Pelvic floor morbidity up to one year after difficult instrumental delivery and cesarean section in the second stage of labor: a cohort study

Does delayed vacuum-assisted delivery harbor greater maternal or neonatal complications?

OBJECTIVE

To compare maternal and fetal outcomes between early (<2 h) and delayed (>2 h) vacuum extraction (VE) deliveries.

METHODS

We performed a retrospective cohort study in a single, university-affiliated medical center (2014-2021). We included term singleton pregnancies delivered by VE, allocated into one of two groups according to second stage duration: <2 h or >2 h. Primary outcome was maternal composite adverse outcome (included chorioamnionitis, 3-4 degree lacerations, and postpartum hemorrhage [PPH]).

RESULTS

We included 2521 deliveries: 2261 (89.6%) with early VE and 260 (10.4%) with delayed VE. Study groups' characteristics were not different, except of parity. Maternal composite outcome almost reached a significance (P = 0.054) comparing between the groups. Comparing second stage length up to 2 h versus more, there was similar rate of advance maternal lacerations. However, extending the second stage to more than 3 h was associated with third degree lacerations compared to 2-3 h (9.8% vs 3%, P = 0.011). There were significantly more PPH events in the later VE group (P = 0.004), but the need for blood transfusions was similar. The rates of 5 min Apgar score ≤7 (P = 0.001) and umbilical artery pH <7.0 were significantly higher in group 2 compared with group 1. The effect was much more pronounced when second stage was >3 h. After conducting multiregression analysis, the results became insignificant.

CONCLUSION

Our study suggests that VE performed in the late second stage of labor, up to 3 h, is safe as VE performed in the early stages regarding maternal and neonatal outcomes. Extra caution is needed with extended second stage to more than 3 h.

Assisted vaginal delivery in the obese patient

Appropriate use of ventouse or obstetric forceps as options in the management of the second-stage of labor is good medical practice. The instruments are not inherently dangerous, however, the manner in which they are used may be. In addition to a working knowledge of the instruments, the operator must have the willingness to abandon an unsuccessful procedure. Awareness that failure of assisted vaginal delivery is more likely in women with BMI >30, hence, gives pause to consider trial in theatre with early recourse to cesarean delivery if unsuccessful Awareness that obesity is associated with increased risk of intrapartum complications, such as the need for second-stage assistance to achieve delivery, shoulder dystocia and postnatal complications, such as obstetric anal sphincter injury and febrile morbidity.

Prevalence, indications and fetal outcomes of operative vaginal delivery in Sub-Saharan Africa, systematic review, and meta-analysis

PURPOSE

This systematic review and meta-analysis is intended to assess the prevalence, indications, and fetal outcome of operative vaginal delivery in sub-Saharan Africa.

METHOD

In this study, 17 studies with a total population of 190,900 were included in both systematic review and meta-analysis. Search for relevant articles was done by using international online databases (like Google Scholar, PubMed, HINARI, EMBASE, Web of Science, and African journals) and online repositories of Universities in Africa. The JOANNA Briggs Institute standard data extraction format was used to extract and appraise high-quality articles before being included in this study. The Cochran Q and I2 statistical tests were used to test the heterogeneity of the studies. The publication bias was tested by a Funnel plot and Egger's test. The overall pooled prevalence, indications, and fetal outcome of operative vaginal delivery along a 95% CI using forest plots and tables.

RESULT

The overall pooled prevalence of operative vaginal delivery in sub-Saharan Africa was 7.98% (95% CI; 5.03-10.65; I2 = 99.9%, P < 0.001). The indications of operative vaginal delivery in sub-Saharan African countries include the prolonged second stage of labor 32.81%, non-reassuring fetal heart rate 37.35%, maternal exhaustion 24.81%, big baby 22.37%, maternal cardiac problems 8.75%, and preeclampsia/eclampsia 2.4%. Regarding the fetal outcome, favourable fetal outcomes were 55% (95% CI: 26.04, 84.44), p =  < 0.56, I2: 99.9%). From those births with unfavourable outcomes, the need for the resuscitation of new-born was highest 28.79% followed by poor 5th minute Apgar score, NICU admission, and fresh stillbirth, 19.92, 18.8, and 3.59% respectively.

CONCLUSION

The overall prevalence of operative vaginal delivery (OVD) in sub-Saharan Africa was slightly higher compared to other countries. To reduce the increased applications and adverse fetal outcomes of OVD, capacity building for obstetrics care providers and drafting guidelines are required.

Comparison of pelvic floor dysfunction 6 years after uncomplicated vaginal versus elective cesarean deliveries: a cross-sectional study

Clinicians and patients have traditionally believed that elective cesarean section may protect against certain previously ineluctable consequences of labor, including a plethora of urinary, anorectal and sexual dysfunctions. We aimed to evaluate fecal, urinary and sexual symptoms 6 years postpartum, comparing uncomplicated vaginal delivery and elective cesarean delivery, and to assess their impact on quality of life. We conducted a cross-sectional study to compare perineal functional symptomatology between women having singleton elective cesarean deliveries (eCS) and singleton uncomplicated vaginal deliveries (uVD). Women who delivered 6 years before this study were chosen randomly from our hospital database. This database includes demographic, labor, and delivery information, as well as data regarding maternal and neonatal outcomes, all of which is collected at the time of delivery by the obstetrician. Four validated self-administrated questionnaires were sent by post to the participants: the short forms of the Urogenital Distress Inventory, Incontinence Impact Questionnaire, Wexner fecal incontinence scale, and Female Sexual Function Index. Current socio-demographic details, physical characteristics, obstetrical history and mode of delivery at subsequent births were also registered using a self-reported questionnaire. A total of 309 women with uVD and 208 with eCS returned postal questionnaires. The response rate was 49%. Socio-demographic characteristics and fecal incontinence were similar between groups. After eCS, women reported significantly less urgency urinary incontinence (adjusted Relative Risk 0.55; 95% confidence interval 0.34-0.88) and stress incontinence (adjusted Relative Risk 0.53; 95% confidence interval 0.35-0.80) than after uVD. No difference in total Incontinence Impact Questionnaire score was found between both modes of delivery. Lower abdominal or genital pain (adjusted Relative Risk 1.58; 95% confidence interval 1.01-2.49) and pain related to sexual activity (adjusted Relative Risk 2.50; 95% confidence interval 1.19-5.26) were significantly more frequent after eCS than uVD. Six years postpartum, uVD is associated with urinary incontinence, while eCS is associated with sexual and urination pain.

A simple sonographic finding is associated with a successful vacuum application: the fetal occiput or forehead sign

BACKGROUND

Intrapartum ultrasound scanning has been proposed as an ancillary tool in the decision-making process of instrumental vaginal delivery.

