Effect of intermittent versus continuous bladder catheterization on duration of the second stage of labor among nulliparous women with an epidural: a randomized controlled trial

Intermittent versus Continuous Catheterization and Differences in the Evolution of Labor: Systematic Review and Meta-analysis

OBJECTIVE

 To evaluate the differences between bladder emptying options (permanent catheterization and intermittent bladder emptying/spontaneous urination) regarding the effects on labor length, need of operative vaginal deliveries, and cesarean section rate.

DATA SOURCES

 The search was conducted in MEDLINE, Scopus, Web of Science, and The Cochrane Central Register of Controlled Trials databases.

SELECTION OF STUDIES

 The survey returned 964 studies. A total of 719 studies were evaluated by title and abstract, of which 4 were selected for inclusion.

DATA COLLECTION

 All references were inserted in the Rayyan QCRI tool (Rayyan Systems Inc., Cambridge, MA, USA). The full text of the selected articles was obtained so we could later decide whether or not to include them in this systematic review.

DATA SYNTHESIS

 No differences were found in the number of instrumented deliveries or in cesarean section rate between groups.

CONCLUSIONS

 After evaluating the studies performed on the topic, we concluded that there is no clear advantage to either method, although continuous catheterization was associated with a greater occurrence of eutocic births. In the remaining outcomes, there were no differences between catheterization types.

Differential effects of different delivery methods on progression to severe postpartum hemorrhage between Chinese nulliparous and multiparous women: a retrospective cohort study

BACKGROUND

Delivery methods are associated with postpartum hemorrhage (PPH) both in nulliparous and multiparous women. However, few studies have examined the difference in this association between nulliparous and multiparous women. This study aimed to explore the difference of maternal and neonatal characteristics and delivery methods between Chinese nulliparous and multiparous women, and then examine the differential effects of different delivery methods on PPH between these two-type women.

METHODS

Totally 151,333 medical records of women who gave birth between April 2013 to May 2016 were obtained from the electronic health records (EHR) in a northern province, China. The severity of PPH was estimated and classified into blood loss at the level of < 900 ml, 900-1500 ml, 1500-2100 ml, and > 2100 ml. Neonatal and maternal characteristics related to PPH were derived from the same database. Multiple ordinal logistic regression was used to estimate associations.

RESULTS

Medical comorbidities, placenta previa and accreta were higher in the nulliparous group and the episiotomy rate was higher in the multiparous group. Compared with spontaneous vaginal delivery (SVD), the adjusted odds (aOR) for progression to severe PPH due to the forceps-assisted delivery was much higher in multiparous women (aOR: 9.32; 95% CI: 3.66-23.71) than in nulliparous women (aOR: 1.70; 95% CI: 0.91-3.18). The (aOR) for progression to severe PPH due to cesarean section (CS) compared to SVD was twice as high in the multiparous women (aOR: 4.32; 95% CI: 3.03-6.14) as in the nulliparous women (aOR: 2.04; 95% CI: 1.40-2.97). However, the (aOR) for progression to severe PPH due to episiotomy compared to SVD between multiparous (aOR: 1.24; 95% CI: 0.96-1.62) and nulliparous women (aOR: 1.55; 95% CI: 0.92-2.60) was not significantly different. The (aOR) for progression to severe PPH due to vacuum-assisted delivery compared to SVD in multiparous women (aOR: 2.41; 95% CI: 0.36-16.29) was not significantly different from the nulliparous women (aOR: 1.05; 95% CI: 0.40-2.73).

CONCLUSIONS

Forceps-assisted delivery and CS methods were found to increase the risk of severity of the PPH. The adverse effects were even greater for multiparous women. Episiotomy and the vacuum-assisted delivery, and SVD were similar to the risk of progression to severe PPH in either nulliparous or multiparous women. Our findings have implications for the obstetric decision on the choice of delivery methods, maternal and neonatal health care, and obstetric quality control.

A Project to Increase Nurses' Comfort in Offering Bedpans to Women Laboring With Epidural Analgesia

OBJECTIVE

To improve nurses' comfort in helping laboring woman void on a bedpan after initiation of epidural analgesia, to increase the frequency of bedpan use in the labor and birth unit, and to decrease the use of continuous indwelling Foley catheters during the intrapartum period.

DESIGN

Quality improvement project.

SETTING

A single large, midwestern U.S. hospital (>3,000 births annually), where bedpans are infrequently used after epidural placement.

PARTICIPANTS

Registered nurses on a labor and birth unit.

