A Study on the Effectiveness of Single Catheterization in Preventing Postpartum Urinary Retention: Based on the Propensity Score Method

A Study on the Effectiveness of Single Catheterization in Preventing Postpartum Urinary Retention: Based on the Propensity Score Method | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Study on the Effectiveness of Single Catheterization in Preventing Postpartum Urinary Retention: Based on the Propensity Score Method Huating Chen, Defeng Chen, Yuyi Chen, Shuai Yang, Jing Hu, Jun Lyu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9000521/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Evidence on the effectiveness of postpartum single catheterization in preventing postpartum urinary retention (PUR) remains insufficient. A previous study reported that postpartum single catheterization reduced the incidence of covert PUR, but its effects on overt PUR and the need for indwelling catheterization were not investigated. Objective: This study aimed to investigate the effectiveness of postpartum single catheterization in preventing PUR. Method: A retrospective cohort study was conducted using real-world data, with participants divided into a catheterization group and a non-catheterization group based on whether they received a single catheterization after delivery. The primary outcomes were PUR and the need for indwelling catheterization, while the secondary outcomes included spontaneous urination and the number of induced urinations. Regression analysis was conducted after adjusting for confounding factors using stabilized inverse probability of treatment weighting (sIPTW). Subgroup analyses of key clinical characteristics were conducted to evaluate primary outcomes. Sensitivity analysis was performed using propensity score adjustment, population adjustment, and propensity score modeling. Results: A total of 1,637 parturients with bladder capacity ≥300ml who failed to urinate spontaneously in the delivery room after vaginal delivery were enrolled. After screening according to inclusion and exclusion criteria, 1,316 parturients were included, with all measurements taken within 3 hours postpartum. The catheterized group comprised 776 participants (59.0%), while the non-catheterized group had 540 participants (41.0%). Regression analysis using sIPTW revealed significantly reduced risks of PUR and covert PUR in the catheterized group, with odds ratios (OR) of 0.47 (0.36,0.61) and 0.40 (0.30,0.53), respectively, both P<0.001. However, no significant differences were observed between groups in terms of risk of overt PUR, urinary catheterization, spontaneous urination, or induced voiding frequency (all OR 0.05). Results remained robust after adjusting for propensity scores and propensity score models. However, when adjusting the inclusion criteria to include only parturients who had not urinated spontaneously within 2 hours postpartum with a bladder volume ≥300ml, single catheterization showed significant effects on PUR, covert PUR, indwelling catheterization, and induced voiding frequency. After adjusting for confounding factors using sIPTW, the covariates between the two groups were balanced. The logistic regression analysis showed adjusted OR values of 0.44 (0.32,0.62),0.43 (0.30,0.62),0.57 (0.34,0.99), and 0.79 (0.64,0.99), all P0.05. Subgroup analyses demonstrated significant interactions between instrument-assisted delivery, perineal wound condition, and single catheterization within 3 hours postpartum (interaction P-values: 0.015 and 0.014). Additionally, bladder volume showed a significant interaction effect with single catheterization within 3 hours (interaction P=0.002). Notably, for parturients with a bladder volume ≥400ml, single catheterization within 3 hours may reduce the risk of PUR (OR=0.45, P<0.001). Conclusion: In real-world clinical settings, performing a single catheterization within 3 hours postpartum significantly reduces the risk of both PUR and covert PUR, while showing no significant effect on overt PUR or spontaneous urination. Additionally, implementing single catheterization within 2 hours postpartum further decreases risks of urinary catheterization and recurrent induced urination. However, these findings require further validation through large-scale, multicenter, high-quality studies to establish more scientifically robust evidence for clinical postpartum bladder management. postpartum urinary retention single catheterization prevention propensity score method Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Postpartum urinary retention (PUR) is a common complication after childbirth, with an incidence of 0.2% to 45% [ 1 , 2 ]. It is divided into overt PUR and covert PUR. Overt PUR refers to the filling of urine in the bladder for 6–8 hours after delivery but cannot be discharged by itself[ 3 ]; covert PUR refers to the Post-void Residual Volume (PVRV) in the bladder after self-voiding ultrasound monitoring or catheter drainage of patients ≥ 150mL [ 4 ]. In 2018, the National Health Commission issued the "Notice on Carrying Out Pilot Work for Labor Analgesia", emphasizing the expansion of the coverage of labor analgesia[ 5 ]. In some domestic specialized obstetric and gynecological hospitals and maternal and child health care institutions, the rate of intraspinal labor analgesia can reach over 80%; in developed Western countries, the rate of labor analgesia has reached as high as 85% or even over 90%[ 6 ]. The common method for labor analgesia is epidural analgesia. The popularization and application of epidural analgesia directly affect the generation and transmission of the micturition reflex signal, causing the contraction of the detrusor muscle and the relaxation of the urethra to be out of sync, thereby leading to the occurrence of urinary retention[ 7 , 8 ]. Therefore, the incidence of urinary retention is likely to increase further with the widespread promotion and application of epidural analgesia. PUR has both short-term and long-term effects. Studies have shown that excessive bladder distension can affect uterine contraction and increase the incidence of postpartum hemorrhage[ 9 ]. It can also easily lead to cystitis[ 10 ]. Furthermore, untreated acute urinary retention for a prolonged period may cause the detrusor muscle to transform into non-contractile fibrosis[ 11 ]. This can result in dysuria, detrusor underactivity, urinary incontinence, urinary frequency, and nocturia, and may even lead to hydronephrosis[ 12 ]. Research indicates that among parturients with PUR, 8.2%, 6.7%, and 4.9% still experienced dysuria at 1, 2, and 3 years of follow-up, respectively. Reports have pointed out that PUR can cause diffuse urothelial edema and bleeding in the bladder [ 11 ]. After 8 weeks of intermittent catheterization, cystoscopy revealed that the bladder had returned to normal in these parturient[ 13 ].In extremely rare cases, PUR can lead to bladder rupture, which is life-threatening[ 14 ]. Preventing excessive bladder distension is key to perinatal bladder management, and catheterization is the most direct method. However, there is still controversy regarding whether to perform a single catheterization before diagnosing PUR. Although existing literature has reported that single catheterization within 2 hours postpartum can reduce the incidence of covert PUR[ 1 ], its impact on clinically more significant outcomes - particularly overt PUR and indwelling catheterization - remains unclear. This evidence gap represents a critical clinical question requiring urgent resolution. Utilizing real-world data, this study constructs a retrospective cohort to investigate the effects of immediate single catheterization in the delivery room on PUR and related outcomes. Our findings aim to provide evidence-based strategies for PUR prevention and inform standardized postpartum bladder management. 2. Data and Methods 2.1 Sources of Data This study enrolled parturients who underwent vaginal delivery at the obstetrics department of a Grade III-A hospital in Guangzhou between January 1, 2021, and March 31, 2024, with postpartum inability to void spontaneously in the delivery room and a bladder capacity ≥ 300 ml. The bladder capacity threshold was determined based on the range of bladder fullness thresholds when the urge to urinate occurs. Relevant data indicate that this threshold includes 300–400 ml[ 15 ] and 400–500 ml[ 16 , 17 ]. The study selected the lower threshold of 300 ml as the bladder capacity cutoff. 2.2 Inclusion and Exclusion Criteria The inclusion criteria included the following four criteria: ① Age ≥ 18 years; ② Gestational age 37 weeks to 41 weeks and 6 days; ③ Single pregnancy; ④ Fetal position was cephalic. Patients are excluded if they meet any of the following criteria: ① Pre-existing urinary system disorders (e.g., urinary calculi, acute/chronic renal insufficiency, nephritis); ② Pre-existing urinary catheterization; ③ Postpartum catheterization required due to clinical changes; ④ Presence of psychiatric disorders; ⑤ Postpartum hemorrhage diagnosed within 2 hours of delivery; ⑥ Failure to perform bladder residual urine testing upon returning to the ward. 2.3 Data Collection The data collection included grouping, basic data, and outcome indicators. The definition and assignment table of study variables, as well as the study quality control, are detailed in Appendix 1 . 2.3.1 Grouping Method Grouping based on whether the parturients received a single catheter in the delivery room (a single catheter refers to the use of sterile techniques to insert a catheter through the urethra into the bladder to drain urine, and then immediately remove the catheter)[ 18 ]. 2.3.2 Basic Information (1) Basic information: ID number, age (years), obstetric history (primiparous or multiparous); (2) Labour process details: anaesthesia method (pudendal nerve block anaesthesia, pudendal nerve block anaesthesia combined with epidural labour analgesia), duration of the second stage of labour, number of intermittent catheterisations during labour, newborn weight, assisted delivery (if any), perineal wound (intact perineum, episiotomy, perineal tear and its degree), date of delivery, placental expulsion time; (3) Postpartum condition: postpartum bladder urine volume (measured by catheterisation or using the PBSV4.1 bladder scanner produced by Mianyang Meike Company), measurement time; postpartum perineal oedema; timing of first spontaneous urination after delivery to assess for overt urinary retention, i.e., the interval between the first spontaneous urination postpartum and the time of placental expulsion. 2.3.3 Outcome Measures Based on previous literature research and available data from the existing electronic medical record database [ 19 ], a team of obstetric nursing professionals, including 2 postgraduate students and 4 master's degree holders (among them 3 experts with senior professional titles and 2 experts with intermediate professional titles), conducted in-depth group discussions. The primary and secondary outcomes were finally determined. The primary outcomes are PUR and an indwelling urinary catheter. PUR includes overt PUR and covert PUR. Overt PUR refers to the inability to void spontaneously despite bladder fullness 6–8 hours postpartum [ 3 ]; covert PUR refers to a PVRV ≥ 150ml measured by ultrasound or catheterisation after spontaneous urination [ 4 ]. In this study, a portable bladder scanner (Model: Meike PBSV 4.1) was used to measure PVRV. Indwelling urinary catheter: after the parturient returns to the ward, if urination remains difficult or impossible despite repeated bladder stimulation and the bladder is still full, catheterisation is performed and the catheter is retained in the bladder to drain urine [ 18 ]. Secondary outcomes: (1) Spontaneous urination: From the time the parturient returns to the maternity ward until discharge, urination occurs spontaneously without the need for inducement[ 20 ]. (2) Number of induced urinations: From the time the parturient returns to the maternity ward until discharge, if difficulty urinating or inability to urinate spontaneously occurs, urine is induced by methods such as listening to the sound of running water, using glycerin suppositories, or intramuscular injection of neostigmine, with one or more methods applied for each induced urination. 