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CLINICAL GUIDELINE FOR INTRAPARTUM AND POST PARTUM BLADDER CARE

1. Aim/Purpose of this Guideline


1.1. To provide guidance to midwives and obstetricians on the management of bladder care during labour and in the immediate post partum period. 1.2. To give guidance for the correct documentation of bladder care

2. The Guidance
2.1. Background Voiding dysfunction includes: urinary retention (failure to pass urine spontaneously or within 6 hrs of catheter removal), multiple small void: may indicate overflow incontinence slow stream, dribble, incomplete emptying, hesitancy, Frequency of micturition, Dysuria Feeling of a full bladder Absence of sensation Intrapartum bladder management is aimed at identifying risk factors for bladder dysfunction and adopting preventive measures to minimize the incidence and impact of post partum voiding dysfunction (PPVD). A womans bladder, post partum has a tendency to be under active and in the phase of post partum diuresis, is vulnerable to retention. Bladder sensation may be affected following birth and women my not have the sensation of a full or over distended bladder. Severe or prolonged bladder over distention can cause permanent damage to the detrusor muscle leading to bladder under activity, recurrent urinary tract infections, incontinence and significant voiding problems in the womans 2, 7 life3.The incidence reported varies from 0.7% to 4% of deliveries 2.2. Risk factors Any woman can develop PPVD regardless of mode of delivery and analgesia used. However the following women are at increased risk4, 5, 6, and 7 Epidural or Spinal anaesthesia Primigravida Prolonged labour Assisted vaginal deliveries Caesarean section Significant perineal or periurethral trauma Significant immobility Past history of voiding problems

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2.3. Intrapartum and immediate post partum bladder care Adequate bladder care during labour and the immediate post partum period can reduce the incidence of bladder over distension and enable prompt recognition of a woman with voiding dysfunction. Bladder emptying including self void should be documented throughout labour1, on the partogram. The volume voided should be recorded. In the community setting, if measuring is not practical an estimation of the amount voided must be documented. If the woman cannot self void then the bladder should be emptied every 4 hours with intermittent catherisation. If an in and out catheter is required a second time during labour, and delivery is not imminent an indwelling catheter should be recommended. For women with epidural analgesia and an indwelling catheter insitu, the indwelling catheter should be left in for at least 6 hrs after the last epidural top up or until the woman is mobile which ever is the sooner. The time of removal of the catheter should be documented and the time of the first void should be documented in the post natal section of the hand held notes Operative delivery/procedure under a normal epidural top up an indwelling catheter should be sited for at least 6-8 hours. If an additional stronger top up is administered then this should be extended to at least 12 hours post delivery. The time of removal of the catheter should be documented and the time of the first void should be documented in the post natal section of the hand held notes Operative delivery with a local anaesthetic - The timing and volume of the first void should be documented on the immediate care after birth page. This should be no later than 6 hours post delivery. If the woman cannot void follow the flow chart in point 4. Spontaneous vaginal delivery: Women should have the timing of the first void documented on the immediate care after birth page, along with the subjective volume. This should be no later than 6 hours post delivery and prior to an early discharge home. For home births women should be asked to contact the on call midwife if she hasnt passed urine within the 6 hour period. Women who have undergone repair of a third or forth degree tear under a spinal or epidural anaesthesia, should have an indwelling catheter for at least 12 hours. If there is other significant genital trauma, consideration should be given to an indwelling catheter for 24 hours following delivery5. The time of removal of the catheter should be documented and the time of the first void should be documented in the post natal section of the hand held notes If the woman has not voided prior to leaving delivery suite this should be communicated to the postnatal ward staff and the timing and subjective volume of first void should be documented on the immediate care after birth page 8. Caesarean section- all women who undergo either elective or emergency caesarean section should have an indwelling catheter inserted for at least 12 hours. The time of removal of the catheter should be documented and the time of the first void should be documented in the post natal section of the hand held notes
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Any woman who has had an indwelling catheter inserted during the first stage of labour should have the balloon deflated for the active second stage.

