European Journal of Cardiovascular Medicine

In the immediate postpartum period  the most common problem was the voiding difficulty and it is known as Postpartum urinary  retention (PPUR).Based  on literatures  the incidence of  PPUR ranges from 0.05% to 37%(1).The postpartum urinary retention was classified as Overt retention and covert retention by Yip et al (2).The  inability to void in presence of signs and symptoms of urinary retention is known as Overt retention. Women without any retention and having a post voidal  residual bladder volume of  >150 ml  on catheterization or ultrasound screening is known as Covert retention. Nulliparity , perineal trauma, regional anesthesia, prolonged labour,  instrumental delivery and physiological changes during pregnancy are  causes of postpartum urinary retention.

Bladder dysfunction , catheter related complications and urinary tract infection are  the most common  complications encountered when the PPUR is not managed properly or when diagnosing it is late(3).As  per RCOG Incontinence in  Women study  group   it recommends that every women have to void within 6 hours post-delivery period. WHO technical consultation on postpartum and postnatal care  and NICE guidelines on postnatal care have recommended to measure the  bladder volume is there is no voiding within 6 hours of birth and  voiding struggle is not successful(4)

Aims Of the Study

• To detect the incidence of post partum urinary retention, (covert and overt), after vaginal delivery.

To determine the obstetric risk factors contributing to post partum urinary retention

Study setting

This study was conducted in the department of Obstetrics and gynaecology between March 2023 and February 2024.

Study Design:Prospective cross sectional study.

Inclusion Criteria:

• Patients who had normal vaginal delivery.
• Patients who had instrumental delivery.(Forceps and vaccum).

Exclusion criteria

• Caesarean delivery
• Patients with indwelling catheterization during labour.
• Patients with indwelling catheterization after delivery for reasons other than acute urinary retention.
• Unwilling to participate.

Sample Size – Based on the  inclusion and the exclusion criteria the study participants  were recruited for the study.The final sample size delivered was 100.

After obtaining the Institutional Ethical Committee clearance, the study was done among all patients who delivered vaginally. An informed consent was obtained from each patient. After vaginal (normal or instrumental) delivery the patients were kept in the labour ward till they voided spontaneously. All the recruited patients underwent a transabdominal scan to estimate post void residual bladder volume, within 15 minutes of voidiThe demographic data like age of the patient, parity were obtained.The post void residual bladder volume was estimated by measuring the three diameters of the bladder and calculated using the formula for approximation of the ellipsoid .Volume = (pie xD1 xD2 xD3 ) / 6.All patients who had post void residual bladder volume ≥ 150 ml were diagnosed to have post partum urinary retention.

If the patients did not void spontaneously after vaginal delivery, they were Encouraged for early ambulation, take a warm bath, listen to running water, or place hands in cold water .If they were still unable to void after 6 hours of vaginal delivery, a continuous bladder drainage catheter was inserted and kept in situ for 24 hours. The patients were then shifted to the post natal wards. All patients who had post void residual bladder volume > 150 ml were rescanned after the second void to check for post void residual volume.If the patients developed symptomatic urinary retention in the ward, they were catherised for 24 hours. After catheter removal, these patients were rescanned after voiding to check their post void bladder volume.All patients with overt retention were contacted after 3 months to look for post void residual volume by ultrasound and for subjective assessment of symptoms like frequency, urgency, poor flow, hesitancy, stress incontinence or urge incontinence.

Having compiled the obstetric data, analysis was done to compare the patients with and without post partum urinary retention, in terms of patient characteristics, obstetric parameters, including age, parity, perineal trauma, episiotomy ,mode of delivery, fetal birth weight, epidural analgesia, duration of labour in minutes.Area under the ROC curve was estimated using duration of labour, and to choose an optimal cutoff point for diagnosis of post partum urinary retention.. A p value < 0.05 was considered statistically significant .

FIGURE 1: INCIDENCE OF POSTPARTUM URINARY RETENTION

The overall incidence of post partum urinary retention was found to be 12%

TABLE 2 COVERT AND OVERT POST PARTUM URINARY RETENTION

Of the 100 women in the study 9% of patients had covert urinary retention  while 3% of women were diagnosed to have overt retention  .

TABLE 3. COMPARISON OF VARIOUS OBSTETRIC CHARACTERISTICS BETWEEN THE PATIENTS WITH POST PARTUM URINARY RETENTION AND THE PATIENTS WITHOUT POST PARTUM URINARY RETENTION.

Increased birth weight of the babies ,assisted  delivery, prolonged duration of labour ,birth canal injury was found to be significantly associated with postpartum urinary  retention of urine .