2.4 Statistical Analysis (1) General Analysis Principles Measurement data conforming to a normal distribution are described as mean ± standard deviation, with intergroup comparisons performed using the independent sample t-test; non-normally distributed data are described as median (M) and interquartile range (IQR), with intergroup comparisons performed using the Wilcoxon rank-sum test. Count data are described as frequency and percentage (%), with intergroup comparisons performed using the χ 2 test. Statistical analysis was conducted using R software (4.1.1) and Zstats (v0.90), with a significance level of 0.05. The probability of binary outcomes is predicted using a Logistic regression model, calculating odds ratios (OR) and 95% confidence intervals (CI), where OR > 1 indicates a risk factor and OR < 1 indicates a protective factor. Postpartum urinary catheterisation frequency was analysed using Poisson regression. Prior to multivariate regression, the variance inflation factor (VIF) was used to check for multicollinearity between variables, with VIF 0.1 considered as no multicollinearity[ 21 ]. (2) Confounding Factor Control Confounding factors are addressed using stabilized inverse probability of treatment weighting (sIPTW) to reduce selection bias in retrospective cohort studies. A multivariable logistic regression model is used to calculate the propensity score (PS). This model retains the study cohort sample, offering an advantage over IPTW and PSM, and reduces the occurrence of false positives compared with IPTW[ 22 ]. Covariates for the propensity model are selected based on literature and real-world data[ 23 – 26 ], including age, obstetric history, anaesthesia method, duration of the second stage of labour, neonatal weight, assisted vaginal delivery, intermittent catheterisation during labour, perineal wound, perineal oedema, and postpartum bladder volume. Standardized Mean Difference (SMD) is calculated to assess the balance between groups, and an SMD < 0.1 indicates a good balance of covariates between groups[ 27 ]. When performing sensitivity analysis using propensity score matching (PSM), 1:1 nearest neighbour matching is used (with a caliper value of 20% of the standard deviation of the logit of the propensity score[ 28 ]. When the sample size is insufficient for PSM, inverse probability weighting (IPTW) is used to handle confounding factors. (3) Subgroup Analysis Subgroups were created based on key maternal clinical characteristics, and multivariate logistic regression was used to adjust for potential confounding factors. A forest plot was drawn to show the OR values and 95% CI for each subgroup. Interaction tests (P interaction) were conducted to determine whether the effect of single postpartum catheterisation was influenced by subgroups: if P > 0.05, it indicates a consistent effect; if P < 0.05, further analysis of differences among subgroups is carried out. 3. Results 3.1 Target Population From January 1, 2021, to March 31, 2024, a total of 1,637 parturients who had vaginal delivery and failed to urinate spontaneously in the delivery room with a bladder volume of ≥ 300 ml were included in the study. After initial screening, 1 case under 18 years old, 40 cases with gestational weeks outside the range of 37-41 +6 weeks, 2 cases of twin pregnancies, and 1 case with a non-cephalic fetal position were excluded. Ultimately, 1,593 parturients met the inclusion criteria. Further screening was conducted according to the exclusion criteria, and finally, 1,316 parturients met both the inclusion and exclusion criteria, with the bladder volume measured within 3 hours postpartum. Among them, 776 cases (59.0%) were in the catheterization group and 540 cases (41.0%) were in the non-catheterization group. (Figure 1) 3.2 Baseline Characteristics Before covariate balance, there were significant differences between the catheterized and non-catheterized groups in terms of anaesthesia type, perineal wound, duration of the second stage of labour, intermittent catheterisation during labour, and postpartum bladder volume (SMD>0.1). (Table 1) After PSM, 838 parturients were successfully matched, with 419 in both the catheterized and non-catheterized groups. After adjusting for confounding factors using sIPTW, the weighted sample sizes for the catheterized and non-catheterized groups were 781.52 and 534.31, respectively. After PSM and sIPTW processing, all baseline characteristics achieved a balanced state, with all SMDs below 0.1 (Figure 2). Compared with PSM, the sIPTW method showed superior covariate balance while retaining a larger effective sample size. 3.3 Analysis of primary outcome measures In this study, a total of 1316 parturients were enrolled. The overall incidence of PUR was 20.1%, with an overall incidence of 16.4% for latent PUR and 4.8% for overt PUR. The overall rate of indwelling urinary catheter was 5.9%. In the absence of confounding factors, performing single catheterization within 3 hours after delivery can significantly reduce the overall incidence of PUR (16.5% vs. 25.4%, χ² = 15.597, P < 0.001). Among them, the risk of occult PUR is lower in the catheterization group (12.4% vs. 22.2%, χ² = 15.597, P 0.05). Additionally, there was no significant difference in the rate of postpartum indwelling urinary catheters between the two groups (5.7% in the catheterization group vs. 6.1% in the non-catheterization group, χ² = 0.047, P>0.05). For details, please refer to Supplementary Appendix 1. After balancing confounding factors using both PSM and sIPTW methods, it was demonstrated that single catheterization within 3 hours after childbirth was a protective factor for both PUR and latent PUR (both OR < 1, P 0.05) (Table 2). 3.4 Analysis of secondary outcome indicators In this study, the overall rate of spontaneous urination was 75.7%. Without adjusting for confounding factors, 74.8% of parturients in the non-catheterization group were able to spontaneously urinate without requiring induced urination during their hospital stay after returning to the obstetric ward postpartum, while 76.3% of parturients in the catheterization group were able to spontaneously urinate during their hospital stay. There was no significant difference in the rate of spontaneous urination between the two groups postpartum, as indicated by the chi-square test result (χ² = 0.302, P>0.05) (See Supplementary Appendix 2 for details). After adjusting for confounding factors using PSM and sIPTW, the results showed that single catheterization within 3 hours had no significant effect on spontaneous urination (OR values all included 1, P>0.05) (Table 3) In the outcome indicator of postpartum induced urination frequency, the median was 0 times and the mean was 0.38 times in the non-catheterization group; the median was 0 times and the mean was 0.36 times in the catheterization group. Before adjusting for confounding factors, the odds ratio (OR) value from the univariate Poisson regression analysis was 0.96 (0.80, 1.15), with P>0.05, indicating no significant difference in induced urination frequency between the two groups. After adjusting for confounding factors using PSM and sIPTW, the results showed that single catheterization within 3 hours had no significant effect on spontaneous urination (OR values all included 1, P>0.05). (Table 3) 3.5 Subgroup analysis Based on important clinical characteristics of parturients, subgroups were set up and forest plots were drawn. The subgroups are as follows: ① Pregnancy and childbirth history is divided into nulliparous and multiparous subgroups; ② According to the anesthesia method, it is divided into pudendal nerve block anesthesia, pudendal nerve block anesthesia combined with intrathecal analgesia; ③ According to whether instrumental delivery is performed during the labor process; ④ According to the condition of perineal wound after delivery: intact, lateral episiotomy, laceration; ⑤ According to whether there is perineal edema after delivery; ⑥ The number of intermittent catheterization during labor is divided into 0 times, 1 time, and ≥2 times[29] ; ⑦ Grouping based on different bladder thresholds for urinary sensation, with a threshold of 400ml (<400ml and ≥400ml) [15-17]. From the forest plot (Figure 3), it can be seen that among the overall population, performing single catheterization within 3 hours after childbirth significantly reduces the risk of PUR, with an OR value of 0.67 (0.50, 0.90) and P = 0.007. Subgroup analysis reveals a significant interaction in the bladder urine volume subgroup (P for interaction = 0.002), indicating that the effect of performing single catheterization within 3 hours after childbirth on the risk of PUR may vary among parturients with different levels of bladder urine volume, especially among those with bladder urine volume ≥400 mL, where the effect is more pronounced, with an OR value of 0.45 (0.30, 0.67) and P 0.05). From the forest plot (Figure 4), it can be seen that in the overall population, there is no significant correlation between the risk of single catheterization and the risk of indwelling catheterization within 3 hours after childbirth, with an OR value of 0.70 (0.41, 1.19) and P > 0.05. Subgroup analysis shows that there is a significant interaction in both the perineal wound and instrumental delivery subgroups (P for interaction is 0.014 and 0.015, respectively). In the perineal wound subgroup, due to the small sample size of intact perineum, the OR value is abnormally high and is not shown in the forest plot. Perineal wound and instrumental delivery may be important factors in the relationship between single catheterization and indwelling catheterization within 3 hours after childbirth. There is no significant interaction in other subgroups (P for interaction > 0.05). 3.6 Sensitivity analysis This study conducted sensitivity analysis through three methods: adjusting the PS method, adjusting the inclusion criteria, and adjusting the PS model. The results section has simultaneously presented the results of both PSM and sIPTW methods. Further sensitivity analysis revealed that single catheterization within 3 hours after delivery is robust for PUR and spontaneous urination results, but not for the number of induced urination attempts and the impact of indwelling catheterization, which is also influenced by the duration of single catheterization. The specific process is as follows. 3.6.1 Impact of single catheterization after adjusting the inclusion criteria on outcome measures By adjusting the inclusion criteria to restrict those who did not urinate spontaneously and had a bladder urine volume of ≥300ml within 2 hours after childbirth, we explored the impact of single catheterization on urinary retention-related outcome indicators in the early postpartum period (within 2 hours after childbirth). Among the 1,316 parturients included, 972 did not urinate spontaneously and had a bladder urine volume of ≥300ml within 2 hours after childbirth. Among them, 704 were in the catheterization group and 268 were in the non-catheterization group. Given that the sample size after adjusting the inclusion criteria was insufficient for a 1:1 PSM (the sample size of this study was 650, with 325 in each group; see Appendix 3 for the calculation process), and the non-catheterization group before PSM was significantly smaller than the catheterization group, making it unsuitable for a 1:n PSM, IPTW combined with sIPTW was used to adjust for confounding factors. After adjusting for confounding factors using IPTW, there were 973.68 cases in the catheterization group and 956.25 cases in the non-catheterization group. After adjusting for confounding factors using sIPTW, 705.22 cases were obtained in the catheterization group and 263.66 cases in the non-catheterization group. After adjusting for confounding factors using both sIPTW and IPTW, the balance of each covariate was good, with SMDs all less than 0.1 (see Appendix 4, Figure 1 for details). (1) The impact of single catheterization within 2 hours after childbirth on primary outcome measures The sensitivity analysis results indicated that after adjusting for confounding factors using sIPTW and IPTW, performing single catheterization within 2 hours after delivery could reduce the risk of PUR and latent PUR (OR value included 1 and P<0.05). Furthermore, regarding the outcome indicator of overt PUR, there was no significant association between performing single catheterization within 2 hours after delivery and the risk of overt PUR (OR value included 1 and P>0.05). Regarding the outcome indicators of indwelling urinary catheter, after adjusting for confounding factors using IPTW and sIPTW (both OR values not including 1, and P<0.05), it was indicated that performing single catheterization within 2 hours after childbirth could reduce the risk of indwelling urinary catheter. (Table 4) (2) The impact of single catheterisation within 2 hours postpartum on secondary outcome indicators The results of the sensitivity analysis indicate that for the outcome measure of spontaneous urination, logistic regression analysis after IPTW and sIPTW adjustment for confounding factors showed OR values including 1, with P>0.05, suggesting that performing a single catheterisation within 2 hours postpartum has no significant effect on maternal spontaneous urination (Table 5). For the outcome measure of induced urination frequency, Poisson regression analysis after IPTW and sIPTW adjustment for confounding factors showed OR values less than 1, with P<0.05, indicating that performing a single catheterisation within 2 hours postpartum significantly reduces the frequency of induced urination (Table 5). 