Anal incontinence after vaginal delivery: a prospective study in primiparous women

The second stage of labor

The second stage of labor extends from complete cervical dilatation to delivery. During this stage, descent and rotation of the presenting part occur as the fetus passively negotiates its passage through the birth canal. Generally, descent begins during the deceleration phase of dilatation as the cervix is drawn upward around the fetal presenting part. The most common means of assessing the normality of the second stage of labor is to measure its duration, but progress can be more meaningfully gauged by measuring the change in fetal station as a function of time. Accurate clinical identification and evaluation of differences in patterns of fetal descent are necessary to assess second stage of labor progress and to make reasoned judgments about the need for intervention. Three distinct graphic abnormalities of the second stage of labor can be identified: protracted descent, arrest of descent, and failure of descent. All abnormalities have a strong association with cephalopelvic disproportion but may also occur in the presence of maternal obesity, uterine infection, excessive sedation, and fetal malpositions. Interpretation of the progress of fetal descent must be made in the context of other clinically discernable events and observations. These include fetal size, position, attitude, and degree of cranial molding and related evaluations of pelvic architecture and capacity to accommodate the fetus, uterine contractility, and fetal well-being. Oxytocin infusion can often resolve an arrest or failure of descent or a protracted descent caused by an inhibitory factor, such as a dense neuraxial block. It should be used only if thorough assessment of fetopelvic relationships reveals a low probability of cephalopelvic disproportion. The value of forced Valsalva pushing, fundal pressure, and routine episiotomy has been questioned. They should be used selectively and where indicated.

Factors affecting elective cesarean section in women with multiple pregnancy in Caruban, Indonesia

Background: Caesarean sections have become the most popular method for delivering twin babies because of the safety concerns associated with a natural birth. This study aims to identify the maternal characteristics and obstetric parameters that serve as risk factors influencing caesarean delivery in twin pregnancies by comparing women delivering via caesarean section and vaginal birth. Methods: A retrospective chart review design was used to analyse 47 women with multiple pregnancies from the medical records at a primary referral hospital in East Java, Indonesia. Women delivering vaginally were then compared with women who underwent a caesarean section to identify any differences between the groups. Results: In our study, more women delivered by caesarean section (n=35) than by vaginal birth (n=12). Women were more likely to undergo a caesarean section if they had a previous history of undergoing a caesarean section (OR 16.5; 95% CI 1.91-142.49; p=0.02). Similar to previous studies, we found that foetal malpresentation significantly increase the risk of caesarean delivery (OR 8.25; 95%CI 0.95-71.09; p=0.03), while labour augmentation decrease the likelihood of caesarean section (OR 0.20; 95% CI 0.49-0.81; p=0.03). There was also a significant older patients in the caesarean section groups (OR 1.26; 95% CI 1.09-1.45 ; p=0.00). Conclusions: The percentage of multiple pregnancies delivered via caesarean section is quite high. Other larger cohort study are warranted, since many factors were involved in the decision of caesarean section.

Pregnancy- and obstetric-related risk factors for urinary incontinence, fecal incontinence, or pelvic organ prolapse later in life: A systematic review and meta-analysis

INTRODUCTION

Risk factors for pelvic floor disorders are often related to pregnancy and delivery. Consistent evidence is needed to develop prevention strategies targeting risk factors. The objective of this study is to identify which pregnancy- and/or obstetric-related risk factors can predict urinary incontinence, fecal incontinence, or pelvic organ prolapse later in life by means of a systematic review and meta-analysis.

MATERIAL AND METHODS

Systematic review Prospero number: CRD42019131758. Literature searches of PubMed, EMBASE, CINAHL, and Cochrane Library were conducted according to PRISMA guidelines (April 2020). Prospective cohort studies describing more than two pregnancy- and/or obstetric-related risk factors on urinary incontinence, fecal incontinence (including flatal incontinence), or pelvic organ prolapse were eligible. Risk of bias was assessed (using Quality In Prognosis Studies [QUIPS]). Studies with high risk of bias were excluded. Data were extracted and checked for accuracy with the CHARMS checklist. Sub-groups were used to distinguish between a short- and long-term follow-up period: <18 months (shortterm) and >18 months (long-term) postpartum. Odds ratios were calculated from reported prevalence rates. Log odds ratios were calculated using SPSS v.24. Variables were pooled using RevMan5.

RESULTS

Data were extracted from nineteen studies for urinary incontinence, nine for fecal incontinence, and two for pelvic organ prolapse. Multivariate analysis was not possible because of the heterogeneity of the population and outcome measures. Pooled univariate risk factors for urinary incontinence were: urinary incontinence during pregnancy, instrumental vaginal delivery, episiotomy, tears, and constipation. Pooled univariate risk factors for fecal incontinence were: fecal incontinence during pregnancy, maternal age over 35 years, prenatal body mass index over 30 kg/m² , instrumental vaginal delivery, a spontaneous vaginal delivery, oxytocin augmentation, and when the weight of the newborn was more than 4000 g. Both studies for pelvic organ prolapse had a short-term follow-up period and cesarean section was the only risk factor that could be pooled.

CONCLUSIONS

Pregnancy- and obstetric-related risk factors predicting pelvic floor disorders postpartum are multifactorial and differ between pelvic floor disorders. The strongest risk factor for incontinence later in life was incontinence during pregnancy. Better quality research with long-term follow up is needed on this topic.

Accuracy of clinical diagnosis of anal sphincter defect: clinical evaluation versus 3D-transperineal ultrasound

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are common and an important factor in the etiology of anal incontinence. The objective of this study was to evaluate, classify and compare the agreement of clinically diagnosed third-degree sphincter tears with 3D-transperineal ultrasound (3D-TPUS) realized within 3-7 days post-delivery.

METHODS

This is a retrospective observational study were 119 patients with third-degree obstetric anal sphincter tears were diagnosed and treated, 85 of those underwent a 3D-TPUS examination 3-7 days postpartum. We compared the proportion of third-degree perineal tears, classified with the clinical examination as grade 3a+b and grade 3c, with the 3D-TPUS.

RESULTS

In 16 patients with clinically diagnosed third-degree perineal tears grade a and b, the ultrasound examination confirmed the lesion of the external anal sphincter (EAS) muscle, but in nine patients (56% of the cases) we found a lesion of the internal anal sphincter (IAS) muscle, missed by clinical examination. In the remaining 69 patients with the third-degree perineal tears grade c, the ultrasound examination confirmed both lesions (EAS and IAS muscles) in 56 women, but in 13 patients (19% of the cases) defects of the IAS muscle could not be confirmed by the ultrasound.

