Anal and urinary incontinence 4 years after a vaginal delivery

Does transperineal ultrasound predict the risk of perineal trauma in women with term pregnancy? A prospective observational study

PURPOSE

This study was conducted to evaluate the prevalence of perineal trauma during childbirth and to assess the correlations of the pelvic floor dimensions and fetal head station with obstetric trauma in a prospectively recruited cohort of women.

METHODS

The study included women with a gestational age of at least 37 weeks, who were carrying a single fetus in a cephalic presentation. Transperineal ultrasound (TPU) was performed prior to the onset of labor or labor induction. The purpose was to measure the anteroposterior diameter (APD) of the levator ani muscle (LAM) and the angle of progression, at both rest and maximum Valsalva maneuver. The head-perineum distance was assessed only at rest.

RESULTS

A total of 296 women were included. Of the 253 women who delivered vaginally, 19% (48/253) experienced no perineal trauma, 18.2% (46/253) received an episiotomy during childbirth, 34.4% (87/253) sustained a first-degree laceration, 25.3% (64/253) had a second-degree laceration, and 3.2% had a third- or fourth-degree laceration (8/253). Women with episiotomy had a significantly shorter median APD under Valsalva than women without perineal trauma. Furthermore, women with LAM coactivation (identified by a negative difference between the APD at Valsalva and the APD at rest) were approximately three times more likely to undergo an operative vaginal delivery and over five times more likely to sustain a third- or fourth-degree tear during childbirth than women who exhibited normal relaxation of the LAM during the Valsalva maneuver.

CONCLUSION

TPU may predict the risk of perineal trauma in women with term pregnancy during childbirth.

Development and Validation of a Tool to Identify Anal Incontinence in Pregnant and Postnatal Women

BACKGROUND

Neuromuscular and mechanical damage to the pelvic floor because of pregnancy and birth can result in anal incontinence. Pregnant and postnatal women are rarely screened for anal incontinence by clinicians who specialize in the care of these women, and no screening tool has been developed for routine use in these women.

OBJECTIVE

To develop and validate a tool for use in everyday clinical practice in the care of pregnant and postnatal women.

DATA SOURCES

The study includes 2 test phases with separate data sources. Phase I included test and retest phases of the Bowel-Screening Questionnaire in health professionals and women who were pregnant or had recently birthed (n = 45). Phase II included a pilot of the tool compared to 2 current scoring systems (n = 358).

SETTING

Large tertiary hospital in South Australia.

PATIENTS

Phase II: prospective recruitment of 358 prenatal parous women attending a first antenatal appointment.

MAIN OUTCOMES MEASURES

To evaluate the reliability and validity of the developed tool.

RESULTS

Test-retest agreement in phase I was excellent for each of the 6 items, with each κ statistic being between 0.83 and 1.0. In phase II, agreement between new and existing tools was fair to good for the detection of anal incontinence symptoms addressed as a composite question (κ between 0.41 and 0.71). Anal incontinence was detected in 191 women (53%) using the new tool, and there was a lower prevalence reported using the Vaizey score (n = 118) and Wexner score (n = 129). Completion rates of the new tool were 99%, higher than both the Vaizey score (33%) and Wexner score (36%).

LIMITATIONS

Sample size limits the generalization of findings.

CONCLUSION

The questionnaire is reliable and valid, reporting a high incidence of bowel incontinence, with predominant symptoms of rectal urgency and flatus as precursors for worsening function.