OBJECTIVE

The purpose of this study was to evaluate the correlation between the sonographic visualization with a transperineal scan of the fetal occiput or forehead distal to the pubic symphysis with anterior or posterior presentation, respectively (fetal occiput or forehead sign), and the outcome of a vacuum delivery.

STUDY DESIGN

We conducted a retrospective cohort study of patients who underwent a vacuum application in our hospital from 2011-2017, excluding outlet applications. In each case, a preliminary transperineal scan was performed to confirm fetal presentation and position and to demonstrate the presence or absence of the fetal occiput or forehead sign. The head direction, angle of progression, and the head perineum distance were also noted. The primary outcome measure was the success of the vacuum. The secondary outcome measures included fetal complications and perineal lacerations.

RESULTS

A total of 196 consecutive patients were enrolled in the study. The occiput or forehead sign was present in 150 and was associated with a successful vaginal extraction in all cases. Of the 46 cases without the sign, 5 babies (10.8%) were delivered by cesarean section after a failed vacuum (P=.0006). The occiput or forehead sign was also associated with fewer grade 3-4 perineal lacerations (10.7% vs 35.7%; P=.0005) and cephalohematomas, although the difference was not statistically significant (1.4% vs 4.3%). There was a good correlation between the occiput or forehead sign and the other sonographic methods that previously had been proposed to predict a successful vacuum extraction, such as head direction, angle of progression, and head perineum distance.

CONCLUSION

In our hands, the fetal occiput or forehead sign was associated strongly with successful vacuum application and with a very low rate of maternal and fetal complications.

Comparison of caesarean section and vaginal delivery for pelvic floor function of parturients: a meta-analysis

OBJECTIVE

To compare the effects and complications of caesarean section (CSD) and vaginal delivery (VD) for pelvic floor function of parturients.

METHODS

Multiple databases were searched for full-text articles regarding the clinical effects and complications of CSD and VD. Review Manager 5.0 was used for meta-analyses, sensitivity analysis and bias analysis.

RESULTS

In total, 4491 patients were included in nine studies that met the eligibility criteria. Of these, 1527 women underwent CSD and 2944 women had a VD. The meta-analyses suggested significant differences in pelvic floor muscle strength [mean difference (MD) -11.94, 95% confidence interval (CI) -12.48 to -11.39, p < 0.00001, p for heterogeneity <0.00001, I² = 93%], vaginal muscle voltage (MD -9.45, 95% CI -9.73 to -9.16, p < 0.00001, p for heterogeneity <0.00001, I² = 94%), maximum urinary flow rate (MD -5.67, 95% CI -5.94 to -5.39, p < 0.00001, p for heterogeneity <0.00001, I² = 96%), stress urinary incontinence [odds ratio (OR) 0.45, 95% CI 0.37-0.55, p < 0.00001, p for heterogeneity = 0.79, I² = 0%] and pelvic organ prolapse (OR 0.59, 95% CI 0.50-0.70, p < 0.00001, p for heterogeneity = 0.24, I² = 23%) between the CSD group and the VD group.

CONCLUSION

This study demonstrated that CSD is the preferred mode of delivery for pregnant woman in terms of pelvic floor function.

Maternal position in the second stage of labour for women with epidural anaesthesia

BACKGROUND

Epidural analgesia in labour prolongs the second stage and increases instrumental delivery. It has been suggested that a more upright maternal position during all or part of the second stage may counteract these adverse effects. This is an update of a Cochrane Review published in 2017.

OBJECTIVES

To assess the effects of different birthing positions (upright or recumbent) during the second stage of labour, on maternal and fetal outcomes for women with epidural analgesia.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 June 2018), and the reference lists of retrieved studies.

SELECTION CRITERIA

All randomised or quasi-randomised trials including pregnant women (primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind. Cluster-randomised controlled trials would have been eligible for inclusion but we found none. Studies published in abstract form only were also eligible.We assumed the experimental intervention to be maternal use of any upright position during the second stage of labour, compared with the control condition of remaining in any recumbent position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risks of bias, and extracted data. We contacted study authors to obtain missing data. We assessed the quality of the evidence using the GRADE approach.We carried out a planned sensitivity analysis of the three studies with low risks of bias for allocation concealment and incomplete outcome data reporting, and further excluded one study with a co-intervention (this was not prespecified).

MAIN RESULTS

We include eight randomised controlled trials, involving 4464 women, comparing upright positions versus recumbent positions in this update. Five were conducted in the UK, one in France and two in Spain.The largest UK trial accounted for three-quarters of all review participants, and we judged it to have low risk of bias. We assessed two other trials as being at low risk of selection and attrition bias. We rated four studies at unclear or high risk of bias for both selection and attrition bias and one study as high risk of bias due to a co-intervention. The trials varied in their comparators, with five studies comparing different positions (upright and recumbent), two comparing ambulation with (recumbent) non-ambulation, and one study comparing postural changes guided by a physiotherapist to a recumbent position.Overall, there may be little or no difference between upright and recumbent positions for our combined primary outcome of operative birth (caesarean or instrumental vaginal): average risk ratio (RR) 0.86, 95% confidence interval (CI) 0.70 to 1.07; 8 trials, 4316 women; I² = 78%; low-quality evidence. It is uncertain whether the upright position has any impact on caesarean section (RR 0.94, 95% CI 0.61 to 1.46; 8 trials, 4316 women; I² = 47%; very low-quality evidence), instrumental vaginal birth (RR 0.90, 95% CI 0.72 to 1.12; 8 trials, 4316 women; I² = 69%) and the duration of the second stage of labour (mean difference (MD) 6.00 minutes, 95% CI -37.46 to 49.46; 3 trials, 456 women; I² = 96%), because we rated the quality of the evidence as very low for these outcomes. Maternal position in the second stage of labour probably makes little or no difference to postpartum haemorrhage (PPH), (PPH requiring blood transfusion): RR 1.20, 95% CI 0.83 to 1.72; 1 trial, 3093 women; moderate-quality evidence. Maternal satisfaction with the overall childbirth experience was slightly lower in the upright group: RR 0.95, 95% CI 0.92 to 0.99; 1 trial, 2373 women. Fewer babies were born with low cord pH in the upright group: RR 0.43, 95% CI 0.20 to 0.90; 2 trials, 3159 infants; moderate-quality evidence.The results were less clear for other maternal or fetal outcomes, including trauma to the birth canal requiring suturing (average RR 1.00, 95% CI 0.89 to 1.13; 3 trials, 3266 women; I² = 46%; low-quality evidence), abnormal fetal heart patterns requiring intervention (RR 1.69, 95% CI 0.32 to 8.84; 1 trial, 107 women; very low-quality evidence), or admission to neonatal intensive care unit (RR 0.54, 95% CI 0.02 to 12.73; 1 trial, 66 infants; very low-quality evidence). However, the CIs around some of these estimates were wide, and we cannot rule out clinically important effects.In our sensitivity analysis of studies at low risk of bias, upright positions increase the chance of women having an operative birth: RR 1.11, 95% CI 1.03 to 1.20; 3 trials, 3609 women; high-quality evidence. In absolute terms, this equates to 63 more operative births per 1000 women (from 17 more to 115 more). This increase appears to be due to the increase in caesarean section in the upright group (RR 1.29; 95% CI 1.05 to 1.57; 3 trials, 3609 women; high-quality evidence), which equates to 25 more caesarean sections per 1000 women (from 4 more to 49 more). In the sensitivity analysis there was no clear impact on instrumental vaginal births: RR 1.08, 95% CI 0.91 to 1.30; 3 trials, 3609 women; low-quality evidence.

