DAY 9
📅 Nov 18 (Mon)
🚽 Urinary Complications
DME 211: Retention & Infection
- Urinary Retention: Neurogenic, mechanical
- UTI: Pyelonephritis, Cystitis
- Management: Catheterization, antibiotics
🚽 REMEMBER: Retention common after epidural/tested bladder. Catheterize if >600ml!
🔥 KEY POINT: Pyelonephritis = Fever + flank pain + dysuria. IV antibiotics required!
"A full bladder delays uterine involution. Keep them empty!"
"Streams of living water will flow." - John 7:38
1. URINARY RETENTION IN PREGNANCY & POSTPARTUM
📚 Definition:
Urinary retention is the inability to empty the bladder completely or partially, with residual urine volume >150ml.
CRITICAL VOLUME: Catheterize if bladder volume >600ml or patient uncomfortable!
💡 EXAM ALERT: Always quantify! "Retention" vs "Full bladder" are different. Document residual volume.
🔍 Types & Causes - The "MEN HURT" Mnemonic:
🧠 MNEMONIC: "MEN HURT BLADDER"
Mechanical obstruction:
• Prolapsed uterus (late pregnancy)
• Fetal head compression (2nd stage)
• Pelvic masses (fibroids)
Epidural anesthesia (common cause!)
• Blocks bladder sensation
• Atonic bladder
Neurogenic causes:
• Spinal anesthesia
• Postpartum neuropathy
• Diabetes (autonomic neuropathy)
Hypotonic bladder (overdistension)
Uterine atony pressing on bladder (PP)
Recent surgery (perineal repair)
Trauma (urethral injury)
Bladder overdistension (ignored urge)
Lack of privacy (psychological)
Antenatal testing (full bladder required)
Drugs (anticholinergics, opioids)
Dehydration (reduced urine output)
Elderly multipara (weak abdominal muscles)
Retention after catheter removal
Mechanical obstruction:
• Prolapsed uterus (late pregnancy)
• Fetal head compression (2nd stage)
• Pelvic masses (fibroids)
Epidural anesthesia (common cause!)
• Blocks bladder sensation
• Atonic bladder
Neurogenic causes:
• Spinal anesthesia
• Postpartum neuropathy
• Diabetes (autonomic neuropathy)
Hypotonic bladder (overdistension)
Uterine atony pressing on bladder (PP)
Recent surgery (perineal repair)
Trauma (urethral injury)
Bladder overdistension (ignored urge)
Lack of privacy (psychological)
Antenatal testing (full bladder required)
Drugs (anticholinergics, opioids)
Dehydration (reduced urine output)
Elderly multipara (weak abdominal muscles)
Retention after catheter removal
🌍 UGANDA CONTEXT: Most common cause in rural HC IIIs is postpartum after long labor with ignored bladder calls. Also common after spinal anesthesia for CS at HCIVs.
📋 Clinical Features - The "3 P's":
- Pain: Suprapubic discomfort, fullness
- Palpation: Palpable bladder above symphysis (>150ml)
- Passive overflow: Dribbling urine (paradoxical incontinence)
⚠️ CRITICAL ASSESSMENT: Always assess for bladder distension by palpation after delivery! A full bladder can cause uterine atony and postpartum hemorrhage!
