Faecal incontinence and mode of first and subsequent delivery: a six-year longitudinal study

OBJECTIVE: To investigate the prevalence of persistent and long term postpartum faecal incontinence and associations with mode of first and subsequent deliveries. DESIGN: Longitudinal study. SETTING: Maternity units in Aberdeen, Birmingham and Dunedin. POPULATION: Four thousand two hundred and fourteen women who returned postal questionnaires three months and six years postpartum. METHODS: Symptom data were obtained from both questionnaires and obstetric data from case-notes for the index birth and the second questionnaire for subsequent births. Logistic regression investigated the independent effects of mode of first delivery and delivery history. MAIN OUTCOME MEASURES: Incontinence to bowel motions three months and six years after index birth. For delivery history, the outcome was incontinence only at six years. RESULTS: The prevalence of persistent faecal incontinence was 3.6%. Almost 90% of these women reported no symptoms before their first birth. The forceps delivery of a first baby was independently predictive of persistent symptoms (OR 2.06, 95% CI 1.40-3.04). A caesarean section first birth was not significantly associated with persistent symptoms (OR 1.07, 95% CI 0.64-1.81). Delivering exclusively by caesarean section also showed no association with subsequent symptoms (OR 1.04, 95% CI 0.72-1.50) but ever having forceps was significantly predictive (OR 1.48, 95% CI 1.18-1.87). Other factors independently associated with persistent faecal incontinence were older maternal age, increasing number of births and Asian ethnic group. Birthweight and long second stage were not significantly associated. CONCLUSIONS: The risk of persistent faecal incontinence is significantly higher after a first delivery by forceps. We found no evidence of a lower risk of subsequent faecal incontinence for exclusive caesarean section deliveries.     

New postnatal urinary incontinence: obstetric and other risk factors in primiparae

OBJECTIVE: To identify obstetric and other risk factors for urinary incontinence that occurs during pregnancy or after childbirth. DESIGN: Questionnaire survey of women. SETTING: Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). POPULATION: A total of 3405 primiparous women with singleton births delivered during 1 year. METHODS: Questionnaire responses and obstetric case note data were analysed using multivariate analysis to identify associations with urinary incontinence. MAIN OUTCOME MEASURES: Urinary incontinence at 3 months after delivery first starting in pregnancy or after birth. RESULTS: The prevalence of urinary incontinence was 29%. New incontinence first beginning after delivery was associated with older maternal age (oldest versus youngest group, OR 2.02, 95% CI 1.35-3.02) and method of delivery (caesarean section versus spontaneous vaginal delivery, OR 0.28, 95% CI 0.19-0.41). There were no significant associations with forceps delivery (OR 1.18, 95% CI 0.92-1.51) or vacuum delivery (OR 1.16, 95% CI 0.83-1.63). Incontinence first occurring during pregnancy and still present at 3 months was associated with higher maternal body mass index (BMI>25, OR 1.68, 95% CI 1.16-2.43) and heavier babies (birthweight in top quartile, OR 1.56, 95% CI 1.12-2.19). In these women, caesarean section was associated with less incontinence (OR 0.39, 95% CI 0.27-0.58) but incontinence was not associated with age. CONCLUSIONS: Women have less urinary incontinence after a first delivery by caesarean section whether or not that first starts during pregnancy. Older maternal age was associated with new postnatal incontinence, and higher BMI and heavier babies with incontinence first starting during pregnancy. The effect of further deliveries may modify these findings.     