AUTHORS' CONCLUSIONS

There may be little or no difference in operative birth between women who adopt recumbent or supine positions during the second stage of labour with an epidural analgesia. However, the studies are heterogeneous, probably related to differing study designs and interventions, differing adherence to the allocated intervention and possible selection and attrition bias. Sensitivity analysis of studies at low risk of bias indicated that recumbent positions may reduce the need for operative birth and caesarean section, without increasing instrumental delivery. Mothers may be more satisfied with their experience of childbirth by adopting a recumbent position. The studies in this review looked at left or right lateral and semi-recumbent positions. Recumbent positions such as flat on the back or lithotomy are not generally used due to the possibility of aorto-caval compression, although we acknowledge that these recumbent positions were not the focus of trials included in this review.

Fetal heart rate changes observed on the CTG trace during instrumental vaginal delivery

INTRODUCTION

Instrumental vaginal delivery (IVD) helps expedite delivery during second stage of labour so as to avoid a second stage caesarean section. However, due to mechanical effects on the fetal head, vacuum and forceps may cause cardiotocograph (CTG) abnormalities due to vigal stimulation as well as increased intracranial pressure.

OBJECTIVE

To determine the features observed on the CTG during IVD in term pregnancy and correlate them to perinatal outcomes.

METHODS

A retrospective analysis of 445 cases who had vacuum deliveries (227) and forceps deliveries (218) at St. George's University Hospitals NHS Foundation Trust during a 12-month period was performed. CTG features were analysed at 10 minutes prior to and immediately after applications of the chosen instrument till delivery. Specific abnormalities were correlated to Apgar score and umbilical blood pH.

RESULTS

Specific CTG abnormalities after applications of vacuum and forceps were: tachycardia (99 (43.61%) versus 88 (40.37%)), increased baseline fetal heart rate (FHR) [14 (6.17%) versus 4 (1.83%) p = .0204], baro-receptor-mediated "variable" deceleration (101 (44.49%) versus 85 (38.99%)), chemoreceptor-mediated "late" deceleration (62 (27.31%) versus 76 (34.86%)), prolonged deceleration (32 (14.10%) versus 24 (11.01%)), saltatory pattern [35 (15.42%) versus 76 (34.86%) p < .0001], and reduced baseline variability (10 (4.41%) versus 7 (3.21%)). There were no significant differences in the mean Apgar Scores at 1 and 5 minutes between ventouse and forceps delivery (8 and 9, respectively) or the umbilical blood pH (both >7.20).

CONCLUSIONS

After application of instruments, 90% of CTG traces showed abnormal features. Tachycardia, baro- and chemoreceptor-mediated decelerations, and saltatory patterns were the most common abnormalities. Increased baseline FHR during vacuum as compared to forceps delivery was possibly secondary to pain/pressure and resultant sympathetic overactivity. The saltatory pattern was more common in forceps deliveries, possibly secondary to increased intracranial pressure and resultant autonomic instability. Despite these CTG abnormalities, the perinatal outcomes were good.

Sexual function and postpartum depression 6 months after attempted operative vaginal delivery according to fetal head station: A prospective population-based cohort study

Objective

To evaluate the effect of the fetal head station at attempted operative vaginal delivery (aOVD), and specifically midpelvic or low aOVD, on female and male sexual function and symptoms of postpartum depression (PPD) at 6 months.

Design

Prospective population-based cohort study.

Setting

1,941 women with singleton term fetuses in vertex presentation with midpelvic or low aOVD between 2008 and 2013 in a tertiary care university hospital.

Methods

Symptoms of female sexual dysfunction using the Pelvic Organ Prolapse/Urinary Incontinence/Sexual Function Short Form Questionnaire (PISQ-12), symptoms of PPD using the Edinburgh Postnatal Depression Scale (EPDS) score, symptoms of male sexual dysfunction using the International Index of Erectile Function (IIEF-15) and perineal pain were assessed 6 months after aOVD. We measured the association between midpelvic or low aOVD and symptoms of female and male sexual function and symptoms of PPD at 6 months using multiple regression and adjusting for demographics, and risk factors of sexual dysfunction, symptoms of PPD and perineal pain with adjusted odds ratios (aORs) and 95% confidence intervals (95% CI).

Results

The study included 907 women (46.7%) who responded to the questionnaire; 18.4% (167/907) had midpelvic aOVD, and 81.6% (740/907) low. Most women (873/907 [96.3%]) of those with partners reported sexual activity at 6 months. No significant difference was observed for PISQ-12, EPDS, IIEF-15 scores and perineal pain between mid and low pelvic groups. Compared with low pelvic aOVD, midpelvic aOVD was not significantly associated with either female or male sexual dysfunction (p = 0.89 and p = 0.76, respectively), or maternal symptoms of PPD (p = 0.83). Perineal pain significantly increased the risk of male and female sexual dysfunction and maternal symptoms of PPD at 6 months (p = 0.02, p = 0.006, and p = 0.02, respectively).

Conclusion

Midpelvic compared with low pelvic aOVD was not associated with an increase in sexual dysfunction, nor with symptoms of PPD at 6 months.

Position in the second stage of labour for women with epidural anaesthesia

BACKGROUND

Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects. This is an update of a Cochrane review first published in 2013.

OBJECTIVES

To assess the effects of different birthing positions (upright and recumbent) during the second stage of labour, on important maternal and fetal outcomes for women with epidural analgesia.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (19 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised or quasi-randomised trials including pregnant women (either primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind. Cluster-RCTs would have been eligible for inclusion in this review but none were identified. Studies published in abstract form only were eligible for inclusion.We assumed the experimental type of intervention to be the maternal use of any upright position during the second stage of labour, compared with the control intervention of the use of any recumbent position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risk of bias, and extracted data. Data were checked for accuracy. We contacted study authors to try to obtain missing data.