🩺 Assessment - The "SCAN & MEASURE" Protocol:
- History: Ask when last voided, difficulty starting stream
- Inspection: Look for lower abdominal swelling
- Palpation: Palpate suprapubic area (dull, tender mass)
- Percussion: Dullness over bladder (confirm full)
- Bladder scan: If available (best method - non-invasive)
- Catheterize & measure: Gold standard (measure residual)
🔥 Complications of Untreated Retention:
🚨 MNEMONIC: "RETENTION HARMS"
Rupture of bladder (rare but catastrophic)
Empyema (infection)
Tract infection (ascending UTI)
Endotoxemia (if infected)
Necrosis of bladder wall
Tract damage (urethral injury)
Ileus (paralytic)
Ovarian vein thrombosis
Necrosis of uterus (if PP atony from displacement)
Hemorrhage (PPH due to uterine atony)
Atonic bladder (permanent damage)
Renal failure (back pressure)
Maternal distress
Secondary infection
Rupture of bladder (rare but catastrophic)
Empyema (infection)
Tract infection (ascending UTI)
Endotoxemia (if infected)
Necrosis of bladder wall
Tract damage (urethral injury)
Ileus (paralytic)
Ovarian vein thrombosis
Necrosis of uterus (if PP atony from displacement)
Hemorrhage (PPH due to uterine atony)
Atonic bladder (permanent damage)
Renal failure (back pressure)
Maternal distress
Secondary infection
2. URINARY TRACT INFECTIONS IN PREGNANCY
📚 Definition & Classification:
UTI = Infection of urinary tract (bacterial count >100,000 organisms/ml)
- Asymptomatic Bacteriuria (ASB): Bacteria in urine without symptoms (10% pregnant women)
- Cystitis: Lower UTI - bladder infection
- Pyelonephritis: Upper UTI - kidney infection (MEDICAL EMERGENCY!)
📊 EXAM CRITICAL: ASB if untreated → 25-40% develop pyelonephritis in pregnancy! ALWAYS screen and treat!
🔴 Why UTIs are Common in Pregnancy - The "PREGNANT" Mechanism:
🤰 MNEMONIC: "PREGNANT BLADDER PROMOTES INFECTION"
Progesterone effect:
• Smooth muscle relaxation
• Bladder hypotonia
• Urinary stasis
Renal changes:
• Increased GFR (40%)
• Glycosuria (nutrient for bacteria)
Enlarged uterus:
• Mechanical compression
• Incomplete bladder emptying
• Vesicoureteric reflux
Glucose in urine (esp. GDM)
Neutrophil function altered (immunosuppression)
Amino acids in urine (pregnancy)
Normal flora changes (pH changes)
Trade-off: Immune tolerance for fetus = infection risk
Bladder overdistension common
Limited mobility (bed rest)
Anatomically shorter urethra (women)
Diabetes mellitus (GDM)
Delayed treatment of ASB
Epidural/spinal (reduces sensation)
Retention leads to stasis
Progesterone effect:
• Smooth muscle relaxation
• Bladder hypotonia
• Urinary stasis
Renal changes:
• Increased GFR (40%)
• Glycosuria (nutrient for bacteria)
Enlarged uterus:
• Mechanical compression
• Incomplete bladder emptying
• Vesicoureteric reflux
Glucose in urine (esp. GDM)
Neutrophil function altered (immunosuppression)
Amino acids in urine (pregnancy)
Normal flora changes (pH changes)
Trade-off: Immune tolerance for fetus = infection risk
Bladder overdistension common
Limited mobility (bed rest)
Anatomically shorter urethra (women)
Diabetes mellitus (GDM)
Delayed treatment of ASB
Epidural/spinal (reduces sensation)
Retention leads to stasis
🦠 Common Organisms:
- E. coli (80% of cases) - from fecal flora
- Klebsiella
- Proteus
- Enterobacter
- Staphylococcus saprophyticus
- Group B Streptococcus (GBS) - important for neonatal sepsis
3. CYSTITIS (LOWER UTI)
📋 Clinical Features - The "BURNING SIGNS":
🔥 MNEMONIC: "BURNING URINE FREQUENCY"
Burning on urination (dysuria)
Urgency (can't hold urine)
Retention feeling (incomplete emptying)
Nocturia (waking to urinate)
Increased frequency (pollakiuria)
Normal temperature (usually afebrile)
Groin/suprapubic pain
Urine cloudy, foul-smelling
Restless but no systemic signs
Flank pain absent
Renal angle not tender
Eyes clear (no jaundice)
Quick recovery with treatment
Uterine contractions may increase (irritability)
Energy level normal
Burning on urination (dysuria)
Urgency (can't hold urine)
Retention feeling (incomplete emptying)
Nocturia (waking to urinate)
Increased frequency (pollakiuria)
Normal temperature (usually afebrile)
Groin/suprapubic pain
Urine cloudy, foul-smelling
Restless but no systemic signs
Flank pain absent
Renal angle not tender
Eyes clear (no jaundice)
Quick recovery with treatment
Uterine contractions may increase (irritability)
Energy level normal
💡 EXAM DIFFERENTIATION: Cystitis = LOCAL symptoms only (dysuria, frequency). NO fever, NO flank pain!