3.6.2 Impact of single catheterisation on outcomes after adjusting the PS model Given that the timing of catheterisation also affects PUR-related outcomes, to adjust for more confounding factors, postpartum catheterisation timing (≤2 hours and >2 hours) was added to the propensity score model. After PSM and sIPTW adjustments for confounding factors, except for the number of intermittent catheterisations during labour after PSM (SMD=0.106), the SMDs of other covariates were <0.1 (see Appendix 4 Figure 2). After PSM, both the catheterisation group and the non-catheterisation group included 319 cases, while after sIPTW, the catheterisation group was 778.2 cases and the non-catheterisation group was 536.6 cases. After adjusting the propensity score model, regression analysis was conducted after handling confounding factors with PSM and sIPTW. The results showed that performing a single catheterisation within 3 hours postpartum could reduce the incidence of PUR and covert PUR (both OR values less than 1, and P0.05), as detailed in Table 6. The results are consistent with the main analysis, indicating that the original model is relatively robust. 4. Discussion In clinical practice, there is still controversy over whether parturients who are unable to urinate spontaneously in the delivery room yet feel the urge to urinate should undergo intermittent catheterisation. This study, based on real-world data, investigates the impact of intermittent catheterisation in the delivery room on PUR, indwelling catheter use, spontaneous urination, and the frequency of induced urination, aiming to provide a reference for the prevention of PUR and to lay a foundation for postpartum bladder management. 4.1 Research on the data characteristics of parturients This study included 1,316 parturients undergoing vaginal delivery. The incidence of overt PUR was 4.8%, which is close to the average incidence of 5.37% reported in a study involving 12,609 parturients[ 30 ]. The incidence of latent PUR is 16.4%, higher than the 11.04% reported by Ain et al. [ 31 ], but lower than the 47% in the study by Mulder et al.[ 4 ]Compared with an overall incidence of covert PUR of 13% in a systematic review report, the difference is not significant[ 32 ]. Covert PUR is defined according to PVRV, but there are differences in the critical values and measurement times of PVRV in the literature, resulting in a wide range of global PUR incidence [ 33 ]. The commonly reported PVRV cut-off values in the literature include 100 mL[ 34 ], 150 mL[ 4 ], and 250 mL [ 33 ]. In this study, 150 mL was selected as the cut‑off value because it is widely used in the literature and has not been associated with reported adverse outcomes, while also helping avoid unnecessary interventions or monitoring [ 35 ]. The timing of PVRV measurement includes after the first postpartum void [ 31 , 36 ], at 4 h postpartum [ 37 ], or at 6–8 h postpartum [ 38 ]. Based on real‑world data, this study performed one or more PVRV measurements for the same parturient and defined PVRV ≥ 150 mL as the diagnostic criterion for covert PUR, which can help reduce the underdiagnosis rate of covert PUR. Regarding data collection records, the missing status of all variables was reported. All covariates in this study were complete, and parturients with missing key variables were excluded. The key missing variable was the absence of recorded post‑void residual urine volume after returning to the ward postpartum, which hinders the identification of covert PUR. For quality control, a data dictionary was used to avoid cumbersome data entry and entry errors. 4.2 The Impact of single catheterization on PUR This study investigated the impact of a single catheterization on PUR. The results indicated that for parturients who had not voided spontaneously and had a bladder volume ≥ 300 mL, performing a single catheterization within 3 hours postpartum significantly reduced the risk of PUR (particularly covert PUR), although its effect on overt PUR was not significant. Sensitivity analyses confirmed the robustness of this result, which was not influenced by the timing of catheterization. The conclusion that postpartum catheterization significantly reduces the risk of PUR is consistent with findings from previous studies [ 39 , 40 ]. However, prior research primarily focused on indwelling or intermittent catheterization, with study populations consisting of assisted delivery or parturients receiving labor analgesia. In contrast, based on real-world data and targeting parturients who had not voided spontaneously with a bladder volume ≥ 300 mL, this study further supplements the evidence for methods to prevent urinary retention, laying a foundation for standardizing postpartum bladder management. Performing a single catheterization within 3 hours postpartum can reduce the risk of covert PUR. This finding, regarding the effect of a single catheterization on covert PUR, aligns with the conclusion of Neron et al., although the timing of catheterization differs from that in their study[ 1 ]. However, among the overall population of parturients in this study, a single catheterization within 3 hours postpartum showed no significant impact on overt PUR. According to the literature included in a scoping review[ 19 ], studies on postpartum catheterization for preventing PUR did not clearly differentiate overt PUR from PUR in general. Therefore, no direct comparison could be made with the effect of postpartum catheterization on overt PUR in previous studies. Nevertheless, based on the definition of overt PUR as "the inability to void spontaneously despite a full bladder 6–8 hours postpartum," the results indicate that performing a single catheterization within 3 hours postpartum to empty the bladder did not prolong the time to first spontaneous voiding. This is consistent with findings from prior studies, which reported that postpartum catheterization has no significant effect on the time to first spontaneous voiding[ 39 , 41 ]. This study primarily involved exploratory subgroup analyses, and the sample size within each subgroup was limited. If multiple comparison corrections were applied, statistical power might have been further reduced. Therefore, this study did not perform corrections for multiple comparisons. However, this may increase the risk of false-positive results; consequently, the related findings should be interpreted with caution and require further validation in subsequent research. In the subgroup analyses, the impact of performing a single catheterization within 3 hours postpartum on the risk of PUR varied among parturients with different levels of bladder volume. The effect appeared potentially more significant in parturients with a bladder volume ≥ 400 mL. Catheterization may work by preventing overdistension of the bladder[ 7 ], and shortening the duration of high bladder capacity[ 1 ]. Some studies also suggest that recommended catheterization—whether single complete drainage or short-term open drainage—allows the bladder and urethral muscles and mucosa to rest adequately[ 42 ], thereby promoting the recovery of detrusor contractile function[ 39 ]. Additionally, catheterization may alleviate perineal trauma, reduce perineal edema, and allow sufficient relaxation of the urethra[ 7 ]. Therefore, increased attention should be given to parturients with high bladder volume who have not voided spontaneously, and further research is needed for validation. 4.3 The Impact of Single Catheterization on the Need for Indwelling Catheterization Although catheterization is an invasive procedure, single catheterization has less impact and causes fewer complications for parturients compared to indwelling catheterization. Studies have shown that single catheterization reduces the incidence of urinary tract infections (UTIs) relative to indwelling catheters[ 43 ]. Furthermore, some research suggests that intermittent catheterization carries a lower risk of UTI than indwelling catheterization[ 41 ].This study focused specifically on the impact of performing a single catheterization in the delivery room on the subsequent need for indwelling catheterization. Parturients who required catheterization due to changes in their clinical condition were explicitly excluded. Consequently, all cases of indwelling catheterization included in the analysis were for PUR. In the overall study population, performing a single catheterization within 3 hours postpartum did not have a significant impact on the rate of indwelling catheterization. This finding is consistent with the results of Feng Peixiao et al. [41]. Their study involved a single catheterization within 6 hours postpartum after failed attempts to induce voiding, compared to routine indwelling catheterization for approximately 24 hours. They found no significant difference in re-catheterization rates but observed a reduction in UTI incidence with the single catheterization approach. However, another study implementing a comprehensive intervention centered around intermittent catheterization for parturients receiving labor analgesia concluded that catheterization could reduce the rate of indwelling catheterization[ 39 ]. This discrepancy may be attributed, on one hand, to the rapid and prolonged bladder filling postpartum, which could diminish the preventive effect of a single catheterization on the need for an indwelling catheter. On the other hand, it may be related to differences in catheterization methods and timing. Therefore, sensitivity analyses were conducted by adjusting the inclusion criteria based on the timing of catheterization. Subgroup analyses suggested that perineal wounds and instrumental delivery might be important factors influencing the relationship between a single catheterization within 3 hours postpartum and the need for indwelling catheterization. However, in this study, all included perineal lacerations were first-degree, and the subgroups with intact perineum and those with instrumental delivery had small sample sizes and low incidence rates of indwelling catheterization. This may explain why no significant impact of single catheterization on indwelling catheterization was observed across subgroups based on perineal status or instrumental delivery. 4.4 Sensitivity Analysis In this study, sensitivity analyses were performed by adjusting both the propensity score method and the model specifications. The results consistently demonstrated that performing a single catheterization within 3 hours postpartum significantly reduced the risk of overall PUR and covert PUR, while showing no significant effect on overt PUR, the need for indwelling catheterization, spontaneous voiding, or the number of attempts to induce voiding. These findings indicate a high degree of robustness. Furthermore, sensitivity analysis was conducted by modifying the inclusion criteria. Based on a previous study where catheterization was performed at 2 hours postpartum[ 1 ], and considering that in the real-world data, catheterization occurred around 2 hours postpartum with more parturients having their bladder volume assessed within 2 hours than after, the inclusion criteria were adjusted to: parturients who had not voided spontaneously and had a bladder volume ≥ 300 mL within 2 hours postpartum. The sensitivity analysis results showed that performing a single catheterization within 2 hours postpartum significantly reduced the risk of overall PUR and covert PUR, while no significant effects were observed on overt PUR or spontaneous voiding. This supports the robustness of the main conclusions. Performing a single catheterization within 2 hours postpartum was associated with a reduced risk of requiring indwelling catheterization and fewer attempts to induce voiding. This finding is inconsistent with the main analysis, which showed no significant impact of catheterization within 3 hours on these outcomes. This difference may be related to the early bladder stimulation provided by catheterization within 2 hours. Research by Bachar et al suggests that early stimulation from bladder refilling immediately after catheter removal can promote spontaneous voiding, whereas delayed stimulation may lead to increased urinary retention[ 44 ]. In clinical practice, methods to induce voiding are varied, and a single attempt may involve one or multiple techniques. Typically, healthcare providers implement these methods only when a parturient attempts but fails to void or experiences difficult urination. Therefore, the number of induction attempts can, to some extent, reflect the frequency of a parturient's attempts to void spontaneously. Although prior research has paid less attention to the metric of induction attempts, it remains clinically significant and warrants attention, particularly for parturients who deliver at night, have prolonged labor, or are in a weakened condition. 