The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence

OBJECTIVE: The purpose of this study was to determine the relative effects of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. STUDY DESIGN: This was a prospective, observational multicenter study of women presenting to 6 gynecology clinics. Demographic data collected included: height, weight, gravidity, parity, and number of vaginal deliveries. Patients were diagnosed with incontinence by questionnaire. Standard univariate logistic regression analyses' were performed to determine the contribution of pregnancy, mode of delivery, and BMI on the prevalence of urinary and fecal incontinence. RESULTS: One thousand and four women were enrolled over an 18-month period. Two hundred and thirty-seven and 128 subjects had urinary and fecal incontinence, respectively. Odds ratio (95% CI) calculated for the prevalence of urinary incontinence by pregnancy and mode of delivery were: any term pregnancy vs no term pregnancy was 2.46 (1.53-3.95), any term pregnancy but no vaginal deliveries (cesarean section only) vs no term pregnancy was 1.95 (0.99-3.80), any term pregnancy and at least 1 vaginal delivery vs no term pregnancy was 2.53 (1.57-4.07), and any term pregnancy but no vaginal delivery (cesarean section only) vs any term pregnancy, and at least 1 vaginal delivery was 1.30 (0.77-3.95). Odds ratio (95% CI) calculated for the prevalence of fecal incontinence by pregnancy and mode of delivery were: any term pregnancy vs no term pregnancy was 2.26 (1.22-4.19), any term pregnancy but no vaginal deliveries (cesarean section only) vs no term pregnancy was 1.13 (0.43-2.96), any term pregnancy and at least 1 vaginal delivery vs no term pregnancy was 2.41 (1.30-4.49), and any term pregnancy but no vaginal deliveries (cesarean section only) vs any term pregnancy, and at least 1 vaginal delivery was 2.15 (0.97-4.77). BMI and age did not impact these results. CONCLUSION: Pregnancy increases the risk of urinary and fecal incontinence. Cesarean section does not decrease the risk of urinary or fecal incontinence compared to pregnancy with a vaginal delivery.     

Symptoms of stress incontinence 1 year after childbirth: prevalence and predictors in a national Swedish sample

BACKGROUND: The aims of the present study were to describe the prevalence of stress incontinence, as described by women themselves, 1 year after childbirth in a national sample of Swedish-speaking women, and to identify possible predictors. METHODS: A cohort study, including 2390 women recruited from 593 antenatal clinics in Sweden during three 1-week periods evenly spread over 1 year (1999-2000), representing 53% of women eligible for the study and 75% of those who consented to participate. Data were collected by means of questionnaires in early pregnancy, 2 months and 1 year after the birth, and from the Swedish Medical Birth Register. RESULTS: One year after the birth, 22% of the women had symptoms of stress incontinence but only 2% said it caused them major problems. The strongest predictor was urinary incontinence (overall leakage) 4-8 weeks after a vaginal delivery (OR 5.5, CI 95% 4.1-7.4) as well as after a cesarean section (OR 11.9, CI 95% 2.9-48.1). Other predictors in women with a vaginal delivery were: multiparity (OR 1.4; CI 95% 1.1-1.8), obesity (OR 1.6; CI 95% 1.1-2.4) and constipation 4-8 weeks postpartum (OR 1.4; CI 95% 1.1-1.9). CONCLUSION: Stress incontinence 1 year after childbirth is a common symptom, which could possibly be reduced by identifying women with urinary leakage at the postnatal check-up.     

Mode of delivery and the risk of delivery-related perinatal death among twins at term: a retrospective cohort study of 8073 births

