Is routine indwelling catheterisation of the bladder for caesarean section necessary? A systematic review

Evidence-based cesarean delivery: preoperative management (part 7)

Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.

Self bladder emptying compared with Foley catheter placement for planned cesarean delivery: a randomized controlled trial

BACKGROUND

The global cesarean delivery rate is high and continues to increase. A bladder catheter is usually placed for the cesarean delivery because a distended bladder is assumed to be at higher risk of injury during surgery and to compromise surgical field exposure. Preliminary data suggest that self bladder emptying (no catheter) at cesarean delivery may have advantages and be safe.

OBJECTIVE

This study aimed to compare the effects of self bladder emptying and indwelling Foley bladder catheterization for planned cesarean delivery on the rate of postpartum urinary retention and maternal satisfaction.

STUDY DESIGN

A randomized controlled trial was conducted in a tertiary university hospital from January 10, 2022 to March 22, 2023. A total of 400 participants scheduled for planned cesarean delivery were randomized: 200 each to self bladder emptying or indwelling Foley catheter. The primary outcomes were postpartum urinary retention (overt and covert) and maternal satisfaction with allocated bladder care. Analyses were performed using t test, Mann-Whitney U test, chi-square test, or Fisher exact test, as appropriate. Logistic regression was used to adjust for differences in characteristics.

RESULTS

Postpartum urinary retention rates were 1 per 200 (0.6%) and 0 per 200 (P>.99) (a solitary case of covert retention) and maternal satisfaction scores (0-10 visual numerical rating scale), expressed as median (interquartile range) were 9 (8-9.75) and 8 (8-9) (P=.003) in the self bladder emptying and indwelling Foley catheter arms, respectively. Regarding secondary outcomes, time to flatus passage, satisfactory ambulation, urination, satisfactory urination, satisfactory breastfeeding, and postcesarean hospital discharge was quickened in the self bladder emptying group. Pain scores at first urination were decreased and no lower urinary tract symptom was more likely to be reported with self bladder emptying. Surgical field view, operative blood loss, duration of surgery, culture-derived urinary tract infection, postvoid residual volume, and pain score at movement were not different. There was no bladder injury.

CONCLUSION

Self bladder emptying increased maternal satisfaction without adversely affecting postpartum urinary retention. Recovery was enhanced and urinary symptoms were improved. The surgeon was not impeded at operation. No safety concern was found.

[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify procedures to reduce maternal morbidity during cesarean.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds.

CONCLUSION

In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

Maternal Sepsis in Italy: A Prospective, Population-Based Cohort and Nested Case-Control Study

Maternal sepsis represents a leading cause of mortality and severe morbidity worldwide. In Italy, it is the second cause of direct maternal mortality. Delay in recognition and treatment initiation are the drivers of sepsis-associated adverse outcomes. Between November 2017 and October 2019, the Italian Obstetric Surveillance System coordinated a prospective population-based study on maternal sepsis occurring before or after childbirth from 22 weeks' gestation onward and up to 42 days following the end of pregnancy. A nested 1:2 matched case-control study on postpartum sepsis was also performed. Maternal sepsis was diagnosed for the presence of suspected or confirmed infection alongside signs or symptoms of organ failure. The aim of this study was to assess maternal sepsis incidence and its associated risk factors, management, and perinatal outcomes. Six Italian regions, covering 48.2% of the national births, participated in the project. We identified an incidence rate of 5.5 per 10,000 maternities (95% CI 4.80-6.28). Seventy percent of patients had a low education level and one third were foreigners with a language barrier. Genital, respiratory, and urinary tract infections were the predominant sources of infection; the majority of cases was caused by E. coli and polymicrobial infections. The presence of vascular and indwelling bladder catheters was associated with a nine-fold increased risk of postpartum sepsis. There were no maternal deaths, but one fourth of women experienced a serious adverse event and 28.3% required intensive care; 1.8% of newborns died. Targeted interventions to increase awareness of maternal sepsis and its risk factors and management should be promoted.

