Received: 3 February 2019 Revised: 24 June 2019 Accepted: 15 July 2019

DOI: 10.1111/jjns.12293

ORIGINAL ARTICLE

Prevalence and risk factors for postpartum urinary retention

after vaginal delivery in Japan: A case-control study

Izumi Kawasoe1,2 | Yaeko Kataoka3

1
Graduate School of Nursing Science,
St. Luke's International University, Tokyo,
Abstract
Japan Aim: This study aimed to clarify the prevalence and risk factors of postpartum uri-
2
Department of Nursing, Aiiku Hospital, nary retention after vaginal delivery. It also described the healing process of
Tokyo, Japan
women who had postpartum urinary retention.
3
Women’s Health/Midwifery, St. Luke's
Methods: In this case-control study, 77 women who had postpartum urinary reten-
International University, Tokyo, Japan
tion were matched by age and parity with 385 women as controls. Data were ana-
Correspondence lyzed by conditional logistic regression analysis. Data were collected from the
Izumi Kawasoe, Graduate School of Nursing
Science, St. Luke's International University,
women in the case group regarding their healing process and conditions for urinary
3-8-5, Tsukiji, Chuo-ku, Tokyo, 104-0045, retention (overt or covert urinary retention).
Japan. Results: The prevalence of postpartum urinary retention was 1.2%. The adjusted
Email: [email protected]
odds ratio and the 95% confidence intervals for risk factors were as follows: epidu-
ral analgesia 4.72, 95% CI 2.38, 9.39; episiotomy 2.68, 95% CI 1.40, 5.13; length
of second stage of labor 1.85, 95% CI 0.98, 3.49; labor augmentation 1.78, 95% CI
0.90, 3.51; instrument delivery 0.96, 95% CI 0.43, 2.17; and Kristeller maneuver
0.93, 95% CI 0.37, 2.37. Among 59 women with overt urinary retention,
29 (49.2%) transitioned to covert urinary retention within 10 days after delivery.
More than half of the women were normal within 72 hr, but there were five women
whose urinary retention did not resolve 11 days following delivery.
Conclusions: The statistically significant risk factors for postpartum urinary reten-
tion were epidural analgesia and episiotomy. Initiatives for the prevention and man-
agement of postpartum urinary retention are necessary.

KEYWORDS
case-control studies, postpartum period, risk factors, urinary retention

1 | INTRODUCTION reported that among 51 women with PUR, 45.1% had reso-
lution of the retention by 48 hr after delivery, and 9.4% had
Postpartum urinary retention (PUR) is a common and tran- resolution by 72 hr after delivery. However, prolonged
sient health problem occurring in women immediately after PUR, defined as lasting for longer than 72 hr and requiring
giving birth, which usually resolves naturally within 72 hr. catheterization for a longer period, caused serious adverse
PUR is defined as an inability to void spontaneously or ade- effects such as stress incontinence, overactive bladder
quately after giving birth (Mulder et al., 2012). Although (Groutz et al., 2011) and urinary tract infections caused from
most cases of PUR are transient, it is well known that it may catheterization (Humburg, Holzgreve, & Hoesli, 2007). In
cause permanent voiding dysfunction and other long-term order to prevent or manage PUR, screening and early inter-
adverse effects (Mulder et al., 2014). Carley et al. (2002) ventions are needed as standard postpartum care.

Jpn J Nurs Sci. 2019;e12293. wileyonlinelibrary.com/journal/jjns © 2019 Japan Academy of Nursing Science 1 of 9
https://doi.org/10.1111/jjns.12293
2 of 9 KAWASOE AND KATAOKA