🩺 Diagnosis:
- Urine dipstick: Leukocytes, nitrites positive
- Microscopy: WBC >10 per high power field
- Culture: >100,000 organisms/ml
- Clinical: Symptoms as above
🏥 Management:
| Drug | Dose | Duration | Safety in Pregnancy |
|---|---|---|---|
| Amoxicillin | 500mg 8-hourly | 5-7 days | Safe |
| Cephalexin | 500mg 6-hourly | 5-7 days | Safe (1st line) |
| Nitrofurantoin | 100mg 12-hourly | 5 days | Safe (avoid at term) |
| Cotrimoxazole | 2 tabs 12-hourly | 5 days | Avoid in 1st trimester (folate antagonist) |
🌍 UGANDA MOH GUIDELINE: First line = Cephalexin 500mg 6-hourly for 5-7 days. Ensure adequate hydration (2-3L fluids/day).
4. PYELONEPHRITIS (UPPER UTI) - MEDICAL EMERGENCY!
🔥 Definition:
Pyelonephritis = Infection of kidney parenchyma & pelvis. LEADING CAUSE OF SEPTIC SHOCK IN PREGNANCY!
Mortality: Up to 2-3% if untreated!
📋 Clinical Features - The "SYSTEMIC SIGNS":
🚨 MNEMONIC: "PYELONEPHRITIS = FEVER + FLANK"
FEVER >38°C (high spiking, rigors)
Elevated pulse (tachycardia)
Vomiting & diarrhea
Exhausted mother (prostration)
Rigors (shaking chills)
FLANK PAIN (costovertebral angle tenderness - CVA tenderness)
Loin pain (unilateral or bilateral)
Abdominal pain (diffuse)
Nausea
Kidney area tender on percussion
Plus cystitis symptoms (dysuria, frequency)
Looking very ill (septic appearance)
Uterine contractions may be triggered (preterm risk!)
Shock signs if severe (hypotension)
FEVER >38°C (high spiking, rigors)
Elevated pulse (tachycardia)
Vomiting & diarrhea
Exhausted mother (prostration)
Rigors (shaking chills)
FLANK PAIN (costovertebral angle tenderness - CVA tenderness)
Loin pain (unilateral or bilateral)
Abdominal pain (diffuse)
Nausea
Kidney area tender on percussion
Plus cystitis symptoms (dysuria, frequency)
Looking very ill (septic appearance)
Uterine contractions may be triggered (preterm risk!)
Shock signs if severe (hypotension)
⚠️ CRITICAL DIFFERENTIATION: Pyelonephritis = FEVER + FLANK PAIN. Cystitis = NO fever, NO flank pain. This distinction is 90% of exam questions!
🩺 Diagnostic Criteria:
- Clinical: Fever + CVA tenderness + urinary symptoms
- Urine: WBC, RBC, nitrites, leukocytes
- Culture: >100,000 organisms/ml (E. coli most common)
- Blood: CBC (leukocytosis), CRP elevated
- Remember: Clinical diagnosis = enough to start treatment!
🏥 EMERGENCY MANAGEMENT - "PYELONEPHRITIS PROTOCOL":
🚨 THIS IS AN EMERGENCY! Admit, IV antibiotics within 1 hour, aggressive fluids!
- ADMIT to hospital: No outpatient treatment!
