The physiological processes of pregnancy and birth involve dramatic changes in the urogenital system, impacting women's bladder health in both the short and long term, and influencing psychological wellbeing (Fritel et al, 2016). The midwife's role involves working alongside women in a trusting, supportive capacity. This uniquely places midwives to engage in meaningful discussions with women about their individual bladder function as part of the development of a trusting midwife–woman dynamic (Strahle and Stainton, 2006). In order to provide a high standard of care, competent skills should be used alongside the best available evidence (Page and McCandlish, 2006; Page, 2008) and midwives should discuss bladder health with sensitivity, acknowledging that matters including stress incontinence, voiding issues, urinary tract infections (UTIs) and pelvic floor dysfunction may be sensitive subjects for women to divulge.
Inadequate knowledge and misinterpretation of women's bladder condition has lasting ramifications not only for the woman's future health and quality of life, but for the NHS. The NHS Litigation Authority (2012) reported 72 bladder claims (not surgically implicated) resulting in £8 824 269 worth of claims from March 2000 to March 2010. Ensuring solid educational foundations and ongoing midwifery expertise in bladder health throughout the childbearing continuum can protect against bladder compromise and mitigate the risk of litigation. However, a suggested decline in these essential skills (Walsh, 2007) and wide disparity in Trust guidance, as well as a dearth of evidence, means midwives may face challenges in providing optimal care across the antenatal, intrapartum and postnatal periods (Doyle and Birch, 2011).
Underpinning physiology of bladder function
To be able to provide holistic care and educate women about bladder health, it is essential for midwives to be knowledgeable about the anatomy and physiology of the urinary tract, recognising the physiological changes that this system undergoes during pregnancy.
The bladder is a muscular organ situated in the anterior part of the pelvis below the uterus, supported in place by the pelvic floor (Doyle and Birch, 2011). Due to displacement by the gravid uterus in later stages of pregnancy, the bladder becomes palpable when full at the symphysis pubis (Richens, 2016). The bladder is connected to the kidneys by two ureters, which transport urine and pass close to the cervix as they enter the bladder (Doyle and Birch, 2011; Velinor, 2015). The urethra is a muscular tube of 3–5 cm in length, which carries urine from the bladder to be voided in the vestibule of the vulva (Doyle and Birch, 2011).
The production of urine is governed by the hypothalamus, which detects serum osmolality and subsequently affects the production of anti-diuretic hormone (ADH) by the posterior pituitary gland in order to achieve homeostasis (Doyle and Birch, 2011). To pass urine, the valve around the urethra relaxes and bladder muscles contract to increase pressure in the bladder, enabling urine to flow down to the urethra. Stretch receptors in the bladder provide an urge to void and, if ignored, the signal will increase in intensity and discomfort, until reflex voiding takes place to protect the bladder from over-distension (Cheung and Lafayette, 2013).
Significant physiological changes in pregnancy occur in the urinary system, due to an increase in circulating hormones and the gravid uterus displacing internal organs (Wylie and Bryce, 2008).
Glomerular filtration rate increases and ADH levels are reduced, resulting in lower osmolality. Blood flow through the kidneys increases and the kidneys themselves increase in length and volume, with dilation of the renal pelvis and ureters being common (hydronephrosis and hydroureter) (Cheung and Lafayette, 2013). Alterations in ureteric tone and peristalsis combined with the relaxant effect of progesterone can lead to incomplete bladder emptying and dilatation of the ureters (Wylie and Bryce, 2008). These changes lead to increased urinary stasis (Oats and Abraham, 2010), compromised ureteric valves and pregnancy-induced vesicouteral reflux, resulting in partial ureteric obstruction (Cadnapaphornchai et al, 2003; Cunningham, 2010).
