Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study

doi:10.1016/S0140-6736(98)11205-9

The Lancet

Volume 354, Issue 9183, 18 September 1999, Pages 983-986

https://doi.org/10.1016/S0140-6736(98)11205-9 Get rights and content

Summary

Background

Because obstetric injury to the anal sphincters may be occult, and because the mechanism of injury differs between first and subsequent deliveries, we prospectively assessed the effects of first and second vaginal deliveries on anal physiology and continence.

Methods

We undertook a prospective observational study of 59 previously nulliparous women through two successive vaginal deliveries by means of a bowel-function questionnaire, and an anorectal-physiology assessment, both antepartum and 6–12 weeks post partum.

Findings

13 (22%) women reported altered faecal continence after their first vaginal delivery: eight had persistent symptoms during their second pregnancy, of whom seven deteriorated after the second delivery, five regained continence before their second pregnancy, but two became incontinent again after the second delivery. Five women developed incontinence for the first time after their second vaginal delivery, of whom three had occult primiparous sphincter injury. 20 (34%) women, seven of whom had no symptoms, had anal-sphincter injury as a result of their first delivery, but only two new injuries occurred after the second vaginal delivery (p=0·013). Although pudendal neuropathy was no more common after the second than after the first vaginal delivery (15 vs 19%, p=0·8), pudendal-nerve latency was longer after the second delivery (p=0·02).

Interpretation

Primiparous women with persistent symptoms of altered faecal continence experience deterioration after a second vaginal delivery. Women with transient faecal incontinence or occult anal-sphincter injury after their first vaginal delivery are at high risk of faecal incontinence after a second vaginal delivery. The risk of mechanical anal sphincter injury is greatest after the first delivery.

Introduction

Vaginal delivery is the most important risk factor for anal-sphincter injury and for development of faecal incontinence in women.1, 2, 3, 4, 5, 6 Two mechanisms of injury are recognised: direct disruption of the anal-sphincter muscles, and traction neuropathy of the pudendal nerves. Although clinically recognisable disruption of the anal-sphincter muscles after vaginal delivery is rare, endoanal sonography has shown that up to 35% of primiparous women have detectable injury after their first vaginal delivery.4, 5 Most of those women are symptom-free (occult injury); many of those with symptoms recover full continence in the months after delivery.2, 3, 4, 5

Direct injury to the anal sphincter is rare in multiparous vaginal delivery, although cumulative pudendal-nerve damage is well recognised.6, 7, 8, 9 Some women with overt anal-sphincter injury after their first vaginal delivery may experience a deterioration or recurrence of faecal incontinence after a second vaginal delivery. The management of second delivery in these women is controversial: some obstetricians advocate a trial of labour with early recourse to caesarean delivery should difficulty in labour arise, whereas others advocate elective caesarean delivery.¹⁰ How to approach subsequent vaginal deliveries in women with occult anal-sphincter injury after their first delivery is an even more difficult question because cumulative anal-sphincter injury or pudendal neuropathy may precipitate overt faecal incontinence either post partum or at the menopause.9, 10

To address these uncertainties, we undertook a prospective study of previously nulliparous women through two vaginal deliveries to assess the effect of second vaginal delivery on the anal-sphincter mechanism and faecal continence. The aim was to identify those women most at risk of cumulative anal-sphincter injury and of subsequent development of faecal incontinence.

Section snippets

Participants

Between June, 1993, and July 1994, all primiparous women presenting to the antenatal clinics of the National Maternity Hospital Dublin (Ireland) were informed of the study, and 297 representative nulliparous volunteers were recruited during their last trimester of pregnancy. We excluded women with a history of diabetes mellitus, anorectal disease, previous anorectal surgery, or pre-existing irritable bowel syndrome.¹ 200 (68%) women subsequently underwent spontaneous vaginal delivery, 63 (21%)

Patients

The mean age of the women when they underwent first vaginal delivery was 27 years (range 19–35), and for those at second vaginal delivery, the mean age was 30 years (22–39). The mean birth interval was 2·9 years (1·5–3·5). There were no significant differences between first and second vaginal delivery in infants' gestational age at birth, mean birthweight, mean body-mass index, or head circumference. These data did not differ significantly from the overall birth statistics recorded at the

Discussion

This prospective study of previously nulliparous women through two successive vaginal deliveries was designed to assess the effect of second vaginal delivery on the anal-sphincter mechanism and faecal continence. We found that most women with impaired faecal continence during their second pregnancy experienced a deterioration in faecal continence after their second vaginal delivery, and that 42% of women with occult anal-sphincter injury detected after their first vaginal delivery develop

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Cited by (226)

Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis
2020, European Journal of Obstetrics and Gynecology and Reproductive Biology
Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review.
We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI.
We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21–30, I² = 91 %), and 19 % experienced anal incontinence (95 %CI, 14–25, I² = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10–17, I² = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6–24, I² = 95 %). Following primary repair of OASIS, 55 % (46–63, I² = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33–43, I² = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17−6.45, I² = 98 %).
Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.
Pelvic Floor Disorders
2020, Braddom's Physical Medicine and Rehabilitation
Pelvic myofascial pain and pelvic floor dysfunction are common but treatable musculoskeletal conditions. Understanding the anatomic relationship between the pelvic floor muscles (PFMs) and the pelvic girdle, spine, and hips will aid the rehabilitation practitioner in the diagnosis and treatment of these conditions. Pelvic floor pain and dysfunction are diagnosed with a thorough history and clinical examination of the PFMs. The treatment consists of a multidisciplinary approach, which may include pelvic floor physical therapy, medications, injections, and complementary treatment options. This chapter reviews the anatomy and physical exam of the pelvic floor, discusses the definitions and epidemiology of pelvic floor disorders, and explains the rehabilitation approach to treating these common conditions.
N<sup>o</sup> 381 – Accouchement vaginal assisté
2019, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
Il est cependant important de remarquer que pour les femmes qui ont subi des LOSA du troisième ou du quatrième degré, le futur plan de soins devrait être évalué au moyen d'un accompagnement adéquat. Un autre accouchement vaginal pourrait entraîner une augmentation du risque de récidive des LOSA et aggraver la morbidité, en particulier chez celles qui présentent déjà des symptômes d'incontinence82. La planification des soins doit en tout temps être flexible et personnalisée en respectant les préférences de la patiente.
Fournir des directives factuelles qui favorisent l'accouchement vaginal assisté sécuritaire et efficace.
Conditions préalables, indications, contre-indications, ainsi que les morbidités maternelles et néonatales liées à l'accouchement vaginal assisté.
Des recherches ont été effectuées dans la base de données Medline pour trouver des articles publiés entre le 1^er janvier 1985 et le 28 février 2018 en utilisant les termes anglais suivants : assisted vaginal birth, instrumental vaginal birth, operative vaginal delivery, forceps delivery, vacuum delivery, ventouse delivery. La qualité des données probantes indiquées s'appuie sur les critères d’évaluation des données décrits dans le rapport du Groupe d’étude canadien sur les soins de santé préventifs.
La présente directive a été approuvée par le comité de pratique clinique – obstétrique et le conseil d'administration de la Société des obstétriciens et gynécologues du Canada.
- 1
  La nécessité d'assister un accouchement vaginal peut être diminuée grâce aux mesures suivantes : soutien dédié et continu durant le travail (I-A), augmentation du travail inadéquat par l'administration d'ocytocine (I-A), retarder de la poussée chez les femmes sous péridurale (I-A), augmentation du temps de poussée chez les femmes nullipares sous péridurale (I-B) et optimisation du positionnement de la tête fœtale par rotation manuelle (I-A).
- 2
  Le fait de favoriser l'AVA sécuritaire et efficace aux mains de fournisseurs de soins compétents et expérimentés peut s'avérer une stratégie efficace pour diminuer le taux de césarienne primaire (II-2B).
- 3
  Pour qu'un accouchement vaginal assisté s'avère sécuritaire et efficace, il est nécessaire de détenir l'expertise requise avec la méthode choisie, d'effectuer une évaluation complète de la situation clinique et de communiquer de façon claire avec la patiente, ses personnes de soutien et le personnel soignant (III-B).
- 4
  Les praticiens qui effectuent un accouchement vaginal assisté doivent avoir les connaissances, les compétences et l'expérience nécessaires pour évaluer la situation clinique, utiliser l'instrument choisi et gérer les complications qui peuvent découler d'un accouchement vaginal assisté (II-2B).
- 5
  Les stagiaires en obstétrique devraient recevoir une formation complète sur l'accouchement vaginal assisté; ils doivent également être déclarés compétents avant de pratiquer un accouchement vaginal assisté sans supervision (III-B).
- 6
  Lorsque l'on juge que l'accouchement vaginal assisté comporte un risque élevé d’échec, on doit le considérer comme une tentative d'accouchement vaginal assisté et l'effectuer dans un endroit où il est possible de recourir immédiatement à la césarienne (III-B).
- 7
  Le médecin doit choisir l'instrument le mieux adapté aux circonstances cliniques en fonction de son degré de compétence. La ventouse et les forceps sont associés à divers risques et avantages à court et à long termes. La ventouse est plus susceptible de conduire à l’échec de l'accouchement que les forceps (I-A).
- 8
  Il n'est pas recommandé de planifier d'utiliser successivement les instruments puisque cette approche est possiblement liée à un risque accru de trauma périnatal. En cas d’échec d'une tentative d'accouchement avec ventouse, le médecin doit évaluer les risques d'une tentative avec les forceps par rapport à ceux d'une césarienne (II-2B).
