Prospective Evaluation of a Risk-Stratified, Symptom-Guided Postpartum Trial Without Catheter (TWOC) Protocol and Its Impact on Bladder Recovery, Maternal Comfort, and Healthcare Utilization
DOI:
https://doi.org/10.69723/njms.05.01.0693Keywords:
Trial without catheter,, Post partum urinary retention,, Voiding efficiency screening, Bladder recoveryAbstract
Background: Postpartum urinary retention (PPUR) is a common but neglected complication of parturition. This leads to overdistension of the bladder, urinary tract infections, and long-term voiding dysfunction. Despite this evident complication, standardized postpartum bladder management protocols are lacking in many maternity units in Pakistan; therefore, this study aims to establish a postpartum trial without a urinary catheter, as recommended by developed countries.
Objective: To evaluate the effectiveness, safety, and feasibility of a risk-stratified, symptom-guided postpartum Trial Without Catheter (TWOC) protocol.
Methods: A prospective observational study was conducted on 220 women in the tertiary care maternity unit of Bahawal Victoria Hospital from June 2024 to September 2025. Postpartum women at risk of PPUR underwent a structured TWOC protocol incorporating timed voiding, Voiding Efficiency Screening & Symptom Inquiry (VESSI), and post-void residual volume measurement. TWOC success, need for re-catheterization, bladder overdistension, urinary tract infection, and patient-reported satisfaction were the outcomes of the study.
Results: Successful TWOC on first attempt was in 70.0%. Overdistension (>700 ml) was in only 5%, and the median time to spontaneous voiding was 5.2 hours (IQR 4.1–6.0). Increasing post-void residual volume and higher VESSI scores were associated with progressively poorer TWOC outcomes (χ² = 55.25, df = 2, p < 0.001). On multivariable analysis, residual volume ≥250 ml (adjusted OR 3.4, 95% CI 2.1–5.6), high VESSI score (≥5) (adjusted OR 2.9, 95% CI 1.8–4.7), and instrumental delivery (adjusted OR 2.2, 95% CI 1.3–3.9) independently predicted TWOC failure (all p ≤ 0.004). Patient-reported outcomes were favorable, with over 80% reporting reduced anxiety and willingness to recommend the protocol.
Conclusion: The TWOC protocol is safe, effective, and associated with high patient satisfaction, supporting its integration into routine postpartum care.
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