Catheter-Associated Urinary Tract Infections in the Adult Patient Group: A Qualitative Systematic Review on the Adopted Preventative and Interventional Protocols From the Literature

Catheter-associated urinary tract infections (CA-UTIs) are among the most common nosocomial infections acquired by patients in health care settings. A significant risk factor for CA-UTIs is the duration of catheterization. To summarize the current strategies and interventions in reducing urinary tract infections associated with urinary catheters, use and the need for re-catheterization on the rate of CA-UTIs, we performed a systematic review. A rapid evidence analysis was carried out in the Medline (via Ovid) and the Cochrane Library for the periods of January 2005 till April 2021. The main inclusion criterion required to be included in this review was symptomatic CA-UTI in adults as a primary or secondary outcome in all the included studies. Only randomized trials and systematic reviews were included, reviewed, evaluated, and abstracted data from the 1145 articles that met the inclusion criteria. A total of 1145 articles were identified, of which 59 studies that met the inclusion criteria were selected. Studies of relevance to CA-UTIs were based on: duration of catheterization, indication for catheterization, catheter types, UTI prophylaxis, educational proposals and approaches, and mixed policies and interventions. The duration of catheterization is the contributing risk factor for CA-UTI incidence; longer-term catheterization should only be undertaken where needed indications. The indications for catheterization should be based on individual base to base cases. The evidence for systemic prophylaxis instead of when clinically indicated is still equivocal. However, antibiotic-impregnated catheters reduce the risk of symptomatic CA-UTIs and bacteriuria and are more cost-effective than other impregnated catheter types. Antibiotic resistance, potential side effects and increased healthcare costs are potential disadvantages of implementing antibiotic prophylaxis. Multiple interventions and measures such as reducing the number of catheters in place, removing catheters at their earliest, clinically appropriate time, reducing the number of unnecessary catheters inserted, decrease antibiotic administration unless clinically needed, raising more awareness and provide training of nursing personnel on the latest guidelines, can effectively lower the incidence of CA-UTIs.

Cesarean delivery: an evidence-based review of the technique

The cesarean section is utilized to deliver babies since the late 19^th century. Nowadays, the frequency of cesarean section is increased, mainly because of the low rate of complications and for the increasing demand from future mothers, scared by the idea of painful labor. Although the technique to perform cesarean section has been refined over time, infections, hemorrhage, pain and other consequences still represent matter of debate. To try to reduce the incidence of these complications many trials, randomized or not, have been performed, with the aim to analyze different technical aspects of this surgery. The aim of our review was to resume all the evidence-based instructions on how to best approach to cesarean section practice, in a step-to-step fashion, considering pre-operative actions, opening and closing steps, and postoperative prophylaxis.

Eight-hour versus 24-h urethral catheter removal following elective caesarean section for reducing significant bacteriuria: A randomized controlled trial

Background:

There is no consensus on the preferred time to remove urethral catheter post caesarean section.

Aim:

To compare rate of significant bacteriuria and urinary retention following 8-h (study) and 24-h urethral catheter removal (control) post elective caesarean section.

Methods:

A randomized controlled trial of eligible participants that underwent elective caesarean section under spinal anaesthesia between March 2019 and November 2019 was conducted. Participants (150 in each arm) were randomly assigned (1:1 ratio) to either 8-h or 24-h group. Primary outcome measures included rates of significant bacteriuria 48-h post-operatively and acute urine retention 6-h post urethral catheter removal. Analysis was by Intention-to-treat. (www.pactr.org:PACTR202105874744483)

Results:

There were 150 participants randomized into each arm and data collection was complete. Significant bacteriuria was less in 8-h group (3% versus 6.0%; risk ratio (RR): 0.85 CI: 0.60 to 5.66; p = 0.274), though not significant. Acute urinary retention requiring repeat catheterisation was significantly higher in 8-h group (11(7.3%) versus 0(0.0%); RR: 0.07; CI: 0.87 to 0.97; p = 0.001). Mean time until first voiding was slightly higher in 8-h group (211.4 ± 14.3 min versus 190.0 ± 18.3 min; mean difference (MD): 21.36; CI: −24.36 to 67.08; p = 0.203); but patient in this group had a lower mean time until ambulation (770.0 ± 26.1 min versus 809 ± 26.2 min; MD: −38.8; CI: −111.6 to 34.0; p = 0.300). The 8-h group were significantly more satisfied (82/150 (54.7%) versus 54/150 (36.0%); p = 0.001)

