|Year : 2015 | Volume
| Issue : 4 | Page : 231-234
Postpartum urinary retention secondary to suture obliteration of the urethral orifice: A complication of home delivery conducted by an untrained birth attendant
Fadimatu Bakari, Adebiyi G Adesiyun, Hajaratu Umar-Sulayman, Nkeiruka Ameh, Solomon Avidime, Zubaida Garba Abdullahi
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
|Date of Web Publication||21-Jan-2016|
Dr. Fadimatu Bakari
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Source of Support: None, Conflict of Interest: None
Postpartum urinary retention (PPUR) secondary to suture obliteration of the urethral orifice by a traditional birth attendant (TBA) is a condition that may not have been heard of in modern day obstetric practice and has certainly not been reported before in our locality. Several risk factors to developing PPUR have been reported. However, following a careful search of the literature, there was no documented case of PPUR secondary to closure of the urethral orifice by TBA. We report a rare case of a 23-year-old multipara who had spontaneous vaginal delivery that was supervised by a TBA at home. She presented 3 days later with complaints of inability to pass urine, abdominal pain, abdominal swelling, and dribbling of urine on straining. She was evaluated and found to have a distended urinary bladder up to the level of the umbilicus. Pelvic examination revealed a vestibule that was almost completely obliterated up to the urethral orifice with continuous surgical silk suture. The vaginal orifice was also partially obliterated. Urine was noticed to be dribbling from the region of the urethral orifice on straining. Lochia was normal. About 2 L of clear urine was drained from the urinary bladder following cutting of the silk suture and passage of an indwelling size 16F Foley's catheter. The uterus was contracted to 16 weeks pregnancy size following catheterization. She had successful bladder training and was discharged 5 days later.
Keywords: Postpartum urinary retention (PPUR), traditional birth attendant (TBA)
|How to cite this article:|
Bakari F, Adesiyun AG, Umar-Sulayman H, Ameh N, Avidime S, Abdullahi ZG. Postpartum urinary retention secondary to suture obliteration of the urethral orifice: A complication of home delivery conducted by an untrained birth attendant. Arch Int Surg 2015;5:231-4
|How to cite this URL:|
Bakari F, Adesiyun AG, Umar-Sulayman H, Ameh N, Avidime S, Abdullahi ZG. Postpartum urinary retention secondary to suture obliteration of the urethral orifice: A complication of home delivery conducted by an untrained birth attendant. Arch Int Surg [serial online] 2015 [cited 2019 Dec 16];5:231-4. Available from: http://www.archintsurg.org/text.asp?2015/5/4/231/174678
| Introduction|| |
Postpartum urinary retention (PPUR) is defined as the inability to have spontaneous micturition within 6 h after vaginal delivery.  This is an uncommon event that occurs in 0.7-0.9% of vaginal deliveries  although higher incidences have been reported by other authors.  There are several documented risk factors in the literature. , A case-control study documented six risk factors,  which are primiparity, vacuum delivery, fundal pressure during the second stage of labor, delayed second stage, medio-lateral episiotomy, and initial high dose of epidural anesthesia. The etiology is usually multifactorial. Physiological changes during pregnancy causes hypotonic bladder with an increased postvoid residual volume.  Additionally, mechanical obstruction and neurological nerve damage to the pelvic floor muscle during vaginal delivery predisposes to urinary retention in a bladder that is already hypotonic. 
A good proportion of women in developing countries are attended to during childbirth by traditional birth attendants (TBAs). Majority of TBAs in sub-Saharan Africa lack formal education or medical training and some of their clients end up with serious obstetric complications that may lead to severe maternal and perinatal morbidities and mortalities.  This is because most of them lack the skills and often do not know their limit. The main aim of writing this paper is to demonstrate an additional risk factor for the development of PPUR in sub-Saharan Africa.
| Case Report|| |
Mrs. HI was a 23-year-old para 4+0 with three children alive. Her last childbirth was 3 days prior to presentation. She presented with 3 days inability to pass urine, abdominal pain, abdominal distention, and dribbling of urine on straining. She had a spontaneous vaginal delivery of an average-sized live male infant that cried at birth. The birth was attended to by a TBA she had called at home. Her labor lasted for about 12 h. She was not given any form of medication during the course of her labor but was given an injection following the delivery. She had a tear that was noticed to be bleeding, which was sutured by the TBA. Postpartum blood loss was significant but there was no history of constitutional symptoms. She was unable to pass urine despite an urge to do so for about 10 h after delivery. She developed gradual lower abdominal distention that was associated with abdominal pain and dribbling of urine on straining. She presented to a private clinic on the third postpartum day where she had an ultrasound scan performed that revealed a distended bladder and was subsequently referred to our facility following a failed attempt at catheterization.