Due to the shortness of the urethra, and its proximity to the vagina and anus, it is easy for infection to be introduced. Uropathogens are often from the perineal flora, and around 10% of women have perineal colonisation of Escherichia coli (Cunningham, 2010), reported to be the invading organism in around 80–90% of cases of pyelonephritis (Ramakrishnan and Scheid, 2005; McCormick et al, 2008). UTIs frequently occur in pregnancy and are the most common health-care-acquired infection (Loveday et al, 2014). Although seemingly innocuous, when left untreated they can ascend the urinary tract causing severe upper UTIs, such as pyelonephritis. Pyelonephritis can cause significant morbidity to both the woman and baby, and if unrecognised and untreated may be fatal (Billington and Hempinstall, 2007; Cantwell et al, 2011; Meads, 2011; Knight et al, 2015).
Establishing antenatal wellbeing
Underpinning knowledge of physiology enables midwives to engage in discussions with women about bladder function and wellbeing, and to recognise when deviations occur from the normal physiological process (Strahle and Stainton, 2006). As frontline practitioners, midwives are in a position to provide preventive interventions to minimise the risk of UTI development and protect wellbeing (Wylie and Bryce, 2008). Education should include discussing perineal hygiene, and ensuring women are aware of the significance of wiping front to back and passing urine after sexual intercourse. Women should be encouraged to ensure adequate fluid intake and eat a well-balanced diet (Weiner and Adamec, 2012). The National Institute for Health and Care Excellence (NICE, 2008) suggests that all women should routinely be screened for asymptomatic bacteriuria in pregnancy via a midstream urine sample, and midwives should carry out routine urinalysis at each antenatal appointment.
The frequent occurrence of UTI in pregnancy highlights the necessity of confident midwifery recognition, assessing the spread and severity and ensuring swift treatment is made to prevent deterioration. It is likely that women with ascending UTIs will feel so unwell they will seek medical attention, presenting in hospital or being referred to hospital by their GP. However, midwives should be prepared that women may present at a routine midwife appointment. Signs and symptoms of UTIs include dysuria, increased urinary frequency and abdominal pain. Women presenting with ascending UTIs are usually very unwell (Box 1).
| Signs and symptoms include: |
| General malaise |
| Nausea and vomiting |
| Pyrexia |
| Loin and flank pain |
| Anorexia |
| Chills |
| Rigors |
| Flank pain |
| Postural hypotension |
Taking a thorough clinical history is vital to recognise the infection, and baseline observations should be taken and documented (Mitchell, 2010) to ensure that pyrexia, hypothermia, tachycardia and tachypnoea associated with infection are quickly recognised (Loveday et al, 2014). The midwife should use a holistic approach and be aware of the woman guarding her abdomen or appearing to be in discomfort. During routine urinalysis, cloudiness and odour may indicate infection alongside leucocytes and nitrites, and the presence of proteinuria and haematuria may suggest ineffective glomerular filtration (Wylie and Bryce, 2008; Loveday et al, 2014). Sending off a midstream sample of urine is important to ensure accurate diagnosis and correct antibiotic usage, ensuring that a sterile sample is accurately obtained (Box 2).
| Provide the woman with a labelled sterile container with patient identifiers clearly documented |
| Advise the woman to wash her hands, showing appropriate technique if necessary |
| Inform the woman that the area surrounding the urethra needs to be clean to eliminate bacteria or contamination, and provide guidance as required |
| Advise the woman to begin to urinate, not collecting the first portion of urine voided |
| Ensure the woman collects midstream sample in a sterile screw-top container |
| The woman should then void the remaining portion of urine without collecting this |
| Ensure the container is securely closed and wash hands thoroughly |
| Send the sample to appropriate department as per local Trust policy |
| Ensure results are followed up, appropriately acted on, and communicated to the correct health professionals |
Although UTIs often self-resolve, if UTI in pregnancy is suspected, referral to the prescribing practitioner is indicated to ensure correct treatment. If an ascending UTI or systemic infection is suspected, swift referral to hospital for obstetric review is indicated (NICE, 2014). Ongoing care should involve close observation for further UTIs or for worsening of symptoms.
