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.