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Postpartum bladder dysfunction& urinary retention
Postpartum voiding dysfunction and urinary retention is common after delivery and can lead to complications if not properly managed. Risk factors include instrumental delivery, epidural analgesia, prolonged labor, and large birth weight. Pathophysiology may involve nerve damage during delivery and physiological changes causing a hypotonic bladder. Management includes encouraging voiding every 2-3 hours during labor, offering an indwelling catheter for 6 hours after an epidural, and measuring voided volumes and post-void residuals to identify retention. Treatment involves catheterization, pelvic floor exercises, analgesia, and clean intermittent self-catheterization if needed.
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Postpartum bladder dysfunction& urinary retention
- 1. Postpartum voiding dysfunction andurinary retention Prativa Dhakal Lecturer, Maternal Health Nursing UCMS, Bhairahawa
- 2. Introduction • Voiding difficultyand urinary retention is a common phenomenon in the immediate postpartum period. • The importance of prompt diagnosis and appropriate management of this condition is the key to ensuring a rapid return to normal bladder function.
- 3. Definition • Postpartum voidingdysfunction—if defined as failure to pass urine spontaneously within 6 hours of vaginal delivery or catheter removal after delivery—occurs in 0.7–4% of deliveries. • Postpartum urinary retention is the inability to void, with a painful (usually), palpable or percussable bladder and the need for catheterisation to obtain relief
- 4. Definition… • Persistent postpartumurinary retention may be defined as the inability to void spontaneously despite the use of an indwelling catheter for three days. • Overt retention refers to the inability to void spontaneously within 6 hours of vaginal birth or removal of indwelling catheter. • Covert retention refers to increased post void residual volumes of > 150 ml and no symptoms of urinary retention.
- 5. • The postpartumbladder has a tendency to be underactive and is, therefore, vulnerable to the retention of urine following trauma to the bladder, pelvic floor muscles and nerves during delivery. • If postpartum voiding dysfunction is unrecognised, it can lead to bladder underactivity and prolonged voiding dysfunction, with sequelae such as recurrent UTI and incontinence
- 6. • The RCOGStudy Group report on incontinence recommends that no woman should be allowed to go longer than 6 hours, without voiding or catheterisation postpartum.
- 7. Incidence • Estimated incidencesrange from 0.05% to 37.0%
- 8. Risk factors • Primiparity •Instrumental delivery • Epidural, spinal or pudendal block in labour • Prolonged second stage of labour • Catheterisation during or after birth
- 9. Risk factors… • Perinealtrauma, vaginal or vulval hematomas, edema • History of voiding difficulties • First vaginal birth • Birth weight > 3.8 kg • Caesaren section
- 10. Pathophysiology of urinary retention •One of the most common cause is the use of regional anaesthesia due to afferent neural blockade which supresses the sensory stimuli from the bladder to the pontine micturition centre. • As a result, the reflex mechanism that induces micturition is blocked which may result in reduced contractility of bladder and urinary retention
- 11. Pathophysiology… • Result ofnerve injury during delivery: The pudendal nerve, with afferent nerve branches (S2- 4) supplying the bladder, is damaged during pelvic surgery and vaginal delivery. There is a significant increase in pudendal nerve terminal motor latencies, which may take a few months to recover post delivery
- 12. Pathophysiology… • Pelvic floortissue stretching during delivery resulting in pudendal nerve damage: Both instrumental delivery and prolonged labour can be predisposing factors to this damage. • Tissue oedema around the urogenital area, resulting in a transient mechanical obstruction to urine outflow.
- 13. Physiological changes contributingto PPUR Elevated progestogen levels in pregnancy and the immediate postpanum period Reduced smooth muscle tone Dilated bladder, ureters and renal pelvises during pregnancy and the first few weeks post-partum. Coupled with changes in vesical pressures (an initial rise in pregnancy followed by a rapid drop to normal values within a few days after delivery) Results in a hypotonic bladder in the early puerperium.
- 14. Clinical presentation • Comp1eteor inability to void, to the asymptomatic patient with large post void residual volumes. • Clinical suspicion: – Small voided volumes, – urinary frequency, – slow or intermittent stream, – urgency, – bladder pain or discomfort, – urinary incontinence and those who strain to void, or describe no sensation to void.
- 15. Management • Intrapartum bladdermanagement: Women should be encouraged to void every 2-3 hours in labour with a low threshold for catheterisation if unable to void (unable to void on 2 occasions or a palpable bladder. • Women who have epidural analgesia: Offered indwelling catheter for a minimum of 6 hours postpartum or until full sensation has returned.
- 16. Management… Postpartum management: • Nopatient should be left >6 h without voiding or being catheterised for residual volumes. • Strict input and output chart should be instituted. • Timing of voids should be recorded, and voided volumes and post void residual volumes should be measured. • Timed voiding every 3-4 h in the immediate postpartum period.
- 17. Measures to aidvoiding • Ensure patient is well analgesed. • Ice to perineum to help reduce oedema. • Help the patient to stand and walk to the toilet. • Provide privacy. • Assist patient into a warm bath. • Prevent constipation.
- 18. Management… • Following thediagnosis of urinary retention, a urine sample should be sent for culture. If UTI is suspected, prompt antibiotic treatment is required. • Place a catheter if swollen pr painful perineum until the swelling and pain have settled. • Avoid constipation
- 19. Management… • Provide adequateanalgesia as perineal pain is a significant factor in the development of retention. • Record the voided volume and postvoid residual volume after removal of catheter. • Further retention or increased residual volume requires continued baldder emptying.
- 20. Management… • Clean intermittentself catheterisation can be taught, or if the perineum is still tender, an indwelling catheter can be sited up to 2 weeks. • Voiding dysfunciton after this period requires careful assessment, including a neurological examination.
- 21.
- 22. Complications • Urinary tractinfection • Urinary / faecal incontinence • Short and long term bladder dysfunction • Ureteric reflux • Bilateral hydronephrosis • Acute renal failure • Long-term renal impairment
- 23. Reference • Kearney R,Cutner A. Postpartum voiding dysfunction. The Obstetrician & Gynaecologist 2008;10:71-74 • Postpartum bladder dysfunction. South Asian Perinatal Practice guidelines. Department of Health. Government of South Australia. 2012 • Lim J.L. Postpartum Voiding Dysfunction and urianry retention. Australian and New Zealand Journal of Obstetrics and Gynaecology 2010; 50: 502-505 • Postpartum Bladder Care: Background, practice and complications. 2011 Retrieved form http://www.ogpnews.com/2011/12/post-partum-bladder-care- background-practice-and-complications/444