The effect of intermittent versus continuous bladder catheterization on labor duration and postpartum urinary retention and infection: a randomized trial

The Effectiveness and Safety of Intrapartum or Postpartum Catheterization in the Prevention of Postpartum Urinary Retention: A Scoping Review

INTRODUCTION AND HYPOTHESIS

Catheterization is a common treatment for postpartum urinary retention (PUR); however, its application before diagnosis of PUR remains unclear. The aim was to give an overview of the existing literature on the effectiveness and safety of intrapartum or postpartum catheterization in the prevention of PUR.

METHODS

This scoping review followed a methodological framework. PubMed, the Cochrane Library, Embase, Web of Science, the China National Knowledge Infrastructure, WanFang, the China Science and Technology Journal Database, and the China Biomedical Literature Database were searched from the inception of each database to 21 May 2023.

RESULTS

The search revealed 16 studies examining three different catheterization methodologies, including 12 intrapartum studies. Ten studies concluded that intrapartum or postpartum catheterization prevented PUR, two of which were only for overt or covert PUR. In 4 out of 13 experimental studies, no significant difference was found: one for intrapartum catheterization versus routine nursing, the other for intrapartum or postpartum intermittent versus indwelling catheterization. However, one found that postpartum disposable catheterization after ineffective targeted care reduced the incidence of PUR compared with indwelling catheterization. One out of the 3 case-control studies concluded that prenatal catheterization ≥2 times was a risk factor for PUR.

CONCLUSIONS

Based on the findings in this scoping review, catheterization prior to the diagnosis of PUR appears to play a role in preventing PUR and is safe. Preliminary evidence is accumulating on the effectiveness of three types of catheterization methods in preventing PUR, but more comprehensive studies are needed to establish these findings.

Risk of urinary tract infection following vaginal delivery: a comparison between intermittent and indwelling bladder catheterization

OBJECTIVES

The primary objective of the study was to determine the risk of postpartum urinary tract infection (UTI) in women exposed to intermittent versus indwelling catheterization in labor. The secondary objective was to identify risk factors for development of postpartum UTI.

METHODS

A case-control study was conducted between 1 January 2013 and 31 December 2016. Cases were defined as patients who were diagnosed with UTI and controls were not diagnosed with UTI. Obstetrical, infectious, and catheterization variables were collected. Univariate and multivariate analyses were performed.

RESULTS

A total of 26,517 full-term vaginal deliveries occurred during the study period with a rate of postpartum UTI of 0.7%. There were 166 cases and 695 controls included in the analysis. There was no significant difference in the rate of UTI between patients who underwent indwelling versus intermittent (reference) catheterization (OR 1.05, 95% CI: 0.67-1.64, p = .826). On multivariate analysis, significant risk factors for UTI included the relationship between use of catheterization and duration of labor (p = .026) and history of UTI during the pregnancy (p < .001).

CONCLUSION

In this study, there was no difference in the rate of postpartum UTI based on catheterization method. Further studies are needed to determine the optimal method of catheterization during labor and to enable providers to implement quality improvement strategies aimed at decreasing the risk of infection.

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.

Multisite Randomized Controlled Trial of Bladder Management in Labor With Epidural Analgesia/Anesthesia

OBJECTIVE

To compare the effects of continuous indwelling catheterization with those of intermittent catheterization during labor with epidural analgesia/anesthesia on mode of birth and incidence of urinary tract infection (UTI) symptoms in the postpartum period.

DESIGN

Randomized clinical trial.

SETTING

Labor and delivery units at three metropolitan hospitals in the Western United States.

PARTICIPANTS

Women (N = 252) who were nulliparous with term, singleton pregnancies in labor with epidural analgesia/anesthesia.

METHODS

Participants were randomized to indwelling or intermittent (every 2 hours) catheterization groups after the administration of epidural analgesia/anesthesia during labor. One to 2 weeks after discharge, participants were contacted and questioned about symptoms of UTI.

RESULTS

A total of 252 participants were enrolled in the study: 81% (n = 202) gave birth vaginally, and 19% (n = 50) gave birth via cesarean. Between the indwelling and intermittent catheterization groups, demographic characteristics were similar. We found no significant difference in the incidence of cesarean birth between groups (15.6% vs. 22.5%, p = .172). Overall, 3% of participants reported and sought treatment for symptoms of UTI within 2 weeks with no significant difference between groups (p = .929).

CONCLUSION

We found no differences in mode of birth or symptoms of UTI in women who received indwelling or intermittent catheterization during epidural analgesia/anesthesia. We recommend additional research with objective data for UTI diagnosis and larger samples to study the multiple potential confounding variables associated with cesarean birth after catheterization during epidural analgesia/anesthesia.

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.

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.

[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.