OBJECTIVE: To determine the risk of perinatal death among twins born at term in relation to mode of delivery. DESIGN: Retrospective cohort study. SETTING: Scotland 1985-2001. POPULATION: All twin births at or after 36 weeks of gestation, excluding antepartum stillbirths and perinatal deaths due to congenital abnormality (n= 8073). METHODS: The outcome of first and second twins was compared using McNemar's test and the outcome of twin pairs in relation to mode of delivery was compared using exact logistic regression. MAIN OUTCOME MEASURES: Intrapartum stillbirth or neonatal death of either twin. RESULTS: Overall, there were six deaths of first twins and 30 deaths of second twins (OR for second twin 5.00, 95% CI 2.00-14.70). The odds ratio for death of the second twin due to intrapartum anoxia was 21 (95% CI 3.4-868.5). The associations were similar for twins delivered following induction of labour and for sex discordant twins. However, there was no association between birth order and the risk of death among 1472 deliveries by planned caesarean section. There was death of either twin among 2 of 1472 (0.14%) deliveries by planned caesarean section and 34 of 6601 (0.52%) deliveries by other means (P= 0.05, odds ratio for planned caesarean section 0.26 [95% CI 0.03-1.03]). The association was similar when adjusted for potential confounders. Assuming causality, we estimate that 264 caesarean deliveries (95% CI 158-808) would be required to prevent each death. CONCLUSION: Planned caesarean section may reduce the risk of perinatal death of twins at term by approximately 75% compared with attempting vaginal birth. This is principally due to reducing the risk of death of the second twin due to intrapartum anoxia.     

Short-term maternal and neonatal outcomes by mode of delivery. A case-controlled study

OBJECTIVE: Side-by-side comparisons of short-term maternal and neonatal outcomes for spontaneous vaginal delivery, instrumental vaginal delivery, planned caesarean section and caesarean section during labor in patients matched for clinical condition, age, and week of gestation are lacking. This case-controlled study was undertaken to evaluate short-term maternal and neonatal complications in a healthy population at term by mode of delivery. STUDY DESIGN: Four groups of healthy women, with antenatally normal singleton pregnancies at term, who underwent instrumental vaginal delivery (no. 201), spontaneous delivery (no. 402), planned caesarean section without labor (no. 402) and caesarean section in labor (no. 402) have been retrospectively selected. Outcome measures were maternal and neonatal short-term complications. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Maternal complications were mostly associated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 6.9; 95% CI: 2.9-16.4 and OR 3.0; 95% CI 1.1-8.8, respectively, versus spontaneous deliveries). No significant differences in overall complications were observed between spontaneous vaginal deliveries and caesarean sections, whether planned or in labor. By comparison with caesarean sections in labor, instrumental deliveries significantly increased the risk of complications (OR: 3.2; 95% CI: 1.6-6.5). Neonatal complications were also mostly correlated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 3.5; 95% CI: 1.9-6.7 and OR 3.8; 95% CI 2.0-7.4, respectively, versus spontaneous deliveries). By comparison with caesarean sections in labor, instrumental vaginal deliveries significantly increased the risk of complications (OR: 4.2; 95% CI: 2.4-7.4). CONCLUSIONS: In healthy women with antenatally normal singleton pregnancies at term, instrumental deliveries are associated with the highest rate of short-term maternal and neonatal complications.     

Caesarean section is protective against stress urinary incontinence: an analysis of women with multiple deliveries

All women who had three elective caesarean sections were selected from a database of 40,000 women delivering between 1977 and 1998, and age-matched with women having three vaginal births. They all completed a (validated) urinary and bowel symptom questionnaire. Women who had vaginal births had a significantly higher prevalence of stress incontinence but not other urinary or faecal symptoms compared with those delivered by caesarean section. The prevalence of faecal incontinence was lower than the prevalence of urinary incontinence. Although the prevalence of faecal incontinence was lower after caesarean delivery, this was not statistically different. These data have shown that caesarean section was associated with a lower risk of urinary incontinence, although a protective effect on development of faecal symptoms was not seen.     

Vaginal delivery parameters and urinary incontinence: the Norwegian EPINCONT study