CONCLUSIONS

There was moderate agreement regarding diagnosis of grade 3a+b and grade c perineal tears between ultrasound and clinical examination, so a combined use of clinical and ultrasound knowledge can improve the possibility to find a gold standard in the diagnosis of OASIS.

Cesarean delivery to prevent anal incontinence: a systematic review and meta-analysis

BACKGROUND

Cesarean delivery (CD), is increasingly recommended as a mode of delivery that prevents the anal incontinence (AI) that arises in some women after vaginal delivery (VD). The assessment of the efficacy of CD in this regard was the subject of this systematic review.

METHODS

Searches were conducted in Medline, EMBASE and the Cochrane Library. Both randomized (RCTs) and non-randomized trials (NRTs) comparing the risk of sustained fecal and/or flatus incontinence after VD or CD were sought from 1966 to 1 January, 2019. Studies were eligible if they assessed AI more than 6 months after birth, and had statistical adjustment for at least one of the three major confounders for AI: age, maternal weight or parity. In addition, each study was required to contain more than 250 participants, more than 50 CDs and more than 25 cases of AI. Data after screening and selection were abstracted and entered into Revman for meta-analysis. Analyses were done for combined fecal and flatus incontinence (comAI), fecal incontinence (FI), gas incontinence (GI), CD before or during labor, time trend of incontinence after delivery, assessment of both statistical and clinical heterogeneity, parity and late incident AI.

RESULTS

Out of the 2526 titles and abstracts found, 24 eligible studies were analyzed, 23 NRTs and one RCT. These included women with 29,597 VDs and women with 6821 CDs. Among the primary outcomes, VD was found not to be a significant predictor of postpartum comAI compared to CD in 6 studies, incorporating 18,951 deliveries (OR = 0.74; 0.54-1.02). VD was also not a significant predictor of FI in 14 studies, incorporating 29,367 deliveries, (OR = 0.89; 0.76-1.05). VD was not a significant predictor of GI in six studies, incorporating 6724 deliveries (OR = 0.96; 0.79-1.18). The strength of the grading of recommendations, assessment, development and evaluations (GRADE) evidence for each of these was low for comAI and moderate for FI and GI (upgrade for lack of expected effect). Time trend FI showed incontinence at 3 months often resolved at 1 year. Other secondary analyses assessing parity, delayed incidence of FI, clinical and statistical heterogeneity, spontaneous VD only, late risk of incidence of AI, and CD in or prior to labor all had similar results as in the primary outcomes.

CONCLUSIONS

There are three components of pelvic floor dysfunction that are thought to be caused by VD and hopefully prevented by CD: AI, urinary incontinence and pelvic floor prolapse. Of these, AI was not found to be reliably prevented by CD in this review.

Incidence of Obstetric Anal Sphincter Injuries After Training to Protect the Perineum

OBJECTIVES

Obstetric anal sphincter injuries (OASISs) are a devastating postpartum complication; reducing rates is paramount to improving quality of care. In Norway, implementation of a perineal protection program decreased the incidence of OASIS by 48%. We sought to assess impact on OASIS rates following a similar program.

METHODS

This institutional review board-approved, retrospective cohort study was performed in an academic hospital system. The periods of analysis were November 2014 through October 2015 for the preintervention arm and November 2015 through October 2016 for the postintervention arm. From November 2 to 6, 2015, 2 Norwegian experts conducted a didactic and hands-on, on-site workshop focusing on perineal protection. The experts were then present on labor and delivery wards to reinforce perineal protection in live deliveries. Teachings were emphasized at departmental meetings for the remainder of the year. Data were extracted from electronic medical records and manually audited.

RESULTS

The rate of vaginal delivery was similar among both periods (6504 and 6650; P = 0.059). Obstetric anal sphincter injury rates decreased from 211 (3.2%) preintervention to 189 (2.8%) after the workshop. Although this represented 32 fewer injuries, it was not statistically significant (P = 0.179). Obstetric anal sphincter injuries following forceps-assisted deliveries did decline significantly from 103 (28%) to 81 (21%) (P = 0.014). In addition, incidence of fourth-degree lacerations during resident deliveries decreased significantly from 10 (0.6%) to 3 (0.2%) (P = 0.047).

CONCLUSIONS

An educational workshop focusing on perineal support was not associated with a significant reduction in overall OASIS rates. Nevertheless, decreased forceps-related OASIS and fourth-degree lacerations rates support positive influence of the intervention.

A surgical technique for secondary repair of obstetric anal sphincter injuries; sphinctero-vagino-perineoplasty

Objective:

This study was conducted to present the preliminary results of seven patients treated with sphinctero-vagino-perineoplasty for secondary repair of obstetric anal sphincter injuries.

Materials and Methods:

This retrospective study was conducted on the records of seven patients who underwent secondary repair of obstetric anal sphincter injuries at the colorectal surgery unit of a tertiary care center between February 2015 and December 2017.

Results:

All patients with solid stool incontinence were fully recovered at postoperative month 3. The Wexner incontinence score was significantly improved (decreased from 14.12 [range: 8-20] to 2.28 [range: 1-4]). The complication rate was 85.7% (wound infection, abscess, hematoma, detachment).

Conclusion:

Combined repair of anal sphinchters, perineal body, superficial transverse perineal muscles, and bulbospongious muscles, which contribute to anal continence, may improve surgical outcomes in patients with obstetric anal sphincter injuries.

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.

Vibrating vaginal balls to improve pelvic floor muscle performance in women after childbirth: a protocol for a randomised controlled feasibility trial

AIM

This paper presents a feasibility trial protocol the purpose of which is to prepare for a future randomised controlled trial to determine the effectiveness of vibrating vaginal pelvic floor training balls for postpartum pelvic floor muscle rehabilitation.

BACKGROUND

Vibrating vaginal pelvic floor training balls are available in Austria to enhance women's pelvic floor muscles and thus prevent or treat urinary incontinence and other pelvic floor problems following childbirth. Nonetheless, there is currently little empirical knowledge to substantiate their use or assess their relative effectiveness in comparison to current standard care, which involves pelvic floor muscle exercises.