The major cause of PUR is thought to be neurological 2 | METHODS

damage (i.e., neurogenic bladder) caused by hyperextension
of the bladder at delivery and compression by the fetal head, The study design was a case-control study conducted in two
resulting in minute nerve damage, urination attenuation/ hospitals in Tokyo, Japan. One was a central perinatal medical
disappearance, and urinary retention (Sugo, Watanabe, Tsu- center (facility A) and the other was a regional perinatal medi-
tsui, Sumikura, & Hayashi, 2010). Yet the precise pathology cal center (facility B). Both were tertiary hospitals with neona-
of PUR is still unknown. tal intensive care units; however, intrapartum management
There have been no changes in the PUR definition since differed between the facilities. In facility A, women were
Yip, Brieger, Hin, and Chung (1997) defined it and then prohibited from walking while epidural analgesia was in use,
classified it as overt (symptomatic) and covert (asymptom- and they had an indwelling bladder catheterization or intermit-
atic). Overt urinary retention was defined as the inability to tent catheterization. In facility B intrapartum women were able
void spontaneously within 6 hr after vaginal delivery or 6 hr to walk if there was no numbness of the lower limbs and were
after removal of an indwelling bladder catheter after cesar- able to use the toilet to urinate. Intermittent catheterization was
ean section, requiring catheterization. Covert urinary reten- performed when women could not urinate.
tion was defined as a post-void residual bladder volume of In this study, a diagnosis of overt PUR after vaginal
more than 150 mL after spontaneous micturition, verified by delivery was the inability to void spontaneously within 8 hr
ultrasound or catheterization. Many researchers have after vaginal delivery. A post-void residual bladder volume
adopted these definitions. Based on the 1997 definition of of more than 150 mL after spontaneous voiding, verified by
Yip et al., a systematic review found that the prevalence of catheterization within 8 hr after vaginal delivery, was
overt urinary retention ranged from 0.3 to 7.4%, and covert defined as covert PUR. We used 8 hr after vaginal delivery
ranged from 0.4 to 45% (Mulder et al., 2014). In addition, as the definition of overt and covert PUR instead of 6 hr
the prevalence of prolonged PUR, which was defined as uri- after vaginal delivery (Yip's definition) because in one facil-
nary retention lasting for longer than 72 hr and requiring ity they used 8 hr as the marker. The definition of healing
catheterization for a longer period was 0.06% (Humburg, process was the number of hours or days until complete
Troeger, Holzgreve, & Hoesli, 2011). In Japan the preva- recovery from overt and covert PUR.
lence of PUR was reported to be 0.5% (Suenaga, Chisaka, & The case group included women who had PUR and: (a) a
Okamura, 2008) to 0.9% (Wakayama, Shimabukuro, Mor- diagnosis of urinary retention, dysuria, or urination disorders
omizato, & Shiroma, 2010), but reports were few. No at the postpartum period; (b) could not urinate on their own
research was conducted to identify the prevalence for PUR for about 8 hr after vaginal delivery (defined as overt urinary
divided by overt and covert urinary retention, or for retention); (c) could urinate by themselves within 8 hr after
prolonged PUR. vaginal delivery but had a feeling of bladder fullness and
Mulder et al. (2012) conducted a systematic review to more than 150 mL of residual urine by urethral catheteriza-
identify various risk factors for PUR. According to their tion (covert urinary retention). The exclusion criteria were
findings, independent risk factors for overt PUR were epidu- women who received an indwelling bladder catheter for
ral analgesia, instrument delivery, episiotomy and postpartum hemorrhage, surgical removal of a vaginal wall
primiparity; however, for covert PUR no significant risk fac- hematoma, or severe perineal damage. The control group
tors were found. In more recent studies, independent risk was composed of women who had no urinary retention after
factors for covert PUR were episiotomy, epidural analgesia, vaginal delivery.
and birth weight (Mulder, Oude Rengerink, van der Post, Data from women in the control group were extracted
Hakvoort, & Roovers, 2016). According to Tiberon et al. from those who gave birth at the same hospital as the case
(2018), risk factors for persistent PUR lasting more than group (hospital control). Matching of the control was per-
72 hr were cesarean delivery, perineal tear or episiotomy, formed in 10-year age increments (20-29, 30-39, 40-) and by
and fluid administration in the delivery room. In Japan, parity. The case-to-control ratio was 1:5.
although there have been case studies of PUR, there has not We reviewed medical and nursing records for data on
yet been any research on risk factors. In order to manage women delivered at facility A from April 1, 2015 to October
PUR and improve the quality of life of postpartum women, 31, 2016, and at facility B from August 31, 2013 to August
identification of risk factors are basic to prevent, screen and 31, 2016. Data from a total of 462 postpartum women's
then to provide the appropriate interventions. records were extracted, consisting of 77 women in the case
The aim of this study was to clarify the prevalence of group and 385 women in the control group. Data collected
overt and covert PUR and to identify the risk factors after were: age, height, non-pregnant weight, parity, gestational
vaginal delivery, and then to describe the healing process of age at delivery, instrument delivery (vacuum, forceps), use
women with PUR from delivery to 11 days after delivery. and type of analgesia (epidural, spinal), labor induction or
KAWASOE AND KATAOKA 3 of 9

