Central Northern Adelaide Health Service

Outcomes following childbirth and voiding

dysfunction
Follow up by the Continence Nurse Practitioner
(CNP) led service and multidisciplinary team

WHA Clinical Forum

Brisbane 2009

Donna Coates CNP, Dr Alex Hubczenko, Julie Tucker CNS, Elaine Steel CNS,
Women’s and Children’s Division Lyell McEwin Hospital Adelaide
 Background

> Yip et al (1998) reports post partum urinary

retention (PPUR) occurs in 10-15% of women

> Groutz (2001) in a large prospective study

reported persistent post partum urinary retention
beyond the early puerperium persists in only
0.05% of cases
 Background

> No universal definition to define PPUR

> Rane and Frazer (1999) have classified overt
PPUR as inability to pass urine within six hours of
delivery
> Yip et al (1998) classified covert PPUR as a post
void residual bladder volume greater than 150mls
without symptoms
> Women with pre-existing neurogenic changes or
recent neurogenic insult may have no pain or
altered threshold for sensation to void (STV)
> A single episode of bladder over distension may
cause persistent retention with recurrent urinary
tract infection (UTI) and permanent voiding
difficulties (Yip et al 1998)
 Background

> Contributing factors include

 duration of labour longer than 800minutes (13 ½
hours)
 epidural analgesia during labour or delivery
 instrumental delivery
 caesarean section
 pelvic floor trauma
 first vaginal birth
(Yip et al 1998 and Ching Chung et al 2002)

> Poor bladder management in labour is thought to

result in voiding difficulties in the immediate post
partum period (Dolman 2003)
Pudendal nerve stretch- geometric changes a computer simulation

Pudendal nerve & pelvic floor

structure geometry at the
beginning of 2nd stage (top)

Simulated pudendal nerve

and pelvic floor geometry at the end
of second stage (bottom) in
oblique view
(Lien et al, May 2005 American J of
O&G)
 Background

> Paucity of literature on how to assess & treat

PPUR
> Women delivered at the Lyell McEwin Hospital
(LMH) with identified PPUR and or bladder injury
are referred to the CNP led service commencing
on the ward before discharge
> A multi disciplinary practice guideline for PPUR
has been in place since 2001
> Midwives conduct a Trial of Void (TOV) for at risk
women using a sticker placed in at risk woman’s
case notes
> If woman has not voided 6 hours post delivery she
requires in/out catheter to determine if poor
hydration or retention
 TOV Sticker
POST PARTUM VOIDING REVIEW
(Circle each response where appropriate)
Date and time of delivery:
Urinary catheter: Yes No Time removed:
Sensation to void: Normal Decreased Absent
Hesitancy initiating void: Yes No
Urine flow: Normal Slow “Start Stop Start”
First Void Volume = Time:
Second Void Volume = Time:
Reassuring Non Reassuring
Action:
 Failed TOV

> Referral to CNP service

> Urine MC &S

> Continuity of care is ensured + CNP/S liaises with

Gynaecology Consultant / Registrar

> Management is individualised according to the

CNP/S assessment and patient treatment choice
CNP Service Options if patient fails
TOV

> ISC post void x 3 for significant PVR (100-500

mls). If residuals not reducing dramatically, insert
IUC and reassess 48 hrs OR
> IUC for 48 hours if residual volume > 500ml

After 48 hours
> If fails TOV with removal of IUC
 IUC with flip flow release program
 Intermittent Self Catheterization
 CNP Service

> Manages ISC or IUC flip flo program

> Monitors urine MC & S
> Treats UTI –if complex→ Consultant / Reg
> Treats thrush
> Bowel management, pelvic floor exercises
> Monitor patient progress and coordinate
management
> Involved with discharge planning, clinic review
one week later, phone service
> Arrange readmit for TOV
> Educate patient re removal of IUC at 0600 and
admit patient 0800 and monitor TOV – liaising with
Midwives and Medical staff
> Counsel woman re birth plan next pregnancy
> Letter to GP and medical stakeholders
 Method of review PPUR patient
outcomes

> Retrospective case note review was performed to

collect data

> The assessment and management

for each woman was captured intrapartum, post
partum and from the CNP/S treatment plans

> Data was analysed and correlated

 Results

> 3,148 women birthed from November 2007 to

December 2008

> 12 women (0.38%) were referred to the CNP

service
 Results for 2 groups

GROUP 1
> 6 women (0.19%) failed the TOV or presented
with PPUR after vaginal childbirth

GROUP 2
> 6 women (0.19%) had LSCS. 4 women in this
group had bladder trauma at section and 2 had no
sensation to void after section
Group 1
 Group 1 vaginal birth

> 4 had PPUR

> 2 referred to CNP service in pregnancy with history
previous PPUR (women did not birth at LMH). Both
women had prior history long labour, instrumental
delivery, perineal trauma, ISC not supervised.
Women sent home to manage ISC alone.
> Ongoing symptoms incomplete emptying (self
initiation double voids), OAB, anxiety re birthing
Group 1: Vaginal birth group 3 women failed the TOV and 1readmitted with
PPUR after vaginal childbirth