Conclusions:

An 8-h group was associated with significant clinical satisfaction and acute urine retention compared to 24-h removal. The timing of urethral catheter removal did not affect rate of significant bacteriuria and other outcomes

A randomized controlled trial of cystoinflation to prevent bladder injury in the adhesive disease of multiple caesarean sections

Caesarean sections carry the risk of urinary bladder injury due to formation of adhesions obscuring pelvic planes. Visualizing bladder during retro-fill (cystoinflation) makes it recognizable as it rises into the abdomen taking a tense rounded contour. We conducted a prospective randomized controlled trial to find out whether improved identification of bladder margins by cystoinflation could decrease bladder injury rate and blood loss without causing urological complications. This study included 214 healthy women with previous operative deliveries undergoing elective caesarean section and found to have dense pelvic adhesions. The subjects were randomly allocated into cystoinflation and control groups. Adhesiolysis was performed using bladder retro-fill with 300 cc saline in cystoinflation group, and without retro-fill in control. The bladder injury rate was significantly lower in cystoinflation group compared to control (2.8% vs 20.6%, P < .0001) with lesser blood loss in cystoinflation group (585.33 cc vs 797.10 cc, P < .0001). Mean operative time was similar in both groups. Urinary tract infection and micturition problems occurred more frequently in control group than cystoinflation group (16.8% vs 1.9%, P = .001 and .47 ± 1.63% vs 077 ± .633%, P = .021 respectively) with fistula in one subject compared to none in cystoinflation group. In this study, cystoinflation was effective to significantly reduce bladder injury rate and blood loss. This technique may also prove useful in the fields of surgery, urology and urogynecology.

The risk of urine bacterial colonisation in patients with a permanent catheter after caesarean section

We present an observational study, conducted in Slovakia, concerning the occurrence of newly acquired urine colonisations in women with Foley catheters after a Caesarean section. A sample of urine was taken from each patient when the Foley catheter was first inserted, before the operation and was sent to the lab for culture. Later, a sample of urine was taken during the removal of the Foley catheter. Out of 176 women, the second urine sample culture result was positive in 13 women. Of those nine women had a positive pathogenic strain (5.1%). The prevalence of asymptomatic bacteriuria in our cohort was 7.7%. De novo acquired colonisation of urine was confirmed in 5.1% of cases. The only confirmed risk factor was delivery by an acute Caesarean section.Impact statementWhat is already known on this subject?: It is well known that catheterisation increases risk of colonisation of lower urinary tract by pathogens. However, the extent of this risk is not determined because there are no studies of de novo colonisation in women with sterile urine before catheterisation. According to literature approximately 8% of women have asymptomatic bacteriuria, which could be confounding factor in previous studies.What do the results of this study add?: Our study excluded women with positive bacteriuria before insertion of Foley catheter. Therefore, the study only assesses de novo colonisation, dependent on insertion of Foley catheter during caesarean section.What are the implications of these findings for clinical practice and/or further research?: De novo colonisation was observed in 5.1% of women in our cohort, with emergency caesarean section as a confirmed risk factor. Therefore, practitioners should consider avoiding catheterisation during caesarean section.

Recommendations and future research initiative to optimize bladder management in pregnancy and childbirth International Consultation on Incontinence - Research society 2018

With increasing birth rates globally, obstetric bladder care and long term pelvic floor dysfunction continues to be a issue. This paper aims to provide an overview of the concerns in the antenatal, intrapartum an post partum periods and presents recommendation for the research requirements necessary and education to challenge current practice.

Catheter-Associated Urinary Tract Infections in Adult Patients

BACKGROUND

Urinary tract infections are among the more common types of nosocomial infection in Germany and are associated with catheters in more than 60% of cases. With increasing rates of antibiotic resistance worldwide, it is essential to distinguish catheter-associated asymptomatic bacteriuria from catheter-associated urinary tract infection (CA-UTI).

METHODS

This review is based on publications from January 2000 to March 2019 that were retrieved by a selective search in Medline. Randomized clinical trials and systematic reviews in which the occurrence of CA-UTI in adult patients was a primary or secondary endpoint were included in the analysis. Two authors of this review, working independently, selected the publications and extracted the data.