DESIGN

Single blind, randomised controlled feasibility trial with two parallel groups.

METHODS

It is planned to recruit 56 postpartum women in Vienna, who will be randomised into one of two intervention groups to use either vibrating vaginal balls or a comparator pelvic floor muscle exercises for 12 weeks. As this is a feasibility study, study design features (recruitment, selection, randomisation, intervention concordance, data collection methods and tools) will be assessed and participants' views and experiences will be surveyed. Tested outcome measures, collected before and after the intervention, will be pelvic floor muscle performance as reported by participants and measured by perineometry. Descriptive and inferential statistics and content analysis will serve the preparation of the future trial.

DISCUSSION

The results of this feasibility trial will inform the design and conduct of a full randomised controlled trial and provide insight into the experiences of women regarding the interventions and study participation.

Planned caesarean section for women with a twin pregnancy

BACKGROUND

Twin pregnancies are associated with increased perinatal mortality, mainly related to prematurity, but complications during birth may contribute to perinatal loss or morbidity. The option of planned caesarean section to avoid such complications must therefore be considered. On the other hand, randomised trials of other clinical interventions in the birth process to avoid problems related to labour and birth (planned caesarean section for breech, and continuous electronic fetal heart rate monitoring), have shown an unexpected discordance between short-term perinatal morbidity and long-term neurological outcome. The risks of caesarean section for the mother in the current and subsequent pregnancies must also be taken into account.

OBJECTIVES

To determine the short- and long-term effects on mothers and their babies, of planned caesarean section for twin pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 November 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials comparing a policy of caesarean section with planned vaginal birth for women with twin pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, quality and extracted data. Data were checked for accuracy. For important outcomes the quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included two trials comparing planned caesarean section versus planned vaginal birth for twin pregnancies.Most of the data included in the review were from a multicentre trial where 2804 women were randomised in 106 centres in 25 countries. All centres had facilities to perform emergency caesarean section and had anaesthetic, obstetrical, and nursing staff available in the hospital at the time of planned vaginal delivery. In the second trial carried out in Israel, 60 women were randomised. We judged the risk of bias to be low for all categories except performance (high) and outcome assessment bias (unclear).There was no clear evidence of differences between women randomised to planned caesarean section or planned vaginal birth for maternal death or serious morbidity (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.67 to 1.11; 2844 women; two studies; moderate quality evidence). There was no significant difference between groups for perinatal or neonatal death or serious neonatal morbidity (RR 1.15, 95% CI 0.80 to 1.67; data for 5565 babies, one study, moderate quality evidence). No studies reported childhood disability.For secondary outcomes there was no clear evidence of differences between groups for perinatal or neonatal mortality (RR 1.41, 95% CI 0.76 to 2.62; 5685 babies; two studies, moderate quality evidence), serious neonatal morbidity (RR 1.03, 95% CI 0.65 to 1.64; 5644 babies; two studies, moderate quality evidence) or any of the other neonatal outcomes reported.The number of women undergoing caesarean section was reported in both trials. Most women in the planned caesarean group had treatment as planned (90.9% underwent caesarean section), whereas in the planned vaginal birth group 42.9% had caesarean section for at least one twin. For maternal mortality; no events were reported in one trial and two deaths (one in each group) in the other. There were no significant differences between groups for serious maternal morbidity overall (RR 0.86, 95% CI 0.67 to 1.11; 2844 women; two studies) or for different types of short-term morbidity. There were no significant differences between groups for failure to breastfeed (RR 1.14, 95% CI 0.95 to 1.38; 2570 women, one study; moderate quality evidence) or the number of women with scores greater than 12 on the Edinbugh postnatal depression scale (RR 0.95, 95% CI 0.78 to 1.14; 2570 women, one study; moderate quality evidence).

AUTHORS' CONCLUSIONS

Data mainly from one large, multicentre study found no clear evidence of benefit from planned caesarean section for term twin pregnancies with leading cephalic presentation. Data on long-term infant outcomes are awaited. Women should be informed of possible risks and benefits of labour and vaginal birth pertinent to their specific clinical presentation and the current and long-term effects of caesarean section for both mother and babies. There is insufficient evidence to support the routine use of planned caesarean section for term twin pregnancy with leading cephalic presentation, except in the context of further randomised trials.

Planned caesarean section for women with a twin pregnancy

BACKGROUND

Twin pregnancies are associated with increased perinatal mortality, mainly related to prematurity, but complications during birth may contribute to perinatal loss or morbidity. The option of planned caesarean section to avoid such complications must therefore be considered. On the other hand, randomised trials of other clinical interventions in the birth process to avoid problems related to labour and birth (planned caesarean section for breech, and continuous electronic fetal heart rate monitoring), have shown an unexpected discordance between short-term perinatal morbidity and long-term neurological outcome. The risks of caesarean section for the mother in the current and subsequent pregnancies must also be taken into account.

OBJECTIVES

To determine the short- and long-term effects on mothers and their babies, of planned caesarean section for twin pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011).

SELECTION CRITERIA

Randomised trials comparing a policy of caesarean section with planned vaginal birth for women with twin pregnancy.

DATA COLLECTION AND ANALYSIS

Two researchers independently assessed eligibility, quality and extracted data. Data were checked for accuracy.

MAIN RESULTS

One small trial with unconfirmed allocation concealment compared caesarean section with planned vaginal birth in 60 women with vertex/non-vertex twin pregnancies. There were no differences in perinatal outcome. The trial was too small to exclude the possibility of clinically meaningful benefits of either approach. There is one additional trial currently ongoing.

AUTHORS' CONCLUSIONS

There is a lack of robust evidence to guide clinical advice regarding the method of birth for twin pregnancies. Women should be informed of possible benefits and risks of either approach, including short-term and long-term consequences for both mother and babies. Future research should aim to provide unbiased evidence, including long-term outcomes.

Biomechanics of the female pelvic floor: a prospective trail of the alteration of force-displacement-vectors in parous and nulliparous women

OBJECTIVE

We hypothesize that the holistic and multiplanar depiction of pelvic floor structures by dynamic MRI is of particular value in rendering information about the extent of functional changes that can lead to pelvic floor dysfunction.

METHODS

134 women were prospectively included for assessment of their pelvic floor function.