Bladder safeguarding during intrapartum care
Childbirth is a known contributing factor for bladder disorders (Birch et al, 2009), but with wide variation of advised frequency for micturition during labour it is challenging for midwives to practise from an evidence-based rationale. NICE (2014) recommends that, at first contact in labour, midwives should conduct urinalysis as part of a holistic clinical assessment, ensuring an individualised risk assessment is performed. During labour women tend to void less frequently (Charles, 2013) due to various factors, including hormonal changes (Doyle and Birch, 2011) further influenced by a tendency to eat and drink less often. Women should be reassured that a light diet in established labour is supported by national guidance, unless risk factors develop increasing chances of anaesthesia, or opioid pain management strategies are accessed (Charles, 2013; NICE, 2014). Women should also be encouraged to ensure good fluid intake, with midwives advising women to include isotonic drinks that may have further benefit than water (NICE, 2014) to aid the physical effort of labour, as water loss increases through additional sweating and breathing (Doyle and Birch, 2011).
There is scant evidence regarding the optimum frequency of intrapartum voiding, with national guidance recommending midwives monitor urination throughout first and second stages (NICE, 2014) with a 4-hourly frequency suggested as appropriate (Kearney and Cutner, 2008). Urinary output in second stage may be reduced (Doyle and Birch, 2011; Charles, 2013), partly due to the antidiuretic mechanism that oxytocin plays in labour, reducing levels of water excretion (Blackburn, 2013) increased with the presence of oxytocin augmentation.
Birch et al's (2009) findings suggest that women who commence second stage of labour having not emptied their bladder for longer than 4 hours are disposed to a 1.94 increase in incidence of ‘any’ type of postnatal incontinence, and 2.36 times more likely to report stress incontinence a year postnatally, regardless of mode of birth. In low-risk labour, women often self-regulate and void spontaneously, particularly in the early stages, but often need prompting as labour becomes established, making bladder palpation a midwifery skill of utmost importance (Walsh, 2012). Accurately monitoring fluid balance and encouraging regular voiding may be made more challenging if women are accessing birthing pools in the intrapartum period. Midwives should encourage regular voiding, while maintaining individualised woman-centred care and respecting maternal choice.
The palpable bladder can be felt above the pelvic brim (Velinor, 2015), and can inhibit the descent of the fetus, contributing to slower progress throughout labour, and possible dystocia if not resolved. A bladder felt on palpation can displace the uterus, indicating the need for bladder emptying and consideration of catheterisation. Midwives should pay close attention to these signs, as well as voiding frequency, to ensure that labour can progress unencumbered. However, it is important to note that as the fetus descends the presenting part may displace the bladder, forcing it upwards and enabling it to become palpable without it being full (Doyle and Birch, 2011); therefore, close fluid balance monitoring is required to determine whether catheterisation is clinically indicated or reduced urination is a normal physiological part of the labour process. Environment can have an impact on voiding frequency as women often birth in unfamiliar surroundings; this is compounded by what Walsh (2007) describes as the medicalisation of bladder care, particularly in the obstetric setting. Walsh (2007) proposes that because bladder compromise may be missed in the puerperium, an imposing medicalised model of bladder care is practised, underestimating midwifery capabilities and deskilling bladder palpation practices.
Known factors contributing to bladder dysfunction and, therefore, longer-term bladder health include body mass index (BMI), maternal age (Buchanan and Beckmann, 2014), parity (Birch et al, 2009) and women's birth experiences. Specific intrapartum occurrences have further impact, including prolonged first and second stages (Kearney and Cutner, 2008; Chaurasia and Tyagi, 2013), epidural analgesia (Weiniger et al, 2009; Chaurasia and Tyagi, 2013; Velinor, 2015) guided pushing efforts (Roberts and Hanson, 2007), instrumental birth (Chaurasia and Tyagi, 2013) and fetal weight (Cavkaytar et al, 2014).
