WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital

Date Issued: February 2003 6.2.2.1 Bladder care
Date Revised: December 2013 Section B
Review Date: December 2016 Clinical Guidelines
Authorised by: OGCCU King Edward Memorial Hospital
Review Team: OGCCU Perth Western Australia
6.2.2 SUBSEQUENT CARE
6.2.2.1 BLADDER CARE
AI MS:
To assess bladder function.
To detect any deviation/s from normal
To carry out timely preventative measures to avoid complications following birth.
KEY POI NTS
1. Postpartum urinary retention is regarded as common event but the reported incidence varies
considerably from 1.7 to 17.9%
1, 2
.

2. Vigilant surveillance of bladder functioning and early intervention where problems exist will
prevent permanent bladder damage
3, 4
.
3. While all women in the immediate postpartum period have the potential to experience urinary
problems several factors increase the risk, i.e:
5-8

Prolonged first and second stages of labour
9

Caesarean section for lack of progress in the first stage of labour
Duration of labour
10

Assisted birth
9, 11

Episiotomy
11, 12

Epidural analgesia
11, 12
, particularly with local anesthetic. (e.g. bupivacaine)
Post Caesarean Epidural Morphine
13

Perineal/vulval trauma
Over distension of the bladder during/immediately following birth
Larger infant than normal term baby
Non English speaking mother
Obesity
12

Nulliparity
11, 12


4. The timing and volume of the first void urine should be monitored and documented in
the patients fluid balance chart or progress notes
14
.




6. ROUTINE POSTPARTUM CARE
6.2 CARE OF MOTHER ON THE POSTNATAL
WARD

CLINICAL GUIDELINES
SECTION B : GUIDELINES RELEVANT TO OBSTETRICS & MIDWIFERY

DPMS
Ref: 2298
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section Page 1 of 7




5. If an indwelling catheter (IDC) is used in labour or for a Caesarean birth, prior to removal,
assess motor function to ensure sensation has returned to normal. Perform a Bromage Score
and check Dermatomes if the epidural contained local Anesthetic. Refer to clinical Guideline
E.2.6 Assessment of Motor Function and E.2.5 Testing of Dermatomes.

6. Spontaneous vaginal birth the first void should be no later than 4-6 hours post birth or
removal of IDC.

7. Operative vaginal birth with local anesthetic to the perineum the first void should be no later
than 4-6 hours post birth or removal of IDC.

8. Operative vaginal birth with spinal or epidural topped up for a trial the woman should
have an indwelling catheter for at least 12 hours post birth to prevent asymptomatic
bladder overfilling
14
.

9. Caesarean Births- Urinary Indwelling Catheters to remain in situ for a minimum of 36 hours

10. Commence monitoring from 4 hrs after birth- see Flow Chart on page 6

11. Best practice indicates that women should have voided prior to leaving labour and
birth suite.

12. To pass a Trial of Void- a woman should have
Normal Sensation
Normal Flow and
Normal Volume

13. Notify the Urology Nurse Practitioner (on page 3136) or ward Physiotherapist if abnormal
bladder sensation/ abnormal voiding function present (see flow chart- hyperlinked).

14. The team Registrar shall be informed if
The woman is not voiding normally after birth.
Normal is defined as
A good sensation of bladder filling
A constant good stream of urine while voiding
Bladder feels empty after a void
No urge or passive incontinence
Void volumes of >150 mls and <600 mls
A residual volume of more than 600mL is obtained.

15. A real-time scanner, such as the Portascan, shall be used to assess residual amounts of urine
in postnatal women (the bladder scanner is not appropriate for use in postnatal women). If
unavailable, a Foleys catheter should be inserted to determine residual volume.












Date Issued: February 2003 6.2.2.1 Bladder care
Date Revised:December2013 Section B
Review Date: December 2016 Clinical Guidelines
Written by:/Authorised by: OGCCU King Edward Memorial Hospital
Review Team: OGCCU Perth Western Australia
DPMS Ref: 2298 All guidelines should be read in conjunction with the Disclaimer at the beginning of this section Page 2 of 7




PROCEDURE


ADDITIONAL INFORMATION
1. Assess the status of the womans bladder
on admission to the ward. The initial
bladder assessment should include:
A review of the labour/birth history to
detect any risk factors,
Bladder palpation
Checking to see if the woman has voided
after birth.
An initial assessment will provide information on:
the presence of any urinary problems,
risk factors that may contribute to urinary
problems,
baseline values for comparison with
subsequent recordings.
2.
2.1
Assessment
Subjective Assessment:
Ask the woman if she has a normal
sensation to voids, or experiencing any
discomfort or difficulty when voiding.

