Because a woman’s bladder is compressed by the infant’s head during birth, several urinary tract disorders can occur.

1. Postpartum UTI
Prepared By:
Reena Bhagat
Senior Nursing Instructor
Maternal Health Nursing
BPKIHS

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Bhagat
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3. Urinary Tract Infection
It is one of the common causes of puerperal pyrexia,
the incidence being 1–5% of all deliveries.
Because a woman’s bladder is compressed by the
infant’s head during birth, several urinary tract
disorders can occur.
The infection may be the consequence of any of the
following:
(1) Recurrence of previous cystitis or pyelitis,
(2) Asymptomatic bacteriuria becomes overt,
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4. Contd..
(3) Infection contracted for the first time during
puerperium is due to:
(a) effect of frequent catheterization either during
labor or in early puerperium to relieve retention
of urine,
(b) stasis of urine during early puerperium due to
lack of bladder tone and less desire to pass
urine.
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5. Contd..
The organisms responsible are:
• E.coli,
• Klebsiella,
• Proteus and
• Staphylococcus aureus..
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6. Contd.
Clinical Features
• Elevated temperature and chills
• Urinary frequency
• Painful micturition
• Flank pain
Diagnosis
• Urine analysis
• Urine culture
• Blood test
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7. Management
• Increase fluid intake
• Empty the bladder frequently
• Appropriate rest
• Administer suitable antibiotic, analgesics.
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8. Retention of Urine
 This is a common complication in early puerperium.
 Urinary retention occurs as a result of inadequate
bladder emptying. After childbirth, bladder
sensation for voiding is decreased because of
bladder edema caused by the pressure of birth.
 Unable to empty, the bladder fills to overdistention.
 When the woman does void, instead of emptying
completely, the bladder empties only a small portion
of its contents (retention with overflow).
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9. Contd..
• As a result, it becomes overdistended again.
Bladder overdistention is potentially serious. If it
is allowed to continue, permanent damage may
occur from loss of bladder tone, leading to
permanent incontinence.
The causes are:
• (1) Bruising and edema of the bladder neck,
• (2) Reflex from the perineal injury,
• (3) Unaccustomed position.
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10. Contd..
Treatment:
• If simple measure fails to initiate micturition, an
indwelling catheter is to be kept in situ for about
48 hours. This not only empties the bladder but
helps in regaining the normal bladder tone and
sensation of fullness.
• Following removal of catheter, the amount of
residual urine is to be measured. If it is found to be
more than 100 mL, continuous drainage is
resumed.
• Appropriate urinary antiseptics should be
administered for about 5–7 days.
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11. Incontinence of Urine
 Urinary incontinence (UI) is also known as "loss of
ladder control” or “urinary leakage”.
 Urinary incontinence is defined as objectively
demonstrable involuntary loss of urine so as to
cause hygienic and social inconvenience for day to
day activity.
 The incontinence may be:
(1)Overflow incontinence,
(2)Stress incontinence,
(3)True incontinence.
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12. Causes of Urinary Incontinence
Urinary Incontinence( UI) is usually caused by
problems with muscles and nerves that help to hold
or pass urine.
Incontinence happens if bladder muscles suddenly
contract or the sphincter muscles are not strong
enough to hold back urine. Such as:
• Pregnancy: Unborn babies push down on the
bladder, urethra and pelvic flour muscles. The
pressure may weaken the pelvic floor support and
lead to leaks or problems passing urine.
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13. Contd.
 Childbirth: Labor and vaginal birth can damage a
pelvic floor and cervical fascia and weaken pelvic
floor support and damage nerves that control the
bladder.
It may be due to mechanical injury to supports of
the bladder neck following childbirth, trauma.
Prolonged pressure of fetal head causes damaged
area of bladder and urethra. However, childbirth is
often considered the main etiological factor.
 Rupture of muscle fibers and connective tissue
and overstretching of supporting ligaments are
other risk factors.