Impact of systematic urinary catheterization protocol in delivery room on covert postpartum urinary retention: a before-after study

We investigated whether implementation of a routine catheterization procedure in labor improves covert postpartum urinary retention (cPUR) rates. We conducted a prospective before-after study. 121 women admitted to delivery room in the observational group, and 82 in the intervention group, in a tertiary university hospital in Southern France were included. All patients in the intervention group were systematically catheterized 2 hours after delivery. cPUR was screened for in both groups. The primary end-point was cPUR (post-void residual bladder volume >150 ml when voided volume is >150 mL). The rate of cPUR decreased from 50% (60 out of 121 patients) in the observational group to 17% (14/82) in the intervention group (OR = 0.21; 95% Confidence Interval [0.13;0.58]; p < 0.001). Similarly, in the subgroup of patients who underwent instrumental delivery, the rate of cPUR was lower in the intervention group (18%, 2/11) than in the observational group (65%, 15/23) (p = 0.02). Systematic intermittent bladder catheterization immediately postpartum could decrease cPUR. Further studies are necessary to assess the long-term outcomes and improve understanding of postpartum voiding dysfunction.

Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults

BACKGROUND

Indwelling urethral catheters are often used for bladder drainage in hospital. Urinary tract infection is the most common hospital-acquired infection, and a common complication of urinary catheterisation. Pain, ease of use and quality of life are important to consider, as well as formal economic analysis. Suprapubic catheterisation can also result in bowel perforation and death.

OBJECTIVES

To determine the advantages and disadvantages of alternative routes of short-term bladder catheterisation in adults in terms of infection, adverse events, replacement, duration of use, participant satisfaction and cost effectiveness. For the purpose of this review, we define 'short-term' as intended duration of catheterisation for 14 days or less.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 26 February 2015), CINAHL (searched 27 January 2015) and the reference lists of relevant articles.

SELECTION CRITERIA

We included all randomised and quasi-randomised trials comparing different routes of catheterisation for short-term use in hospitalised adults.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and performed 'Risk of bias' assessment of the included trials. We sought clarification from the trialists if further information was required.

MAIN RESULTS

In this systematic review, we included 42 trials.Twenty-five trials compared indwelling urethral and suprapubic catheterisation. There was insufficient evidence for symptomatic urinary tract infection (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.61 to 1.69; 5 trials, 575 participants; very low-quality evidence). Participants with indwelling catheters had more cases of asymptomatic bacteriuria (RR 2.25, 95% CI 1.63 to 3.10; 19 trials, 1894 participants; very low quality evidence) and more participants reported pain (RR 5.62, 95% CI 3.31 to 9.55; 4 trials, 535 participants; low-quality evidence). Duration of catheterisation was shorter in the indwelling urethral catheter group (MD -1.73, 95% CI -2.42 to -1.05; 2 trials, 274 participants).Fourteen trials compared indwelling urethral catheterisation with intermittent catheterisation. Two trials had data for symptomatic UTI which were suitable for meta-analysis. Due to evidence of significant clinical and statistical heterogeneity, we did not pool the results, which were inconclusive and the quality of evidence was very low. The main source of heterogeneity was the reason for hospitalisation as Hakvoort and colleagues recruited participants undergoing urogenital surgery; whereas in the trial conducted by Tang and colleagues elderly women in geriatric rehabilitation ward were recruited. The evidence was also inconclusive for asymptomatic bacteriuria (RR 1.04; 95% CI 0.85 to 1.28; 13 trials, 1333 participants; very low quality evidence). Almost three times as many people developed acute urinary retention with the intermittent catheter (16% with urethral versus 45% with intermittent); RR 0.45, 95% CI 0.22 to 0.91; 4 trials, 384 participants.Three trials compared intermittent catheterisation with suprapubic catheterisation, with only female participants. The evidence was inconclusive for symptomatic urinary tract infection, asymptomatic bacteriuria, pain or cost.None of the trials reported the following critical outcomes: quality of life; ease of use, and cost utility analysis.

AUTHORS' CONCLUSIONS

Suprapubic catheters reduced the number of participants with asymptomatic bacteriuria, recatheterisation and pain compared with indwelling urethral. The evidence for symptomatic urinary tract infection was inconclusive.For indwelling versus intermittent urethral catheterisation, the evidence was inconclusive for symptomatic urinary tract infection and asymptomatic bacteriuria. No trials reported pain.The evidence was inconclusive for suprapubic versus intermittent urethral catheterisation. Trials should use a standardised definition for symptomatic urinary tract infection. Further adequately-powered trials comparing all catheters are required, particularly suprapubic and intermittent urethral catheterisation.

Identifying and applying a targeted evidence-based practice change in the maternal/child health inpatient setting

As the literature on implementation research continues to expand, it's important to address the unique aspects and challenges of research dissemination and implementation in maternal/child health settings. This article describes a nurse-initiated evidence-based practice (EBP) study on urinary catheterization at a labor and delivery unit in the southwestern United States. It describes successful strategies for implementing EBP, as well as barriers encountered, and provides recommendations for the facilitation of EBP in the maternal/child inpatient setting.