2.4. Postpartum bladder care If the woman has not successfully voided within 6 hours of birth or catheter removal, efforts to assist voiding should be undertaken, such as taking a warm bath or shower. If measures to encourage voiding are not immediately successful the flow chart below should be followed. If a woman is at home and has not successfully passed urine within 6 hours, immediate arrangements should be made to admit her to the post natal ward.

Insert in/out catheter and measure and document volume drained or measure residual volume with a bladder scanner

If < 500mls drained/measured

If >500ml drained

Encourage voiding within next 2 hours, measure volume voided and post void residual with either an in out catheter or bladder scanner

Insert indwelling catheter for 24 hours Inform Obstetrician

Remove catheter and encourage voiding within 4 hours. If residual volume <150 mls for discharge with no follow up

If post void residual <150ml then no further management unless symptomatic

If unable to void or post void residual >150ml

If post void residual >150 mls catheter to stay in for 7 days. For persistent voiding problems, to teach intermittent self catheterisation (ISC) and refer to Nurse Consultant for continence

2.5. Following the emptying of the bladder by catheterisation in the post partum period1: Check for vulval oedema and if present, maintain an indwelling catheter for 24hrs or until oedema has resolved. Check urine dipstick and send MSU or CSU to check for infection Ensure the woman is drinking at least 1500 ml of fluid in 24 hours.

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2.6. References 1. Rohna Kearney, Alfred Cutner; Postpartum voiding dysfunction; The Obstetrician & Gynaecologist, 2008; 10:2:71-74 2. Ching-Chung L. Shuenn-Dhy C. Ling-Hong T. Ching-Chang H. Chao-Lun C. Po-Jen C. Postpartum urinary retention: assessment of contributing factors and long-term clinical impact; Australian & New Zealand Journal of Obstetrics & Gynaecology. 2002; 42(4):365-8, 3. Dorflinger A, Monga A.Voiding dysfunction.Curr Opin Obstet Gyneco 2001; 13:507-12 4. Jeffery TJ. Thyer B. Tsokos N. Taylor JD. (1990) chronic urinary retention postpartum. Australian & New Zealand Journal of Obstetrics & Gynaecology; 1990 Nov. 30(4):364-6. 5. Watson WJ. (1991) Prolonged postpartum urinary retention. Military Medicine; 1991. 156(9):502-3. 6. Carley ME. Carley JM. Vasdev G. Lesnick TG. Webb MJ. Ramin KD. Lee RA. Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery. American Journal of Obstetrics & Gynecology; 2002; Aug 187(2):430-3. 7. Glavind K. Bjork J. (2003) Incidence and treatment of urinary retention postpartum. International Urogynecology Journal; 2003; Jun 14(2):119-21. 8. Zaki MM, et al. National survey for intrapartum and postpartum bladder care: assessing the need for guidelines. BJOG; 2004Monitoring compliance and effectiveness

3. Monitoring compliance and effectiveness


Element to be monitored The audit will take into account record keeping by obstetric, anaesthetic and paediatric doctors, midwives, nurse, students and maternity support workers. The results will be inputted onto an excel spreadsheet The audit will be registered with the Trusts audit department Maternity risk management midwife

Lead Tool

No intrapartum catheter in situ: Was the timing of the first void documented on the immediate care after birth page. Was the timing of the first void within 6 hours, prior to discharge home or prior to the midwife leaving the womans home. If there was no void within 6 hours was the flow chart on page 3 followed. Catheter insitu: Was the time the catheter was removed documented in the post natal notes. Was the timing of the first void following catheter removal documented in the post natal notes.