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14. Contd.
• Developmental weakness of the supporting
structures maintaining the bladder neck and
proximal urethra in position.
• Diseases conditions: People with diabetes,
urinary tract infection, spinal cord injury.
Medicines urinary incontinence (UT) may be a
side effect of medicines such as diuretics
Hormone replacement has been shown to cause
worsening urinary incontinence.
• Caffeine and alcohol: Drinks with caffeine, such
as coffee or soda, cause the bladder to fill quickly
and sometimes leak.
•
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15. Contd..
• Infection: Infections of the urinary tract and bladder
may cause incontinence for a short time. Bladder
control returns when the illness goes away
• Nerve damage. Damaged nerves may send signals to
the bladder at the wrong time, or not
at all. Trauma or diseases such as diabetes and
multiple sclerosis can cause nerve damage Nerves
may also become damaged during childbirth
• Excess weight. Being overweight is also known to
put pressure on the bladder and make incontinence
worse.
• Smoking Regular smokers are more likely to develop
a chronic cough, which may result in episodes of
incontinence.
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17. Types of UI
• True incontinence: Continuous escape of urine
per vagina (true incontinence) is the classic
symptom. The patient has got no urge to pass
urine. However, if the fistula is small, the escape of
urine occurs in certain position and the patient can
also pass urine normally.
• Stress incontinence: The symptom of urine loss
may be associated with the stressful activity and/or
other physical activity (stress incontinence).
Leakage happens with coughing sneezing
exercising, laughing lifting heavy things and other
movements that put pressure on the bladder.
•
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18. Contd..
• Urge incontinence: The involuntary urine loss
may follow a strong desire and need to void
(urge incontinence) and there may be no
awareness of urinary leak (unconscious
incontinence). This is sometimes called
"overactive bladder." Leakage usually happens
after a strong, sudden urge to urinate. This may
occur when you do not expect it, such as during
sleep, after drinking water, or when you hear or
touch running water.
•
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19. Contd..
• Overflow incontinence Urine leakage happens
because the bladder does not empty completely.
• Mixed incontinence: This is 2 or more types of
incontinence together (usually stress and urge
incontinence).
• Transient incontinence: Urine leakage happens
for a short time due to an illness (such as a
bladder infection). The leaking stops when the
illness is treated.
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20. Diagnosis
• History taking: history of type of incontinence, use
of drug, urinary tract infection, recent surgery and
drinking habit.
• Examination: pelvic examination should be done
with full bladder.
• Diagnosis of stress incontinence is established by
noting the escape of urine through the urethral
opening during stress.
• The exact nature of urinary fistula is established by
noting the fistula site by examining the patient in
Sims’ position using Sims’ speculum or by three
swabs test, if the fistula is tiny.
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21. Three swab test
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22. Investigations
Bladder stress test: During this test, when the patient
is asked to cough or bear down, few drops of urine are
seen escaping from the external urethral meatus.
Urinalysis: A urinalysis tests for signs of infection or
other causes of incontinence.
Pad test: A one hour extended pad test is
recommended of cases when the clinical stress test is
negative. The patient wears a pre weighed sanitary pad,
drinks about 500ml of water and rests for 15 minutes,
then performs exercises like walking for 30 minutes.
After a period of as hour, the sanitary pad is removed
and weighed. An increase in weight by 1g is considered
as significant loss.
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23. Contd..
Frequency volume chart: Patient is asked to record
her fluid intake, output, episodes of leakage in relation
to time and activity. It should be recorded at least for 3
days.
Post void residual urine: The woman is asked to
void. A catheter is inserted in the bladder within the
nest 10 minutes to measure the remaining urine in the
bladder. Normally residual urine should be <50 ml.
Ultrasound: Sound waves are used to take a picture of
the kidneys, bladder, and urethra.
Cystoscopy: place a thin tube connected to a tiny
camera in the urethra to look at the inside of the
urethra and bladder.