augmentation, length of first and second stages of labor, epi- number of vaginal deliveries was 3,026 (74.7%), of which
siotomy, degree of perineal laceration, Kristeller maneuver, the number of vacuum extractions was 350 (11.6%) and that
birth weight, head circumference, time of urination (pre-par- of forceps delivery was 79 (2.6%). The number of cesarean
turition, postpartum), uresiesthesia, and urinary volume (ure- sections was 1,023 (25.3%). The average number of mid-
thral catheterization). In addition, only in the case group data wives was 36, and the number of obstetric beds was 45. The
were the healing processes and conditions for urinary reten- total number of deliveries at facility B was 4,599, the num-
tion (overt or covert urinary retention), and use of indwelling ber of vaginal deliveries was 3,387 (73.6%), of which the
bladder catheter collected. Other data were collected to number of vacuum extractions was 156 (4.6%) and that of
describe the study setting of the hospitals: total number of forceps delivery was 44 (1.3%). The number of cesarean sec-
deliveries, number of vaginal deliveries (number of vacuum tions was 1,212 (26.4%). The average number of midwives
extractions, number of forceps deliveries), number of cesar- was 53 and the number of obstetric beds was 33.
ean sections, number of midwives, and number of obstetric Table 2 shows the percentage of women with vaginal
beds. The data collection period was from October 25, 2016 deliveries who had urinary retention by facility. There were
to April 30, 2017. The university ethics review committee 49 and 28 postpartum women in the case group at facilities
approved this study. A and B, respectively. The frequencies of PUR at facilities
Statistical analysis was performed using EZR on R com- A and B were 1.6 and 0.8%, respectively. At facility A in
mander (programmed by Y. Kanda) version 1.35. The level the case group, overt urinary retention occurred in 36 women
of significance was set to 5% by the two-sided test. For the and covert urinary retention in 13 women. At facility B in
categorical variables, either the Chi-square (χ2) test or Fish- the case group, 23 women had overt urinary retention and
er's exact test was performed to analyze the association of five women had covert urinary retention.
two variables. To analyze the differences between continu-
ous variables, the t test or Welch's t test was performed. Uni-
3.2 | Prevalence of PUR
variate analysis of categorical variables and continuous
variables was also performed. Odds ratio and 95% confi- Among 6,413 vaginal deliveries at facilities A and B,
dence interval were calculated for categorical variables. In 77 (1.2%) women had PUR. Of those, 59 (0.9%) women had
univariate analysis, all variables with a p < .05 excluding overt urinary retention, and 18 (0.3%) women had covert uri-
gestational age at delivery and head circumference were nary retention.
inputted to the conditional logistic regression model, and the
adjusted odds ratio, 95% confidence interval, and p value 3.3 | Comparison of obstetric characteristics
were calculated. and delivery outcomes between the case and
control groups
3 | RESULTS Table 3 shows the data on obstetric characteristics and deliv-
ery outcomes. The mean age was 33.1 years (SD = 3.81) in
3.1 | Features of the medical facilities the case group and 33.0 years (SD = 4.20) in the control
cooperating with the research group. The number of primiparous women was 71 in the
Table 1 shows the data on the cooperating medical facilities. case group (92.2%) and 355 in the control group (92.2%).
The total number of deliveries at facility A was 4,049, the The height, non-pregnant weight, non-pregnant body mass
index, length of first stage of labor (minutes), birth weight,
TABLE 1 Characteristics of the study site hospitals labor induction, and degree of perineal laceration were com-
Facility Aa Facility Bb parable between the two groups. The mean gestational age at
Total deliveries, n 4,049 4,599
Vaginal deliveries, n (%) 3,026 (74.7%) 3,387 (73.6%) TABLE 2 Comparison of urinary retention from vaginal delivery
by facility
Vacuum, n (%) 350 (11.6%) 156 (4.6%)
Forceps, n (%) 79 (2.6%) 44 (1.3%) Facility A Facility B
Cesarean sections, n (%) 1,023 (25.3%) 1,212 (26.4%) n (%) n (%)
c
Midwives, n 36 53 Vaginal delivery 3,026 3,387
Obstetric beds, n 45 33 Urinary retention 49 (1.6) 28 (0.8)
a
Data on facility A (from April 1, 2015 to October 31, 2016). Overt 36 (73.5) 23 (82.1)
b
Data on facility B (from August 31, 2013 to August 31, 2016).
c Covert 13 (26.5) 5 (17.9)
Only the midwives of the postpartum ward.
4 of 9 KAWASOE AND KATAOKA