OBJECTIVE: The study was undertaken to investigate the effect of nine delivery parameters on urinary incontinence in later life. STUDY DESIGN: Incontinence data from the EPINCONT study were linked to the Medical Birth Registry of Norway. Effects of birth weight, gestational age, head circumference, breech delivery, injuries in the delivery channel, functional delivery disorders, forceps delivery, vacuum delivery, and epidural anesthesia were investigated. The study covered women younger than 65 years, who had had vaginal deliveries only (n=11,397). RESULTS: Statistically significant associations were observed between any incontinence and birth weight 4000 g or greater (odds ratio [OR] 1.1, 95% CI 1.0-1.2); moderate or severe incontinence and functional delivery disorders (OR 1.3, 95% CI 1.1-1.6); stress incontinence and high birth weight (OR 1.2, 95% CI 1.1-1.3) and epidural anesthesia (OR 1.2, 95% CI 1.0-1.5); and urge incontinence and head circumference 38 cm or larger (OR 1.8, 95% CI 1.0-3.3). CONCLUSION: The effects were too weak to explain a substantial part of the association between vaginal delivery and urinary incontinence, and statistically significant results may have incurred by chance.     

Caesarean section and subsequent fertility in sub-Saharan Africa

OBJECTIVE: To determine the impact of caesarean section on fertility among women in sub-Saharan Africa. DESIGN: Analysis of standardised cross-sectional surveys (Demographic and Health Surveys). SETTING: Twenty-two countries in sub-Saharan Africa, 1993-2003. SAMPLE: A total of 35 398 women of childbearing age (15-49 years). METHODS: Time to subsequent pregnancy was compared by mode of delivery using Cox proportional hazards regression models. MAIN OUTCOME MEASURES: Natural fertility rates subsequent to delivery by caesarean section compared with natural fertility rates subsequent to vaginal delivery. RESULTS: The natural fertility rate subsequent to delivery by caesarean section was 17% lower than the natural fertility rate subsequent to vaginal delivery (hazard ratio = 0.83, 95% CI 0.73-0.96, P < 0.01; controlling for age, parity, level of education, urban/rural residence and young age at first intercourse). Caesarean section was also associated with prior fertility and desire for further children: among multiparous women, an interval > or =3 versus <3 years between the index birth and the previous birth was associated with higher odds of caesarean section at the index birth (OR = 1.4, 95% CI 1.1-1.7, P= 0.005); among all women, the odds of desiring further children were lower among women who had previously delivered by caesarean section (OR = 0.67, 95% CI 0.54-0.84, P < 0.001). Caesarean section did not appear to increase the risk of a subsequent pregnancy ending in miscarriage, abortion or stillbirth. CONCLUSIONS: Among women in sub-Saharan Africa, caesarean section is associated with lower subsequent natural fertility. Although this reflects findings from developed countries, the roles of pathological and psychological factors may be quite different because a much higher proportion of caesarean sections in sub-Saharan Africa are emergency procedures for maternal indication.     

Stress urinary incontinence 4 years after the first delivery: a retrospective cohort survey

BACKGROUND: Our aim was to estimate the prevalence of stress urinary incontinence 4 years after the first delivery and analyze its risk factors. METHODS: A retrospective cohort survey was conducted in a French university hospital. The 669 primiparous women who delivered in our department in 1996 a singleton in a vertex position between 37 and 41 weeks of amenorrhea were included. A mailed questionnaire was sent 4 years after the indexed delivery. The main outcome measure was stress urinary incontinence 4 years after the first delivery. RESULTS: Three hundred and seven women replied, 274 had moved and 88 did not respond. Four years after the first delivery, prevalence of stress urinary incontinence was 29% (89/307). According to multiple logistic regression analysis, the independent risk factors were urine leakage before the first pregnancy [odds ratio (OR) 18.7; 95% confidence interval (CI) 3.6-96.4], urine leakage during the first pregnancy (OR 2.5; 95% CI 1.3-4.8), duration of first labor > or = 8 h (OR 3.1; 95% CI 1.7-5.7), mother's age > 30 years at the first delivery (OR 2.4; 95% CI 1.4-4.2) and cesarean section at the first delivery (OR 0.3; 95% CI 0.1-0.9). CONCLUSION: Our results suggest that stress urinary incontinence after pregnancy arises from a multifactorial condition. The main risk factors are: age, previous incontinence (before or during the first pregnancy), prolonged labor and vaginal delivery.     

