International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - Vol 12 Issue 09, May, 2020

Pages: 10-13

Date of Publication: 04-May-2020


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Merits and Demerits of Using Indwelling Catheter in Lower Segment Caesarean Section

Author: Samina Sultana, Shagufta Yasmeen Rather, Iqra Rehman

Category: Healthcare

Abstract:Background: The reported incidence rates of urinary retention after caesarean section vary from 3.3 to 39.2%. The use of indwelling urinary catheters has been implicated as a main cause of urinary tract contamination occurring in 1.7 per 1000 of caesarean delivery patients, and accounting for greater than 80% of nosocomial UTIs and greater postoperative pain.
Objectives: The aim of this study was to assess whether carrying out CS without urethral catheterization is safe in terms of intraoperative safety, prevalence of UTI, and the rate of the first voiding discomfort.
Methods: A prospective case control study done at L.D. hospital, GMC Srinagar over a period of one year from December 2018 to December 2019. 200 pregnant women without any medical / surgical complication undergoing emergency / elective CS were randomly selected by use of table of random numbers and allocated to two groups. Caesarean section was done under SA by the same surgeon using conventional technique. The duration of surgery was defined as interval between skin incision to skin closure by standard clock in OT.
Results: Women in both groups had no significant difference in age, parity and indication for cesarean section. They received the same pre and postoperative treatment. Time to first void was 4-8 hrs in 62 patients and more than 9 hrs in 38 patients in NC group. Discomfort at first void was seen in 34 patients of NC group and 59 of C group. Of the C group 30 had mild and 4 had severe discomfort. Among the C group, 45 had mild and 14 had severe discomfort at first void. The incidence of UTI in C/S after 48hrs was 4/100 among NC group and 17/100 among C group. Febrile morbidity was seen in 1 patient of NC group and 8 of C group. Hospital stay among NC group was 3.7 days and among C group was 4.3 days.
Conclusion: Non-use of urinary catheter at caesarean section causes less pain at first void less time to ambulate and less chance of urinary tract infections with a slightly increased chance of postoperative urinary retention.

Keywords: Caesarean section, Voiding discomfort, Urinary tract infections

Full Text:

INTRODUCTION

An indwelling urinary catheter is a routine part of most surgeries including cesarean section (CS) performed today, inserted prior to surgery and remains 12 – 24 h post operation1. The rationale for catheterization is to prevent bladder injury, intra-operative dif?culties and postoperative urinary retention in the belief that an empty bladder is at less risk of damage during surgery than one that is distended2,3.

The reported incidence rates of urinary retention after caesarean section vary from 3.3 to 39.2%, depending on the de?nitions used4,5 and catheterization has been consistently associated with urinary tract infections (UTIs)6,7. Bacterial access is gained to the bladder intraluminally by entering catheter system at catheter collecting tube junction or patients own gut flora may colonize the periurethral area and reach bladder via external surface of catheter8. The use of indwelling urinary catheters has been implicated as a main cause of urinary tract contamination9,10 occurring in 1.7 per 1000 of cesarean delivery patients11, and accounting for greater than 80% of nosocomial UTIs12 and greater postoperative pain13. UTIs may lead to local and systemic morbidity, as well as serious complications, such as septic shock, respiratory insuf?ciency, secondary bloodstream infection, ?uid balance disorders, chronic renal insuf?ciency and death, and related increases in healthcare costs14-18.

Clinical trials have been performed comparing the safety and feasibility of urinary catheterization use and non-use during caesarean section2,19,20.

OBJECTIVE

To assess whether carrying out caesarean section without urethral catheterization is safe in terms of intraoperative safety, prevalence of UTI, and the rate of the first voiding discomfort.

METHODS

A prospective case control study done at L.D. hospital, GMC Srinagar over a period of one year from December 2018 to December 2019. 200 pregnant women without any medical /surgical complication undergoing emergency/elective CS were randomly selected by use of table of random numbers and allocated to two groups.

Group 1 (NC): Non Catheterized (NC)

Group 2 (C): Catheterised for 24hrs postoperative.

The groups were comparable in terms of age, parity, indication of CS, type of CS, anaesthesia and same operating surgeon.

Exclusion criteria

  1. Medical disorders associated with pregnancy e.g. GDM, PIH, CKD etc.

  2.  Previous LSCS/ surgical complication.

  3. Rupture of membranes > 4hrs

  4. Pre-existing UTI

All patients received a single dose of antibiotics before surgery after cord clamping which as per hospital protocol was continued for 2 days postoperatively.

Parameters noted were;

  1. Duration of surgery.

  2. Time to ambulation

  3. Postop retention

  4. Time of first void

  5. Discomfort at first void

  6. UTI [urine routine / morning (U-R/M), urine culture sensitivity (U – C/S) done on urine sample at end of 24hrs post op in both groups.

