Letters to the Editors ajog.

org

Postoperative urinary catheter removal for Enhanced

Recovery After Cesarean protocols
TO THE EDITORS: We appreciate the work of the Enhanced
Recovery After Surgery (ERAS) for Cesarean Committee and
commend them on the publication of “Guidelines for post-
operative care in cesarean delivery: Enhanced Recovery After
Surgery (ERAS) Society recommendations (part 3).”1 We have
utilized ERAS at our institution for more than 2 years and
looked forward to the committee’s recommendations. We
write to express concern for the authors’ recommendation for
immediate removal of the bladder catheter following surgery
in the setting of long-acting neuraxial analgesia.
There is strong evidence that long-acting neuraxial opioids
reduce postpartum pain and decrease oral and parenteral
opioid use.2 Thus, leading anesthesia societies, including the
Society for Obstetric Anesthesia and Perinatology,2 as well as
the American College of Obstetricians and Gynecologists3
support the use of long-acting neuraxial opioids for cesar-
ean delivery. The ERAS society guidelines similarly support
the use of long-acting neuraxial opioids whenever feasible to
improve postcesarean pain control.1
The authors share a strong recommendation for immediate
removal of the urinary catheter following surgery, although
they acknowledge that existing evidence is low quality. We are
concerned that unrestricted implementation of this guideline
may negatively affect patients. For patients with immediate
catheter removal after cesarean, the cited Cochrane review
reported decreased urinary tract infections and unchanged
incidence of voiding dysfunction.4
Included studies utilized predominantly regional analgesia,
but none reported the use of long-acting neuraxial analgesia.
In fact, there is evidence of decreased bladder function and
increased urinary retention in women receiving long-acting
neuraxial analgesia. For these reasons, the Society for Ob-
stetric Anesthesia and Perinatology guidelines recommend
catheter removal at 6e12 hours postpartum with protocols
for managing postcatheter retention.2
There is compelling evidence to standardize long-acting
neuraxial analgesia. And there is reasonable concern over
immediate postoperative catheter removal in this setting. We
therefore advocate for (1) long-acting neuraxial analgesia; (2)
early (6e12 hours after cesarean delivery) but not immediate
urinary catheter removal, and (3) well-defined protocols to
screen for and manage urinary retention, with assessment of
bladder volumes and use of urinary straight catheterization as
needed. These strategies will best balance the need for
excellent pain control with the potential risks of prolonged
catheterization, ensuring women are able to safely ambulate,
void, and recover postpartum. -
Alex F. Peahl, MD, MSc
Department of Obstetrics and Gynecology
University of Michigan
Ann Arbor, MI
National Clinician Scholars Program
Institute for Health Policy and Innovation
University of Michigan
Ann Arbor, MI
alexfrie@med.umich.edu
Joanna A. Kountanis, MD
Department of Obstetrics and Gynecology
University of Michigan
Ann Arbor, MI
Department of Anesthesiology
University of Michigan
2800 North Plymouth Road
Ann Arbor, MI 48109
Roger D. Smith, MD
Department of Obstetrics and Gynecology
University of Michigan
Ann Arbor, MI
The authors report no conflict of interest.
REFERENCES
1. Macones GA, Caughey AB, Wood SL, et al. Guidelines for Post-
operative care in cesarean delivery: Enhanced Recovery After Surgery
(ERAS) Society recommendations (part 3). Am J Obstet Gynecol
2019;221:247.e1–9.
2. Society of Obstetric Anesthesia and Perinatology. Enhanced Recovery
After Cesarean (ERAC) consensus statement. 2019. Available at:
https://soap.org/SOAP-Enhanced-Recovery-After-Cesarean-Consensus-
Statement.pdf. Accessed September 14, 2019.
3. American College of Obstetricians and Gynecologists. Postpartum
pain management. ACOG Committee opinion no. 742. Obstet Gynecol
2018;132:e35–43.
4. Abdel-Aleem H, Aboelnasr MF, Jayousi TM, Habib FA. Indwelling
bladder catheterisation as part of intraoperative and postoperative care
for caesarean section. Cochrane Database Syst Rev 2014;4. Available at:
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010322.
pub2/abstract. Accessed September 14, 2019.
ª 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajog.
2020.01.040

634 American Journal of Obstetrics & Gynecology JUNE 2020