WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital

CLINICAL GUIDELINES
OBSTETRICS & MIDWIFERY

POSTNATAL CARE (ROUTINE)

MATERNAL POSTNATAL CARE
SUBSEQUENT CARE

BLADDER CARE
Keywords: bladder, urinary function, trial of void, urine, retention, bladder sensation, fluid balance, real
time scanner, residual volume
AIMS:
To assess bladder function.
To detect any deviation/s from normal
To carry out timely preventative measures to avoid complications following birth.
KEY POINTS
1.
2.
3.

Postpartum urinary retention is regarded as common event but the reported incidence varies
1, 2
considerably from 1.7 to 17.9% .
Vigilant surveillance of bladder functioning and early intervention where problems exist will prevent
3, 4
permanent bladder damage .
While all women in the immediate postpartum period have the potential to experience urinary
5-8
problems several factors increase the risk, i.e:
Prolonged first and second stages of labour

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

Duration of labour
Assisted birth

10

9, 11

11, 12

Episiotomy

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
12

Obesity

11, 12

Nulliparity
4. The timing and volume of the first void urine should be monitored and documented in the
14
patients fluid balance chart or progress notes .
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 Anaesthetics: 4.6
Assessment of Motor Function and Anaesthetics: 4.5 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
14
bladder overfilling .
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.
DPMS
Ref: 2298

All guidelines should be read in conjunction with the Disclaimer at the beginning of this section

Page 1 of 6

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.
PROCEDURE

PROCEDURE
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.

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.

ADDITIONAL INFORMATION
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.
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,

2.2

Objective Assessment:
check the frequency with which urine is
passed,

involuntary loss of urine,

voiding frequent small amounts (retention
with overflow),
increasing lower abdominal pain.
300- 500 mls is normal bladder volume. But
if a woman is dehydrated, 150- 600 mls is
acceptable.

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.
Bladder care
Clinical Guidelines: Obstetrics & Midwifery
DPMS Ref: 2298

A distended bladder displaces the uterus

upward and to the right side. There may
also be a painful cystic swelling palpable in
15
the suprapubic region.
King Edward Memorial Hospital
Perth Western Australia

All guidelines should be read in conjunction with the Disclaimer at the beginning of this section

Page 2 of 6

PROCEDURE
3
3.1

Prevention and Management

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.

3.2

ADDITIONAL INFORMATION

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.

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
17
distension related to urinary retention.
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,
18
urinary problems may go unrecognised.

Refer to flow chart.

Suspect urinary retention if the voiding
pattern is one of frequent small voids
16
(<100mL).
3.3

4.

5.

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)
Urinary retention
Where urinary retention (residual urinary
2
volume of 150mL ) is suspected, confirm by
performing either a post micturition
19
ultrasound , or a residual catheterization
immediately after a void.
When inserting a catheter for a residual urine
always:
inform the Urology Nurse Practitioner on
pager 3136 and RMO

Early diagnosis and intervention for urinary

retention is required to prevent irreversible
20
bladder damage.

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
16
required.

If after hours- inform RMO

use a Foley's catheter
observe residual volume after 10
minutes
use a strict aseptic technique
6.

Indications for an indwelling catheter

Lack of sensation from epidural block
21
following birth in which case the catheter
22
should remain in for at least 12 hours
and until full sensation returns.
2

Long or difficult labour in which case the

catheter should be left in for 24 hours.
Bladder care
Clinical Guidelines: Obstetrics & Midwifery
DPMS Ref: 2298

Epidural analgesia impedes sensory impulses in

the bladder increasing the risk of urinary
21
retention. It has been reported that it may take
up to 8 hours after epidural analgesia for
23
bladder sensation to return.
Prolonged difficult labour may cause trauma
24
and swelling of the bladder and urethra.
King Edward Memorial Hospital
Perth Western Australia

All guidelines should be read in conjunction with the Disclaimer at the beginning of this section

Page 3 of 6

PROCEDURE

Extensive perineal/vulval trauma in which

case the catheter should be left in for 24
21
hours, or until swelling subsides.