  7. Duration of hospital stay.

Caesarean section was done under SA by the same surgeon using conventional technique. The duration of surgery was defined as interval between skin incision to skin closure by standard clock in OT. Postoperatively patients were monitored closely and were kept fasting for a minimum of 8 hrs and received tramadol as analgesia for first 24 hrs. Discomfort at first void was defined as burning, urging, and painful voiding.

For assessing level of discomfort visual analog scale (VAS) was used. VAS uses numerical rating of 0-10 as was explained to each patient. The patient chooses a number from 0-10 that best described her pain intensity. Accordingly, three categories were divided (i) No discomfort VAS -0, Mild discomfort (VAS: 1-3) and Moderate discomfort (VAS: 4-10).  Time of first void was defined as time interval between removal of urinary catheter and first spontaneous void.

The time of first ambulation was defined as interval between onset of surgery and time patient first ambulated. Urine of all patients was sampled immediately before and 24 hrs post-surgery and subjected to routine and microscopy exam and culture and sensitivity. Antibiotics were changed according to culture report. Criteria for discharge were: (i) Patient afebrile for 24hrs, (ii) On oral medications, (iii) Accepting orally well     (iv) bowel and bladder function normal.

Statistical Method: The recorded data was compiled and entered in a spreadsheet (Microsoft Excel) and then exported to data editor of SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as Mean±SD and categorical variables were summarized as frequencies and percentages. Chi-square test was applied for comparing categorical variables and continuous variables were compared by Student’s independent t-test. A P-value of less than 0.05 was considered statistically significant. All P-values were two tailed.

RESULTS

200 women enrolled in the study were assigned to two groups. Women in both groups had no significant difference in age, parity and indication for cesarean section. They received the same pre and postoperative treatment. Duration of surgery was almost similar in both groups.

Initiation of ambulation was 9 hrs in NC group and 15 hrs in C group. This was statistically significant with a p value of < 0.001.  Postoperative retention was seen in 2 women among the NC group for which catheterization was done on the first postoperative day.

Time to first void was 4-8 hrs in 62 patients and more than 9 hrs in 38 patients in NC group. Discomfort at first void was seen in 34 patients of NC group and 59 of C group. Of the C group 30 had mild and 4 had severe discomfort. Among the C group, 45 had mild and 14 had severe discomfort at first void. The difference was statistically significant with a p value of < 0.001.

The incidence of UTI in C/S after 48 hrs was 4/100 among NC group and 17/100 among C group. Febrile morbidity was seen in 1 patient of NC group and 8 of C group. Hospital stay among NC group was 3.7 days and among C group was 4.3 days.

DISCUSSION

The study confirms that catheterisation during cesarean section is not necessary. We found that non placement of indwelling catheter during LSCS was associated with significantly fewer UTIs, a lower rate of discomfort at first voiding, less time until first voiding and ambulation and shorter duration of hospital stay. Duration of surgery was comparable in both groups. The patients in NC group ambulated early. This was due to restriction of mobility with the indwelling catheter because of pain and fear of accidental expulsion in the C group21. The C group had a longer hospital stay because of post op UTI and associated fever. Discomfort at first void was seen more in group C patients (59%) with 14% patients experiencing moderate to severe discomfort. Majority of patients in group NC had mild discomfort at first void. In a study by Arlyn et al 83% of group C patients had discomfort at first void of which 28% had severe discomfort22. The urethral catheter as a cause of UTI in pregnancy and puerperium is well known. Bacteriuria associated with indwelling catheter in the postoperative period has been found to be an important cause of hospital acquired UTI. It was seen in 14% of patients of group C and the results were significant. Febrile morbidity was seen in 1% of patients in NC group as compared to 8% patients in group C.

A major rationale for catheterisating urinary bladder was to avoid postoperative retention. However in our study non-use of urinary catheterisation during cesarean section was not associated with an increase in urinary retention. Urinary retention was seen in 2% patients in group NC and was probably due to inadequate analgesia and fear of early ambulation. Hence indwelling catheterisation leads to increased incidence of UTI. More discomfort at first void and delayed ambulation. In cases where required, proper aseptic catheter insertion technique, closed drainage maintenance, avoiding prolonged catheterisation and proper catheter care can reduce the risk of acquiring UTIs.

CONCLUSION

            Routine use of indwelling catheter for cesarean section in haemodynamically stable patients is not necessary. Use of catheter is associated with increased incidence of urinary infection, more discomfort at first voiding, immobility and increased cost of healthcare delivery services.

Acknowledgement

We acknowledge the help and support of the Head of the Department of Obstetrics and Gynaecology. We extend our gratitude to all the participating patients.

Conflict of interest: None

Financial support: None

References:

  1. Lang JF, Bowen JC, Strong P., Use of indwelling urinary catheter at cesarean delivery, Obstetrics & Gynecology. 2001; 97(4): S 66.