RESULTS

Study groups differed significantly in the direction of their force-displacement-vectors. A shift from ventral to dorsal is present depending on parity, mode of delivery and age. Maternal age and body height correlated to the force-displacement-vector, whereas maternal weight did not. Pressing direction proved to be dependent on the inclination of the pelvis and the aperture of the levator hiatus while remaining independent from the aperture of the abdominal wall.

CONCLUSION

Biomechanical data interpretation uncovered the pathogenetic relevance of progressive retroflection of the force-displacement-vector. This is responsible for the onset of a vicious cycle of trauma-related force deflection perpetuating pelvic floor traumatization.

Validation of the Wexner scale in women with fecal incontinence in a Turkish population

INTRODUCTION AND HYPOTHESIS

The main aim of this study was to validate the Turkish translated version of the Wexner scale.

METHODS

After establishing the test-retest reliability and internal consistency of the Turkish version of Wexner scale on 31 patients, total and subscale scores and anal manometric measurements of 60 participants were performed. Correlation between Wexner scale scores and manometric measurement values were analyzed and those values of patients with or without anal incontinence symptoms were compared.

RESULTS

Of the 60 participants, 47 (78%) showed no signs or symptoms of anal incontinence. Wexner scale showed a high internal consistency (Cronbach's alpha = 0.816). Total and each subscale score of Wexner scale showed strong correlation with resting and maximal squeeze pressures and between each other (p < 0.005). The pressure values were significantly less in asymptomatic patients compared to patients with any degree of symptoms (p < 0.05).

CONCLUSION

The Turkish translated version of the Wexner scale is a reliable, consistent, and valid instrument to evaluate anal functions in women with anal incontinence for Turkish speaking women. Total and subscale scores of the Wexner scale and anal manometric measurements showed significant correlation.

Evaluation of the incision angle of mediolateral episiotomy at 60 degrees

OBJECTIVE

To study the angle of mediolateral episiotomy at the time of cut, after primary repair, and 6 months postpartum; and the incidence and severity of perineal pain and anal incontinence 6 months after delivery.

METHODS

The study group comprised 60 consecutively recruited primiparous women who required episiotomy during delivery assisted by 2 obstetricians. The incision angle of episiotomy (defined as 60°) was measured before cutting, after primary repair, and after 6 months. At follow-up, perineal pain was evaluated by a verbal rating score; anal incontinence was assessed by St Mark's score.

RESULTS

The angles differed significantly among the incision (60°), repair (45°), and 6-month (48°) measurements (P < 0.001). There was a poor correlation between the suture angle and the angle measured at 6 months postpartum. No severe perineal tear was diagnosed in the cohort. At 6 months postpartum, only 1 woman reported mild symptoms of de novo anal incontinence, whereas 7 women reported perineal pain related to episiotomy.

CONCLUSION

An incision angle of mediolateral episiotomy of 60° resulted in a low incidence of anal sphincter tearing, anal incontinence and perineal pain. A randomized controlled trial is needed to assess the outcome when different angles of episiotomy are used.

Impaired rectal sensation at anal manometry is associated with anal incontinence one year after primary sphincter repair in primiparous women

PURPOSE

This study investigates the association between endoanal ultrasonography and anorectal manometry in relation to anal incontinence after primary repair of obstetric sphincter injury in primiparous, premenopausal women.

METHODS

The study population of this nested case-control study comprised 108 women who had previously been part of a randomized controlled trial comparing immediate with delayed primary repair of obstetric sphincter injuries, and who had been evaluated by anorectal manometry and endoanal ultrasound 1 year after their repair. Twenty cases and 88 controls were defined. Cases were defined as having a score greater than 2 on the Pescatori incontinence scale. Controls had a score of 2 or less. Ten obstetric, 9 ultrasonographic, and 7 manometric variables were studied.

RESULTS

Of the manometric variables, volume of first sensation and volume of first urge proved to be associated with anal incontinence at univariate statistical analysis. Volume of first sensation remained independently associated with anal incontinence after multivariate analysis. In addition, age, degree of tear, duration of second stage of labor, and a distal scar at ultrasound proved to be independently associated with anal incontinence.

CONCLUSIONS

Impaired rectal sensation at anorectal manometry and a distal scar at endoanal ultrasonography are associated with anal incontinence 1 year after primary sphincter repair in primiparous women. Additional studies need to evaluate whether these findings are associated with increased risk of anal incontinence in women that are continent 1 year after primary repair.

Short vs long second stage of labour: is there a difference in terms of postpartum anal incontinence?

OBJECTIVE

Our purpose was to determine if prolonged second-stage labour independently increases postpartum anal incontinence.

STUDY DESIGN

360 primiparous women were studied retrospectively after vaginal delivery of term cephalic singletons, including a group with short second-stage labour (<30min, n=163) and a group with a prolonged second stage (>90min, n=197). A quality of life questionnaire on anal incontinence (FIQOL) was sent out at 15 months after delivery.

RESULTS

184 women (96 with short second-stage labour and 88 with a prolonged second stage) answered the questionnaire (response rate 51%). Flatus incontinence was reported after prolonged second-stage labour in 9.1% of women vs 15.6% after short second stage (p=0.18). Fecal incontinence was reported after prolonged second-stage labour in 2.3% vs 5.2% after a short second stage (p=0.45).

CONCLUSION

We suggest that prolonged second stage of labour should not be associated with an increased risk of postpartum incontinence.

Faecal incontinence after first instrumental vaginal delivery using Thierry's spatulas

OBJECTIVE

The purpose of this study is to estimate the prevalence of faecal incontinence after first vaginal delivery and to assess the impact of Thierry's spatulas-assisted delivery.

METHODS

A prospective observational study of primiparas who underwent a vaginal delivery at term was conducted. Faecal incontinence was assessed at 2 and 6 months postpartum by a questionnaire (Wexner score >or=5 was considered significant). Univariate and multivariate analyses were performed.

RESULTS

Five hundred thirty-eight women were recruited with undergoing 176 spatulas-assisted deliveries and 362 spontaneous vaginal deliveries. The response rate was 85.9% (2 months) and 80.5% (6 months). The prevalence of faecal incontinence was similar between the two groups at 2 months (14.3% and 9.7%). Episiotomy (odds ratio [OR] = 5.0) and maternal age over 35 years (OR = 4.1) were independently associated with faecal incontinence after adjustment.

CONCLUSIONS

Anal symptoms are common after the first vaginal delivery. Thierry's spatulas do not increase the prevalence of faecal incontinence after delivery given that an episiotomy is performed.