Cases Controls
T A B L E 3 Comparison of case and
(n = 77) (n = 385) control groups by obstetric characteristics
and delivery outcomes
Mean (SD) Mean (SD) t p value
Maternal age 33.1 (3.81) 33.0 (4.20) −0.11 .912
Height (cm) 160.8 (4.93) 160.0 (5.21) −1.25 .211
Non-pregnant weight (kg) 51.8 (5.66) 51.1 (6.97) −0.84 .403
Non-pregnant body mass 20.0 (1.76) 20.0 (2.49) −0.14 .892
index
Gestational age (weeks) 39.6 (0.93) 39.4 (1.02) −2.03 .043*
First stage (min) 925.4 (811.0) 750.4 (655.1) −1.78 .078
Second stage (min) 172.2 (135.0) 100.1 (87.9) −4.50 <.001✳✳✳
Birth weight (g) 3,172.6 3,086.0 (345.9) −1.96 .051
(394.2)
Head circumference (cm) 33.8 (1.33) 33.5 (1.19) −2.04 .042*
n (%) n (%) χ 2

Instrument delivery 24 (31.2) 53 (13.8) 12.77 <.001✳✳✳

Vacuum 20 (83.3) 42 (79.2)
Forceps 4 (16.7) 11 (20.8)
Analgesia 58 (75.3) 122 (31.7) 49.56 <.001✳✳✳
Epidural 56 (96.6) 115 (94.3)
Spinal 1 (1.7) 1 (0.8)
Combined spinal / epidural 1 (1.7) 6 (4.9)
Primiparous 71 (92.2) 355 (92.2)
Kristeller maneuver 16 (20.8) 32 (8.3) 9.42 .002✳✳
Labor induction 10 (13.0) 45 (11.7) 0.02 .898
Labor augmentation 54 (70.1) 138 (35.8) 29.66 <.001✳✳✳
Episiotomy 56 (72.7) 196 (50.9) 11.46 <.001✳✳✳
Perineal laceration 0〜2nda 60 (95.2) 340 (97.7)
a
Perineal laceration 3rd/ 4th 3 (4.8) 8 (2.3) .386
Perineal laceration (missing) 14 37

Note: The t test was used for continuous variables and χ2 test was used for categorical variables.
a
Fisher's exact test.
*p < .05.; ✳✳p < .005.
✳✳✳
p < .001.

delivery was 39.6 weeks (SD = 0.96) in the case group and χ2 = 12.77, df = 1, p < .001), use of analgesia (case group
39.4 weeks (SD = 1.02) in the control group, showing a sig- 75.3%, control group 31.7%, χ2 = 49.56, df = 1, p < .001),
nificant difference (t = −2.03, df = 460, p = .043) but has labor augmentation (case group 70.1%, control group 35.8%,
no clinical significance. The mean head circumference was χ2 = 29.66, df = 1, p < .001), episiotomy (case group
significantly different (t = −2.04, df = 460, p = .042) 72.7%, control group 50.9%, χ2 = 11.46, df = 1, p < .001),
between the case group at 33.8 cm (SD = 1.33) and the con- Kristeller maneuver (case group 20.8%, control group 8.3%,
trol group at 33.5 cm (SD = 1.19), but again had no clinical χ2 = 9.42, df = 1, p = .002).
significance.
The following parameters showed significant differences
3.4 | Predictive factors for PUR
between the case group and the control group: length of the
second stage of labor (case group 172.2 min, control group After selection of possible risk factors through univariate
100.1 min, t = −4.50, df = 89.32, p < .001), instrument analysis, conditional logistic regression analysis revealed
delivery (case group 31.2%, control group 13.8%, epidural analgesia and episiotomy as independent risk
KAWASOE AND KATAOKA 5 of 9