MAIN RESULTS

Five randomised controlled trials, involving 879 women, comparing upright positions versus recumbent positions were included in this updated review. Four trials were conducted in the UK and one in France. Three of the five trials were funded by the hospital departments in which the trials were carried out. For the other three trials, funding sources were either unclear (one trial) or not reported (two trials). Each trial varied in levels of bias. We assessed all the trials as being at low or unclear risk of selection bias. None of the trials blinded women, staff or outcome assessors. One trial was poor quality, being at high risk of attrition and reporting bias. We assessed the evidence using the GRADE approach; the evidence for most outcomes was assessed as being very low quality, and evidence for one outcome was judged as moderate quality.Overall, we identified no clear difference between upright and recumbent positions on our primary outcomes of operative birth (caesarean or instrumental vaginal) (average risk ratio (RR) 0.97; 95% confidence interval (CI) 0.76 to 1.29; five trials, 874 women; I² = 54% moderate-quality evidence), or duration of the second stage of labour measured as the randomisation-to-birth interval (average mean difference -22.98 minutes; 95% CI -99.09 to 53.13; two trials, 322 women; I² = 92%; very low-quality evidence). Nor did we identify any clear differences in any other important maternal or fetal outcome, including trauma to the birth canal requiring suturing (average RR 0.95; 95% CI 0.66 to 1.37; two trials; 173 women; studies = two; I² = 74%; very low-quality evidence), abnormal fetal heart patterns requiring intervention (RR 1.69; 95% CI 0.32 to 8.84; one trial; 107 women; very low-quality evidence), low cord pH (RR 0.61; 95% CI 0.18 to 2.10; one trial; 66 infants; very low-quality evidence) or admission to neonatal intensive care unit (RR 0.54; 95% CI 0.02 to 12.73; one trial; 66 infants; very low-quality evidence). However, the CIs around each estimate were wide, and clinically important effects have not been ruled out. Outcomes were downgraded for study design, high heterogeneity and imprecision in effect estimates.There were no data reported on blood loss (greater than 500 mL), prolonged second stage or maternal experience and satisfaction with labour. Similarly, there were no analysable data on Apgar scores, and no data reported on the need for ventilation or for perinatal death.

AUTHORS' CONCLUSIONS

There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. The GRADE quality assessment of the evidence in this review ranged between moderate to low quality, with downgrading decisions based on design limitations in the studies, inconsistency, and imprecision of effect estimates.Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour.More studies with larger sample sizes will need to be conducted in order for solid conclusions to be made about the effect of position on labour in women with an epidural. Two studies are ongoing and we will incorporate the results into this review at a future update.Future studies should have the protocol registered, so that sample size, primary outcome, analysis plan, etc. are all clearly prespecified. The time or randomisation should be recorded, since this is the only unbiased starting time point from which the effect of position on duration of labour can be estimated. Future studies might wish to include an arm in which women were allowed to choose the position in which they felt most comfortable. Future studies should ensure that both compared positions are acceptable to women, that women can remain in them for most of the late part of labour, and report the number of women who spend time in the allocated position and the amount of time they spend in this or other positions.

Pelvic Floor Disorders 6 Months after Attempted Operative Vaginal Delivery According to the Fetal Head Station: A Prospective Cohort Study

Objective

To evaluate the effect of the fetal head station at attempted operative vaginal delivery (aOVD), and specifically midpelvic or low aOVD, on urinary incontinence (UI), anal incontinence (AI), and perineal pain at 6 months.

Design

Prospective cohort study.

Setting

1941 women with singleton term fetuses in vertex presentation with midpelvic or low aOVD between 2008 and 2013 in a tertiary care university hospital.

Methods

Symptoms of urinary incontinence (UI) using the Bristol Female Lower Urinary Tract Symptoms questionnaire, and symptoms of anal incontinence (AI) severity using Fecal Incontinence Severity Index (FISI) were assessed 6 months after aOVD. We measured the association between midpelvic or low aOVD and symptoms of UI, AI, and perineal pain at 6 months using multiple regression and adjusting for demographics, and risk factors of UI and AI, with adjusted odds ratios (aORs) and 95% confidence intervals (95% CI).

Results

The study included 907 women (46.7%) who responded to the questionnaire; 18.4% (167/907) had midpelvic aOVD, and 81.6% (740/907) low; and none of women with symptoms of UI (26.6%, and 22.4%, respectively; p = 0.31), AI (15.9%, and 21.8%; p = 0.09), the FISI score, and perineal pain (17.2%, and 12.7%; p = 0.14) differed significantly between groups. The same was true for stress, urge, and mixed-type UI, severe UI and difficulty voiding. Compared with low pelvic aOVD, the aORs for symptoms of UI in midpelvic aOVD were 0.70 (0.46–1.05) and AI 1.42 (0.85–2.39). Third- and fourth-degree tears were a major risk factor of symptoms of UI (aOR 3.08, 95% CI 1.35–7.00) and AI (aOR 3.47, 95% CI 1.43–8.39).

Conclusion

Neither symptoms of urinary nor anal incontinence differed at 6 months among women who had midpelvic and low pelvic aOVD. These findings are reassuring and need further studies at long-term to confirm these short-term data.

Determinants and Outcomes of Emergency Caesarean Section following Failed Instrumental Delivery: 5-Year Observational Review at a Tertiary Referral Centre in London

OBJECTIVES

To review the determinants for a failed operative vaginal delivery and to examine associated fetal and maternal morbidity. Design. Retrospective observational study. Setting. Large London Teaching Hospital.

METHOD

A retrospective review of case notes during a 5-year period was carried out.

RESULTS

Overall 119 women (0.44%) out of 26,856 births had a caesarean section following a failed instrumental delivery, which comprised 5.1% of all operative vaginal births. 73% had a spontaneous onset of labour and 63% required syntocinon at some time prior to delivery. 71.5% of deliveries were complicated by malposition. Only 20% of deliveries were attended by a consultant obstetrician. Almost 50% of women and 8.4% of neonates sustained trauma at the time of either their failed instrumental delivery or the caesarean section.

CONCLUSIONS

Emergency caesarean section during the second stage of labour is associated with maternal and fetal complications. A 'failed instrumental delivery score' (FIDS) may aid practitioners in predicting an increased likelihood of a failed operative vaginal birth and therefore to consider a trial of operative vaginal delivery in the theatre. Senior input should also be sought because a failed operative vaginal birth is associated with increased maternal and fetal morbidity.

Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop

In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.

Position in the second stage of labour for women with epidural anaesthesia

BACKGROUND

Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects.