DESARROLLO Y VALIDACIN DE UNA HERRAMIENTA PARA IDENTIFICAR LA INCONTINENCIA ANAL EN MUJERES EMBARAZADAS Y PURPERAS

ANTECEDENTES:El daño neuromuscular y mecánico del piso pélvico debido al embarazo y al parto puede resultar en incontinencia anal. Las mujeres embarazadas y puérperas rara vez son examinadas para la incontinencia anal por médicos que se especializan en el cuidado de estas mujeres, y no se ha desarrollado ninguna herramienta de detección para uso rutinario en estas mujeres.OBJETIVO:Desarrollar y validar una herramienta para uso en la práctica clínica diaria en el cuidado de las mujeres embarazadas y puérperas.FUENTES DE DATOS:El estudio incluye 2 fases de prueba con fuentes de datos separadas. Fase 1, fase test y retest del Bowel Screening Questionnaire en profesionales sanitarios y mujeres embarazadas o recién paridas (n = 45). La Fase 2 incluyó una prueba piloto de la herramienta en comparación con dos sistemas de puntuación actuales (n = 358).ENTORNO CLINICO:Gran hospital terciario en el sur de Australia.PACIENTES:Fase 2: reclutamiento prospectivo de 358 mujeres con parto prenatal que asisten a una primera cita prenatal.PRINCIPALES MEDIDAS DE VALORACIÓN:Evaluar la confiabilidad y validez de la herramienta desarrollada.RESULTADOS:La concordancia test-retest en la fase 1 fue excelente para cada uno de los 6 ítems con cada estadística kappa entre 0,83 y 1,0. En la fase 2, el acuerdo entre las herramientas nuevas y las existentes fue regular a bueno para la detección de síntomas de incontinencia anal abordados como una pregunta compuesta (kappa entre 0,41 y 0,71). Se detectó incontinencia anal en 191 (53%) de las mujeres que utilizaban la nueva herramienta, y se notificó una prevalencia más baja utilizando la puntuación de Vaizey (n = 118) y la puntuación de Wexner (n = 129). Las tasas de finalización de la nueva herramienta fueron del 99%, más altas que la puntuación de Vaizey (33%) y las puntuaciones de Wexner (36%).LIMITACIONES:El tamaño de la muestra limita la generalización de los hallazgos.CONCLUSIONES:El cuestionario es confiable y válido reportando una alta incidencia de incontinencia intestinal, con síntomas predominantes de urgencia rectal y flatos como precursores del empeoramiento de la función. (Traducción-Dr. Ingrid Melo ).

Follow up of women after obstetric anal sphincter injuries (OASI)-What is the role of anorectal testing?

AIMS

To evaluate the benefit of performing anorectal studies on all women following primary obstetric anal sphincter injury (OASI) repair over performing them on symptomatic women only.

METHODS

Women who attended perineal clinic between 2007 and 2020 underwent symptom assessment and anorectal studies at 6 weeks and 6 months postpartum. Anorectal studies including endo anal ultrasound (EAUS) and anal manometry (AM) were performed. The anorectal studies of symptomatic women who were the case group, were compared with asymptomatic women who were the control group.

RESULTS

A total of 1348 women were seen in the perineal clinic over 13 years. A total of 454 (33.7%) women were symptomatic. A total of 894 (66.3%) women were asymptomatic. A total of 313 (35%) asymptomatic women had two abnormal anorectal studies, 274 (31%) had abnormal AM alone, and 86 (9.6%) had abnormal EAUS alone. A total of 221 (24.7%) asymptomatic women had normal anorectal studies.

CONCLUSION

Almost 70% of women were asymptomatic 6 months following primary OASI repair. Most had at least one abnormal anorectal study result. Selectively performing anorectal tests on symptomatic women would not identify asymptomatic women at risk of future faecal incontinence following further vaginal birth. Without anorectal study results, women would not receive accurate counseling about the risks of vaginal birth. Anorectal studies should be offered to all women following OASI where resources allow.

Under-classified obstetric anal sphincter injuries

INTRODUCTION AND HYPOSTHESIS

Obstetric anal sphincter injuries (OASIs) that are missed at delivery can have long-term consequences. OASIs that are under-classified at delivery are likely to be inadequately repaired, resulting in a persistent anal sphincter defect. We aimed to identify women who have persistent defects on endoanal ultrasound, inconsistent with the original diagnosis, and compare the effect on St Mark's incontinence scores (SMIS). We also aimed to look for changes in numbers of under-classification over time.