All her pregnancies were booked and were all carried to term. She had spontaneous vaginal deliveries of all her babies at home except the first. She had no history of difficult vaginal deliveries. Her second child died from a complication of measles at 18 months of life. She had no history of chronic medical condition. She was the only wife of a driver.
General physical examination revealed a young woman who was acutely ill-looking, afebrile, moderately pale, and in painful distress. Her pulse rate was 92 beats per minute and her blood pressure was 110/70 mmHg. She had urinary bladder distention up to the level of the umbilicus [Figure 1]. Her uterus was contracted to 16 weeks pregnancy size following urethral catheterization and emptying of the urinary bladder. There was no palpable organomegaly. Pelvic examination revealed vaginal canal that was partially obliterated and urethral orifice that was completely obliterated with silk suture [Figure 2]. Urine was noticed to be dribbling on straining.
|Figure 1: Showing distended abdomen with silk surgical suture obliterating the urethral orifice and vagina|
Click here to view
The suture was cut loose, opening both the urethral orifice and the vaginal canal. There was some flow of urine after cutting the suture although with a poor stream. Some blood clots were evacuated from the vagina. She had a first-degree perineal laceration with edges that were poorly apposed leaving some slight raw edges. An indwelling urethral catheter was passed with the aid of a lubricant. About 2 L of urine was drained from the bladder. Urine sample was taken for urinalysis and microscopy culture and sensitivity. Her packed cell volume was 29%. She was commenced on prophylactic antibiotic, hematinics, analgesia, and sitz bath. The catheter was removed after 72 h following establishment of good bladder training. Her urine sample did not culture any organism. She had no proteinuria or glycosuria. The perineal tear had healed by the sixth postpartum day. She was discharged after 5 days. She was adequately counseled on the need for hospital delivery in her subsequent pregnancies.
| Discussion|| |
Mechanical obliteration of the urethra by an unskilled birth attendant in an attempt to repair a perineal laceration was the cause of PPUR in this patient. A significant proportion of women in developing countries, particularly in sub-Saharan Africa are attended to at birth by unskilled birth attendant, popularly known as TBA. Nigeria is not an exception as a significant number of women still prefer to deliver at home than deliver in the hospital despite adequate antenatal clinic attendance. According to the Nigeria Demographic and Health Survey (NDHS) 2013, only 12% of the deliveries are attended to by the skilled attendant in the North-West compared with 80% in the South-West and South-East.  A study conducted in Zaria, northern Nigeria, showed high rates of home deliveries and deliveries not supervised by skilled attendant, which were 70% and 78%, respectively. 
The incidence of this condition varies widely. However, in the literature, the estimated incidence of PPUR ranges between 0.05% and 37%.  PPUR can be classified as overt (symptomatic) or covert (asymptomatic).  Overt is the inability to void spontaneously within 6 h after vaginal delivery or 6 h after removal of an indwelling bladder catheter following cesarean section requiring recatheterization while covert is when the postvoid residual urine volume is ≥150 mL after spontaneous micturition verified by ultrasonography or catheterization.  This patient presented to us with symptomatic PPUR and a bladder that extended to the level of the umbilicus, abdominal pain, and dribbling of urine on straining.