factors for PUR. We used six significant factors identified for PUR. The crude odds ratios were as follows: length of
by univariate analysis in the conditional logistic regression the second stage of labor 3.28 (95% CI 1.83, 5.83), instru-
model. Variable input to the model was carried out using a ment delivery 2.83 (1.54, 5.13), use of analgesia 6.55 (3.66,
forced entry method. Table 4 shows the predictive factors 12.18), Kristeller maneuver 2.88 (1.39, 5.81), labor augmen-
tation 4.19 (2.41, 7.48), and episiotomy 2.57 (1.46, 4.64).
TABLE 4 Predictive factors for PUR From the conditional logistic regression analysis, the
Crude OR Adjusted OR
adjusted odds ratios were as follows: length of the second
Factors (95% CI) (95% CI)a stage of labor 1.85 (95% CI 0.98, 3.49), instrument delivery
0.96 (0.43, 2.17), use of analgesia 4.72 (2.38, 9.39),
Length of the second 3.28 (1.83, 5.83) 1.85 (0.98, 3.49)
stage of labor
Kristeller maneuver 0.93 (0.37, 2.37), labor augmentation
(180 min ≦) 1.78 (0.90, 3.51), and episiotomy 2.68 (1.40, 5.13). Signifi-
cant differences in the adjusted odds ratios were found in the
Instrument delivery 2.83 (1.54, 5.13) 0.96 (0.43, 2.17)
use of analgesia 4.72 (2.38, 9.39) and episiotomy 2.68
Epidural analgesia 6.55 (3.66, 12.18) 4.72 (2.38, 9.39)
(1.40, 5.13).
Kristeller maneuver 2.88 (1.39, 5.81) 0.93 (0.37, 2.37)
Labor augmentation 4.19 (2.41, 7.48) 1.78 (0.90, 3.51)
3.5 | Healing process and conditions of women
Episiotomy 2.57 (1.46, 4.64) 2.68 (1.40, 5.13)
who suffered PUR after vaginal delivery
Abbreviations: OR, odds ratio; PUR, postpartum urinary retention.
a
Conditional logistic regression analysis. Variable input to the model was carried Figures 1 and 2 portray the healing process and conditions of
out in a forced entry method. women who developed PUR after delivery. After delivery,

Within 24hours 2-3days 4-5days 6-10days After 11th

Continued to
Transition to
be overt Cured (n =1)
covert (n =1)
(n =1)
Continued to
Transition to
be overt Unknown (n =1)
covert (n =2)
(n =4)

Cured (n =1) Cured (n =1)

Continued to Continued to Continued to

Transition to Unknown
be overt be covert be covert
covert (n =5) (n =1)
(n =22) (n =3) (n =3)

Cured (n =13) Cured (n =2) Cured (n =2)

Overt Continued to Continued to Continued to
Transition to Unknown
PUR be covert be covert be covert
covert (n =21) (n =2)
(N =59) (n =10) (n =7) (n =4)
FIGURE 1 Healing process Unknown (n =2)
of women with overt postpartum
urinary retention (PUR) Cured (n =16) Cured (n =11) Cured (n =3) Cured (n =1) Cured (n =2)

Within 24hours 2-3days 4-5days 6-10days After 11th

Continued to Continued to Continued to Continued to

Unknown
be covert be covert be covert be covert
(n =2)
(n =15) (n =8) (n =4) (n =2)

