A Prospective Comparative Study of Removal of Urinary Catheter at 12 hours versus at or >24 Hours Following Elective Cesarean Section in Women

Background & Objective : To compare the outcomes of urinary catheter removal at 12 Hours versus at or >24 Hours post elective cesarean section. To assess and compare symptomatic UTI, time of ambulation, length of hospital stays and need for recatherization amongst these 2 groups. Methods: In all patients undergoing elective primary cesarean section, Preoperative urine routine and microscopy¯ were sent, UTI was ruled out, clinical examination was performed and were NPO at least 8 hours prior to surgery and given antibiotics. A foley catheter was inserted on the operating table immediately before starting cesarean section. Cesarean sections were performed in the usual manner under spinal anesthesia. After this, in Group 1 patients, catheter were removed 12hours post-operatively while in Group 2 it was removed 24 hours post-operatively. After catheter removal, women were encouraged to void and helped to ambulate. Results: 2 groups were compared and the overall rates of post caesarean section urinary complaints dysuria (8.69%), urinary frequeny(14.13%), urgency(10.86%), burning micturition(9.76%) were higher in 24 hours catheter removal group. The Mean duration of first Post-op voiding time (4 hours), ambulatory time(4 hours) and hospital stay(4 days) were shorter in 12 hours catheter removal group. Conclusion: Urinary catheter removal post Caesarean section at duration of 12 hours postoperatively is associated with decreased complications and morbidity in post Caesarean section women.


Introduction
Worldwide, caesarean sections are now the most frequently performed obstetric procedures. 1 Rates of caesarean sections have been continuously rising.As a result of improved anesthetic management and the use of prophylactic antibiotics before surgery to avoid infections, maternal mortality related to caesarean delivery is now uncommon.However, there are still some morbidities that can be avoided, such as urination problems and UTIs.To lower the risk of these morbidities and avoid postoperative complications, interventional measures should be used.
The use of urinary catheter (flexible elastic tube used to drain urine from bladder) during and after cesarean section is routinely used. 1 Alleged benefits of using catheter includes, maintains bladder drainage that improves visualization during surgery and minimizes bladder injury, less urinary retention post-operatively but it could be associated with increased incidence of CAUTI ( Catheter Associated Urinary Tract Infections), urethral pain, voiding difficulty after removal, delayed ambulation and increased hospital stay. 1 There is currently no agreement on a precise time for catheter removal.According to certain research, after a caesarean section under spinal anaesthesia, urine retention and bacteriuria occur more frequently and the catheter stays in place longer 3 .According to some studies, removing the urine catheter earlier may promote early ambulation and reduce the length of the hospital stay 3 .There were several studies suggesting that routine use of urinary catheter in all caesarean sections is not essential 2 .Our goal is to strike a balance between the length of urethral catheterization and the benefits of early ambulation, reduced bacteriuria rates, shorter hospital stays, and decreased incidence of urine retention following surgery.Therefore, we will compare the morbidities and benefits of removing the urinary catheter after two different lengths of time in our study.

Materials and Methods
This study was a prospective study conducted over a period of 2 years and 2 months on 184 women admitted in antenatal ward for primary elective cesarean sections in the Department of Obstetrics and Gynecology, SMS Medical College, Jaipur.

Inclusion Criteria
 Those who are willing to give consent. Primigravidae women with term pregnancy prepared for elective cesarean section.

Exclusion Criteria
 Women who had preoperative urinary tract infections, bladder injuries during surgery. Women with any medical condition where post op urine output measurement is essential like Preeclampsia, eclampsia, gestational hypertension and GDM.

Methodology
Institutional review board and ethical committee clearance was taken.Women undergoing antenatal care on the basis of inclusion and exclusion criteria were selected.Informed consent of the patient was taken.A detailed assessment of patient was performed including history, general examination and obstetrics examination.Routine investigations and a midstream urine analysis were done to rule out UTI in preoperative patients.
Patients enrolled in the study were divided into 2 study groups: - Study group -Patients in which catheter was removed 12 HOURS postoperatively.
 Control group -Patients in which catheter was removed 24 HOURS postoperatively.

Outcome Measures
• Symptomatic urinary tract infections -Significant bacteriuria, presence of 10 5 CFU of bacteria per ml (clean catch midstream urine sample postoperatively 48 HOURS.) • Other outcome measures as Dysuria (defined as painful micturition); frequency (micturition more than 7 times during the day or more than twice during night); urgency (severe irresistible urge to micturate); burning micturition.
• Post-operative first ambulation time.
• Length of hospital stay-from day of surgery till discharge.
• Rate of re-catheterization (those who fail to pass urine >8 hrs after catheter removal.

