WOMEN AND NEWBORN HEALTH SERVICE 6. ROUTINE POSTPARTUM CARE 6.2 C

WOMEN AND NEWBORN HEALTH SERVICE
King Edward Memorial Hospital
CLINICAL GUIDELINES
SECTION B : GUIDELINES RELEVANT TO OBSTETRICS & MIDWIFERY
6. ROUTINE POSTPARTUM CARE
6.2 CARE OF MOTHER ON THE POSTNATAL
WARD
Date Issued: February 2003
Date Revised: December 2013
Review Date: December 2016
Authorised by: OGCCU
Review Team: OGCCU
6.2.2.1 Bladder care
Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia
6.2.2 SUBSEQUENT CARE
6.2.2.1 BLADDER CARE
AIMS:
•
To assess bladder function.
•
To detect any deviation/s from normal
•
To carry out timely preventative measures to avoid complications following birth.
KEY POINTS
1. Postpartum urinary retention is regarded as common event but the reported incidence varies
1, 2
considerably from 1.7 to 17.9% .
2. Vigilant surveillance of bladder functioning and early intervention where problems exist will
3, 4
prevent permanent bladder damage .
3. While all women in the immediate postpartum period have the potential to experience urinary
5-8
problems several factors increase the risk, i.e:
•
Prolonged first and second stages of labour
•
Caesarean section for lack of progress in the first stage of labour
•
Duration of labour
•
Assisted birth
•
Episiotomy
•
Epidural analgesia
•
Post Caesarean Epidural Morphine
•
Perineal/vulval trauma
•
Over distension of the bladder during/immediately following birth
•
Larger infant than normal term baby
•
•
•
Non English speaking mother
12
Obesity
11, 12
Nulliparity
9
10
9, 11
11, 12
11, 12
, particularly with local anesthetic. (e.g. bupivacaine)
13
4. The timing and volume of the first void urine should be monitored and documented in
14
the patient’s fluid balance chart or progress notes .
DPMS
Ref: 2298
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 1 of 7
5. If an indwelling catheter (IDC) is used in labour or for a Caesarean birth, prior to removal,
assess motor function to ensure sensation has returned to normal. Perform a Bromage Score
and check Dermatomes if the epidural contained local Anesthetic. Refer to clinical Guideline
E.2.6 Assessment of Motor Function and E.2.5 Testing of Dermatomes.
6. Spontaneous vaginal birth – the first void should be no later than 4-6 hours post birth or
removal of IDC.
7. Operative vaginal birth with local anesthetic to the perineum– the first void should be no later
than 4-6 hours post birth or removal of IDC.
8. Operative vaginal birth with spinal or epidural topped up for a trial – the woman should
have an indwelling catheter for at least 12 hours post birth to prevent asymptomatic
14
bladder overfilling .
9. Caesarean Births- Urinary Indwelling Catheters to remain in situ for a minimum of 36 hours
10. Commence monitoring from 4 hrs after birth- see Flow Chart on page 6
11. Best practice indicates that women should have voided prior to leaving labour and
birth suite.
12. To pass a Trial of Void- a woman should have
 Normal Sensation
 Normal Flow and
 Normal Volume
13. Notify the Urology Nurse Practitioner (on page 3136) or ward Physiotherapist if abnormal
bladder sensation/ abnormal voiding function present (see flow chart- hyperlinked).
14. The team Registrar shall be informed if
• The woman is not voiding normally after birth.
• ‘ Normal’ is defined as
 A good sensation of bladder filling
 A constant good stream of urine while voiding
 Bladder feels empty after a void
 No urge or passive incontinence
 Void volumes of >150 mls and < 600 mls
• A residual volume of more than 600mL is obtained.
15. A real-time scanner, such as the Portascan, shall be used to assess residual amounts of urine
in postnatal women (the bladder scanner is not appropriate for use in postnatal women). If
unavailable, a Foley’s catheter should be inserted to determine residual volume.
Date Issued: February 2003
6.2.2.1 Bladder care
Date Revised:December2013
Section B
Review Date: December 2016
Clinical Guidelines
Written by:/Authorised by: OGCCU
King Edward Memorial Hospital
Review Team: OGCCU
Perth Western Australia
DPMS Ref: 2298
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 2 of 7
1.
PROCEDURE
ADDITIONAL INFORMATION
Assess the status of the woman’s bladder
on admission to the ward. The initial
bladder assessment should include:
An initial assessment will provide information on:
•
A review of the labour/birth history to
detect any risk factors,
•
Bladder palpation
•
•
the presence of any urinary problems,
•
baseline values for
subsequent recordings.
risk factors that may contribute to urinary
problems,
comparison
with
Checking to see if the woman has voided
after birth.