Covert
PUR
(N =18)
FIGURE 2 Healing process
of women with covert postpartum
urinary retention (PUR) Cured (n =3) Cured (n =7) Cured (n =4) Cured (n =2)
6 of 9 KAWASOE AND KATAOKA

59 women developed overt PUR. At 24 hr after delivery, midwife's voiding assessment alone, and urged the use of
22 (37.3%) continued to have overt PUR, 21 (35.6%) women objective indicators such as ultrasound. Tanaka et al. also
reverted to covert PUR and 16 (27.1%) returned to normal. suggested that there are many women who have residual
Only one woman who had overt PUR 24 hr after delivery urine shortly after childbirth, and in the future it seems
continued to have overt PUR 4-5 days after delivery. Among important to identify residual urine by ultrasound. Satoh,
the 22 women who continued to have overt PUR at 24 hr Goto, Herrera, Otsuka, and Ishikawa (2016) observed daily
after delivery, three were cured and one woman could not be changes in postpartum residual urine volume by bladder
followed after discharge from the hospital at 11 days after scan. Satoh et al. (2016) reported that among 65 postpartum
delivery. Among the 21 women who reverted to covert PUR women, 12 (18.5%) on the first day and 20 (30.8%) on the
at 24 hr after delivery, seven continued with covert PUR third day had a residual urine of 150 mL or more. And
beyond 72 hr after delivery. At 11 days after delivery, two among 65 women, 47 (72.3%) on the first day after vaginal
women who had reverted to covert PUR at 24 hr after deliv- delivery have reported reduced bladder sensation. Since
ery were lost to follow-up. After day 11 of delivery one postpartum women have diminished micturition desire
woman healed by the 19th day, one woman by the 24th day, because of vaginal delivery trauma, post-void residual urine
one woman by the 29th day and two women by the 30th day. measurement is used to confirm that the bladder is
Eighteen women had covert PUR at delivery. Among completely emptied. The post-void residual urine volume is
them 15 (83.3%) still had covert PUR at 24 hr after delivery. considered of clinical significance. In Japan, after a vaginal
Four women remained with covert PUR beyond 72 hr and
delivery, women often walk to the bathroom at the latest
two women continued with covert PUR at 6-10 days after
6-8 hr, hence a post-void residual urine measurement should
delivery. At 11 days after delivery, the two women were lost
be performed at that time. Women having reduced bladder
to follow-up.
sensation, straining to void and feeling of incomplete blad-
der emptying should be followed up for residual urine. In
4 | DISCUSSI ON order to clarify the exact prevalence of PUR in Japan, a pro-
spective study is needed that includes accurate data such as
4.1 | Definition and prevalence of PUR ultrasound measurement of the amount of residual urine in
In this study, the prevalence of PUR was 1.2%: overt urinary all postpartum women.
The definitions of PUR have varied among studies
retention was 0.92% and covert urinary retention 0.28%.
Regarding the prevalence of PUR, the Yip et al. (1997) despite the overall acceptance of Yip's definition. Carley
study found an overt urinary retention of 4.9%, Pifarotti et al. (2002) defined PUR as the inability to urinate spon-
et al. (2014) reported 0.8%, Carley et al. (2002) 0.45%, and taneously within 12 hr after vaginal delivery. Teo et al.
Teo, Punter, Abrams, Mayne, and Tincello (2007) 0.2%. The (2007) defined covert PUR as a sudden inability to urinate
prevalence of overt urinary retention in this study was simi- and a residual urine volume more than 100 mL with ultra-
lar to the frequency of 0.8% in Pifarotti et al. (2014), which sound or more than 100 mL with catheter urine volume.
was lower than that of 4.9% in Yip et al. (1997). It is consid- Since the definition of PUR is different in the previous
ered that these differences were due to study design. Pifarotti studies the prevalence of PUR in this study cannot be ade-
et al. (2014) was a retrospective case-control study as was quately compared. However, subjects' ages in this study,
this study, but Yip et al. (1997) conducted a prospective at time of labor, tended to be higher than the national
study. average with the average age of women at delivery as
In this study covert urinary retention was only 0.28%, 33.1 years for the case group, 33.0 years for the control
compared to Buchanan and Beckmann (2014) at 5.1%, using group. The percentage of the primiparous women
the same definition as Yip et al. (1997) with a finding of exceeded 90%. They were younger compared to the 2017
9.7%. In the prospective study by Yip et al. (1997), residual trend in Japan where the average age of mothers by birth
urine volume was measured by ultrasound on the first day order was 30.7 years for first child, 32.5 years for second
after vaginal delivery in all women surveyed except women child, and 33.5 years old for third child (Ministry of
with overt urinary retention who had a bladder indwelling Health, Labor and Welfare, 2017 p. 10). Both A and B
catheter inserted. Even for women who had urinated after facilities were perinatal medical centers and it is conceiv-
birth and had no reported problems, there have been cases in able that the mothers’ average age at birth was higher than
which a large amount of residual urine was confirmed by the national average and the proportion of high-risk preg-
transvaginal ultrasound at the discharge examination on day nant women was also larger. Therefore, it is expected that
four after vaginal delivery. Tanaka et al. (2015) stated resid- the prevalence of PUR was somewhat higher than in facil-
ual urine could not be accurately documented by the ities handling low-risk labor.
KAWASOE AND KATAOKA 7 of 9

