Main findings
According to these results, the option of not using a UC for a CD when
the above-mentioned criteria are met was a safe procedure in our
context. No increase in surgical or postsurgical complications was
observed. Until now, few studies have assessed the non-use of UC.
Although no severe complications occurred, an increased incidence of
urinary retention was observed in our study. A cautious selection of
those candidate patients for UC non-use and a better assessment of
urinary retention should optimize this approach. High maternal BMI,
urgent procedures or anticipated technical difficulties should be
indicators for the use of UC in CD. Moreover, the use of bedside
ultrasound for assessing the residual vesical volume was demonstrated to
be reliable and to decrease the necessity of intermittent
catheterization (10).
Patients with non-use of UC or its early removal achieved first
micturition after CD significantly faster than those who had a delayed
UC removal. We found that not using a UC or removing it early could lead
to a prompter hospital discharge, compared to the delayed removal group.
Although this might be related to the fact that women who needed a UC
were more likely to experience complications in the postpartum period,
these findings are consistent with published data and updated ERAS
guidelines(2).
Not inserting a UC decreased CD surgical time, but this difference did
not appear to be clinically relevant. Procedure duration differences
were discreet probably due to the fact that this analysis was made
during a protocol implementation process, when surgeons were still
becoming accostumed to operating without UC. The fact that the surgical
team was not always the same may be also a cause of bias in surgical
times.
Autonomous patient mobilization and oral post operative feeding are
known to be negatively affected when patients have invasive devices,
such as a UC. This fact agrees with the findings of our study, since
time to first mobilization was shorter when a UC was not used or when it
was early removed. Concerning time to first oral intake, although
statistically significant, it did not represent a relevant clinical
difference between groups, probably because hunger is not affected by
the placement of a UC. No studies have evaluated this correlation
between the use of UC and early oral feeding before. Although, more
research is needed to confirm these findings, the use of UC would not
delay oral feeding after surgery.
The use of neuraxial morphine as postoperative analgesia is widely
implemented in our institution at the specific doses that are usually
recommended in the literature for CD (2,6,7). At these doses, adverse
events are rarely reported (6,7). This is consistent with our findings,
as we did not see an increased tendency in pruritus, nausea, or
vomiting. A slightly higher incidence of urinary retention in those
patients having a CD under spinal anesthesia with morphine was observed
but this fact did not increase the time to first micturition,
mobilization and oral intake.
Regarding pain control, overall NPRS indicated an adequate analgesia,
with the mean NPRS being less than 3 at rest and less than 4 at movement
in all cases. Interestingly, in patients who underwent spinal
anesthesia, the addition of morphine improved NPRS at 6 h both at rest
and at movement by at least 1 point, a statistically significant
difference (Figure 2). Even though the literature reports that 2 to 3 mg
of morphine administered epidurally is equivalent to 50 to 100 µg
administered in spinal anesthesia (6), we did not see the same grade of
improvement when administering these doses through epidural catheter
after fetal extraction. The main difference of spinal administration
with respect to epidural administration lies in the duration of the
clinical effect, the speed of redistribution towards the brain centers
and the mechanism by which the drug reaches these centers. Morphine is
an opioid that, when deposited in the intrathecal space at doses of 100
to 200 µg, produces analgesia that can last up to 24h(8). It is
important to point out that due the special physiological changes in the
obstetric population, an intrathecal dose not higher than 100 µg is
recommended. In addition, it should not be forgotten that the use of
fentanyl to optimize analgesia during CD also achieves an analgesic
effect with a variable but shorter duration than morphine (9). Because
of this, we use a lower dose of morphine (50 to 100 µg) and we still
achieved significantly and clinically better pain control without
increasing adverse morphine effects.
All these findings should be taking cautiously as we did not take other
factors into consideration including previous interventions, either CD
or surgeries.