5. Innovation and Limitations 5.1 Innovation On the one hand, this study addresses a clinically debated issue by investigating the effectiveness of single in‑and‑out catheterization in preventing PUR based on real‑world data, thereby reflecting patient characteristics that are more aligned with actual clinical practice. On the other hand, this study employed two complementary propensity score methods—matching and weighting—to control for potential selection bias inherent in the retrospective cohort design. These approaches helped minimize between‑group data discrepancies and the influence of confounding variables, improving the balance and comparability of baseline characteristics after adjustment, thereby enhancing the reliability of the findings. 5.2 Limitations First, this study was retrospective and single‑center in design, which carries a risk of bias. Although propensity score adjustment was used to control for confounders, there may still be unbalanced factors such as subjective information related to pain level and the sensation of needing to void. Second, while this study collected data from parturients who had not voided spontaneously and had a bladder volume ≥ 300 mL, it did not include those with difficult voiding despite bladder fullness. This group also warrants attention and requires planned bladder management. Additionally, although a large number of case records were collected, the process of identifying and extracting eligible cases relied heavily on manual review of relevant documents, which was time‑consuming and inefficient. Therefore, future research should incorporate intelligent and informatized data‑collection methods, such as natural language processing, to automate the extraction of information from clinical texts. This would improve the efficiency and quality of clinical research, reduce costs, and strengthen the reliability of evidence. Although the subgroup analyses in this study were limited by sample size, their results provide important clues for further research. Future studies with larger samples and more rigorous designs are needed to validate these findings and explore the clinical value of individualized catheterization strategies, so as to optimize the management of PUR. 6. Conclusion In a real-world setting, performing a single catheterization within 3 hours postpartum significantly reduces the risk of PUR and covert PUR, while it shows no significant effect on overt PUR or spontaneous voiding. Furthermore, if the single catheterization is performed within 2 hours postpartum, it may additionally reduce the risk of requiring an indwelling catheter and repeated attempts to induce voiding. However, these conclusions still require further validation through large-sample, multicenter, high-quality studies to provide a more scientific and reliable evidence base for clinical postpartum bladder management. Abbreviations postpartum urinary retention (PUR); inverse probability of treatment weighting (sIPTW); odds ratios (OR); Post-void Residual Volume (PVRV); interquartile range(IQR); median (M); confidence intervals (CI); variance inflation factor (VIF); Standardized Mean Difference (SMD); propensity score matching (PSM) inverse probability weighting (IPTW); urinary tract infections (UTIs) Declarations Conflict of Interest: The authors report no conflicts of interest. Consent to Publish declaration not applicable Ethics approval and consent to participate This study was approved by the Clinical Research and Applied Ethics Committee of The Third Affiliated Hospital, Guangzhou Medical University (Approval No. : Linlun Audit Research [2024] No.013) and was performed in accordance with the ethical standards of the Declaration of Helsinki. Contributions : Huating Chen: Conceptualization, Investigation, Software, Formal Analysis, Writing - Original Draft preparation. Yuyi Chen: Resources, Supervision, Project Administration, Writing - Review & Editing. Shuai Yang: Data Curation, Validation, Visualization, Writing - Review & Editing. Jing Hu: Supervision, Project Administration, Visualization, Original Draft preparation. Jun Lyu: Methodology, Software, Formal Analysis, Writing - Review & Editing. Defeng Chen: Investigation, Writing - Original Draft preparation. Taizhen Luo: Conceptualization, Supervision, Writing - Review & Editing, Funding Acquisition. Funding: None Author Contribution Huating Chen: Conceptualization, Investigation, Software, Formal Analysis, Writing - Original Draft preparation.Yuyi Chen: Resources, Supervision, Project Administration, Writing - Review & Editing.Shuai Yang: Data Curation, Validation, Visualization, Writing - Review & Editing.Jing Hu: Supervision, Project Administration, Visualization, Original Draft preparation.Jun Lyu: Methodology, Software, Formal Analysis, Writing - Review & Editing.Defeng Chen: Investigation, Writing - Original Draft preparation.Taizhen Luo: Conceptualization, Supervision, Writing - Review & Editing, Funding Acquisition. Acknowledgments We acknowledge the Guangzhou Medical University Library for providing the database and the Third Clinical College of Guangzhou Medical University for offering learning opportunities. Data Availability The datasets generated during and analysed during the current study are available from the corresponding author on reasonable request. 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Zhijing S, Yan S, Jin H, Huiwen X, Lijun C. Observation on the efficacy of medium-frequency pulse acupoint electrical stimulation in preventive care of postpartum urinary retention. Chin Gen Pract Nurs. 2019;17(33):4158–60. Divakova O, Panayi D, Khan Z, Doumouchtsis SK. A rapid systematic review of postpartum bladder care guidelines and recommendations in the context of the COVID-19 pandemic. J OBSTET GYNAECOL. 2022;42(7):2634–42. Mulder FE, Oude RK, van der Post JA, Hakvoort RA, Roovers JP. Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery. INT UROGYNECOL J. 2016;27(1):55–60. Buchanan J, Beckmann M. Postpartum voiding dysfunction: identifying the risk factors. AUST NZ J OBSTET GYN. 2014;54(1):41–5. Kawasoe I, Kataoka Y. Prevalence and risk factors for postpartum urinary retention after vaginal delivery in Japan: A case-control study. JPN J NURS SCI. 2020;17(2):e12293. Xinyang L, Yurong J, Fangshu L, Yuanhuan H, Yuan W, Xiaoling Z. Effect of comprehensive nursing intervention centered on intermittent catheterization on the prevention of urinary retention after labor analgesia. Nurs Pract Res. 2023;20(8):1166–9. Jin Y. Observation on the effectiveness of indwelling urinary catheterization in preventing urinary retention after dystocia. NANFANG J Nurs. 2003;10(5):21. Peixiao F, Chengbei C, Huiya X, Haixia W, Si C, Miauna X, Fengji Z, Zhihui H. Comparing the Effects of Intermittent Catheterization and Indwelling Catheterization on Urination Disorder in the Maternal. Med Innov China. 2017;14(28):85–8. Youliang O. Research on the predictive value of bladder pressure and volume in micturition outcomes of intrapartum dominant urinary retention and postpartum dominant urinary retention in parturient women. Southern Medical University; 2020. Yijian C, Guifang G, Fang F. The necessity study of urinary catheterization during painless labor. Mod Prev Med. 2012;39(11):2724–5. Bachar G, Siegler Y, Kabakov E, Lauterbach R, Justman N, Ben-Ezry E, Weiner E, Ganor-Paz Y, Yefet E, Khamaisi T, et al. Intermittent vs continuous catheterization for postpartum urinary retention: A multicenter randomized controlled trial. AM J OBST GYNEC MFM. 2023;5(10):101084. Goh R, Goh D, Ellepola H. Perineal tears - A review. AUST J GEN PRACT. 2018;47(1–2):35–8. Tables Table 1 to 6 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1Baselinecharacteristicsofparturientsbeforepropensityscore.docx Table2Theimpactofsinglecatheterizationbeforeandafterpropensityscorematchingonprimaryoutcomemeasures.docx Table3ImpactofsinglecatheterizationafterPSonsecondaryoutcomemeasures.docx Table4Impactofsinglecatheterizationwithin2hoursafterdeliveryonprimaryoutcomemeasures.docx Table5Theeffectofadisposablecatheterisationwithin2hourspostpartumonsecondaryoutcomemeasures.docx Table6Effectofpostpartumsinglecatheterisationonoutcomeindicatorsafteradjustingthemodel.docx Appendix14.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Introduction","content":"\u003cp\u003ePostpartum urinary retention (PUR) is a common complication after childbirth, with an incidence of 0.2% to 45% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is divided into overt PUR and covert PUR. Overt PUR refers to the filling of urine in the bladder for 6\u0026ndash;8 hours after delivery but cannot be discharged by itself[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]; covert PUR refers to the Post-void Residual Volume (PVRV) in the bladder after self-voiding ultrasound monitoring or catheter drainage of patients \u0026ge;\u0026thinsp;150mL [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2018, the National Health Commission issued the \"Notice on Carrying Out Pilot Work for Labor Analgesia\", emphasizing the expansion of the coverage of labor analgesia[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In some domestic specialized obstetric and gynecological hospitals and maternal and child health care institutions, the rate of intraspinal labor analgesia can reach over 80%; in developed Western countries, the rate of labor analgesia has reached as high as 85% or even over 90%[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The common method for labor analgesia is epidural analgesia. The popularization and application of epidural analgesia directly affect the generation and transmission of the micturition reflex signal, causing the contraction of the detrusor muscle and the relaxation of the urethra to be out of sync, thereby leading to the occurrence of urinary retention[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, the incidence of urinary retention is likely to increase further with the widespread promotion and application of epidural analgesia.\u003c/p\u003e \u003cp\u003ePUR has both short-term and long-term effects. Studies have shown that excessive bladder distension can affect uterine contraction and increase the incidence of postpartum hemorrhage[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It can also easily lead to cystitis[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, untreated acute urinary retention for a prolonged period may cause the detrusor muscle to transform into non-contractile fibrosis[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This can result in dysuria, detrusor underactivity, urinary incontinence, urinary frequency, and nocturia, and may even lead to hydronephrosis[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Research indicates that among parturients with PUR, 8.2%, 6.7%, and 4.9% still experienced dysuria at 1, 2, and 3 years of follow-up, respectively. Reports have pointed out that PUR can cause diffuse urothelial edema and bleeding in the bladder [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. After 8 weeks of intermittent catheterization, cystoscopy revealed that the bladder had returned to normal in these parturient[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].In extremely rare cases, PUR can lead to bladder rupture, which is life-threatening[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Preventing excessive bladder distension is key to perinatal bladder management, and catheterization is the most direct method. However, there is still controversy regarding whether to perform a single catheterization before diagnosing PUR.\u003c/p\u003e \u003cp\u003eAlthough existing literature has reported that single catheterization within 2 hours postpartum can reduce the incidence of covert PUR[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], its impact on clinically more significant outcomes - particularly overt PUR and indwelling catheterization - remains unclear. This evidence gap represents a critical clinical question requiring urgent resolution.\u003c/p\u003e \u003cp\u003eUtilizing real-world data, this study constructs a retrospective cohort to investigate the effects of immediate single catheterization in the delivery room on PUR and related outcomes. Our findings aim to provide evidence-based strategies for PUR prevention and inform standardized postpartum bladder management.