The woman may complain of:
15, 16

an inability to void,
reduced or loss of sensation of filling,
hesitancy or intermittent flow,
difficulty in emptying her bladder,
involuntary loss of urine,
voiding frequent small amounts (retention
with overflow),
increasing lower abdominal pain.

2.2
Objective Assessment:
check the frequency with which urine is
passed,
check the volume passed with each
void,
examine the womans abdomen for
displacement of the uterus and
swelling of the lower abdomen,
palpate the womans bladder.
300- 500 mls is normal bladder volume. But if
a woman is dehydrated, 150- 600 mls is
acceptable.


A distended bladder displaces the uterus
upward and to the right side. There may also
be a painful cystic swelling palpable in the
suprapubic region.
15


3

Prevention and Management


3.1 Encourage 2 to 3 hourly voiding for the
first 24 hours.
Use supportive measures, such as
analgesia, ambulation, privacy, warm
bath or shower or running water, to
enhance the likelihood of micturition.
During the early postpartum period a marked
diuresis occurs and the woman produces
copious amounts of urine. This, combined
with a decreased sensation of a full bladder
and the need to void, predisposes the woman
to over distension of the bladder.
Regular voiding, and observation of urine output
will reduce the likelihood of bladder over
distension related to urinary retention.
17

Date Issued: February 2003 6.2.2.1 Bladder care
Date Revised:December2013 Section B
Review Date: December 2016 Clinical Guidelines
Written by:/Authorised by: OGCCU King Edward Memorial Hospital
Review Team: OGCCU Perth Western Australia
DPMS Ref: 2298 All guidelines should be read in conjunction with the Disclaimer at the beginning of this section Page 3 of 7




PROCEDURE


ADDITIONAL INFORMATION
3.2 Measure and document voids and any
associated symptoms (e.g. dysuria, loss of
sensation).
Cease when bladder sensation and
voiding function is normal and two
consecutive voids of 150-600 mls are
achieved.
Refer to flow chart.
Suspect urinary retention if the voiding
pattern is one of frequent small voids
(<100mL).
16

Initial voids should always be measured and
recorded to give an indication of the amount and
frequency of voids.
It has been shown that where postpartum
documentation of urinary output has been poor,
urinary problems may go unrecognised.
18

3.3 If at 4-6 hours post birth the woman has
not voided, make an assessment of
bladder fullness using either a real time
scanner or Foleys catheterization (see flow
chart)

4. Urinary retention
Where urinary retention (residual urinary
volume of 150mL
2
) is suspected, confirm
by performing either a post micturition
ultrasound
19
, or a residual catheterization
immediately after a void.

Early diagnosis and intervention for urinary
retention is required to prevent irreversible
bladder damage.
20

5. When inserting a catheter for a residual
urine always:
inform the Urology Nurse Practitioner
on pager 3136 and RMO
If after hours- inform RMO
use a Foley's catheter
observe residual volume after 10
minutes
use a strict aseptic technique
Using a Foley catheter, instead of an in-out
catheter prevents the risk of introducing bacteria
into the urinary tract from a second
catheterization should an indwelling catheter be
required.
16

6. Indications for an indwelling catheter

Lack of sensation from epidural block
following birth
21
in which case the
catheter should remain in for at least
12 hours
22
and until full sensation
returns.
Epidural analgesia impedes sensory impulses in
the bladder increasing the risk of urinary
retention.
21
It has been reported that it may take
up to 8 hours after epidural analgesia for bladder
sensation to return.
23


Long or difficult labour
2
in which case
the catheter should be left in for 24
hours.
Prolonged difficult labour may cause trauma and
swelling of the bladder and urethra.
24


Extensive perineal/vulval trauma in
which case the catheter should be left
in for 24 hours, or until swelling
subsides.
21

Pain associated with this type of trauma my inhibit
voiding.
17

Date Issued: February 2003 6.2.2.1 Bladder care
Date Revised:December2013 Section B
Review Date: December 2016 Clinical Guidelines
Written by:/Authorised by: OGCCU King Edward Memorial Hospital
Review Team: OGCCU Perth Western Australia
DPMS Ref: 2298 All guidelines should be read in conjunction with the Disclaimer at the beginning of this section Page 4 of 7




PROCEDURE


ADDITIONAL INFORMATION
History of difficulty in voiding, abnormal
voiding pattern or an inability to void for
6 hours in which case the catheter
should be left in for 24 hours
During labour the bladder may become numbed
and oedematous through injury and pressure.
This may result in an inability to void or in an
altered voiding pattern. Catheterization for 24
hours allows recovery from the initial trauma.
17

7 Management of Bladder after excessive
distention


Where the residual urinary volume is
150-600 mls- IDC to stay in for 24 hrs
Where the urinary volume is >600 mls-
IDC to stay in for 48 hrs.
Over distension of the bladder causes a loss of
bladder muscle tone and detrusor hypotonia.
Catheterization for 48 hours allows adequate
drainage and prevents chronic bladder damage
4,
17, 20
.

