NICE GUIDELINES INTRAPARTUM

Observations during established first and second stage of labour include frequency of emptying the bladder which should be plotted on a partogram. If pushing is ineffective or if requested by the woman, strategies to assist birth can be used, such as support, change of position, emptying of the bladder and encouragement. First void should be documented. Difficult trauma should be repaired by an experienced practitioner in theatre under regional or general anaesthesia. An indwelling catheter should be inserted for 24 hours to prevent urinary retention. Information should be given to the woman regarding the extent of the trauma, pain relief, diet, hygiene and the importance of pelvic-floor exercises.

Failure to void in labour: postnatal urinary and anal incontinence (118kb)

Linda Birch, Patrick M Doyle, Roger Ellis, Elaine Hogard British Journal of Midwifery 17(9): 562 - 566 (Sep 2009) The objectives was to identify the impact of intrapartum voiding on postnatal urinary and anal incontinence. A longitudinal, prospective, repeated measures, cohort study design was used. The study was set in one of the biggest and busiest acute NHS university teaching hospitals in the North West of England, which provides maternity care to over 4000 women each year. Primiparous women with no pre-existing disease (n=516) participated and were recruited after a normal 20 -week gestation obstetric ultrasound scan. Data was collected using validated questionnaires during the last trimester of pregnancy and postnatally at six weeks, six months and finally at one year. Obstetric and demographic data was extracted from case notes. This included age, body mass index, gestation, duration of labour, analgesia, birth weight, mode of delivery and perineal trauma. Statistical analysis was undertaken using Statistics Package for Social Sciences (SPSS version 13.0). The main outcome measures were urinary incontinence symptoms and anal incontinence symptoms. Prolonged periods of time in labour without emptying the bladder was associated with increased rates of postnatal urinary incontinence (OR 2.36) and may also contribute to anal incontinence. Postnatal urinary incontinence may be reduced if intrapartum bladder care policies reflect frequent emptying. This preliminary data supports large-scale exploration of the association between postnatal anal incontinence and bladder emptying in labour.

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Peri-partum Bladder Management

Purpose of guideline Women at highest risk Diagnosis Overt and covert bladder retention Preventing acute bladder distension in labour and postpartum Treatment References

Why
10-15% of women have voiding dysfunction to some degree and for some time following delivery. 5% have significant and longer lasting dysfunction , which if not recognised in the early peripartum period (delivery suite, postnatal ward) may lead to bladder overdistension and overflow incontinence with long term, significant bladder dysfunction

Women at highest risk include:

Primigravidae Prolonged labour, especially prolonged stage 2 Epidural for labour/delivery, irrespective of mode of delivery Need for catheter in labour Assisted vaginal delivery Caesarean Section Perineal injury: haematoma/bruising/tear with inadequate analgesia Many women with voiding dysfunction peri -and postpartum have no discernible risk factors. A high index of suspicion must be maintained.

How does it present?

Commonest error is failure to diagnose the bladder distension and incomplete bladder emptying. Beware of the woman who is voiding OFTEN: she may have overflow incontinence due to bladder over distension. Palpate a bladder after voiding, when you palpate the uterine fundus. An arbitrary residual volume of 150ml may imply a degree of dysfunction.
Overt Bladder Retention

Inability to pass urine within 6 hours of delivery, requiring catheterisation to drain a volume > normal bladder capacity (normal 400 -600ml in females). This woman will often complain of pain and the desire to void, may have oveflow incontinence mistaken as stress incontinence. OR may be asymptomatic particularly if an epidural was employed in labour
Covert Bladder Retention:

Failure of the bladder to empty at least 50% of normal capacity, or a post void residual volume of 150ml. Thi s woman will often have frequency and pass volumes of <150ml.

Prevention is better than Treatment

Prevent acute bladder distension
In Labour

1.Encourage patient to void every 3 hours. 2.If unable to void on 2 occasions, threshold for catheterisation should be low. If the bladder is palpable and patient cannot void - catheterise. 3.A soft catheter is preferable. Be sure not to tape it too much on the stretch to the thigh as this will decrease the mobility of the urethra, and decrease the mobility of the balloon in the bladder neck; it needs to be loose enough to allow the balloon to float above the presenting part as it descends below the bladder neck during the late first and second stages of labour. Postpartum 1.Urine volumes of > 150 mL should be voided at least 3 times in 24 hours .

Treatment
Start if has not voided within 6 hours of delivery: Adequate analgesia Encourage to void in the toilet. proceed to in/out catheterisation. If the patient is not able to void well (as above) after the in/out catheter, an IDC should be inserted and left in for 48 hours.

If the volume voided is < 150ml, or the residual volume is >150ml (if assessed with ultrasound)

Assessment of adequate voiding (bladder palpation, measured voided vol mes of >150ml on three occasions in 24 hours, or measured residuals of <1 u Send MSU, if MSU positive institute antibiotics as appropriate If the MSU is negative and repeat trial of void fails then-

1. refer to the Urogynaecology Unit (patients of RWH) for inpatient review, or to a physician with a Urogynae interest 2. be taught intermittent self-catheterisation 3. followed up in the Urogynae Clinic.

There is no evidence that pharmacological interventions have any place in management. Postpartum chronic/covert retention is usually a self -limiting condition and most patients are better by day 7.
Continence Advisor-Urogynaecology Pelvic Floor Service: Kate Sloane ext 2781

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