RESULTS

508 studies were identified and 69 publications were selected for analysis by the prospectively defined criteria. The studies that were included dealt with the following topics: need for catheterization, duration of catheterization, type of catheter, infection prophylaxis, education programs, and multiple interventions. The duration of catheterization is a determinative risk factor for CA-UTI. The indications for catheterization should be carefully considered in each case, and the catheter should be left in place for the shortest possible time. The available data on antibiotic prophylaxis do not permit any definitive conclusion, but they do show a small benefit from antibiotic-impregnated catheters and from systemic antibiotic prophylaxis.

CONCLUSION

Various measures, including careful consideration of the indication for catheterization, leaving catheters in place for the shortest possible time, and the training of nursing personnel, can effectively lower the incidence of CA-UTI. The eous in some respects, and thus no recommendations can be given on certain questions relevant to CA-UTI.

Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3)

BACKGROUND

This Enhanced Recovery After Surgery Guideline for postoperative care in cesarean delivery will provide best practice, evidenced-based recommendations for postoperative care with primarily a maternal focus.

OBJECTIVE

The pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider time from completion of cesarean delivery until maternal hospital discharge.

STUDY DESIGN

The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Delivery," "Cesarean Section Delivery," and all postoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence, and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Guidelines.

RESULTS

The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a pathway for postoperative care. Specifics include sham feeding, nausea and vomiting prevention, postoperative analgesia, nutritional care, glucose control, thromboembolism prophylaxis, early mobilization, urinary drainage, and discharge counseling. A number of elements of postoperative care of women who undergo cesarean delivery are recommended, based on the evidence.

CONCLUSION

As the Enhanced Recovery After Surgery cesarean delivery pathway (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, there will be an opportunity for focused and optimized areas of care and recommendations to be further enhanced.

Does timing of urinary catheter removal after elective cesarean section affects postoperative morbidity?: a prospective randomized trial

Objective: To assess whether immediate (0 h), intermediate (after 6 h), or delayed (after 24 h) removal of an urinary catheter after elective caesarian section (CS) regarding, the rate of urinary retention with recatheterization, rate of symptomatic urinary tract infections (UTI), time of ambulation, and the length of hospital stay.Methods: Prospective randomized controlled trial conducted at King Abd Al-Aziz Hospital, KSA. Two hundred twenty-one women underwent for term elective CS and were randomly allocated into three groups by simple randomization using computer-generated random numbers. Women in group A (73 patients) had their urinary catheter removed immediately after surgery. Group B (81 patients) had the catheter removed 6 h postoperatively while in group C (67 patients) the catheter was removed after 24 h. The following outcomes were assessed for each group: rate of recatheterization, symptomatic UTI, time of ambulation, and the length of hospital stay.Results: All groups were matched regarding maternal age, body mass index, gestational age at delivery, and duration of surgery there was a significantly higher incidence of urinary retention needing recatheterization in the immediate removal group compared to the intermediate and delayed removal groups (13.6 vs. 2.5 and 0%, respectively). Delayed urinary catheter removal was associated with a higher incidence of UTI (13.4%), delayed ambulation time (10.3 h), and longer hospital stay (3.9 days) compared to the early (1.4%, 4.1 h, and 1.9 days, respectively) and intermediate (3.7%, 6.8 h, and 2.4 days respectively) removal groups.Conclusion: Removal of the urinary catheter 6 h postoperatively appears to be more advantageous than early or late removal in cases of CS.

Early versus delayed removal of indwelling urinary catheter after elective cesarean delivery: systematic review and meta-analysis of randomized controlled trials

