Urinary catheterisation is increasingly used in a number of women during labour, preoperatively and in the postnatal period. During the physiological process of labour, bladder care is a fundamental part of midwifery care, with the National Institute for Health and Care Excellence making recommendations on the frequency for passing urine from admission through labour, birth and postnatal period.
Knowledge of the anatomy and physiology of the urinary tract is vital in being able to make considered clinical decisions when caring for pregnant women who require urinary catheterisation (Figure 32.1).
Urinary catheterisation drains urine using a small hollow tube (catheter), which is inserted into the bladder, most commonly via the urethra, using an aseptic technique. Catheters are made from a variety of materials Including plastic, silicone, PTFE (Teflon) and latex. Due consideration should be given when choosing the type of catheter where a patient has a latex allergy. The catheter may be left in situ secured in the bladder by a small balloon on the tube inflated with sterile saline, which drains urine continuously into a collection bag (indwelling or Foley catheter) or inserted and immediately removed once the urine has drained (intermittent). Catheterisation is a relatively straightforward procedure; however, it does carry some risk. Boxes 32.1 and 32.2 outlines indication for catheterisation.
Urinary catheterisation should be avoided if possible as it can cause pain, infection and/or trauma. Pain can be caused by the introduction of the catheter into the urethra. The urethra is lined by transitional epithelium cells, which are not lubricated and are also very sensitive. By using a sterile lubricant, such as 6 mL lidocaine 2% gel, tissue damage can be minimised but this will also give an anaesthetised effect to the urethra, helping to manage any pain or discomfort. Infection is often caused by poor aseptic technique where micro-organisms are introduced as the catheter is inserted, from the hands of the practitioner or from the flora of the perineum. Where catheterisation is prolonged, the risk of infection increases; therefore an assessment of need must be made regularly.
Midwives should consider the risks of using a catheter alongside the benefits and always discuss with the woman prior to the procedure. They must also ensure that the woman’s identity has been checked and that informed consent has been given for any procedure. The midwife needs to gather all the equipment required for the procedure (Box 32.3).
The midwife may need to assist the woman into a semirecumbent position, helping her to remove any underwear or sanitary towels, with her knees bent, hips flexed, ankles together and feet resting on the bed.
An aseptic technique must be used throughout the procedure, prepare the equipment by opening the packs on to a clean trolley that can be taken to the bedside. The midwife must ensure that hands are washed and sterile gloves are used to minimise the risk of introducing infection. The disposable sheet should be placed under the woman’s buttocks helping to maintain an aseptic field.
Separate the labia and clean the vulva using the dominant hand, from front to back starting with the labia majora and then the labia minora using each swab once only.
Locate the urethral orifice and insert the anaesthetic gel and allow it to take effect for 3–5 minutes before inserting the catheter. Remove gloves, wash and dry hands thoroughly and put on a second pair of sterile gloves.
Using a gauze swab to separate the labia, introduce the tip of the catheter into the urethra passing it slowly in an upward and backward direction until urine is visualised.
If there is any difficulty in passing the catheter or the woman is in pain, the procedure should be stopped.
If catheterisation is erroneously placed into the vagina and not the urethra, the catheter must be discarded and a new sterile one used.
Once urine is seen the catheter can be advanced further and the balloon inflated by slowly injecting the sterile water from the syringe into the valve. If there is any pain this could indicate that the balloon is misplaced in the urethra and not in the bladder. The catheter needs to be attached to the drainage bag and this is then attached securely to the bedside.
Clear the area, correctly dispose of any equipment and remove gloves and wash hands.
The procedure for intermittent catheterisation is the same except the catheter is single-use and is removed once urine is drained.
Removal of the catheter should be considered according to the woman’s clinical condition. Gather together a disposable receiver, 10 mL syringe, non-sterile gloves, disposable sheet and cleansing solution. Place the disposable sheet under the woman’s buttocks, wash hands and put on gloves. Deflate the balloon by withdrawing the water into the syringe. Ask the women to inhale and remove the catheter smoothly and quickly as she exhales and place it into the receiver. Cleanse the perineum as per local protocols.
The woman’s urinary function and output must be monitored according to local protocols following removal of a catheter. The woman should be given information to ensure she is aware of the need to void within the first 6 hours, that her output should equal her input, possible signs of urinary retention, increase oral fluids and to be aware of urethral irritability or trauma from the catheterisation.
The midwife should document the procedure with the indications, any complications and details of all the equipment and drugs used.