Does Cesarean Section Reduce Postpartum Urinary Incontinence? A Systematic Review

ABSTRACT: Background: The impact of delivery mode on the development of urinary incontinence has been much debated. The primary objective of this systematic review was to compare the prevalence of postpartum urinary incontinence after cesarean section compared with vaginal birth. Methods: The MEDLINE (1966–2005) and CINAHL (1982–2005) databases were searched for reports specifying postpartum prevalence or incidence of unspecified, stress, urge, and mixed urinary incontinence by mode of birth. Primary authors were contacted to request unpublished data about severity, parity, and timing of cesarean section. All data were entered into Review Manager software, and odds ratio (OR), absolute risk reduction, and number needed to prevent were calculated. Results: Cesarean section reduced the risk of postpartum stress urinary incontinence from 16 to 9.8 percent (OR = 0.56 [0.45, 0.68], number needed to prevent = 15 [12,22]) in 6 cross‐sectional studies, and from 22 to 10 percent in 12 cohort studies (OR=0.48 [0.39, 0.58], number needed to prevent = 10 [8,13]). Differences persisted by parity and after exclusion of instrumental delivery, but risk of severe stress urinary incontinence and urge urinary incontinence did not differ by mode of birth. Conclusions: Although short‐term occurrence of any degree of postpartum stress urinary incontinence is reduced with cesarean section, severe symptoms are equivalent by mode of birth. Risk of postpartum stress urinary incontinence must be considered in the context of associated maternal and newborn morbidity and mortality. (BIRTH 34:3 September 2007)     

Sexual function, delivery mode history, pelvic floor muscle exercises and incontinence: a cross-sectional study six years post-partum

Background: There is controversy over the effect of mode of delivery, pelvic floor muscle exercises (PFME), incontinence and sexual function.
Aim: To investigate the relationship of sexual function with delivery mode history, PFMEs and incontinence.
Methods: This was a cross-sectional postal survey of women, six years post-partum, who had given birth in maternity units in Aberdeen, Birmingham and Dunedin and had answered a previous questionnaire. Each sexual function question was analysed separately by anova .
Results: At six years post-index delivery, 4214 women responded, of whom 2765 (65%) answered the optional ten sexual function questions. Although there was little association between delivery mode history and most sexual function questions, women who had delivered exclusively by caesarean section scored significantly better on the questions relating to their perception of vaginal tone for their own ( P -value < 0.0001) and partner's ( P -value 0.002) sexual satisfaction, especially when compared with women who had had vaginal and instrumental deliveries. Women who reported that they were currently performing PFME scored significantly better on seven questions. Women with urinary or faecal incontinence scored significantly poorer on all sexual function questions.
Conclusions: Mode of delivery history appeared to have minimal effect on sexual function. Current PFME performance was positively associated with most aspects of sexual function, however, all aspects were negatively associated with urinary and faecal incontinence.     

女性压力性尿失禁发生的危险因素分析

目的 调查城市社区女性压力性尿失禁发生的危险因素。方法 按照1：8随机抽样的方法,抽取福州市鼓楼区6066例妇女。调查项目包括：年龄、职业、文化程度、体重、血压、月经史、孕产史、分娩方式、新生儿体重、慢性疾病(高血压、糖尿病、慢性咳嗽、习惯性便秘)、腹腔或盆腔手术史、生活习惯(吸烟、酗酒、体育锻炼方式等)、尿失禁症状和发生频率、就医情况等。数据采用多因素回归分析。结果 问卷回收率为92．1％(5587／6066)。尿失禁发生率为18．1％,其中压力性尿失禁占8．8％。调查显示,诸因素中年龄[OR：1．010;95％可信限(CI)：1．001—1．025]、高体重指数(OR：1．092;95％CI：1．054—1．132)、高血压(OR：2．342;95％CI：1．026～5．349)、便秘(OR：1．448;95％CI：1．216—1．725)、多次流产(OR：1．306;95％,CI：1．113～1．533)、多次阴道分娩(OR：1．205;95％CI：1．009—1．440)、加腹压助产(OR．1．684;95％CI:1．140—2．489)、会阴直切(OR：2．244;95% CI：1．162～4．334)、会阴裂伤(OR：2．576;95％CI：1．724～3．851)、会阴切口感染(OR：5．988;95％CI：1．936—18．616)是尿失禁发生的危险因素。结论 压力性尿失禁的发生与多种因素有关,尤其与年龄和妊娠、分娩等产科因素关系密切。     