METHODS

Records of women attending a perineal clinic who had endoanal ultrasound from 2012 to 2020 were reviewed. Women who had a modified Starck score implying a defect greater than the classification [indicated by the depth of external anal sphincter or internal anal sphincter (IAS) defect] at delivery were identified.

RESULTS

A total of 1056 women with a diagnosis of 3a or 3b tears were included. Of these, 120 (11.36%) were found to have a defect greater than the original diagnosis and therefore were incorrectly classified at delivery. Women who had a 3b tear diagnosed at delivery, but had an IAS defect, had a significantly higher SMIS (p < 0.01). When comparing two 4-year periods, there was a significant improvement in the diagnosis of IAS tears.

CONCLUSION

Some women with OASIs that have under-classified OASIs are associated with worse anorectal symptoms. This is likely because of an incomplete repair. Some improvement in diagnosis of IAS tears has been noted. We propose improved training in OASIs can help reduce the number of incorrectly classified tears and improve repair.

Obstetric risk factors for anorectal dysfunction after delivery: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Pregnancy and childbirth are considered risk factors for pelvic floor dysfunction, including anorectal dysfunction. We aimed to assess the effect of obstetric events on anal incontinence and constipation after delivery.

METHODS

We systematically reviewed the literature by searching MEDLINE, Embase and CENTRAL. We included studies in women after childbirth examining the association between obstetric events and anorectal dysfunction assessed through validated questionnaires. We selected eligible studies and clustered the data according to the type of dysfunction, obstetric event and interval from delivery. We assessed risk of bias using the Newcastle Ottawa Scale and we performed a random-effects meta-analysis and reported the results as odds ratios (ORs) with their 95% confidence intervals. Heterogeneity across studies was assessed using I² statistics.

RESULTS

Anal sphincter injury (OR: 2.44 [1.92-3.09]) and operative delivery were risk factors for anal incontinence (forceps-OR :1.35 [1.12-1.63]; vacuum-OR: 1.17 [1.04-1.31]). Spontaneous vaginal delivery increased the risk of anal incontinence compared with caesarean section (OR: 1.27 [1.07-1.50]). Maternal obesity (OR:1.48 [1.28-1.72]) and advanced maternal age (OR: 1.56 [1.30-1.88]) were risk factors for anal incontinence. The evidence on incontinence is of low certainty owing to the observational nature of the studies. No evidence was retrieved regarding constipation after delivery because of a lack of standardised validated assessment tools.

CONCLUSIONS

Besides anal sphincter injury, forceps delivery, maternal obesity and advanced age were associated with higher odds of anal incontinence, whereas caesarean section is protective. We could not identify obstetric risk factors for postpartum constipation, as few prospective studies addressed this question and none used a standardised validated questionnaire.

The impact of a nationwide hands-on workshop on the diagnostic rates and management of obstetrical anal sphincter Injuries in Israel

AIM

The aim was to evaluate the influence of a half day, hands-on, workshop on the detection and repair of obstetric anal sphincter injuries (OASIs).

METHOD

Starting in February 2011, hands-on workshops for the diagnosis and repair of OASIs were delivered by trained urogynaecologists in departments of tertiary medical centres in Israel. The structure of the hands-on workshop resembles the workshop organized at the International Urogynecological Association annual conferences. Participants included medical staff, midwives and surgical residents from each medical centre. We collected data regarding the rate of OASIs, 1 year before and 1 year following the workshop, in 11 medical centres. The study population was composed of parturients with the following inclusion criteria: singleton pregnancy, vertex presentation and vaginal delivery. Pre-viable preterm gestations (< 24 weeks), birth weight < 500 g, stillborn, and those with major congenital anomalies, multifoetal pregnancies, breech presentations and caesarean deliveries were excluded from the analysis.

