Optimal Timing for Foley Catheter Removal After Cesarean Section
The urinary catheter should be removed immediately after cesarean delivery (within 0-6 hours postoperatively) in women who do not require ongoing strict urine output monitoring. 1
Primary Recommendation
The Enhanced Recovery After Surgery (ERAS) Society provides a strong recommendation for immediate catheter removal after cesarean delivery, supported by multiple randomized controlled trials demonstrating superior outcomes. 1 This guideline explicitly states that immediate removal results in:
- Significantly reduced urinary tract infection rates (0.5% vs 5.7% when removed at 12 hours) 1
- Shorter time to first voiding 1
- Decreased dysuria, urinary frequency, and urgency 2
- Earlier ambulation (mean 4.1 hours vs 6.8-10.3 hours with delayed removal) 3, 4
- Shorter hospital stays (1.9 days vs 2.4-3.9 days with delayed removal) 3, 4
Evidence Hierarchy and Nuances
While the ERAS Society guideline strongly favors immediate removal 1, one recent randomized trial suggests a potential middle ground at 6 hours postoperatively. 3 This study found that 6-hour removal had:
- Lower urinary retention requiring recatheterization compared to immediate removal (2.5% vs 13.6%) 3
- Lower UTI rates compared to 24-hour removal (3.7% vs 13.4%) 3
- Balanced outcomes for ambulation time and hospital stay 3
However, a 2023 network meta-analysis of 19 studies including 3,086 women definitively supports the 0-6 hour window as optimal, with the highest SUCRA values for preventing UTI (92.30%), frequent urination (85.00%), and reducing hospital stay (80.60%). 5
Clinical Algorithm
For routine post-cesarean patients:
- Remove catheter immediately after surgery or within 6 hours maximum 1, 2
- Ensure patient voids within 4-6 hours after catheter removal 2, 6
- Assess bladder volume with ultrasound if no void occurs by 6 hours 2
- Perform intermittent catheterization only if significant retention confirmed 2
Exceptions requiring delayed removal beyond 6 hours:
- Patients requiring strict hourly urine output monitoring (e.g., severe preeclampsia, acute kidney injury) 1
- Hemodynamically unstable patients needing precise fluid balance 7
Critical Pitfalls to Avoid
Do not routinely delay catheter removal to 12-24 hours as this practice significantly increases:
- Bacteriuria and symptomatic UTI risk (5-fold to 27-fold increase) 5
- Patient discomfort and catheter-related complications 1
- Delayed mobilization, which increases thromboembolism risk 1
Monitor for post-removal complications:
- UTI symptoms develop in 10% of patients, with >80% occurring after discharge 1
- Urinary retention is uncommon (approximately 14% in ERAS programs) and should not drive routine delayed removal 1
Supporting Interventions
To optimize outcomes with early catheter removal:
- Encourage early mobilization as soon as regional anesthesia resolves 2
- Increase fluid intake to promote natural voiding 2
- Use multimodal analgesia (scheduled acetaminophen and NSAIDs) to reduce opioid-related retention 2
- Educate patients preoperatively about expected voiding timeline 2
The evidence overwhelmingly supports immediate to early (0-6 hours) catheter removal as the standard of care, balancing minimal retention risk against substantial reductions in infection, delayed recovery, and patient discomfort.