\u003c/p\u003e"},{"header":"2. Data and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Sources of Data\u003c/h2\u003e \u003cp\u003eThis study enrolled parturients who underwent vaginal delivery at the obstetrics department of a Grade III-A hospital in Guangzhou between January 1, 2021, and March 31, 2024, with postpartum inability to void spontaneously in the delivery room and a bladder capacity\u0026thinsp;\u0026ge;\u0026thinsp;300 ml. The bladder capacity threshold was determined based on the range of bladder fullness thresholds when the urge to urinate occurs. Relevant data indicate that this threshold includes 300\u0026ndash;400 ml[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and 400\u0026ndash;500 ml[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The study selected the lower threshold of 300 ml as the bladder capacity cutoff.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Inclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eThe inclusion criteria included the following four criteria: ① Age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; ② Gestational age 37 weeks to 41 weeks and 6 days; ③ Single pregnancy; ④ Fetal position was cephalic.\u003c/p\u003e \u003cp\u003ePatients are excluded if they meet any of the following criteria: ① Pre-existing urinary system disorders (e.g., urinary calculi, acute/chronic renal insufficiency, nephritis); ② Pre-existing urinary catheterization; ③ Postpartum catheterization required due to clinical changes; ④ Presence of psychiatric disorders; ⑤ Postpartum hemorrhage diagnosed within 2 hours of delivery; ⑥ Failure to perform bladder residual urine testing upon returning to the ward.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Collection\u003c/h2\u003e \u003cp\u003eThe data collection included grouping, basic data, and outcome indicators. The definition and assignment table of study variables, as well as the study quality control, are detailed in \u003cspan refid=\"Sec28\" class=\"InternalRef\"\u003eAppendix 1\u003c/span\u003e.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Grouping Method\u003c/h2\u003e \u003cp\u003eGrouping based on whether the parturients received a single catheter in the delivery room (a single catheter refers to the use of sterile techniques to insert a catheter through the urethra into the bladder to drain urine, and then immediately remove the catheter)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Basic Information\u003c/h2\u003e \u003cp\u003e(1) Basic information: ID number, age (years), obstetric history (primiparous or multiparous);\u003c/p\u003e \u003cp\u003e(2) Labour process details: anaesthesia method (pudendal nerve block anaesthesia, pudendal nerve block anaesthesia combined with epidural labour analgesia), duration of the second stage of labour, number of intermittent catheterisations during labour, newborn weight, assisted delivery (if any), perineal wound (intact perineum, episiotomy, perineal tear and its degree), date of delivery, placental expulsion time;\u003c/p\u003e \u003cp\u003e(3) Postpartum condition: postpartum bladder urine volume (measured by catheterisation or using the PBSV4.1 bladder scanner produced by Mianyang Meike Company), measurement time; postpartum perineal oedema; timing of first spontaneous urination after delivery to assess for overt urinary retention, i.e., the interval between the first spontaneous urination postpartum and the time of placental expulsion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.3 Outcome Measures\u003c/h2\u003e \u003cp\u003eBased on previous literature research and available data from the existing electronic medical record database [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], a team of obstetric nursing professionals, including 2 postgraduate students and 4 master's degree holders (among them 3 experts with senior professional titles and 2 experts with intermediate professional titles), conducted in-depth group discussions. The primary and secondary outcomes were finally determined.\u003c/p\u003e \u003cp\u003eThe primary outcomes are PUR and an indwelling urinary catheter. PUR includes overt PUR and covert PUR. Overt PUR refers to the inability to void spontaneously despite bladder fullness 6\u0026ndash;8 hours postpartum [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]; covert PUR refers to a PVRV \u0026ge;\u0026thinsp;150ml measured by ultrasound or catheterisation after spontaneous urination [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In this study, a portable bladder scanner (Model: Meike PBSV 4.1) was used to measure PVRV. Indwelling urinary catheter: after the parturient returns to the ward, if urination remains difficult or impossible despite repeated bladder stimulation and the bladder is still full, catheterisation is performed and the catheter is retained in the bladder to drain urine [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSecondary outcomes: (1) Spontaneous urination: From the time the parturient returns to the maternity ward until discharge, urination occurs spontaneously without the need for inducement[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. (2) Number of induced urinations: From the time the parturient returns to the maternity ward until discharge, if difficulty urinating or inability to urinate spontaneously occurs, urine is induced by methods such as listening to the sound of running water, using glycerin suppositories, or intramuscular injection of neostigmine, with one or more methods applied for each induced urination.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical Analysis\u003c/h2\u003e \u003cp\u003e(1) General Analysis Principles Measurement data conforming to a normal distribution are described as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, with intergroup comparisons performed using the independent sample t-test; non-normally distributed data are described as median (M) and interquartile range (IQR), with intergroup comparisons performed using the Wilcoxon rank-sum test. Count data are described as frequency and percentage (%), with intergroup comparisons performed using the χ\u003csup\u003e2\u003c/sup\u003etest. Statistical analysis was conducted using R software (4.1.1) and Zstats (v0.90), with a significance level of 0.05. The probability of binary outcomes is predicted using a Logistic regression model, calculating odds ratios (OR) and 95% confidence intervals (CI), where OR\u0026thinsp;\u0026gt;\u0026thinsp;1 indicates a risk factor and OR\u0026thinsp;\u0026lt;\u0026thinsp;1 indicates a protective factor. Postpartum urinary catheterisation frequency was analysed using Poisson regression. Prior to multivariate regression, the variance inflation factor (VIF) was used to check for multicollinearity between variables, with VIF\u0026thinsp;\u0026lt;\u0026thinsp;10 and tolerance\u0026thinsp;\u0026gt;\u0026thinsp;0.1 considered as no multicollinearity[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e(2) Confounding Factor Control\u003c/p\u003e \u003cp\u003eConfounding factors are addressed using stabilized inverse probability of treatment weighting (sIPTW) to reduce selection bias in retrospective cohort studies. A multivariable logistic regression model is used to calculate the propensity score (PS). This model retains the study cohort sample, offering an advantage over IPTW and PSM, and reduces the occurrence of false positives compared with IPTW[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Covariates for the propensity model are selected based on literature and real-world data[\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], including age, obstetric history, anaesthesia method, duration of the second stage of labour, neonatal weight, assisted vaginal delivery, intermittent catheterisation during labour, perineal wound, perineal oedema, and postpartum bladder volume. Standardized Mean Difference (SMD) is calculated to assess the balance between groups, and an SMD\u0026thinsp;\u0026lt;\u0026thinsp;0.1 indicates a good balance of covariates between groups[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen performing sensitivity analysis using propensity score matching (PSM), 1:1 nearest neighbour matching is used (with a caliper value of 20% of the standard deviation of the logit of the propensity score[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. When the sample size is insufficient for PSM, inverse probability weighting (IPTW) is used to handle confounding factors.\u003c/p\u003e \u003cp\u003e(3) Subgroup Analysis\u003c/p\u003e \u003cp\u003eSubgroups were created based on key maternal clinical characteristics, and multivariate logistic regression was used to adjust for potential confounding factors. A forest plot was drawn to show the OR values and 95% CI for each subgroup. Interaction tests (P interaction) were conducted to determine whether the effect of single postpartum catheterisation was influenced by subgroups: if P\u0026thinsp;\u0026gt;\u0026thinsp;0.05, it indicates a consistent effect; if P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, further analysis of differences among subgroups is carried out.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Target Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom January 1, 2021, to March 31, 2024, a total of 1,637 parturients who had vaginal delivery and failed to urinate spontaneously in the delivery room with a bladder volume of \u0026ge; 300 ml were included in the study. After initial screening, 1 case under 18 years old, 40 cases with gestational weeks outside the range of 37-41\u003csup\u003e+6\u003c/sup\u003e weeks, 2 cases of twin pregnancies, and 1 case with a non-cephalic fetal position were excluded. Ultimately, 1,593 parturients met the inclusion criteria. Further screening was conducted according to the exclusion criteria, and finally, 1,316 parturients met both the inclusion and exclusion criteria, with the bladder volume measured within 3 hours postpartum. Among them, 776 cases (59.0%) were in the catheterization group and 540 cases (41.0%) were in the non-catheterization group. (Figure 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Baseline Characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore covariate balance, there were significant differences between the catheterized and non-catheterized groups in terms of anaesthesia type, perineal wound, duration of the second stage of labour, intermittent catheterisation during labour, and postpartum bladder volume (SMD\u0026gt;0.1). (Table 1)\u003c/p\u003e\n\u003cp\u003eAfter PSM, 838 parturients were successfully matched, with 419 in both the catheterized and non-catheterized groups. After adjusting for confounding factors using sIPTW, the weighted sample sizes for the catheterized and non-catheterized groups were 781.52 and 534.31, respectively. After PSM and sIPTW processing, all baseline characteristics achieved a balanced state, with all SMDs below 0.1 (Figure 2). Compared with PSM, the sIPTW method showed superior covariate balance while retaining a larger effective sample size.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Analysis of primary outcome measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, a total of 1316 parturients were enrolled. The overall incidence of PUR was 20.1%, with an overall incidence of 16.4% for latent PUR and 4.8% for overt PUR. The overall rate of indwelling urinary catheter was 5.9%.\u003c/p\u003e\n\u003cp\u003eIn the absence of confounding factors, performing single catheterization within 3 hours after delivery can significantly reduce the overall incidence of PUR (16.5% vs. 25.4%, \u0026chi;\u0026sup2; = 15.597, P \u0026lt; 0.001). Among them, the risk of occult PUR is lower in the catheterization group (12.4% vs. 22.2%, \u0026chi;\u0026sup2; = 15.597, P \u0026lt; 0.001). However, there was no significant difference in the incidence of overt PUR between the two groups (5.3% in the catheterization group vs. 4.1% in the non-catheterization group, \u0026chi;\u0026sup2; = 1.123, P \u0026gt; 0.05). Additionally, there was no significant difference in the rate of postpartum indwelling urinary catheters between the two groups (5.7% in the catheterization group vs. 6.1% in the non-catheterization group, \u0026chi;\u0026sup2; = 0.047, P\u0026gt;0.05). For details, please refer to Supplementary Appendix 1.