Parity Gestation Analgesia LOL Perineal Vaginal Birth

trauma Outcome
1. G3P3 T+3 SOL Nil BBA Intact NVB
Readmit 2/7 later
with POP Grade 2
Uterine and Grade
3 cystocoele

2. Primip T+10 IOL IM Pethidine 1st 7h 45m RMLE Ventouse

Epidural 2nd 2h 33m
3rd 7m
3. Primip T+9 SOL IM Pethidine 1st 8h 40m 2nd deg tear Ventouse
Epidural 2nd 2h 43m Cervical McRoberts
3rd 2m tear S.Dystocia
4. Primip Term IOL Epidural 1st 5h 30m 2nd deg tear Fail ventouse to
2nd 2h 18m Wrigleys
3rd 5m forceps
 2 with previous PPUR

Birth plan after CNP/Consultant review:

-Experienced accoucher
-Ensure good progress in labour
-Try to avoid epidural / instrument delivery
-Early senior medical review if slow progress in labour
-Ensure TOV pp and early CNP review if TOV non reassuring
-Ensure woman is confident and feels supported

1. G3 P1 T+2 Nit Oxide 1st 3hr 2nd deg tear NVB

SOL 2nd 18m
3 rd 4m

2.G3P2 T-5 ind Nit Oxide 1st 2h 25m 2nd deg tear NVB
2nd 11m
3rd 9m
 Mean birth weight Mean head circumference
vaginal birth group vaginal birth group

3437grams 34.4cms

Range 2730 - 4288 Range 32.5 -37

 Practice issues
6 vaginal birth women

> Delay in referral for 3 primip pts to CNP after

failing TOV (referred days 7,6,3 pp)

> CNP and Multi d follow up resulted in successful

TOV @ 3,8 and 4 weeks pp respectively

> All women chose IUC with flip- flo valve

 Practice issues 4 vaginal birth
women with PPUR
> 3 women had poor partogram documentation of
bladder function in labour

> While TOV stamps were used, 3 patients who

failed the TOV were not referred to CNP service

> The 3 women were subject to repeat

instrumentation, detrusor over distension and UTI
before referral to CNP service
 Impact on maternal – baby bonding
 ↑ risk long term sequel
 Practice issues

> 1 primip pt failed TOV. ISC 700ml→ IUC

→removed @ 24 hours, poor documentation with
TOV
> 1/7 later patient c/o UTV. Discharged home with
midwife counseling pt to use shower to help void +
ural sachets
> No CNP referral
> Woman readmitted day 6 ?pyelonephritis
/endometritis, urinary retention, constipation.
Triple IVI antibiotic
> Referral CNP
> IUC flip-flow and oral antibiotic → prophylactic
cover
> Neuro exam N
> TOV 3/52 pp successful
> 5/52 pp patient happy with bladder and bowel
function
2 women with previous PPUR

> 2 passed TOV on ward

> Midwives good documentation and liaison with
CNP
> Both had borderline PVR 150mls at clinic visits
with CNP post partum
> Both women declined ISC
> Managed with active voiding program → double
voids, crede, complete emptying techniques,
charts, close monitoring from CNP → total bladder
volume to be < 600mls
> No UTI
> 1 had EAUS previous lat sphincterotomy fissure →
flatus inc daily. IAS defect and EAS thinned
anteriorly
> Both women now report good bladder function,
one has residual flatus incontinence
 Recommendations

> Identify pregnant women at 1st triage visit with

risk factors/previous PPUR → refer CNP service
> Review birth plans for women with history voiding
dysfunction, urinary retention with relevant
stakeholders
> Avoid induction and epidural if possible
> Fetal size→ presentation /experienced accoucher
> Ensure good progress in labour
> Early senior medical review for concern with slow
progress
> Documentation bladder function intra partum
> TOV guideline followed
> Early contact with CNP service with failed or non
reassuring TOV
> CNP liaises with Consultant / Registrar
 Modify Trial of Void Sticker

POST PARTUM VOIDING REVIEW

(Circle each response where appropriate)
Date and time of delivery:
Urinary catheter: Yes No Time removed:
Sensation to void: Normal Decreased Absent
Hesitancy initiating void: Yes No
Urine flow: Normal Slow “Start Stop Start”
First Void Volume = Time:
Second Void Volume = Time:
Reassuring: Cease Trial of Void Yes No
Non Reassuring: Refer to CNP Service Yes No
Refer to TOV flow chart Yes No
 Flow Chart
Care of Women at Risk of Voiding Dysfunction Post Partum

Woman has risk factors for voiding dysfunction

(see protocol)

Insert TOV sticker in case notes with removal of indwelling urinary catheter or
post partum