Background: Timing of removal of the indwelling urinary catheter after elective cesarean delivery (CD) is controversial. Early removal could be associated with fewer urinary symptoms.Objective: This review aims to evaluate the evidence from published randomized clinical trials (RCTs) about the outcomes of early versus delayed removal of indwelling urinary catheter after elective cesarean delivery (CD).Data sources: Electronic databases were searched using the following MeSH terms (early Or Late Or immediate OR delayed removal) AND (Urinary catheter) AND (cesarean section OR cesarean delivery OR CS)Methods of study selection: All RCTs assessing the timing of removal of urinary catheter were considered for this meta-analysis. One hundred seventy-two studies were identified of which three studies deemed eligible for this review. Quality and risk of bias assessment were performed for all studies.Data extraction: Two researchers independently extracted the data from the individual articles and entered into RevMan software. The relative risk (RR), the weighted mean difference (WMD) and 95% confidence interval (CI) were calculated. The extracted outcomes were significant bacteriuria, urinary symptoms (urinary retention necessitating re-catheterization, dysuria, urinary frequency, urgency) postoperative oral rehydration and length of hospital stay.Results: Three RCTs (early removal: n = 298 and delayed removal: n = 311) were included. The pooled estimate showed that early removal significantly reduced dysuria (RR = 0.60, 95% CI [0.38, 0.95], p=.03), urinary frequency (RR = 0.32, 95% CI [0.16, 0.66], p=.002) and significant bacteriuria (RR = 0.49, 95% CI [0.30, 0.83], p=.007) than delayed removal.Conclusions: This meta-analysis suggests that early removal of the indwelling urinary catheter in patients who underwent elective CD showed significant less dysuria, less urinary frequency and a decrease in the incidence of significant bacteriuria.

Postpartum urinary tract infection by mode of delivery: a Danish nationwide cohort study

OBJECTIVES

To examine the association between postpartum urinary tract infection and intended mode of delivery as well as actual mode of delivery.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

All live births in Denmark between 2004 and 2010 (n=450 856). Births were classified by intended caesarean delivery (n=45 053) or intended vaginal delivery (n=405 803), and by actual mode of delivery: spontaneous vaginal delivery, operative vaginal delivery, emergency or planned caesarean delivery in labour or prelabour.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was postpartum urinary tract infection (n=16 295) within 30 days post partum, defined as either a diagnosis of urinary tract infection in the National Patient Registry or redemption of urinary tract infection-specific antibiotics recorded in the Register of Medicinal Product Statistics.

RESULTS

We found that 4.6% of women with intended caesarean delivery and 3.5% of women with intended vaginal delivery were treated for postpartum urinary tract infection.Women with intended caesarean delivery had a significantly increased risk of postpartum urinary tract infection compared with women with intended vaginal delivery (OR 1.33, 95% CI 1.27 to 1.40), after adjustment for age at delivery, smoking, body mass index, educational level, gestational diabetes mellitus, infection during pregnancy, birth weight, preterm delivery, preterm prelabour rupture of membranes, pre-eclampsia, parity and previous caesarean delivery (adjusted OR 1.24, 95% CI 1.17 to 1.46).Using actual mode of delivery as exposure, all types of operative delivery had an equally increased risk of postpartum urinary tract infection compared with spontaneous vaginal delivery.

CONCLUSIONS

Compared with intended vaginal delivery, intended caesarean delivery was significantly associated with a higher risk of postpartum urinary tract infection. Future studies should focus on reducing routine catheterisation prior to operative vaginal delivery as well as improving procedures related to catheterisation.

The Maternal Infant Microbiome: Considerations for Labor and Birth

The human microbiome plays a role in maintaining health, but is also thought to attenuate and exacerbate risk factors for adverse maternal-child health outcomes. The development of the microbiome begins in utero; however, factors related to the labor and birth environment have been shown to influence the initial colonization process of the newborn microbiome. This "seeding" or transfer of microbes from the mother to newborn may serve as an early inoculation process with implications for the long-term health outcomes of newborns. Studies have shown that there are distinct differences in the microbiome profiles of newborns born vaginally compared with those born by cesarean. Antibiotic exposure has been shown to alter the microbial profiles of women and may influence the gut microbial profiles of their newborns. Considering that the first major microbial colonization occurs at birth, it is essential that labor and birth nurses be aware of factors that may alter the composition of the microbiome during the labor and birth process. The implications of various activities and factors unique to the labor and birth environment that may influence the microbiome of women and newborns during the labor and birth process (e.g., route of birth, antibiotic use, nursing procedures) are presented with a focus on the role of labor nurses and the potential influence of nursing activities on this process.

Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Evidence-Based Cesarean Delivery for the Nonobstetrician

Cesarean delivery (CD) is one of the most common major surgeries performed in the United States and worldwide. Surgical techniques evaluated in well-designed randomized controlled trials (RCTs) that demonstrate maternal benefit should be incorporated into practice. The objective of this review is to provide a summary of surgical techniques of the procedure and review the evidence basis for them for the nonobstetrician. The following techniques with the strongest evidence should be commonly performed, when feasible: (1) prophylactic antibiotics with a single dose of ampicillin or first-generation cephalosporin prior to skin incision; (2) postpartum hemorrhage prevention with oxytocin infusion of 10 to 40 IU in 1 L crystalloid over 4 to 8 hours; (3) low transverse skin incision; (4) blunt or sharp subcutaneous and fascial expansion; (5) blunt, cephalad-caudad uterine incision expansion; (6) spontaneous placental removal; (7) blunt-tip needle usage during closure; (8) subcutaneous suture closure (running or interrupted) if thickness is ≥2 cm; and (9) skin closure with suture. Although the number of RCTs designed to optimize maternal and neonatal outcomes of this common procedure is encouraging, further work is needed to minimize surgical morbidity. Optimal methods for postpartum hemorrhage prevention, adhesion prevention, and venous thromboembolism prophylaxis remain ongoing areas of active research, with outcomes that could markedly improve maternal morbidity and mortality. If evidence of a surgical technique appears preferred over another, clinicians should be comfortable adopting the evidence-based technique when performing and teaching CD.

Compliance With Guideline Statements for Urethral Catheterization in an Iranian Teaching Hospital

BACKGROUND

It is believed that healthcare staff play an important role in minimizing complications related to urethral catheterization. The purpose of this study was to determine whether or not healthcare staff complied with the standards for urethral catheterization.

METHODS

This study was conducted in Imam Reza teaching hospital, Tabriz, Iran, from July to September 2013. A total of 109 catheterized patients were selected randomly from surgical and medical wards and intensive care units (ICUs). A questionnaire was completed by healthcare staff for each patient to assess quality of care provided for catheter insertion, while catheter in situ, draining and changing catheter bags. Items of the questionnaire were obtained from guidelines for the prevention of infection. Data analysis was performed with SPSS 16.

RESULTS

The mean age of the patients was 50.54±22.13. Of the 109 patients, 56.88% were admitted to ICUs. The mean duration of catheter use was 15.86 days. Among the 25 patients who had a urinalysis test documented in their hospital records, 11 were positive for urinary tract infection (UTI). The lowest rate of hand-washing was reported before bag drainage (49.52%). The closed drainage catheter system was not available at all. Among the cases who had a daily genital area cleansing, in 27.63% cases, the patients or their family members performed the washing. In 66.35% of cases, multiple-use lubricant gel was applied; single-use gel was not available. The rate of documentation for bag change was 79%.

CONCLUSION

The majority of the guideline statements was adhered to; however, some essential issues, such as hand hygiene were neglected. And some patients were catheterized routinely without proper indication. Limiting catheter use to mandatory situations and encouraging compliance with guidelines are recommended.

Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA). the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

A prospective randomized clinical trial comparing immediate versus delayed removal of urinary catheter following elective cesarean section

OBJECTIVE

To compare immediate and 12h postoperative removal of urinary catheter after elective cesarean section.

STUDY DESIGN

In a prospective clinical trial at a university teaching hospital, 300 eligible women admitted for primary or repeat elective cesarean section were randomized into two equal groups. In group A, the catheter was removed immediately after the procedure; whereas in group B, the catheter was removed 12h postoperatively.

RESULTS

The incidence of postoperative significant bacteruria (p=0.020), dysuria (p=0.030), burning on micturition (p=0.016), urinary frequency (p=0.031), and urgency (p=0.011) were significantly lower in group A compared with group B. The mean postoperative ambulation time (p<0.001), time till the first voiding (p<0.001), and length of hospital stay (p<0.001) were also significantly shorter in group A. There were no significant differences between the two groups in the incidence of urinary retention necessitating recatheterization (p=0.371).

CONCLUSION

Immediate removal of urinary catheter after elective cesarean section is associated with lower risk of urinary infection and earlier postoperative ambulation.