\u003c/p\u003e\n\u003cp\u003eAfter balancing confounding factors using both PSM and sIPTW methods, it was demonstrated that single catheterization within 3 hours after childbirth was a protective factor for both PUR and latent PUR (both OR \u0026lt; 1, P \u0026lt; 0.001). However, it had no significant effect on the risk of overt PUR and the occurrence of indwelling urinary catheters (both OR values included 1, P\u0026gt;0.05) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Analysis of secondary outcome indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, the overall rate of spontaneous urination was 75.7%. Without adjusting for confounding factors, 74.8% of parturients in the non-catheterization group were able to spontaneously urinate without requiring induced urination during their hospital stay after returning to the obstetric ward postpartum, while 76.3% of parturients in the catheterization group were able to spontaneously urinate during their hospital stay. There was no significant difference in the rate of spontaneous urination between the two groups postpartum, as indicated by the chi-square test result (\u0026chi;\u0026sup2; = 0.302, P\u0026gt;0.05) (See Supplementary Appendix 2 for details). After adjusting for confounding factors using PSM and sIPTW, the results showed that single catheterization within 3 hours had no significant effect on spontaneous urination (OR values all included 1, P\u0026gt;0.05) (Table 3)\u003c/p\u003e\n\u003cp\u003eIn the outcome indicator of postpartum induced urination frequency, the median was 0 times and the mean was 0.38 times in the non-catheterization group; the median was 0 times and the mean was 0.36 times in the catheterization group. Before adjusting for confounding factors, the odds ratio (OR) value from the univariate Poisson regression analysis was 0.96 (0.80, 1.15), with P\u0026gt;0.05, indicating no significant difference in induced urination frequency between the two groups. After adjusting for confounding factors using PSM and sIPTW, the results showed that single catheterization within 3 hours had no significant effect on spontaneous urination (OR values all included 1, P\u0026gt;0.05). (Table 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Subgroup analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on important clinical characteristics of parturients, subgroups were set up and forest plots were drawn. The subgroups are as follows: ① Pregnancy and childbirth history is divided into nulliparous and multiparous subgroups; ② According to the anesthesia method, it is divided into pudendal nerve block anesthesia, pudendal nerve block anesthesia combined with intrathecal analgesia; ③ According to whether instrumental delivery is performed during the labor process; ④ According to the condition of perineal wound after delivery: intact, lateral episiotomy, laceration; ⑤ According to whether there is perineal edema after delivery; ⑥ The number of intermittent catheterization during labor is divided into 0 times, 1 time, and \u0026ge;2 times[29]\u0026nbsp;; ⑦ Grouping based on different bladder thresholds for urinary sensation, with a threshold of 400ml (\u0026lt;400ml and \u0026ge;400ml)\u0026nbsp;[15-17].\u003c/p\u003e\n\u003cp\u003eFrom the forest plot (Figure 3), it can be seen that among the overall population, performing single catheterization within 3 hours after childbirth significantly reduces the risk of PUR, with an OR value of 0.67 (0.50, 0.90) and P = 0.007. Subgroup analysis reveals a significant interaction in the bladder urine volume subgroup (P for interaction = 0.002), indicating that the effect of performing single catheterization within 3 hours after childbirth on the risk of PUR may vary among parturients with different levels of bladder urine volume, especially among those with bladder urine volume \u0026ge;400 mL, where the effect is more pronounced, with an OR value of 0.45 (0.30, 0.67) and P \u0026lt; 0.001. No significant interactions were observed in other subgroups (P for interaction \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003eFrom the forest plot (Figure 4), it can be seen that in the overall population, there is no significant correlation between the risk of single catheterization and the risk of indwelling catheterization within 3 hours after childbirth, with an OR value of 0.70 (0.41, 1.19) and P \u0026gt; 0.05. Subgroup analysis shows that there is a significant interaction in both the perineal wound and instrumental delivery subgroups (P for interaction is 0.014 and 0.015, respectively). In the perineal wound subgroup, due to the small sample size of intact perineum, the OR value is abnormally high and is not shown in the forest plot. Perineal wound and instrumental delivery may be important factors in the relationship between single catheterization and indwelling catheterization within 3 hours after childbirth. There is no significant interaction in other subgroups (P for interaction \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.6 Sensitivity analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study conducted sensitivity analysis through three methods: adjusting the PS method, adjusting the inclusion criteria, and adjusting the PS model. The results section has simultaneously presented the results of both PSM and sIPTW methods. Further sensitivity analysis revealed that single catheterization within 3 hours after delivery is robust for PUR and spontaneous urination results, but not for the number of induced urination attempts and the impact of indwelling catheterization, which is also influenced by the duration of single catheterization. The specific process is as follows.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.6.1 Impact of single catheterization after adjusting the inclusion criteria on outcome measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy adjusting the inclusion criteria to restrict those who did not urinate spontaneously and had a bladder urine volume of \u0026ge;300ml within 2 hours after childbirth, we explored the impact of single catheterization on urinary retention-related outcome indicators in the early postpartum period (within 2 hours after childbirth). Among the 1,316 parturients included, 972 did not urinate spontaneously and had a bladder urine volume of \u0026ge;300ml within 2 hours after childbirth. Among them, 704 were in the catheterization group and 268 were in the non-catheterization group. Given that the sample size after adjusting the inclusion criteria was insufficient for a 1:1 PSM (the sample size of this study was 650, with 325 in each group; see Appendix 3 for the calculation process), and the non-catheterization group before PSM was significantly smaller than the catheterization group, making it unsuitable for a 1:n PSM, IPTW combined with sIPTW was used to adjust for confounding factors.\u003c/p\u003e\n\u003cp\u003eAfter adjusting for confounding factors using IPTW, there were 973.68 cases in the catheterization group and 956.25 cases in the non-catheterization group. After adjusting for confounding factors using sIPTW, 705.22 cases were obtained in the catheterization group and 263.66 cases in the non-catheterization group. After adjusting for confounding factors using both sIPTW and IPTW, the balance of each covariate was good, with SMDs all less than 0.1 (see Appendix 4, Figure 1 for details).\u003c/p\u003e\n\u003cp\u003e(1) The impact of single catheterization within 2 hours after childbirth on primary outcome measures\u003c/p\u003e\n\u003cp\u003eThe sensitivity analysis results indicated that after adjusting for confounding factors using sIPTW and IPTW, performing single catheterization within 2 hours after delivery could reduce the risk of PUR and latent PUR (OR value included 1 and P\u0026lt;0.05). Furthermore, regarding the outcome indicator of overt PUR, there was no significant association between performing single catheterization within 2 hours after delivery and the risk of overt PUR (OR value included 1 and P\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003eRegarding the outcome indicators of indwelling urinary catheter, after adjusting for confounding factors using IPTW and sIPTW (both OR values not including 1, and P\u0026lt;0.05), it was indicated that performing single catheterization within 2 hours after childbirth could reduce the risk of indwelling urinary catheter. (Table 4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(2)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eThe impact of single catheterisation within 2 hours postpartum on secondary outcome indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of the sensitivity analysis indicate that for the outcome measure of spontaneous urination, logistic regression analysis after IPTW and sIPTW adjustment for confounding factors showed OR values including 1, with P\u0026gt;0.05, suggesting that performing a single catheterisation within 2 hours postpartum has no significant effect on maternal spontaneous urination (Table 5). For the outcome measure of induced urination frequency, Poisson regression analysis after IPTW and sIPTW adjustment for confounding factors showed OR values less than 1, with P\u0026lt;0.05, indicating that performing a single catheterisation within 2 hours postpartum significantly reduces the frequency of induced urination (Table 5).\u003c/p\u003e\n\u003cp id=\"_Toc26194\"\u003e\u003cstrong\u003e3.6.2\u003c/strong\u003e \u003cstrong\u003eImpact of single catheterisation on outcomes after adjusting the PS model\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven that the timing of catheterisation also affects PUR-related outcomes, to adjust for more confounding factors, postpartum catheterisation timing (\u0026le;2 hours and \u0026gt;2 hours) was added to the propensity score model. After PSM and sIPTW adjustments for confounding factors, except for the number of intermittent catheterisations during labour after PSM (SMD=0.106), the SMDs of other covariates were \u0026lt;0.1 (see Appendix 4 Figure 2). After PSM, both the catheterisation group and the non-catheterisation group included 319 cases, while after sIPTW, the catheterisation group was 778.2 cases and the non-catheterisation group was 536.6 cases.\u003c/p\u003e\n\u003cp\u003eAfter adjusting the propensity score model, regression analysis was conducted after handling confounding factors with PSM and sIPTW. The results showed that performing a single catheterisation within 3 hours postpartum could reduce the incidence of PUR and covert PUR (both OR values less than 1, and P\u0026lt;0.05), with no significant effect on overt PUR, indwelling catheter, spontaneous urination, or the risk of induced urination (all OR values include 1, and P\u0026gt;0.05), as detailed in Table 6. The results are consistent with the main analysis, indicating that the original model is relatively robust.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn clinical practice, there is still controversy over whether parturients who are unable to urinate spontaneously in the delivery room yet feel the urge to urinate should undergo intermittent catheterisation. This study, based on real-world data, investigates the impact of intermittent catheterisation in the delivery room on PUR, indwelling catheter use, spontaneous urination, and the frequency of induced urination, aiming to provide a reference for the prevention of PUR and to lay a foundation for postpartum bladder management.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Research on the data characteristics of parturients\u003c/h2\u003e \u003cp\u003eThis study included 1,316 parturients undergoing vaginal delivery. The incidence of overt PUR was 4.8%, which is close to the average incidence of 5.37% reported in a study involving 12,609 parturients[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The incidence of latent PUR is 16.4%, higher than the 11.04% reported by Ain et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], but lower than the 47% in the study by Mulder et al.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]Compared with an overall incidence of covert PUR of 13% in a systematic review report, the difference is not significant[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCovert PUR is defined according to PVRV, but there are differences in the critical values and measurement times of PVRV in the literature, resulting in a wide range of global PUR incidence [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The commonly reported PVRV cut-off values in the literature include 100 mL[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], 150 mL[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and 250 mL [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In this study, 150 mL was selected as the cut‑off value because it is widely used in the literature and has not been associated with reported adverse outcomes, while also helping avoid unnecessary interventions or monitoring [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The timing of PVRV measurement includes after the first postpartum void [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], at 4 h postpartum [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], or at 6\u0026ndash;8 h postpartum [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Based on real‑world data, this study performed one or more PVRV measurements for the same parturient and defined PVRV\u0026thinsp;\u0026ge;\u0026thinsp;150 mL as the diagnostic criterion for covert PUR, which can help reduce the underdiagnosis rate of covert PUR.