The purpose of this initiative is to reduce the use of indwelling urinary catheters as a routine intervention for laboring patients with an epidural. This has been a common practice throughout a major southwestern hospital system.  However, there is no evidence that this process improves patient care. Studies indicate a patient’s perception and satisfaction of her labor are improved with less intervention. Likewise, there is no evidence to suggest the use of an indwelling catheter will shorten labor.  Therefore, the use of an indwelling urinary catheter should not be dependent upon a patient receiving a labor epidural, but rather upon her clinical need.  

Clinical indications for the necessity for a urinary catheter may include Category III fetal heart rate tracing or arrest of labor, where an operative or cesarean section is likely to occur; closer monitoring of I&O’s, as in a patient receiving magnesium sulfate, or obese patients where bladder assessment is unobtainable.

The greatest risk for urinary tract infections is via an indwelling urinary catheters.  this practice change will align Labor and Delivery units with national initiatives to decrease catheter acquired urinary tract infections (CAUTI),

Proposed change: Remove “insert indwelling catheter” from Labor Order Sets.

Order indwelling catheter for laboring patient only when clinically appropriate.

Patient should be encouraged to void prior to epidural placement, and subsequently every 2-4 hours.

Nurses should assess the bladder and perform peri-care every 2 hours for every patient in labor. 

If patient is unable to void, proceed with straight catheteriztion, using sterile technique, and record volume.  

Implementation, outcomes and evaluation: This initiative was instituted in April, 2011 at one facility. The Clinical Nurse Specialist (CNS) provided evidence based information to the nursing staff and physicans to support the proposed change. In the first three month indwelling catheter use fell from 66% to 25%. This data was presented to the system's Clincial Consensus Group by the CNS and approved as an expected system practice. At the time of submission, the initiative is in the "Design" phase of the project, with a projected roll-out date of October, 2011.

Implications for nursing practice: Nurses will have the opportunity to improve patient care, based on evidence, considering patient preference and using critical thinking skills to make sound clinical decisions. It also illustrates  the Clinical Nurse Specialist's role as a facilitator of change through the advancement of evidence-based practice.

Keywords: Indwelling Urinary Catheter, Labor, Epidural, Intermittent Catheterization