Effects of carrying a pregnancy and of method of delivery on urinary incontinence: a prospective cohort study

BACKGROUND: This study was carried out to identify risk factors associated with urinary incontinence in women three months after giving birth. METHODS: Urinary incontinence before and during pregnancy was assessed at study enrolment early in the third trimester. Incontinence was re-assessed three months postpartum. Logistic regression analysis was used to assess the role of maternal and obstetric factors in causing postpartum urinary incontinence. This prospective cohort study in 949 pregnant women in Quebec, Canada was nested within a randomised controlled trial of prenatal perineal massage. RESULTS: Postpartum urinary incontinence was increased with prepregnancy incontinence (adjusted odds ratio [adj0R] 6.44, 95% CI 4.15, 9.98), incontinence beginning during pregnancy (adjOR 1.93, 95% CI 1.32, 2.83), and higher prepregnancy body mass index (adjOR 1.07/unit of BMI, 95% CI 1.03,1.11). Caesarean section was highly protective (adjOR 0.27, 95% CI 0.14, 0.50). While there was a trend towards increasing incontinence with forceps delivery (adjOR 1.73, 95% CI 0.96, 3.13) this was not statistically significant. The weight of the baby, episiotomy, the length of the second stage of labour, and epidural analgesia were not predictive of urinary incontinence. Nor was prenatal perineal massage, the randomised controlled trial intervention. When the analysis was limited to women having their first vaginal birth, the same risk factors were important, with similar adjusted odds ratios. CONCLUSIONS: Urinary incontinence during pregnancy is extremely common, affecting over half of pregnant women. Urinary incontinence beginning during pregnancy roughly doubles the likelihood of urinary incontinence at 3 months postpartum, regardless whether delivery is vaginal or by Caesarean section.     

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

Objectives  To assess if mode of delivery is associated with increased symptoms of anal incontinence following childbirth.
Design  Systematic review of all relevant studies in English.
Data sources  Medline, Embase, Cochrane Library, bibliographies of retrieved primary articles and consultation with experts.
Study selection and data extraction  Data were extracted on study characteristics, quality and results. Exposure to risk factors was compared between women with and without anal incontinence. Categorical data in 2 × 2 contingency tables were used to generate odds ratios.
Results  Eighteen studies met the inclusion criteria with 12 237 participants. Women having any type of vaginal delivery compared with a caesarean section have an increased risk of developing symptoms of solid, liquid or flatus anal incontinence. The risk varies with the mode of delivery ranging from a doubled risk with a forceps delivery (OR 2.01, 95% CI 1.47–2.74, P < 0.0001) to a third increased risk for a spontaneous vaginal delivery (OR 1.32, 95% CI 1.04–1.68, P = 0.02). Instrumental deliveries also resulted in more symptoms of anal incontinence when compared with spontaneous vaginal delivery (OR 1.47, 95% CI 1.22–1.78). This was statistically significant for forceps deliveries alone (OR 1.5, 95% CI 1.19–1.89, P = 0.0006) but not for ventouse deliveries (OR 1.31, 95% CI 0.97–1.77, P = 0.08). When symptoms of solid and liquid anal incontinence alone were assessed, these trends persisted but were no longer statistically significant.
Conclusion  Symptoms of anal incontinence in the first year postpartum are associated with mode of delivery.     