4.2 | Predictive factors for PUR In addition to the complex effects on the urological and
reproductive systems during delivery, edema and pain in the
Overt and covert urinary retention factors were combined
perineum also made it difficult to urinate. Larsson, Platz-
and analyzed with conditional logistic regression, which
Christensen, Bergman, and Wallstersson (1991) investigated
showed the use of epidural analgesia and episiotomy as risk
perineal laceration and pain after birth using a visual analog
factors of PUR. The adjusted odds ratio for use of epidural
scale. Women with mediolateral episiotomies had more pain
analgesia was 4.72, and was the largest result. In the system-
on the first and third days after birth than the natural lacera-
atic review and meta-analysis by Mulder et al. (2012), seven tion group and no laceration group. They reported that it was
studies on the use of epidural analgesia (four prospective about the same level on the fifth day. Irie et al. (1995)
studies and three retrospective studies) were integrated, and reported that voiding dysfunction appeared at a significantly
the adjusted odds ratio was 7.7. As in the Mulder et al. higher rate in episiotomy groups. Episiotomy itself incurred
(2012) review, the use of epidural analgesia in this study the same degree of damage as a second-degree perineal lac-
resulted in the risk factor of PUR. According to the eration (Shimada, 2003), and it was unlikely that it was
Cochrane Systematic Review of Anim-Somuah, Smyth, and directly related to voiding dysfunction. Shimada (2003)
Jones (2011), epidural analgesia increased instrument deliv- suggested that in previous research there was a possibility
ery (relative risk [RR] 1.42, 95% CI 1.28 to 1.57, 23 trials, that the sensation of pain in the perineum after delivery may
7,935 women), urinary retention (RR 17.05, 95% CI 4.82 to differ between an episiotomy and perineal laceration. Irie
60.39, three trials, 283 women), longer second stage of labor et al. (1995) reported that a significant number of dysuria
(mean difference 13.66 min, 95% CI 6.67 to 20.66, 13 trials, symptoms appeared in the episiotomy group and described
4,233 women), and oxytocin administration (RR 1.19, 95% the involvement of emotional factors. For example, urination
CI 1.03 to 1.39, 13 trials, 5,815 women). It is clear that the could be difficult when the woman is anxious that it will
use of epidural analgesia was a risk factor for PUR. increase the pain from her laceration or episiotomy or that it
While the very nature of a vaginal delivery can be a risk might make her wound dehisce. Women who had an episiot-
factor for PUR, there are other factors to consider. One omy often feared urination itself might be painful. It is pre-
important one is the impact of epidural analgesia. During sumed that there is an influence on women's emotional state
epidural analgesia, the local anesthetics ropivacaine and syn- due to the episiotomy.
thetic opioid fentanyl are used. Opioids have four classic
side effects: pruritus, nausea / vomiting, urinary retention
and respiratory depression. Epidural opioids act on opioid 4.3 | PUR healing process after delivery
receptors in the sacral spinal cord, causing detrusor relaxa- In this study, there were 59 women with overt urinary reten-
tion and maximal bladder capacity increase (Chaney, 1995). tion, and all were transitioning to covert urinary retention. In
In addition to epidural analgesia weakening the contraction addition, within 72 hr after birth, 50 (64.9%) women had
force of the detrusor muscles, excessive extension of the healed: 40 women (67.8%) with overt PUR and 10 women
bladder occurs if a large amount of urine is stored due to an (55.6%) with covert PUR. Carley et al. (2002) reported that
increase in maximum bladder capacity. For this reason, in 23 (45.1%) of 51 women with overt PUR resolved by 48 hr
women who received epidural analgesia, observations of the postpartum and 15 (29.4%) were healed by 72 hr. As a
effect of anesthesia on the bladder and detrusor muscles and result, 38 women (74.5%) with overt PUR were healed
voiding assessment are crucial. As noted earlier, Sugo et al. within 72 hr. In this study, similar to the results of Carley
(2010) explained that the cause of urinary retention after et al. (2002) about 70% of overt PUR healed within 72 hr. In
childbirth is due to nerve damage referred to as neuropathic this study, the number of women who had not healed at the
bladder and is caused by hyperextension of the bladder dur- time of discharge (vaginal delivery was usually 4-5 days)
ing delivery. Pressure of the infant's head during descent can were 13 (22.0%) with overt PUR and four (22.2%) with
cause fine nerve injury, and urination attenuation or disap- covert PUR. There were 17 (22.0%) women who did not
pearance and urinary retention may occur. heal within 5 days after birth. Carley et al. (2002) reported
In this study, another perceived risk factor was episiot- that 13 (25.5%) did not heal after 72 hr, and 10 (19.6%) of
omy. The adjusted odds ratio of episiotomy was 2.68. 13 women were still unhealed at discharge. In the Carley
Mulder et al. (2012) conducted a systematic review and et al. (2002) research about 20% of women with PUR had
meta-analysis, which combined five studies (three prospec- been discharged from the hospital without healing. The dis-
tive studies and two retrospective studies) together with epi- parate reporting time frames of healing from PUR make it
siotomies and perineal lacerations; their adjusted odds ratio more difficult to compare the healing trajectories but a com-
was 4.8. Mulder et al. (2012) gave an adjusted odds ratio for parison suggests that this study and the Carley et al. (2002)
perineal damage, with similar results obtained in this study. study were similar.
8 of 9 KAWASOE AND KATAOKA

