Effect of the duration of labor on postpartum postvoid residual bladder volume

Incidence, risk factors and diagnostic accuracy of clinical palpation in picking up post-void residual urine in postnatal women

PURPOSE

To determine the incidence of covert and overt postpartum urinary retention after vaginal delivery and the associated risk factors for postpartum urinary retention. To determine how well clinical examination by abdominal palpation correlates with ultrasound findings of urinary retention.

METHODS

Patients after delivery were screened with ultrasound and examined clinically to check for retention of urine after voiding.

RESULTS

A total of 822 of women were recruited in the study of which 86 (10.5%) women had significant post-void residue of urine. 33 (38.4%) had overt retention, while 53 (61.6%) had covert retention. Duration of labour and an increased VAS score were found to be significantly higher among those with urinary retention. Using clinical examination to diagnose postpartum urinary retention had a sensitivity of 66.1%, specificity of 88.6%, positive predictive value of 76.5% and negative predictive value of 82.3%.

CONCLUSIONS

Clinical examination by abdominal palpation is not a very sensitive test in diagnosing PPUR.

Postpartum urinary retention and its associated obstetric risk factors among women undergoing vaginal delivery in tertiary care hospital

INTRODUCTION

Postpartum urinary retention (PUR) is not an uncommon consequence of bladder dysfunction after vaginal delivery. Despite its ubiquity, morbidity and discomfort brought to the postpartum women, it's a poorly discussed condition. Patients with Overt PUR are unable to void spontaneously within 6h of vaginal delivery and those with Covert PUR are able to void spontaneously but have a post void residual bladder volume (PVRV) of >150mL. Reported incidences of PUR vary widely ranging from 1.7 %-17.9 %.

AIM AND OBJECTIVES

To identify the prevalence and obstetric risk factors for PUR after vaginal delivery in order to identify women with increased risk of PUR.

MATERIALS AND METHODS

The PVRV of women who delivered vaginally was measured after the first spontaneous micturition by ultrasonography. PVRV of more than 150mL was considered as covert PUR. Patient data including age, obstetric history, mode of delivery, duration of labor, PVRV were compared between women with and those without PUR.

RESULTS

Of 878 included women, the overall prevalence of PUR after vaginal delivery was 12.9 %, the prevalence of overt and covert PUR were 1.8 % and 11.04 % respectively. Parturient who were primigravidae, had perineal injury, instrumental delivery, birth weight >3.5kg and a longer duration of second stage of labor were risk factors for developing PUR.

CONCLUSION

Any misdiagnosis or delay in diagnosis of PUR can cause bladder over distension leading to irreversible detrusor damage. Hence vigilant monitoring and early detection of PUR helps in facilitating timely interventions and prevention of immediate and long term sequelae.

Neuroanatomic and behavioral correlates of urinary dysfunction induced by vaginal distension in rats

The aim of the present study was to use a model of simulated human childbirth in rats to determine the damage to genitourinary structures and behavioral signs of urinary dysfunction induced by vaginal distension (VD) in female rats. In experiment 1, the length of the genitourinary tract and the nerves associated with it were measured immediately after simulated human delivery induced by VD or sham (SH) procedures. Electroneurograms of the dorsal nerve of the clitoris (DNC) were also recorded. In experiment 2, histological characteristics of the bladder and major pelvic ganglion of VD and SH rats were evaluated. In experiment 3, urinary parameters were determined in conscious animals during 6 h of dark and 6 h of light before and 3 days after VD or SH procedures. VD significantly increased distal vagina width (P < 0.001) and the length of the motor branch of the sacral plexus (P < 0.05), DNC (P < 0.05), and vesical nerves (P < 0.01) and decreased DNC frequency and amplitude of firing. VD occluded the pelvic urethra, inducing urinary retention, hematomas in the bladder, and thinness of the epithelial (P < 0.05) and detrusor (P < 0.01) layers of the bladder. Major pelvic ganglion parameters were not modified after VD. Rats dripped urine in unusual places to void, without the stereotyped behavior of micturition after VD. The neuroanatomic injuries after VD occur alongside behavioral signs of urinary incontinence as determined by a new behavioral tool for assessing micturition in conscious animals.

Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery

Introduction and hypothesis

Postpartum urinary retention (PUR) is a common consequence of bladder dysfunction after vaginal delivery. Patients with covert PUR are able to void spontaneously but have a postvoid residual bladder volume (PVRV) of ≥150 mL. Incomplete bladder emptying may predispose to bladder dysfunction at a later stage of life. The aim of this cross-sectional study was to identify independent delivery-related risk factors for covert PUR after vaginal delivery in order to identify women with an increased risk of covert PUR.

Methods

The PVRV of women who delivered vaginally was measured after the first spontaneous micturition with a portable bladder-scanning device. A PVRV of 150 mL or more was defined as covert PUR. Independent risk factors for covert PUR were identified in multivariate regression analysis.

Results

Of 745 included women, 347 (47 %) were diagnosed with covert PUR (PVRV ≥150 mL), of whom 197 (26 %) had a PVRV ≥250 mL (75th percentile) and 50 (7 %) a PVRV ≥500 mL (95th percentile). In multivariate regression analysis, episiotomy (OR 1.7, 95 % CI 1.02 – 2.71), epidural analgesia (OR 2.08, 95 % CI 1.36 – 3.19) and birth weight (OR 1.03, 95 % CI 1.01 – 1.06) were independent risk factors for covert PUR. Opioid analgesia during labour (OR 3.19, 95 % CI 1.46 – 6.98), epidural analgesia (OR 3.54, 95 % CI 1.64 – 7.64) and episiotomy (OR 3.72, 95 % CI 1.71 – 8.08) were risk factors for PVRV ≥500 mL.

Conclusions

Episiotomy, epidural analgesia and birth weight are risk factors for covert PUR. We suggest that the current cut-off values for covert PUR should be reevaluated when data on the clinical consequences of abnormal PVRV become available.

Urogynaecological problems in pregnancy

The majority of urogynaecological problems can manifest during pregnancy or as a direct result of pregnancy and delivery. Those most commonly occurring during pregnancy are urinary tract infection, filling and voiding disorders, urinary incontinence, pelvic organ prolapse and faecal incontinence. The development of these may be as a result of physiological changes that occur in pregnancy or as a result of previous pregnancies. There may also be urogynaecological sequelae that occur as a result of trauma sustained during delivery. These include perineal and anal sphincter trauma, bladder or ureteric injuries during caesarean section or operative deliveries, and the development of vesico-vaginal or recto-vaginal fistulae.

Maternal urological problems in pregnancy

Urological conditions in pregnancy represent a major diagnostic and therapeutic challenge. During pregnancy the urinary tract undergoes some anatomical and physiological changes that may result in many symptoms and pathological conditions affecting both the mother and fetus. With prompt evaluation and expeditious treatment, the prognosis is good. Fear of causing harm is unfounded. This article describes urological problems in pregnancy, specifically infection, calculus, renal failure, renal tumour, lower urinary tract symptoms and trauma and their management.

Use of epidural anesthesia and the risk of acute postpartum urinary retention

OBJECTIVE

We aimed to examine the relationship between the use of epidural analgesia during labor and acute postpartum urinary retention.

STUDY DESIGN

A retrospective cohort study was conducted using 1994 labor and postpartum health records from 3 primary care centers.

RESULTS

Logistic regression analysis revealed that a longer second stage of labor (odds ratio [OR] 2.62; 95% confidence interval [CI] 1.41-4.85), use of systemic narcotics (OR 1.63; 95% CI 1.04-2.57), perineal laceration (OR 1.73; 95% CI 1.02-2.91), and instrumental delivery (OR 1.86; 95% CI 1.16-2.97) predicted urinary retention. There was a trend toward association of epidural analgesia and urinary retention (OR 1.69; 95% CI 0.98-2.92). Propensity score analysis revealed that any effect of epidural analgesia was likely due to effect modification of other obstetric variables.