Quality of life in women with postpartum anal incontinence

OBJECTIVE

To estimate the effect of anal incontinence on postpartum quality of life (QOL).

METHODS

We conducted a longitudinal follow-up study of women reporting anal incontinence on a statewide postpartum survey to estimate the effect of anal incontinence on QOL up to 2 years postpartum. Quality of life was assessed every 6 months for 2 years based on the Uebersax incontinence impact questionnaire. The effect of severe anal incontinence on QOL was determined by multivariate logistic regression.

RESULTS

A total of 1,050 women reported persistent anal incontinence and returned at least two completed QOL surveys during the 2-year study period. Among women with anal incontinence, 51% reported frustration caused by anal incontinence, 26% reported that anal incontinence affected their emotional health, 18.5% reported anal incontinence affected their child-caring abilities, and 16.2% reported a negative effect on social activities. One in three women with anal incontinence reported severe symptoms. Compared with women with mild anal incontinence, women with severe anal incontinence were four to seven times as likely to report that anal incontinence affected emotional health and the ability to perform daily activities. However, only 10% of women sought medical help for anal incontinence at 6 months, 13.5% at 1 year, and 16.7% at 2 years.

CONCLUSION

Even 2 years after delivery, more than a quarter of women who experience a new onset of anal incontinence after childbirth report persistently negative QOL. Despite this, few women discuss anal incontinence with their medical providers.

LEVEL OF EVIDENCE

III.

Postpartum pelvic floor trauma

PURPOSE OF REVIEW

There is strong epidemiological evidence linking vaginal childbirth and the development of postpartum incontinence and prolapse. This article examines possible mechanisms of pelvic floor damage related to delivery and their possible consequences.

RECENT FINDINGS

Histology, imaging and physiology studies have revealed that vaginal delivery results in direct pelvic muscle trauma, disruption of fascial supports and pudendal nerve injury.

SUMMARY

Epidemiology studies implicate parity and childbirth in the development of incontinence and prolapse; however, despite imaging and functional studies revealing damage to the pelvic floor muscles, nerves and fascial supports, it is unclear what the clinical significance of these findings is. In addition, the effect of mode of delivery is uncertain, and although cesarean section reduces the risk of pelvic floor trauma, it is not entirely protective. Further research is required into the effect of pregnancy on pelvic floor dysfunction and the effect of mode of delivery.

Cesarean delivery for the prevention of anal incontinence

BACKGROUND

Caesarean delivery (CD) is a common form of delivery of a baby, rising in frequency. One reason for its performance is to preserve maternal pelvic floor function, part of which is anal continence.

OBJECTIVES

To assess the ability of CD in comparison to vaginal delivery (VD) to preserve anal continence in a systematic review

SEARCH STRATEGY

Search terms include: "Caesarean section, Cesarean delivery, vaginal delivery, incontinence and randomised". PubMed, EMBASE and the Cochrane Central Register of Controlled Trials (Central) were searched from their inception through July, 2009.

SELECTION CRITERIA

Both randomised and non-randomised studies that allowed comparisons of post partum anal continence (both fecal and flatus) in women who had had babies delivered by either CD or VD were included.

DATA COLLECTION AND ANALYSIS

Mode of delivery, and when possible mode of all previous deliveries prior to the index pregnancy were extracted, as well as assessment of continence post partum of both faeces and flatus. In Non-RCTs, available adjusted odds ratios were the primary end point sought. Incontinence of flatus is reported as a separate outcome. Summary odds ratios are not presented as no study was analysed as a randomised controlled trial. Numbers needed to treat (NNT) are presented, that is, the number of CDs needed to be performed to prevent a single case of fecal or flatus incontinence, for each individual study. Quality criteria were developed, selecting studies that allowed maternal age adjustment, studies that allowed a sufficient time after the birth of the baby for continence assessment and studies in which mode of delivery of prior pregnancies was known. Subgroup analyses were done selecting studies meeting all quality criteria and in comparisons of elective versus emergency CD, elective CD versus VD and nulliparous women versus those delivered by VD or CD, in each case again, not calculating a summary risk statistic.

MAIN RESULTS

Twentyone reports have been found eligible for inclusion in the review, encompassing 31,698 women having had 6,028 CDs and 25,170 VDs as the index event prior to anal continence assessment . Only one report randomised women (with breech presentation) to CD or VD, but because of extensive crossing over, 52.1%, after randomisation, it was analysed along with the other 20 studies as treated, i.e. as a non-randomised trial. Only one of these reports demonstrated a significant benefit of CD in the preservation of anal continence, a report in which incontinence incidence was extremely high, 39% in CD and 48% in VD, questioning, relative to other reports, the timing and nature of continence assessment. The greater the quality of the report, the closer its Odds ratio approached 1.0. There was no difference in continence preservation in women have emergency versus elective CD.

AUTHORS' CONCLUSIONS

Without demonstrable benefit, preservation of anal continence should not be used as a criterion for choosing elective primary CD. The strength of this conclusion would be greatly strengthened if there were studies that randomised women with average risk pregnancies to CD versus VD.

Fecal incontinence in pregnancy and post partum

OBJECTIVE

To assess the prevalence of fecal incontinence (FI) during pregnancy and post partum, and to determine any associations with demographic and birth variables.

METHODS

Secondary analysis of 240 primiparous women conducted during pregnancy and post partum. Women were asked at various time points if they had lost control over their stool or bowel movements, and if they were practicing Kegel exercises. Associations of bowel symptoms with demographic and birth data were evaluated.

RESULTS

Most participants were white (87%), with a median age of 30 years (range, 18-42 years). Women who reported fecal incontinence at 1 year were more educated than those who did not report it. No other demographic or birth data were associated with fecal incontinence at 1 year.

CONCLUSIONS

Prevalence of FI during pregnancy and post partum is low and not linked to low-risk birth. Furthermore, when FI occurs it is often sporadic. This should be reassuring to patients and providers alike.