  2. Senanayake H., Elective cesarean section without urethral catheterization.             J ObstetGynaecol Res 2005;31:32–37.

  3. Arulkumaran S, Cheng S, Ingemarsson I, Ratnam SS, Low SH, Is there a need for routine indwelling catheter after caesarean section? Singapore Med J 1986;27:54–57.

  4. Tangtrakul S, Taechaiya S, Suthutvoravut S, Linasmita V., Post-caesarean section urinary tract infection: a comparison between intermittent and indwelling catheterization. J Med Assoc Thai 1994;77: 244–48.

  5. Humburg J., Postpartum urinary retention – without clinical impact? Ther Umsch 2008;65:681–85.

  6. Schwartz MA, Wang CC, Eckert LO, Critchlow CW, Risk factors for urinary tract infection in the postpartum period. Am J Obstet Gynecol 1999;181:547–53.

  7. Barnes JS, Is it better to avoid urethral catheterization at hysterectomy and caesarean section? Aust NZ J Obstet Gynaecol 1998; 38:315–16.

  8. Pandey D, Mehta S, Grover A, Goel N. Indwelling Catheterization in Caesarean Section: Time To Retire It! J Clin Diagn Res. 2015;9(9):QC01–QC4.

  9. Hemsell DL, Infections after gynecologic surgery. Obstet Gynecol Clin North Am 1989; 16: 381–85.

  10. Kunin CM, Urinary tract infections in females, Clin Infect Dis 1994; 18(1): 1–10.

  11. Rochelle L In: Cunningham FG, MacDonald PC, Gant NF (eds). Williams Obstetrics. 22nd edn. Vol 23 McGraw-Hill: New York, 2005, pp 523.

  12. Sedor J, Mulholland SG. Hospital-acquired urinary tract infections associated with the indwelling catheter. UrolClin North Am 1999; 26(4): 821–28.

  13. Leksawasdi N, Chanchai N, Wongkolkijsin N. Patient’s Pain Level During Indwelling Urinary Catheter. Faculty of Nursing, Chiang Mai University, Thailand, 1995.

  14. Saint S, Chenoweth CE. Bio?lms and catheter-associated urinary tract infections. Infect Dis Clin North Am 2003;17:411–32.

  15. Warren JW. The catheter and urinary tract infection. Med Clin North Am 1991; 75: 481–93.

  16. Maki DG, Tambyah PA, Engineering out the risk for infection with urinary catheters. Emerg Infect Dis 2001;7:342–47.

  17. Saint S, Lipsky BA, Goold SD, Indwelling urinary catheters: aonepoint restraint? Ann Intern Med 2002;137:125–57.

  18. Plowman R, Graves N, Grif?n MA, Roberts JA, Swan AV, Cookson B, et al. The rate and cost of hospital-acquired infections occurring in patients admitted to selected specialties of a district general hospital in England and the national burden imposed. J Hosp Infect 2001;47:198–209.

  19. Nasr AM, El-Bigawy AF, Abdelamid AE, Al-Khulaidi S, Al-Inany HG, Sayed EH. Evaluation of the use vs nonuse of urinary catheterization during cesarean delivery: a prospective, multicenter, randomized controlled trial. J Perinatol 2009;29:416–21.

  20. Ghoreishi J., Indwelling urinary catheters in cesarean delivery. Int J Gynaecol Obstet 2003;83:267–70.

  21. Beeson PB, The case against the catheter. Am J Med.2000;24:1-6.

  22. Arlyn E, Antonia E, et al. Early removal of urinary catheter in CS in a tertiary       training hospital. Philippine Journal of Obs & Gynae.2007;31(2):69-74.

Research Incentive Schemes

Awards, Research and Publication incentive Schemes by IJCRR

Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

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Best Article Award

A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma COLAKOGLU entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by Arpita M. et al entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09
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List of Awardees

Awardees of COVID-19 Research

Woman Researcher Award

A Study by Neha Garg et al. entitled "Optimization of the Response to nCOVID-19 Pandemic in Pregnant Women – An Urgent Appeal in Indian Scenario" published in Vol 12 issue 09

A Study by Sana Parveen and Shraddha Jain entitled "Pathophysiologic Enigma of COVID-19 Pandemic with Clinical Correlates" published in Vol 12 issue 13

A Study by Rashmi Jain et al. entitled "Current Consensus Review Article on Drugs and Biologics against nCOVID-19 – A Systematic Review" published in Vol 12 issue 09

Emerging Researcher Award

A Study by Madhan Jeyaraman et al. entitled "Vitamin-D: An Immune Shield Against nCOVID-19" published in Vol 12 issue 09

Study by Dheeraj Kumar Chopra et al. entitled "Lipid-Based Solid Dispersions of Azilsartan Medoxomil with Improved Oral Bioavailability: In Vitro and In Vivo Evaluation" published in Vol 12 issue 19


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