This clinical condition is more prevalent in primigravid women than multiparous women.  Episiotomy, birth canal injury, and severe perineal laceration have been reported to increase the risk of urinary retention.  However, our patient was a multiparous woman who has had three successful spontaneous vaginal deliveries without any complication. She sustained first-degree perineal laceration following the index pregnancy, which was unlikely to be associated with much pain to result in development of urinary retention in her. However, the occlusion of the urethral orifice in an attempt to repair the laceration may have caused mechanical obstruction, intense pain, and reflex urethral spasm culminating into PPUR in the patient. Her baby was of average weight and there was no history of prolonged labor, fundal pressure, or difficulty in delivering the baby. There were no other obvious factors that could have caused urinary retention in this patient other than the mechanical occlusion of the urethra by an unskilled birth attendant.
A delay in diagnosis or misdiagnosis of this important clinical condition can result in irreversible damage to the bladder with long-term sequelae.  A case of postpartum bladder rupture secondary to PPUR in a primigravida has been reported.  This patient presented relatively late but a prompt diagnosis was established in her and appropriate management was instituted, which prevented development of complication in her.
Preventing PPUR and identifying it early when it occurs are of utmost importance in preventing long-time bladder dysfunction. According to the Royal College of Obstetrics and Gynaecology (RCOG) Incontinence in the Women Study Group, every postdelivery woman should void within 6 h or else catheterization should be performed.  This patient missed the opportunity of early catheterization because she delivered at home. However, at presentation an indwelling bladder catheter was inserted to relieve the retention and was also retained for 72 h until adequate bladder training was achieved in other to prevent another episode of urinary retention.
| Conclusion|| |
This case illustrates that urinary retention can be caused by mechanical occlusion of the urethra by an unskilled birth attendant. This, therefore, calls for a need to raise community awareness for the need to utilize skilled personnel for maternal care services. In areas where there is a scarcity of skilled birth attendants and lack of affordable health services, it becomes necessary to train TBAs in health promotion maternal services while providing opportunity for them for retraining and monitoring of their activities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pifarotti P, Gargasole C, Folcini C, Gattei U, Nieddu E, Sofi G, et al
. Acute post-partum urinary retention: Analysis of risk factors, a case-control study. Arch Gynaecol Obstet 2014;289:1249-53.
Bouhours AC, Bigot P, Orsat M, Hoarau N, Descamps P, Fournié A, et al
. Postpartum urinary retention. Prog Urol 2011;21:11-7.
Ajenifuja KO, Oyetunji IO, Orji EO, Adepiti CA, Loto OM, Tijjani MA, et al
. Post-partum urinary retention in a teaching hospital in southwestern Nigeria. J Obstet Gynaecol Res 2013;39:1308-13.
Training workshop for traditional birth attendants at Aliero, Kebbi State, Nigeria: A community development service at Aliero, Kebbi State, Nigeria.
Int J Trop Med 2010;7.
National Population Commission (NPC) [Nigeria] and ICF International. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International. 2014. p. 139-40.
Idris SH, Guarzo UM, Shehu AU. Determinants of place of delivery among women in a semi-urban settlement in Zaria, northern Nigeria. Ann Afr Med 2006;5:68-72.
Cavkaytar S, Kokanalı MK, Baylas A, Topçu HO, Laleli B, Taºçı Y. Post partum urinary retention after vaginal delivery: Assessment of risk factors in a case-control study. J Turk Ger Gynecol Assoc 2014;15:140-3.
Yip SK, Brieger G, Hin LY, Chung T. Urinary retention in the post-partum period: The relationship between Obstetric factors and the post-partum post-void residual bladder volume. Acta Obstet Gynaecol Scand 1997;76: 667-72.
Caley ME, Caley JM, Vasdey G, Lesnick TG, Webb MJ, Ramin KD, et al
. Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery. Am J Obstet Gynaecol 2002;187:430-3
Buchanan J, Beckmann M. Postpartum voiding dysfunction: Identifying the risk factors. Aust N Z J Obstet Gynaecol 2014;54:41-5.
Duenas-Garcia OF, Rico H, Gorbea-Sanchez V, Herrerias- Canedo T. Bladder rupture caused by Post partum urinary retention. Obstet Gynecol 2008;112:481-2.
Maclean AB, Cardozo L. Incontinence in Women-Study Group Statement. London: Royal College of Obstetrician and Gynaecology Press; 2002. p. 433-41.
[Figure 1], [Figure 2]