drink 7.30am

No urge felt

Reason for being wet

Type of drink Tea

Amount (1cup = 250ml) 250ml

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APPENDIX 2 BACKGROUND INFORMATION Postpartum Urinary Retention (PUR) There is currently no standardized definition of PUR. Suggested definitions include: absence of spontaneous micturition within six hours of vaginal birth. in the case of caesarean section it is defined as no spontaneous micturition within 6 hour after removal of an indwelling catheter. as sudden painful or painless inability to void over a 24 hour period. PUR may result due to: Hormones and contractile responses of the bladder Injured bladder innervation Overt Bladder Retention Inability to pass urine within 6 hours of delivery, requiring catheterisation to drain a volume above normal bladder capacity (normal 400 600ml in females). Women will often complain of pain and the desire to void, may have overflow incontinence mistaken as stress incontinence or maybe asymptomatic, particularly if an epidural was employed in labour. Covert Bladder Retention Failure of the bladder to empty at least 50% of normal capacity or a post void residual volume of 150ml. This woman will often have frequency and pass volumes of less than 150 ml. Assessing the Bladder Clinically preferred methods to estimated post void residual bladder volumes are palpation, catheterisation and ultrasound. Bladder palpation using a single hand abdominally may detect a bladder with 300ml or more. Catheterisation is associated with pain, haematuria, UTI Ultrasound (bladder scan) - ultrasound estimation of post void residual bladder volume (PVRBV) in the postpartum period is accurate and not invasive.

Women with residual urine volumes of less than 700ml immediately postpartum are less likely to need repeat catheterisation. Urinary retention in the postpartum period is common with reported incidence ranging from 1.5 to 17.9%

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APPENDIX 3 REFERENCES Ching-Chung L, Shuenne-Dhy C, Ling-Hong T, Ching-Chung H, Chao-Lun C & Po-Jen C 2002 Postpartum urinary retention: assessment of contributing factors and long-term clinical impact Australian and New Zealand Journal Obstetrics & Gynaecology; 42: 4; 365. Glavind K & Bjork J 2003 Incidence and treatment of urinary retention postpartum International Urogynecological Journal; 14: 119-121 Gyampoh B, Crouch N, OBrien, OSullivan C & Cutner A 2004 Intrapartum ultrasound estimation of total bladder volume. BJOG; 111:103-108 King Edward Memorial Hospital Clinical Guidelines 2006 Management of third and fourth degree perineal trauma. Online: http://www.kemh.health.wa.gov.au/development/manuals/guidelines.htm National Institute for Health and Clinical Excellence 2006 Routine postnatal care of women and their babies. Online: http://www.nice.org.uk/guidance/CG37/guidance/pdf/English Royal Womens Hospital Clinical Practice Guidelines 2005 Management of third and fourth degree tears. Online: http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3143 Yip S, Sahota D, Pang M & Chang A 2004 Postpartum urinary retention Acta Obstetricia et Gynaecologica Scandinavica; 83: 881-891. Yip S, Sahota D & Chang A 2003 Determining the reliability of ultrasound measurements and the validity of the formulae for ultrasound estimation of postvoid residual bladder volume in postpartum women. Neurology and Urodynamics; 22:255-260. Zaki M, Pandit M & Jackson S 2004 National survey for intrapartum and postpartum bladder care: assessing the need for guidelines. BJOG: 111: 874-876

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