OBJECTIVES

To assess the effects of different birthing positions (upright versus recumbent) during the second stage of labour, on important maternal and fetal outcomes for women with epidural analgesia.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012) and reference lists of retrieved studies

SELECTION CRITERIA

All randomised or quasi-randomised trials including pregnant women (either primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind.We assumed the experimental type of intervention to be the maternal use of any upright position during the second stage of labour, compared with the control intervention of the use of any recumbent position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risk of bias, and extracted data. Data were checked for accuracy. We contacted authors to try to obtain missing data.

MAIN RESULTS

Five randomised controlled trials, involving 879 women, were included in the review.Overall, we identified no statistically significant difference between upright and recumbent positions on our primary outcomes of operative birth (caesarean or instrumental vaginal) (average risk ratio (RR) 0.97; 95% confidence interval (CI) 0.76 to 1.29; five trials, 874 women), or duration of the second stage of labour measured as the randomisation to birth interval (average mean difference -22.98 minutes; 95% CI -99.09 to 53.13; two trials, 322 women). Nor did we identify any clear differences in the incidence of instrumental birth or caesarean section separately, nor in any other important maternal or fetal outcome, including trauma to the birth canal requiring suturing, operative birth for fetal distress, low cord pH or admission to neonatal intensive care unit. However, the CIs around each estimate were wide, and clinically important effects have not been ruled out.There were no data reported on excess blood loss, prolonged second stage or maternal experience and satisfaction with labour. Similarly, there were no analysable data on Apgar scores, and no data reported on the need for ventilation or for perinatal death.

AUTHORS' CONCLUSIONS

There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour. Future research should involve large trials of positions that women can maintain and predefined endpoints. One large trial is ongoing.

Evaluation of pelvic floor symptoms and sexual function in primiparous women who underwent operative vaginal delivery versus cesarean delivery for second-stage arrest

OBJECTIVES

This study aimed to compare the prevalence and severity of pelvic floor symptoms and sexual function at 1 year postpartum in women who underwent either operative vaginal delivery (OVD) or cesarean delivery (CD) for second-stage arrest.

METHODS

In this cohort study, women with second-stage arrest in their first pregnancy who delivered between January 2009 and May 2011 at 2 different institutions were identified by an obstetric database using International Classification of Diseases, Ninth Revision, codes. Validated questionnaires evaluating pelvic floor symptoms and sexual function were administered. Subjects were dichotomized into those who underwent an OVD or a CD. Additional analyses by intent-to-treat and stratification of vacuum versus forceps operative deliveries were performed.

RESULTS

Of the 109 women who completed the 1-year postpartum symptom questionnaires, 53 (48.6%) had a successful OVD, 20 (18.3%) failed OVD and underwent CD, and 36 (33%) underwent CD only. There were no differences between those who had a successful OVD and those who underwent a CD in either pelvic floor function or sexual function, but bulge symptoms were more common in the OVD group (7.5% vs 0, P = 0.05). When analyzed by intent-to-treat (planned OVD vs planned CD), pelvic floor symptoms remained similar between groups. However, those in the planned CD group reported higher orgasm and overall sexual satisfaction scores.

CONCLUSIONS

In this sample of primiparous women with second-stage arrest, mode of delivery did not significantly impact pelvic floor function 1 year after delivery, except for bulge symptoms in the OVD group and sexual satisfaction in the planned CD group.

First do no harm: interventions during childbirth

Although medical and technological advances in maternity care have drastically reduced maternal and infant mortality, these interventions have become commonplace if not routine. Used appropriately, they can be life-saving procedures. Routine use, without valid indications, can transform childbirth from a normal physiologic process and family life event into a medical or surgical procedure. Every intervention presents the possibility of untoward effects and additional risks that engender the need for more interventions with their own inherent risks. Unintended consequences to intrapartum interventions make it imperative that nurse educators work with other professionals to promote natural childbirth processes and advocate for policies that focus on ensuring informed consent and alternative choices. Interdisciplinary collaboration can ensure that intrapartum caregivers "first do no harm."

Trial of instrumental delivery in theatre versus immediate caesarean section for anticipated difficult assisted births

BACKGROUND

The majority of women have spontaneous vaginal births, but some women need assistance in the second stage with delivery of the baby, using either the obstetric forceps or vacuum extraction. Rates of instrumental vaginal delivery range from 5% to 20% of all births in industrialised countries. The majority of instrumental vaginal deliveries are conducted in the delivery room, but in a small proportion (2% to 5%), a trial of instrumental vaginal delivery is conducted in theatre with preparations made for proceeding to caesarean section.

OBJECTIVES

To determine differences in maternal and neonatal morbidity between women who, due to anticipated difficulty, have trial of instrumental vaginal delivery in theatre and those who have immediate caesarean section for failure to progress in the second stage.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 June 2012).

SELECTION CRITERIA

Randomised controlled trials comparing trial of instrumental vaginal delivery (vacuum extraction or forceps) in operating theatre to immediate caesarean section for women with failure to progress in the second stage (active second stage more than 60 minutes in primigravidae).

DATA COLLECTION AND ANALYSIS

We identified no studies meeting our inclusion criteria.

MAIN RESULTS

No studies were included.

AUTHORS' CONCLUSIONS

There is no current evidence from randomised trials to influence practice.

Prevalence, incidence and obstetric factors' impact on female urinary incontinence in Europe: a systematic review

OBJECTIVES

A systematic review of the published data on the prevalence, incidence and risk factors of female urinary incontinence (UI) and obstetric treatment of UI in Europe.

DATA SOURCES

Epidemiologic studies were sought via PubMed to identify articles published in English, French, Spanish, German and Italian between 2000 and September 30, 2010, in Europe.

RESULTS

The prevalence of UI ranged from 14.1 to 68.8% and increased with increasing age. Significant risk factors for UI in pregnancy were maternal age ≥35 years and initial body mass index, a family history of UI and parity. UI in women who delivered 'at term' ranged from 26 to 40.2%, with a remission rate of 3 months after childbirth of up to 86.4%. Pelvic floor muscle training may help to prevent postpartum UI in primiparous women without UI during pregnancy.

CONCLUSION

UI definition, outcome measures, survey methods and validation criteria are still heterogeneous, and thus it is difficult to compare data and impossible to draw definite conclusions.

Menopause and obstetric history as risk factors for fecal incontinence in women

BACKGROUND

Fecal incontinence is a highly prevalent condition, especially in women. However, few data on prevalence in women attending primary care are available, particularly regarding the presence of risk factors.

OBJECTIVE

The aim of this study was to determine characteristics of women with fecal incontinence and to analyze obstetric history and menopause as potential risk factors.

DESIGN

Observational study with a cross-sectional design.

SETTINGS

Patients in primary care at 10 health care centers in Barcelona, Spain.