Effects of parity and mode of delivery on urinary incontinence among postmenopausal women in Taiwan

ObjectiveTo investigate the association between the prevalence of urinary incontinence and parity or mode of delivery among Taiwanese women aged 60 years or older.MethodsBetween July 1999 and December 2000, a nationwide epidemiologic study was conducted in Taiwan among 2410 women selected by a multistage random sampling method. Face-to-face interviews with 1517 women were conducted. The relationship between the prevalence of urinary incontinence and the number of vaginal deliveries or number of cesarean deliveries was assessed by frequency and Pearson χ² test using a significance level of less than 0.05. Logistic regression was used to investigate the significance of dichotomous dependent variables.ResultsDecades ago, most Taiwanese women (1435 of 1511 respondents, 94.97%,) gave birth via vaginal delivery and the rate of cesarean delivery was low (20 of 1513 respondents, 1.32%). Parity (odds ratio [OR], 2.42; 95% confidence interval [CI], 0.87–6.71; P = 0.091), vaginal delivery (OR, 0.76; 95% CI, 0.39–1.47; P = 0.408), and cesarean delivery (OR, 1.47; 95% CI, 0.59–3.70; P = 0.409) did not increase the risk of urinary incontinence.ConclusionThere was no association between urinary incontinence and parity or mode of delivery among Taiwanese postmenopausal women decades after their first delivery.     

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

OBJECTIVE: To compare pelvic floor symptoms at three years following instrumental delivery and cesarean section in the second stage of labor and to assess the impact of a subsequent delivery. STUDY DESIGN: We conducted a prospective cohort study of 393 women with term, singleton, cephalic pregnancies who required instrumental vaginal delivery in theatre or cesarean section at full dilatation between February 1999 and February 2000. 283 women (72%) returned postal questionnaires at three years. RESULTS: Urinary incontinence at three years post delivery was greater in the instrumental delivery group as compared to the cesarean section group (10.5% vs 2.0%), OR 5.37 (95% CI, 1.7, 27.9). There were no significant differences in ano-rectal or sexual symptoms between the two groups. Pelvic floor symptoms were similar for women delivered by cesarean section after a failed trial of instrumental delivery compared to immediate cesarean section. A subsequent delivery did not increase the risk of pelvic floor symptoms at three years in either group. CONCLUSION: An increased risk of urinary incontinence persists up to three years following instrumental vaginal delivery compared to cesarean section in the second stage of labor. However, pelvic floor symptoms are not exacerbated by a subsequent delivery.     

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

OBJECTIVE: This study was undertaken to assess symptoms of pelvic floor morbidity at 6 weeks and at 1 year after difficult instrumental vaginal delivery or cesarean section during the second stage of labor. STUDY DESIGN: Prospective cohort study of 393 women with term, singleton, cephalic pregnancies who required operative delivery in surgery at full dilatation between February 1999 and February 2000. Postal questionnaires were used for follow-up at 6 weeks and at 1 year. RESULTS: Instrumental delivery was associated with a greater risk of urinary incontinence at 6 weeks and at 1-year postdelivery, adjusted odds ratio [OR] 7.8 (95% CI, 2.6-23.6) and OR 3.1 (95% CI, 1.3-7.6), respectively. Although instrumental delivery was associated with an increased risk of moderate-to-severe dyspareunia at 6 weeks, adjusted OR 3.35 (95% CI, 1.36-8.25), this difference was not significant at 1 year. Cesarean section after attempted instrumental delivery was associated with an increased risk of moderate-to-severe pain during intercourse at 1 year compared with immediate cesarean section, (18% vs 9%) P=.01. CONCLUSION: Although cesarean section at full dilatation does not completely protect women from pelvic floor morbidity, those that followed instrumental delivery had a significantly greater prevalence of urinary symptoms and dyspareunia. Urinary symptoms persist up to 1 year after delivery.     