- IV fluids: 3L/day minimum (correct dehydration, flush kidneys)
- IV antibiotics:
- 1st line: Ceftriaxone 1g IV daily for 7 days
- Alternative: Gentamicin 5mg/kg IV daily + Ampicillin 2g IV 6-hourly
- Antipyretics: Paracetamol for fever
- Monitor: Vitals (BP may drop!), urine output (>30ml/hr), FHR
- Investigations: Urine & blood cultures before antibiotics
- Observe for: Septic shock, preterm labor
🌍 UGANDA MOH GUIDELINE: Pyelonephritis = REFERRAL TO HOSPITAL! HC III cannot manage. Give first dose antibiotics then transfer.
⚠️ Complications of Pyelonephritis:
- Maternal: Septic shock, ARDS, DIC, renal failure
- Fetal: Preterm labor, IUGR, fetal demise
- Recurrence: 10-20% risk (need suppressive therapy)
5. BLADDER CATHETERIZATION - THE PROCEDURE
🎯 Indications:
- Acute urinary retention (>600ml or symptomatic)
- Accurate urine output monitoring (critical care)
- Before CS or instrumental delivery
- Prolonged labor with full bladder
- Spinal/epidural anesthesia
- Urine collection for culture (sterile sample)
⚠️ Contraindications:
- Suspected urethral injury (trauma)
- Unidentified vaginal bleeding (rule out placenta previa first)
- Acute prostatitis (in males - not relevant for midwifery)
🩺 Procedure - Aseptic Technique:
🧤 MNEMONIC: "CLEAN CATHETERIZATION PROCEDURE"
Consent and explain to patient
Lie patient supine, knees flexed
Ensure privacy & good lighting
Aseptic hand wash & sterile gloves
Non-touch technique throughout
Cleanse vulva with antiseptic (chlorhexidine)
Allow antiseptic to dry
T isolate urethral orifice (separate labia)
Hold catheter 3-4cm from tip (Foley 14-16G)
Ease catheter gently through urethra
T advance until urine flows (5-7cm in adults)
Expand balloon with 10ml sterile water
Retraction (gently pull back to feel resistance)
Inspect urine (color, clarity, volume)
ZSecure catheter to thigh
Attach to drainage bag (below bladder level)
Teach patient about care
Issue instructions (increase fluids)
Offer pain relief if needed
Notify doctor if any difficulty
Consent and explain to patient
Lie patient supine, knees flexed
Ensure privacy & good lighting
Aseptic hand wash & sterile gloves
Non-touch technique throughout
Cleanse vulva with antiseptic (chlorhexidine)
Allow antiseptic to dry
T isolate urethral orifice (separate labia)
Hold catheter 3-4cm from tip (Foley 14-16G)
Ease catheter gently through urethra
T advance until urine flows (5-7cm in adults)
Expand balloon with 10ml sterile water
Retraction (gently pull back to feel resistance)
Inspect urine (color, clarity, volume)
ZSecure catheter to thigh
Attach to drainage bag (below bladder level)
Teach patient about care
Issue instructions (increase fluids)
Offer pain relief if needed
Notify doctor if any difficulty
⚠️ CRITICAL SAFETY: NEVER force catheter! If resistance, STOP! May be urethral spasm or obstruction. Try smaller size or call senior.
📏 Catheter Selection:
| Type | Size | Duration | Use |
|---|---|---|---|
| Foley (indwelling) | 14-16G | Short-term (<7 days) | Most common |
| Silicone | 16-18G | Long-term (up to 3 months) | Chronic retention (rare in maternity) |
| Coude tip | 14G | Single use | Difficult insertion (prostate issues - rare in women) |
🧴 Catheter Care & Prevention of Infection:
🛡 "CATHETER CARE PREVENTS INFECTION"
Proper perineal hygiene: Wipe front to back, wash daily
Avoid spermicides: Can alter normal flora
Treat vaginal infections: Prompt treatment of candidiasis, BV
Empty bladder before/after sex: Reduces bacterial entry
Prophylaxis for recurrent UTIs: Low-dose cephalexin 250mg nightly
A) Oral amoxicillin at home
B) Admit for IV antibiotics ⭐ CORRECT
C) Catheterization to relieve retention
D) Increase fluids and observe
b) Catheterization is indicated if a postpartum woman has not voided for 4 hours.
c) Nitrofurantoin is safe to use for UTI treatment at term.
