ROYAL HOSPITAL FOR WOMEN

LOCAL OPERATING PROCEDURE

CLINICAL POLICIES, PROCEDURES & GUIDELINES

Approved by Quality & Patient Safety Committee 19/7/12

BLADDER CARE DURING LABOUR AND THE POSTPARTUM PERIOD

1. AIM

Maintenance of normal bladder function during labour and the immediate postpartum period Early detection of bladder dysfunction and appropriate management

2. PATIENT Woman in labour or postpartum 3. STAFF Registered Midwives Medical staff Student Midwives Registered Nurses 4. EQUIPMENT Foleys 14 Gauge Catheter Catheter Pack Sterile Water 0.9% Sodium Chloride 10mls 20ml Syringe Catheter Bag 5. CLINICAL PRACTICE Educate woman regarding the importance of optimal bladder care function during labour and postpartum period Encourage woman to void and empty her bladder completely : o at least every 2 hours during labour o prior to insertion of an epidural block (EDB) Insert an Indwelling Catheter (IDC) if any of the following situations occur:

1 STAGE
o o o

ST

2 STAGE
o o o

ND

3 STAGE
o o

RD

EDB has been inserted Palpable bladder but woman unable to void If unable to void 4 hours from previous void

EDB Palpable bladder but woman unable to void nd 2 stage is >=2 hours and the woman has not been able to void

o o o o o

Periurethral tears Extensive labia / perineal swelling likely to impede voiding Perineal haematoma Unable to void within 6 hours of birth Post partum haemorrhage (PPH) rd th 3 and 4 degree tear Retained placenta

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ROYAL HOSPITAL FOR WOMEN

LOCAL OPERATING PROCEDURE

CLINICAL POLICIES, PROCEDURES & GUIDELINES

Approved by Quality & Patient Safety Committee 19/7/12

BLADDER CARE DURING LABOUR AND THE POSTPARTUM PERIOD contd

Urinary Catheter and 2nd Stage o Deflate balloon of IDC at commencement of pushing and remove o In-out catheter is recommended prior to assisted vaginal delivery Consider insertion of IDC when: o In-out catheter for assessment of urinary retention o Deviated fundus or poorly contracted uterus, especially if there is heavy lochia 1 post partum void within 4 hours of birth or removal of IDC o Ask the woman the following questions to ascertain if they have: A decreased sensation to void To strain to start, maintain or complete a void A poor / interrupted stream A sense of incomplete emptying A need to re-void within 5 mins A deviated fundus or poorly contracted uterus post void Leaking/ incontinence of urine (if this is the only criteria-refer to Physiotherapy) o Refer to flowchart 6. DOCUMENTATION Trial of void chart Integrated clinical notes Fluid balance chart Maternal Clinical Care Plan Partogram ObstetriX 7. EDUCATIONAL NOTES Women who are at risk of bladder over distension and urinary retention have had one or more of the following: o Epidural o IDC in labour st nd o Prolonged 1 stage > 12 Hrs and/or 2 Stage > 2 Hrs o Instrumental birth o Lower Segment Caesarean Section (LSCS) rd th o 3 / 4 Degree Tear 8. RELATED POLICIES / PROCEDURES / CLINICAL PRACTICE LOPs First Stage Labour Care for Women with Low Risk Pregnancy Second Stage of Labour Third Stage Management Instrumental Vaginal Delivery rd th 3 and 4 Degree Tear Caesarean birth maternal preparation and receiving the newborn by midwives and nurses Retained Placenta Postpartum Haemorrhage - Prevention and Management (PPH) Epidural Policy and Management Catheterisation /3
st

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ROYAL HOSPITAL FOR WOMEN

LOCAL OPERATING PROCEDURE

CLINICAL POLICIES, PROCEDURES & GUIDELINES

Approved by Quality & Patient Safety Committee 19/7/12

BLADDER CARE DURING LABOUR AND THE POSTPARTUM PERIOD contd

9. REFERENCES 1 Prevention and management of postnatal urinary retention flowchart, (2011) King Edward Hospital, Perth 2 Postpartum Voiding Dysfunction: Treatment Algorithm(2006) The Royal Womens Hospital, Melbourne 3 Yip, S.K., Pang, M.W., Day, L., (2005) Postpartum Urinary Retention American College of Obstetricians and Gynecologists 106 (3) 602-606 4 Groutz, A., Gordon, D., Wolman, I., Jaffa, A., Kupferminic, M.J., Lessing,J.B. (2001) Persistent postpartum urinary retention in contemporary obstetric practice Journal of reproductive medicine 46 (1) 44-48 Carley, M.E., Carley, J., Vasdev, G., Lesnick, T., Webb, M.,Ramin, K., Lee, R. (2002) Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery. American Journal of Obstetrics and Gynecology 187 (2) 430-433. Kearney, R. and Cutner, A. (2008) Review postpartum voiding dysfunction. The Obstetrician and Gynaecologist 10 71-74. Yip, S.K., Brieger, G., Hin, L.Y., Chung, T., (1997) Urinary Retention in the post-partum period Acta Obstetricia et Gynecologica Scandinavica 76 667-672 Andolf, E., Losif, C.S., Jorgensen, C., Rydhstrom, H. (1994) Insidious urinary retention after vaginal delivery: prevalence and symptoms at follow up in a population based study Gynecologic and Obstetric Investigation 38 (1) 51-53 Rizvi, R.M. And Rizvi, J. (2006) Management of postpartum urinary retention. Reviews in Gynaecological and Perinatal Practice 6 40-144.