MAIN OUTCOME MEASURES

Fecal incontinence was defined as loss of flatus or liquid/solid stool occurring at least monthly. Data on the following variables were collected by face-to-face interviews and patient questionnaires: demographic and clinical characteristics, obstetric history, menopause data, fecal incontinence, and quality of life. Univariable and multivariable analyses were performed to study the association of potential risk factors with fecal incontinence.

RESULTS

The study included 332 women with a mean age of 60.8 (SD, 17.8) years. The prevalence of fecal incontinence was 12.0% (40/332). Flatus incontinence was reported in 27 patients (67.5%), liquid stool incontinence in 25 (62.5%), and solid stool incontinence in (19) 47.5%. On multivariable analysis, the only independent risk factors for fecal incontinence were an obstetric history of complicated deliveries (instrumentation or podalic presentation; OR, 3.66; 95% CI, 1.54-8.68, P = .003) and menopause (OR, 5.67; 95% CI, 1.35-23.78; P = .018).

LIMITATIONS

The cross-sectional design hampered identification of the time at which the impact of menopausal status occurred, and data obtained from patient interviews was subject to recall bias.

CONCLUSIONS

Complicated deliveries are risk factors for fecal incontinence in women. Fecal incontinence appears to be more prevalent in menopausal women.

Prevalence of pelvic floor disorders in the female population and the impact of age, mode of delivery, and parity

PURPOSE

Dysfunction of pelvic floor may cause many different symptoms, such as urinary and anal incontinence, obstructed defecation and constipation. No previous studies have examined all of these symptoms together. The purposes of the present study were to determine prevalence of pelvic floor disorders among the female population and to evaluate the impact of age, parity, and mode of delivery on these disorders.

METHODS

The study was performed on a general population of Turkish women. Women were excluded who were pregnant, who were within 6 months postpartum, who had cognitive disorders or neurological diseases, and who had a history of previous gastrointestinal, anorectal, or gynecological surgery. A questionnaire about urinary incontinence, anal incontinence, constipation, and obstructed defecation along with an extensive obstetric history was administered to 4002 women in face-to-face interviews. All symptoms were defined according to the standard terminology.

RESULTS

The median age of the participants was 41 years (range, 15-86). Of the women interviewed, 1067 had no deliveries, 434 women delivered by cesarean only, and 2501 women had one or more vaginal deliveries. Five hundred thirty women had delivered one child, 1880 women had delivered 2 to 3 children, and 582 women had delivered ≥4 children. Overall, 67.5% of women experienced pelvic floor dysfunction of at least one major type. The prevalence of each pelvic floor disorder evaluated in this study was as follows: anal incontinence, 19.8%; urinary incontinence, 50.7%; constipation, 33.2%; and obstructed defecation, 26.8%. Analysis of risk factors demonstrated that age was the major factor associated with the development of pelvic floor dysfunction. Vaginal delivery and higher parity increased the risk of both urinary and defecatory symptoms of pelvic floor dysfunction.

CONCLUSION

The study data demonstrate that pelvic floor dysfunction is a common problem among women and it is strongly linked to childbirth and aging.

Trial of instrumental delivery in theatre versus immediate caesarean section for anticipated difficult assisted births

BACKGROUND

The majority of women have spontaneous vaginal births, but some women need assistance in the second stage with delivery of the baby, using either the obstetric forceps or vacuum extraction. Rates of instrumental vaginal delivery range from 5% to 20% of all births in industrialised countries. The majority of instrumental vaginal deliveries are conducted in the delivery room, but in a small proportion (2% to 5%), a trial of instrumental vaginal delivery is conducted in theatre with preparations made for proceeding to caesarean section.

OBJECTIVES

To determine differences in maternal and neonatal morbidity between women who, due to anticipated difficulty, have trial of instrumental vaginal delivery in theatre and those who have immediate caesarean section for failure to progress in the second stage.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2008).

SELECTION CRITERIA

Randomised controlled trials comparing trial of instrumental vaginal delivery (vacuum extraction or forceps) in operating theatre to immediate caesarean section for women with failure to progress in the second stage (active second stage more than 60 minutes in primigravidae).

DATA COLLECTION AND ANALYSIS

We identified no studies meeting our inclusion criteria.

MAIN RESULTS

No studies were included.

AUTHORS' CONCLUSIONS

There is no current evidence from randomised trials to influence practice.

Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review

OBJECTIVES

To assess if mode of delivery is associated with increased symptoms of anal incontinence following childbirth.

DESIGN

Systematic review of all relevant studies in English.

DATA SOURCES

Medline, Embase, Cochrane Library, bibliographies of retrieved primary articles and consultation with experts.

STUDY SELECTION AND DATA EXTRACTION

Data were extracted on study characteristics, quality and results. Exposure to risk factors was compared between women with and without anal incontinence. Categorical data in 2 x 2 contingency tables were used to generate odds ratios.

RESULTS

Eighteen studies met the inclusion criteria with 12,237 participants. Women having any type of vaginal delivery compared with a caesarean section have an increased risk of developing symptoms of solid, liquid or flatus anal incontinence. The risk varies with the mode of delivery ranging from a doubled risk with a forceps delivery (OR 2.01, 95% CI 1.47-2.74, P < 0.0001) to a third increased risk for a spontaneous vaginal delivery (OR 1.32, 95% CI 1.04-1.68, P = 0.02). Instrumental deliveries also resulted in more symptoms of anal incontinence when compared with spontaneous vaginal delivery (OR 1.47, 95% CI 1.22-1.78). This was statistically significant for forceps deliveries alone (OR 1.5, 95% CI 1.19-1.89, P = 0.0006) but not for ventouse deliveries (OR 1.31, 95% CI 0.97-1.77, P = 0.08). When symptoms of solid and liquid anal incontinence alone were assessed, these trends persisted but were no longer statistically significant.

CONCLUSION

Symptoms of anal incontinence in the first year postpartum are associated with mode of delivery.

Urinary and anal incontinence in African American teenaged gravidas during pregnancy and the puerperium

STUDY OBJECTIVE

To determine the prevalence of urinary and anal incontinence during pregnancy and immediately postpartum in a convenience sample of African American teenaged women in an urban setting and to assess for an association between this incontinence and obstetrical risk factors.

METHODS

74 African American adolescents, ages 14-19, participated in the study. During third trimester prenatal visits and at 6 weeks postpartum, participants completed the Wexner Continence Grading Scale and Urogenital Distress Inventory Short Form (UDI-6). Chart abstraction was conducted for other relevant history.