2.
2.1
Assessment
Subjective Assessment:
•
Ask the woman if she has a normal
sensation to voids, or experiencing any
discomfort or difficulty when voiding.
The woman may complain of:
•
•
•
•
•
•
15, 16
an inability to void,
reduced or loss of sensation of filling,
hesitancy or intermittent flow,
difficulty in emptying her bladder,
involuntary loss of urine,
voiding frequent small amounts (retention
with overflow),
• increasing lower abdominal pain.
2.2
Objective Assessment:
•
check the frequency with which urine is
passed,
•
check the volume passed with each
void,
•
examine the woman’s abdomen for
displacement of the uterus and
swelling of the lower abdomen,
•
palpate the woman’s bladder.
•
300- 500 mls is normal bladder volume. But if
a woman is dehydrated, 150- 600 mls is
acceptable.
•
A distended bladder displaces the uterus
upward and to the right side. There may also
be a painful cystic swelling palpable in the
15
suprapubic region.
Prevention and Management
3
3.1
•
Encourage 2 to 3 hourly voiding for the
first 24 hours.
•
Use supportive measures, such as
analgesia, ambulation, privacy, warm
bath or shower or running water, to
enhance the likelihood of micturition.
During the early postpartum period a marked
diuresis occurs and the woman produces
copious amounts of urine. This, combined
with a decreased sensation of a full bladder
and the need to void, predisposes the woman
to over distension of the bladder.
Regular voiding, and observation of urine output
will reduce the likelihood of bladder over
17
distension related to urinary retention.
Date Issued: February 2003
6.2.2.1 Bladder care
Date Revised:December2013
Section B
Review Date: December 2016
Clinical Guidelines
Written by:/Authorised by: OGCCU
King Edward Memorial Hospital
Review Team: OGCCU
Perth Western Australia
DPMS Ref: 2298
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 3 of 7
3.2
3.3
4.
5.
PROCEDURE
ADDITIONAL INFORMATION
Measure and document voids and any
associated symptoms (e.g. dysuria, loss of
sensation).
Initial voids should always be measured and
recorded to give an indication of the amount and
frequency of voids.
•
Cease when bladder sensation and
voiding function is normal and two
consecutive voids of 150-600 mls are
achieved.
It has been shown that where postpartum
documentation of urinary output has been poor,
18
urinary problems may go unrecognised.
•
Refer to flow chart.
•
Suspect urinary retention if the voiding
pattern is one of frequent small voids
16
(<100mL).
If at 4-6 hours post birth the woman has
not voided, make an assessment of
bladder fullness using either a real time
scanner or Foley’s catheterization (see flow
chart)
Urinary retention
Where urinary retention (residual urinary
2
volume of ≥150mL ) is suspected, confirm
by performing either a post micturition
19
ultrasound , or a residual catheterization
immediately after a void.
Early diagnosis and intervention for urinary
retention is required to prevent irreversible
20
bladder damage.
When inserting a catheter for a residual
urine always:
Using a Foley catheter, instead of an in-out
catheter prevents the risk of introducing bacteria
into the urinary tract from a second
catheterization should an indwelling catheter be
16
required.
•
inform the Urology Nurse Practitioner
on pager 3136 and RMO
6.
•
•
•
If after hours- inform RMO
•
use a strict aseptic technique
use a Foley's catheter
observe residual volume after 10
minutes
Indications for an indwelling catheter
•
Lack of sensation from epidural block
21
in which case the
following birth
catheter should remain in for at least
22
and until full sensation
12 hours
returns.
•
Long or difficult labour in which case
the catheter should be left in for 24
hours.
Prolonged difficult labour may cause trauma and
24
swelling of the bladder and urethra.
•
Extensive perineal/vulval trauma in
which case the catheter should be left
in for 24 hours, or until swelling
21
subsides.
Pain associated with this type of trauma my inhibit
17
voiding.
2
Epidural analgesia impedes sensory impulses in
the bladder increasing the risk of urinary
21
retention. It has been reported that it may take
up to 8 hours after epidural analgesia for bladder
23
sensation to return.
Date Issued: February 2003
6.2.2.1 Bladder care
Date Revised:December2013
Section B
Review Date: December 2016
Clinical Guidelines
Written by:/Authorised by: OGCCU
King Edward Memorial Hospital
Review Team: OGCCU
Perth Western Australia
DPMS Ref: 2298
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 4 of 7
PROCEDURE
•
7
8.
