|Year : 2020 | Volume
| Issue : 2 | Page : 410-414
The necessity of urethral catheterization in repeated versus primary cesarean section
Fatheia S Mohamed1, Mohamed M Fahmy2, Alaa El Deen F. El Halaby2, Nabih I El Khouly2
1 Department of Obstetrics and Gynecology, Kotor Central Hospital, Gharbia, Egypt
2 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||22-Jan-2019|
|Date of Decision||27-Feb-2019|
|Date of Acceptance||02-Mar-2019|
|Date of Web Publication||27-Jun-2020|
Fatheia S Mohamed
Source of Support: None, Conflict of Interest: None
To determine the necessity and safety of urethral catheterization in repeated versus primary cesarean section as it is not addressed clearly in the previous literature.
Urethral catheterization is done as a routine procedure in a cesarean section. It is associated with high incidence of urinary tract infections, discomfort, delayed ambulation, and longer hospital stay.
Patients and methods
This randomized, controlled trial was carried out from April 2016 to October 2018; the study was conducted at Menoufia University Hospital, Obstetrics and Gynecology Department, the patients were recruited from the inward section. The study included 200 patients who were subjected to a cesarean section. After the selection of all patients, informed consent was obtained from all the participants. Ethics committee approval was obtained prior to the start of the study. The patients were randomly allocated by using a computer-generated random number table to either catheterized or noncatheterized.
There were highly significant differences between primary and repeated cesarean sections with and without catheter as regards urine culture and sensitivity, signs and symptoms of urinary tract infection, first ambulation, and first voiding discomfort (P < 0.001), while there was no significant difference between them as regards the time of surgery and Postpartum hemorrhage (PPH) and there was no significant difference between them as regards age, gestational age, urine retention, bladder injury, and blood loss (P = 0.005).
Routine placement of indwelling urinary catheters for cesarean delivery in hemodynamically stable patients is not necessary and can be harmful. Moreover, the women needing catheterization should be selectively chosen. Thus, it should be selective catheterization rather than catheterization for all.
Keywords: cesarean section, indwelling urinary catheters, urinary tract infection
|How to cite this article:|
Mohamed FS, Fahmy MM, El Halaby AE, El Khouly NI. The necessity of urethral catheterization in repeated versus primary cesarean section. Menoufia Med J 2020;33:410-4
|How to cite this URL:|
Mohamed FS, Fahmy MM, El Halaby AE, El Khouly NI. The necessity of urethral catheterization in repeated versus primary cesarean section. Menoufia Med J [serial online] 2020 [cited 2020 Jul 13];33:410-4. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/410/287743
| Introduction|| |
Cesarean section is the most common obstetric operative procedure worldwide. The incidence of cesarean section is continuously rising giving women frequently an obstetric status of previous cesarean section. However, this makes future obstetric performances and future abdominal explorations risky. Urinary catheterization before a cesarean section is a long-standing practice that is justified by research evidence. The rationale for catheterization is to prevent bladder injury, intraoperative difficulties, and postoperative urinary retention in the belief that an empty bladder is at less risk of damage during surgery than one that is distended; a distended bladder is also expected to interfere with exposure and make surgery more difficult. Surgery near the uterovesical area can cause bruising and edema of the bladder and lower abdominal pain, leading to retention of urine. Since experience has now shown that routine urinary catheterization may not be necessary for all cesareans and its use might carry a high risk for infection, confirmation of these findings should be approached before opening the gate to other techniques need to be explored. The best way to prevent complication is to avoid catheterization whenever possible. A few clinical trials have been performed comparing the safety and feasibility of urinary catheterization use to nonuse during cesarean section,. The aim of this study is to determine the necessity and safety of urethral catheterization in repeated versus primary cesarean section as it is not addressed clearly in previous literature.
| Patients and Methods|| |
A prospective, randomized, controlled trial was carried out from April 2016 to October 2018 at the Obstetrics and Gynecology Department, Menoufia University Hospital. This study included 200 patients who had undergone cesarean section out of which 100 were primary cesarean sections divided into two equal groups [50 primary with catheter (A1), 50 primary without catheter (A2)], and 100 repeated cesarean section and were divided into two equal groups:[50 repeated with catheter (B1), 50 repeated without catheter (B2)].