Remove the catheter in the morning
around 06:00 hrs.
Morning removal of the catheter allows time for
careful and regular post catheterization bladder
assessment.
8. Management following the removal of
catheter

8.1 Reassess the bladder as outlined in
#2.

8.2 After removal of the catheter, palpate
the bladder 2/24 for 12 hours or until
normal voiding patterns are
established and two measured voids of
150mL or greater are obtained.

8.3 Measure residual urine if the woman
becomes distressed or is unable to
void for 4 hours either by Real Time
Ultrasound or by Foleys Catheter
Because retention may be gradual and
asymptomatic
23
, performing a residual urine is
necessary to ensure the bladder has regained its
tone and woman is able to empty her bladder
completely.
9. Document all findings as a variance point
on the clinical pathway and in the womans
medical notes.

10 Consider referral to urology team for
further management.











Date Issued: February 2003 6.2.2.1 Bladder care
Date Revised:December2013 Section B
Review Date: December 2016 Clinical Guidelines
Written by:/Authorised by: OGCCU King Edward Memorial Hospital
Review Team: OGCCU Perth Western Australia
DPMS Ref: 2298 All guidelines should be read in conjunction with the Disclaimer at the beginning of this section Page 5 of 7



PREVENTI ON AND MANAGEMENT OF POSTPARTUM URI NARY RETENTI ON
























































Voiding difficulty, unabl e to void or no sensation of bladder
filling within 4 hours of delivery or removal of IDC
Ensure adequate fluid intake (2-3 litres per day)
Encourage to void within 30 minutes
Instigate non-invasive measures - analgesia, privacy, Ural,
void in shower, relaxed void, mobilise
Commence bl adder diary

Assess symptoms and diary
Determine bladder volume:
either refer urology nurse for
ultrasound
or drain with IDC, record volume,
send CSU
Void 150-600ml within 30
minutes


Timed void 2-3 hourly

Void 150 600 ml
Voiding well adequate
sensation and flow, no
hesitancy or straining, feels
empty, no incontinence
No further action
IDC removed at 0600
Trial of void
Timed void 1.5 2 hourly


Refer urology nurse or
physio if not done so
already (MO after hrs)

Volume > 600ml
IDC 48 hours

Educate to:
Continue bladder diary 24
hours (even if discharged)
Continue timed void for
2 -3 days to ensure volumes
within normal limits

Insert IDC

No void or void
< 150ml within 4
hours
Management
planning with
urology nurse (MO
after hrs)

Sensation of
filling and
voiding well
no need to
refer

Loss of sensation
and/or voiding
difficulty refer
urology nurse
or physio


Void > 600ml within 30
minutes

Reassess bladder diary
and symptoms after next 2
voids
Loss of
sensation
and/or voiding
difficulty refer
urology nurse
or physio

Sensation
of filling
and voiding
well no
need to
refer

No void, unable to void or
void < 150ml within 30
minutes
Refer urology nurse/MO after hrs
Volume 150-600ml
IDC 24 hours

Void > 600ml
and/or
Voiding difficulty
continues

Date Issued: February 2003 6.2.2.1 Bladder care
Date Revised:December2013 Section B
Review Date: December 2016 Clinical Guidelines
Written by:/Authorised by: OGCCU King Edward Memorial Hospital
Review Team: OGCCU Perth Western Australia
DPMS Ref: 2298 All guidelines should be read in conjunction with the Disclaimer at the beginning of this section Page 6 of 7



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1994;38:51-3.
7. Yip SK, Brieger G, Hin LY, Chung T. Urinary retention in the postpartum period:the realationship
between obstetric factors and the postpartum post-void residual bladder volume. Acta Obstetric
Gynecol Scand. 1997;76:667-72.
8. Pifarotti P, Gargasole C, Folcini C, Gattei U, Nieddu E, Sofi G, et al. Acute post-partum urinary retention:
analysis of risk factors, a casecontrol study. Arch Gynecol Obstet. 2014 2014/01/21:1-5.
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Date Issued: February 2003 6.2.2.1 Bladder care
Date Revised:December2013 Section B
Review Date: December 2016 Clinical Guidelines
Written by:/Authorised by: OGCCU King Edward Memorial Hospital
Review Team: OGCCU Perth Western Australia
DPMS Ref: 2298 All guidelines should be read in conjunction with the Disclaimer at the beginning of this section Page 7 of 7