BLADDER CARE FOR THE OBSTETRIC PATIENT,

CLINICAL GUIDELINE
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 in the post-
partum period 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 may not have the sensation of a full or over distended bladder.

Severe or prolonged bladder over distension 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 life. The
incidence reported varies from 0.7% to 4% of deliveries2, 7
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

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
labour 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 catheterisation.
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 in-situ,
the indwelling catheter should be left in for at least 6 hours after the last
epidural top up or until the woman is mobile whichever is the sooner. The
time of removal of the catheter should be documented and the time and
volume 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, see
point 2.4.
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 fourth 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 delivery 5.
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.

Caesarean section-
Removal of the urinary catheter should be carried out at 6-8hrs following
Elective CS and 12 hours following an Emergency CS, unless instructed to
leave in for a longer time by the surgeon.
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
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 Following the emptying of the bladder by catheterisation in the post-partum

period: -

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.
2.5 Postpartum urinary incontinence
If urinary incontinent, insert in-dwelling catheter for 7 days and follow TWOC pathway.
If incontinence persists, rule out fistula(uretero-vaginal/vesico-vaginal) and refer to the
physiotherapist.

SUMMARY: 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.
 Measure residual volume with a bladder scanner
TWOC
Protocol

If 150 - 500mls Remove catheter and

If < 150mls If > 500ml
insert I/O encourage voiding
catheter within 4 hours. If
residual volume <150
mls and void
Insert indwelling vol.>150mls, for
Encourage normal fluid
catheter for 72 hours discharge with no
intake and
Inform Obstetrician. follow up
Encourage voiding within
Consider home on
next 2 hours, measure
catheter and review If voids <150mls or
volume voided and post void
in TWOC clinic post void vol. >150
residual volume with bladder
(EGU 2686) mls, catheter to stay
scanner
Follow TWOC in for 7 days. TWOC
protocol in TWOC clinic.
For persistent
If post void If unable to void voiding problems
residual or void vol. refer to Nurse
<150ml and <150msl or post Consultant for
void vol.>150ml void residual continence
then no further >150 400 mls Tel 01726 873095
management
unless
symptomatic

NB: Always check voided volume and check residual volume within 20mins
3 Monitoring compliance and effectiveness

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

Catheter in situ:
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.
If there was no void within 6 hours of catheter removal was the
flow chart 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 maternity
arrangements 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 discussed at the
recommendations maternity risk management and clinical audit forum and an action plan
and Lead(s) developed.
Action leads will be identified and a time frame for the action to be
completed.
The action plan will be monitored by the maternity risk management
and clinical audit forum until all actions completed.
Change in Required changes to practice will be identified and actioned within
practice and a time frame agreed on the action plan.
lessons to be A lead member of the forum will be identified to take each change
shared 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

4.4 This document complies with the Royal Cornwall Hospitals NHS Trust service Equality
and Diversity statement.

4.5 Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Appendix 1. Governance Information
BLADDER CARE FOR THE OBSTETRIC
Document Title
PATIENT CLINICAL GUIDELINE

Date Issued/Approved: 7th July 2016

Date Valid From: 7th July 2016

Date Valid To: 7th July 2019

Directorate / Department responsible Dr Rex Sote

(author/owner): Obs and Gynae Directorate

Contact details: 01872 252729

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:
To provide guidance to midwives and
obstetricians on the management of
bladder care during labour and in the
immediate postpartum period.
To give guidance for the correct
documentation of bladder care.
Bladder, care, labour, post, delivery, urine,
incontinence, retention.
RCHT PCH CFT KCCG
Medical Director
7th July 2016
Guideline for Intrapartum and postpartum
bladder care
Maternity Guidelines Group
Obs and Gynae Directorate