The study was approved by the ethics committee of Menoufia Faculty of Medicine and an informed consent was obtained from all patients before the study started.
Sample size was calculated using computer sample block randomization type to either catheterized or noncatheterized.
Patients with a singleton pregnancy planned for elective cesarean section who had voided immediately prior to arrival in the operation theater. Exclusion criteria: patients with a past history of bladder injury during a cesarean section, multiple pregnancies, diabetes with pregnancy, rupture of membranes, and patients with established preoperative urinary tract infection (UTI). All patients were subjected to: detailed history, physical examination, and preoperative investigations including urine routine microscopic, complete blood count analysis as well as ultrasonography. Patients without the catheter group were asked to void just before entering the operating room. For the catheter group, urinary bladder was catheterized using a 14 Fr Foley catheter. All patients in both groups received a single dose of intravenous Cefazolin 2 g after sensitivity test as a prophylactic antibiotic just before the start of surgery and were operated under spinal anesthesia. Cesarean section was performed in a conventional manner. Oxytocin 20 U was given in a running intravenous drip of Ringer's lactate solution following the delivery of the baby. The duration of surgery was being defined as an interval between the skin incisions till the completion of skin closure. The urinary catheter was removed 6 h from the onset of surgery. Patients in the noncatheterized group were asked to void only upon feeling the urge. If the urge to void was reported at a time when mobilization was not possible, a bedpan was given. If this failed, helping measures like adequate analgesia and privacy were provided. If still, the patient had difficulty in passing urine after 6 h or if the abdominal examination shows palpable urinary bladder, Foley catheterization was done. Soakage of vulval pads and the presence of fresh bleeding or clots were considered as PPH. Time of beginning of ambulation was noted considering the beginning of surgery as the zero time. Discomfort in the first voiding was defined as burning, urging, and difficulty at voiding time. The time of first voiding was taken as the interval between the start of the operation and first voiding. Urine for culture and sensitivity was done 24 h postoperatively. UTI was diagnosed by the presence of clinical features (dysuria, frequency, loin pain, pyrexia) with either the presence of 100 bacteria per milliliter of urine with more than or equal to 10 leukocytes per high power field.
The results were tabulated and statistically analyzed by using a personal computer using Microsoft Excel 2016 and SPSS, version 21 (SPSS Inc., Chicago, Illinois, USA). Statistical analysis was done using: descriptive, for example, percentage, mean, and SD. Analytical: that includes: χ2, t test, and Fisher's exact test. A value of P less than 0.05 was considered statistically significant.
| Results|| |
The patients in primary and repeated cesarean sections with and without catheterization were similar in terms of age, period of gestation, duration of surgery, and hospital stay [Figure 1] and [Figure 2]. Ambulation time was significantly shorter in patients without urethral catheter. The first voiding time was 2.24 ± 0.60 h in a primary cesarean section without catheter and 5.04 ± 0.61 h in a primary cesarean section with catheter with statistically significant differences between them [Figure 1] The first voiding time was 2.28 ± 0.74 h in repeated cesarean sections without catheter and 5.12 ± 0.73 h in repeated cesarean sections with catheter with statistically significant difference between them [Figure 2]. Signs and symptoms of UTI and urine culture were significantly associated with the use of the urethral catheter in primary and repeated cesarean sections ([Table 1] and [Table 2]). Urine retention was observed in four patients in a repeated cesarean section without catheter with no significance [Table 2]. No cases of bladder injury were observed in patients without catheter while one case finding in a repeated cesarean section with the catheter [Table 2] with no significant differences between them. There was a significant difference between catheterized and noncatheterized groups regarding the first voiding discomfort. Also, two patients of the primary noncatheterized group and four patients of the repeated noncatheterized group had PPH ([Table 1] and [Table 2]).