[Evaluation of urine postvoid residuals in post-partum period: a prospective and descriptive clinical study]

INTRODUCTION

Few studies have evaluated urine postvoid residuals (PVRs) and their risk factors during the post-partum (PP) period. The aim of this prospective study was to screen postvoid residuals in a cohort of patients in PP, and to identify the risk factors.

MATERIALS AND METHODS

For three months, patients in PP were given an evaluation of their PVR (ultrasounds method) after a spontaneous urination. Clinical data as regards delivery were collected.

RESULTS

One hundred and sixty-eight patients were included. Among them, 61% had a urine volume at the first urination over 500 mL, and 52% presented with a pathological PVR (PVR over 150 mL for a urine volume over 150 mL). The median PVR was 153.50 mL. The median volume of the first spontaneous urination was 400 mL. Among patients with a pathological PVR, the total duration of the labor and the duration of its second phase were significantly longer (P=0.003 and P<0.05, respectively), and the volume of the first urination was higher. Indwelling catheterization during the delivery decreased the volume of the first spontaneous urination (volume over 500 mL in 28% vs 72% of patients, P=0.017) but was not associated with a decreased PVR in non-pathological deliveries. Instrumental deliveries were associated with higher PVRs than caesarean or physiological deliveries (244 mL, 180 mL et 156 mL; P=0.033). A bacteriuria was not significantly associated with PVR (54% vs 49%, P>0.05).

CONCLUSION

We were able to identify risk factors for PVR in the PP, such as the duration of labor, instrumental delivery and elevated volume of the first urination after delivery.

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.

Impact on caesarean section rates following injections of sterile water (ICARIS): a multicentre randomised controlled trial

BACKGROUND

Sterile water injections have been used as an effective intervention for the management of back pain during labour. The objective of the current research is to determine if sterile water injections, as an intervention for back pain in labour, will reduce the intrapartum caesarean section rate.

METHODS/DESIGN

DESIGN

A double blind randomised placebo controlled trialSetting: Maternity hospitals in AustraliaParticipants: 1866 women in labour, ≥18 years of age who have a singleton pregnancy with a fetus in a cephalic presentation at term (between 37 + 0 and 41 + 6 weeks gestation), who assess their back pain as equal to or greater than seven on a visual analogue scale when requesting analgesia and able to provide informed consent.

INTERVENTION

Participants will be randomised to receive either 0.1 to 0.3 millilitres of sterile water or a normal saline placebo via four intradermal injections into four anatomical points surrounding the Michaelis' rhomboid over the sacral area. Two injections will be administered over the posterior superior iliac spine (PSIS) and the remaining two at two centimetres posterior, and one centimetre medial to the PSIS respectively.

MAIN OUTCOME MEASURE

Proportion of women who have a caesarean section in labour.Randomisation: Permuted blocks stratified by research site.Blinding (masking):Double-blind trial in which participants, clinicians and research staff blinded to group assignment.

FUNDING

Funded by the National Health and Medical Research CouncilTrial registration:Australian New Zealand Clinical Trials Registry (No ACTRN12611000221954).

DISCUSSION

Sterile water injections, which may have a positive effect on reducing the CS rate, have been shown to be a safe and simple analgesic suitable for most maternity settings. A procedure that could reduce intervention rates without adversely affecting safety for mother and baby would benefit Australian families and taxpayers and would reduce requirements for maternal operating theatre time. Results will have external validity, as the technique may be easily applied to maternity populations outside Australia. In summary, the results of this trial will contribute High level evidence on the impact of SWI on intrapartum CS rates and provide evidence of the analgesic effect of SWI on back pain.

Rates of bacteriuria in laboring women with epidural analgesia: continuous vs intermittent bladder catheterization

OBJECTIVE

The purpose of this study was to compare the rates of bacteriuria in laboring women with epidural analgesia with the use of intermittent bladder catheterization (IC) vs continuous indwelling Foley catheterization (CIF).

STUDY DESIGN

We conducted a randomized, nonblinded trial in which 160 laboring women received IC or CIF. An initial catheterized urine culture was taken at the time of epidural placement. A second catheterized or voided culture was taken at discharge. Results were analyzed to compare bacteriuria rates between CIF and IC with the use of the Center for Disease Control (CDC) and Infectious Disease Society of America (IDSA) definitions.

RESULTS

Samples from 146 women were analyzed. Randomization, demographics, and labor characteristics were not significantly different between groups; 5.48% of the samples met CDC criteria for bacteriuria, and 17.8% of the samples met IDSA criteria. In the IC group, 7 samples (8.9%) met CDC criteria for bacteriuria, and 18 samples (22.8%) met IDSA criteria for bacteriuria. In the CIF group, 1 sample (1.5%) met CDC criteria, and 8 samples (12.1%) met IDSA criteria. There was a significantly higher rate of bacteriuria by both criteria in the IC group among all deliveries, all vaginal deliveries, and spontaneous vaginal deliveries (P < .05).

CONCLUSION

Compared with CIF, IC was associated with significantly higher rates of bacteriuria.