RESULTS

Seventy-eight percent (58/74) of the adolescents were followed for the duration of the study; 22% were lost to follow-up. Incontinence was defined by a positive response on either questionnaire, irrespective of severity. In the third trimester, 44% of patients complained of urinary urge incontinence and 43% of stress incontinence; 12% complained of fecal and 41% of flatal incontinence. At six weeks postpartum, only 9% complained of urge incontinence and 5% of stress symptoms. Similarly, fecal incontinence decreased to 4% and flatal incontinence to 9%. Postpartum, the rate of flatal incontinence in the women who underwent instrumental deliveries was significantly increased when compared to those who had a spontaneous vaginal delivery or cesarean section (OR 12, P = 0.04).

CONCLUSION

Urinary and anal incontinence is present in this convenience sample of pregnant African American teenagers and should be addressed during pregnancy and the puerperium. Instrumental delivery significantly increased the risk of flatal incontinence postpartum in this population.

Operative vaginal delivery and the use of episiotomy—A survey of practice in the United Kingdom and Ireland

OBJECTIVE

To establish the views and current practice of obstetricians with regard to operative vaginal delivery and the use of episiotomy.

STUDY DESIGN

A national survey of consultant obstetricians and specialist registrars practising in the United Kingdom and Ireland registered with the Royal College of Obstetricians and Gynaecologists (RCOG), London. A postal questionnaire was sent to all obstetricians with two subsequent reminders to non-responders. The choice of procedure for specific circumstances, instrument preference, use of episiotomy and views on the relationship between episiotomy use and anal sphincter tears at operative vaginal delivery were explored.

RESULTS

The response rate was 80.4%. Instrument preference varied according to the fetal position and station and the grade of operator. Vacuum and forceps were both used for mid-cavity non-rotational deliveries (64% and 56% reported frequent use respectively). Rotational vacuum was preferred for a mid-cavity mal-position (69%) followed by equal numbers using rotational forceps or manual rotation and forceps (34% and 36%, respectively). Inexperienced operators were more likely to proceed directly to caesarean section (35%). A restrictive approach to use of episiotomy was preferred for vacuum delivery (72%) and a routine approach for forceps (73%). Obstetricians varied greatly in their perception of the relationship between episiotomy use and anal sphincter tears at operative vaginal delivery.

CONCLUSION

There is wide variation in the use of episiotomy at operative vaginal delivery with uncertainty about its role in preventing anal sphincter tears. A randomised controlled trial would address this important aspect of obstetric care.

Symptoms of anal and urinary incontinence following cesarean section or spontaneous vaginal delivery

OBJECTIVE

The objective of the study was to compare the prevalence of incontinence disorders in relation with spontaneous vaginal delivery or cesarean section.

STUDY DESIGN

Two hundred women with spontaneous vaginal deliveries only were compared with 195 women with cesarean deliveries only 10 years after first delivery.

RESULTS

When compared with cesarean section, vaginal delivery was associated with an increased frequency of stress urinary incontinence (P = .006) and an increased use of protective pads (P = .008) as well as an increased frequency of fecal urgency (P = .048) and gas incontinence (P = .01). At multivariate regression analysis, mode of delivery showed no significant association with incontinence symptoms other than an increased risk for flatus incontinence in women with a history of obstetric anal sphincter injury (odds ratio 3.1; 95% confidence interval, 1.5 to 8.9).

CONCLUSION

Incontinence symptoms are more common following spontaneous vaginal delivery when compared with cesarean section 10 years after first delivery. However, cesarean section is not associated with a major reduction of anal and urinary incontinence.

A urogynecologist's view ofthe pelvic floor effects of vaginal delivery/cesarean section for the urologist

Pregnancy and parturition have been implicated in the development of pelvic floor dysfunction. These disorders include urinary incontinence, fecal incontinence, pelvic organ prolapse, and other pelvic and sexual dysfunctions. The urologist caring for women with urinary dysfunction needs to be familiar with the causes of pelvic floor dysfunction and their implications. Defects of the pelvic floor have clearly resulted from the traumatic effect of vaginal delivery. The likely mechanisms of injuries during vaginal delivery involve stretching and compression of the pudendal nerve and peripheral branches, as well as an additional tearing of muscles and connective tissue. Optimal management of labor and optimal techniques of repair of unavoidable sphincteric lacerations, ante- and postpartum pelvic floor muscle conditioning, and timely and proper indications for cesarean delivery will minimize the effect of incidental traumatic delivery.

Chart Documentation of Informed Consent for Operative Vaginal Delivery: Is It Adequate?

OBJECTIVES

To determine the documentation frequency of informed consent for women undergoing a trial of nonemergent instrumental delivery.

STUDY DESIGN

A retrospective chart review of instrumented vaginal deliveries from 1992 to 2005 was performed. Cases were identified from a Labor and Delivery database and hospital records were reviewed for documentation of associated risks, general consent for the procedure, indication, and option of cesarean delivery (CD).

RESULTS

Three hundred forty six charts were reviewed: 246 were excluded for an emergency delivery (19%), misclassification (25%), or lost notes (27%). In the remaining 100 cases, 61% had a general consent for instrumented vaginal delivery. Documentation of any maternal or neonatal risks was found in 3% and 0%, respectively. The option of a cesarean delivery was documented in 22% of the cases. When comparing 5-year time intervals before and after 2000, there was no increased frequency in documentation of maternal or neonatal risks.

CONCLUSIONS

Documentation of informed consent for instrumented vaginal delivery is inconsistent and should be improved.

Risk of urinary incontinence after childbirth: a 10-year prospective cohort study

OBJECTIVE

To estimate prospectively the effect of first delivery on subjective bladder function and to assess the influence of subsequent deliveries and obstetric events

METHODS

We performed a prospective, observational cohort study. During a 10-week period in 1995, 304 of 309 eligible primiparous women (98%) entered the study at the postpartum maternity ward and completed a bladder function questionnaire. The 10-year observational period was completed by 246 of 304 subjects (81%).

RESULTS

Prevalence of moderate-severe stress urinary incontinence increased from 5 of 304 subjects (2%) at baseline to 27 of 229 (12%) at 10 years follow-up (P < .001). Prevalence of moderate-severe urinary urgency increased from 0 subjects (0%) at baseline to 31 of 229 (13%) at the 10-year follow-up (P < .001). The relative risk (RR) (adjusted for maternal age and parity) of moderate to severe urinary incontinence increased significantly 10 years after first delivery (RR 5.8, 95% confidence interval [CI] 1.2-33.7). At multivariable analysis adjusted for age and parity, stress urinary incontinence symptoms at 9 months and 5 years follow-up were independently associated with the presence of symptoms at 10 years after index delivery (RR 13.3, 95% CI 3.9-33.1 and RR 14.1, 95% CI 2.5-18.8, respectively). Number of vaginal deliveries or other obstetric covariates did not affect the risk of stress urinary incontinence or urinary urgency.