|Figure 1: Comparison between primary cesarean section with and without catheter as regards demographic data, time of surgery, hospital stay/day, first ambulation, and time of first voiding.|
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|Figure 2: Comparison between repeated cesarean sections with and without catheter as regards demographic data, time of surgery, hospital stay/day, first ambulation, and time of first voiding.|
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|Table 1: Comparison between primary with and without catheter according to urine culture sensitivity, signs and symptoms of urinary tract infection, urine retention, bladder injury, PPH, first voiding discomfort, and blood loss|
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|Table 2: Comparison between repeated with and without catheter according to urine culture sensitivity, signs, and symptoms of urinary tract infection, urine retention, bladder injury, PPH, first voiding discomfort, and blood loss|
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| Discussion|| |
Our study showed a lower prevalence of UTI in the noncatheterized group (2%) which was similar to the study done by Oriji and Nyeche, who found 4.4% which is same as the study done by Senanayake which found a lower prevalence of UTI in the noncatheterized group (4%). Our results showed a significantly higher incidence of UTI among the catheterized group. This finding was comparable to Pandey et al. who found that among 75 women assigned for catheterization the incidence of UTI detected by urine culture was 29.3% compared with 4% of the noncatheterized group (P < 0.005). A case–control study done by Amat-Alkaram and Athmar showed a significantly higher incidence of UTI among the catheterized group (28 vs. 8%, P < 0.005). This results were in contrast to our study (65 vs. 2%) and this is explained by the small sample size (n = 100). In another study, Onile et al. reported a higher prevalence of UTI among the catheterized group. The UTI and fever led to longer hospital stay and the use of postoperative antibiotics. UTI was the main reason for the use of postoperative antibiotics in the catheterized group. In our study, a low rate of postoperative urine retention in a cesarean section without catheter (four cases, 8%) was in agreement with the study done by Ghoreishi, who reported low incidence of postoperative urinary retention (4.4%) which is probably due to a combination of factors such as good postoperative analgesia-promoted early ambulation which allowed initiation of voiding in the toilet. Participants initiated voiding only upon feeling the urge to void, rather than according to a time frame. It is also possible that modification of the technique to avoid blunt dissection of the bladder prevented disturbance of the innervation of the bladder, thereby keeping the voiding reflex intact. In a prospective, randomized controlled study Acharya et al. reported a high incidence of postoperative urine retention (21%), which was in disagreement with our study and this may be due to that in–out catheterization was not done, rather directly Foley catheterization was inserted. In our study, there was no case of accidental cystotomy and aspiration of the bladder to relieve distension at surgery was not required in any of the noncatheterized group. This result was in agreement with Acharya et al.. On the other hand, in our study, there was one case of accidental cystotomy in the catheterized group. In our study, there was no statistically significant difference between the studied groups regarding PPH, which is similar to the study done by Senanayake who concluded that 6.68% cases of postpartum uterine atony causes hemorrhage. Another study by Jansen et al. reported that 4% of the patients without indwelling catheter had PPH which was in agreement with our study. A study done by Chowdhury and Jahan showed that none of the patients without indwelling catheter had PPH and this was in disagreement with our study. This lower incidence of PPH in our study may be because multiple pregnancies and prolonged labor, which are the risk factors for PPH were excluded from this study. In contrast, a study done by Jansen et al. reported a high percentage of PPH 30% which was in contrast with our study (6%). In this study, there was a highly significant difference between cesarean section with and without catheter as regards first voiding discomfort. This was in agreement with Nasr et al. which found discomfort at urination at 24 h and 1 week after surgery which was significantly high in the catheterized group, which is in agreement with another study. Acharya et al. showed first void discomfort in 9% of noncatheterized and 64% of catheterized patients and similarly the study of Ghoreishi shows 6 versus 93%. This study reported a higher incidence of the first voiding discomfort experienced among the catheterized group with statistically significant difference between them. These results were in agreement with the results observed by Arlyn et al. which reported 85% first voiding discomfort same as Pandey et al. which reported 83% first voiding discomfort. In our study, there was highly significanct difference between cesarean section with and without catheter as regards the time of first voiding which was similar to the results of Ghoreishi. In contrast to another studies which reported longer time of first void after operation in the trial of Senanayake (8.70 ± 2.37 h) and Nasr et al. (7.64 ± 3.61). This is explained by taking a larger sample size. In our study, there was a highly significant difference between the studied groups as regards the time of ambulation. Patients in the noncatheterized group initiated ambulation significantly earlier. This was due to the physical restraints in moving freely with the indwelling catheter because of pain and fear of accidental expulsion. This was similar to several studies done by Ghoreishi and Nasr et al. which concluded that nonuse of urinary catheters was associated with less time until ambulation. In the present study, there was no significant difference between catheterized and noncatheterized groups regarding the duration of surgery; the mean duration of surgery was not statistically significant between the two groups which was in accordance to the study of Senanayake which concluded that cesarean section without urethral catheterization does not compromise the safety and ease of surgery and reduces the risk of UTI as well. In our study, there was no statistically significant difference between the studied groups as regards hospital stay which was a shorter stay but without a significant difference which is similar to the study done by Ghoreishi, Senanayake similar to the study done by Ghoreishi, and Arlyn et al.. They concluded that the hospital stay was shorter in the noncatheterized group.