Statistical Analysis
• Continuous variables were summarized as mean and were analyzed by using unpaired t-test.Nominal / categorical variables were summarized as proportions and were analyzed by using chisquare/ Fischer exact test.P-value <0.05 will be taken as significant.
A total of 184 women were participated in the study group.They were divide into two groups by random allocation table.
In Group I: Catheter removal was done 12hours postoperatively in 92 women.
In Group II: Catheter removal was done 24hours post operatively in 92 women.

Patient preparation:
All the women who were included in the study, preoperative urine routine and microscopy were sent and UTI was ruled out.Any patient under the exclusion criteria were excluded from the study.In all participants, clinical examination was performed.Non stress test was performed on the day of admission.Recently performed haematocrit and serology, blood grouping and typing is checked.Informed consent for cesarean section and anesthesia were obtained.They were kept nil per orally at least 8 hours prior to surgery.Antibiotic prophylaxis of 1g injection Ceftriaxone intravenous is given 30 minutes prior to surgery after the test dose.In all women who were undergoing elective cesarean section, a foley catheter (French size 16) was inserted under sterile precautions on the operating table immediately before starting cesarean section.
Cesarean sections were performed in the usual manner under spinal anesthesia.Abdomen opened by pfannensteil incision.Then dissecting through different layers of abdomen until the uterus is reached.Uterus is closed with vicryl.Abdomen closure was done.
After this, in Group 1 patients, catheter was removed 12hours post-operatively while in Group 2 it was removed 24 hours post-operatively.After catheter removal, women were encouraged to void and helped to ambulate.Their ambulatory time was noted and their first voiding time was noted in both categories.If even after 8 hours of removal, if they are not able to void or if there is palpable bladder, recatheterization is necessary.(Urinary retention meansdifficulty to void 8 hours after catheter removal or residual urine ≥200ml.)In both the groups urine analysis was done 48 hours post-operatively and results were compared.
ResultsDuring the study period, a sum of 184 women finally enrolled in this trial.
Out of which, in 92 of them catheter was removed 12 hours post-operatively and in 92 women delayed catheter removal after 24 hours post-operatively was done.The two groups were matched and there were no significant differences between the two groups regarding maternal age and gestational age.

Figure 1:
shows that 4 women in the 12 hours post-operative catheter removal group had urinary retention requiring re-catheterization and 1 of the women in the 24 hours post-operative catheter removal group was re-catheterized.This Difference in the need for re-catheterization in both the groups was non-significant (p-value is 0.3645).Post-operative bacteriuria was noted in 11 patients of the group II and only 2 patients of group I. Significant difference was seen with pvalue of 0.0214.

Discussion
This study is undertaken to determine whether 12 hours post-op catheter removal decreases the occurrence of urinary tract infection, shortens first postoperative voiding time, ambulation time, duration of hospital stay and the need for recatheterization for urinary retention.
In this study, women admitted in the common labour room ward for elective cesarean section were selected after screening for eligibility and consent was taken and complete physical and obstetric examination was done.A pre-operative urine routine and microscopy was done along with other blood investigations.Total 184 women participated in the study and in all participants foley catheter was inserted by resident doctor prior to caesarean section.
In Group I: In 92 women catheter removal was done 12hours postoperatively.In Group II: In 92 women catheter removal was done 24 hours postoperatively.
In the present study, we compared the age group, parity and gestational age between the two groups and they were matched and there is no significant difference.

Study
To compare the outcomes of urinary catheter removal at 12 Hours versus at or >24 Hours post elective cesarean section. To assess and compare symptomatic UTI. To assess and compare time of ambulation. To assess and compare length of hospital stay.
FIGURE 2-FIRST POST-OP VOIDING TIME

Table 1 :
Distribution of Patients According to their Post-Op Urinary Complaints Figure 1: Distribution of Patients According To First Post-Operative Voiding Time Mean Post-operative voiding time in 12 hours group is 4 hours whereas it is 5 hours in the 24 hours group.Statistical significant difference was noted with a p-value of 0.001.Post-op voiding time is shorter in 12 hours catheter removal group.

Table 2 :
Distribution of Pati ents According To Their First Post-Operative Ambulation

Table 3 :
Distribution of Patients According To Post-Operative Bacteriuria