The presence of epidural analgesia significantly affects bladder care, increasing incidence of catheterisation as women lose the indicators to spontaneously void, as bladder nerves become anaesthetised, and communication between the bladder and the pontine micturition centre is impaired (Teo et al, 2007), inhibiting normal micturition (Lim, 2010). This is further compounded by limited mobility, with an increase in postpartum residual volume found in women who have regional analgesia (Evron et al, 2008; Weiniger et al, 2009). Evidence shows that epidural can prolong labour stages (Anim-Somuah et al, 2011; Sanders and Lamb, 2014) and increases the chance of instrumental birth, in turn creating pelvic floor trauma, pudendal nerve damage and perineal oedema resulting in mechanical obstruction and bladder motility problems following birth (Lim, 2010; Millet et al, 2012). Birth weight in excess of 3.8 kg also increases the chance of bladder complications arising from birth, which cannot be helped, but a woman-centred midwifery approach to pushing may avoid long-term urodynamic issues. Women who are guided through pushing efforts are shown to have decreased bladder capacity and lessened urge to void initially after birth (Roberts and Hanson, 2007). If the integrity of pelvic floor structures becomes compromised this can cause lower urinary tract damage, contributing to stress incontinence (Chaliha, 2006; Herbert, 2009; Blackmoore, 2015). Midwives should strive to support women's self-guidance through the expulsive efforts of second stage, being mindful of bladder implications.
Midwifery reminders during labour to void frequently may be useful for additional reasons, not just bladder health. Frequent urination offers opportunities for changes of position, moments of privacy, and mobilisation, particularly relevant during instances of continuous fetal monitoring.
Considerations for postnatal health
Postnatal urinary retention (PUR) presents in 0.05–37% of women—the wide variation in incidence results from a range of definitions—and is widely considered to be multifactorial in nature (Lim, 2010; Chaurasia and Tyagi, 2013; Cavkaytar et al, 2014). PUR is generally considered to be a lack of spontaneous voiding following vaginal birth or removal of an indwelling catheter (Buchanan and Beckmann, 2014). Though often transient in nature, if not properly recognised PUR can lead to recurrent UTIs, upper urinary tract damage and permanent bladder and voiding dysfunction (Humburg et al, 2011). With the potential for severe long-term impact on women's physical and psychological wellbeing, PUR should be considered a public health and risk management issue (Zaki et al, 2004; Fritel et al, 2016). An increase of bladder pressure in late pregnancy, intrapartum pelvic floor damage, postnatal hypertonia and over-distension can contribute to PUR, causing long-term difficulties (Foon et al, 2010). It is also important to note that increased oxytocin levels following birth further decrease water excretion (Blackburn, 2013).
With national guidance recommending the promotion of successful bladder voiding in the immediate postnatal period, midwives must closely monitor output for the first 6 hours following birth (MacLean and Cardozo, 2002; NICE, 2006). If voiding has not been achieved, swift recognition and action is vital, requiring competent bladder palpation skills to determine whether transfer to an obstetric-led approach with subsequent medical management is indicated (NICE, 2006). Midwives can be instrumental in holistic approaches to encourage postnatal voiding, ensuring women are comfortable with correct levels of analgesia to aid relaxation and allow spontaneous micturition to take place. Abdominal palpation to evaluate uterine involution should also assess whether the uterus is displaced, felt above the umbilicus or set off to one side—another indicator that PUR may have occurred. There may be additional bleeding if the bladder remains full, impeding uterine ability to contract following birth, increasing chances of postpartum haemorrhage (Bick et al, 2008). Practices used to encourage urination include:
If these simple measures are taken prior to considering catheterisation, voiding can be achieved in 50% of cases (Ching-Chung et al, 2002; Yip et al, 2004; Saultz et al, 2008).
