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Postpartum Bladder Dysfxn

Postpartum Bladder Dysfxn

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Published by Shitanjni Wati

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Published by: Shitanjni Wati on Apr 16, 2011
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02/06/2013

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Abstract
The development of postpartum urinary symptoms such as incontinence and voidingdysfunction are not uncommon and often difficult to resolve. The urinary tract undergoes both structural and functional changes during pregnancy and after delivery. Thesechanges may be specific in response to pregnancy and in some women may becompounded by pathological changes that persist after delivery. In labour, factors such as prolonged labour, assisted vaginal delivery, and perineal laceration have been associatedwith development of bladder dysfunction. Anatomical and functional changes to the pelvic floor may occur secondary to pelvic floor distension during descent of the fetalhead and maternal expulsive efforts during the active second stage of labour. This chapter focuses on the effect of pregnancy and childbirth on the lower urinary tract and discussesthe possible mechanisms by which pelvic floor damage may occur and their long-termsequelae and management.
Keywords:
Incontinence; Urinary retention; Caesarean section; Vaginal delivery
Definition
 
Postpartum urinary retention is the inability to void, with a painful (usually), palpableor percussable bladder and the need for catheterisation to obtain relief. (Rizvi et al.2005)
o
 
Women with pre-existing neurogenic changes or recent neurogenic insultmay have no pain or altered threshold for sensation to void
 
In its covert form, urinary retention consists of increased postvoid residual volume;in its overt postpartum form, it refers to the inability to void the bladder spontaneously after delivery (Rizvi et al. 2005)
 
Persistent postpartum urinary retention may be defined as the inability to voidspontaneously despite the use of an indwelling catheter for three days (Groutz et al.2001)top
Risk factors
 
History of voiding difficulties
 
Primiparity
 
Epidural, spinal or pudendal block in labour 
 
Difficult instrumental birth and / or shoulder dystocia
 
Prolonged second stage
 
Excessive perineal trauma i.e. Para-urethral tear, clitoral tear, large episiotomy, large2
nd
or 3
rd
degree tear, significant oedema
 
Catheterisation during or after birth
 
Change in sensation to void after birth
 
Incomplete emptying of bladder (Jeffery et al. 1990; Kulkarni et al. 1994; Yip et al.1998; Lee et al. 1999)
 
 
NB:
Ensure that women from non English speaking backgrounds are aware of normalvoiding function and understand the risks and symptoms associated with postpartumurinary retention
Symptoms
 Symptoms of incomplete emptying of bladder include:
 
Feeling full or partially full bladder after voiding
 
Dribbling urine during or after voiding
 
Urinary frequency with small voided volumes
 
Slow urinary flow rate or straining to void
 
 Nocturia more frequent than 2-3 times not related to feeding the baby
 
Delay in voiding for more than 6 hours after birth
 
Difficulty in initiating micturition after birth
 
High or displaced uterine fundus with palpable bladder (detected with dense soundon percussion) and possible lower abdominal pain 
NB:
A detailed assessment of the woman’s voiding function is requiredtop
Management 
 
Women should be encouraged to void every 2-3 hours in labour with a low thresholdfor catheterisation if unable to void
 
After birth, encourage all women to void within 1-2 hours – maximum 6 hours
 
Discuss with the woman the importance of ensuring urinary function returns tonormal
 Normal voiding function:
 
 Normal frequency of micturition is up to 8 times in a 24 hour period – allow for afew extra voids in the first 24 - 48 hours after birth
 
80 % of the bladder volume should be passed with each void. Usual volumes are between 300 - 400 mL
 
Some women are only able to void standing in the shower or sitting over a warm bidet. Document time and check with woman about nature of void (as above). This isacceptable for a first void. Second void document time and volume
 
At first void after birth, assess and document the following in clinical record:
o
 
 Normal sensation to void
o
 
Any difficulty encountered with initiating void, change in urineflow rate, feeling of incomplete bladder emptying
o
 
Volume voided and time
o
 
Frequency of voiding
 
Regardless of hydration status, women with symptoms of incomplete emptyingrequire assessment of residual urine, preferably with an ultrasound and /or bladder scan, otherwise assess by in / out catheter 
 
NB:
The standard bladder scanner may report on echogenic uterine debris whenmeasuring urinary residual. An in / out catheter is the only reliable tool in the first 2weeks postpartum
 Process for residual urine:
o
 
Ask woman to void
o
 
Pass in / out catheter immediately after the void (within 10minutes as later measurements reflect renal perfusion )
o
 
Record volume voided and residual obtained (a significant residualurine is greater than 100 mL. Expect woman to pass 80 % of total bladder volume)
o
 
Report findings to Medical Officer and Continence Nurse Advisor or Continence Physiotherapist
 If unable to void six hours after birth or removal of catheter:
 
Regardless of perceived hydration status, pass an in / out catheter and record volume
 
If in doubt about woman’s bladder function, check for constipation, commence 24hour fluid balance chart and record:
o
 
Fluids consumed
o
 
Volume of urine voided
o
 
 Number of times voided
o
 
Difficulties encountered including need for catheterisation andvolume obtained
o
 
Urinary incontinence
o
 
Avoid detrusor overdistension (> 600 mL)
 
If still unable to void after a further 6 hours, insert indwelling catheter and leave in place for 24 hours (also obtain MSSU specimen for microbiology at this time)
 
Commence prophylactic antibiotics after six hours and discontinue when the catheter is removed
 
Women who continue to have high urine residuals or retention after removal of theindwelling catheter should be offered a choice between management with another indwelling catheter or intermittent self-catheterisation
 
If bladder retraining is required, refer to Continence Nurse Advisor / Urology Nurse, Continence Physiotherapist or Dedicated Catheter Nurse experienced in bladder retraining as soon as possible 
NB:
To enable an accurate assessment of a woman’s bladder function, a good historyneeds to be obtained from the woman and accurate documentation and communication isrequired
 
 Discharge planning 
 
All women should have voided before discharge. Usual early postpartum volume is between 400+mL
 
Women who have required an in / out or indwelling urinary catheter must have threedocumented voids with normal voiding parameters post removal of catheter beforethey may discharged hometop

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