🛡️ MNEMONIC: "PREVENT UTI IN PREGNANCY"
Pee regularly (every 3-4 hours)
Respond to urge immediately
Empty bladder before & after sex
Ventilate area (cotton underwear, no synthetics)
Eradicate vaginal infections quickly
Normal flora protection (avoid spermicides)
Treat ASB aggressively
Urine cultures as scheduled
Take all prescribed antibiotics
Increase fluids (2-3L water daily)
No holding urine (even at night)
Proper wiping (front to back)
Regular ANC attendance
Early treatment of symptoms
Good perineal hygiene
No tight clothing
Antibiotic prophylaxis if recurrent
Notify midwife of any burning sensation
Cranberry juice may help (safe, evidence limited)
Yield to treatment - complete full course!
Pee regularly (every 3-4 hours)
Respond to urge immediately
Empty bladder before & after sex
Ventilate area (cotton underwear, no synthetics)
Eradicate vaginal infections quickly
Normal flora protection (avoid spermicides)
Treat ASB aggressively
Urine cultures as scheduled
Take all prescribed antibiotics
Increase fluids (2-3L water daily)
No holding urine (even at night)
Proper wiping (front to back)
Regular ANC attendance
Early treatment of symptoms
Good perineal hygiene
No tight clothing
Antibiotic prophylaxis if recurrent
Notify midwife of any burning sensation
Cranberry juice may help (safe, evidence limited)
Yield to treatment - complete full course!
LIKELY EXAM QUESTIONS FOR DAY 9
1. FILL-IN-THE-BLANK (2 marks)
Catheterization should be performed if the bladder volume exceeds ______ ml in a postpartum woman, and the most common organism causing UTIs in pregnancy is ______.
ANSWER: 600ml, E. coli
2. MULTIPLE CHOICE (3 marks)
A pregnant woman at 28 weeks presents with fever of 39°C, right flank pain, and dysuria. She is diagnosed with acute pyelonephritis. The most appropriate initial management is:A) Oral amoxicillin at home
B) Admit for IV antibiotics ⭐ CORRECT
C) Catheterization to relieve retention
D) Increase fluids and observe
EXPLANATION: Pyelonephritis is a medical emergency in pregnancy requiring hospital admission and IV antibiotics!
3. SHORT ANSWER (5 marks)
Differentiate between cystitis and pyelonephritis based on clinical features.
ANSWER GUIDE: Must include:
• Fever (cystitis=no, pyelo=high fever) - 1 mark
• Flank pain (cystitis=suprapubic, pyelo=CVA tenderness) - 1 mark
• Systemic symptoms (pyelo=systemic, cystitis=localized) - 1 mark
• Maternal condition (pyelo=very ill, cystitis=well) - 1 mark
• Treatment setting (cystitis=outpatient, pyelo=hospital) - 1 mark
• Fever (cystitis=no, pyelo=high fever) - 1 mark
• Flank pain (cystitis=suprapubic, pyelo=CVA tenderness) - 1 mark
• Systemic symptoms (pyelo=systemic, cystitis=localized) - 1 mark
• Maternal condition (pyelo=very ill, cystitis=well) - 1 mark
• Treatment setting (cystitis=outpatient, pyelo=hospital) - 1 mark
4. PRACTICAL SCENARIO (10 marks)
A woman 6 hours post-vaginal delivery has not voided urine, has suprapubic discomfort, and a palpable mass above the symphysis. Outline your management.