RESULTS

In the reviewed centres, 70 663 (49.3%) women delivered prior to the workshop (pre-workshop group) and 72 616 (50.7%) women delivered following the workshop (post-workshop group). Third- or fourth-degree perineal tears occurred in 248 women (0.35%) before the workshop, and in 328 (0.45%) following the workshop, a significant increase of 28.7% (P = 0.002). The increase in diagnosis was significant also in women with third-degree tears alone, 226 women (0.32%) before the workshop and 298 (0.41%) following the workshop, an increase of 28.3% (P = 0.005).

CONCLUSION

The detection rate of OASIs has significantly increased following the hands-on workshop. The implementation of such programmes is crucial for increasing awareness and detection rates of OASI following vaginal deliveries.

Parturition mode recommendation and symptoms of pelvic floor disorders after obstetric anal sphincter injuries

INTRODUCTION AND HYPOTHESIS

Our primary objective was to evaluate parturition mode (PM) recommendations following obstetric anal sphincter injuries (OASIs) and adherence to these recommendations and to evaluate recurrence of OASIs in women who had a subsequent vaginal delivery (VD). The hypothesis was that adherence to the PM recommendations leads to a reasonable OASI recurrence rate.

METHODS

This was a retrospective observational cohort study of patients with previous OASIs between 2010 and 2016. After an outpatient visit including 3D transperineal ultrasound to screen for pelvic floor and anal sphincter injuries, all patients received recommendations for a subsequent PM. Patients were invited to complete validated questionnaires 2 to 5 years post-OASIs.

RESULTS

The majority of invited patients (265/320) attended follow-up, with 264 receiving a recommendation for PM. Only 5.6% did not adhere to the received recommendation. One hundred sixty-one patients delivered again, 58% had a VD, and 42% had a cesarean section (CS). Recurrence of OASIs was observed in 4.3% of the patients that had a VD. Fecal incontinence occurred in 4.9%, however any form of anal incontinence in 48% of patients. While dyspareunia was common in patients with residual external anal sphincter (EAS) injuries and levator ani muscle (LAM) avulsions, anal pain occurred more frequently in EAS injuries and fecal incontinence in LAM avulsions.

CONCLUSIONS

This study showed that the vast majority of patients followed PM recommendations, and this resulted in a low recurrence of OASIs with a high CS rate. Fecal incontinence after OASIs was correlated with the degree of OASIs.

Does water birth affect the risk of obstetric anal sphincter injury? Development of a prognostic model

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASI) is a significant complication of vaginal delivery. Water birth has become a popular preference for women giving birth in the UK, however, there is limited data on the risk of OASI following water birth. Our aim was to assess OASI risk in low-risk women giving birth in water without medical intervention compared with on land and to create a prognostic model for OASI prediction.

METHODS

This was a retrospective study of 15,734 low-risk women giving birth by spontaneous vaginal delivery between January 2008 and October 2014 in a midwifery-led unit (MLU). Patient factors and delivery data were analysed to identify differences between water and land births. Univariate analysis determined factors that statistically predicted OASI and was then used to create multivariate analysis. Significant multivariate factors were used to create a prognostic model to predict likelihood of OASI.

RESULTS

OASI rates were 1.6% on land and 3.3% in water [odds ratio (OR) 2.10, 95% confidence interval (CI) 1.5-2.94). Multivariate analysis confirmed water birth, ethnicity and parity as independent risk factors for OASI (adjusted OR water birth: 1.77 (CI 1.25-2.51). Our prognostic model showed Black and Asian primigravidae following water birth had the highest risk of OASI and white multiparae on land the lowest.

CONCLUSION

This study of comparable low-risk women shows an increased risk of OASI following water birth compared with land birth. Use of this prognostic model will help women determine their risk of OASI following birth in water or on land.

