POSTPARTUM URINARY

RETENTION (PUR)
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
RSU DOKTER SOEDARSO PONTIANAK
2014
Presented By : Tri Catur Sari (I11111048)

Dr. Manuel Hutapea, sp.OG (K) Onk

1. http://www.rnceus.com/uro/norm2.htm
Anatomic Changes During Pregnancy
The primary change enlargement and dilation of
the kidneys and urinary collecting system
2
The kidneys lengthen by approximately 1 cm during
pregnancy as a result of greater interstitial volume as
well as distended renal vasculature
2

The renal calyces, pelves, and ureters dilate during
pregnancy because of mechanical and hormonal
factors
2

2. Beckmann CRB, Ling FW, Herbert WNP, Laube DW, Smith RP, Casanova R, Chuang A, Goepfert AR, Hueppchen NA, Weiss PM. Obstetrics and Gynecology. 7
th
Revised
Edition. Philadhelphia: Wolter Kluwer Lippincott Williams and Wilkins; 2014.
Mechanical compression of the ureters occurs as the
uterus enlarges and rests on the pelvic brim.
Compression of the bladder by the enlarged uterus
results in urinary frequency
2

Progesterone causes relaxation of the smooth
muscle of the ureters and decreases bladder tone, so
the residual volume is increased. As the uterus
enlarges as pregnancy progresses, bladder capacity
decreases
2

2. Beckmann CRB, Ling FW, Herbert WNP, Laube DW, Smith RP, Casanova R, Chuang A, Goepfert AR, Hueppchen NA, Weiss PM. Obstetrics and Gynecology. 7
th
Revised
Edition. Philadhelphia: Wolter Kluwer Lippincott Williams and Wilkins; 2014.
3. Lowdermilk DL. Perry SE. Maternity Nursing. 7
th
Edition. United State of America: Mosby Elsevier Incorporation; 2006. h. 208-230
General Terminology
Urinary retention Complaint of the inability to
pass urine despite persistent effort
4
Urinary Retention :
5
1. Acute Urinary Retention (generally) as a painful,
palpable, or percussable bladder with the patient
unable to pass any urine
2. Chronic Urinary Retention Non-painful bladder ,
which remains palpable or percussable after the
patient has passed urine
4. Haylen BT, de ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, Monga A, Petri E, Rizk DE, Sand PK, Schaer GN. An International Urogynecological Association
(IUGA)/International Incontinence Society (ICS) Joint Report on the Terminology for Female Pelvic Floor Dysfunction. Journal of the Association of Chartered Physiotherapists
in Womans Health 2012; 110: 33-57.
5. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function:
Report from the Standardisation sub-Committee of the International Continence Society. Neurology and Urodynamics 2002; 21: 167-178.

Postpartum Urinary Retention
Absence of spontaneous micturition within 6 hours
of vaginal delivery; in case of Caesarian Section it is
defined as no spontaneous micturition within 6
hours after the removal of an in dwelling catheter
(>24 hours after delivery)
6
The incidence of PUR after vaginal delivery is 10.9%,
and after Caesarian delivery is 24.1%
7,8

6. Saultz JW, Toffler WL, Shackles JY. Postpartum Urinary Retention. The Journal of the American Board of Family Practice/American Board of Family Practice 1991; 4 (5): 341-
344.
7. Kekre AN, Vijayanand S, Dasgupta R, Kekre N. Postpartum Urinary Retention after Vaginal Delivery. International Journal of Gynecology and Obstetrics 2011; 112: 112-115.
8. Liang CC, Chang SD, Chang YL, Chen SH. Postpartum Urnary Retention after Cesarean Delivery. International Journal of Gynecology and Obstetrics 2007; 99: 229-232.
Risk Factors
Risk Factors of PUR :
7-10

Parity

Prolonged labour

Assisted/instrumental delivery


Perineal injury

Caesarean section

Epidural and regional anaesthesia

7. Kekre AN, Vijayanand S, Dasgupta R, Kekre N. Postpartum Urinary Retention after Vaginal Delivery. International Journal of Gynecology and Obstetrics 2011; 112: 112-115.
8. Liang CC, Chang SD, Chang YL, Chen SH. Postpartum Urnary Retention after Cesarean Delivery. International Journal of Gynecology and Obstetrics 2007; 99: 229-232.
9. Mulder FEM, Schoffelmeer MA, Hakvoort RA, Limpens J, Mol BWJ, van der Post JAM, Roovers JPWR. Risk Factors for Postpartum Urinary Retention: A Systematic Review
and meta-Analysis. BJOG: An International Journal of Obstetrics and Gynecology 2012; 119: 1440-1446.
10. Musselwhite KL, Faris P, Moore K, Berci D, King KM. Use of Epidural Anesthesia and the Risk of Acute Postpartum Urinary Retention. American Journal of Obstetrics and
Gynecology 2007; 196: 472.e1-472.e5.

Types of PUR
- Overt retention The inability to pass urine within 6
hours of birth thus requiring catheterization, in
which volumes greater than normal bladder capacity
(400-600mL) are drained from the bladder
11
- Covert retention The women is able to void
however fails to empty at least 50% of her normal
bladder capacity, or a post void residual volume of
greater than 150mL
11

11. The Royal Womens Hospital. Policy, Guideline, and Procedure Manual Bladder Management - Intrapartum and Postpartum. Melbourne; 2013.
The Aim of Bladder Training
The aim :
11

1. Decrease the time to go to the toilet
2. Increase the amount of urine that pass each time
3. Hold on for longer or put off emptying bladder

Postpartum Warning Sign
All women who unable to pass urine 6 hours
following delivery and women who are symptomatic
of voiding dysfunction
12
11. The Royal Womens Hospital. Policy, Guideline, and Procedure Manual Bladder Management - Intrapartum and Postpartum. Melbourne; 2013.
12. Kearney AR, Cutner A. Review Postpartum Voiding Dysfunction. The Obstetricians and Gynecologist 2008; 10: 71-74.
Prevention
In labour
11
1. Encourage woman to void every 2 hours
2. If the patient unable to void in 2 occasions,
catheterization threshold should be low, but if the
bladder palpable and the patient cant void insert the
catheter immediately
3. Soft catheter is preferable (balloons filled with 5ml
sterile water), if the women doesnt have an epidural
and catheterization, the purpose merely for emptying
the bladder and in/out catheter should be considered
Postpartum
11

Urine volumes of >100 mL should be voided 3x/24hours


11. The Royal Womens Hospital. Policy, Guideline, and Procedure Manual Bladder Management - Intrapartum and Postpartum. Melbourne; 2013.
Management
Management of PUR :
11

ALGORITHM
11. The Royal Womens Hospital. Policy, Guideline, and Procedure Manual Bladder Management - Intrapartum and Postpartum. Melbourne; 2013.