Postpartum urinary retention (PUR) is underrecognized and understudied, leading to confusion for both patients and nurses. Researchers do not agree on its incidence, with estimates ranging from 0.18% to 47% of postpartum women, in part due to differences the diagnostic criteria used (Li et al., 2020; Mohr et al., 2022; Nutaitis et al., 2023). The wide range of incidence estimates reflects the need for more research.

There are three types of PUR. Overt PUR is symptomatic, and patients feel that they cannot void, whereas covert PUR is asymptomatic and defined by incomplete bladder emptying. Persistent PUR continues past the first 3 days postpartum and is typically managed by outpatient urogynecology experts. However, screening, diagnosis, and treatment protocols are not standardized. Some researchers have concluded that PUR rarely leads to long-term sequalae and spontaneously resolves, thus they recommend against screening (Dolezal et al., 2022).

Risk factors have not been adequately studied. Although damage to pelvic floor muscles and the detrusor muscle increases the risk of PUR, other mechanisms such as hormonal shifts and nerve fiber distension also appear to contribute without a clear etiology (Nutaitis et al., 2023). Other possible risk factors include length of first- and second-stage labor, epidural anesthesia or systemic opioid medications, and operative vaginal birth (Li et al., 2020; Mohr et al., 2022). There is no consensus on whether newborn size is an independent risk factor. Further research is needed to determine patients at high risk for PUR.

Nurses should frequently assess for bladder distension in the first 24 hours after birth. Clear expectations for postpartum voiding can help nurses recognize patients with covert PUR. Many hospital protocols require measurement of the first two voids after giving birth or after regaining sensation following neuraxial anesthesia. A spontaneous void of less than 150 mL should raise suspicions that the bladder is not completely empty.

Some protocols include measurement of postvoid residual volumes (PVR) using bladder scanners. A PVR of greater than 150 mL may indicate covert PUR (Nutaitis et al., 2023). Other protocols suggest that a PVR of less than 1/3 of the volume voided indicates sufficient voiding (Nutaitis et al., 2023). All protocols with PVR measurements are dependent on nurses' timely and accurate use of bladder scanners to correctly determine PVR. One challenge of these protocols is that nurses are reliant on patients' timely reporting of spontaneous voids.

Prevention of PUR is helped by frequent bladder emptying during labor (either spontaneous voiding or via straight or indwelling catheters). During labor, bladder emptying should occur at least every 4 hours with an expected volume of less than 500 mL (Nutaitis et al., 2023). More frequent emptying may be necessary if volumes are greater than 500 mL. Nurses should prioritize education on bladder emptying for patients both during labor and the postpartum period. Early response to bladder distension is essential to prevent further denervation and ongoing bladder dysfunction. Once PUR is identified postpartum, an indwelling catheter may be placed to avoid further bladder distension.

The nursing leadership team should recognize that bladder protocols necessitating frequent measurement of voids or PVR require significant nursing time, which should be considered when balancing nursing assignments. Ideally, development of protocols for treatment will include a multidisciplinary team including staff nurses, midwives, and physicians to accurately balance patient needs with nursing workload. Protocols should be revised and improved as further research on PUR is published. This is an area of intrapartum and postpartum nursing care that nurses could take the lead on to contribute to the minimal existing evidence for incidence, treatment, and sequelae.

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