Description of Postoperative Void Patterns After Scheduled Cesarean Delivery Without Use of Routine Intraoperative Urinary Catheterization in a Large-Volume Safety Net Hospital.

Background And Objectives: While urinary catheters are widely utilized during cesarean delivery, little evidence exists to support the practice, and it may be associated with increased risk of urinary tract infections and unnecessary intervention. In this study we aim to describe postoperative voiding patterns and assess the prevalence of complications in patients undergoing scheduled cesarean delivery without an indwelling intraoperative urinary catheter.  Materials and methods: This is a prospective observational cohort of patients undergoing scheduled cesarean delivery at an urban safety-net teaching institution from April 2022 to April 2023. During the study period an institutional protocol was in place for non-use of routine urinary catheters at time of cesarean unless deemed necessary by the attending surgeon. Patients who underwent cesarean delivery in labor, had twin gestation, or needed a catheter postpartum, such as for administration of magnesium sulfate or for hemodynamic instability, were excluded. The primary outcomes included postoperative voiding patterns, including time to and volume of first spontaneous void, need for intervention for presumed urinary retention, and frequency of postoperative urinary retention. Secondary outcomes included postpartum hemorrhage, postpartum length of stay, postpartum pain scores, ureteral or bladder injury, urinary tract infection and unscheduled postpartum visits. Demographics, cesarean characteristics, voiding patterns, and complication rates were abstracted from the electronic medical record. Descriptive statistics were used to analyze the data.

Results: During the study period there were 3587 deliveries. Of those, 910 were cesarean deliveries, and 264 (29%) were non-laboring cesarean deliveries. A total of 215 (81.4%) of the cesarean deliveries were performed without a urinary catheter. Of those, the majority (73%) were scheduled elective repeats. After excluding postoperative catheter placement (N=16, 7.4%), the final cohort included 199 patients. The majority of patients were Latina (N=141, 70.9%), publicly insured (N=169, 84.9%), and at term (38.9±9 weeks). The most frequent indication for cesarean delivery was elective repeat (N=147, 73.9%), and the majority were performed under spinal anesthesia (N=193, 97.0%). The mean time to first postoperative void was 8.53 hours (SD 3.19) with median volume of 300 mL (IQR 175 - 400 mL). Thirty-nine (19.6%) patients had transient postoperative urinary retention based on inability to void by 10 hours (per institutional protocol) and catheterization volume ≥ 300mL. Only one (0.3%) patient required an indwelling catheter while hospitalized, and none were discharged home with a catheter. There were no intraoperative bladder or ureteral injuries. Postpartum length of stay, unscheduled outpatient visits, and postoperative urinary tract infection rates were comparable to those who had an intraoperative urinary catheter.  Conclusions: The mean time to the first postoperative void was 8.5 hours, which is longer than current algorithms for the management of postoperative urinary retention. Non-use of routine urinary catheter at the time of scheduled cesarean delivery was associated with transient urinary retention in 19.6% of patients; however, there was no increase in sequelae at time of discharge.