Indwelling bladder catheterisation as part of intraoperative and postoperative care for caesarean section

BACKGROUND

Caesarean section (CS) is the most common obstetric surgical procedure, with more than one-third of pregnant women having lower-segment CS. Bladder evacuation is carried out as a preoperative procedure prior to CS. Emerging evidence suggests that omitting the use of urinary catheters during and after CS could reduce the associated increased risk of urinary tract infections (UTIs), catheter-associated pain/discomfort to the woman, and could lead to earlier ambulation and a shorter stay in hospital.

OBJECTIVES

To assess the effectiveness and safety of indwelling bladder catheterisation for intraoperative and postoperative care in women undergoing CS.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2013) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing indwelling bladder catheter versus no catheter or bladder drainage in women undergoing CS (planned or emergency), regardless of the type of anaesthesia used. Quasi-randomised trials, cluster-randomised trials were not eligible for inclusion. Studies presented as abstracts were eligible for inclusion providing there was sufficient information to assess the study design and outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility and trial quality, and extracted data. Data were checked for accuracy.

MAIN RESULTS

The search retrieved 16 studies (from 17 reports). Ten studies were excluded and one study is awaiting assessment. We included five studies involving 1065 women (1090 recruited). The five included studies were at moderate risk of bias.Data relating to one of our primary outcomes (UTI) was reported in four studies but did not meet our definition of UTI (as prespecified in our protocol). The included studies did not report on our other primary outcome - intraoperative bladder injury (this outcome was not prespecified in our protocol). Two secondary outcomes were not reported in the included studies: need for postoperative analgesia and women's satisfaction. The included studies did provide limited data relating to this review's secondary outcomes. Indwelling bladder catheter versus no catheter - three studies (840 women) Indwelling bladder catheterisation was associated with a reduced incidence of bladder distension (non-prespecified outcome) at the end of the operation (risk ratio (RR) 0.02, 95% confidence interval (CI) 0.00 to 0.35; one study, 420 women) and fewer cases of retention of urine (RR 0.06, 95% CI 0.01 to 0.47; two studies, 420 women) or need for catheterisation (RR 0.03, 95% CI 0.01 to 0.16; three studies 840 participants). In contrast, indwelling bladder catheterisation was associated with a longer time to first voiding (mean difference (MD) 16.81 hours, 95% CI 16.32 to 17.30; one study, 420 women) and more pain or discomfort due to catheterisation (and/or at first voiding) (average RR 10.47, 95% CI 4.71 to 23.25, two studies, 420 women) although high levels of heterogeneity were observed. Similarly, compared to women in the 'no catheter' group, indwelling bladder catheterisation was associated with a longer time to ambulation (MD 4.34 hours, 95% CI 1.37 to 7.31, three studies, 840 women) and a longer stay in hospital (MD 0.62 days, 95% CI 0.15 to 1.10, three studies, 840 women). However, high levels of heterogeneity were observed for these two outcomes and the results should be interpreted with caution.There was no difference in postpartum haemorrhage (PPH) due to uterine atony. There was also no difference in the incidence of UTI (as defined by trialists) between the indwelling bladder catheterisation and no catheterisation groups (two studies, 570 women). However, high levels of heterogeneity were observed for this non-prespecified outcome and results should be considered in this context. Indwelling bladder catheter versus bladder drainage - two studies (225 women)Two studies (225 women) compared the use of an indwelling bladder catheter versus bladder drainage. There was no difference between groups in terms of retention of urine following CS, length of hospital stay or the non-prespecified outcome of UTI (as defined by the trialist).There is some evidence (from one small study involving 50 women), that the need for catheterisation was reduced in the group of women with an indwelling bladder catheter (RR 0.04, 95% CI 0.00 to 0.70) compared to women in the bladder drainage group. Evidence from another small study (involving 175 women) suggests that women who had an indwelling bladder catheter had a longer time to ambulation (MD 0.90, 95% CI 0.25 to 1.55) compared to women who received bladder drainage.

AUTHORS' CONCLUSIONS

This review includes limited evidence from five RCTs of moderate quality. The review's primary outcomes (bladder injury during operation and UTI), were either not reported or reported in a way not suitable for our analysis. The evidence in this review is based on some secondary outcomes, with heterogeneity present in some of the analyses. There is insufficient evidence to assess the routine use of indwelling bladder catheters in women undergoing CS. There is a need for more rigorous RCTs, with adequate sample sizes, standardised criteria for the diagnosis of UTI and other common outcomes.