ANSWER:
Assessment: Urinary retention (2 marks)
• Palpate & percuss bladder
• Bladder scan if available
Immediate: (3 marks)
• Catheterize aseptically (14-16G Foley)
• Measure residual volume
• Continue drainage
Further: (3 marks)
• Encourage fluids 2-3L/day
• Teach breathing exercises for voiding
• Remove catheter after 24-48 hours (trial)
Prevention: (2 marks)
• Encourage regular voiding
• Provide privacy
• Analgesia if perineal pain is cause
Assessment: Urinary retention (2 marks)
• Palpate & percuss bladder
• Bladder scan if available
Immediate: (3 marks)
• Catheterize aseptically (14-16G Foley)
• Measure residual volume
• Continue drainage
Further: (3 marks)
• Encourage fluids 2-3L/day
• Teach breathing exercises for voiding
• Remove catheter after 24-48 hours (trial)
Prevention: (2 marks)
• Encourage regular voiding
• Provide privacy
• Analgesia if perineal pain is cause
5. TRUE/FALSE (2 marks each)
a) Asymptomatic bacteriuria in pregnancy should be treated because it can lead to pyelonephritis.b) Catheterization is indicated if a postpartum woman has not voided for 4 hours.
c) Nitrofurantoin is safe to use for UTI treatment at term.
ANSWERS:
a) TRUE - 25-40% risk of pyelonephritis if untreated
b) FALSE - Catheterize if >6 hours or symptomatic or >600ml
c) FALSE - Avoid at term (risk of hemolytic anemia in newborn)
a) TRUE - 25-40% risk of pyelonephritis if untreated
b) FALSE - Catheterize if >6 hours or symptomatic or >600ml
c) FALSE - Avoid at term (risk of hemolytic anemia in newborn)
6. LIST QUESTION (8 marks)
List four causes of urinary retention in postpartum women and four complications of untreated retention.
ANSWER:
Causes: Epidural anesthesia, bladder overdistension, perineal pain, neurogenic bladder, dehydration, lack of privacy (any 4)
Complications: UTI, bladder rupture, PPH (uterine atony), renal failure, sepsis (any 4)
MARKING: 1 mark per correct answer
Causes: Epidural anesthesia, bladder overdistension, perineal pain, neurogenic bladder, dehydration, lack of privacy (any 4)
Complications: UTI, bladder rupture, PPH (uterine atony), renal failure, sepsis (any 4)
MARKING: 1 mark per correct answer
📊 STATISTICS: UTI questions appear in 85% of midwifery exams! The key is differentiating cystitis vs pyelonephritis - they ask this in multiple formats (MCQ, SAQ, case scenarios). Master this distinction!
📚 DAY 9 SUMMARY: URINARY COMPLICATIONS
🎯 The Retention Rules:
- Catheterize if: >600ml, symptomatic, or >6 hours postpartum
- Common causes: Epidural, overdistension, pain, fear
- Danger: PPH risk! Full bladder displaces uterus → atony
🎯 UTI Distinctions - "FEVER = FLANK":
🚻 MNEMONIC: "CYSTITIS SITS LOW, PYELO REACHES HIGH"
Cystitis:
• Burning urine (dysuria)
• Frequency & urgency
• Suprapubic pain
• NO fever
• NO flank pain
• Outpatient treatment
Pyelonephritis:
• Fever >38°C (high, spiking)
• Flank pain (CVA tenderness)
• Vomiting, prostration
• VERY ill appearance
• HOSPITAL admission
• IV antibiotics
Cystitis:
• Burning urine (dysuria)
• Frequency & urgency
• Suprapubic pain
• NO fever
• NO flank pain
• Outpatient treatment
Pyelonephritis:
• Fever >38°C (high, spiking)
• Flank pain (CVA tenderness)
• Vomiting, prostration
• VERY ill appearance
• HOSPITAL admission
• IV antibiotics
🎯 The "NEVER FORGET" Trio:
- NEVER let bladder overdistend: Check postpartum void within 6 hours
- NEVER ignore dysuria in pregnancy: Could progress to pyelo
- NEVER treat pyelonephritis as outpatient: Admit for IV antibiotics!
"A simple bladder check can prevent a major hemorrhage. Be vigilant, be thorough!"
"He who believes in Me, out of his heart will flow rivers of living water." - John 7:38