Périnée et grossesse

[Anal incontinence and obstetrical anal sphincter injuries, epidemiology and prevention]

Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.

[Cultural adaptation of the female pelvic floor questionnaire (FPFQ) into French]

AIMS

The Female Pelvic Floor Questionnaire (FPFQ) is a self-administered tool on pelvic floor function. Our aim was to carry out a cultural adaptation of the FPFQ into French and to assess its psychometric properties.

METHODS

After cross-cultural adaptation into French, acceptability and reliability of the questionnaire were assessed through a sample of 56 women in a test-retest. Discriminative construct validity was evaluated by comparing the results obtained by the FPFQ to those of other validated questionnaires. Longitudinal follow-up of the 282 pregnant women included in the PreNatal Pelvic floor Prevention trial (3PN) was used to analyze responsiveness.

RESULTS

The proportion of missing data did not exceed 4 % for questions about bladder function, bowel function and pelvic organ prolapse; 10 % for issues related to sexual function. Question 9 was considered difficult to understand by 14 % of women. After rewriting, this issue was retested in a new sample of 52 women and presented no further problems. The intra-class correlation coefficient was greater than or equal to 0.7 for all domains during the test-retest. The FPFQ was strongly and significantly correlated (Spearman r>0.5) with the other validated questionnaires. The French version of FPFQ recorded changes in urinary and sexual symptoms for the women involved in 3PN trial with a standardized response mean equal to 0.83 and 0.44, respectively.

CONCLUSION

The French version of the FPFQ is self-administered, reliable, valid, and can detect a change in symptoms during follow-up.

LEVEL OF EVIDENCE

Level 4.

Cultural adaptation of the female pelvic floor questionnaire (FPFQ) into French

AIMS

The Female pelvic floor questionnaire (FPFQ) is a self-administered tool on pelvic floor function. Our aim was to carry out a cultural adaptation of the FPFQ into French and to assess its psychometric properties.

METHODS

After cross-cultural adaptation into French, acceptability and reliability of the questionnaire were assessed through a sample of 56 women in a test-retest. Discriminative construct validity was evaluated by comparing the results obtained by the FPFQ to those of other validated questionnaires. Longitudinal follow-up of the 282 pregnant women included in the PreNatal Pelvic floor Prevention trial (3PN) was used to analyze responsiveness.

RESULTS

The proportion of missing data did not exceed 4% for questions about bladder function, bowel function, and pelvic organ prolapse; 10% for issues related to sexual function. Question 9 was considered difficult to understand by 14% of women. After rewriting, this issue was retested in a new sample of 52 women and presented no further problems. The intra-class correlation coefficient was greater than or equal to 0.7 for all domains during the test-retest. The FPFQ was strongly and significantly correlated (Spearman r > 0.5) with the other validated questionnaires. The French version of FPFQ recorded changes in urinary and sexual symptoms for the women involved in 3PN trial with a standardized response mean equal to 0.83 and 0.44, respectively.

CONCLUSION

The French version of the FPFQ is self-administered, reliable, valid, and can detect a change in symptoms during follow-up. Neurourol. Urodynam. 36:253-258, 2017. © 2015 Wiley Periodicals, Inc.

Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor

Pelvic floor dysfunction (PFD), although seems to be simple, is a complex process that develops secondary to multifactorial factors. The incidence of PFD is increasing with increasing life expectancy. PFD is a term that refers to a broad range of clinical scenarios, including lower urinary tract excretory and defecation disorders, such as urinary and anal incontinence, overactive bladder, and pelvic organ prolapse, as well as sexual disorders. It is a financial burden on the health care system and disrupts women's quality of life. Strategies applied to decrease PFD are focused on the course of pregnancy, mode and management of delivery, and pelvic exercise methods. Many studies in the literature define traumatic birth, usage of forceps, length of the second stage of delivery, and sphincter damage as modifiable risk factors for PFD. Maternal age, fetal position, and fetal head circumference are nonmodifiable risk factors. Although numerous studies show that vaginal delivery affects pelvic floor structures and their functions in a negative way, there is not enough scientific evidence to recommend elective cesarean delivery in order to prevent development of PFD. PFD is a heterogeneous pathological condition, and the effects of pregnancy, vaginal delivery, cesarean delivery, and possible risk factors of PFD may be different from each other. Observational studies have identified certain obstetrical exposures as risk factors for pelvic floor disorders. These factors often coexist; therefore, the isolated effects of these variables on the pelvic floor are difficult to study. The routine use of episiotomy for many years in order to prevent PFD is not recommended anymore; episiotomy should be used in selected cases, and the mediolateral procedures should be used if needed.

Current approach to episiotomy: Inevitable or unnecessary?

An episiotomy is a surgical incision through the perineum made to provide sufficient area for the delivery of the infant. About 10 to 95% of women who deliver will have episiotomy depending on which part of the world they are having delivery.

Too early episiotomy causes extensive bleeding and too late episiotomy causes the excessive stretching of a pelvic floor and lacerations could not be prevented.

According to widely accepted arguments, there are many benefits of episiotomy for the neonate: prevention of injuries, shoulder dystocia and mental retardation of the infant. Benefits for the mother are: reduction of severe lacerations, prevention of sexual dysfunction, prevention of urinary and fecal incontinence. But those things could also be complications of episiotomy, if it is being used nonrestrictively. Some other complications are also extensive bleeding, hematoma or infection.

There are many different opinions in literature about using episiotomy restrictively or routinely, so it is the right doubt arisen: is it inevitable or unnecessary?

There is a wide variation in episiotomy practice, and the decision of performing it or not depends of actual clinical situation.

There is still a great need for continuous obstetrics education according to the evidence based guidelines for the patient’s safety.