Royal College of Obstetricians and Gynaecologists

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Royal College ofObstetricians andGynaecologists
Setting standards to improve womens health
Risk Management and Medico-Legal Issues In
Womens Health Joint RCOG/ENTER Meeting
Please turn off all mobile phones and pagers
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National Maternity Hospital Dublin

• Postpartum Urinary Retention
• R.C.O.G. Risk Management Medico Legal Issues in
  Womans Health
• 30th April 2008
• M. Jacob MSc BSc RGN RCN RM FFNMRCSI
• Midwife Prescriber

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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

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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

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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)

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Consequences of Postpartum Urinary Retention

• In short term, may lead to atonic bladder and
  infection if not identified and relieved
• Page (2005)

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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)

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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.

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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.
• Yip et al. (2004) Acta Obstet Gynecol Scand 83
  881-891

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Literature Review

• Dearth of studies
• Limited urodynamic studies in women following
  postpartum urinary retention
• Bladder remains a largely neglected organ

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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)

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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)

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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

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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)

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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.

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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
• Musselwhite et al., 2007 Am J Obstet Gynaecol)

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Acute Postpartum Urinary Retention in Calgary
Health Regions 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)

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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

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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.

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Results of NMH audit of patients with postpartum
urinary retention (volumes gt1,000ml)

• 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.

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Action Research CycleCoughlan, D. Brannick, T.
(2001) Doing Action Research in Your Own
Organisation. Sage pg 17

Diagnosing
Planning Action
Evaluation
Taking Action
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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

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Birth Weight Range
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Parity
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Primips

• Number in cohort 62/91 68.1
• Number of primips 2006 3579/7986 44.8
• Chi squared test for proportions 18.8 (plt0.0001)

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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
  (plt0.05)
• In primiparous women retention rate 1.52
• Primips were 52 more likely to get urinary
  retention

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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)

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Epidural

• Number in cohort 62/91 68.1
• Number of epidurals in 2006 3567/7986 44.6
• Chi squared test for proportions 19.08 (plt0.001)

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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)

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Postpartum Urinary Retention

• Integration of audit into clinical practice
• National Maternity Hospital Postpartum Urinary
  Retention Guideline

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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.

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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

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Management of urinary retention

• If within 6 hours a woman has not passed urine,
  or lt200ml 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.

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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.

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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.

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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.

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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.

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Thank you
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Royal College ofObstetricians andGynaecologists
Setting standards to improve womens health
Risk Management and Medico-Legal Issues In
Womens Health Joint RCOG/ENTER Meeting
Please turn off all mobile phones and pagers