Although the postpartum period is the time to acquire the Therefore, initiatives for the prevention and management of
mothering role, it is obvious that the burden increases with PUR are necessary.
PUR. Therefore, midwives who support postpartum women
need to know the healing process of women in PUR. Then,
ACKNOWLEDGMENTS
it is necessary to deepen their knowledge of PUR and to be
able to make appropriate voiding assessments. We would like to thank the staff, of each participating hospi-
tal for their cooperation and support of this research. Sarah
E. Porter PhD RN provided editorial assistance.
4.4 | Limitation of the study
The main limitation of this study was the data collection C O N F L I C T O F I N T ER ES T
method using the chart review, and therefore there may have
been charting inaccuracies and missing data in the medical The authors declare no conflict of interest.
and nursing records. Therefore, not all data could be col-
lected. Also, since it was a retrospective study, the selection
AU THOR CON TRIBU TIONS
bias of controls was also a weak point of the research design.
Although there was a possibility of selection bias, there was IK was involved in the design of the study, data collection,
no significant difference in obstetric characteristics between data analysis and manuscript writing. YK participated in the
the case group and control group. This study was a case- design of the study, data analysis and manuscript writing.
control study with chart review and had no memory bias. In Both authors read and approved the final manuscript.
addition, there was no factor for PUR to be declared directly
by the subjects, and the factor that was exposed was the
OR CI D
result of vaginal delivery and there was no information bias
because it was not something that the subjects or staff could Izumi Kawasoe https://orcid.org/0000-0002-1777-5422
control. The risk factors were not clarified because the sam-
ple size was small at both hospitals, protocols for epidural
REF ER ENC ES
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