Associação entre via de parto e complicações maternas em hospital público da Grande São Paulo, Brasil

O estudo objetivou avaliar associação entre via de parto e complicações maternas. Realizou-se coorte retrospectiva com partos ocorridos durante o ano de 2003, em um hospital público. As complicações avaliadas foram: infecção, hemorragia, histerectomia, rotura uterina, lesão de órgão contíguo, trombose venosa profunda e embolia pulmonar. Utilizou-se a odds ratio (OR) e os testes de qui-quadrado de Pearson e de Fisher, além da regressão logística. Estabeleceu-se o nível de 0,05 como significante. Foram encontradas 15 complicações. Tomando-se o parto vaginal como referência, encontrou-se associação entre cesárea e as complicações tomadas em conjunto. Analisando-se variáveis confundidoras, encontrou-se associação das complicações com hipertensão, soropositividade para HIV, placenta prévia e descolamento prematuro de placenta. Após controle para estas quatro variáveis, manteve-se a associação entre cesárea e complicações (OR = 9,7; p = 0,04). Encontrou-se também associação entre complicações e cesárea eletiva comparada ao parto vaginal (OR = 4,7; p = 0,02), e maior proporção de complicações, no limite da significância estatística, nas cesáreas eletivas comparadas à "tentativa de parto vaginal" (OR = 3; p = 0,058). Conclui-se que a cesárea associa-se a complicações maternas, mesmo após a realização de vários ajustes.

Sphincter tears in primiparous women: is age a factor?

Anal sphincter tears during vaginal delivery may result in serious sequelae. We examined whether younger primiparous patients were at increased risk for sphincter tears during vaginal delivery. Data from an obstetric automated record were analyzed. Primiparous women delivering term infants (n = 5,937) were included to test for an association between age and sphincter tear rates. Three age groups were considered: young adolescents (≤ 16 years), older adolescents (17-20 years), and adults (≥ 21 years). No significant difference was found in tear rates among age cohorts (9.2%, 8.0%, and 9.6% respectively; p = 0.12). Logistic regression modeling revealed that young adolescents were not more likely to have sphincter tears compared to older cohorts. Younger adolescents may not be at increased risk of anal sphincter tears. Decisions regarding interventions to decrease sphincter tears during vaginal delivery should not be made on the basis of maternal age alone.

Does cesarean protect against fecal incontinence in primiparous women?

The objective of this study was to identify factors associated with new onset of postpartum fecal incontinence in primiparous women. A population-based study was conducted that surveyed all women delivering between 2002 and 2003 in Oregon. Factors associated with fecal incontinence were identified using logistic regression analysis. A total of 6,152 primiparous women completed the survey 3-6 months postpartum with 2,482 reporting a new onset of fecal incontinence (FI) after childbirth. Vaginal delivery was associated with a greater risk of FI compared to cesarean (odds ratio = 1.45; 95% confidence interval, 1.29 to 1.64). However, vaginal delivery without laceration or instrument assistance did not increase the risk of FI over cesarean. Being overweight (body mass index >/=30 kg/m(2)), pushing for greater than 2 h, and constipation were independently associated with postpartum FI (p < 0.05) regardless of route of delivery. This study provides important data to inform counseling and management of primiparous women.

Design and validation of a comprehensive fecal incontinence questionnaire

PURPOSE

Fecal incontinence can have a profound effect on quality of life. Its prevalence remains uncertain because of stigma, lack of consistent definition, and dearth of validated measures. This study was designed to develop a valid clinical and epidemiologic questionnaire, building on current literature and expertise.

METHODS

Patients and experts undertook face validity testing. Construct validity, criterion validity, and test-retest reliability was undertaken. Construct validity comprised factor analysis and internal consistency of the quality of life scale. The validity of known groups was tested against 77 control subjects by using regression models. Questionnaire results were compared with a stool diary for criterion validity. Test-retest reliability was calculated from repeated questionnaire completion.

RESULTS

The questionnaire achieved good face validity. It was completed by 104 patients. The quality of life scale had four underlying traits (factor analysis) and high internal consistency (overall Cronbach alpha = 0.97). Patients and control subjects answered the questionnaire significantly differently (P < 0.01) in known-groups validity testing. Criterion validity assessment found mean differences close to zero. Median reliability for the whole questionnaire was 0.79 (range, 0.35-1).

CONCLUSIONS

This questionnaire compares favorably with other available instruments, although the interpretation of stool consistency requires further research. Its sensitivity to treatment still needs to be investigated.

Impact of route of delivery on continence and sexual function

Urinary and fecal incontinence have been linked to pregnancy and childbirth. This article reviews the rates of pelvic floor dysfunction following vaginal delivery and cesarean section as cited in short-term and long-term follow-up studies.

Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial

OBJECTIVE

To estimate whether prophylactic antibiotics at the time of repair of third- or fourth-degree perineal tears after vaginal delivery prevent wound infection and breakdown.

METHODS

This was a prospective, randomized, placebo-controlled study. Patients who sustained third- or fourth-degree perineal tears after a vaginal delivery were recruited for the study. Each patient was given a single intravenous dose of a second-generation cephalosporin (cefotetan or cefoxitin) or placebo before repair of third- or fourth-degree perineal tears. Obstetricians and patients were blinded to study drug. The perineum was inspected for evidence of infection or breakdown at discharge from the hospital and at 2 weeks postpartum. Primary end points were gross disruption or purulent discharge at site of perineal repair by 2 weeks postpartum.

RESULTS

One hundred forty-seven patients were recruited for the study. Of these, 83 patients received placebo and 64 patients received antibiotics. Forty patients (27.2%) did not return for their 2-week appointment. Of the patients seen at 2 weeks postpartum, 4 of 49 (8.2%) patients who received antibiotics and 14 of 58 (24.1%) patients who received placebo developed a perineal wound complication (P=.037). There were no differences between groups in parity, incidence of diabetes, operative delivery, or third-degree compared with fourth-degree lacerations.

CONCLUSION

By 2 weeks postpartum, patients who received prophylactic antibiotics at the time of third- or fourth-degree laceration repair had a lower rate of perineal wound complications than patients who received placebo.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clincaltrials.gov, NCT00186082.

LEVEL OF EVIDENCE

I.

Immediate or delayed repair of obstetric anal sphincter tears-a randomised controlled trial

OBJECTIVE

To investigate if an 8- to 12-hour time delay of primary repair affects anal incontinence at 1-year follow up.

DESIGN

Randomised controlled trial.

SETTING

University hospital in Sweden.

POPULATION

A total of 165 women diagnosed with a third- to fourth-degree perineal tear.

METHODS

The participants were randomised to immediate or delayed (8- to 12-hour delay) end-to-end repair; 78 were allocated to immediate operation and 87 to a delayed repair. An incontinence and pelvic floor symptom questionnaire was completed by the participants at baseline and at 6- and 12-month follow up.