Divisional Manager confirming

Head of Midwifery
approval processes
Name and Post Title of additional
Not Required
signatories
Signature of Executive Director giving
{Original Copy Signed}
approval
Publication Location (refer to Policy
on Policies Approvals and Internet & Intranet Intranet Only
Ratification):
Document Library Folder/Sub Folder Clinical/Midwifery and Obstetrics
Links to key external standards CNST 5.7

Related Documents/ References.
Training Need Identified?
Version Control Table
Rohna Kearney, Alfred Cutner;
Postpartum voiding
dysfunction; The Obstetrician &
Gynaecologist, 2008; 10:2:71-74
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,
Dorflinger A, Monga A.Voiding
dysfunction.Curr Opin Obstet
Gyneco 2001; 13:507-12
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.
Watson WJ. (1991) Prolonged
postpartum urinary retention.
Military Medicine; 1991.
156(9):502-3.
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.
Glavind K. Bjork J. (2003)
Incidence and treatment of
urinary retention postpartum.
International Urogynecology
Journal; 2003; Jun 14(2):119-21.
Zaki MM, et al. National survey
for intrapartum and postpartum
bladder care: assessing the
need for guidelines. BJOG;
2004Monitoring compliance and
effectiveness
No.
 Version Changes Made by
Date Summary of Changes
No (Name and Job Title)
Changes to
March 2011 V1.0 Initial document compliance
monitoring only
Jan Clarkson
September
V1.1 Changes to compliance monitoring only Maternity Risk
2012
Manager
Rex Sote
November
V1.2 Obs & Gynae
2015
Direcorate
Timing of removal of catheter post LSCS Miss Aylur Rajasri
changed. Postpartum bladder care consultant
July 2016 V1.3
changed in line with Trust gynae bladder obstetrician and Dr
care CG. Rex Sote
Obs & Gynae
Direcorate
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.
Appendix 2. Initial Equality Impact Assessment Form
Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter
referred to as policy) (Provide brief description):
Directorate and service area: Is this a new or existing Policy?
Obs & Gynae Directorate Existing

Name of individual completing Telephone:

assessment: 01872 252879
Elizabeth Anderson

1. Policy Aim* To provide guidance to midwives and obstetricians on the

Who is the strategy / management of bladder care during labour and in the immediate
policy / proposal / post-partum period.
service function To give guidance for the correct documentation of bladder care
aimed at?
2. Policy Objectives* To ensure safe management of the bladder through labour and
immediate post-partum period.

3. Policy intended Up to date, evidence based practice.

Outcomes*

4. *How will you Via compliance monitoring tool.

measure the
outcome?
5. Who is intended to Pregnant and newly delivered woman.
benefit from the
policy?
6a) Is consultation No
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?

b) If yes, have these N/A

*groups been
consulted?

C). Please list any N/A

groups who have
been consulted about
this procedure.

7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Rationale for Assessment / Existing Evidence
Age X All pregnant and newly delivered women
Sex (male, female, trans- X All pregnant and newly delivered women
gender / gender
reassignment)

Race / Ethnic X All pregnant and newly delivered women

communities /groups

Disability - X All pregnant and newly delivered women

learning
disability, physical
disability, sensory
impairment and
mental health
problems
Religion / X All pregnant and newly delivered women
other beliefs
Marriage and civil X All pregnant and newly delivered women
partnership

Pregnancy and maternity X All pregnant and newly delivered women

Sexual Orientation, X All pregnant and newly delivered women

Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to All pregnant and newly delivered women a full Equality Impact
Assessment if the following have been highlighted:
You have ticked Yes in any column above and
No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
Major service redesign or development
8. Please indicate if a full equality analysis is recommended. Yes No
X
9. If you are not recommending a Full Impact assessment please explain why.

N/A

Signature of policy developer / lead manager / director Date of completion and submission
Rex Sote

Names and signatures of 1.

members carrying out the 2.
Screening Assessment

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD

A summary of the results will be published on the Trusts web site.

Signed: Sarah-Jane Pedler

Date 7th July 2016