| Conclusion|| |
Cesarean section even in repeated cases can be done safely without urethral catheterization with reduced morbidities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pai M, Sundaram P, Radhakrishnan KK. A high rate of cesarean sections in an affluent section of Chennai: is it cause for concern? Natl Med J India 1999; 12
Senanayake H. Elective cesarean section without urethral catheterization. J Obstet Gynecol Res 2005; 31
Kirkwood A, Price L. The influence upon design of differing conceptions of teaching and learning with technology. In: Olofsson AD, Lindberg O, eds. Informed design of educational technologies in higher education: enhanced learning and teaching (1-20)
. Hershey, Pennsylvania: IGI Global; 2012. p. 1-20.
Cramer KM, Collins KR, Snider D, Fawcett G. The virtual lecture hall: utilization, effectiveness and student perceptions. Br J Educ Technol 2007; 38
Torrisi-Steele G. This thing called blended learning – a definition and planning approach. Res Dev Higher Educ 2011; 34
Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerling SE, Rice JC. Diagnosis, prevention and treatment of catheter associated urinary tract infection in adults: 2009 international clinical practice guidelines from the infectious diseases Society of America. Clin Infect Dis 2010; 50
Nasr AM, Elbigawy AF, Abdelamid AE, AI-Khulaid S, Al-Inany HG, Sayed EH. Evaluation of the use vs nonuse of urinary catheterization during cesarean section delivery: a prospective, multicenter, randomized controlled trial. J Perinatol 2009; 29
Oriji K, Nyeche S. Comparative analysis of the duration of urethral catheterization for cesarean delivery IOSR. JDMS 2018; 17
Pandey D, Mehta S, Grover A, Goel N. Indwelling catheterization in caesarean section: time to retire it! J Clin Diagn Res 2015; 9
Amat-Alkaram KA, Athmar H. Caesarean section without using bladder catheterization is safe in uncomplicated patients. J Gynecol Obstetr 2017; 5
Onile T, Kuti O, Orji E. A prospective randomized clinical trial of urethral catheter removal following elective cesarean delivery. Int J Gynaecol Obstet 2008; 102
Ghoreishi J. Indwelling urethral catheter in cesarean delivery. Int J Obstet Gynecol 2003; 83
Acharya S, Uprety D, Pokharel H, Amatya R, Rai R. Cesarean section without urethral catheterization: a randomized control trial. Kathmandu Univ Med J 2012; 38
Jansen AJ, Van Rhenen DJ, Steegers EA, Duvekot JJ. Postpartum hemorrhage and transfusion of blood and blood components. Obstet Gynecol Surv 2005; 60
Chowdhury L, Jahan I. Cesarean section without urethral catheterization. JAFMC Bangladesh 2015; 11
Arlyn E, Antonia E, Habana D. Early removal of urinary catheter in caesarean delivery in a tertiary training hospital. Philippine J Obstetr Gynecol 2007; 31
[Figure 1], [Figure 2]
[Table 1], [Table 2]