History of difficulty in voiding, abnormal
voiding pattern or an inability to void for
6 hours in which case the catheter
should be left in for 24 hours
During labour the bladder may become numbed
and oedematous through injury and pressure.
This may result in an inability to void or in an
altered voiding pattern. Catheterization for 24
17
hours allows recovery from the initial trauma.
Management of Bladder after excessive
distention
•
Where the residual urinary volume is
150-600 mls- IDC to stay in for 24 hrs
•
Where the urinary volume is >600 mlsIDC to stay in for 48 hrs.
•
Remove the catheter in the morning
around 06:00 hrs.
Over distension of the bladder causes a loss of
bladder muscle tone and detrusor hypotonia.
Catheterization for 48 hours allows adequate
4,
drainage and prevents chronic bladder damage
17, 20
.
Morning removal of the catheter allows time for
careful and regular post catheterization bladder
assessment.
Management following the removal of
catheter
8.1
•
Reassess the bladder as outlined in
#2.
8.2
•
After removal of the catheter, palpate
the bladder 2/24 for 12 hours or until
normal
voiding
patterns
are
established and two measured voids of
150mL or greater are obtained.
8.3
•
Measure residual urine if the woman
becomes distressed or is unable to
void for 4 hours – either by Real Time
Ultrasound or by Foley’s Catheter
9.
10
ADDITIONAL INFORMATION
Because retention may be gradual and
23
asymptomatic , performing a residual urine is
necessary to ensure the bladder has regained its
tone and woman is able to empty her bladder
completely.
Document all findings as a variance point
on the clinical pathway and in the woman’s
medical notes.
Consider referral to urology team for
further management.
Date Issued: February 2003
6.2.2.1 Bladder care
Date Revised:December2013
Section B
Review Date: December 2016
Clinical Guidelines
Written by:/Authorised by: OGCCU
King Edward Memorial Hospital
Review Team: OGCCU
Perth Western Australia
DPMS Ref: 2298
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 5 of 7
PREVENTION AND MANAGEMENT OF POSTPARTUM URINARY RETENTION
Voiding difficulty, unable to void or no sensation of bladder
filling within 4 hours of delivery or removal of IDC
Ensure adequate fluid intake (2-3 litres per day)
Encourage to void within 30 minutes
Instigate non-invasive measures - analgesia, privacy, Ural,
void in shower, relaxed void, mobilise
Commence bladder diary
No void, unable to void or
void < 150ml within 30
minutes
Assess symptoms and diary
Determine bladder volume:
either refer urology nurse for
ultrasound
or drain with IDC, record volume,
send CSU
Volume 150-600ml
→ IDC 24 hours
Volume > 600ml
→ IDC 48 hours
Refer urology nurse/MO after hrs
Void 150-600ml within 30
minutes
Sensation of
filling and
voiding well
– no need to
refer
Loss of sensation
and/or voiding
difficulty refer
urology nurse
or physio
Timed void 2-3 hourly
Void > 600ml within 30
minutes
Sensation
of filling
and voiding
well – no
need to
refer
Loss of
sensation
and/or voiding
difficulty refer
urology nurse
or physio
Timed void 1.5 – 2 hourly
Reassess bladder diary
and symptoms after next 2
voids
IDC removed at 0600
Trial of void
No void or void
< 150ml within 4
hours
Insert IDC
Management
planning with
urology nurse (MO
after hrs)
Void 150 – 600 ml
Voiding well – adequate
sensation and flow, no
hesitancy or straining, feels
empty, no incontinence
Educate to:
Continue bladder diary 24
hours (even if discharged)
Continue timed void for
2 -3 days to ensure volumes
within normal limits
Void > 600ml
and/or
Voiding difficulty
continues
Refer urology nurse or
physio if not done so
already (MO after hrs)
No further action
Date Issued: February 2003
6.2.2.1 Bladder care
Date Revised:December2013
Section B
Review Date: December 2016
Clinical Guidelines
Written by:/Authorised by: OGCCU
King Edward Memorial Hospital
Review Team: OGCCU
Perth Western Australia
DPMS Ref: 2298
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 6 of 7
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Date Issued: February 2003
6.2.2.1 Bladder care
Date Revised:December2013
Section B
Review Date: December 2016
Clinical Guidelines
Written by:/Authorised by: OGCCU
King Edward Memorial Hospital
Review Team: OGCCU
Perth Western Australia
DPMS Ref: 2298
All guidelines should be read in conjunction with the Disclaimer at the beginning of this section
Page 7 of 7