CONCLUSION

Vaginal delivery is independently associated with a significant long-term increase in stress urinary incontinence symptoms, as well as urinary urgency, regardless of maternal age or number of deliveries.

LEVEL OF EVIDENCE

II-2.

Sexual function and childbirth

OBJECTIVE

This manuscript reviews the potential impact of cesarean delivery on maternal sexual function.

FINDING

The majority of new mothers resume intercourse within the first 3 months after delivery. However, during the first year after delivery, the majority of women experience at least one problem related to sexual function. The question with respect to maternal-choice cesarean is whether this obstetrical intervention affects maternal sexual function. We review the available evidence regarding sexual function after cesarean delivery and present several plausible mechanisms by which route of delivery could impact long-term postpartum sexual function.

CONCLUSION

Further research is needed to investigate whether maternal-choice cesarean delivery affects female sexual function.

The Ottawa Hospital’s Clinical Practice Guidelinefor the Second Stage of Labour

The management of the second stage of labour remains controversial, and there are very few comprehensive evidence-based clinical practice guidelines to assist care providers. We describe an approach to developing a local clinical practice guideline that included extensive review of the literature; use of a guideline appraisal instrument to assess methodological rigour, content, clarity and applicability; use of a recommendation matrix; drafting a local guideline; obtaining formal feedback; making revisions; and designing an implementation and evaluation plan. Recommendations from this guideline include timelines for the total length of second stage, waiting time, and pushing time. Positioning of the woman, use of oxytocin, and fetal assessment are also discussed. This guideline is not intended to be used for women with multiple gestation and women attempting vaginal birth after Caesarean (VBAC) or in clinical situations where little evidence on best practice exists and management is individualized. We advocate an approach to the second stage of labour that enhances patient safety through team planning, communication, and documentation.

Complications associated with cesarean section in the second stage of labor

OBJECTIVE

To determine maternal and neonatal complications associated with cesarean section done in the second stage of labor.

METHOD

Cohort study comparing cesarean sections done in the second stage of labor (cases) with those done for poor progress in the first stage (controls). Only singleton cephalic live pregnancies at 36 weeks or more, without previous cesarean section, were included.

RESULT

There were 39 cases and 39 controls. Cesarean section in the second stage of labor took significantly longer (median 45 vs. 30 min; P<0.001), and was associated with more frequent postoperative pyrexia (10 vs. 2; P=0.012). There were more neonatal admissions in the case group (17 vs. 3; P<0.001). Hypoxic ischemic encephalopathy was more frequent in infants following second-stage cesarean section (8 vs. 1; P=0.013), as was subaponeurotic hemorrhage (6 vs. 0; P=0.012).

CONCLUSION

Cesarean section in the second stage of labor is associated with significant intraoperative and neonatal morbidity.

Women's health 18 years after rupture of the anal sphincter during childbirth: II. Urinary incontinence, sexual function, and physical and mental health

OBJECTIVE

We studied maternal health 18 years postpartum in women having sustained an anal sphincter tear and controls.

STUDY DESIGN

We assessed symptoms with the short form of the urogenital distress inventory, the female sexual function index, and physical and mental health with the Short Form-12 summary scales.

RESULTS

Women with a sphincter tear had no increased risk of urinary symptoms (54 of 251, 22%, versus 51 of 273, 19%, risk ratio 1.2, 95% confidence interval 0.8 to 1.6) or sexual symptoms (84 of 223, 38%, versus 90 of 230, 39%, risk ratio 1.0, 95% confidence interval 0.8 to 1.2). Their physical health was also similar to controls (mean score +/- SD, 47 +/- 7 versus 47 +/- 6), whereas their mental health was slightly lower (score 45 +/- 6 versus 46 +/- 6, difference 1, 95% confidence interval 0 to 2, P = .05).

CONCLUSION

Women who sustained an anal sphincter tear have no more urinary or sexual symptoms 18 years after delivery.

Maternal health study: a prospective cohort study of nulliparous women recruited in early pregnancy

Background

In the first year after childbirth, 94% of women experience one or more major health problems (urinary incontinence, faecal incontinence, perineal pain, back pain). Difficulties in intimate partner relationships and changes affecting sexual health are also common. The aim of this study is to investigate changes in women's health from early pregnancy until four years after the birth of a first child.

Methods/design

The Maternal Health Study is a longitudinal study designed to fill in some of the gaps in current research evidence regarding women's physical and psychological health and recovery after childbirth. A prospective pregnancy cohort of >1500 nulliparous women has been recruited in early pregnancy at six metropolitan public hospitals in Melbourne, Australia between April 2003 and December 2005. In the first phase of the study participants are being followed up at 30–32 weeks gestation in pregnancy, and at three, six, nine, 12 and 18 months postpartum using a combination of self-administered questionnaires and telephone interviews. Women consenting to extended follow-up (phase 2) will be followed up six and 12 months after any subsequent births and when their first child is four years old. Study instruments incorporate assessment of the frequency and severity of urinary and bowel symptoms, sexual health issues, perineal and abdominal pain, depression and intimate partner violence. Pregnancy and birth outcome data will be obtained by review of hospital case notes.

Discussion

Features of the study which distinguish it from prior research include: the capacity to identify incident cases of morbidity and clustering of health problems; a large enough sample to detect clinically important differences in maternal health outcomes associated with the method of birth; careful exposure measurement involving manual abstraction of data from medical records in order to explore mediating factors and possible causal pathways; and use of a variety of strategies to improve ascertainment of health outcomes.

Pelvic floor morbidity at 3 years after instrumental delivery and cesarean delivery in the second stage of labor and the impact of a subsequent delivery

OBJECTIVE

To compare pelvic floor symptoms at three years following instrumental delivery and cesarean section in the second stage of labor and to assess the impact of a subsequent delivery.

STUDY DESIGN

We conducted a prospective cohort study of 393 women with term, singleton, cephalic pregnancies who required instrumental vaginal delivery in theatre or cesarean section at full dilatation between February 1999 and February 2000. 283 women (72%) returned postal questionnaires at three years.

RESULTS

Urinary incontinence at three years post delivery was greater in the instrumental delivery group as compared to the cesarean section group (10.5% vs 2.0%), OR 5.37 (95% CI, 1.7, 27.9). There were no significant differences in ano-rectal or sexual symptoms between the two groups. Pelvic floor symptoms were similar for women delivered by cesarean section after a failed trial of instrumental delivery compared to immediate cesarean section. A subsequent delivery did not increase the risk of pelvic floor symptoms at three years in either group.

CONCLUSION

An increased risk of urinary incontinence persists up to three years following instrumental vaginal delivery compared to cesarean section in the second stage of labor. However, pelvic floor symptoms are not exacerbated by a subsequent delivery.