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REVISION & APPROVAL HISTORY

Also replaced Protocol for Management of Significant Postnatal Retention (approved Quality Council 23/4/01) Reviewed Obstetrics LOP Group June 2012 Approved Quality & Patient Safety Committee 17/2/11 Reviewed November 2010 Approved Quality Council 16/8/04

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FLOWCHART
PREVENTION AND MANAGEMENT OF POSTPARTUM URINARY RETENTION
1st post partum void within 4 hours of birth with risk factors for bladder issues or removal of IDC, measure void a) If answers no to voiding criteria for 1st 2 voids Continue to STEP 2 a) b) If unable to void or answers yes to voiding criteria Continue to STEP 1
Risk Factors for bladder complications : Epidural IDC in labour Prolonged 1st stage > 12 Hrs and / or 2nd Stage > 2 Hrs Instrumental birth LSCS 3rd / 4th Degree Tear Previous bladder complications

STEP 1 * Instigate non-invasive measures analgesia, privacy, Urinary Alkaliser, shower, mobilise * Ensure adequate fluid intake up to 250 ml / Hr * Encourage to void within 2 Hrs, if previously unable to void

Voiding Criteria Questions Decreased sensation to void ? Strain to start, maintain or complete void ? Poor / interrupted stream ? Sense of incomplete emptying ? Need to re-void within 5 mins ? Deviated fundus or not firm and central post void Leaking / incontinence of urine (if only criteria-refer to Physio)

STEP 2 a)

* Voids 150 800ml within 2 Hrs * Answers No to voiding criteria * Repeat for 2nd void

STEP 2 b) * Voids > 800 mls * Answers no to voiding criteria (or only yes to decreased sensation)

STEP 2 c) * Voids > 150 ml within 2 Hrs * Answers yes to voiding criteria * Go to STEP 3 b)

STEP 2 d) Unable to void or void < 150ml within next 2 Hrs

STEP 3 a) * Educate re : normal bladder/voiding criteria * Commence bladder diary * Timed voids 2-3 hourly are within normal limits (150 800 ml) * Encourage fluid intake up to 250 ml / hr

STEP 3 b) * Determine bladder residual volume by inserting In / out catheter record volume + send CSU * Notify multidisciplinary team including Obstetric, Gynae OPD NUM * Develop management plan and record in notes

No further action Reassess bladder diary and voiding criteria after next two voids * Voids 150 800ml * Answers No to voiding criteria * Volumes continue > 800 mls * Continue bladder diary until sensation improves

Residual volume = 150 800 mls Continue 2nd trial of void (starting back at STEP 2) * Commence bladder diary * Commence timed voiding 23 hourly (refer to STEP 3a) if still unable to void IDC for 24 Hrs 48 Hrs or IDC removed at 06:00 Hrs

Residual > 800 ml IDC 24 48 Hrs

* Trial of void (TOV) Starting back at STEP 2 * Document on Bladder Diary * Timed void 2 3 hourly * Assess voiding criteria for each void (+/- in/out catheter) * Maintain fluid up to 250 ml / Hr

No further action

* Volumes 150 800 ml * If answers No to voiding criteria

No spontaneous void or void <150ml within 4 Hrs

* Continue above management * Refer to team, for further management if not done so already

No further action

Discuss options with woman re: self in / out catheters or SPC

Management plan with Gynae OPD NUM and EndoGynae Consultant in Tuesday PM clinic

PATIENT LABEL

BLADDER DIARY

VOIDING ASSESSMENT QUESTIONS

Decreased sensation to void (pass urine) ? Strain to start, maintain or complete void ? Poor/ Interrupted stream ?

YE
S

NO

RISK FACTORS FOR BLADDER COMPLICATIONS

Epidural anaesthesia IDC in labour Prolonged 1st Stage >12 Hrs and / or 2nd stage > 2 Hrs Instrumental birth LSCS 3rd and 4th degree tear Previous urinary complications

YES

Sense of incomplete emptying ? Need to re-void within 5 mins ? Deviated fundus or not firm and central post void Leaking / incontinence of urine (if only criteria refer to Physio)

0 = No bladder sensation + no desire to void 1 = Sense of bladder filling, no desire to void, could delay 1 hr 2 = Desire to void but could delay 30 mins 3 = Strong desire to void, unable to delay > 15mins 4 = Urgent desire to void, unable to delay 5 mins

SENSATION TO VOID (PASS URINE)

DATE/ TIME

ORAL INTAKE

SENSATION TO VOID 04

1ST VOID

2ND VOID

IN/OUT CATH

Total Void +/Cath 800 ML MAX

BOWELS