\u003c/p\u003e \u003cp\u003eRegarding data collection records, the missing status of all variables was reported. All covariates in this study were complete, and parturients with missing key variables were excluded. The key missing variable was the absence of recorded post‑void residual urine volume after returning to the ward postpartum, which hinders the identification of covert PUR. For quality control, a data dictionary was used to avoid cumbersome data entry and entry errors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.2 The Impact of single catheterization on PUR\u003c/h2\u003e \u003cp\u003eThis study investigated the impact of a single catheterization on PUR. The results indicated that for parturients who had not voided spontaneously and had a bladder volume\u0026thinsp;\u0026ge;\u0026thinsp;300 mL, performing a single catheterization within 3 hours postpartum significantly reduced the risk of PUR (particularly covert PUR), although its effect on overt PUR was not significant. Sensitivity analyses confirmed the robustness of this result, which was not influenced by the timing of catheterization. The conclusion that postpartum catheterization significantly reduces the risk of PUR is consistent with findings from previous studies [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, prior research primarily focused on indwelling or intermittent catheterization, with study populations consisting of assisted delivery or parturients receiving labor analgesia. In contrast, based on real-world data and targeting parturients who had not voided spontaneously with a bladder volume\u0026thinsp;\u0026ge;\u0026thinsp;300 mL, this study further supplements the evidence for methods to prevent urinary retention, laying a foundation for standardizing postpartum bladder management.\u003c/p\u003e \u003cp\u003ePerforming a single catheterization within 3 hours postpartum can reduce the risk of covert PUR. This finding, regarding the effect of a single catheterization on covert PUR, aligns with the conclusion of Neron et al., although the timing of catheterization differs from that in their study[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, among the overall population of parturients in this study, a single catheterization within 3 hours postpartum showed no significant impact on overt PUR.\u003c/p\u003e \u003cp\u003eAccording to the literature included in a scoping review[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], studies on postpartum catheterization for preventing PUR did not clearly differentiate overt PUR from PUR in general. Therefore, no direct comparison could be made with the effect of postpartum catheterization on overt PUR in previous studies. Nevertheless, based on the definition of overt PUR as \"the inability to void spontaneously despite a full bladder 6\u0026ndash;8 hours postpartum,\" the results indicate that performing a single catheterization within 3 hours postpartum to empty the bladder did not prolong the time to first spontaneous voiding. This is consistent with findings from prior studies, which reported that postpartum catheterization has no significant effect on the time to first spontaneous voiding[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study primarily involved exploratory subgroup analyses, and the sample size within each subgroup was limited. If multiple comparison corrections were applied, statistical power might have been further reduced. Therefore, this study did not perform corrections for multiple comparisons. However, this may increase the risk of false-positive results; consequently, the related findings should be interpreted with caution and require further validation in subsequent research.\u003c/p\u003e \u003cp\u003eIn the subgroup analyses, the impact of performing a single catheterization within 3 hours postpartum on the risk of PUR varied among parturients with different levels of bladder volume. The effect appeared potentially more significant in parturients with a bladder volume\u0026thinsp;\u0026ge;\u0026thinsp;400 mL. Catheterization may work by preventing overdistension of the bladder[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and shortening the duration of high bladder capacity[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Some studies also suggest that recommended catheterization\u0026mdash;whether single complete drainage or short-term open drainage\u0026mdash;allows the bladder and urethral muscles and mucosa to rest adequately[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], thereby promoting the recovery of detrusor contractile function[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Additionally, catheterization may alleviate perineal trauma, reduce perineal edema, and allow sufficient relaxation of the urethra[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, increased attention should be given to parturients with high bladder volume who have not voided spontaneously, and further research is needed for validation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.3 The Impact of Single Catheterization on the Need for Indwelling Catheterization\u003c/h2\u003e \u003cp\u003eAlthough catheterization is an invasive procedure, single catheterization has less impact and causes fewer complications for parturients compared to indwelling catheterization. Studies have shown that single catheterization reduces the incidence of urinary tract infections (UTIs) relative to indwelling catheters[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Furthermore, some research suggests that intermittent catheterization carries a lower risk of UTI than indwelling catheterization[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].This study focused specifically on the impact of performing a single catheterization in the delivery room on the subsequent need for indwelling catheterization. Parturients who required catheterization due to changes in their clinical condition were explicitly excluded. Consequently, all cases of indwelling catheterization included in the analysis were for PUR. In the overall study population, performing a single catheterization within 3 hours postpartum did not have a significant impact on the rate of indwelling catheterization. This finding is consistent with the results of Feng Peixiao et al. [41]. Their study involved a single catheterization within 6 hours postpartum after failed attempts to induce voiding, compared to routine indwelling catheterization for approximately 24 hours. They found no significant difference in re-catheterization rates but observed a reduction in UTI incidence with the single catheterization approach.\u003c/p\u003e \u003cp\u003eHowever, another study implementing a comprehensive intervention centered around intermittent catheterization for parturients receiving labor analgesia concluded that catheterization could reduce the rate of indwelling catheterization[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This discrepancy may be attributed, on one hand, to the rapid and prolonged bladder filling postpartum, which could diminish the preventive effect of a single catheterization on the need for an indwelling catheter. On the other hand, it may be related to differences in catheterization methods and timing. Therefore, sensitivity analyses were conducted by adjusting the inclusion criteria based on the timing of catheterization.\u003c/p\u003e \u003cp\u003eSubgroup analyses suggested that perineal wounds and instrumental delivery might be important factors influencing the relationship between a single catheterization within 3 hours postpartum and the need for indwelling catheterization. However, in this study, all included perineal lacerations were first-degree, and the subgroups with intact perineum and those with instrumental delivery had small sample sizes and low incidence rates of indwelling catheterization. This may explain why no significant impact of single catheterization on indwelling catheterization was observed across subgroups based on perineal status or instrumental delivery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Sensitivity Analysis\u003c/h2\u003e \u003cp\u003eIn this study, sensitivity analyses were performed by adjusting both the propensity score method and the model specifications. The results consistently demonstrated that performing a single catheterization within 3 hours postpartum significantly reduced the risk of overall PUR and covert PUR, while showing no significant effect on overt PUR, the need for indwelling catheterization, spontaneous voiding, or the number of attempts to induce voiding. These findings indicate a high degree of robustness.\u003c/p\u003e \u003cp\u003eFurthermore, sensitivity analysis was conducted by modifying the inclusion criteria. Based on a previous study where catheterization was performed at 2 hours postpartum[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and considering that in the real-world data, catheterization occurred around 2 hours postpartum with more parturients having their bladder volume assessed within 2 hours than after, the inclusion criteria were adjusted to: parturients who had not voided spontaneously and had a bladder volume\u0026thinsp;\u0026ge;\u0026thinsp;300 mL within 2 hours postpartum. The sensitivity analysis results showed that performing a single catheterization within 2 hours postpartum significantly reduced the risk of overall PUR and covert PUR, while no significant effects were observed on overt PUR or spontaneous voiding. This supports the robustness of the main conclusions.\u003c/p\u003e \u003cp\u003ePerforming a single catheterization within 2 hours postpartum was associated with a reduced risk of requiring indwelling catheterization and fewer attempts to induce voiding. This finding is inconsistent with the main analysis, which showed no significant impact of catheterization within 3 hours on these outcomes. This difference may be related to the early bladder stimulation provided by catheterization within 2 hours. Research by Bachar et al suggests that early stimulation from bladder refilling immediately after catheter removal can promote spontaneous voiding, whereas delayed stimulation may lead to increased urinary retention[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In clinical practice, methods to induce voiding are varied, and a single attempt may involve one or multiple techniques. Typically, healthcare providers implement these methods only when a parturient attempts but fails to void or experiences difficult urination. Therefore, the number of induction attempts can, to some extent, reflect the frequency of a parturient's attempts to void spontaneously. Although prior research has paid less attention to the metric of induction attempts, it remains clinically significant and warrants attention, particularly for parturients who deliver at night, have prolonged labor, or are in a weakened condition.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Innovation and Limitations","content":"\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Innovation\u003c/h2\u003e \u003cp\u003eOn the one hand, this study addresses a clinically debated issue by investigating the effectiveness of single in‑and‑out catheterization in preventing PUR based on real‑world data, thereby reflecting patient characteristics that are more aligned with actual clinical practice. On the other hand, this study employed two complementary propensity score methods\u0026mdash;matching and weighting\u0026mdash;to control for potential selection bias inherent in the retrospective cohort design. These approaches helped minimize between‑group data discrepancies and the influence of confounding variables, improving the balance and comparability of baseline characteristics after adjustment, thereby enhancing the reliability of the findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Limitations\u003c/h2\u003e \u003cp\u003eFirst, this study was retrospective and single‑center in design, which carries a risk of bias. Although propensity score adjustment was used to control for confounders, there may still be unbalanced factors such as subjective information related to pain level and the sensation of needing to void. Second, while this study collected data from parturients who had not voided spontaneously and had a bladder volume\u0026thinsp;\u0026ge;\u0026thinsp;300 mL, it did not include those with difficult voiding despite bladder fullness. This group also warrants attention and requires planned bladder management. Additionally, although a large number of case records were collected, the process of identifying and extracting eligible cases relied heavily on manual review of relevant documents, which was time‑consuming and inefficient. Therefore, future research should incorporate intelligent and informatized data‑collection methods, such as natural language processing, to automate the extraction of information from clinical texts. This would improve the efficiency and quality of clinical research, reduce costs, and strengthen the reliability of evidence. Although the subgroup analyses in this study were limited by sample size, their results provide important clues for further research. Future studies with larger samples and more rigorous designs are needed to validate these findings and explore the clinical value of individualized catheterization strategies, so as to optimize the management of PUR.