MATERNITY SERVICES GUIDELINE POSTPARTUM BLADDER CARE. Sandra Reading, Women s CAG Deputy Director

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1 MATERNITY SERVICES GUIDELINE POSTPARTUM BLADDER CARE Sandra Reading, APPROVING COMMITTEE(S) Women s CAG Date approved: Deputy Director EFFECTIVE FROM 9 th September 2013 DISTRIBUTION All staff in the maternity service Intranet RELATED DOCUMENTS Care of Women in Labour Guideline Postnatal Care Guideline STANDARDS OWNER AUTHOR/FURTHER INFORMATION SUPERCEDED DOCUMENTS 9 th September 2013 NICE (2006) Routine Postnatal Care of Women and their Babies. London: NICE. CNST Clinical Risk Management Standards for Maternity Services ( ) (Criterion 5.7) Sandra Reading, Women s CAG Deputy Director Mr. A. Antoniou, Consultant Obstetrician and Bladder Care in Labour and the Postnatal Period, Barts and the London NHS Trust, (February 2010) Bladder Care in the Antenatal, Intrapartum and Postpartum Period, Whipps Cross University Hospital NHS Trust (November 2010) Care of Urinary Bladder in Labour and following Delivery, Newham University Hospital NHS Trust (November 2011) REVIEW DUE September 2016 KEYWORDS Bladder, postnatal, urine, catheter Forms/AllItems.aspx?RootFolder=%2FBHFileshare%2 FShared%20Documents%2FAll%20Trust%2FLocal%2 INTRANET LOCATION(S) 0Policies%20and%20Procedures%2FWomen%27s%2 FBH%20Women%27s%20CAG%20new%20policies&I nitialtabid=ribbon%2edocument&visibilitycontext=w SSTabPersistence CONSULT ATION Barts Health Barts and the London unit (BLT) Women s CAG Quality, Safety and Assurance Committee Mr. M. Hogg - Consultant Obstetrician and Page 1 of 7

2 Newham University Hospital unit (NUH) Whipps Cross University Hospital (WX) External Partner(s) Mr. A. Antoniou - Consultant Obstetrician and Miss. S. Thamban - Consultant Obstetrician and Not applicable SCOPE OF APPLICATION AND EXEMPTIONS Included in policy: For the groups listed below, failure to follow the policy may result in investigation and management action which may include formal action in line with the Trust's disciplinary or capability procedures for Trust employees, and other action in relation to organisations contracted to the Trust, which may result in the termination of a contract, assignment, placement, secondment or honorary arrangement. All Trust staff, working within or for the maternity service in whatever capacity All agency staff, students midwives, student nurses and doctors in training working within the maternity service Exempted from policy: The following groups are exempt from this policy Non-maternity staff TABLE OF CONTENTS POSTPARTUM BLADDER CARE 3 1 INTRODUCTION 3 2 PROCESS 3 3 MONITORING THE EFFECTIVENESS OF THIS POLICY 6 Appendix 1: Change Log 6 Appendix 2 Impact assessments 7 Appendix 3 Additional guidance and information 7 Page 2 of 7