Obstetric Anal Sphincter Injuries at Vaginal Delivery: A Review of Recently Published National Guidelines

Importance

Obstetric anal sphincter injuries (OASISs) complicate approximately 1 in 10 deliveries.

Objective

The aims of this study were to review and compare recommendations from recently published national guidelines regarding OASISs at vaginal delivery.

Evidence Acquisition

Three national guidelines on OASISs at vaginal delivery are presented through a descriptive review: Royal College of Obstetricians and Gynaecologists on "The Management of Third- and Fourth-Degree Perineal Tears," American College of Obstetricians and Gynecologists on "Prevention and Management of Obstetric Lacerations at Vaginal Delivery," and Society of Obstetricians and Gynaecologists of Canada on "Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair." These guidelines were summarized and compared in terms of prevention and management of OASISs. Quality of evidence was also reviewed based on method of reporting for each guideline.

Results

This published evidence reflects the differences between the national recommendations on the prevention and management of OASISs. Especially, as for the prevention of OASIS, routine use of episiotomy is not recommended, whereas warm perineal compresses and perineal massage during the second stage of labor seem to have a protective role. In the management of OASIS, special care is needed during the repair process of the torn anorectal mucosa and the internal and external anal sphincter. The postoperative use of broad-spectrum antibiotics, oral laxatives, and analgesia is also recommended.

Conclusions

Summarized guidelines can have an impact on special care in prevention and management of OASIS; this may support the reduction of morbidity associated with that entity.

Enhancing recognition of obstetric anal sphincter injuries in six maternity units in Palestine: an interventional quality improvement study

OBJECTIVE

To explore the impact of a training intervention on obstetric anal sphincter injuries' (OASIS) detection rate.

DESIGN

Prospective quality improvement interventional study.

SETTING

Six secondary and tertiary maternity units in Palestine.

POPULATION

Women having singleton vaginal births ≥23 weeks' gestation or babies weighing ≥500 g (n=22 922). Caesarean births (n=5431), multiple gestations (n=443) and vaginal births of unregistered perineum status (n=800) were excluded.

INTERVENTIONS

Training programme for enhancing OASIS detection was conducted between 31 January and 31 December 2015. International experts delivered 2-day standardisation workshop teaching OASIS diagnosis and repair to each maternity unit. They also provided additional training to three research fellows employed in three of the maternity units. This was followed by 13-week period of data collection (phase 1). Research fellows then delivered training intervention over 15-week interval (phase 2), including theoretical teaching and 'onsite' training in perineal trauma assessment within the six maternity units. Finally, 13-week postintervention observation (phase 3) followed.

PRIMARY OUTCOME MEASURE

OASIS rates were used as surrogate for OASIS recognition. OASIS rates were compared between different phases and between the two maternity unit groups (research fellow and non-research fellow based) using Pearson's χ² test.

RESULTS

A total 22 922 women were included. Among primiparous women, OASIS rate was higher in phase 2 (2.8%, p<0.001) and phase 3 (3.1%, p<0.001) than phase 1 (0.5%). However, no significant differences were detected in the rates of severe OASIS (third-degree 3c and fourth-degree tears) between phase 1 and 2 (0.5% vs 0.3%), because this would have required at least 103 women with severe OASIS to be included in each phase. Among parous women, OASIS rate was significantly higher in phase 2 (0.6%, p=0.002) but not in phase 3 (0.4%, p=0.071) compared with phase 1 (0.2%). Research fellows' maternity units showed higher OASIS rates among primiparous women in phase 2 (3.6% vs 1.4%, p=0.001) and phase 3 (4.3% vs 0.8%, p<0.001) than non-research fellows' maternity units.

CONCLUSIONS

This work is basically an epidemiological study which has identified the prevalence of perineal lacerations and their severity on a large sample of women representative of an entire geographical ethnic region. The quality improvement intervention improved OASIS detection mainly in the research fellows' maternity units. Regular mandatory national programmes in obstetric perineal trauma assessment and management by local champions are essential to mitigate the risk of missing significant degrees of trauma.