MAIN OUTCOME MEASURES

Anal incontinence measured by the validated Pescatori incontinence score.

RESULTS

A total of 161 (98%) and 155 (94%) women completed the two follow-up questionnaires. There was no significant difference in anal incontinence between the groups. There were no significant differences in pelvic floor symptoms between the groups. A multivariate proportional odds model revealed that increasing maternal age was significantly associated with both increased symptoms of faecal urgency and inability to discriminate flatus from faeces.

CONCLUSION

Delayed repair provided the same functional outcome at 1-year follow up. Delaying the repair should thus not be recommended routinely, but can be an alternative under special circumstances when appropriate surgical expertise is not readily available.

[What are the risk factors of anal incontinence after vaginal delivery?]

Fecal incontinence is one of the most feared complications of vaginal delivery. It may be the consequence of sphincter tears, of pudendal neuropathy, or of a combination of the two. Fecal incontinence occurs immediately following 13-54% of vaginal deliveries but its persistence in the mid and long term is poorly known. The incidence of perineal tear with anal sphincteric defect varies from 1-9% and the incidence of unrecognized sphincter injury may be as high as 18-35%. Half the women who undergo primary anal sphincter repair have short or long term continence problems. Pudendal neuropathy is caused by nerve stretch during pushing in the second stage of labor and descent of the fetal head; it may occur even with the first delivery. Risk factors for sphincter injury and pudendal neuropathy include forceps delivery, large neonatal size, and prolonged second stage of labor. The risk of fecal incontinence must be considered even during the first pregnancy. Routine episiotomy does not prevent sphincter injury and may even predispose to it. Pudendal neuropathy following delivery may lead to delayed fecal incontinence abetted by postmenopausal hormonal deficiency and tissue senescence. The possible benefit of early episiotomy for women at high risk of sphincter injury must be evaluated by prospective studies.

The impact of fecal and urinary incontinence on quality of life 6 months after childbirth

OBJECTIVE

The objective of the study was to investigate the impact of postpartum fecal incontinence (FI) and urinary incontinence (UI) on quality of life (QOL).

STUDY DESIGN

Seven hundred fifty-nine primiparous women in the Childbirth and Pelvic Symptoms study were interviewed 6 months postpartum. FI and UI were assessed with validated questionnaires. We measured QOL with SF-12 summary scores, health utility index score (a measure of self-rated overall health), and the modified Manchester Health Questionnaire.

RESULTS

Women with FI had worse self-rated health utility index scores (85.1 +/- 9.8 vs 88.0 +/- 11.6, P = .02) and Medical Outcomes Study Short Form Health Survey (SF-12) mental summary scores (46.8 +/- 9.2 vs 51.1 +/- 8.7, P < .0001) than women without FI or flatal incontinence. Women with UI had worse SF-12 mental summary scores (48.3 +/- 9.8 vs 51.6 +/- 7.8, P < .01) and self-rated health utility index scores (84.1 +/- 12.5 vs 88.7 +/- 10.1, P < .01) than women without UI. Women with both FI and UI had the lowest SF-12 mental summary scores (44.5 +/- 9.0).

CONCLUSION

Six months after delivery, women experiencing FI or UI reported negative effects on health-related QOL. FI and UI together have a greater impact than either condition alone.

The prevalence of occult obstetric anal sphincter injury following childbirth--literature review

OBJECTIVE

To calculate the published prevalence of ultrasound-detected occult anal sphincter damage associated with different modes of delivery.

METHODS

A search of the English language literature for articles using keywords describing the prevalence of ultrasound-diagnosed anal sphincter injury following childbirth. The weighted mean prevalence of occult anal sphincter injury was calculated in the following groups: (1) primiparous women (unselected); (2) primiparous women after an unassisted normal vaginal delivery; (3) multiparous women (unselected); (4) following forceps delivery; (5) following ventouse delivery; (6) following cesarean section.

RESULTS

Nineteen articles described ultrasound-diagnosed occult anal sphincter injury. The prevalence in unselected primiparous women (excluding cesarean section) was 29.2% (288/983). After unassisted vaginal delivery in primiparae the prevalence was 21.7% (74/341). The incidence in multiparous women (unselected) is 32.3% (107/331); following forceps delivery 49.1% (131/267) and with ventouse delivery it is 45.2% (66/146). Only one woman (in 173 cases) had anal sphincter injury following cesarean section.

CONCLUSIONS

After a review of the literature, occult anal sphincter injury is mostly associated with the first vaginal delivery and is particularly high following instrumental deliveries. Ventouse is less traumatic than forceps. Cesarean section is protective to the anal sphincter.

Operative vaginal delivery: a cause of birth injury or is it?

Operative vaginal delivery has been maligned since the days of W.J. Little with the word "forceps" becoming nearly synonymous with "Birth Injury" and "Cerebral Palsy." However in his presentation to the Obstetrical Society of London in 1861, Little's emphasis was on difficult labors being the culprit in subsequent disabilities in the offspring. Instrumented deliveries in that era were the end result of a long, obstructed labor performed for maternal benefit and to avoid a destructive procedure to the fetus thus allowing a chance at life. If there had been a normal progress in labor, operative assistance for delivery would not have been needed. Thus, was it the instrument or the obstructed labor that led to fetal injury? In this article, we will review what injuries to the fetus and the mother can be directly attributable to the instrument. We will explore the processes of labor, conduct of labor management, and concurrent fetal factors that can modulate the occurrence of birth trauma. Evidence regarding inexperience and improper use as contributing to injury will also be explored.

The clinical significance of postpartum transperineal ultrasound of the anal sphincter

BACKGROUND AND OBJECTIVE

To evaluate the clinical significance of postpartum anal sphincter damage by transperineal ultrasonography (TPUS) performed on the day of delivery.

METHODS

Continence questionnaires were handed out and TPUS was performed on 154 consecutive primiparous women 6-24h after vaginal delivery. At 2 and 6 months later, complaints and sphincteric sonographic appearance were reassessed. The puerperal women's clinical status and sonographic findings in the immediate and late postpartum period were evaluated.

