Obstetric care has been significantly affected by the COVID-19 pandemic due to shortened hospital stay and early discharges aiming to reduce risks of coronavirus transmission in the hospital setting. Many changes in intrapartum and postpartum care aim to expedite discharge, minimize the hospital attendances and shift care to community, self-care and remote care, however there is further need to improve management pathways in the view of pandemic while maintaining patient safety principles. An important aspect of postpartum care is bladder care. The main aim of bladder care is to ensure women void normally within a certain time frame after delivery or catheter removal, rule out or diagnose and manage postpartum urinary retention (PPUR). The incidence of PPUR varies widely between 0.05% and 37% depending on definition used and asymptomatic cases which may be undiagnosed, unreported or underreported. There is lack of clinical guidelines and recommendations on the management of postpartum urinary retention and assessment of voiding function. New pathways on the management of postpartum voiding dysfunction and PPUR are essential for prevention of long-term urinary tract sequelae. This rapid systematic review was undertaken by a working group of CHORUS: An International Collaboration for Harmonising Outcomes, Research and Standards in Urogynaecology and Women's Health, aiming to identify relevant national and international guidelines, and summarize available recommendations on postpartum bladder care that are relevant to women’s care and management at the time of the COVID-19 pandemic.

The Healthcare Databases Advanced Search platform was used to conduct a comprehensive literature search of Medline, Embase and The Cochrane Library Databases from inception till December 2020. Our search strategy consisted of the words postnatal, postpartum, bladder, urinary, guidelines, guidance and recommendations. The search was restricted to humans and adults. English language restrictions were applied. An extensive manual search of national and international specialist societies’ websites was performed. Hand searching of reference lists of the articles, guidelines and recommendations was also performed in order to retrieve other articles that might have been missed by our search strategy. This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement.

The search strategy identified 48 titles and abstracts. We screened 39 titles and abstracts following the exclusion of 9 duplicate records (Figure 1). We included one international technical consultation, one international society’s recommendations and two national guidelines: 
• World Health Organization (WHO) [1];
• International Continence Society (ICS) [2];
• National Institute for Health and Care Excellence (UK) [3];
• Institute of Obstetricians and Gynecology, Royal College of Physicians of Ireland.

17 recommendations were identified and arranged into 3 clinical domains (Table 1):
• Diagnosis of postpartum voiding dysfunction (1 recommendation)
• Timing of the first void (4 recommendations)
• Management of postpartum urinary retention (12 recommendations)

Evidence on postpartum bladder care available in the literature is limited. Good quality guidelines on intrapartum and postpartum care represent an extensive topic on postpartum care where bladder care recommendations are brief and often inadequate.

The recommendation that the first urine void should be documented that has occurred within 6 hours after delivery or catheter removal aims to prevent from bladder overdistension. Suggestions that healthcare professionals should be alerted after 4 hours of not passing urine are very crucial, as this will provide time to try conservative measures with no pressure on a patient.

As the cut-off of 150 ml for the diagnosis of significant postvoid residual volume is commonly used with no reported adverse outcomes, it could be beneficial to adopt this instead of 100 ml as further unnecessary interventions or monitoring can be avoided. Such changes can reduce the number of women staying in the hospital.

Indwelling catheterisation is more widely used for treatment of PPUR rather than  clean intermittent self-catheterisation (CISC) as teaching patients to do clean intermittent self-catheterisation initially requires more resources (more midwives or specialist nurses, time). There might be negative perception from patients as well to do CISC. Nowadays CISC could become a method of choice due to the fact that it facilitates early discharge and self-management comparing to the situation when women are being catheterised for 12-24 hours and are usually awaiting trial without a catheter (TWOC) in the hospital. When patients are discharged home with an indwelling catheter, there is further need to come back to the hospital to pass TWOC. CISC allows remote management of postpartum voiding dysfunction with no repeat attendances. Telephone consultations are conducted to monitor patient’s progress and address any issues. Community-based approach can also be implemented when women require more help and education. It is arguable whether CISC can be a better option in relation to decreased risk of infection, but some authors suggest that the risk of developing bacterial infection increases with multiple catheterisations and approximately 40% of women will develop a urinary tract infection (UTI) when there is an indwelling catheter for >24 hours. Prophylactic antibiotics could mitigate this risk. Other potential barriers for CISC could be vaginal and perineal discomfort secondary to trauma or low acceptability by some women. 
Some experts who deal with chronic urinary retention may question whether CISC is indicated at all if patient is able to void but having significant PVR. Non-neurogenic chronic urinary retention defined as an elevated post-void residual of greater than 300 ml that persisted for at least 6 months and documented on 2 or more separate occasions. A treatment algorithm, for example, is based on stratifying patients with chronic urinary retention first by risk and then by symptoms and does not necessarily warrant CISC or any type of catheterisation.

In summary, intermittent self-catheterisation for management of postpartum urinary retention could be considered as an option during the COVID-19 pandemic aiming to shorten hospital stay and avoid further attendances. Patient education on self-catheterisation antenatally may increase awareness compliance if indicated postnatally. Self-care by monitoring of symptoms and consideration of bladder diaries is an alternative approach and could obviate any form of catheterisation. However, this  would require regular review and clinical input via tele-care by appropriately trained clinicians.  High quality research is also needed to improve our knowledge and support our practice standards.

Our rapid systematic review demonstrated that guidance on management of PPUR is very limited and based on expert opinion. Optimised bladder care has become more relevant during coronavirus pandemic with striving towards self-care, community-based and remote care. We propose using the 150 ml as cut off volume for significant post void residuals and consideration of CISC in cases of PPUR where clinically warranted, enabling self-care and avoidance of hospital visits. Early recognition of bladder symptoms is crucial to prevent long term urinary tract dysfunction, reduce hospital stay and shift management approaches to safer care.

World Health Organization. WHO Technical Consultation on Postpartum and Postnatal Care.  2008. https://apps.who.int/iris/bitstream/handle/10665/70432/WHO_MPS_10.03_eng.pdf?sequence=1.
International Continence Society. Urinary Retention after Childbirth. 2012. https://www.ics.org/folder/committees/working-group-documents/intra-and-postpartum-working-group-documents/d/urinary-retention-after-childbirth.
National Institute for Health and Clinical Excellence. Postnatal care up to 8 weeks after birth. Clinical guideline. 2006. https://www.nice.org.uk/guidance/cg37/resources/postnatal-care-up-to-8-weeks-after-birth-pdf-975391596997.