Parity, mode of delivery, and pelvic floor disorders

OBJECTIVE: This study aimed to assess the associations between parity, mode of delivery, and pelvic floor disorders. METHODS: The prevalence of pelvic organ prolapse, stress urinary incontinence, overactive bladder, and anal incontinence was assessed in a random sample of women aged 25-84 years by using the validated Epidemiology of Prolapse and Incontinence Questionnaire. Women were categorized as nulliparous, vaginally parous, or only delivered by cesarean. Adjusted odds ratios and 95% confidence intervals (CIs) for each disorder were calculated with logistic regression, controlling for age, body mass index, and parity. RESULTS: In the 4,458 respondents the prevalence of each disorder was as follows: 7% prolapse, 15% stress urinary incontinence, 13% overactive bladder, 25% anal incontinence, and 37% for any one or more pelvic floor disorders. There were no significant differences in the prevalence of disorders between the cesarean delivery and nulliparous groups. The adjusted odds of each disorder increased with vaginal parity compared with cesarean delivery: prolapse = 1.82 (95% CI 1.04-3.19), stress urinary incontinence = 1.81 (95% CI 1.25-2.61), overactive bladder = 1.53 (95% CI 1.02-2.29), anal incontinence = 1.72 (95% CI 1.27-2.35), and any one or more pelvic floor disorders = 1.85 (95% CI 1.42-2.41). Number-needed-to-treat analysis revealed that 7 women would have to deliver only by cesarean delivery to prevent one woman from having a pelvic floor disorder. CONCLUSION: The risk of pelvic floor disorders is independently associated with vaginal delivery but not with parity alone. Cesarean delivery has a protective effect, similar to nulliparity, on the development of pelvic floor disorders when compared with vaginal delivery. LEVEL OF EVIDENCE: II-2.     

How much influence do women in Sweden have on caesarean section? A follow-up study of women's preferences in early pregnancy

OBJECTIVE: to investigate factors associated with having a caesarean section, with special emphasis on women's preferences in early pregnancy. DESIGN: a cohort study using data from questionnaires in early pregnancy and 2 months after childbirth, and data from the Swedish Medical Birth Register. SETTING: women were recruited from 97% of all antenatal clinics in Sweden at their booking visit during 3 weeks between 1999 and 2000, and followed up 2 months after birth. PARTICIPANTS: a total of 2878 Swedish-speaking women were included in the study (87% of those who consented to participate and 63% of all women eligible for the study). FINDINGS: Of 236 women who wished to have their babies delivered by caesarean section when asked in early pregnancy, 30.5% subsequently had an elective caesarean section and 14.8% an emergency caesarean section. The logistic regression analyses showed that, a preference for caesarean section in early pregnancy (odds ratio [OR] 9.63, 95% confidence interval [CI] 5.94-15.59), a medical diagnosis (OR 9.03, 95% CI 5.68-14.34), age (OR 1.08, 95% CI 1.03-1.13), parity (OR 0.58, 95% CI 0.37-0.91), a previous elective caesarean section (OR 15.11, 95% CI 6.83-33.41) and a previous emergency caesarean section (OR 18.29, 95% CI 10.00-33.44) was associated with having an elective caesarean section. Having an emergency caesarean section was associated with a preference for a caesarean section (OR 2.59, 95% 1.61 to 4.18), a medical diagnosis (OR 4.12, 95% CI 2.91-5.88), age (OR 1.08, 95% CI 1.05-1.12), primiparity (OR 3.34, 95% CI 1.78-6.27), a previous emergency caesarean section (OR 10.69, 95% CI 6.03-18.94), and a previous elective caesarean section (OR 7.21, 95% CI 2.90-17.92). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: a woman's own preference about caesarean section was associated with the subsequent mode of delivery. Asking women about their preference regarding mode of delivery in early pregnancy may increase the opportunity to provide adequate support and possibly also to reduce the caesarean section rate.