In the absence of consensus on what constitutes problematic residual bladder volume, it has been suggested that a volume of ≥ 150–200 ml constitutes PUR (the normal female bladder holds 600–800 ml) (Shah and Dasgupta, 1999; Buchanan and Beckmann, 2014). With the wide disparity in postnatal bladder care, it is imperative that midwives are aware of which women are at higher risk of bladder compromise (Williams et al, 2003) (Box 3). In a study by Zaki et al (2004), only 23% of 156 units that participated followed the Royal College of Obstetricians and Gynaecologists recommendations of catheterisation at 6 hours to prevent bladder damage (MacLean and Cardozo, 2002). If catheterisation (or re-catheterisation) is indicated, a midstream urine specimen should also be sent to rule out infection (Kearney and Cutner, 2008). Constipation should be avoided with midwives advising minor lifestyle changes, a balanced diet and increased levels of hydration (Lamb and Sanders, 2015), and the perineum should be further assessed as pain can be a contributing factor, itself requiring catheterisation in the absence of other factors (Foon et al, 2010). There is some suggestion that further studies are required to investigate whether the use of routine bladder scanning could reduce the incidence of catheterisation (Cavkaytar et al, 2014), therefore reducing interventions for women in the immediate postnatal period.
| Primagravida |
| Perineal injury or trauma (particularly anal sphincter damage) |
| Prolonged labour (first and second stages) |
| Epidural/regional analgesia |
| Instrumental birth |
| Caesarean section |
Because preventive measures need initiating during intrapartum care, if midwives strive to facilitate normality and physiological birth when possible, this in turn safeguards bladder health; although it is widely acknowledged that PUR can manifest regardless of mode of birth or analgesia (Foon et al, 2010).
Catheterisation: Processes for best practice
Catheterisation should be avoided where possible in pregnancy and the puerperium (Richens, 2016) as catheter-associated UTIs are the most common nosocomial infections (Tambyah and Maki, 2000). However, there are various reasons why urinary catheterisation—either intermittent or indwelling—may be clinically indicated. Midwives should be confident in the procedure of catheterisation to ensure maternal safety and wellbeing and minimise complications. Before commencing the procedure, the indication for catheterisation should be fully considered to obtain rationale; this should be discussed with the woman in order to obtain informed consent (Nursing and Midwifery Council (NMC), 2015).
Equipment should be prepared prior to commencing the procedure, ensuring the woman is covered to protect dignity (Baston, 2011). Richens (2016) advocates the use of lubricating gel for catheterisation as this can help to reduce trauma, infection and pain. As the urethra has no lubricating glands it can be easily damaged during catheterisation (Richens, 2016). Guidelines for insertion of the catheter should be followed (Pomfret, 2007). Aseptic non-touch technique is paramount, and thoroughly cleaning the urethral meatus is vital to avoid introducing infection.
Infection can occur at varying points of the procedure: transient skin surface bacteria has the potential to be carried into the bladder on the catheter, or bacteria could develop within the catheter itself. If using an indwelling device, ensuring the catheter bag is kept below the bladder helps to minimise reflux of urine which could also cause infection (Doyle and Birch, 2011). Using an intermittent in/out catheter reduces this risk and enables the maintenance of the woman's own voiding cycle, thus when clinically appropriate the use of these should be default. Appropriate use of correct documentation such as a fluid balance chart and a catheter care chart is necessary (NMC, 2012).
Conclusion
In order to provide holistic care, midwives should regularly discuss bladder health with women, making it part of routine care throughout the childbearing continuum. Opportunities to diagnose continence changes, particularly in the antenatal phase, could assist in the prevention of bladder damage following birth (Butterfield et al, 2007). Women's basic comfort measures should be at the forefront of midwifery care, ensuring homeostasis is monitored and facilitating individualised discussions about ensuring successful and comfortable bladder function.
To protect women's urogenital health, midwives are urged to champion normality, acting in a sensitive yet timely manner to avoid dystocia, prolonged stages of labour or instrumental birth, and to inform women of the postnatal bladder risks of regional analgesia. To retain normality and avoid over-medicalisation, the essential skill of bladder palpation should be highlighted and brought to the fore in midwifery education as a key component of care (Walsh, 2007).
Midwives should consider the psychological impact of short-term interventions such as catheterisation, and the long-term implications of bladder dysfunction, remaining vigilant to alterations in women's emotional wellbeing.
Owing to the high workload experienced in many maternity departments, the speed at which women transfer across maternity services means that handover of care must be conducted with strict attention, safeguarding women's health during the transition into early motherhood.