Figure 2: Duration of labour

The area under the curve was found to be 0.825 (95% CI, 0.736- 0.894), with p = 0.0001. When 320 minutes was used as the optimum cut off for duration of labour, the specificity of the test was 61.36%, sensitivity of 100%. The likelihood ratio for positive test is 2.59.It is found that as the duration of labour  increases ,the sensitivity decreases and the specificity decreases.

The area under the curve using birth weight was 0.743 with 95% confidence interval (0.646-0.825) with p =0.0016. The table shows a range of cutoff values with a specificity ranging from 36.36 %to 100 % for the fetal  birth weight.When a cut off of 3245 gms was used ,the specificity of the test was 73.86% and sensitivity was 66.67%.The likelihood ratio for a positive  test was 2.55 and the likelihood ratio for a negative test was  0.45 . It is found that as the birth weight increases ,the sensitivity of the test decreases and the specificity increases.

FOLLOW UP

The nine patients with covert urinary retention were followed up with a second post void bladder volume estimation by ultrasound .No one had post void volume of > / = 150ml. At discharge, no one  had any symptoms of bladder dysfunction.There were three patients who had overt retention. The ultrasound first post void bladder volume for these patients were 1200 ml,1000 and 750ml respectively. Both these patients were catheterised for 24 hours. After catheter removal the patients were rescanned after their first void. Their post void residual bladder volumes were 52ml,45ml and 33ml respectively.  Then these patients were advised for follow up after 3 months.They were contacted through phone and enquired about the urinary symptoms. None of them had  symptoms of frequency, hesitancy, urgency, stress incontinence, poor flow, or incomplete voiding.

Post partum urinary retention occurs in significant number of women,and it can cause permanent damage to the bladder detrusor muscle and long term complications if left untreated.PPUR goes undetected as most of the patients are asymptomatic.  .In  our study ,the overall incidence of post partum urinary retention was found to be 12% . The incidence of covert retention is 9% which is much more than that of overt retention which is 3%. In studies done by Buchanan J  et al (5)and  Carley ME et al (6) the incidence of  the PPUR was ranging from 0.05% to 37%.

The mean age of the study participants in  our study in group with PUR was 23.5 and group without PUR was 25.09.Similarly in Agrawal et al (7)study the mean age was found to be28.67 in  No PUR and 28.11 in PUR group  and it is not statistically significant. In our study Primipara was found more in  PUR group than in No PUR group  but the difference is not statistically significant. Similar results was also seen in Carley ME et al (6) study and Liang et al study but the difference was statistically significant.

Assisted deliveries in our study was found in PUR group compared to other group. Similar results was also observed in Carley ME  et al (6) where 47.1% have assisted deliveries compared to control group  12.4% and the difference is statistically significant.

In our study Increased birth weight of the babies ,assisted  delivery, prolonged duration of labour ,birth canal injury was found to be significantly associated with postpartum urinary  retention of urine . In Agrawal et al study (7)the mean birth weight,perineal laceration  ,episiotomy are found to have associated with PPUR

In our study the area under the curve was found to be 0.825 (95% CI, 0.736- 0.894), with p = 0.0001. When 320 minutes was used as the optimum cut off for duration of labour, the specificity of the test was 61.36%, sensitivity of 100%. The likelihood ratio for positive test is 2.59.It is found that as the duration of labour  increases ,the sensitivity decreases and the specificity decreases.In Yip et al(8) study where an optimal cutoff of 700 min, for the duration of labour was used, area under the curve ROC was 0.63, (95% CI 0.57-0.69), which gave a specificity of 95%, sensitivity 15%, Negative Predictive Value of 86%,Likelihood ratio of negative test of 88%, Likelihood ratio for positive test was 4.9% .The sensitivity ,Positive Predictive Value, Likelihood Ratio for Positive Test could not be raised without compromise to specificity.In agrawal et al study (7)duration of labour was used to plot an ROC curve and the AUC ROC was used to predict post partum urinary retention. The area under the curve was found to be 0.825 (95% CI, 0.736- 0.894), with p = 0.0001. When 320 minutes was used as the optimum cut off for duration of labour,thespecificity of the test was 61.36%, sensitivity of 100%.

Our study concluded that the  overall incidence of post partum urinary retention was 12%. .Overt retention was 3% and Covert retention 9%.Duration of labour ,Women with assisted delivery ,Women who had birth canal injury and birth weight of the baby was significantly associated with post partum urinary retention.

Contributions: All authors contributed to this journal

Funding: Nil

Conflict of Interest: Nil

Acknowledgement:

The authors like to thank the Dean and Head of the Department of Obstetrics and Gynaecology for helping and guiding in completing this research.

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