Obstetric practice and faecal incontinence three months after delivery

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Abstract

Objective To determine whether obstetric and maternal factors relate to faecal incontinence at three months postpartum.

Setting Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand).

Population All women who delivered during one year in the three maternity units.

Methods Postal questionnaire at three months postpartum, to obtain information on faecal incontinence, linked to obstetric casenote data.

Main outcome measures Prevalence of faecal incontinence.

Results 7879 questionnaires were returned, a 71.7% response rate. The prevalence of faecal incontinence was 9.6%, with 4.2% reporting this more often than rarely. Logistic regression, confined to primiparae, showed that forceps delivery was a predictor of an increased risk of symptoms (OR=1.94, 95% CI 1.30 to 2.89) while vacuum extraction was not associated. Caesarean section was marginally associated with a reduced risk (OR=0.58, 95% CI 0.35 to 0.97). Older maternal age, Indian sub-continent ethnic origin and body mass index ‘not known’ also showed significant associations. No associations were found for induced labour, duration of second stage labour, episiotomy, laceration or birthweight.

Conclusions Women delivered by forceps had almost twice the risk of developing faecal incontinence, whereas vacuum extraction was not associated with faecal incontinence at three months postpartum. Caesarean section appears to offer some protection.

Introduction

Faecal incontinence in women is known to be related to childbirth1, but its relationship with particular obstetric factors is less well known. There is increasing evidence that instrumental delivery is a risk factor2., 3., 4., 5., but the effects of the type of instrument used, forceps or vacuum extraction, are not known. Sultan et al.2., 3. found anal sphincter defects and symptoms of anal incontinence to be more common after forceps delivery and not after vacuum extraction, but the patients were selected by agreeing to undergo anal investigations and numbers were too small to draw conclusions on the relative effects of instrument type. MacArthur et al.4, in a larger study, found that an increased risk of new postpartum incontinence of stool was independently associated with both forceps and vacuum extraction, but since the latter was infrequently practised in the study maternity unit, the number of vacuum deliveries was too small.

To date, therefore, no study has been able to provide evidence on whether forceps or vacuum extraction should be the instrument of choice to reduce the risk of faecal incontinence. Similarly, adequate evidence to support the generally presumed protective effect of caesarean section delivery in relation to symptoms of faecal incontinence is unavailable.

This paper reports on the relationship between faecal incontinence at three months postpartum and maternal and obstetric characteristics, especially mode of delivery, among primiparous births in a large multicentre study.

Section snippets

Methods

All women who were delivered during one year (1993/1994) in three maternity units, in Dunedin (New Zealand), Aberdeen (Scotland), and Birmingham (England) were sent a postal questionnaire at three months postpartum to assess the prevalence of urinary and faecal incontinence. Those with urinary stress incontinence were asked to take part in a randomised controlled trial of the effects of an intensive pelvic floor exercise programme, (reported elsewhere)6. In addition to the questions on urinary

Results

Questionnaires were returned by 7879 of the 10,989 women who had delivered during the study period, a response rate of 71.7%. Casenote data were also available for the non-respondents. Comparisons with the respondents showed that non-respondents were more likely to be under 25 years (39.8% cf 23.2%), multiparous (65.4% cf 55.0%) to have had a spontaneous vaginal delivery (74.0% cf 69.3%) and an intact perineum (56.4% cf 42.6%). There were no other differences in obstetric factors. There was

Discussion

This study has shown that faecal incontinence reported at three months postpartum was significantly more likely to be associated with forceps delivery than with spontaneous vaginal delivery, but was not significantly associated with vacuum extraction. Caesarean section delivery was negatively associated with symptoms, although this was marginal.

This is the first study of childbirth-related faecal incontinence with large enough numbers to provide acceptable evidence that faecal incontinence is

Conclusion

The lack of a standard definition or classificatory system for post-obstetric faecal incontinence has led to various forms of questioning, which in turn affects incidence and prevalence estimates. The primary emphasis of this study as a whole was on urinary incontinence6 so questions on anal incontinence were less detailed. In particular our form of questioning, which was similar to that used in other studies16, did not specify faecal urgency, nor ask about symptom onset. To take account of the

Acknowledgements

The study was funded by a grant from Wellbeing UK. The authors would like to thank Ms J. Cook, Ms J. Harvey, Ms A. McDonald and Ms A. M. Rennie, who were involved in collecting and processing the data. Thanks also to all the women who took part.

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