Anal Sphincter Injuries After Operative Vaginal Versus Spontaneous Delivery-Is There a Difference in Postpartum Symptoms?

OBJECTIVE

The aim of this study was to determine whether there is a difference in pelvic floor symptoms between women who had obstetric anal sphincter injuries (OASIS) after an operative vaginal delivery versus those who had OASIS after a spontaneous delivery.

METHODS

This was a secondary analysis of a prospective cohort study of women who sustained OASIS. Women were evaluated at 1 week postpartum and again at 12 weeks; at both of these visits, they completed a battery of validated questionnaires including a visual analog scale for pain, Patient Health Questionnaire 9 depression inventory, Fecal Incontinence Severity Index, Urogenital Distress Inventory 6, and Incontinence Impact Questionnaire 7.

RESULTS

Two hundred sixty-eight women with OASIS were included in this analysis (194 operative vaginal, 74 spontaneous). Ninety-one percent of those with operative vaginal delivery had a forceps-assisted delivery. After multivariate regression, operative OASIS was independently associated with greater Urogenital Distress Inventory 6 scores (P = 0.02), Fecal Incontinence Severity Index scores (P = 0.04), and visual analog scale pain scores (P = 0.03) and higher rates of urgency urinary incontinence (P = 0.04), stress urinary incontinence (P = 0.02), and anal incontinence (P = 0.04) at 1 week postpartum. At 3 months postpartum, symptoms were no different between the groups.

CONCLUSIONS

Women who sustain OASIS secondary to operative vaginal delivery report more bothersome urinary symptoms and higher rates of anal incontinence immediately postpartum as compared with women with OASIS secondary to spontaneous delivery. These differences may resolve by 3 months postpartum.

Postpartum two- and three-dimensional ultrasound evaluation of anal sphincter complex in women with obstetric anal sphincter injury

OBJECTIVE

To compare the sensitivity and specificity of two- (2D) and three- (3D) dimensional transperineal ultrasound (TPUS) and 3D endovaginal ultrasound (EVUS) with the gold standard 3D endoanal ultrasound (EAUS) in detecting residual defects after primary repair of obstetric anal sphincter injuries (OASIS).

METHODS

External (EAS) and internal (IAS) anal sphincters were evaluated by the four ultrasound modalities in women with repaired OASIS. 2D-TPUS was evaluated in real-time, whereas 3D-TPUS, 3D-EVUS and 3D-EAUS volumes were evaluated offline by six blinded readers. The presence/absence of any tear in EAS or IAS was recorded and defects were scored according to the Starck system. Sensitivity, specificity and predictive values were calculated, using 3D-EAUS as reference standard. Inter- and intraobserver analyses were performed for all 3D imaging modalities. Association between patients' symptoms (Wexner score) and ultrasound findings (Starck score) was calculated.

RESULTS

Images from 55 patients were analyzed. Compared with findings on 3D-EAUS, the agreement for EAS evaluation was poor for 3D-EVUS (κ = 0.01), fair for 2D-TPUS (κ = 0.30) and good for 3D-TPUS (κ = 0.73). The agreement for IAS evaluation was moderate for both 3D-EVUS (κ = 0.41) and 2D-TPUS (κ = 0.52) and good for 3D-TPUS (κ = 0.66). Good intraobserver (3D-EAUS, κ = 0.73; 3D-TPUS, κ = 0.78) and interobserver (3D-EAUS, κ = 0.68; 3D-TPUS, κ = 0.60) agreement was reported. Significant association between Starck and Wexner scores was found only for 3D-EAUS (Spearman's rho = 0.277, P = 0.04).