- 9
  L'utilisation restreinte de l’épisiotomie médiolatérale est indiquée lors d'un accouchement vaginal assisté (II-2B).
- 10
  Un retour doit être effectué avec la patiente et ses personnes de soutien immédiatement après une tentative d'accouchement vaginal assisté, qu'elle soit fructueuse ou non. Si ce n'est pas possible, il faut idéalement le faire avant que la patiente n'obtienne son congé et lui faire part des indications pour l'accouchement vaginal assisté, du plan de prise en charge de toute complication et du pronostic pour de futurs accouchements (III-B).
- 11
  Les patientes devraient être encouragées à envisager un accouchement vaginal spontané pour les grossesses subséquentes. Le plan de soins devrait néanmoins être personnalisé et respecter les préférences de la patiente (II-3B).
No. 381-Assisted Vaginal Birth
2019, Journal of Obstetrics and Gynaecology Canada
To provide evidence-based guidelines for safe and effective assisted vaginal birth.
Prerequisites, indications, contraindications, along with maternal and neonatal morbidity associated with assisted vaginal birth.
Medline database was searched for articles published from January 1, 1985, to February 28, 2018 using the key words “assisted vaginal birth,” “instrumental vaginal birth,” “operative vaginal delivery,” “forceps delivery,” “vacuum delivery,” “ventouse delivery.” The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventive Health Care.
These guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada.
- 1
  The need for assisted vaginal birth can be reduced by: dedicated and continuous support during labour (I-A), oxytocin augmentation of inadequate labour (I-A), delayed pushing in women with an epidural (I-A), increased time pushing in nulliparous women with an epidural (I-B), as well as optimization of fetal head position through manual rotation (I-A).
- 2
  Encouraging safe and effective assisted vaginal birth by experienced and skilled care providers may be a useful strategy to reduce the rate of primary Caesarean delivery (II-2B).
- 3
  Safe and effective assisted vaginal birth requires expertise in the chosen method, comprehensive assessment of the clinical situation alongside clear communication with the patient, support people, and health care personnel (III-B).
- 4
  Practitioners performing assisted vaginal birth should have the knowledge, skills, and experience necessary to assess the clinical situation, use the selected instrument, and manage complications that may arise from assisted vaginal birth (II-2B).
- 5
  Obstetrical trainees should receive comprehensive training in assisted vaginal birth and be deemed competent prior to independent practice (III-B).
- 6
  When assisted vaginal birth is deemed to have a higher risk of not being successful, it should be considered a trial of assisted vaginal birth and be conducted in a location where immediate recourse to Caesarean delivery is available (III-B).
- 7
  The physician should determine the instrument most suitable to the clinical circumstances and their level of skill. Vacuum and forceps are associated with different short- and long-term benefits and risks. Unsuccessful delivery is more likely with vacuum than forceps (I-A).
- 8
  Planned sequential use of instruments is not recommended as it may be associated with an increased risk of perinatal trauma. If an attempted vacuum is unsuccessful, the physician should consider the risks of proceeding to an attempted forceps delivery versus Caesarean section (II-2B).
- 9
  Restrictive use of mediolateral episiotomy is supported in assisted vaginal birth (II-2B).
- 10
  A debrief should be done with the patient and support people immediately following an attempted or successful assisted vaginal birth. If this is not possible, ideally this should be done prior to hospital discharge and include the indication for assisted vaginal birth, management of any complications, and the prognosis for future deliveries (III-B).
- 11
  In a subsequent pregnancy, patients should be encouraged to consider spontaneous vaginal birth. However, care planning should be individualized and patient preference respected (II-3B).
Evaluation of the Anal Sphincter by Anal Endosonography
2018, Endosonography, Fourth Edition
This chapter describes the use of anal endosonography to characterize the anal sphincter complex, namely the morphology of the external and internal sphincters. Anal endosonography is the pivotal diagnostic test for investigation of anal incontinence since characterization of sphincter morphology will both indicate the etiology and direct the choice of subsequent therapeutic strategy. The equipment and technique necessary to perform anal endosonography is described. The sonographic appearance of the normal anal sphincter complex is illustrated and contrasted with appearances found in a variety of causes of anal incontinence. The role of anal endosonography for investigation of other anal pathologies is also described.
Pelvic Floor Disorders
2018, Braddom's Rehabilitation Care: A Clinical Handbook

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ArticlesEffect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Participants

Patients

Discussion

Lancet

Obstet Gynecol

Surg Clin North Am

Am J Surg

Obstet Gynecol

Lancet

Lancet

Faecal incontinence after childbirth

BrJ Obstet Gynaecol

Faecal incontinence: childbirth is responsible for most cases

BMJ

Anal sphincter disruption during vaginal delivery

N EnglJ Med

Pelvic floor damage and childbirth: a neuropsychological study

BrJ Obstet Gynaecol

Articles
Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study