3 POSTPARTUM BLADDER CARE 1 INTRODUCTION 1.1 This guideline has been developed to optmise bladder health post delivery for all women, in order to reduce the risks of urinary retention which if undetected can lead to long term voiding problems, recurrent urinary tract infections and incontinence. 1.2 Within the first hours following delivery women should pass copious amounts of urine. This diureses rapidly reduced the plasma volume. Micturition following delivery may be difficult for some women and the bladder can be become over distended. If this is not dealt with promptly, over distension of the bladder can lead to long term bladder dysfuntion. Urinary retention with bladder distension should be avoided. Bladder sensation may be temporarily affected by childbirth and/or regional anaesthesia, so lack of sensation does not indicate that the bladder is not full. Multiple voids may also suggest a degree of urinary retention. Midwives should establish whether any woman is experiencing pain or difficulty passing urine postnatally. Over distention can cause permanent damage to the bladder muscle and function 2 PROCESS 2.1 Intermittent catheterisation is prefereable to indwelling catheters as it has been demonstrated to be associated with lower rates of urinary tract infection whilst encouraging normal bladder function. An aseptic has been shown to further reduce the risk of urinary tract infections (UTI s). 2.2 Women wih high risk conditions e.g. Pre-Eclampsia or Massive Postpartum Haemorrhage who remain on Delivery Suite will have an individualised care plan. 2.3 Operative delivery, prolonged labour, traumatic delivery, dense epidural/spinal anaesthesia may predispose to postpartum urinary retention, even minor perineal tears or an episiotomy can put women at increased risk. 2.4 Women who have had spinal/epidural analgesia or an operative vaginal delivery in theatre as a trial may be at increased risk of urine retention and should be offered an indwelling catheter to be kept in place for at least 12 hours following delivery to prevent asymptomatic bladder overfilling (allow reasonable amount of flexibility to suit the woman). 2.5 Encourage women to void after delivery. Women should have voided within 6 hours of last bladder emptying (spontanoues/catheterisation). The time and ideally the volume of the first void must be recorded in the maternal health record. Ideally this should be documented in the designated first urinary void section in the maternal postnatal notes (purple) or in the labour record (yellow notes). Page 3 of 7

4 2.6 A post void residual urine should be measure if retetnion is suspected. 2.7 If an indwelling catheter is in situ for over 48 hours, obstetric review is required prior to removal and catheter specimen urine (CSU) collected for microscopy, culture and sensitivities (MCS). 2.8 The time of removal of the indwelling catheter should be recorded in the maternal postnatal notes. 2.9 See Flow Chart 1 for management of urinary retention which should be instigated 6 hours post birth or catheter removal or if a woman reports passing small, frequent volumes of urine involuntarily. Page 4 of 7

5 Flowchart 1: Postnatal Management Plan for Urinary Retention Monitor by eliciting feedback from the mother and encourage adequate fluid intake and balanced diet to avoid constipation. No void after 6 hours of the birth or catheter removal or woman reports passing small, frequent volumes of urine involuntarily. Midwife to refer to member of the obstetric team Appropriately trained midwife, member of the obstetric team, or continence advisory nurse to confirm retention or residual volume with Ultra Sound Scan (USS) In-Out Catheter Measure residual volume and document. Send mid-stream urine (MSU) for MCS. Assess pain relief Inspect perineum if vaginal birth Measure volume of next void and record on fluid balance chart No void after 4 hours or abdominal discomfort or voiding volumes <150ml Catheterise with indwelling Foley Catheter Residual volume on catheterisation less than 500ml 24 hour Indwelling Foley Residual volume on catheterisation 500ml to 800ml 48 hour indwelling Foley Catheter REMOVE CATHETER MEASURE NEXT VOID AND SCAN BLADDER IN DAY TIME HOURS Residual urine remains high Refer to Continence Nurse for teaching of intermittent catheterisation Residual volume on catheterisation >800mls indwelling Foley Catheter until seen at Urology Nurse Outpatient trial without catheter (TWOC) appointment. Can be discharged home. Refer to UroGynaecology Clinic Refer to Obstetric team Page 5 of 7

6 3 MONITORING THE EFFECTIVENESS OF THIS POLICY Issue being monitored Monitoring method Responsibility Frequency Reviewed by and actions arising followed up by Recording of the time of the first void in the postnatal record. Audit of 400 of women who have delivered Postnatal Clinical Lead Midwives Quarterly Women s CAG Quality, Safety and Assurance Committee Appendix 1: - Change Log Substantive changes since previous version Change Log Postpartum Bladder Care Reason for Change Author & Group(s) approving change(s) New Policy Merger of 3 policies Consultant Obstetricians/Consultant Midwives/Supervisor of Midwives/CNST Guidelines Group. Page 6 of 7

7 Appendix 2 Impact assessments Equalities impact checklist - must be completed for all new policies equalities Organisational impact checklist - must be completed for all new policies Organisational impact assessment Appendix 3 Additional guidance and information NICE (2006) Routine Postnatal Care of Women and their Babies. London: Available at NICE. RCOG (2011) Operative Vaginal Deliveries Green Top Guidelines No. 26. London: RCOG Press. Available at Page 7 of 7

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