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24. Prevention
• Proper management of first and second stage of
labor to preserve the tone of the bladder and
prevent extensive injuries to the bladder and
urethra.
• Teach and encourage doing pelvic floor muscle
exercises. Kegel exercises (tightening the muscles
of the pelvic floor as if trying to stop the urine
stream) may help prevent symptoms. Doing Kegel
exercises during and after pregnancy can decrease
the risk developing stress urinary incontinence after
childbirth.
•
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25. contd.
• Avoidance of repeated childbirth trauma and delay
in second stage of labor.
• Maintain a normal weight.
• Management of obesity, diabetes, chronic
pulmonary and neurological diseases.
• Eat more fiber, which can prevent constipation, a
cause of urinary incontinence.
• Avoid caffeinated drink.
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26. Treatment
Treatment depends on severity and affect everyday
life. Types of treatments include:
 Advice to ask to stop smoking (if smoke) and avoid
caffeinated beverages and alcohol.
 Asked to keep a urinary diary, recording how many
times urinate during the day and night, and how
often leak urine.
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27. Contd..
Behavior changes
Examples of behavior changes include:
 Drinking less fluid (drink more than normal
amounts of fluid)
• Urinating more often to reduce the amount of urine
that leaks.
• Avoiding jumping or running which can cause
more urine to leak.
• Making your bowel movements mare regular by
taking dietary fiber or laxatives to avoid
constipation (which can make incontinence worse).
•
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28. Contd..
• Quitting smoking to reduce coughing and bladder
irritation.
• Avoiding alcohol and caffeine, which can stimulate
the bladder.
• Losing weight if woman are overweight. Extra
weight puts more pressure on bladder and nearby
muscles. This can cause bladder control problems.
Work with doctor to plan a diet and exercise
program if women are overweight.
• Avoiding food and drinks that irritate the bladder,
such as spicy foods and citrus fruits
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29. Contd..
• Keeping blood sugar under control if woman have
diabetes.
• Pelvic floor muscle exercise/ training: Pelvic muscle
training exercises (called Kegel exercises) may help
control urine leakage. These exercises keep the
urethral sphincter strong and working properly
Kegel exercises are most effective when the patient
has received proper instruction from a health care
professional. Simply trying to stop your urine flow or
trying to do the exercises hundreds of times a day
without instruction from a health professional will not
help.
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30. Contd..
Surgery: Surgery is only recommended after the exact
cause of urinary incontinence has been found. Most of
the time, health care provider will try bladder
retraining or Kegel exercises before considering
surgery. If woman has true incontinence (VVF), it
should be correct surgically. Anterior vaginal repair
procedures are often done in women when the bladder
is bulging into the vagina (called a cystocele).
Catheterization: May suggest a catheter if women are
incontinent because bladder never empties completely
(overflow incontinence)
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31. Contd..
• Medicines for bladder control: Medicines tend to
work better in patients with mild to moderate stress
incontinence.
• There are several types of medications that may be used
alone or in combination. They include: anticholinergic
drugs control overactive bladder. Antimuscarinic drugs
block bladder contractions.
• Alpha-adrenergic agonist drugs, such as
phenylpropanolamine and pseudoephedrine (common
ingredients in over-the-counter cold medications), help
increase sphincter strength and improve symptoms in
many patients. However, these drugs are rarely
prescribed because of possible side effects on the heart.
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32. References
 Dutta DC. Textbook of Obstetric including
Perinatology and Contraception. 7th ed. Jaypee
Brothers Medical Publishers (P) Ltd. New Delhi,
India: 2013; Page No.: 434-437.
 Myles Textbook of Midwives, 16th edition, United
Kingdom, Churchill Livingstone Elsevier ltd., 2014,
Page No. 629-634
 Subedi DP. A Textbook of Midwifery
Nursing(Postpartum Care) Part III. First ed.
Reprint:2020. Akshav Publication Kathmandu; Page
No. 128-133.
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