The Phantom Urine: An Unexpected Finding during a Routine Cesarean Section

We present here an atypical finding during an elective repeat cesarean section. Despite urine flow through an indwelling bladder catheter, bladder remains distended during the whole procedure. Unexpected anatomical variations and malformations can make routine surgery challenging. Urinary tract anomalies should be suspected in cases of unexpected difficult bladder catheterization.

Evidence-based surgery for cesarean delivery: an updated systematic review

The objective of our systematic review was to provide updated evidence-based guidance for surgical decisions during cesarean delivery (CD). We performed an English-language MEDLINE, PubMed, and COCHRANE search with the terms, cesarean section, cesarean delivery, cesarean, pregnancy, and randomized trials, plus each technical aspect of CD. Randomized control trials (RCTs) involving any aspect of CD technique from Jan. 1, 2005, to Sept. 1, 2012, were evaluated to update a previous systematic review. We also summarized Cochrane reviews, systematic reviews, and metaanalyses if they included additional RCTs since this review. We identified 73 RCTs, 10 metaanalyses and/or systematic reviews, and 12 Cochrane reviews during this time frame. Recommendations with high levels of certainty as defined by the US Preventive Services Task Force favor pre-skin incision prophylactic antibiotics, cephalad-caudad blunt uterine extension, spontaneous placental removal, surgeon preference on uterine exteriorization, single-layer uterine closure when future fertility is undesired, and suture closure of the subcutaneous tissue when thickness is 2 cm or greater and do not favor manual cervical dilation, subcutaneous drains, or supplemental oxygen for the reduction of morbidity from infection. The technical aspect of CD with high-quality, evidence-based recommendations should be adopted. Although 73 RCTs over the past 8 years is encouraging, additional well-designed, adequately powered trials on the specific technical aspects of CD are warranted.

Emergency cesarean delivery: special precautions

An emergent cesarean delivery is performed to immediately intervene to improve maternal or fetal outcome for such indications as fetal distress, prolapsed cord, maternal hemorrhage from previa or trauma, uterine rupture, and complete placental abruption. It is paramount to reduce morbidity and mortality by preparing health care providers for special precautions.

Bladder Injury During Cesarean Delivery

Cesarean section is the most common surgery performed in the United States with over 30% of deliveries occurring via this route. This number is likely to increase given decreasing rates of vaginal birth after cesarean section (VBAC) and primary cesarean delivery on maternal request, which carries the inherent risk for intraoperative complications. Urologic injury is the most common injury at the time of either obstetric or gynecologic surgery, with the bladder being the most frequent organ damaged. Risk factors for bladder injury during cesarean section include previous cesarean delivery, adhesions, emergent cesarean delivery, and cesarean section performed at the time of the second stage of labor. Fortunately, most bladder injuries are recognized at the time of surgery, which is important, as quick recognition and repair are associated with a significant reduction in patient mortality. Although cesarean delivery is a cornerstone of obstetrics, there is a paucity of data in the literature either supporting or refuting specific techniques that are performed today. There is evidence to support double-layer closure of the hysterotomy, the routine use of adhesive barriers, and performing a Pfannenstiel skin incision versus a vertical midline subumbilical incision to decrease the risk for bladder injury during cesarean section. There is also no evidence that supports the creation of a bladder flap, although routinely performed during cesarean section, as a method to reduce the risk of bladder injury. Finally, more research is needed to determine if indwelling catheterization, exteriorization of the uterus, and methods to extend hysterotomy incision lead to bladder injury.

First do no harm: interventions during childbirth

Although medical and technological advances in maternity care have drastically reduced maternal and infant mortality, these interventions have become commonplace if not routine. Used appropriately, they can be life-saving procedures. Routine use, without valid indications, can transform childbirth from a normal physiologic process and family life event into a medical or surgical procedure. Every intervention presents the possibility of untoward effects and additional risks that engender the need for more interventions with their own inherent risks. Unintended consequences to intrapartum interventions make it imperative that nurse educators work with other professionals to promote natural childbirth processes and advocate for policies that focus on ensuring informed consent and alternative choices. Interdisciplinary collaboration can ensure that intrapartum caregivers "first do no harm."