CONCLUSION

Epidural analgesia during labor may increase the risk of developing urinary retention by up to 3 times. However, this effect is mediated by other obstetric variables.

Post-void residual volume in labor: a prospective study comparing parturients with and without epidural analgesia

BACKGROUND

This prospective, non-randomized study compared post-void residual volume in laboring and postpartum women with or without epidural analgesia.

METHODS

The study was conducted over 1 year with institutional review board approval. Parturients were recruited in early labor and self-selected to either the study (with epidural) or control (without epidural) group. Post-void residual volume was compared between groups, using transabdominal ultrasound during labor, and on postpartum day 1 and 2. Main outcome measure was intrapartum residual bladder volume.

RESULTS

Thirty patients were recruited to each group. During labor, residual bladder volume was significantly larger in the epidural group compared with the non-epidural group [median (range)] 240 (12-640), ml vs. 45 (13-250) ml, respectively, P < 0.001], but was similar on postpartum day 1 and 2. Twenty-five (83%) women with epidural analgesia required bladder catheterization during labor vs. one (3.3%) without (P < 0.0001).

CONCLUSION

The greater post-void residual volume and increased inability to void in parturients with epidurals suggests that epidural analgesia plays a role in intrapartum urinary retention.

Intrapartum ultrasound estimation of total bladder volume

OBJECTIVE

To determine whether real-time ultrasound measurement of multiple linear dimensions of the bladder could be used to estimate total bladder volumes of women in labour.

AIM

To create a simple reproducible formula using ultrasound techniques to help estimate total bladder volumes of women in labour. This may prevent unnecessary catheterisation and conversely, avoid failure to catheterise when indicated, thereby reducing the complications associated with catheterisation and bladder overdistension.

DESIGN

Prospective, observational study of women in labour.

SETTING

Delivery Suite, Obstetric Hospital, University College London Hospitals.

POPULATION

Forty-nine women in labour recommended for catheterisation by their attending midwives.

METHOD

A real-time ultrasound scanner was used to measure bladder diameters in two planes: transverse width and height, and sagittal width and height. A Foley's catheter was inserted and the bladder drained into a graduated bowl under sterile conditions. These values and urine volumes were recorded and a formula for detecting bladder volumes above 300 mL was developed using linear regression methods and the Bland-Altman limits of agreement.

MAIN OUTCOME MEASURE

Sensitivity and specificity of derived formulae in predicting bladder volume from ultrasound measurements. Correctly predicted volumes greater than 300 mL.

RESULTS

Among the 49 women, 36 were nulliparous and 13 were multiparous. All had full-term pregnancies with cephalic presentation and were in active labour with cervical dilatations ranging from 3 to 10 cm. There were no previous caesarean sections among the multiparous women. Thirty-nine women had epidural analgesia. Indications for catheterisation included a palpable bladder per abdomen, or the interval from last urine voided. The catheterised volumes ranged from 30 to 720 mL with a median of 150 mL. The new equation (0.68 x h x d x w) had a sensitivity of 77% (95% CI 46-95%) and specificity of 86% (95% CI 71-95%) for detecting bladder volumes greater than 300 mL. In order to ensure that about 95% of women in need of catheterisation are detected, the above equation was improved using the Bland-Altman limits of agreement. The sensitivity of this final equation (1.74 x h x d x w) was 100% (95% CI 75-100%) and the specificity dropped to 36% (95% CI 21-54%).

CONCLUSION

It is possible to use real-time ultrasound in estimation of total bladder volumes of women in labour. The implications are that all of those normally selected as being in need of catheterisation could be detected, while about a quarter of those women would avoid unnecessary catheterisation.

Knowledge of female bladder care among medical staff, nurses and midwives: results of a questionnaire survey

OBJECTIVE

To determine knowledge about bladder care among junior medical staff and allied health professionals, and to examine any difference in knowledge among the subgroups.