INTERVENTION/MEASUREMENTS

A 20-minute educational presentation that included current urinary catheter evidence-based practice, preferential use of bedpans, and methods to help women void successfully was taught to all registered nurses in the author's labor unit. Nurses rated on a scale of 0 (not comfortable at all) to 10 (extremely comfortable) their comfort level at helping a woman with a bedpan. Primary data were collected through a convenience sample of anonymous surveys (n = 52) completed by registered nurses regarding their experience with bedpan and catheter use during labor and their comfort level helping women be successful with voiding. This was followed by a retrospective chart audit for women with term, singleton pregnancies who labored with epidural analgesia.

RESULTS

Nurses' comfort levels increased from an average of 5.7 to 7.2 (p = .067). Postepidural bedpan use increased from 5.5% (n = 12) to 19% overall (n = 20; p < .001), with five women using bedpans exclusively. When assisted with bedpan use, 38% (n = 12) of women were able to void 34 of the 53 times it was offered (64%). Use of continuous indwelling Foley catheters decreased from 61.7% (n = 137) to 54.7% (n = 58), and use of intermittent catheterization increased from 30.6% (n = 68) to 37.7% (n = 40).

CONCLUSION

When assisted by nurses educated in and comfortable with different voiding techniques, women may be able to avoid medically unnecessary use of urinary catheters during labor.

The effect of bladder catheterization on the incidence of urinary tract infection in laboring women with epidural analgesia: a meta-analysis of randomized controlled trials

INTRODUCTION AND HYPOTHESIS

There is conflicting evidence on whether intermittent catheterization (IC) is less associated with urinary tract infection (UTI) and more likely to prevent urinary retention than continuous catheterization (CC). We aimed to compare the effect of IC with that of CC on the incidence of postpartum UTI, urinary retention and hemorrhage in laboring women with epidural analgesia.

METHODS

Electronic searches were performed in PubMed, EMBASE and Cochrane Library from their inception to October 2018. We selected RCTs comparing IC with CC in laboring women with epidural analgesia. A meta-analysis was performed using the RevMan software, and a random-effects model was used to pool the effect size. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence.

RESULTS

Six RCTs (N = 850) were included in this review. The meta-analyses indicated that there was no significant difference between the IC and CC group in the incidence of postpartum UTI (RR = 1.25, 95% CI: 0.91 to 1.71, P = 0.16), postpartum urinary retention (RR = 0.76, 95% CI: 0.21 to 2.77, P = 0.68) and postpartum hemorrhage (RR = 1.72, 95% CI: 0.60 to 4.95, P = 0.31). GRADE assessment results showed that the quality of evidence was low.

CONCLUSIONS

Based on the available evidence, there is no measurable difference in rates of UTI between CC and IC, not that neither stragety decreases UTI, since the included trials do not address this.

[Which interventions during labour to decrease the risk of perineal tears? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The objective of this review was to evaluate whether interventions performed during labour could influence the risk of perineal tears.

METHODS

A separate keyword search for each medical intervention during labor was performed by selecting only studies evaluating perineal consequences, particularly the risk of obstetrical anal sphincter injury (LOSA). Interventions during pregnancy and during fetal expulsion have been specifically addressed in other chapters of the recommendations.

RESULTS

Maternal mobilisation and postures during the first stage of labour have not been shown to reduce the risk of OASIS (LE3). No particular posture has demonstrated its superiority over any other during the second stage of labour for preventing obstetric perineal lesions including OASIS and postnatal incontinence (urinary or faecal) (LE2). There is no reason to recommend one maternal posture rather than another during the first and the second stages of labour for the purpose of reducing the risk of OASIS (Grade C). Women should be allowed to choose the position most comfortable for them during the first and second stages of labour (Professional consensus). Posterior cephalic positions present the greatest risks of perineal injury (LE2). Manual rotation of cephalic posterior positions to the anterior during the second stage of labour may make it possible to reduce the risk of operative vaginal delivery, although no reduction in the risk of perineal injuries or OASIS has been clearly demonstrated (LE3). For fetuses in posterior cephalic positions, no data justifies a preference for manual rotation at full dilation to diminish the risk of perineal injury (Professional consensus). Urinary catheterisation is recommended for women with epidural analgesia during labour when spontaneous micturition is not possible (Professional consensus). Although current data does not justify a preference for continuous or intermittent urinary catheterisation (LE2), intermittent catheterisation nonetheless appears preferable in this situation (Professional consensus). During the second stage phase, delayed pushing does not modify the risk of OASIS (LE1). It does, however, increase the chances of spontaneous delivery (LE1). It is thus recommended that, when maternal and fetal status allow it, the start of pushing should be delayed (Grade A). There is no evidence to support preferring one pushing technique rather than another to diminish the risk of OASIS (grade B). Performing an operative vaginal delivery for the sole purpose of reducing the duration of the second stage of labour may increase the risk of OASIS (LE3). Perineal massage or the application of warm compresses during the second stage of labour appear to reduce the risk of OASIS (LE2). However, we have not made a determination about their use in clinical practice.