CONCLUSIONS

2D-TPUS and 3D-EVUS are not accurate modalities for the assessment of anal sphincters after repair of OASIS. 3D-TPUS shows good agreement with the gold standard 3D-EAUS and a high sensitivity in detecting residual defects. It, thus, has potential as a screening tool after primary repair of OASIS. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Residual defects after repair of obstetric anal sphincter injuries and pelvic floor muscle strength are related to anal incontinence symptoms

INTRODUCTION AND HYPOTHESIS

The aim was to analyze the correlation between residual anal sphincter (AS) defects and pelvic floor muscle (PFM) strength on anal incontinence (AI) in patients with a history of obstetric AS injuries (OASIS).

METHODS

From September 2012 to February 2015, an observational study was conducted on a cohort of females who underwent repair of OASIS intrapartum. The degree of OASIS was scored intrapartum according to Sultan's classification. Participants were assessed at 6 months postpartum. Incontinence symptoms were evaluated using Wexner's score and PFM strength using the Modified Oxford Scale (MOS). 3D-endoanal ultrasound was performed to classify AS defects according to Starck's system. Correlation between Sultan's and Starck's classifications was calculated using Cohen's kappa and Spearman's rho (R_s) test. The impact of residual AS defects and PFM strength on AI was analyzed using a multiple regression model.

RESULTS

A total of 95 women were included in the study. Good correlation (κ= 0.72) was found between Sultan's and Starck's classifications. Significant positive correlation was observed between Wexner's score and both Sultan's (p = 0.023, R_s =0.212) and Starck's (p < 0.001, R_s =0.777) scores. The extent of the residual AS defect was the most relevant factor correlating with AI symptoms. In patients with severe AS injuries, higher MOS values were associated with lower Wexner's score.

CONCLUSIONS

The degree of AS tear measured intrapartum was the most important factor related to AI after primary repair of OASIS. PFM strength was associated with lower incontinence symptoms in the postpartum period.

Degree of bother from pelvic floor dysfunction in women one year after first delivery

OBJECTIVE

To investigate rates and range of pelvic floor dysfunction complaints, including anterior and posterior compartments and sexual function, in an unselected population of primiparous women one year from delivery, and examine the degree of bother they cause.

STUDY DESIGN

Cross sectional study. Primiparous women who delivered their first child in our delivery wards 10-14 months previously, were approached by phone and asked to complete the Pelvic Floor Symptom Bother Questionnaire (PFBQ) and provide general demographic information. Details regarding participants' labor and delivery were extracted from electronic medical records. PFBQ score was correlated to demographic and labor and delivery parameters.

RESULTS

198 women completed the questionnaire. Response rate was 94%. Scores ranged from 0 to 44.4 (out of a possible 100). At least one symptom of PFD was reported by 64% of respondents. Various degrees of urinary incontinence were reported by 9.1-12.1% of women. Some degree of fecal or flatus incontinence was reported by 10.1% of women; 11.1% reported some degree of obstructed defecation. Severe degree of bother from one or more PFD symptoms was reported by 40.1-90.9%. Some level of dyspareunia was reported by 37.3%. A "dose response" trend between mode of delivery and rate of dyspareunia was observed.

CONCLUSIONS

Two-thirds of primiparous women one year after delivery suffer PFD symptoms that cause some degree of bother. When asked, women are willing to discuss pelvic floor function; caregivers should initiate discussion and refer women promptly to interventions where necessary.

Health status and quality of life in postpartum women: a systematic review of associated factors

Since health care is becoming more and more patient centered, patient-reported outcomes such as quality of life (QOL) and health status (HS) are becoming increasingly important. The aim of this systematic review was to provide an overview of physical, psychological, and social domains of QOL and HS in postpartum women, and to assess which factors are associated with QOL and HS domains postpartum. A computerized literature search was performed using the PubMed, PsycINFO, and Cochrane databases. Studies were selected if the three domains of QOL or HS were measured in a (sub)group of postpartum women, by using validated standardized questionnaires. The methodological quality of the 66 included studies was examined by two independent reviewers. All three domains of QOL were impaired in postpartum women with urinary incontinence, with even worse QOL in women with mixed urinary incontinence. Mental QOL was impaired in women with urge urinary incontinence after cesarean section. Social QOL was decreased in HIV-positive women. HS was impaired in all three domains in postpartum depressed women. Physical HS was impaired after cesarean section for at least two months postpartum. Additional supportive interventions from health care social support were not associated with improved HS. Urinary incontinence and being HIV-positive seemed to be associated with impaired QOL. Postpartum depression and a cesarean section seemed to be associated with impaired HS. Prospective longitudinal research is needed in order to draw valid conclusions regarding postpartum HS and QOL, and the predictive value of the associated factors.