Documentation on TOV sticker Documentation on TOV sticker completed

completed Non Reassuring – Failed TOV
Reassuring

TOV completed Prompt referral of woman to CNP service

No further action

ADDITIONAL INFORMATION
Woman has post void residual 100-499mls
Do ISC for 3 consecutive voids immediately post void
If residuals significantly reducing → continue with regimen
and contact CNP service
If residual 500mls or greater insert IUC and contact CNP
service
Suggest TOV in 48 hours
If TOV fails CNP/S to counsel woman about treatment options

© Women and Children’s Division Lyell McEwin Hospital October 2009

Group 2
 LSCS Group 6 women: 4 with trauma
and 2 with no STV
Breech Failure to Failed Maternal Grade IV
Progress Ventouse pneumonia/GD Placenta
Insulin Praevia/Accreta
1→emerg 2→emerg 1→emerg 1 elec →crash 1→ elec
7 hr labour 16 hr and
7hrs labour

Bladder tear at LSCS Voiding dysfunction-no sensation to void

post LSCS
4 2

Mean birth weight Mean head Mean birth Mean head circumference
Emerg LSCS circumference weight elective LSCS 2 babies
4 babies Emerg LSCS elective LSCS Data available for 1 baby
2 babies
3501grams 36.1cms 2543 grams 36.5cms
Range 3060-3860 Range35.5-36.5 2025-3060
 Outcomes for 4 women with
bladder trauma
> IUC with free drainage to leg bag and connected
at night to overnight bag. Weekly MC &S
> Leg bag changed weekly. New O/N bag daily
> 3 ordered cystogram prior to TOV (all N)
> 3 had successful TOV day 25, 14 and 18
> 1 had non reassuring TOV documentation day 11
but discharged home with double voids. CNP and
Consultant readmit pt TOV 3/7 later → successful.
Patient DNA follow up CNP. Gynae review @ 1/12
states normal bladder function
> 3 women were treated for UTI
> 1 woman treated with Vesicare for 8/52 for
bladder pain, frequency, urgency (cystectomy /
hysterectomy for PP Grade IV + accreta)
 Outcomes for 2 women with
no STV post emerg LSCS

> 1 woman with decreased - no STV. FBC non

reassuring –no in/out catheter. UTI treated day 5
by GP. CNS did not follow up with scans but
documented per phone consult normal void
pattern. Full resolution within 10/7 per CNS. PH
consult follow up by CNS not completed

> 1 woman (13 hour 1st stage, 3hr 8m 2nd stage

VBAC) had ↓sensation call to stool and no STV.
S4 recovery @ 10/7. Pre and post void scans
normal with CNP. Bowel regimen and bladder
active voiding program effective
 Recommendations for practice

> Ensure women diagnosed with UTI are prescribed

correct antimicrobial (suggest minimum 7 days)
and the IUC is changed 48 hours after
antimicrobial commenced → biofilm /
recolonisation once antimicrobial withdrawn with
no IUC change
> Consider prophylactic antimicrobial if recurrent
UTI – check pt compliance
 Recommendations for practice

> Dedicated RM/RN or preferably a credentialed

CNS/P to work with woman and multi d team to
ensure
-continuity of care
-best practice
-correct selection / management of urinary
drainage systems
-patient education about urinary drainage system,
bowel management, good bladder care, pelvic
floor exercises
-follow up after ward discharge, serial pre and
post void scans prn , reviews voiding parameters,
frequency void chart, urine MC & S
-woman reassured and supported
-ensure normal bladder, bowel and pelvic floor
function restored
 Take home message

> Know the diuresis for each woman

> Know the voiding pattern for each woman
> Bowel regimen in place
> If in doubt do in/out catheter and ensure follow up
> Excellent knowledge urinary drainage systems
and legal implications
> Avoid long term sequel
> Birth planning next pregnancy with trial of void
> Bard or GE scanner not reliable first 3-4 weeks ↑↑
prevalence echogenic debris from uterus
> Multi D communication → engage the expert
 References

> Ching – Chung L et al. Postpartum urinary retention: assessment of

contributing factors and long-term clinical impact. Aust NZ J Obstet
Gynaecol 2002; 42(4):365-8

> Dolman M. Mostly female. In Getliffe K, Dolman M, editors. Promoting

continence a clinical research resource. London: Bailliere Tindall;2003.
p.53-79

> Groutz A et al. Persistent postpartum urinary retention in contemporary

obstetric practice. Definition, prevalence and clinical implications.
Journal of Reproductive Medicine.2001.45(1):44-8

> Rane A, Frazer M. Intrapartum and postpartum bladder care. Obs &
Gynae 1999; 1(14):311-313

> Yip SK, Hin LY, Chung T. Effect of the Duration of Labour on
Postpartum Postvoid Residual Bladder Volume. Gynaecol Obstet
Invest 1998; 45(3): 177-180
Any questions?