Pain associated with this type of trauma my

17
inhibit voiding.

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
17
hours allows recovery from the initial trauma.

Management of Bladder after excessive

distention
Where the residual urinary volume is 150600 mls- IDC to stay in for 24 hrs
Where the urinary volume is >600 mlsIDC to stay in for 48 hrs.
Remove the catheter in the morning
around 06:00 hrs.

8.

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
4, 17, 20
damage
.
Morning removal of the catheter allows time for
careful and regular post catheterization bladder
assessment.

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

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.

Bladder care
Clinical Guidelines: Obstetrics & Midwifery
DPMS Ref: 2298

ADDITIONAL INFORMATION

Because retention may be gradual and

23
asymptomatic , performing a residual urine is
necessary to ensure the bladder has regained
its tone and woman is able to empty her bladder
completely.

King Edward Memorial Hospital

Perth Western Australia

All guidelines should be read in conjunction with the Disclaimer at the beginning of this section

Page 4 of 6

PREVENTION AND MANAGEMENT OF POSTPARTUM URINARY RETENTION

Voiding difficulty, unable 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 bladder diary

No void, unable to void or

void < 150ml within 30
minutes

Assess symptoms and diary

Determine bladder volume:
either refer urology nurse for
ultrasound
or drain with IDC, record volume,
send CSU

Volume 150-600ml
IDC 24 hours

Volume > 600ml

IDC 48 hours

Refer urology nurse/MO after hrs

Void 150-600ml within 30

minutes

Sensation of
filling and
voiding well
no need to
refer

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

Timed void 2-3 hourly

Void > 600ml within 30

minutes

Sensation
of filling
and voiding
well no
need to
refer

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

Timed void 1.5 2 hourly

Reassess bladder diary

and symptoms after next 2
voids

IDC removed at 0600

Trial of void

No void or void
< 150ml within 4
hours

Insert IDC

Management
planning with
urology nurse (MO
after hrs)

Void 150 600 ml

Voiding well adequate
sensation and flow, no
hesitancy or straining, feels
empty, no incontinence

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

Void > 600ml

and/or
Voiding difficulty
continues

Refer urology nurse or

physio if not done so
already (MO after hrs)

No further action

Bladder care
Clinical Guidelines: Obstetrics & Midwifery
DPMS Ref: 2298

King Edward Memorial Hospital

Perth Western Australia

All guidelines should be read in conjunction with the Disclaimer at the beginning of this section

Page 5 of 6

REFERENCES / STANDARDS
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20.

21.
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23.
24.