\u003c/p\u003e \u003c/div\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eIn a real-world setting, performing a single catheterization within 3 hours postpartum significantly reduces the risk of PUR and covert PUR, while it shows no significant effect on overt PUR or spontaneous voiding. Furthermore, if the single catheterization is performed within 2 hours postpartum, it may additionally reduce the risk of requiring an indwelling catheter and repeated attempts to induce voiding. However, these conclusions still require further validation through large-sample, multicenter, high-quality studies to provide a more scientific and reliable evidence base for clinical postpartum bladder management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003epostpartum urinary retention (PUR); inverse probability of treatment weighting (sIPTW); odds ratios (OR); Post-void Residual Volume (PVRV); interquartile range(IQR); median (M); confidence intervals (CI); variance inflation factor (VIF); Standardized Mean Difference (SMD); propensity score matching (PSM) \u0026nbsp;inverse probability weighting (IPTW); urinary tract infections (UTIs)\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eConflict of Interest:\u003c/strong\u003e \u003cp\u003eThe authors report no conflicts of interest.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e \u003cp\u003e \u003cb\u003e\u003c/b\u003enot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was approved by the Clinical Research and Applied Ethics Committee of The Third Affiliated Hospital, Guangzhou Medical University (Approval No. : Linlun Audit Research [2024] No.013) and was performed in accordance with the ethical standards of the Declaration of Helsinki.\u003c/p\u003e \u003ch2\u003eContributions :\u003c/h2\u003e \u003cp\u003eHuating Chen: Conceptualization, Investigation, Software, Formal Analysis, Writing - Original Draft preparation.\u003c/p\u003e \u003cp\u003eYuyi Chen: Resources, Supervision, Project Administration, Writing - Review \u0026amp; Editing.\u003c/p\u003e \u003cp\u003eShuai Yang: Data Curation, Validation, Visualization, Writing - Review \u0026amp; Editing.\u003c/p\u003e \u003cp\u003eJing Hu: Supervision, Project Administration, Visualization, Original Draft preparation.\u003c/p\u003e \u003cp\u003eJun Lyu: Methodology, Software, Formal Analysis, Writing - Review \u0026amp; Editing.\u003c/p\u003e \u003cp\u003eDefeng Chen: Investigation, Writing - Original Draft preparation.\u003c/p\u003e \u003cp\u003eTaizhen Luo: Conceptualization, Supervision, Writing - Review \u0026amp; Editing, Funding Acquisition.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHuating Chen: Conceptualization, Investigation, Software, Formal Analysis, Writing - Original Draft preparation.Yuyi Chen: Resources, Supervision, Project Administration, Writing - Review \u0026amp; Editing.Shuai Yang: Data Curation, Validation, Visualization, Writing - Review \u0026amp; Editing.Jing Hu: Supervision, Project Administration, Visualization, Original Draft preparation.Jun Lyu: Methodology, Software, Formal Analysis, Writing - Review \u0026amp; Editing.Defeng Chen: Investigation, Writing - Original Draft preparation.Taizhen Luo: Conceptualization, Supervision, Writing - Review \u0026amp; Editing, Funding Acquisition.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eWe acknowledge the Guangzhou Medical University Library for providing the database and the Third Clinical College of Guangzhou Medical University for offering learning opportunities.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated during and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNeron M, Allegre L, Huberlant S, Mousty E, de Tayrac R, Fatton B, Letouzey V. 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Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. PHARM STAT. 2011;10(2):150\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng PD, Huixing ZCYX. Observation on micturition situation of 143 cases of maternal undergoing forceps and its influencing factors. Int Med Health Guidance News. 2015;21(4):546\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao D, Rao L, Yuan J, Zhang D, Lu B. Prevalence and risk factors of overt postpartum urinary retention among primiparous women after vaginal delivery: a case-control study. BMC PREGNANCY CHILDB. 2022;22(1):26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAin QU, Shetty N. Postpartum urinary retention and its associated obstetric risk factors among women undergoing vaginal delivery in tertiary care hospital. J Gynecol Obstet Hum Reprod. 2021;50(2):101837.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoshida A, Yoshida M, Kawajiri M, Takeishi Y, Nakamura Y, Yoshizawa T. Prevalence of urinary retention after vaginal delivery: a systematic review and meta- analysis. INT UROGYNECOL J. 2022;33(12):3307\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDolezal P, Ostatnikova M, Balazovjechova B, Psenkova P, Zahumensky J. Covert postpartum urinary retention: causes and consequences (PAREZ study). INT UROGYNECOL J. 2022;33(8):2307\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhijing S, Yan S, Jin H, Huiwen X, Lijun C. Observation on the efficacy of medium-frequency pulse acupoint electrical stimulation in preventive care of postpartum urinary retention. Chin Gen Pract Nurs. 2019;17(33):4158\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDivakova O, Panayi D, Khan Z, Doumouchtsis SK. A rapid systematic review of postpartum bladder care guidelines and recommendations in the context of the COVID-19 pandemic. J OBSTET GYNAECOL. 2022;42(7):2634\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMulder FE, Oude RK, van der Post JA, Hakvoort RA, Roovers JP. Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery. INT UROGYNECOL J. 2016;27(1):55\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuchanan J, Beckmann M. Postpartum voiding dysfunction: identifying the risk factors. AUST NZ J OBSTET GYN. 2014;54(1):41\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawasoe I, Kataoka Y. Prevalence and risk factors for postpartum urinary retention after vaginal delivery in Japan: A case-control study. JPN J NURS SCI. 2020;17(2):e12293.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXinyang L, Yurong J, Fangshu L, Yuanhuan H, Yuan W, Xiaoling Z. 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Southern Medical University; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYijian C, Guifang G, Fang F. The necessity study of urinary catheterization during painless labor. Mod Prev Med. 2012;39(11):2724\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBachar G, Siegler Y, Kabakov E, Lauterbach R, Justman N, Ben-Ezry E, Weiner E, Ganor-Paz Y, Yefet E, Khamaisi T, et al. Intermittent vs continuous catheterization for postpartum urinary retention: A multicenter randomized controlled trial. AM J OBST GYNEC MFM. 2023;5(10):101084.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoh R, Goh D, Ellepola H. Perineal tears - A review. AUST J GEN PRACT. 2018;47(1\u0026ndash;2):35\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"postpartum urinary retention, single catheterization, prevention, propensity score method","lastPublishedDoi":"10.21203/rs.3.rs-9000521/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9000521/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Evidence on the effectiveness of postpartum single catheterization in preventing postpartum urinary retention (PUR) remains insufficient. A previous study reported that postpartum single catheterization reduced the incidence of covert PUR, but its effects on overt PUR and the need for indwelling catheterization were not investigated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eThis study aimed to investigate the effectiveness of postpartum single catheterization in preventing PUR.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eA retrospective cohort study was conducted using real-world data, with participants divided into a catheterization group and a non-catheterization group based on whether they received a single catheterization after delivery. The primary outcomes were PUR and the need for indwelling catheterization, while the secondary outcomes included spontaneous urination and the number of induced urinations. Regression analysis was conducted after adjusting for confounding factors using stabilized inverse probability of treatment weighting (sIPTW). Subgroup analyses of key clinical characteristics were conducted to evaluate primary outcomes. Sensitivity analysis was performed using propensity score adjustment, population adjustment, and propensity score modeling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 1,637 parturients with bladder capacity ≥300ml who failed to urinate spontaneously in the delivery room after vaginal delivery were enrolled. After screening according to inclusion and exclusion criteria, 1,316 parturients were included, with all measurements taken within 3 hours postpartum. The catheterized group comprised 776 participants (59.0%), while the non-catheterized group had 540 participants (41.0%). Regression analysis using sIPTW revealed significantly reduced risks of PUR and covert PUR in the catheterized group, with odds ratios (OR) of 0.47 (0.36,0.61) and 0.40 (0.30,0.53), respectively, both P\u0026lt;0.001. However, no significant differences were observed between groups in terms of risk of overt PUR, urinary catheterization, spontaneous urination, or induced voiding frequency (all OR \u0026lt;1, P\u0026gt;0.05). Results remained robust after adjusting for propensity scores and propensity score models. However, when adjusting the inclusion criteria to include only parturients who had not urinated spontaneously within 2 hours postpartum with a bladder volume ≥300ml, single catheterization showed significant effects on PUR, covert PUR, indwelling catheterization, and induced voiding frequency. After adjusting for confounding factors using sIPTW, the covariates between the two groups were balanced. The logistic regression analysis showed adjusted OR values of 0.44 (0.32,0.62),0.43 (0.30,0.62),0.57 (0.34,0.99), and 0.79 (0.64,0.99), all P\u0026lt;0.05. However, no significant effects were observed on overt PUR or spontaneous urination, with OR values of 0.67 (0.37,1.23) and 1.31 (0.95,1.80) respectively, both P\u0026gt;0.05. Subgroup analyses demonstrated significant interactions between instrument-assisted delivery, perineal wound condition, and single catheterization within 3 hours postpartum (interaction P-values: 0.015 and 0.014). Additionally, bladder volume showed a significant interaction effect with single catheterization within 3 hours (interaction P=0.002). Notably, for parturients with a bladder volume ≥400ml, single catheterization within 3 hours may reduce the risk of PUR (OR=0.45, P\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIn real-world clinical settings, performing a single catheterization within 3 hours postpartum significantly reduces the risk of both PUR and covert PUR, while showing no significant effect on overt PUR or spontaneous urination. Additionally, implementing single catheterization within 2 hours postpartum further decreases risks of urinary catheterization and recurrent induced urination. However, these findings require further validation through large-scale, multicenter, high-quality studies to establish more scientifically robust evidence for clinical postpartum bladder management.\u003c/p\u003e","manuscriptTitle":"A Study on the Effectiveness of Single Catheterization in Preventing Postpartum Urinary Retention: Based on the Propensity Score Method","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-24 13:18:08","doi":"10.21203/rs.3.rs-9000521/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"09af29e8-bfe8-4ebb-9bf6-c719a0812dc2","owner":[],"postedDate":"March 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T16:11:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-24 13:18:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9000521","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9000521","identity":"rs-9000521","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}