SUBJECTS AND METHODS

Using a single-questionnaire survey in a large obstetrics and gynaecology Hospital Trust in an inner city setting, midwives, nurses and medical staff (not consultants) were asked eight questions about different aspects of female bladder physiology and care. The differences in responses among the professional groups were assessed.

RESULTS

In all, 120 completed questionnaires were returned (32 doctors, 40 nurses, and 48 midwives). Knowledge was similar on urethral length, bladder capacity, daily fluid intake, ideal size of catheter, catheter balloon size, and the maximum time of use of a short-term catheter. Correct responses for normal daily fluid intake, duration of both short and long-term catheterization were given by fewer than half the respondents. There were significant differences among the professional groups in the correct response rate for long-term catheter duration (P = 0.031) and the normal time interval between voids (P = 0.038).

CONCLUSION

There were significant differences in the knowledge of all subgroups about bladder care, and poor levels of knowledge in several areas. This is a potentially serious problem for women at risk of bladder complications after gynaecological surgery and childbirth. All staff involved in managing women after childbirth and gynaecological surgery should have formal training in bladder care, to optimize patient care.

Postpartum urinary retention: assessment of contributing factors and long-term clinical impact

OBJECTIVES

To investigate the relationships between various obstetric parameters and postpartum urinary retention, and to offer some clinical guidance for resolution of urinary retention problems.

DESIGN

An observational prospective study.

SETTING

A private teaching hospital medical centre.

POPULATION

A total of 2,866 vaginally delivered women were recruited with 114 women classified as urinary retention group and the remaining 2752 women categorised as control group.

MAIN OUTCOME MEASURES AND RESULTS

Women in the urinary retention and control groups did not differ significantly in terms of age, fetal head circumference and fetal birth weight. Women suffering from postpartum urinary retention demonstrated significantly longer labour duration, more nulliparity and epidural analgesia and higher percentages of instrument-assisted delivery and vaginal or perineal damage.

CONCLUSION

Nulliparity, longer labour course, instrumental delivery, extensive vaginal and perineal laceration and use of epidural analgesia were contributing obstetric factors to postpartum urinary retention. Long-term follow-up showed that the problems of all but three of the 114 women, who complained of persistent minor urinary symptoms, were eventually resolved.

The effect of epidural analgesia on postpartum urinary retention in women who deliver vaginally

There have been several investigations reporting on urinary retention in postpartum women who delivered vaginally with epidural blockade. The mechanism and incidence of urinary retention in relation to epidural analgesia, however, are not established. The objectives of this study were to investigate the association between various obstetric parameters and urinary retention and to determine whether those women with postpartum urinary retention subsequently develop urinary problems. From December 1999 to September 2000, 110 primiparas who delivered vaginally with epidural analgesia for labor pain relief were recruited prospectively. One hundred primiparas delivering under similar conditions without epidural analgesia were selected as the control group. Residual urine volume was calculated by trans-abdominal sonogram. A computerized obstetric database was analysed to compare the two groups. Women with epidural analgesia, especially those with residual volume exceeding 500 ml, had significantly longer labor course, a higher percentage of instrumental deliveries and more extensive vaginal or perineal lacerations than the control group. Only a few women had persistent problems with micturition six months after delivery. Epidural analgesia provides valuable pain relief but may be associated with greater residual urine. Postpartum urinary retention is, however, more related to prolonged labor than to the effect of epidural analgesia itself. Close monitoring of the progress of labor and avoiding urine retention are essential.

Urological problems in pregnancy

During pregnancy the urinary tract undergoes extensive anatomical and physiological changes. These changes can result in many symptoms and pathological conditions that may affect the mother and fetus. It is well documented that childbirth may result in urinary tract damage which may predispose to postpartum symptoms. This review describes the physiological and pathological consequences of pregnancy and delivery on the urinary tract, and how these may be minimized.