Saultz JW, Toffler WL, Shackles JY. Postpartum urinary retention. J AM Board Fam Pract. 1991;4:341-4.
Yip S, Sahota D, Pang MW, Chang A. Postpartum urinary retention. Acta Obstet Gynecol Scand. 2004;83:881-91.
Jeffery TJ, Thyer B, Tsokos N, Taylor JD. Chronic urinary retention postpartum. Australian New Zealand Journal of
Obstetrics and Gynaecology. 1990;30(4):364-6. (Level IV).
Mehta S, Anger J. Evaluation and Management of Postpartum Urinary Retention. Curr Bladder Dysfunct Rep. 2012
2012/12/01;7(4):260-3.
Kermans G, Wyndaele JJ, Thiery M, Se Sy W. Puerperal urinary retention. Acta Urol Belg. 1986;54:376-85.
Andolf E, Losif CS, Jorgensen C, Rydhstrom H. Isidious urinary retention after vaginal delivery:prevalence and
symptoms at follow up in a population based study. Gynecol Obstet Invest. 1994;38:51-3.
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.
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.
Kekre A N, Vijayanand S, Dasgupta R, Kekre N. Postpartum urinary retention after vaginal delivery. International
Journal of Gynecology and Obstetrics. 2011;112:112-5.
Yip S, Sahota D, Pang M, Et al. Screening test model using duration of labor for detection of postpartum urinary
retention. Neurourol Urodyn. 2005;24:248-53.
Mulder FEM, Schoffelmeer MA, Hakvoort RA, Limpens J, Mol BWJ, van der Post JAM, et al. Risk factors for postpartum
urinary retention: a systematic review and meta-analysis. BJOG: An International Journal of Obstetrics &
Gynaecology. 2012;119(12):1440-6.
Handler S J, Cheng Y W, Knight S, Lyell D, Caughey A B. What factors are associated with postpartum urinary
retention? American Journal of Obstetrics & Gynecology. 2011;204(1):S79.
Liang C-C, Chang S-D, Wong S-Y, Chang Y-L, Cheng P-J. Effects of postoperative analgesia on postpartum urinary
retention in women undergoing cesarean delivery. Journal of Obstetrics and Gynaecology Research.
2010;36(5):991-5.
Royal College of Obstetricians and Gynaecologists. Operative Vaginal Delivery- Greentop Guidline no.26. 2011;
Available from: http://www.rcog.org.uk/files/rcog-corp/GTG26.pdf.
World Health Organisation. Postpartum care of the mother and newborn: a practical guide. Report of a technical
working group. Geneva: WHO1998. Report No.: Publication no. WHO/RHT/MSM/98.3.
Pillitteri A. Maternal and Child Health Nursing. Philadelphia: Lippincott Williams and Wilkins; 2003.
Hynes L. Physiology, complications and management of the puerperium. In: Benntt V, Brown L, editors. Myles
Textbook for Midwives. Sydney: Churchill Livingstone; 1999.
Dolman M. Midwive's recording of urinary output. Nursing Standard. 1992;6(27):25-7. (Level IV).
Weissman A, Grisaru D, Shenhav M, Peyser RM, Jaffa AJ. Postpartum surveillance of urinary retention by
ultrasonography: the effect of epidural analgesia. Ultrasound in Obstetrics and Gynecology. 1995;6(2):130-4 (Level
IV)
Groutz A, Gordon D, Wolman I, Jaffa A, Kupferminc MJ, Lessing JB. Persistent postpartum urinary retention in
contemporary obstetric practice. Definition, prevalence and clinical implications. Journal of Reproductive Medicine.
2001;46(1):44-8. (Level IV).
Ramsay IN, Torbet TE. Incidence of abnormal voiding patterns in the immediate postpartum period. Neurology and
Urodynamics. 1993;12(2):179-83. (Level IV).
Gynecologists RCoOa. Guidelines 26 Operative vaginal delivery. RCOG. 2005;Guideline 26:1-13.
Bick D, MacArthur C, Knowles H, Winter H. Postnatal Care: Evidence and Guidelines For Management. London:
Churchill Livingstone; 2002.
Johnson R, Taylor W. Skills for Midwifery Practice. Sydney: Churchill Livingstone; 2000.

National Standards 1- Care Provided by the Clinical Workforce is Guided by Current Best Practice
Legislation - Nil
Related Policies Clinical Guidelines: Obstetrics & Midwifery: Postnatal Care (Routine); Anaesthetics: Testing of
Dermatomes; Anaesthetics: Assessment of Motor Function
Other related documents

RESPONSIBILITY
Policy Sponsor
Initial Endorsement
Last Reviewed
Last Amended
Review date

Nursing & Midwifery Director OGCCU

February 2003
December 2013
December 2016

Do not keep printed versions of guidelines as currency of information cannot be guaranteed.

Access the current version from the WNHS website.
Bladder care
Clinical Guidelines: Obstetrics & Midwifery
DPMS Ref: 2298

King Edward Memorial Hospital

Perth Western Australia

All guidelines should be read in conjunction with the Disclaimer at the beginning of this section

Page 6 of 6