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If there was no void within 6 hours of catheter removal was the flow chart on page 3 followed Frequency 1% or 10 sets whichever is the greater, of all health records of women who have delivered will be audited over a 12 month period Reporting A formal report of the results will be received annually at the arrangements maternity risk management and clinical audit forum, as per the audit plan During the process of the audit if compliance is below 75% or other deficiencies identified, this will be highlighted at the next maternity risk management and clinical audit forum and an action plan agreed Acting on Any deficiencies identified on the annual report will be recommendations discussed at the maternity risk management and clinical audit and Lead(s) forum and an action plan developed Action leads will be identified and a time frame for the action to be completed by The action plan will be monitored by the maternity risk management and clinical audit forum until all actions complete Change in Required changes to practice will be identified and actioned practice and within a time frame agreed on the action plan lessons to be A lead member of the forum will be identified to take each shared change forward where appropriate. The results of the audits will be distributed to all staff through the risk management newsletter/audit forum as per the action plan

4.

Equality and Diversity


4.1This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement. 4.2Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information


Document Title Date Issued/Approved: Date Valid From: Date for Review: Directorate / Department responsible (author/owner): Contact details: Clinical guideline for intrapartum and post partum bladder care 8th October 2012 8th October 2012 1st October 2015 Dr Rajasri Obs and gynae directorate 01872 252729 To provide guidance to midwives and obstetricians on the management of bladder care during labour and in the immediate post partum period. To give guidance for the correct documentation of bladder care Bladder care during labour and post delivery RCHT PCT CFT Medical Director

Brief summary of contents

Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder

Guideline for Intrapartum and postpartum bladder care Maternity guideline group Obs and gynae directorate meeting

{Original Copy Signed} Internet & Intranet Intranet Only

Midwifery and obstetrics

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Links to key external standards Related Documents: Training Need Identified? Version Control Table Date March 2011 Versio n No 1.0

CNST 5.7

no

Summary of Changes Initial document

Changes Made by (Name and Job Title) Dr Rajasri Consultant obstetrician Jan Clarkson Maternity risk manager

Septembe 1.1 r 2012

Changes to compliance monitoring only

All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.

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Appendix 2.Initial Equality Impact Assessment Screening Form


Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: Clinical guideline for intrapartum and post partum bladder care Directorate and service area: Is this a new or existing Procedure? Obs and gynae diractorate Exisiting Name of individual completing Telephone: assessment: Jan clarkson 01872 252270 1. Policy Aim* To provide guidance to midwives and obstetricians on the management of bladder care during labour and in the immediate post partum period. To give guidance for the correct documentation of bladder care 2. Policy Objectives* 3. Policy intended Outcomes* 4 How will you measure the outcome? 5. Who is intended to benefit from the Policy? 6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b. If yes, have these groups been consulted? c. Please list any groups who have been consulted about this procedure. To ensure safe management of the bladder through labour and immediate post partum period Up to date, evidence based practice

Via compliance monitoring tool

Pregnant and newly delivered woman

*Please see Glossary 7. The Impact Please complete the following table using ticks. You should refer to the EA guidance notes for areas of possible impact and also the Glossary if needed. Where you think that the policy could have a positive impact on any of the equality group(s) like promoting equality and equal opportunities or improving relations within equality groups, tick the Positive impact box. Page 8 of 9

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Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, tick the Negative impact box. Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, tick the No impact box. Positive Impact Yes Yes Yes Negative Impact No Impact Reasons for decision All pregnant and newly delivered women All pregnant and newly delivered women All pregnant and newly delivered women All pregnant and newly delivered women All pregnant and newly delivered women All pregnant and newly delivered women All pregnant and newly delivered women All pregnant and newly delivered women All pregnant and newly delivered women

Equality Group Age Disability Religion or belief Gender Transgender Pregnancy/ Maternity Race Sexual Orientation Marriage / Civil Partnership

Yes Yes Yes Yes Yes

Yes

You will need to continue to a full Equality Impact Assessment if the following have been highlighted: A negative impact and No consultation (this excludes any policies which have been identified as not requiring consultation). 8. If there is no evidence that the policy promotes equality, equal opportunities or improved relations - could it be adapted so that it does? How? Full statement of commitment to policy of equal opportunities is included in the policy

Please sign and date this form. Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ A summary of the results will be published on the Trusts web site. Date 24th September 2012
Signed Jan Clarkson

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