RESULTS

Thirty-five (23%) women complained of anal incontinence on the first postpartum day and anal sphincter damage was demonstrated by TPUS in 31 (89%) of them. Four women with anorectal complaints had an intact anal sphincter by TPUS. Follow-up questionnaires, 2 months later, revealed 30 symptomatic women: all of them had sonographically recognized tears on the initial TPUS and 27 of them had positive findings on the TPUS performed 2 months after birth. Six months after delivery, 27 women reported symptoms and all of them had sphincteric disruption evidenced on TPUS performed on the day of delivery. All the women with intact sphincter on the initial TPUS were asymptomatic 6 months later.

CONCLUSION

TPUS findings on the day of delivery are related to long-term anorectal complaints, supporting a potential role for TPUS as a screening aid for anal sphincter tears.

Urinary incontinence after obstetric anal sphincter injuries (OASIS)—is there a relationship?

This study aimed to compare urinary symptoms and its impact on women's quality of life after obstetric anal sphincter injuries (OASIS) with a matched control group in the short term. The study group consisted of 100 primiparous women with OASIS and 104 controls who sustained a second-degree tear or had a mediolateral episiotomy performed. All women completed a validated International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire 10 weeks after delivery. Compared to controls, significantly more women with OASIS reported overall urinary incontinence (21.2 vs 38%, p = 0.005) and had significantly worse quality of life score (incontinence score: 2.42 vs 1.2; p = 0.008). Significantly more women with OASIS suffered from stress urinary incontinence (33 vs 14%; p = 0.002; OR 3.06; CI = 1.54-6.07) than controls. Logistic regression analysis revealed that OASIS and a prolonged (>50 min) second stage of labour were independent risk factors for the development of stress urinary incontinence. This study highlights the importance of inquiring about urinary incontinence in women with OASIS.

The risk of anal incontinence in obese women

The objectives of this study was to estimate the risk of anal incontinence in morbidly obese women and to identify risk factors associated with anal incontinence in an obese population sample. A case-control study based on the registry of a university hospital obesity unit. A consecutive sample of women with body mass index > or = 35 (obesity class II) was randomly matched by age, gender and residential county to control subjects using the computerised Register of the Total Population. Data were collected by a self-reported postal survey including detailed questions on medical and obstetrical history, obesity history, socioeconomic indices, life style factors and the validated Cleveland Clinic Incontinence Score. The questionnaire was returned by 131/179 (73%) of the cases and 453/892 (51%) of the control subjects. Compared to the control group, obese women reported a significantly increased defecation frequency (p < 0.001), inability to discriminate between flatus and faeces (p < 0.001) and flatus incontinence (p < 0.001). Compared with non-obese women, the adjusted odds ratio (OR) for flatus incontinence in morbidly obese women was 1.5 [95% confidence interval (CI) 1.1-4.1]. A history of obstetric sphincter injury was independently associated with an increased risk of flatus incontinence (OR, 4.3; 95% CI, 2.0-9.2) and incontinence of loose stools (OR, 6.6; 95% CI, 1.4-31.4). Other medical and life style interactions did not remain at significant levels in an adjusted multivariable analysis. Obese women are at increased risk for mild to moderate flatus incontinence.

Incidence of fecal incontinence after childbirth

OBJECTIVE

Fecal incontinence is an embarrassing and disabling condition of which the epidemiology is poorly understood. Our goal is to estimate the incidence of fecal incontinence after childbirth.

METHODS

A population-based survey was mailed to all women who delivered a liveborn infant in the state of Oregon between April 2002 and September 2002. The survey estimated the incidence of fecal incontinence. Surveys were to be completed within 3-6 months postpartum. Women were considered to have fecal incontinence based upon the National Institute of Child Health and Human Development definition of fecal incontinence: recurring episodes of involuntary loss of stool or flatus.

RESULTS

Surveys were mailed to 21,824 eligible postpartum women. A total of 8,774 women responded (40%) to the survey, 2,569 (29%) of whom reported experiencing fecal incontinence since delivery. Almost half (46%) of all women with postpartum fecal incontinence reported incontinence of stool, and 38% reported exclusively incontinence of flatus. Approximately 46% reported onset of incontinence after delivery of their first child. Higher body mass index, longer pushing, forceps-assisted delivery, third- or fourth-degree laceration, and smoking were associated with severe fecal incontinence.

CONCLUSION

In this population-based study, more than one in four women reported fecal incontinence within 6 months of childbirth, with almost half reporting onset of symptoms after delivery of their first child. Four in 10 women reported loss of flatus or stool during intercourse. Given the burden of this condition, both in number and social impact coupled with the hesitancy of women to want to initiate this conversation, providers should ask women about symptoms of fecal incontinence during postpartum examinations. Additionally, these data suggest that there may be a benefit to extending postpartum follow-up visits beyond the typical 6-8 weeks to provide surveillance for potential incontinence.

LEVEL OF EVIDENCE

II.

Risk factors for anal sphincter tear during vaginal delivery

OBJECTIVE

To identify risk factors associated with anal sphincter tear during vaginal delivery and to identify opportunities for preventing this cause of fecal incontinence in young women.

METHODS

We used baseline data from two groups of women who participated in the Childbirth and Pelvic Symptoms (CAPS) study: those women who delivered vaginally, either those with or those without a recognized anal sphincter tear. Univariable analyses of demographic and obstetric information identified factors associated with anal sphincter tear. We calculated odds ratios (ORs) for these factors alone and in combination, adjusted for maternal age, race, and gestational age.

RESULTS

We included data from 797 primaparous women: 407 with a recognized anal sphincter tear and 390 without. Based on univariable analysis, a woman with a sphincter tear was more likely to be older, to be white, to have longer gestation or prolonged second stage of labor, to have a larger infant (birth weight/head circumference), or an infant who was in occiput posterior position, or to have an episiotomy or operative delivery. Logistic regression found forceps delivery (OR 13.6, 95% confidence interval [CI] 7.9-23.2) and episiotomy (OR 5.3, 95% CI 3.8-7.6) were strongly associated with a sphincter tear. The combination of forceps and episiotomy was markedly associated with sphincter tear (OR 25.3, 95% CI 10.2-62.6). The addition of epidural anesthesia to forceps and episiotomy increased the OR to 41.0 (95% CI 13.5-124.4).

CONCLUSION

Our results highlight the existence of modifiable obstetric interventions that increase the risk of anal sphincter tear during vaginal delivery. Our results may be used by clinicians and women to help inform their decisions regarding obstetric interventions.

LEVEL OF EVIDENCE

II.