Can the risk of obstetric anal sphincter injuries (OASIs) be predicted using a risk-scoring system?

BACKGROUND

Perineal trauma involving the anal sphincter is an important complication of vaginal delivery. Prediction of anal sphincter injuries may improve the prevention of anal sphincter injuries. Our aim was to construct a risk scoring model to assist in both prediction and prevention of Obstetric Anal Sphincter Injuries (OASIs). We carried out an analysis of factors involved with OASIs, and tested the constructed model on new patient data.

METHODS

Data on all vaginal deliveries over a 5 year period (2004-2008) was obtained from the electronic maternity record system of one institution in the UK. All risk factors were analysed using logistic regression analysis. Odds ratios for independent variables were then used to construct a risk scoring algorithm. This algorithm was then tested on subsequent vaginal deliveries from the same institution to predict the incidence of OASIs.

RESULTS

Data on 16,920 births were analysed. OASIs occurred in 616 (3.6%) of all vaginal deliveries between 2004 and 2008. Significant (p < 0.05) variables that increased the risk of OASIs on multivariate analysis were: African-Caribbean descent, water immersion in labour, water birth, ventouse delivery, forceps delivery. The following variables remained independently significant in decreasing the risk of OASIs: South Asian descent, vaginal multiparity, current smoker, home delivery. The subsequent odds ratios were then used to construct a risk-scoring algorithm that was tested on a separate cohort of patients, showing a sensitivity of 52.7% and specificity of 71.1%.

CONCLUSIONS

We have confirmed known risk factors previously associated with OASIs, namely parity, birth weight and use of instrumentation during delivery. We have also identified several previously unknown factors, namely smoking status, ethnicity and water immersion. This paper identifies a risk scoring system that fulfils the criteria of a reasonable predictor of the risk of OASIs. This supersedes current practice where no screening is implemented other than examination at the time of delivery by a single examiner. Further prospective studies are required to assess the clinical impact of this scoring system on the identification and prevention of third degree tears.

Fecal incontinence after obstetric anal sphincter injuries

OBJECTIVE

To determine obstetric variables associated with the long-term prevalence of flatal and/or fecal incontinence among women who sustained obstetric anal sphincter injuries (OASIS).

METHODS

In a retrospective study of women who gave birth between January 1974 and December 1983 at the University Women's Hospital, Tuebingen, Germany, women with OASIS (n=460) were identified on the basis of chart review. Eligible women were recruited to participate in a telephone interview regarding symptoms and their retrospective preference about elective cesarean delivery.

RESULTS

The records of 20 999 deliveries, including all modes of delivery, within the 10-year study period were reviewed, and 99 women who sustained OASIS agreed to participate. The mean follow-up was 27.5±2.4 years. Among the participants, 39.4% reported fecal or flatal incontinence. Operative vaginal delivery (forceps and/or vacuum) was significantly associated with fecal but not flatal incontinence (odds ratio, 3.27; 95% confidence interval, 1.12-9.56, P=0.026). Only 9% of women with flatal incontinence and 13% of women with fecal incontinence would have opted retrospectively for cesarean delivery.

CONCLUSION

Operative vaginal delivery was significantly associated with fecal but not flatal incontinence. No other obstetric variables tested were associated with the long-term prevalence of fecal or flatal incontinence.